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%^j< NT ' 
 
 
 
 
A
PRACTICAL SURGERY,
                 containing  Jfl&J&tfnC?*
A COMPLETE EXHIBITION OF THE PRESENT STATE
             OF THE
 PRINCIPLES AND PRACTICE
                 OF
           SURGERY,
COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF
            INFORMATION,
    'AND ILLUSTRATED BY CRITICAL REMARKS.
         BY SAMUEL^COOPER,
MEMBER OF THE ROYAL COLLEGE OF SURGEONS, LONDON, AND AUTHOR OF THE
       " FIRST LINES OF THE PRACTICE OF SURGERY."

  WITH NOTES AND ADDITIONS,
     BY JOHN SYNG DORSEY, M. D.
ADJUNCT PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA^ &C.
IN TWO VOLUMES.
SECOND AMERICAN
r,AlliN ENLATlOfiJkLONDON EDITION.
             PHILADELPHIA.     s

PUBLISHED BY II. & T. KITE, JOHNSON &? WARNER, M. CAREY, I. PIERCE, S. W. CON HA II,
          B. C UUZBY, E. PAUKER, AND A. SMALL.
1816. 
 
A  DICTIONARY
PRACTICAL   SURGERY.
>»®»<
    HEMATOCELE, (from ce/^«e, blood,
      and jmjAjj, a tumour.)   This is a
swelling of the scrotum, or  spermatic
cord,  proceeding  from, or caused by,
blood.
  A distinction of the different kinds of
hematocele, though not usually made, is
absolutely necessary toward rightly un-
derstanding the  disease;  the  general
idea, or conception of which, appears to
Mr. Pott  to be somewhat erroneous, and
to have produced a prognostic which is
ill-founded, and hasty.   According to
this eminent surgeon, " the disease, pro-
perly called hxmatocele, is of four kinds;
two of which have their seat within the
tunica vaginalis testis; one within the
albuginea; and the fourth in the tunica
communis, or common cellular mem-
brane, investing the spermatic vessels.
  " In passing an instrument, in order to
let out the water  from an hydrocele of
the vaginal coat, a vessel is sometimes
wounded, which is of such size, as  to
tinge the fluid pretty deeply at the time
of its  running out; the orifice  becoming
close,  when the water is all discharged,
and a plaster being applied, the blood
ceases to flow from thence, but insinuates
itself partly into the cavity of the vaginal
coat, and partly into the cells of the dar-
tos ; making, sometimes, in the space of
a few  hours, a tumour nearly equal in
size to the original hydrocele.  This is
one species.
  " It sometimes happens, in tapping an
hydrocele, that although the fluid dis-
charged by that operation be perfectly
clear  and limpid,  yet, in  a very  short
space of time, (sometimes in a few hours)
the scrotum becomes  as large as it was
before, and palpably as full of  a  fluid.
If a new puncture be now made, the dis-
charge, instead of being  limpid, (as be.
    Voi. II
fore) is now either pure blood, or Very
bloody.  This  is  another species: but,
like the preceding, confined to the tunica
vaginalis.
  " The whole vascular compages of the
testicle is sometimes very much enlarged,
and at the same time rendered so lax and
loose, that the tumour produced thereby
has, to the fingers of an examiner, very
much the appearance of a swelling com-
posed of a mere  fluid, supposed to be
somewhat  thick  or viscid.  This is in
some measure a deception; but not total-
ly so : the greater part of the tumefaction
is caused by the loosened texture of the
testis; but there is  very  frequently a
quantity of extravasated blood also.
  " If tliis be supposed to be an hydros
cele, and pierced, the discharge will be
mere blood.  This is a third kind of he-
matocele ;  and very different, in all  its
circumstances, from the two preceding:
the fluid is shed  from the vessels of the
glandular part of the testicle,  and con-
tained within the  tunica albuginea.
  " The fourth consists in a  rupture of,
and an effusion of blood from, a-branch of
the spermatic vein, in its passage  from
the groin to the testicle.  In which case,
the extravasation  is made into the tunica
communis, or cellular  membrane invest-
ing the spermatic vessels."
  Each of these  four, Mr. Pott says, he
has seen so distinctly, and perfectly, that
he has not the smallest doubt concerning
their existence, and of their difference
from each other.
  " The tunica vaginalis testis, (he con-
tinues) in a natural and healthy state, is
a membrane, which, although firm, is of
no great thickness; it is white, or rather
of a reddish white colour; and its blood-
vessels are (in a healthy state) no more
apparent to the eye, than are those of the
    A 
HEMATOCELE
  tunica albuginea:  bt.t when it  has  been
  long  or much distended, it thereby be-
  comes thick, and tough; and the vessels
  (especially those of its inner surface) are
  sometimes so large, a9 to be very visiole,
  and even varicous.  If one of these lies in
  the way of the instrument, wherewith the
  palliative cure is  performed, it is some-
  times wounded ; in which ca"e, as I have
  already observed,  the  first part of the
  serum which is discharged, is pretty deep-
  ly tinged with blood
    " Upon the collapsion of the membranes,
  and of the empty bag, this kind of hemor-
  rhage generally cc : s-.es, and nothing more
  comes of it.  But it sometimes  happens,
  either  from  the  toughness of the tunic,
  or from the varicous state of the vessel,
  that  the wound (especially if made  by a
  lancet) does not immediately unite; but
  continues  to discharge blood  into the
  cavity of the said tunic, thereby producing
  a new  tumour, and a fresh necessity  of
  operation."
    This is  what Mr. Pott calls  the  first
  species of hematocele,  which evidently
  consists in a wound of a vessel of the va-
  ginal turnc.
    " Upon  the sudden discharge  of the
  fluid,  from the b..g of  an over-stretched
  hydrocele, and thereby removing all coun-
  ter-pressure  against the  sides of the ves-
  sels, some of which are become varicous,
  one of them will, sometimes, without  hav-
  ing been wounded, burst. If the quantity
  of blood, shed from the vessel so burst,
  be small, it is soon absorbed again j and,
  creating no  trouble, the thing  is  not
  known*.  But if the quantity be consid-
  erable, it, like the preceding, occasions a
  new tumour, and calls for a repetition of
  the operation."  This, Mr. Pott calls the
  second species: "which, like  the first,
  belongs entirely to the vaginal coat,  and
  has no concern  either widi the testicle,
♦• or with the spermatic vessels.   In both,
  the bag which was full of water, becomes
  in a short space of time distended with
  blood;  which blood, if not carried off by
  absorption, mu't be discharged by open-
  ing the containing cyst: but in neither
  of these can castration (though  said to
  be the only remedy) be  ever necessary:
  the mere division of the sacculus, and the
  application  of  dry  lint   to its   inside,
  will, in general, if not  always,  restrain
  the hemorrhage, and answer every pur-
  pose, for which so severe a remedy hns
  been prescribed.   The other two  are in-
  deed of more consequence ;  they interest
    Hence, the last running of the water
from an hydrocele, i8 often bloody.
 cither the testicle itself, or the vessels by
 which it is supplied with blood, and ren-
 dered capable of executing its office ; and
 are sometimes not curable, but by removal
 of the part.            (
   " One of these  i« seated within the tu-
 nica albuginea of  the  testicle ;  the other
 in  the  tunica communis of its  vessels:
 they are neither of  them very frequent;
 but when they do happen, they call li>r all
 our attention.
   " If blood  be extravasatcd within the
 tunica albuginea,  or proper coat of the
 testicle, in consequence of a great relaxa-
 tion, and (.s it were, dissolution of part of
 the vascular compages of that gland, and
 the quantity be considerable, it will afford
 or  produce a fluctuation, to  the hand of
 an examiner, very like to that of an hydro-
 cele of  the tunica  v igiualis ;  allowing
 something for the  different density of the
 different fluids, and the  greater depth of
 the former from the surface.
  " If this be mistaken for  a simple hy-
 drocele, and an opening be made, the dis-
 charge  will be blood; not fluid, or very
 thin; not like to blood circulating through
 its proper vessels ; but dark, and dusky in
 colour,  and  nearly of  the consistence of
 thin chocolate (like to what is most fre-
 quently found in the imperforate vagina )
 The quantity discharged will be much
 smaller than was expected from the size
 of the tumour; which size  will not be
 considerably diminished  When this small
 quantity of blood  has  been  so drawn off,
 the testicle will,  upon  examination, be
 found to be much larger  than it  ought to
 he ; as well as much more loose and  flab-
 by ; instead of that roundness and resist-
 ance arising from  an healthy state of the
 gland,  within its firm strong coat;  it is
 soft, and capable of being compressed al-
 most flat, and that generally without any
 of that pain and uneasin-ss, which always
 attend the compression ofa sound testicle.
 If the bleeding ceases upon the withdraw-
 ing the cannula, (supposing a trochar to
 have been used) and the  puncture closes,
 a fresh accumulation of the «ame kind of
 fluid is soon made, and the  same degree
 of tumefaction is produced, as before the
 operation:  if the orifice does not close,
 the hemorrhage continues, and very soon
 becomes alarming.
  " In  the  two preceding  species, the
 blood comes from the tunica vaginalis, the
 testis itself being safe, and unconcerned ;
 and the remedy is found, by opening the
cavity of the said tunic ;  but in  this, the
hemorrhage comes frow  the substance of
the testicle; from the convolutions of the
spermatic artery, within  the tunica albu-
ginea:  the division  of the  vaginal  coat 
                  II AR

 can here do no  good;  and the incision
 made into the albuginea can only increase
 the mischief: the  testicle  is spoiled, or
 rendered useless, by that kind of altera-
 tion made in it, previous to the extrava-
 sation;  and castration  is the only cure,
 which a patient in such circumstances can
 d*pen«l upon.
  " The last species of this  disease arises
 from a burstiog of a branch of the sper-
 matic vein,  between the groin and scro-
 tum, in  what i->  generally known by the
 name of  the  spermatic process.  This,
 which is  generally produced by great or
 sudden  exertions of strength, feats of
 agility,  &c. may happen to persons in the
 best healt'i,  whose blood and juices are
 in the best order, and whose genital parts
 are free from blemish, or disease.
  " The effusion, or extravasation, is made
 into the cellular membrane,  which invests
 and envelopes the spermatic vessels,  and
 has something the appearance of a true
 hernia.   When the case is clear, and  the
 extravasated blood  does not give way to
 disculient applications, the  only remedy
 is to lay the tumour fairly open, through
 its whole length.   If the vessel or breach
 be small, the hemorrhage may be restrain-
 ed  by mere compression with dry lint, or
 by the use of styptics; but if it be large,
 and these means do not succeed, the liga-
 ture must be made use of."   {Pott's Chi-
 rurgical Works, Vol. II.)
  The bleeding point should be tied  sin-
 gly. It can never be warrantable to tie the
 whole spermatic chord, and  then perform
 castration, in a case like this,  notwith-
standing  Mr. Pott advises  this plan, in
 case the bleeding branch cannot be tied
 singly.  Discutient applications, and an
 occasional purge, will almost always dis-
 perse the swelling; and if not, opening
 it, taking out the blootl, filling the cavity
with lint, and using compression, one may
say, will  always answer.
  The best of the old-writers on Hematocele,
 are Celmis and Paulus JEgineta : Pott has
 excelled every modern one.
  H.EMOIilMAGlA.  (See  Hemorrhage.)
  H.EMORimOIDES.    (See   Hemor-
 rhoids.)
  HAUE-LIP.  {Labia Leporina.)  A  fis-
sure, or  longitudinal division of one  or
 both lips.
  Children are frequently born with this
kind of malformation, particularly of  the
 upper lip.  Sometimes the portions of the
 lip, which ought to be united, have a con-*
 sider.ible  interspace,  between them;  in
 other instances they are not much apart.
 The cleft is occasionally double, there
 being'a little lobe, or small ponion of the
 j.p, 'situated between the  ttvo •fissures.
               HAR                3

Every species  of the deformity has the
same appellation  of hare-lip,  in  conse-
quence  of the  imagined  resemblance
which the part has to the upper lip of a
hare.
  The fissure commonly affects only the
lip itself.   In many cases, however, it ex-
tends along the bones of the palate, even
as far as the uvula. Sometimes these bones
are totally wanting; sometimes, they are
only divided by a fissure.
  Such a malformation is always peculiar-
ly afflicting.  In  its least degree, it con-
stantly occasions  considerable  deformity;
and when it is more marked, it frequently
hinders infants from suckiag,  and makes
it indispensable to nourish them by other
means. When the lower Up alone is affect-
ed, which is not most frequently the case,
the child can neither retain  its saliva, nor
learn to speak, except with  the greatest
impediment.  But when the fissure per-
vades  the palate,  the  patient not only
never articulates  but very imperfectly,
but cannot masticate nor swallow, except
with  great difficulty, on account  of the
food readily getting up into  the nose.
  After these remarks, it is obviously very
important to  cure the malformation  as
soon as possible.  But as this  object can-
not be accomplished without an  opera-
tion, attended with some  degree of pain,
several  practitioners,  as Dionis, Garen-
geot, and others, have advised waiting
till  the child is four or five years old, on
the supposition,  that, at an earlier age,
the  child's  agitations  and cries  would
render the operation impracticable,  or de-
range all the proceedings taken to ensure
its success.  It is plain, however, that such
reasons are not exceedingly weighty.  A
child four or five  years old,  and, very
often, even one eight or ten  years of age,
is more difficult to manage, in this cir-
cumstance,  than an infant only  a few
months old.  There is no child, though
advanced to that age, which  has  not a
thousand  times more dread of the pain
than of the deformity, or of the inconveni-
ences of the complaint, to which  he  is
habituated; while an infant of tender years
fears  nothing, and  only feels the pain  of
the moment.
  A more rational objection is the liability
of infants to convulsions after operations,
and this has induced many excellent sur-
geons of the present day to advise post-
poning the  cure of the hare-lip, till the
child is about  two years old.  Perhaps
this apprehension, however,  does not vin-
dicate the delay.
  Mr. Sharp observes, " there are  many-
lips, where the loss of  substance  is so
great, that \ht edgss of tl./ fisstvre cannot 
4
HARELIP
be brought  together, or, at best,  where
they can but just touch ; in which case it
need not be advised to  forbear the  at-
tempt ; it is likewise forbid in young chil-
dren, and with reason, if they  suck ; but
otherwise it may be undertaken with great
safety, and even with more probability  of
-success  than  in others that are older."
(Operations in Surgery, chap. 34 )
  Le Dran has performed  the operation
on children of all ages, even on those  at
the breast.  B. Bell did it with success on
an  infant only three months old.   Muys
advises it to be undertaken as soon as the
child is six months old.  Roonhuysen ope-
rated on children ten weeks  after their
birth, and  all his contemporaries have
praised his singular dexterity and success.
This latter surgeon advises, as a step- es-
sential to the success of the operation, to
hinder  chddren from sleeping a certain
time before undertaking it, in  order that
they may fall  asleep immediately  after-
wards.   Opiates have also  been recom-
mended to ensure this occurrence.  M.
Louis is of opinion, that  the operation
done without any suture will succeed bet-
ter  on  infants,  than any  other method.
This subject, however, we shall treat of in
due time.
   All practitioners entertain the same sen-
timent  with regard to the  object of this
operation, which consists in reducing  the
preternatural solution of continuity to the
State of a simple wound, b) cutting off the
edges of the  separated parts throughout
their lcng'h,and then approximating these
parts, so as to make them continue in con-
tact until they have completely grown to-
gether.   But although such principles are
admitted by all surgeons, all are not of the
same opinion with respect to ihe method,
 which  it is best to follow in practice;
 some having recourse to sutures to keep
 the edges of the wound in contact; others
 disapproving of the plan, and believing
 that a perfect cure may always be  accom-
 plished by  means of adhesive plaster and
 a uniting bandage, so as to save the pa-
 tient a great deal of pain,  which sutures
 always occasion.
   M. Louis has been the  chief advocate
 for this method, which proscribes sutures,
 and he has pubhshed on this subject  two
 very interesting memoirs,  which we shall
 presently quote, for the purpose of inform-
 ing the reader of the reasons, on which
 this celebrated man founded his  opinion
 on this matter, and of the means which
 he employed.
   M. Louis thought that the  use  of su-
 tures,  in the  operation for the hare-lip,
 originated from a  false idea which  pre-
 vailed, respecting the na.ure of the dis-
 ease.  The fissure hi the lip having been
imprudently imputed to the loss  of sub-
stance, it was thought impossible to keep
the parts in contact, except by a suture.
  " The separation of the edges of the
fissure in the lip is only the effect of the
retraction  of the muscles, and  is always
proportioned to the extent of the cleft.
Those who have hare-lips  are capable  tj!
biinging the edges of the fissure together
by muscular action, when they pucker up
their  mouths.   On the other  hand, the
separation is considerably increased wheft
such persons laugh, and  the breach ap-
pears excessively large, after superficially
paring off its edges on both sides. Hence,
the interspace  in the hare-lip  must not
be mistaken for a loss of substance. The
truth of this is confirmed by the effects of
sticking plaster, which  has sometimes
been applied to the hare-lip, as  a prepa-
ratory  measure before the operation, and
which exceedingly lessens the separation
of the parts.
  " According to  the  confession  of  all
who have written in favour of the twisted
suture, it  seems  advisable only  on the
false idea, that the hare-lip is the  effect of
a greater or lesser loss of  substance; and
they say, positively, that we must not have
recourse to it when there is only a simple
division to be  united.  The  twisted su-
ture must then be proscribed  from the
operation  for the  natural hare-lip, since
it is proved that this malformation is un-
attended with  a loss of substance.  But
the loss of substance is but too real, after
the extirpation of scirrhous and cancerous
tumours, to which the lips are  very sub-
ject.  Yet, even in these  very cases, the
extensibility of the lips allows an attempt
to be made to  reunite the double incision,
by which  the tumour has been removed,
and it succeeds without the smallest de-
formity, when care has been taken to  di-
rect each incision obliquely, so that both
of them form, where they meet, an acute
angle, in the base of which the tumour is
comprised. It is on this occasion, that  the
means to procure an union ought to be  the
more efficacious, because the difficulty of
keeping the edges of the wound approxi-
mated is greater.   M. Pibrac has already
shewn, in his  memoir on the abuse of su.
tures, when speaking of the hare-lip, that
they are badly conceived means, and more
hurtful in proportion to the greater loss of
 substance, because the greater the inter-
 space is between the two parts, the more
fear is there of their efforts on the needles
or pins left in  the wound.  Hence, care
 has always been taken to make the dress-
 ings aid the operation of the suture. After
 this  consideration, judiciously  made by
 the partisans  of this plan, there was only
 one more step to be taken,  according to> 
HARE-LIP.
5
M. Pibrac, in order to evince the necessity
of proscribing it. The cap, or copper head-
piece, described by Verduc and Nuck, for
compressing  the cheeks;  the  clasps  of
Heister;  the strips  of adhesive  plaster,
which no author has  neglected expressly
to recommend; all this has been invented
in order to support  the parts, and keep
them from being disunited. When the su-
ture  failed, it was by these means, that
the original deformity was  corrected, to-
gether with that produced by the lacera-
tion, which would not have occurred with-
out the suture.   As, then, the dressings,
when methodically applied, are capable of
effectually rectifying the mischief of the
suture, why  should they be  considered
only  as a resource in a mere accidental
case  ?  Why should they not be made the
chief and primary means of reuniting the
lips,  even when there is aloss of substance ?
  "Nothing can be opposed to the proofs
adduced upon this point.  They are even
drawn from  the practice of those,  who
have employed sutures without  success.
Such persons themselves have furnished
the arguments in favour of the bandage
being capable  of  repairing the mischief
resulting from the twisted suture.  Prac-
titioners  can only be vindicated in em-
ploying this suture by confessing, that the
true principles  of  the art have not been
established concerning this subject."
   M Louis, with a view of perfecting our
notions on this matter, lays it down as a
fact, that, the  retraction of the  muscles
being the cause of the separation of the
edges  of the fissure,  it is not to those
edges  we are to apply the force which is
to unite them;  but that it- should be ap-
plied further to the very parts, whose ac-
tion  (the cause of the separation) is to be
impeded, and whose contraction is thus to
be prevented.  A  great many  means for
supporting the wound, only irritate  the
muscles and  excite them to action, and it
is this action which we should endeavour
to overcome.  The means for promoting a
union can only be methodical, when di-
rectly employed to prevent such action, by
an immediate  application on  the  point
where it is to be resisted.  The  facility,
with which the parts may be brought for-
ward, so as to bring the two commissures
of the lips into contact, by the mere pres-
sure of the  hands,  shews what  may  be
expected from a very  simple apparatus,
which will execute the same office without
any  efldrts, in a firm and permanent man-
ner,  and which will render sutures, unne-
cessary, the  inconveniences of which are
too  well known.
   M. Louis, after having explained the
reasons of the theory, on which he found-
ed his method, relates several cases, taken
either from his own practice, or that  of
others, to illustrate its advantages.   He
details the history of twenty cases,  in
which his plan perfectly succeeded, both
in accidental  hare-lips, with considerable
loss of substance, and in natural ones.  In
most of these instances, however,  it was
thought proper to assist the bandage with.
one stitch at the extremity of the fissure,
close to the vermilion border of the lip,
for the purpose of keeping the parts se-
curely on a level.
  Notwithstanding  the operation as  per-
formed with the twisted suture, is opposed
by an authority of ..such weight as that of
M. Louis, still it is the one most common-
ly practised. Few practitioners doubt that
a hare-lip may be cured by means of ad-
hesive plaster, and uniting bandages, quite
as perfectly as by a suture; and all readily
allow, that the first of these methods,  as
being more simple and less painful, would
be preferable to the latter one, if it were
equally sure of succeeding.  But it is con-
sidered far more uncertain in its effect.
To accomplish a complete cure, the parts
to be united must be maintained in  per-
fect contact, until  they  have contracted
the necessary adhesion ; and how can we
always depend upon a bandage keeping
them from being displaced ?  What other
means, besides a suture, affords in  this
respect such perfect security ?
   We shall not take upon us to  decide
which of these two  methods  is the best,
contenting ourselves with explaining the
mode of proceeding in both,  and leaving
it for surgeons to determine, by their own
experience, and  the  evidence of facts,
which one merits the difference.  First, of
the ancient plan.
   Having placed the patient  in a  conve-
nient situation,  the first thing is to ex-
amine whether there is any adhesion of the
lip to the gum ; and, if there be one,  to
divide it with  a knife.   Some  authors
{Sharp) recommend always dividing the
frenulum, which attaches  the lip to the
gum ; but,  when  the  hare-lip is at some
distance from this part, and will not be in
the way in the operation, there is no need
of dividing it; but, when the frenulum is
situated in the centre of the division, it is
clear that, in operating,  we  must neces-
sarily  include  it in  the incision, and it
must be divided before-hand, taking  care
not to encroach too much upon the gum,
lest the alveolary process should be laid
bare; nor too much upon the Up,  because
making it thinner would  be unfavourable
to its union.
   Sometimes one of the incisor teeth be-
ing  opposite the fissure, and projecting 
6                                  HARE-LfP.
  forward, must be drawn, Us  it should
  distend and irritate the parts, after they
  have been brought into contact.
    Sometimes also, but particularly in Cases
  in which there is a cleft in the bony part
  of the palate, a portion of the os maxillare
  superius forms such a projection, just in
  the situation of the fissure in the lip, that
  it would render the union very difficult, if
  not  impracticable.   In this circumstance,
  the  only plan is to cut off" the projecting
  angles of bone,  which may easily be done
  with a strong pair of bone-nippers.
    In the operation, the grand object is to
  make the wound as smooth and even a cut
  as possible, in order that it may more cer-
  tainly unite by the  first intention, and of
  such a shape, that  the cicatrix may form
  only one narrow line. The edges of the
  fissure should, therefore, never be cut oft'
  with scissars,  which always  bruise  the
  fibres which they divide, and a sharp knife
  is always to be preferred.  The best plan
i  is, either to place any flat instrument, such
  as a spatula, underneath one pirtion of
  the lip, and then holding the part stretch-
  ed and supported on it,  to cut away the
  whole of the callous edge;  or else to nold
 the part with a pair of forceps, the  under
 blade of which is much  broader than  the
 upper one: the first serves  to support the
 lip ; the other contributes also to this ef-
 feet, and, at the same time, serves as a
 sort of ruler in guiding'the  knife in an ac-
 curately straight line.  When the forceps
 are preferred, the surgeon must of course
 leave on the side of the upper blade, just
 as much of the edge of the  fissure as is to
 be removed, so that it can b cut off with
 one sweep  of the  knife.   Ti is  is to be
 done on each side of the  clefi,  observing
 the rule, to make the new wound in straight
 lines, because tne sides of it can never be
 made to correspond without
 this caution.  For instance, if
 the hare-lip had this shape, the
 incision  ef the edges must be
 continued in straight lines,  till they meet
 in the manner here represented.
 In short, tlie two incisions are
 to  be perfectly straight,  and
 are to meet at an angle above,
 in order that the whole track of the wound
 may be brought together, and united  by
 the first intention.
   Two silver pins, made with steel points
 are next to be introduced through the
 edges of the wound, so as  to keep them
 accurately in contact.  A piece of thread
 is thai to be repeatedly wound  round th^
 ends of the  pins,  from one side of the di-
 vision to the other, first transversely, then
 obliquely, from the right or left end of one
 p.n above, to the opposite end of the lower
one, &c.  Thus the thread is  made to cross
as many points of the wound as possipV
  which greatly  contributes to maintaining:
  its edges in even apposition.  It is obvious,
  that a great deal of exactness is requisite
  in introducing  the pins, in order that the
  edges of the incision may afterwards be
  precisely applied to each other.   For this
  purpose, some previously place the tides
  of the wound  in  the  best position, and
  mark with a pen  the points at which the
  pins  should  enter, and come out again.
  The  pins  ought never to extend  more
  deeply than about two-thirds through the
  substance  of the lip, and it would be a
  great improvement always to have them
  constructed a little curved, as this is  the
  course which they naturally ought to take
  when introduced.  The steel points should
  also admit of being easily taken off, when
  the pins have been applied; and, perhaps,
  having them to screw of! and on  is l\\e
  best  mode, as removing them in this way
  is not so likely to be attended with any
  sudden jerk, which might be injurious to
  the wound, as if they were made to pull off.
  The pins may commonly be safely removed
  in about four days, after which the support
  ofsticking-plasier will be quite sufficient.
   The process  we have just been describ-
 ing,  is what is well known by the name of
  the twisted suture.
   it is worthy of attention, that this suture
 is applicable  to other  surgical cases, in
 wh.ch the grand object is to heal some fis-
 tula or opening, by the first intention.  Mr.
 Sharp says, iii» of great service in fistula of
 the urethra, remaining after the operation
 for the stone,  in which c.se the callous
 edges may be cut off; and the lips  of the
 wound h<-ld together by the above method.
   What has hitherto been stated, refers to
 the most s:mple form of the hare-lip, viz.
 to that wh.ch  presents  only  one fissure!
 When there are two clefts, the cure is ac-
 complished on the same principles ; bui, it
 is more difficult of execution  ; indeed  so
 much so,  that the old surgeons, until the
 time of Heistei, have almost all regarded
 the operation for the double  hare-lip  as
 impracticable, though they have described
 it, directing us to operate on each fissure,
just as if there were onlv one.  M  de la
 Faye, however,  performed this operation
 with success, as may be learnt in'the Me-
 moires de I Acad, de Chirurgie, Tom  4. 4to
 But, we are indebted to M.  Louis for hav-
 ing obviated all the difficulties, by simply-
 proposing to do the  operation at two times
 and to await the perfect cure of one of the
 fissures,  before  undertaking  that of the
other.  Heister seems to have  conceived ■,
R milar idea, about  the same time, but lie
never  put  it in practice,  nor did he even
positively  advise it.
  In cutting off the edges of the fissure,
the incisions must be carried to the upper
part of the lip; and even when the fissure 
HARE-LIP.
?
does not reach wholly up the lip, the same
thing should be done ; for, in this manner,
the sides of the wound will admit of being
applied together more uniformly, and the
cicrti ix will have a better appearance. We
should also not be too sparing of the edges
which are to be cut off. Practitioners, says
M Louis, persuaded that the hare-lip was
a division with loss of substance, have in-
variably advised the removal of the callous
edges. But, in the natural hare-lip there is
no callosity; the margins of the fissure are
composed, like those of the lip itself,  of a
pulpy, fresh-coloured, vermilion flesh, co-
vered with  an exceedingly delicate  cu-
ticle.  The  whole of the pari having this
appearance, must be taken  away, even
encroaching a little way  on the true skin.
At the  lower part of the fissure, towards
the  nearest commissure, a rounded  red
substance is commonly situated, which  it
is absolutely necessary  to include .n  the
incision.  Were this neglected, the union
below would be unequal, and, through an
injudicious  economy, a degree of deform-
ity would remain, which  is  always  un-
pleasant,  when it  can be avoided.  The
grand object, however, is to make the two
incisions diverge at  an  acute angle,  so
that the edges may be put into reciprocal
contact their  whole length,  without the
least inequality.
   M. Louis used  to  operate  as follows :
the patient  being seated in a  good light,
-his head is to be supported on an assist-
ant's breast, who, with the fingers of both
hands,  pushes the cheeks forward, in or-
der to bring the edges of the fissure near
to each other.   These are to be laid on a
piece of pasteboard, which is to be put
between the jaw and lip, and be an  inch
and a  half long,  from twelve to fifteen
lines broad, and at most one line thick.
The  upper end should be rounded, by-
flattening the corners.  To facilitate the
 incision, the lip is to be stretched  over
 the pasteboard, the operator  holding one
 portion over the right with the thumb and
 index finger of the left hand, while the
 assistant does the same thing on the left
 side.  Things being thus disposod, the
 edges  of the hare-lip are to be cut off
 with two sweeps of the bistoury, in two
 oblique lines,  forming an  acute angle
 above the fissure.
   For. a long while  scissars were prefer-
 red to  a knife, for cutting off the edges of
 the hare-lip;  but,  they are now very ge-
 nerally  disused for this purpose.   The
 pinching and bruising,  which result from
 the action of the two blades, in overlap-
 ping each other, are deemed obstacles to
 the union of the sides of the  wound; for,
 the  bruised  fibres must necessarily sup-
 purate-,  and, slignt as this  may be, the
cure is at least retarded by it.  Let not
practitioners be led by Mr. B. Bell's stat-
ing,  that in one instance he  cut off" one
side  of the fissure with a knife, and the
other with scissars;  that the latter cut
produced least pain, and that on this side
there was no  more swelling nor inflam-
mation than on the opposite one.
  The pins should be introduced  at least
two-thirds of the  way through the  sub-
stance of the  lip, lest a furrow should re-
main on the  inside of the part,  which
might  prove  troublesome,  by allowing
pieces of food to lodge in it.  There  is,
however, a stronger reason for attending
to this circumstance, viz. the hemorrhage
which may take place when it is neglect-
ed.  The bleeding almost always ceases,
as soon as the edges of the  wound have
been brought together by means of the
suture,  when  the  pins  are  properly
placed; but, when they have not been in-
troduced deeply enough,  the posterior
surfaces of the incisions not been applied
to each other, the blood may continue to
run into the mouth, and give the surgeon
an immense  deal of trouble.  In  the me-
moir written  by Louis,  there is a history
of a case, in which  the patient  died in
consequence  of such an accident.  Persons
who  had undergone  the operation^ were
always advised  to  swallow their spittle,
even though  mixed with blood, in order
to avoid disturbing the wound, by getting
rid of it otherwise.  In the case  alluded
to, the patient, who had been operated
upon  for a cancer which he had in the
lip,  swallowed the blood as he had  been
directed to do, and  he bled so profusely
that he died.  On the examination of the
body, the stomach, and  small intestines
were  found  full  of  blood.   •« This de-
plorable case,"  says the illustrious author
who relates  it,  "deserves to be recorded
for pubic  instruction, for the purpose of
keeping alive the attention of surgeons
on all occasions,  where, in  consequence
of any operation whatsoever, there is rea-
son to fear any bleeding in the cavity of
the  mouth.   Platner is the only  writer,
 who,  as far as 1 know, foresaw this k.nd
 of danger.  The bleeding from the edges
of the wound stops of itself, (says he) as
 soon as they have been brought into con-
 tact,  and  stitched together; but, care
 must be taken that  the patient does  not
 swallow the blood,  which  might make
 him vomit, or else suffocate him.   Hence,
 his  head  should be  elevated, that  the
 blood may escape externally, a precaution
 more particularly necessary in regard to
 voung children."
 '  Having described the mode of operat-
 ing for the hare-lip, as approved of by the
 generalitv of practitioners,  and  detailed 
8                               HARELIP
 every thing which seemed material, we
 have  now  only to describe the method
 which M, Louis adopted.  His sentiments
 respecting several particular points of the
 operation, have been already stated ; and
 an account of the means which he em-
 ployed,  in lieu of the twisted suture, for
 uniting  the edges of the wound, is all
 that we  have to offer farther on the pre-
 sent subject.
   Different authors, as already mention-
 ed, have devised bandages for supporting
 the two  portions of the divided lip, and
 lessening the pressure which they make
 against  the pins designed  for  uniting
 them.  Franco  and Quesnay,  in parti-
 cular, have described two  kinds, which
 .have been considered very well calculated
 for this object; and these means were not
 only  employed as auxiliary,  but even
 sometimes as curative ones, when it was
 impossible to use needles. To such band-
 ages, too complicated and too uncertain,
 in their effect, M. Louis prefers a simple
 linen roller, one  inch wide, three  ells
 long,  and  rolled up into  two unequal
 heads.  He begins with applying the body
 of tli is bandage to the middle of the fore-
 head ; he unrolls the two heads, from be-
 fore backward, tbove  the  ears  between
 the upper part of the cartilage, and the
 cranium, in order to make them cross on
 the nape of the neck, and then be carried
 forward  again.   The assistant,  who sup-
 ports the head, and pushes forward the
 cheeks, must lift up the ends of his fin-
 gers, in the  place of which, on each side,
 a thick compress is to be put.   This be-
 ing covered,  and pushed  from behind
 forward, by the roller,  will constantly
 perform  the office of the assistant's fin-
 ge. .,  who is to continue to support the
 apparatus,  until it is all completely ap-
 plrd.  The longest of the  two  heads of
 the n Her, being slit in two places near
 the lip, presents  two parallel openings;
 the remnant of the shortest one is divided
 into two parts, as far as  its end.  The
 two little narrow bands, in which  it ter-
 minates,  must be  passed  through  the
 openings of the former, and made to cross
 upon the middle of the lip.   The ends of
 the roller, being carried from before back-
 ward, are then  to be made to cross again
 on the nape of the neck, where the short-
 est is to end.  The remainder of  the long
 one is  to be employed in m king  turns
 round  the head.  This bandage may be
 rendered much more stable, bv a piece of
 tape, wh.ch  is to pass the forehead, over
 the sagittal suture, and be pinned at each
 end to  the circumvolutions of the roller;
while a second piece of tape is to cross
tne hrstone at the top of the head, and
 also to be attached, at its extremities, t6
 the uniting bandage, and the compresses,
 placed under the  zygomatic  arches,  for
 the purpose of pushing  forward  the
 cheeks.
   This bandage is extremely simple, and
 would promise  great  advantages, even if
 its success  had not been already proved
 by the cures which it  has effected  under
 the hands of its inventor, and several other
 surgeons, who have employed it, in con-
 sequence of his recommendation.  Per-
 haps, if it has not been equally successful
 With others, this is rather owing to  the
 defective manner of applying,  than to any
 fault in the plan itself.  However it may
 be, it is much to be wished that this means
 were  sufficiently certain in  its effect, to
 become more generally adopted, so that
 the suture might be relinquished.
   All  that we have said concerning  the
 operation for the hare-lip, is  equ lly appli-
 cable, not only to the treatment of cancer
 of the lip, but  also to that of accidental
 cuts,  or lacerations, of this part, from any
 cause whatsoever.  We shall only remark
 that,  in  a recent wound, all  the duty of
 the surgeon is to have recourse  immedi-
 ately, either to the twisted suture,  or the
 uniting bandage.
   In  cases,  in Which the  fissure affects
 the bones forming the roof of the mouth,
 after  the soft parts have been united in
 the manner above related, the bones, and
 other separated parts, are ordinarily ob-
 served to become approximated, and na-
 ture thus corrects, more or less, this kind
 of deformity.   But  this  does  not always
 happen, and when  these parts remain so
 considerably separated,  as to obstruct
 speech and deglutition, or cause any other
 inconvenience, a plate of gold or  silver,
 exactly adapted  to the arch of the palate,
 and steadied  by  means of a  piece  of
 sponge, fixed to its convex side, and in-
 troduced into the cleft, may sometimes
 be usefully employed.  When  the sponge
 is of  suitable size,  and  very dry, before
 being  used,  it  will be  swelled by  the
 moisture of the adjacent  parts,  which
 alone  will be sufficient, in many cases, to
 keep  it in its situation,  so  as  greatly to
 facilitate speaking and swallowing.  Some-
 times,  however, the fissure  is so shaped,
 that the  sponge cannot  be  fixed  in it:
 this principdly  happens  when the open-
 ing widens very much, as it approaches
externally.   In such  cases  it  has been
proposed to  fix a plate of gold, by means
of  springs,  made  of the  same metal,
so  constructed  as  to  fit  the  cavity;
but, no contrivance seems  yet to have
answered.
  On the subject of the hare-lip, consult 
HEAD.
8
 JS. Bell's Surgery, Vol. 4- /leister*s Surgery.
 Le Dran's Operations; Sharp's Operations;
 Latta's Surgery,  Vol. 2 ;  L' Encyclop6die
 Mitliodique,  Purtie  Chirurgicale,  Art.
 Bee. de Lievre.   The Observations of M.
 Louis,  in M6m. de  CAcad. de  Chirurgie,
 Tom. 4. in Ato. De la Medecine Opiratoire,
 par Sabatier, Tom.  3.  (Euvres. Chirurgi-
 cales  de  Desault,  par  Bichat, Tom.  2.
 Traits des Operations de Chirurgie, par A.
 Bertrandi,  Chap.  19.  Richter's  Anfangs-
 grunde der   IVandarzneykunst,  Bund 2.
 Kap. 7. Richerand's JYosographie Chirur-
 gicale,  Tom. 3. p. 245, &c.  Edit. 2.   Las-
 sus, Pathologie  Chirurgicale, Tom.  2, p.
 451, &c. Edit. 2.

          HEAD,  injuries or.

   Mr.  Pott: remarks, that, though  the
 scalp be called the common tegument of
 the head, yet, from the variety of parts of
 which it  is composed, from their  struc-
 ture, connexions, and uses, injuries done
 to it by external violence, become of much
 more consequence, than the same kind of
 ills can prove, when  inflicted on  the com-
 mon teguments of the rest of the body;
   Passing over incised wounds, which
 have no particularity, Mr.  Pott  proceeds
 immediately to those which, (though the
 mischief  is  originally confined to  the
 mere scalp)  yet are frequently veiy ter-
 rible  to behold, are often attended with
 alarming symptoms, and sometimes with
 danger. Lacerated and punctured wounds,
 are those referred to.  " The former may
 be reduced to two kinds, viz.  those in
 wliich  the scalp,  though  torn, or  une-
 qually divided, still  keeps  its natural si-
 tuation, and  is not  stript  nor separated
 from  the  cranium,  to any  considerable
 distance beyond the breadth of the wound;
 and  those, in  which  it is considerably
 detached  from the parts it ought  to
 cover.
  " The first of these, if simple, and not
 combined with the symptoms, or appear-
 ances of any  other mischief, do not re-
 quire any particular or  different  treat-
 ment, from what the  same kind of wounds
 require  on all other parts ;  but the latter,
 (those in  which the scalp  is separated
 and detached from the parts it ought to
 cover) are not only, by the different me-
thods in which they may be treated,  fre-
quently capable of  being  cured with a
considerable deal more or  less ease and
expedition,  but  are  also sometimes a
matter of great consequence to the health
and well-being of the patient."
  Mr. Pott makes no scruple of declaring
it as his opinion, that the preservation of
rlie scalp ought alwavs to  be attempted.
    Vol.  II.
 unless it be so torn as to be absolutely spoiled,
 or there are manifest present symptoms of
 ot/ier  mischief.  This  kind of wound is
 sometimes very terrible to  look  at, and
 they who have not been accustomed to
 see it, may be inclined to think there is
 no remedy but excision; but, Mr. Pott
 says, he has so often made the experiment
 of  endeavouring to  preserve the torn
 piece, and so often succeeded, that he
 would recommend it as a thing always to
 be attempted, even though a part of  the
 cranium should be perfectly bare.  The
 removal of it necessarily produces a larger
 sore, which must require a good deal  of
 time to heal, and must leave considerable
 deformity: the preservation of it prevents
 both.
   Here we may remark, that all practi-
 tioners now invariably avoid cutting away
 the scalp, even in the circumstances,  in
 which such practice was allowed by Pott.
 By spoiled this eminent writer must mean
 so injured  as necessarily to slough after-
 wards.   However, as  no  harm  results
 from taking the chance of its not slough-
 irisr^ which never can be with certainly
 foretold; and as the excision of the part
 is painful, and productive of no benefit,
 even if sloughing  must follow, such ope-
 ration is,  in every point of view, quite
 wrong.  With respect to other mischief,
 as a reason, the examination of the cia-
 nium, and  even trephining, never require
 any of the scalp to be cut away.  See
 Trephine.
   Let the surgeon,  therefore, always
 make the  torn piece clean from all dirt,
 or foreign  b'odies, and restore it as quick-
 ly, and as perfectly as he can, to its na-
 tural situation.
   Notwithstanding Mr.  Pott assents  to
 the employment of sutures, for uniting
 certain lacerated wounds of the scalp, we
 may state,  that the best practitioners  of
 the present  day only employ sticking-
 plaster.  Sometimes, the loosened scalp
 will unite  with  the parts from which it
 was torn and separated,  and there will
 be no other sore than what arises from the
 impracticability  of bringing  the lips  of
 the wound  into smooth and immediate
 contact, the scar of which sore must be
 small  in proportion.   Sometimes  such
 perfect re-union is not to be obtained; in
 which  case, matter will be  formed and
 collected in those places where the parts
 do not coalesce: but this does not neces-
sarily make any difference, either in the
general intention,  or in  the  event; this
matter may easily be discharged, by one
or two small openings made with a lan-
cet; the  head will still  preserve its na-
tural  covering;  and  the  cure will  be
    B 
10
HEAD.
 very little retarded  by a few small ab-
 scesses.
   In some cases (as Pott proceeds to de-
 scribe,) the  whole  separate piece will
 unite perfectly, and give little or no trou-
 ble, especially in young and healthy per-
 sons.   In some, the union will take place
 in some parts and not  in  others ;  and,
 consequently, matter will be formed, and
 require to be discharged, perhaps at se-
 veral different points; and, in some par-
 ticular cases, circumstances, and  habits,
 there will be no union  at all,  the  torn
 cellular membrane, or the naked aponeu-
 rosis, will inflame, and become sloughy, a
 considerable quantity of matter will be
 collected, and, perhaps, the cranium will
 be denuded.  But, even in this state of
 things, which does not  very often  hap-
 pen, where care has  been taken,  and is
 almost  the worst which can happen, in
 the  case of  mere simple laceration and
 detachment,  if  the surgeon will not be
 too soon, nor too much alarmed, nor in a
 hurry to cut, he will  often find  the cure
 much more feasible than he may at  first
 imagine:  let him take care to keep the
 inflammation under by proper means, let
 him have patience till the matter is fairly
 and fully formed, and  the sloughs  per-
 fectly separated, and when this is accom-
 plished, let him make a proper number
 of dependent openings for the discharge
 of them,  and   let  him  by  bandage,
 and other proper management, keep the
 parts in constant contact with each other,
 and  he will often find, that although he
 was foiled in his first intention  of pro-
 curing  immediate union, yet he will fre-
 quently succeld in this his  second; he
 w.ll still save the scalp, shorten the cure,
 and prevent the great deformity arising,
 (particularly to women) not only from
 the scar, but from the total loss of hair.
   This  union may of:en be procured,
 even though the cranium should have been
 perfectly denuded by  the accident; and,
 it is true, not only though it should have
 been stripped of its pericranium at first,
 but even if that pericranium should have
 become sloughy and cast off,  as Mr. Pott
 has often seen.
   " Exfoliation from a cranium laid bare
 by exrernal  violence, and to which no
 other injury has  been done, than merely
 stripping it of its covering, is a  circum-
 stance (says  Pott)  which would not so
 often happen, if it was not  taken  for
 granted that  it  must be, and the  bone
 treated  according to  such  expectation
 The  soft open texture of the bones of
ttiildren and  young  people, will  fre.
quently furnish  an  incarnation, which
 will cover their surface, and render exfo-
 liation quite unnecessary;  and even  in
 those of mature age, and in whom the
 bones are still harder, exfoliation  is full
 as often the effect of art as the intention
 of nature,  and produced by a method of
 dressing, calculated to accomplish such
 end, under a supposition of its being ne-
 cessary.  Sometimes, indeed, it happens
 that a small scale  will necessarily sepa-
 rate, and  the sore  cannot,  be perfectly
 healed till such separation has been made;
 but this  kind of exfoliation will be very
 small  and   thin, in proportion to that
 produced by art, that is, that produced by
 dressing the surface of the bare  bone with
 spirituous  tinctures, &c.  and when a
 wound on the head, with a sound unin-
 jured bone, denuded by accident,  shews
 a disposition to heal without /exfoliation,
 it  never can be right to covLnteract na-
 ture, and oblige her to do what  she  is
 not inclined to, and which she would ac-
 complish her purpose better without do-
 ing.
   " Small  wounds, that is,  such as are
 made by instruments,  or bodies  which
 pierce, or puncture, rather than cut^are
 in  general  more  apt to become  inflamed,
 and to  give trouble, than those which are
 larger,  and in this part particularly, are
 sometimes  attended  with so high inflam-
 mation, and with such symptoms as alarm
 both patient and surgeon."
   The  parts  capable of being hurt by
 such kind of wound, are the skin, the cel-
 lular membrane,  the expanded tendons
 of the muscles of the scalp, and the peri-
 cranium.
   " If  the  wound  affects the cellular
 membrane only, and has not reached the
 aponeurosis or pericranium, the inflam-
 mation  and  tumour affect the whole head
 and face,  the skin of which wears  a yel-
 lowish  cast, and is  sometimes thick set
 with  small  blisters, containing  the same
 coloured  serum;  it receives the impres-
 sion of  the fingers, and becomes pale for
 a moment, but returns immediately to its
 inflamed colour ;  it  is not very painful
 to the  touch, and the eye-lids  and ears
 are always comprehended in the  tumefac-
 tion,  the former of which are sometimes
 so distended, as to be closed; a feverish
 heat and  thirst generally accompany it;
 the patient is restless, has a quick pulse,
 and most commonly a nausea, and inclina-
tion to vomit.
  " Tliis accident generally  happens te
persons  of bilious habit,  and is indeed an
inflammation of the erysipelatous kind;
it is somewhat alarming to look at, but is
not often attended  with danger.   The
wound does  indeed neither look well, nor
yield a kindly discharge, while the  fever 
HEAD                                  11
contuses,  but still it has nothing threat-
ening in its appearance, none of that look
which bespeaks  internal mischief;  the
scalp continues  to adhere firmly to the
skull, and  the patient does not complain
of that tensive pain, nor is afflicted with
that fatiguing restlessness  which gene-
rally  attends  mischief  underneath  the
cranium.
  " Phlebotomy, lenient  purges, and the
use of the  common febrifuge  medicines,
particularly those of the  neutral kind,
generally remove it in a short time. When
the inflammation is gone  off, it leaves on
the skin a yellowish tint,  and a dry scurf,
which continues  until perspiration carries
them away, and upon the  disappearance
of the disease, the wound immediately
recovers a healthy aspect, and soon heals
without any farther trouble.
  " Wounds and contusions of the head,
which affect the  brain  and  its  mem-
branes, are also  subject  to an erysipela-
tous kind of swelling and inflammation;
but it is very different,  both in its cha-
racter and consequences, from the pre-
ceding.
  «' In this, (which is one of the effects of
inflammation  of the meninges,)  the  fe-
brile  symptoms  are  much higher,  the
pulse harder  and  more frequent,  the
anxiety  and restlessness extremely  fa-
tiguing, the pain  in  the head intense;
and  as  this kind of appearance is,  in
these circumstances, most frequently the
immediate precursor  of  matter forming
between the skull and dura mater, it  is
generally attended with  irregular shiver-
ings,  which are not followed by a critical
sweat, nor  afford any relief to the pa-
tient.  To-which  it maybe added, that
in the former case the  erysipelas gene-
rally  appears  within  the  first three or
four days;  whereas in the latter, it sel-
dom cornes on till several days after the
accident, when the symptomatic fever is
got to some height.  Jn the simple erysi-
pelas, although the wound be  crude and
undigested, yet it has no otlier mark of
mischief; the pericranium adheres firmly
to the skull,  and upon  the cessation  of
the fever, all  appearances become imme-
diately favourable.  In that which accom-
panies injury  done to the parts under-
neath, the wound not only has a spongy,
glassy, unhealthy aspect, but the pericra-
nium  in   its  neighbourhood  separates
spontaneously from the  bone, and  quits
all cohesion with it.  In  short, one is an
accident, proceeding from a bilious habit,
and not indicating any  mischief beyond
itself; the other is a symptom, or a part
of a disease, which is occasioned by in-
jury done  to the membranes of the brain;
one portends little «r no  ill to the patient,
and almost always ends well; the other
implies great hazard, and most commonly
ends fatally.   It is therefore hardly ne-
cessary to say, that it behoves every prao
titioner to be careful in distinguishing
them from each other.
  " If the wound be a small one, and ha9
passed through the cellular membrane to
the aponeurosis, and pericranium, it is
sometimes attended with very disagree-
able, and even very alarming symptoms,
but which arise from  a  different  cause,
and  are  very  distinguishable from what
has been yet mentioned.
  " In  this, the inflamed scalp does not
rise into that degree of tumefaction, as in
the erysipelas, neither does it pit,  or re-
tain  the  impression of the fingers of aq
examiner ; it  is of a  deep red  colour,
unmixt with the yellow tint of the erysi-
pelas ;  it appears tense, and is extremely
painful to the touch; as it is not an affec-
tion of the cellular membrane, and as the
ears  and the eye-lids are not covered by
the parts in which the wound is inflicted,
they are seldom, if ever, comprehended
in the  tumour, though they may partake
of the  general inflammation of  the skin ;
it is generally attended with acute pain
in the  head, and  such a degree of fever
as prevents sleep,  and sometimes brings
on a delirium.
  "A  patient in  these  circumstances,
will admit more free evacuations by phle-
botomy, than one labouring under an ery-
sipelas ; the use of warm fomentation is
required in both,  in order  to  keep the
skin clean and perspirable, but an emol-
lient cataplasm, which is generally  for-
bid in  the former,  may in this latter case
be used to great advantage.
   "When  the symptoms  are  not very
pressing, nor the  habit very inflammable,
this  method will prove sufficient: but it
sometimes happens that the scalp is so
tense,  the pain so great, and the symp-
tomatic fever so high, that by waiting for
the slow effect of such means, the patient
runs a risk from the continuance of the
fever,  or else the injured aponeurosis and
pericranium becoming sloughy, produce
an abscess, and render the case both te-
dious and troublesome. A division of the
wounded part by a simple incision down
to the  bone, about half an inch or an inch
in length, will most commonly  remove
all the bad symptoms, and  if it be done
in time,  will render every thing else un-
necessary."  {Pott.)
   The injuries, to which the scalp is lia-
ble from contusion,  or the appearances
produced in  it by  such general cause,
may be divided into  those  in which, the
mischief is confined merely to the scalp; 
U                                 HEAD.
  and those  in  which other parts  are  in-
  terested.
    The former, which only comes under
  our present consideration, is not  indeed
  of  importance,  considered abstractedly.
  The tumour attending it is either very
  easily  dissipated, or  the extravasated
  blood causing it, is easily got nd off by a
  small  opening   Mr.  Pott  particularly
  notices this case, on account of an acci-
  dental  circumstance,  which sometimes
  attends it, and renders it liable to be very
  much mistaken.
    " When th? scdp receives a very smart
  blow, it often happens that a quantity  of
  extravasated blood immediately forms  a
  tumour, easily  distinguishable  from all
  others, and generally  very easily  cured.
  But it also sometimes happens, that this
  kind of tumour produces to the fingers of
  an unadvised  or inattentive  examiner,  a
  sensation, so  like to that of  a /racture,
  with depression of the cranium, as may
  be easily mistaken." Now, if, upon such
  supposition, a surgeon immediately makes
  an incision into the tumid scalp, he may
  give his patient  a  great deal of unneces.
  ;->ary pain, and for that reason run some
  risk of his own character.
    "The touch is, in this case, so liable
  to deception, that recourse should always
  be had to other circumstances and  symp-
  toms, before an opinion be given.
    " If a person, with such tumour occa-
 sioned by a blow, and attended with such
 appearances, and feel, has any  complaint,
 which seems to be the  effect of pressure
 made on the brain and nerves, or of any
 mischief done to the parts within the cra-
 nium, the division or removal of the scalp
 in  order to enquire into the  state of the
 skull, is right and necessary; but  if there
 are no such general symptoms, and the
 patient is in  every respect perfectly well,
 the mere feel of something like a fracture
 will not authorize or vindicate  such ope-
 ration, since  it will often  be found, that
 such sensation  is a deception, and that
 when the extravasated  fluid is removed,
 or  dissipated, the cranium  is perfectly
 sound and uninjured.
  "The second  kind of tumour attend-
 ing the  contused scalp, viz. that which
 arises from injury done to the cranium, and
 parts within,  does so absolutely proceed
 from and depend upon such injury, as not
 to  fall under our  consideration  in this
 place at all,  but will  be  considered at
 large when we come to speak of the mis-
 chiefs dtoe to the skull and brain by col-
lision, or contusion.
  " From what has been said it appears,
that the scalp,  taken in a general sense,
 is,  when wounded or bruised, liable to
 be  affected with  four kinds of-tumour,
  each of which has a distinct cause, and
  requires, or permits, a different method
  of treatment.
    " The first does not imply any  injury
  done to  the parts within the skull,  re-
  quires no operation, and almost always is
  cured by general remedies.
    " The second, or that which is  caused
  by the spontaneous separation of the peri-
  cranium from the skull,  in  consequence
  of internal mischief, is not at first attend-
  ed with  very pressing  symptoms;  but
  whoever has observed their progress, and
  attended to their event, must know  what
  fatal and frequently irresistible evil it  is
  the forerunner of, nothing less  than the
  inflammation  and  putrefaction  of  the
  membranes of the brain,  and the  forma-
  tion  of  matter between  them  and  the
  skull; and  that  is a case which,  of all
  others, will  hast admit delay.
    "  The third* though it sometimes gives
  way  to  free  evacuation,  and lenient ex-
  ternal applications,  yet  is sometimes also
  attended  with symptoms  which are too
  pressing to wait the effect of such  reme-
 dies, and is capable of being immediately
 relieved by a division of the inflamed and
 irritated parts:  whereas  the same  inci-
 sion, made into the first kind  of tumefac-
 tion, would most probably exasperate the
 disease, and heighten the symptoms.
   "The  fourth,   consisting  of  extrava-
 sated blood, seldom requires any chirurgie
 operation; time, and the use  of the com-
 mon  diseutient  applications, (of which
 the lotio salis ammoniaci is best,) almost
 always dissipate it; and it only becomes
 of consequence, by the possibility of its
 being misunderstood and  mistreated."__
 {Pott on Injuries oftlie Head)

 2.  Effects of Contusion  on the Dura Mater
       and Parts ivithin tlie Skull.
   Mr. Pott remarks, "tliat  in  order  to
 understand rightly, and  to have a  clear
 idea of, this  kind of injury, it  is neces-
 sary to recollect, that  the  vessels of the
 pericranium, those of the  diploe, or me-
 dullary substance between  the two  tables
 of some parts of the cranium, and those
 of the dura mater within  it, do  all con-
 stantly and freely communicate with each
 other; and that  this  communication  is
 carried on by  means of innumerable  fora-
 mina, found in all plrts of both surfaces
 of the skull,  as well as at the sutures •
 that upon the freedom of this communical
 tion depends  the healthy and sound  state
 of all the parts concerned in it; and that
 from  the  interruption or  destruction of
 this proceed  most  of  the  symptoms at-
 tending violent contusions of the  head
extravasations of fluid between  the era'
mum  and  dura mater,,, inflammations of 
HEAfl.                                U
 the  said  membrane,  and simple unde-
 pressed fracture of the skull.
   " The pericranium is so firmly attach-
 ed to the outer surface of the skull, as not
 to be separable from it  without consider-
 able violence; and  when such violent
 separation is made  in a living subject
 (especially if young,) the cranium is al-
 ways seen to bleed  freely, from an  infi-
 nite  number of small  foramina.   The
 dura mater, which is a firm strong mem-
 brane, is almost as intimately attached to
 the  inside of the skull,  as the pericra-
 nium is to the outside,  and  by the same
 means, viz.  by vessels;  and  by these
 means a constant circulation and commu-
 nication are  preserved and maintained
 between the two  membranes and  the
 bones dividing them.   This, all the  ap-
 pearances  which attend the, scalping a
 living person, or the separation of  the
 skull from the dura mater of a  dead  one,
 (especially if such person died apoplectic,
 or was hanged) prove beyond all doubt;
 in the former, the blood will be seen issu-
 ing from every point of the surface of the
 cranium ; in  the latter, not only a consi-
 derable degree  of force  will  be found
 necessary to detach the sawn bone from
 the subjacent membrane,  but when it is
 removed, a great number of bloody points
 will be seen  all over the  surface of the
 latter; which points, if wiped  clean, do
 immediately become bloody again, being
 only  the  extremities of broken vessels.
 These vessels are largest at, and about
 the sutures, at which places the adhesion
 is the strongest, and the hemorrhage upon
 separation the greatest.
   " It has been thought by many that the
 dura mater was  attached to the skull,
 only  at the  sutures ;  that in  all  other
 parts it was loose  and unconnected with
 it;  and that it  constantly  enjoyed or
 performed an, oscillatory kind of motion,
 and  was alternately  elevated  and  de-
 pressed.  This idea  and  opinion were
 borrowed from the appearance which the
 dura mater makes in a living subject after
 a portion of the skull has  been removed :
 but  although it has been inculcated by
 writers of great eminence, yet  it has no
 foundation  in  truth  or nature, and  has
 misled  many practitioners in their  opi-
 nions, not only of the structure and dis-
 position of this membrane,  but in their
 ideas of its diseases.
  " The dura mater does on the internal
surface of the bones  of the cranium, the
office of periosteum, in the same manner
as the pericranium does on the  external;
 (at least they have no other:) to this it is
so firmly, and so generally attached, as to
be incapable of any, even the smallest de-
gree of motion.  The alternate elevation
 and subsidence of it, which are observable
 when  any portion of it is laid bare, are
 owing to a very different cause from any
 power in itself; neither  is, nor can ever
 be performed,  until  a piece of the cra-
 nium has been forcibly taken away; and
 consequently cannot possibly be natural,
 Or necessary.
   "By  blows,  falls, and other shocks,
 some of the larger of those vessels which
 carry on this communication between the
 dura mater and the skull are broken, and
 a quantity of blood is shed upon the sur-
 face of that membrane.  This is one spe-
 cies of bloody extravasation, and indeed
 the  only one which  can be formed be-
 tween the skull and dura mater.  If the
 broken vessels be few, and the quantity
 of blood which is  shed  be small,  the
 symptoms are generally  slight, and by
 proper treatment disappear.  If they are
 large, or numerous, or the quantity of ex-
 travasated fluid considerable, the symp-
 toms are generally urgent in proportion ;
 but whether they be  slight, or consider-
 able, whether  immediately alarming or
 not, they are always, and uniformly,  such
 as indicate pressure  made on  the  brain
 and nerves,  viz. stupidity, drowsiness,
 diminution or loss of sense, speech, and
 voluntary motion.
   " This every practitioner knows to be
 one frequent consequence of blows on the
 head.  But it also  often happens,  from
 the same  kind  of violence, thaJs*ome of
 the small vessels, which carry onthe cir-
 culation  between the  pericranium, skull,
 and dura mater, are  so damaged, as not
 to be able properly to execute that office,
 although there are none so broken  as to
 cause an actual effusion of blood.
   " Smart and severe strokes on the mid-
 dle part of the bones at a distance  from
 the sutures, are most frequently  followed
 by this kind  of mischief; the  coats of
 the small vessels, which sustain the in-
jury, inflame and become sloughy, and, in
 consequence of  such  alteration in them,
 the pericranium separates from the  out-
 side of that part of the bone,  which re-
 ceived the blow, and the dura mater from
 the  inside, the latter of which  mem-
 branes, soon after such inflammation, be-
 comes sloughy also, and furnishes matter,
 which matter being collected between the
 said membrane  and  the  cranium,  and
 having  no natural  outlet,  whereby to
 escape, or be  discharged,  brings  on a
 train of very terrible symptoms, and is a
 very frequent cause of destruction.   The
 effect of this kind of violence is frequent- ,
 ly confined to the vessels connecting the
 dura mater to the cranium, in which case
 the matter is  external to the said mem-
 brane ; but it sometimes happens, that by 
14
HEAD.
  the force either of the stroke or of the
  concussion,  the vessels which pass be-
  tween and connect  the two meninges are
  injured  in  the  same manner; in which
  case, the matter formed in consequence
  of such  violence is  found on tlie surface
  of the brain, or between the pia and dura
  mater, as well  as on the surface of the
  latter ;  or perhaps in all these three situ-
  ations at the same time.
    " The difference of this kind of dis-
  ease, from  either  an  extravasation  of
  blood, or a commotion of the medullary
  parts of  the brain, is great and obvious.
  All the complaints produced by extrava-
  sation, are, such as proceed from pres-
  sure, made on the brain and nerves,  and
  obstruction to the circulation of tlie blood
  through  the former; stupidity,  loss  of
  sense  and  voluntary motion,  laborious
  and obstructed pulse and respiration, 8cc.
  and (which  is of importance to remark,)
  if the effiteion be at all considerable, these
  symptoms appear immediately, or very
  soon after tlie accident
   " The  symptoms attending an inflamed
  or sloughy state of the membranes,  in
  consequence of external  violence,  are
  very different; they  are all of the febrile
  kind, and never, at  first, imply any  un-
  natural pressure; such  are, pain in  the
  head, restlessness, want of sleep, frequent
  and hard pulse, hot and dry skin, flushed
  countenance, inflamed eyes ;  nausea, vo-
  miting, ^or ; and toward the end,  con-
  vulsion, ^bid  delirium.    And  none  of
 these appeal- at first,  that is, immediately
 after the  accident;  seldom  until some
 days are past.
   " One set  or class of symptoms  is pro-
 duced by an  extravasated  fluid, making
 such pressure on the brain and origin of
 the  nerves, so as to impair or abolish vo-
 luntary motion and the senses; the other is
 caused by the inflamed or putrid state of the
 membranes coveringthe brain, and seldom
 affects the organs of sense, until the latter
 endof tlie disease, that is, until a con,idera-
 ble quantity . f matter is formed, which
 matter must press like anv other fluid."
   Mr. Pott next refutes the generally re-
 ceived opinion, ^hat blood shed from its
 vessels, and  remaining confined  in one
 place, will become pus; and that the mat-
 ter found  on the  surface of the dura ma-
 ter,  towards the  end 'of these cases, was
 originally extravasated blood.  Both these
 positions are false. That pure blood shed
 from  its vessels,  by means of  external
 violence,  and kept from  the air, w ill not
.turn to, or become matter, is proved  in.
 contestably by every day's experience, in
 many instances, in  aneurisms  by punc-
 ture,  in retained  menses by imperforate
 vagina, and in all ecchymoses.   True pus
  cannot be made from blood merely,  as
  may be known from the  manner in which
  all abscesses are formed, and from every
  circumstance attending suppuration ; and
  that" the matter  found on the surface of
  tlie dura mater,  after great contusions of
  the head, never was mere blood, Mr. Pott
  is as certain, as  observation and  experi-
  ence can make him.
 .   " If there be neither fissure nor frac-
  ture of the skull, nor extravasation, nor
  commotion underneath  it, and the scalp
  be neither considerably  bruised,  nor
  wounded,  the mischief is seldom disco-
  vered  or attended to for some few days.
  The first attack is generally by pain in
  the part which received the blow.  This
  pain, though beginning  in that point, is
  soon extended all over the head,  and is
  attended with  a  languor,  or dejection  of
  strength and spirits,  which are soon fol-
  lowed  by  a nausea,  and inclination  to
 vomit,  vertigo or giddiness, a quick and
 hard pulse, and an incapacity of sleeping,
 at least quietly.   A day or two after this
 attack, if no means preventive of inflam-
 mation are used,  the part stricken gene-
 rally swells, and  becomes  puffy, and ten-
 der, but not painful;   neither  does the
 tumour rise to any considerable  height,
 or spread  to  any great  extent: if this
 tumid part of the  scalp be now divided,
 the pericranium  will be found of a dark-
 ish hue; and either quite detached, or
 very easily separable from the skull, be-
 tween which and  it will be found a small
 quantity of a dark-coloured ichor.
   " If the disorder has  made  such pro-
 gress, that  the pericranium is quite sepa-
 rated and detached from the skull, the
 latter will even now be found to be some-
 what altered  in  colour  from  a  sound
 healthy bone.  Of this alteration it is not
 very  easy to convey an idea by  words,
 but it is a very  visible one, and what some
 very able writers have noticed.
   " From this time the symptoms gene- ;
 rally advance more hastily and more ap-
 parently; the  fever increases,  the skin
 becomes  hotter,  the pulse quicker and
 harder, the  sleep more disturbed,  the
 anxiety and restlessness more fatiguing;
 and to these ate  generally added irregul
 lar rigors, which  are not followed by any
 critical  sweat, and which,  instead of re.
 heving  the patient, add considerably to
 his sufferings.  If the  scalp has not been
 divided or removed, until the symptoms
 are thus far advanced, the alteration of
 the colour of the bone will be found to be
 more remarkabfe; it will be found to be
 whiter and more dry than  a healthy one;
or, as Fallopius  has very justly observed)
it will be found to be more like a dead 
HEAD.
15
bone:  the sanies, or fluid, between it and
the pericranium will  also, in this state,
be found to be more in quantity, and the
said membrane will have a more livid dis-
eased aspect.      •
  " In this  state of matters, if the dura
mater  be denuded,  it will be found to be
detached from the inside of the cranium,
to have lost its bright silver hue, and to
be, as it were, smeared over with a kind
of mucus, or  with  matter, but not with
blood.  Every hour after this period, all
the symptoms are  exasperated, and ad-
vance  with  hasty strides :  the head-ach
and  thirst  become  more  intense,  the
strength decreases, the rigors  are more
frequent, and  at last convulsive motions,
attended in some with delirium, in others
with  paralysis,  or  comatose  stupidity,
finish the tragedy.
  " If the scalp has not been divided till
this  point of  time,  and it  be done now,
a very offensive discoloured kind of fluid
will be found  lying on the bare cranium,
whose appearance will be still more un-
like  to the  healthy natural  one; if the
bone be now  perforated, matter will be
found  between it and the dura mater,
generally  in considerable quantity,  but
different in  different  cases  and circum-
stances.   Sometimes  it will be  in great
abundance, and diffused over  a very large
part of the  membrane;  and sometimes
the quantity will be less, and consequent-
ly the space which it occupies smaller.
Sometimes it lies only on tlie exterior sur-
face of the dura mater ; and sometimes
it is between it and the pia mater, or also
even on the surface  of the brain, or with-
in the substance of it.
  " The primary and original cause of all
this, is the stroke upon the skull: by this
the "vessels which should carry on the cir-
culation between the  scalp, pericranium,
skull,  and meninges,  are injured, and no
means  being used to prevent tlie impend-
ing mischief, or such  as have been made
use of proving ineffectual,  the  necessary
and mutual  communication between  all
these parts ceases, the pericranium is de-
tached from the skull, by means of a sa-
nies  discharged from the ruptured ves-
sels, the bone  being deprived of its  due
nourishment  and  circulation  loses   its
healthy appearance, the  dura mater (its
attaching vessels being destroyed, or ren-
dered unfit for their office) separates from
the inside of the cranium, inflames  and
suppurates.
  " "Whoever will attend to  the appear-
ances which the parts concerned make in
every stage of the disease,  to the nature
of tlie symptoms, the time of their access,
their progress, and  most frequent event,
will find them all  easily and fairly de-
ducible from  the one  cause, which has
just been assigned, viz.  the contusion.
As the inflammation and separation of
the dura mater, is not an immediate con-
sequence of the violence, so neither are
the  symptoms immediate, seldom  until
some days have passed; the fever at first
is slight, but increases gradually ; as the
membrane becomes more and more dis-
eased, all the febrile symptoms are height-
ened ; the formation of matter occasions
rigors, frequent and irregular, until such
a quantity is collected, as brings on deli«
rium, spasm, and death."
   Hitherto Mr. Pott has been describing
this disease as unaccompanied  by any
other, not even by any external  mark of
injury, except perhaps a trifling bruise of
the  scalp ; " Let  us now, (says this emi-
nent  surgeon,) suppose  the scalp to be
wounded at the time of the accident, by
whatever gave the  contusion ; or let us
suppose, that  the immediate  symptoms
having been alarming, a wound had been
made, in order to examine the skull.
   " In this case,  the wound will for some
little time have the same appearance as a
mere simple wound of this part, unattend-
ed with other mischief,  would have;  it
will, like that, at first discharge  a thin
sanies, or gleet, and then begin to suppu-
rate i it will digest, begin to incarn, and
look perfectly  well; but, after a few days,
all these favourable appearances will va-
nish ;  the sore will lose  its florid  com-
plexion, and granulatedssurface ; will be-
come pale, glassy, and flabby;  instead of
good matter, it will discharge only a thin
discoloured sanies ;  the  lint with which
it is dressed, instead of coming off easily
(as in a kindly suppurating sore) will
stick to all parts  of it; and the pericra-
nium, instead of adhering firmly to the
bone,  will separate from it, all round, to
some distance  from the edges.
   " This alteration  in  the face  and cir-
cumstances of the sore, is produced mere-
ly by the diseased state of the parts un-
den.cath the  skull; which  is  a circum-
stance of great importance,  in support of
the doctrine advanced;  and  is demon-
strably proved, by observing that this dis-
eased aspect of the  sore, and this sponta-
neous separation of the pericranium, are
always confined to that part which covers
the altered or  injured portion of the dura
mater, and do  not at all affect the rest of
the scalp ; nay, if it has by accident been
wounded  in  any other part, or a por-
tion  has  been removed from  any part
where no  injury has  been done to the
dura mater, no such separation will hap-
pen,  tlie  detachment  above, will always 
  correspond to Uiat below, and be found no
  where eise.
    " The  first appearance of alteration in
  tlie wound immediately succeeds the fe-
  brile attack; and as  the  febrile  symp-
  toms increase, the sore becomes worse
  and worse, that is, degenerates more and
  more from a healthy, kindly aspect.
    " Through  the whole time, from  the
  first attack of the fever, to the last and
  fatal period, an attentive observer will re-
  mark tlie  gradual alteration of the colour
  of the bone, if it be bare.  At first it will
  be found to be whiter, and more dry, than
  the  natural one; and as the  symptom*
  increase, and  either  matter is collected,
  or tlie dura mater becomes sloughy, the
  bone inclines  more and more to a kind of
  purulent hue, or whitish yellow; and it
  may also be worth while in  this place to
  remark, that if the blow was on or very
  near to a suture, and the subject young,
  the said suture will often separate in sucn
 a manner as to let through it a loose, pain-
 ful,  ill-natured fungus;  at which time
 also  it is  no uncommon thing for  the
 patient's head and face  to be  attacked
 with an erysipelas.
   " In those cases, in which the scalp is
 very little injured  by the bruise, and in
 which there is no wound, nor any immedi-
 ate alarming  symptoms or  appearances,
 the patient feels little or no inconveni-
 ence,  and  seldom makes any complaint,
 until some few days are past. At the end
 of this  uncertain time, he is  generally
 attacked by the symptoms already recit-
 ed ; these are not pressing  at  first,  but
 they soon increase to such a degree, as to
 baffle all our art:  from whence it  will
 appear, that when this  is the  case, the
 patient frequently suffers from what seems
 at first to indicate his safety, and prevents
 such attempts being made, and  such care
 from being taken of them, as might prove
 preventive of mischief.
   " But if the integuments are so injured
 as to  excite or claim  our early regard,
 very useful information may from thence'
 be  collected;  for whether "the  scalp  be
 considerably  bruised,  or whether it  be
 found necessary to divide it for the dis-
 charge of extravasated blood,  or on ac-
 count of  worse appearances, or more  ur-
 gent symptoms, the state of the pericra-
 nium  may  be  thereby sooner  and more
 certainly  known: if in the place of such
 bruise, the pericranium be found sponta-
neously detached from  the skull, liaving
 a quantity of discoloured sanies between
them under  the tumid part, in the man-
 ner already mentioned, it may be regard-
ed as a pretty  certain indication, either
that the dura mater is  beginning to sepa-
  rate in the same manner,  or that if soriif
  preventive  means  be  not  immediately
  used, it will soon suffer; that is, it will
  inflame, separate from the skull, and give
  room for a collection »of matter between
  them.  And  with  regard to  the wound
  itself, whether it was made at  the time of
  the accident, or afterward artificially, it
  is the same thing ;  if the alteration of its
 appearance be as related, if the edges of
 it s-pontaneously quit their adhesion to the
 bone, and the febrile symptoms are at the
 same time making their attack, these cir-
 cumstances will serve to convey the same
 information, ami to prove the same tiring.-
   " This particular effect of contusion is
 frequently  found  to attend on fissures,
 and undepressed fractures of the cranium,
 as well as on extravasations of fluid, in
 cases where the bone is entire; and, on
 the other hand, all these do often happen
 without the concurrence of this individual
 mischief.   All this is matter of accident;
 but  let the other circumstances be what
 they may,  the spontaneous separation of
 the altered  pericranium, in consequence
 of a  severe blow, is almost always follow-
 ed by a suppuration  between the cranium
 and dura mater; a circumstance extreme-
 ly well worth attending to in fissures and
 undepressed fractures  of the  skull,  be-
 cause it  is from  this circumstance prin-
 cipally, that the bad symptoms, and the
 hazard, in such cases arise.
   " It is no very uncommon thing for a
 smart blow on the head to  produce some
 immediate  bad symptoms,  which, after a
 short space of time  disappear,  and leave
 the patient perfectly well.  A slight pain
 in the head, a little acceleration of pulse,
 a vertigo and sickness,  sometimes imme-
 diately follow such  accident, but do  not
 continue many hours, especially, if any
 evacuation has been used.  These are not
 improbably owing to a ^ light commotion
 of the brain,  which having  suffered no
 material injury thereby, soon cease.  But
 if, after  an interval of  some  time,  the
 same symptoms are  renewed;  if the  pa-
 tient, having  been  well, becomes again
 feverish, and  restless, and that  without
 any new cause; if he complains of being
 languid and  uneasy, sleeps disturbedly,
 loses  his appetite, has a hot skin, a hard
quick pulse, and a flushed, heated coun-
tenance ; and neither irregularity of diet,
nor accidental cold, have been productive
of these ; mischief is most certainly  im-
pending, and  that most probably under
the skull.
  " .If.tne symptoms of pressure, such as
stupidity, loss of sense, voluntary motion,
&c appear some few days  after the head
has suffered injury from  external mis 
HEAD.                                  1?
chief, they do most probably  imply an
effusion of a fluid somewhere : this effu-
sion may be in the substance of the brain,
in its ventricles, between its membranes,
or on the surface of the dura mater; and
which of these is the real situation of such
extravasation, is a matter of great uncer-
tainty, none of them being  attended with
any peculiar  mark or  sign that can be
depended upon, as pointing it out precise-
ly; but the  inflammation   of  the  dura
mater, and the formation of matter be-
tween it and the skull, in consequence of
contusion, is  generally indicated and pre-
ceded by one which Mr. Pott  has hardly
ever known to fail; a puffy, circumscrib-
ed, indolent  tumour of the scalp, and a
spontaneous separation of the pericranium
from the skull under such tumour.
  " These appearances,  therefore, follow.
ing a smart blow on the head, and attend-
ed with languor, pain, restlessness, watch-
ing, quick pulse, head-ach, and  slight
irregular shiverings, do almost infallibly
indicate  an  inflamed dura mater,  and
pus, either forming or formed, between it
and the cranium."
  By detachment of the pericranium,  is
not meant every separation of it from the
bone which it should cover.  It may be,
and often is cut, torn, or scraped off,  with-
out  any  such consequence ;  but  these
separations are violent, whereas that which
Mr.  Pott  means  is spontaneous, and  is
produced by the destruction of those ves-
sels  by which it was connected with the
skull, and by which the communication
between it and the internal parts was car-
ried on; and therefore it is to be observed,
that it is  not the mere removal of that
membrane  which causes the bad symp-
toms, but it  is the inflammation of the
dura mater; of which inflammation, this
spontaneous secession of the pericranium
is an almost certain indication.
  Sometimes the scalp is so wounded at
the time of the accident, or so torn away,
as to leave the bone perfectly bare; and
yet the violence has not been such  as to
produce the evil just now spoken of.  In
this case, if the pericranium be only turn-
ed back, along with the detached portion
of scalp, there may be  probability of its
re-union ; and it should  therefore be im-
mediately  made clean  and replaced, for
the purpose of such experiment; which,
if it succeeds, will save time, and prevent
considerable  deformity.  Should the at-
tempt fail,  it can only be in consequence
of the detached part sloughing.  Hence,
removing it with a knife, though allowed
by  Pott, is now never practised.  Fre-
quently, when the scalp does not adhere
at once, it becomes attached to the cra-
nium afterwards by a granulating process.
     Vol. II.
When the detached piece sloughs, the
worst that can happen, is  an exfoliation
from the bare skull.
   Sometimes, the  force which detaches,
or removes the scalp, also  occasions the
mischief in question;  but, the integu-
ments being wounded  or  removed, we
cannot have the criterion of the tumour
o/the scalp for the direction of our judg-
ment.  Our whole attention must  be di-
rected to  the wound and  general  symp-
toms. The edges of the former will  digest
as well, and look as kindly, for a few tlays,
as if no  mischief  was  done underneatn.
But, after some little space  of time, when
the patient begins to be restless, and hot,
and to complain of pain in the head, these
edges will lose their vermilion hue, and
become pale and flabby.  Instead of mat-
ter, they will discharge a thin gleet, and
the  pericranium  will  loosen  from the
skull, to  some distance from the said
edges.  Immediately after  this, all the
general  symptoms are  increased and ex-
asperated ; and as the inflammation of
the membrane is heightened, or < xtended,
they become daily worse and worse, until
a quantity of matter  is formed, and col-
lected, and brings on  that fatal period,
which, though uncertain as to date, very
seldom fails to arrive.
   " Tlie  method of attempting the relief
of this kind of injury consists in two
points, viz. to endeavour to prevent the
inflammation of the dura mater; or, that
being neglected, or found impracticable,
to give  discharge to the fluid collected
within the cranium, in consequence of
such inflammation.
   " Oi all the remedies in the  power of
art,  for  inflammations of membranous
parts, there is none equal to phlebotomy.
To this truth many diseases bear testimo-
ny; pleurisies, ophthalmies, strangulated
hernias, &c. and if any  thing can particu-
larly contribute to the  prevention of the
ills likely to follow severe contusions of
the head,  it  is this  kind of evacuation;
but then it must be made tyse of in -such a
manneF as  to become truly a preventive;
that is, it must be made use of immedi-
ately, and freely."
   This eminent surgeon says, he is very
sensible that it will  in  general be found
very difficult to persuade a person, who
has had what may be called only a  knock
on the pate, to submit to such discipline,
especially  if he finds  himself  tolerably
well: yet, in many instances, the timely
use, or the neglect of this single remedy,
makes all  the difference between  safety
and fatality
   " It may be said, that as the force of^
the blow, the height of the fall, the weight
of the  instrument, &c. can  never pre-
    C 
18
HEAD
 cisely or cert.!inly determine the effect,
 nor inform us,  whether miscnief is done
 under the bone, or not, a large quantity
 of blood my be drawn off unnecessarily,
 in  order to prevent an  imaginary  evil.
 This is in sonic degree true; and if the
 advice just-given  was un versally follow-
 ed, many people  would be largely  bled
 without necessiiy ; but then, on the other
 hand, many a very valuable life would
 be preset ved, which, for want of this kind
 of assistance, is lost.   JWiil interest, prx-
 ndium an satis tutum sit, quod unicum est,
 is  an incontested maxim in  medicine;
 and if it be allowed to use such means as
 may be  in themselves hazardous, surely
 it cannot be wrong to employ one which
 is not so ; av least, if it be considered in a
 general sense, whatever it may accident-
 ally  pr ve  to some few  particular  indi-
 viduals."
   Acceleration, or hardness of pulse, rest-
 lessness, anxiety, and any degree of fever,
 after a smart blow on the head, are al-
 ways to be  suspec ed and attended to.
 Immediate, plentiful, and repeated evacua-
 tions by bleeding,  have, in many instances,
 removed these, in persons to whom, Mr.
 Pott verily  believes,  very terrible  mis-
 chief would have happened, had not such
 precaution been used.   In this, as well as
 some other parts  of practice, we nei'.her
 hava, nor  can have any other method of
 judging, than by comparing  together ca-
uses apparently similar. Mr Pott has more
 than once or twice seen that increased ve-
 locity and hardness of pulse, and that op-
 pressive languor,  which most  frequently
 precede mischief under  the bone, re-
 moved by  free and repeated blood-let-
 ting j and has often, much too often, seen
 cases end fatally,  whose beginnings  were
 full  as slight, but in  which  such  eva-
 cuation had been either neglected, or not
 complied with.  This  judicious  writer,
 " would by no means be thought to infer
 from hence, that  early bleeding will al-
 ways prove  a certain preservative;  and
 that they  only die, to whom it has not
 been applied : this, like all other human
 means, is  fallible;  and,  perhaps, there
 are  more cases   out of  its reach,  than
 within  it:  but, where  preventive means
 can take place, this is certainly the best,
 and the most frequency successful.
   "The second   intention, viz.  the  dis-
 cliarge of  matter,  collected  under the
 cranium, can be  answered  only by the
 perforation of it.
   " When, from  the symptoms and ap-
 pearances already described, there is just
 reason for supposing matter  to be formed
 under tlie skull, the  operation of perfor-
 ation cannot be  performed  too soon;  it
seldom  happens  that it  is  done  soon
enough.                      _
  " The propriety,  or impropriety, ot ap-
plying the trepl'ine, in cases where there
is "neither fissure, fracture, nor symptom
of extravasation,  is a point  which  has
been  much litigated,  and remains still
un-et led  either  by  writers   or  practi-
tioners.
  " When there is no reason  for suspect-
ing any of those injuries, either from the
symptoms, or from  the appearances ;  and
the pericranium,  whether the  scalp be
wounded or not, remains firmly attached
in all parts  to  the  skull; there certainly
is not (let the general symptoms be  what
they maj)  any  indication whereto apply
the instrument, and consequently no  suffi-
cient authority for using it  at all:  but
whenever that  membrane, after the  head
has received an external violence, sepa-
rates, or is detached  spontaneously  from
the bone underneath it, and such  separa-
tion is attended with the collection of a
small quantity of thin, brown ichor, an al-
teration of colour in the separated pericra-
nium,  and  an  unnatural dryness  of the
bone,  Mr.  Pott cannot  help thinking,
that there is as good reason  for  trepan-
ning, as in  the case of fracture;  he be-
lieves experience would vindicate  him,  if
he said, better reason ;  since  it is by no
means infrequent for  the former kind of
case to do well without such operation;
whereas suppuration under tlie skull ne-
ver can.
  " The  spontaneous  separation  of the
pericranium, if attended with  general dis-
order of the patient, with dullness, horri-
pilatio, languor, and some degree of fever,
appears to Mr. Pott, from all the observa-
tion he has  been capable of making,  to be
so sure and certain an indication  of mis-
chief underneath,   either in  present, or
impending,  that he should never  hesitate
about perforating  the  bone  in such cir-
cumstances.
  " When the skull has been once perfo-
rated, and  the dura  mater thereby laid
bare,, the state of the matter must prin-
cipally  determine  the  surgeon's future
conduct.   In some cases, one opening will
prove sufficient for  all necessary  pur-
poses;  in  others, several  may be neces-
sary.  This variation will depend on the
space of detached dura mater  and the
quantity of collected matter.  The repe-
tition of the operation is warranted,  both
by the nature of  the case,  and  by the
best authorities;  there  being po compa-
rison to be made between  the  possible
inconvenience  arising  from   largely de-
nuding the dura mater, and the certain,
as well as terrible evils which must follov 
HEAD
iy
 Oie formation and confinement of matter
 between it and the skull.
   " It  can hardly be  necessary to  ob-
 serve, that notwithstanding the operation
 of perf »ration be absolutely and unavoida-
 bly  necessary, vet the repetition of blood
 letting or  cooling laxative medicines,  the
 use of antiphlogistic remedies, and a most
 strict observance  of a low diet and regi-
 men, are as indispensably requisite  after
 such operation as before ; the perforation
 sets the membrane free from pressure, and
 gives  vent to  collected  matter,  but  no-
 thing  more;  the inflamed state of  the
 parts under the  skull,  and all the neces-
 sary consequences of such inflammation,
 call for all our  attention, full as much
 afterwards  as before; and although  the
 patient must have perished without  the
 use of the  trephine, yet, the merely hav-
 ing  used it, will not preserve him, with-
 out every other caution and care."
  Both tables of the skull sometimes ex-
 foliate in consequence of external violence.
 The dead bone must be removed,  as  soon
 as loose;  and,  if necessary,  the scalp
 divided for the purpose.

 3. Fissures  and Fractures of the Cranium,
           without Depression.

  " Fractures .of tlie cranium,  (says Mr.
 Pott) were,,by the ancient writers, divided
 into  many  different sorts, each of which
 was  distinguished by an appellation  of
 Greek etymology, borrowed either from
 the figure  of the  fracture, or the dispo-
 sition of the broken pieces.  These are to
 be found in most of the old books; but as
 they merely load the memory,  without
 informing the understanding, or assisting
 the  practitioner,   modern  authors have
 generally laid them aside.
  " This kind of  injury is divisible into
 two general heads, viz. those in which the
 broken parts keep their proper level,  or
 equality of surface, with the rest of the
 skull, and those in which they do not; or,
 in other words, fractures without depres-
 sion, and fractures with.
  " These  two distinctions are all which
 are really necessary to be made, and will
 be found to comprehend every violent di-
vision of the parts  of the skull (not made
by a cutting-instrument) from the finest
capillary fissure, up to the most  compli-
cated fracture:  for, fissures and fractures
differing from  each  other only  in  the
width of the breach, or in the distance  of
the separated parts, and the disposition of
broken  pieces,  in  large  fractures, being
subject  to  an almost  infinite varieiy, dis-
tinctions and appellations,  drawn  and
made from  these circumstances, might  be
 multiplied  to  even three times the old
 number without ;mparting the  smallest
 degree of useful knowledge  to  the man,
 whu snould be at the pa.ns to get them by
 heart.
   " What are the  symptoms  of a frac-
 tured cianium? is often asked; and there
 is hardly any one who does not,  from the
 authority of writers,  both ancient  and
 modern,  answer,  Vomiting,  giddiness,
 loss of sense, speech,  and voluntary  mo-
 tion, bleeding at  h'  ears, nose, and mouth,
 &c.  This  is  the  doctrine  of  Celsus,
 which has been most invariably copied by
 almost all succeeding authors, and impli-
 citly believed by almost all readers.
   " The  symptoms  just  mentioned  do
 indeed very frequently  accompany a brok-
 en skull, but they are not produced by the
 breach made in the  bone ; nor do they in-
 dicate such  breach  to have been  made.
 They proceed from  an affection of the
 brain, or from injury done to some of the
 parU within the cranium, independent of
 any  ill which the bones  composing it may
 have sustained.   They are  occasioned by-
 violence offered  to  the contents of the
 head in general;  are qui e independent of
 the  mere breach  made  in  the  bone;  and
 either do or do  not accompany fracture,
 as such fracture may happen to be, or not
 to be, complicated with such other ills.
   " They are frequently produced by ex-
 travasations of blood, or serum, upon, or
 between the membranes of the bi ain; or
 by shocks, or concussions of its subsU.nce,
 in cases where the skull is perfectly intire
 and unhurt.   On the other hand, the bones
 of the skull are sometimes cracked, brok-
 en, nay, even depressed, and  the patient
 suffers none of these symptoms.  In short,
 as the breach made  in the bone is not,
 nor can be the cause of such complaints,
 they ought not to be attributed to it; and
 that for reasons, which are by no means
 merely speculative.   For the practitioner,
 who supposes  that such symptoms do ne-
 cessarily and certainly imply  that  the
 cranium  is fractured, must regulate  his
 conduct by such supposition, and remove
 the scalp, very  often without  either  ne-
 cessity or benefit-, that  is, without disco-
 vering what  he  looks  for: and, on  the
 other hand, if he does  find the skull to
 be broken,  believing all these  complaints
 to be caused by, and deducible from  the
 fracture, he will most  probably  pa}  his
whole attention to that >upposeo < .use,
and  may think,  that when he has done
 what the rules of his  art prescribe  for
 such case, he has done all  that is in  his
power:----an opinion  not  unfrequently
embraced;  and which has  been  tlie de-
struction of many a  patient.  Per,  as on
one hand, the loss of sense, speech, and
voluntary motion, as well as the hemorr- 
20
nii ad.
hage from  the  nose, car.-, ke. are some-
times totally removed by,  or at least dis-
appear,  during  the use of free and" fre-
quent evacua ion,  without any  opera-
tion  on  the scalp or skull;  so,  on the
other,  as diese symptoms and appear-
ances are not produced by the solution of
continuity of the bone, they cannot be re-
medied by such chirurgie treatment as the
mere fracture may require.
  " If any  one  doubts the truth  of this
doctrine, (continues  Mr. Pott,) I would
desi' e him to consider the nature,  as well
as most  generally successful method of
treating  these  symptoms; and,  at the
same time, to reflect seriously  on the
operation of the trepan,  as practised in
simple,  undepressed fractures   of the
skull.
  "The  sickness, giddiness,  vomiting,
and loss of  sense and motion, can only be
the cmsequence  of an afli ction  of tlie
brain, as the common sensorium.   They
may  be produced by its having been vio-
lently shaken,  by a derangement of its
medullar} structure, or by unnatural pres-
sure made  by a fluid extravasated on its
surface, or within its ventricles;  but ne-
ver can be  caused by  the mere division
of the  bone, (considered  abstractedly) ;
which division, in a  simple fracture, can
neittier press on, nor derange, the struc-
ture of the  parts within the cranium.
  " If the solution of continuity in the
bnne be either produced by such a degree
of violence, as  hath caused a  consider-
able disturbance  in  the medullary  parts
of the brain, or has disturbed any of the
functions of the nerves going off' from it;
or has occasioned a breach  of any vessel,
or vessels whether sanguine or lymphatic,
and  that hath  been  followed  by an ex-
travasation, or lodgment of fluid; ihe
symptoms  necessarily  consequent  upon
such derangement, or such pressure, will
follow .-  but they do not follow, because
the bone is broken;  their causes  are su-
peradded to the fracture, and,  although
produced by 'he  s„me external violence,
are  yet perfectly  and  absolu ely  inde-
pendent of it: so  much so, that they are
frequently  found where no fracture is
  " The operation of the  trepan  is fre-
quently performed in the  case of simple
fractures, and that very judiciously and
properly; but  it  is not performed, be-
cause the bone  is  broken, or cracked: a
mere fracture, or fissure of the skull, can
never  require  perforation,  or that the
dura mater under it be  laid  bare; the
reason for doing this, springs from  other
causes than the fracture, and those  really
independent of it: they spring from tlie
nature of the  mischief which  the, parts
withir. tlie  cranium live sustained, and
not from the  accidental division of  the
bone.  From these  arise the threatening
symptoms;  from these all the hazard;
and from these,  the necessity, and vindi-
cation of performing the operation of  the
trepan.
  " If  a simple  fracture of the cranium
was unattended  in-present with any of
the  before-mentioned  symptoms,   and
there  was no reason  for  apprehending
any other evil in future, that  is,  if  the
solution of continuity in the bone was the
whole  disease, it c.uld not possibly in-
dicate  any  other curative intention, but,
the  general  one in all fractures,   viz.
union of the divided parts."
  In many cases of simple undepressed
fractures of the  cranium, it is true, that
trephining is necessary : but, .the reasons
for the opera) ion, in these instances,  are,
first,  the  immediate  relief of present
symptoms arising  from the pressure of
extravasated fluid; and, secondly,  the
discharge of matter, formed between the
skull  and dura mater, in consequence of
inflammation.   The operation  of   tre-
phining was also recommended by Pott,
as a preventive  of  ill  consequences;  a
practice, however,  which  is  now  never
adopted  by the  most eminent  surgeons;
and  many  writers  of  the  highest  repu-
tation,  especially  Desaultj Dease,   Mr.
John Bell, and Mr. Abernethy,  urgently,
and properly remonstrate against the  me-
thod.
  The latter remarks : " In the accounts,
which  we have  in the  former practice in
France, it is related, that surgeons made
numerous perforations  along  the  whole
track of a fracture  of  the cranium; and,
as far as I am able to judge, without  any
clear design.  Mr. Pott also advises such
an operation, with a view to prevent  the
inflammation and suppuration of the dura
mater, which  he so much  apprehended.
But, many  cases have occurred of late,
where, even in fractures with depression,
the patients have  done well without an
operation."
   Mr. Abernethy   next relates several
cases of fracture of the cranium with de-
pression,  which terminated  favourably,
although  no  operation was  performed.
Th s judicious surgeon thinks, that these
cases,  as well as a great many others on
record, prove,  that a slight  degree  of
pressure does not derange  the  functions
of the brain,  for a  limited time after its
application: and all those, whom  he had
an opportunity of knowing for any length
of time after  the accident, continued  as
well as if nothing of the  kind had  hap-
pened to them. In  Mr.  Hill's cases  in
surgery, two  instances of this sort are
related, and Mr. Hill  knew both  the pa- 
HEAD.                                  21
tients for many years afterwards;  yet, no
inconvenience arose.  Indeed, it  is  not
easy to conceive, that the pressure, which
caused no ill effects at a time, when the
contents of the cranium  filled its cavity
Completely, should afterwards prove in-
jurious,  when they have adapted'them-
selves to its altered size and shape.  Se-
vere illness, indeed, does often intervene
between  the receipt of  the injury, and
the time  of its recovery; and many sur-
geons might be inclined  to attribute this
to pressure ; but, it equally  occurs when
the depressed portion is elevated.  If  a
surgeon, prepossessed with the opinion,
that elevation of the bone  is necessary
in every instance of depressed cranium,
should have  acted  upon this  opinion in
several of the cases, which Mr. Abernethy
has related,  and afterwards  have  em-
ployed proper evacuations, his patients
would  probably hare had no  bad symp-
toms, and he would naturally  have attri-
buted their well-doing  to  the mode  of
treatment, which he had pursued: yet,
these cases did  equally  well without an
operation.  {Abernethy on Injuries of the
Head.)
  Depressed  fractures of the  skull not
being our immediate consideration,  we
need not expatiate upon them ;  but, it
seemed right to  make the preceding re-
marks, in order to shew how unnecessary
it must be to  trephine a patient, merely
because there is a fracture of the cranium,
and with a view of preventing  bad  conse-
quences.  Even when the fracture is  de-
pressed, it is not necessary,  unless there
are evident signs, that the degree of pres-
sure, thus produced on the brain,  is the
cause of existing bad symptoms.
  The inflammation and suppuration of
the parts,  beneath  the skull,  which Mr.
Pott wished so much to prevent by tre-
phining early, do not arise  from the oc-
currence of a breach in the cranium, but,
are the consequences of the  same vio-
lence, which was the occasion of the frac-
ture.  Hence, it is obvious, that removing
a portion of the bone  cannot in the least
prevent the inflammation and suppura-
tion, which must result from the external
violence  which was first applied  to  the
head;  but on the  contrary, such  a re-
moval being an additional violence, must
have a tendency to increase the inevitable
inflammatory mischief.
  From  what has  been  said,  it  is not
to be inferred,  however, that  trephin-
ing is  never proper,  when   there   is
a simple   undepressed fracture of the
skull.  Such injury may be joined with
an extravasation  of blood on the dura
mater ;  or, it may be followed by the for-
mation of matter between this membrane
 and the cranium ; in botli which circum-
 stances,  the operation  is essential to the
 preservation of the patient, immediately,
 but not before, the symptoms  indicative
 of the existence of dangerous pressure on
 the brain, begin to shew themselves.  (See
 Trephine.)
  A fracture  of the  skull, unattended
 with urgent symptoms, and not brought
 into the surgeon's view by any  accidental
 wound of the  integuments, often remains
 for ever undiscovered ; and as  no benefit
 could arise from laying it bare  by an in-
 cision, such practice  should  never be
 adopted.  The surgeon ought only to be
 officious  in this way, when he can ac-
 complish by it some better object,  than
 tlie merely satisfying his own  curiosity.
 And as we shall find from the perusal  of
 this article, and the one intitled, Trephine,
 that the removal of pressure off' the sur-
face of the brain is the only possible rea-
 son for ever perforating the  cranium  with
 this  instrument;  and  as  dividing the
 scalp is only a useful measure, when  it is
 preparatory to such  operation;  neither
the one,  nor the other, should ever be
practised, unless there exist unequivocal
symptoms, that there  is a dangerous de-
gree of pressure operating on  the brain,
 and  caused either by  matter, extrava-
 sated blood, or a depressed portion  of
 the skull.
  The true  mode  of preventing the bad
 effects, frequently  following, but not aris-
 ing from, simple fractures of  the skull,
 is not to  trephine,  but, to put in practice
 all  kinds of antiphlogistic means.  For
 this purpose, let the patient be repeatedly
and  copiously  bled, both from the  arm
 and temporal  arteries;  let  him be  pro-
perly purged;  give  him  antimonials;
 keep him on the lowest diet; let him re-
 main in the most quiet situation possible;
and if, notwithstanding  such  steps, the
symptoms  of inflammation  of  the  brain
continue  to>increase,  let his  head be
shaved and a large blister be applied t«
 it.  When, in spite of all these  measures,
 matter forms under the cranium, attended
 with symptoms of pressure, a  puffy tu-
 mour of  the injured part of the scalp, or
 those changes of the  wound, if there  is
 one, which  Mr. Pott has so excellently
 described, and we have  already related;
 not a moment should be  lost in delaying
 to perforate the bone with  the trephine,
 and giving vent to  the matter beneath.

 4. Fractures of the Cranium-nth Depression.

  " Simple  fractures of the  skull, or
those in  which the parts of the  broken
bone are  not depressed from their situa-
 tion (observes Mr. Pott) differ from what
 are called fissures, only in the distance of 
02
HEAD.
the edges of the breach from each other.
When tlie separation is considerable, it is
called a fracture ; when it i> very fine and
small, it is called a fissure.  The chirur-
gical  intention, and  requisite  treatment,
are the  same in each, v'u. to procure a
discharge for any fluid which may be  ex-
travasated in present, {here -we must under-
stand supposing tlie pressure of such extrava-
sation produces urgent symptoms) and to
guard against the formation, or confine-
ment of matter.  The prevention of sup-
puration  will, as  we  have  already  re-
marked,  be  best accomplished, not  by
perforating the cranium, as Mr.  Pott  ad-
vised, but by copious bleeding, evacua-
tions, blisters,  and a rigorous  antiphlo-
gistic regimen.  The confinement of mat-
ter, producing symptoms  of pressure on
the brain certainly indicates  the  immedi-
ate use of the trephine.
  " But, in fractures,  attended with  de-
pression, (says  Pott) the intentions  are
more.  In these  the  depressed parts  are
to be elevated, and such  as  are  so  sepa-
rated as to be incapable of reunion,  or of
being brought to lie  properly, and  with-
out pressing on the brain, are to be  to-
tally removed.  These circumstances  are
peculiar to a d pressed fracture; but, al-
though they are peculiar,  they must  not
be considered as sole, but, as additional
to those, which have been mentioned at
large under  the head of simple fracture :
commotion,  extravasation,  inflammation,
suppuration,  and  every ill, which can
attend on, or be found in the  latter,  are
to be met with in the former, and will re-
quire the same method of treatment."
That loose splintered pieces of the cra-
nium, when  quite detached, and already
in view, in consequence of the scalp  be-
ing wounded, ought to be taken  away, no
one will be inclined to question.   That
they ought also to be exposed by an inci-
sion, even when tlie scalp is unwounded,
and then taken  away,  whenever  they
cause symptoms of irritation, or pressure,
I  believe,  will be  universally  allowed.
But, the reader will  already understand,
from what has been said, in the preced-
ing section, that several  excellent sur-
geons do not coincide with Pott, hi believ-
ing, that every depressed  fracture of  the
skull necessarily demands the application
of the trephine.
   " There certainly are (says  Mr.  Aber-
nethy) degrees of this injury,  which it
would be highly imprudent to treat in
this manner.  Whenever  the patient  re-
tains his senses perfectlv, I should  think
it improper to trepliine him, unless symp-
toms arose, that indicated the nee- ssity of
it."  P.  21.
  Every  surgeoo, indeed, cannot be  too
fully impressed with the following truth,
tha; existing symptoms  of   dangerous
pressure on the brain, which symptoms
will be presently related, can  alone form
a true  reason for perforating the cranium.
The mode of operating, in  order to ele-
vate depressed  portions of the skuil,  is
explained in the article, Trephine.

5. Extravasationunder the Cranium ; Symp-
    toms of Pressure on the Brain, &c.

  Mr.  Pott  remarks, " the  shock,  which
the head sometimes receives by falls from
on  high, or by strokes  from  ponderous
bodies, does  not  infrequently  cause a
breach in some of the vessels, either of
the brain, or its meninges; and, thereby,
occasions extravasation of the fluid, which
should circulate through them.  This ex-
travasation  may be  the only  complaint
produced by the accident; or  it may be
joined  with, or added to,  a  fr cture of
the skull.  But this is not all, for it may
be produced not only when the cranium  is
unhurt by  the  blow, but even when no
violence of any kind has been offered to,
or received by the head."
  When  blood  is extravasated  beneath
the skull, the  violence which produces
the rupture of the vessel, usually stuns
the patient, from which state, provided
the quantity and pressure  of  the  blood,
and the force of the concussion be not too
great,  he gradually recovers, and regains
his  senses.   If  the first extravasation be
trival,  the  patient,  after  regaining his
senses, may only feel  a little drowsiness,
and go to bed.   The  bleeding from the
ruptured vessel continuing, and the pres-
sure on the  brain increasing, he becomes
more and more insensible,  and begins to
breathe in a slow, interrupted, stertorous
manner.  In cases of  compression, whe-
ther from blood or a depressed portion of
the skull, there is a general insensibility,
the eyes are half open, the pupil dilated,
and motionless even  when a candle  is
brought  near the eye; the  retina is in-
sensible; the limbs relaxed; the breath-
ing stertorous;  the pulse slow, and, ac-
cording to Mr. Abernethy, less subject to
intermission, than in cases of concussion.
Nor is the  patient ever sick, when the
pressure on the brain and the general in-
sensibility,  are  considerable;  for, the
very action of vomiting betrays an irrita-
bility  in the  stomach and  oesophagus.
These  symptoms are not peculiar to pres-
sure  from  blood,  but arise  also  from
that of many depressed fractures  cf the
skull,  and of suppuration under this part.
Th-y are all attributable to the unnatural
pressure made on the brain and  nerves,
and have too often been mistaken, as in- 
HEAD.
<?3
 ttcations of a disease, which, considered
 abstractly,  can never cause them; we
 allude to a simple undepressed fracture of
 the cranium, which may be accompanied
 by them, but cannot cause them.  They
 differ in degree, according to the quan-
 tity, kind, and situation of the pressing
 fluid. The hemorrhage from tlie nose and
 ears, which often follows violence applied
 to tlie  head,  leads to  no particular  or
 useful  inference :  we cannot even cal-
 culate,  by this sign, that the force has ex-
 ceeded a certain degree;  for, such bleed-
 ings take place, in many persons, from
 much slighter causes  than in others.
   The  preceding class of symptoms only
 inform us, that the  brain is suffering com-
 pression ; and, leaves us quite in  the dark,
 respecting several  other  very important
 circumstances.  " We not only have no
 certain  infallible rule,  whereby to dis-
 tinguish, what the pressing  fluid is,  or
 where it is situated, but we are, in many
 instances absolutely incapable of know-
 ing, whether the symptoms be occasioned
 by any  fluid at all;  for, a fragment  of
 bone, broken  off from the internal table
 of the  cranium,  and making an equal
 degree  of pressure, will produce exactly
 the same complaints." {Pott.) In detail-
 ing the  symptoms of pressure from blood,
 I  took  particular  notice  of the patient
 being at first generally stunned by the
 blow ;  of  his gradually regaining  his
 senses,  and of his afterwards relapsing
 into a state of insensibility again.   The
 interval  of  sense, which  thus occurs, i9
 a  circumstance, of the greatest conse-
 quence in making the  surgeon understand
 the nature of the case.
   " A  concussion,  and an extravasation
 (as Mr. Pott observes) are very  distinct
 causes of mischief, though not always very
 distinguishable.
  " M.  Le Dran, and others of tlie mo-
 dern French writers, have made a very
 sensible and  just  distinction  between
 that kind  and degree of loss  of sense
 which arises from  a mere commotion of
 the brain, and that which is caused by a
 mere extravasation, in those instances  in
 which the time of  the attack or appear-
 ance of such symptoms are different or
 distinct.  The loss of sense, which imme-
 diately follows the  violence,  say they,  is
 most probably owing to a commotion ; but
 that which comes on after an  interval  of
 time has past, is most probably caused by
 extravasation.
  " This distinction is certainly just and
 good, as far as it will go. That degree
 of abolition or diminution  of sense, which
immediately attends or follows  the blow
 or fall,  and goes  off again without the
 assistance  of art,  is in  all  probability
 occasioned, by the sudden shake or tem-
 porary  derangement of the contents of
 the  head; and the  same kind of symp-
 toms recurring  again  some  time after
 they had ceased, or not coming on until
 some time had passed from tlie receipt of
 the  violence, do most  probably proceed
 from the  breach of a vessel within  or
 upon the brain.  But unluckily, we have
 it not very often in our power to make
 this exact distinction.  An extravasation
 is often  made  so immediately, and  so
 largely,  at the  instant of the accident,
 that all sense and  motion are instanta-
 neously  lost, aud  never  again return.
 And it  also sometimes happens,  that
 although an extravasation  may possibly
 not have been made at the moment of the
 accident, and the first complaints may
 have been owing to commotion merely,
 yet a quantity of fluid  having been shed
 from its proper  vessels very soon after
 the  accident, and producing its  proper
 symptoms, before those caused by  the
 commotion have had time to go off, the
 similarity of  the effects of  each of these
 different causes  is such, as  to deprive us
 of all power of distinguishing between
 the one and the other, or of determining
 with any tolerable precision to which of
 them such symptoms as remain are really
 owing.
  "  When an extravasation of any kind is
 made, either upon  or  within the brain,
 if it be in such quantity, or so situated,
 as to disorder the economy of the ani-
 mal, it always produces such disorder,
 by making an unnatural pressure on  the
 parts where it lies.  The nature and  de-
 gree of the  symptoms  hereby produced
 are various and different in different per-
 sons, according to the kind, quantity, and
 situation  of  the pressing fluid.  Some-
 times it is mere fluid blood, sometimes
 blood in  a state  of coagulation,  some-
 times it  is a clear lymph,  and at  others
 blood and water are found mixed toge-
 ther; each of these is found either simple
 or mixed in  different situations, that is,
 between the  skull and  dura mater,  be-
 tween the  dura and  pia mater, or in  the
 natural  cavities  of the brain called  its
 ventricles,  and  sometimes,  in cases  of
 great violence,  they are  found at the
 same time in all these different parts.
 Sometimes a' considerable quantity  is
 shed instantly, at the time of tlie acci-
 dent ; and sometimes the breach by which
the effusion is made is so circumstanced,
 both as to nature and situation, that it is
 at first very small, and increases by faster
 or slower  degrees.  In tlie former, the
symptoms  are generally immediate and
 urgent,  and  the extravasation  is of the
 bloody kind ; in the latter,  they are fre- 
•:i
HEAD.
nuently slight at first, appear after some
tittle interval of time, increase gradually
till uiey become urgent or fatal, and are
in such case,  generally occasioned by ex-
travasated lymph.  So that although the
immediate appearance of bad symptoms
does most certainly  imply  mischief of
some kind or other,  yet, on the  other
hand, no man ought to suppose his pa-
tient free  from  hazard,  either because
such svmptoms do not shew themselves
at first,  or because  they appear to be
but slight: those which come on late, or
appearing slight at first, increase gradu-
ally , being full as much to be dreaded as
to consequence, as the more immediately
alarming ones; with  this material eliffer-,
ence between them, that the one may be
the consequence of a  mere concussion of
the brain, and may by means of quietude
and evacuation go quite  off;  whereas,
the other being most  frequently owing to
an extravasation of lymph, (though some-
times of blood also)'within the substance
•f the brain, are very seldom removed by
art."  {Pott.)
  The case of extravasation, between the
cranium and dura mater, is almost the
only one, which admits of relief from tre-
phining.   Mr.  Abernethy  informs us,
that, in the cases, which he has seen, of
blood extravasated, between the dura and
pia mater, on a division of the former
membrane being made for its discharge,
only the serous part of it could be eva-
cuated : for,  the coagulum  was spread
over the hemisphere of die brain, and had
descended, as low as possible, towards
its inferior part, so that very little relief
was obtained by  the  operation.  {P. 32.)
  Fractures of the cranium, which take
place across the  lower and front angle of
the parietal bone, and the rest of the track
of the  trunk, and large branches  of the
spinous artery of the dura mater, are
cases very apt to be attended with a co-
pious  extravasation.   This  vessel, and
others  more deeply seated, however, may
be ruptured, pour .^ut a considerable quan-
tity of blood, and induce urgent symptoms
of pressure  on the brain,  not only with-
out the co-existence of a fracture, but
even of any external  mark of violence on
the scalp.
  The effused blood  is,  more frequently,
situated below the part, on which the vio-
lence has operated, and, hence, when such
part is pointed out by a wound,  or dis-
colouration of the scalp, and the^jyuip-
toms of pressure are considerable, there
cannot be two opinions, respecting the
propriety of immediately trephm-ng, and
the place, where to m dee the perforation.
But, what is to be done, wi en dangerous
symptoms of pressure  prevail, without
any external mark to denote, what par*
of the head rece ved the blow, or whether
any at ail; for, a general concussion of
the head may produce an effusion ot blood
within the  cramum.  Under these  cir-
cumstances,  Mr.  Pott  was  against  the
operation, and says that " the only chance
of relief is from phlebotomy, and an open
belly; by wh.ch we may hope so to lessen
tlie quantity of the circulating fluids as to
assist nature in the dissipation or absorp-
tion of what has been extravasated.  This
is an effect which, although not highly
improbable in  itself, yet is no£ to be ex-
pected from a slight or trifling applica-
tion of the means  proposed.  The use of
them must be proportioned to the hazard
of the case.   Blood must  be drawn off
freely and repeatedly, and from different
veins; the  belly must be kept constantly
open, the body quiet, and the strictest re-
gularity of general regimen  must be ri-
gidly observed.   By these  means, very
alarming symptoms  have  now and then
been removed, and  people in seemingly-
very hazardous circumstances have been
recovered."
  If the symptoms, however were urgent,
it certainly might be proper to perforate
the cranium in the course of the spinous
artery of the dura mater.  If no blood
should be found under one parietal bone t
the operation might be done on the other.
This situation, we know, is the chief one
for copious extravasations  between the
cranium and dura mater, and if the blood
be more deeply effused, we have the con-
solation of knowing, that the patient had
the chance of that benefit, which might
have resulted  from the operation, had the
pressure originated from an extravasation
in one of the most common places, between
the dura mater and the .skull.
   This part of, practice, however, is ex-
ceedingly  doubtful  and obscure.  But,
should  the mode of  judging,  whether
blood lies  immediately under the .skull,
suggested by Mr. Abernethy, prove, inva-
riably correct, our line of,conduct may be
hereafter more easily detei mined, respect-
ing whether tlie  trephine should be ap-
plied in such dubious cases, or not. Even
when the injured  scalp shews where  the
violence has'operated,  the  criterion, we
are about to notice, may inform us, whe-
ther we should perforate the bone, or not;
for, though the extravasation is sometimes
found immediately  under  the  external
mark, yet, it often is not so; but, is in a
part distant from that mark, to which we
have nothing to  lead  us, and to  which,
indeed, if >ve knew it, we could not re ich.
 M   Abernethy his  observed, " tlia" un-
less one of the large arteries of  the dura
mater be wounded, the quantity of blood, 
HEAD.
25
 poured out, will probably be inconsider-
 able ; and  the  slight compression of the
 brain, which this occasions, may not be
 attended with any peculiar symptoms, or
 perhaps, it may occasion some stupor, or
 excite an  irritation,  disposing the subja-
 cent parts  to become inflamed.  It is  in-
 deed highly probable, that, in many cases,
 which have done well without an opera-
 tion,  such an extravasation has  existed.
 But,  if there be so much  blood on the
 dura mater, as  materially to derange the
 functions of the brain, the bone, to a cer-
 tain extent, will  no  longer receive blood
 from within, and by the operation, per-
 formed for its exposure, the pericranium
 must have been separated from its outside.
 I believe, that a bone, so circumstanced, will
 not be found to bleed"  In some cases, re-
 lated by this gentleman,  there was no he-
 morrhage ; twice he was able, by attend-
 ing to this circumstance, to tell how far
 the  detachment  of  the  dura mater ex-
 tended ; and often, when symptoms seem-
 ed to demand a perforation  of the skull,
 he has seen the operation contra-indi-
 cated by the hemorrhage from the bone,
 and as the event shewed, with accuracy.
 (P. 33.)
   Pott .justly remarks,  that " if the ex-
 travasation be  of blood, and that  blood
 be in a fluid state, small in quantity, and
 lying between the skull and dura mater,
 immediately under or near to the place
 perforated, it may happily be all discharg-
 ed by such perforation, and the patient's
 life may thereby be saved; of which many
 instances  are  producible.   But  if the
 event does not  prove so  fortunate, if the
 extravasation be so large or so  situated
 that the operation proved insufficient, yet
 the symptoms  having  been urgent, gene-
 ral evacuation  having been used ineffec-
 tually, and a wound or bruise of the scalp
 having pointed out the  part which  most
 probably  received the  blow: although
 the  removal of  that  part  of  the scalp
 should not detect any injury done to the
 bone, yet the symptoms still  subsisting, I
 cannot  help thinking, that perforation of
 the cranium is in these circumstances so
 fully warranted, that the omission  of it
 may truly be called a neglect of having
 done that which might have proved ser-
 viceable, and,  rebus sic stantibus, can do
 no harm.   It is very true,  that  no man
 can  beforehand tell  whether such opera-
 tion  will prove beneficial or not,  because
 he cannot  know the precise nature, de-
 gree, or situation of the mischief; but,
 this  uncertainty  properly  considered, is
 so far from being a dissuasive from the
 attempt, that it is really a strong incite-
 ment to make it; it  being fully as impos-
sible to know, that the extrav asated fluid
     Vol. II.
 does not lie  between the  skull and dura
 mater, and that  under the part stricken,
 as that it does; and if the latter  should
 be the case, and the operation be not per-
 formed, one, and most probably the only
 means of relief, will have been omitted.
   When there  is no interval of sense, be-
 tween the blow, and  the coming on  of
 perilous symptoms, it is frequently impos-
 sible to determine, whether  the mischief
 be owing  to the largeness and suddenness
 of the extravasation, to the violence of the
 shock, which the brain  has  received, or
 to both these causes at once, which, un-
 fortunately, is  too often the case.  In this
 latter  complication,  indeed, trephining
 will frequently be of no avail, even though
 it serve for the entire removal of all pres-
 sure off the brain; for, the patient cannot
 recover from the violence of the concus-
 sion, and never regains his senses.  This
 is no reason, however, why the chance of
 the operation doing good should  not  be
 taken,  when there are evident symptoms
*of pressure.    Let us in  these darkened
 cases, call to  mind  the sentiments  of
 Pott,  who says: " No man,  who is at all
 acquainted with this  subject, will ever
 venture to pronounce  or promise success
 from the  use of the trephine, even in the
 most  apparently slight cases; he knows
 that honestly he cannot; it is enough that
 it has  often been successful where  and
 when every other means have failed. The
 true and  just  consideration is this :  does
 the  operation of perforating the cranium
 in such case add at all to that degree of
 hazard which the patient is  in  before it
 is performed ? or can he in many instances
 do well without it.' If it does add to the
 patient's  hazard,  that is  certainly a very
 good reason  for laying it  aside, or for us-
 ing it very cautiously; but, if it does not,
 and the only objection made  to it,  is, that
 it frequently  foils  of being successful,
 surely it  cannot  be right to  disuse that,
 which has often been, not only salutary,
 but the causa sine qufi  non of preservation,
 merely, because  it is also  often unsuc-
 cessful, that is, because it is not infalli-
 ble."
   Mr. Pott thought, that, whenever the
 dura was detached from the inner surface
 of the skull by blood, as well as matter,
 the  pericranium  covering the outer part
 of the same bone would generally become
 detached also, and  this  spontaneous  se-
 paration of the latter  membrane he very
 justly regards, as a positive indication for
 the operation.  However, it  is very cer-
 tain, that if, in  cases of extravasation,
 the  surgeon were to  wait for this crite-
 rion, the operation would be done  too
 late, and, therefore, whenever unequivo-
 cal  symptoms  of pressure on the brain
     D 
26
HEAD.
 exist, trephining should never  be delay-
 ed.  Giving vent to the confined blood
 " may produce a cure, or it may prove
 only a temporary relief, according to the
 different circumstances of different cases.
 The disappearance, and even the allevia-
 tion of the most pressing symptoms is un-
 doubtedly a favourable circumstance,  but
 is not to be depended upon  as absolutely
 portending a good event.  Either a bloody,
 or limpid extravasation may be formed,
 or forming between the meninges, or upon,
 or within the brain, and may prove as cer-
 tainly pernicious in  future, as the more
 external effusion would have done, had it
 not been discharged; or  the dura mater
 may  have been  so damaged by the vio-
 lence of the blow as to inflame  and sup-
 purate, and thereby destroy the  patient."
 (Pott.)
   " If the disease (says the same eminent
 surgeon) lies between the dura and  pia
 mater, mere  perforation of the skull can
 do nothing; and, therefore,  if the symp-
 toms are pressing, there is no remedy but
 division of the outer of these membranes.
 The division of tlie dura mater is an ope-
 ration, which  I  have  several times seen
 done by others,  and  have often done my-
 self; I have seen it, and found it now and
 then successful; and, from those  instan-
 ces of success, am satisfied of the proprie-
 ty, and necessity of its being sometimes
done."  He next states, however, his sen-
timent, that wounding the dura  mater is
itself attended with dangerous consequen-
ces.   Mr. Abernethy's  opinion  of such
operation has already been given.
  " Upon the removal of a piece of bone
by means of the trephine; if the operation
has been performed over the part where
the disease is situated,  and  the  extrava-
sation be of the  fluid kind, anel  between
tlie cranium and dura mater; such fluid,
whether  it be blood,  water, or  both, is
immediately seen, and is partly discharg-
ed  by such opening ;  if,  on  the other
hand, the extravasation be of blood in a
coagulated >r grumous state, it is  either
loose, or in some degree adherent to the
dura mater; if the former of these be the
case, it is either totally or partially dis-
charged at t. e time of,  or soon after, the
operation, according to  the qwrntity  or
extent of the mischief;  if the latter, the
perforation discovers, but does not imme-
diately discharge it  In both instances,
the conduct of the surgeon,  with regard
to repetition of  the operation,  must  be
determined  by  the  particular  circum-
stances of each individual case ; a large
extravasation  must necessarily require a
more free removal of bone than a small
one; not only on account of freedom  of
discharge, but on  account of larger  de-
 tachment of dura mater j and a grumous
 or coagulated  extravasation  requires a
 still more free use of the instrument, not
 only because  the blood in such state is
 discharged with  difficulty, but because
 the whole surface of  the  dura  mater so
 cove; ed is always put  under the  necessity
 of  suppurating,  which  suppuration  has
 but one chance of a happy event, and that
 derivable from the free use of tlie perfor-
 ator.
   " When the extravasation is  not  be-
 tween the cranium and dura mater,  but
 either between the meninges, or  in  the
 ventricles of the brain, the appearances
 are not only different  from tlie preceding
 state of the case, but  from each other.
   " When the extravasated fluid lies be-
 tween the skull and dura mater ; as soon
 as that extravasation is discharged, or the
 grumous blood has been wiped off,  the
 dura mater appears  flaccid, easily yields
 to or does not resist  the impression of a
 finger,  and (the  discharge being made)
 enjoys that kind of motion, that  elevation
 and  depression, which  our fathers sup-
 posed it  to have naturally and always,
 but which is only the  consequence of  the
 circulation through the brain,  and  the
 artificial  removal of  the piece  of  bone.
 But when the extravasation is  situated
 between the meninges, or on tlie surface
 of the brain,  tlie appearance is not  the
 same.  In this case, there is no discharge
 upon removing the  bone;  and  the dura
 mater, instead of being flaccid and readily
 obeying the motion of the blood, appears
 full  and turgid, has little or no motion,
 and  pressing hard against  the  edges  of
 the perforation, rises into a kind of  sphe-
 roidal form in the hole of the perforated.
 bone.  If the extravasation be of the lim-
 pid kind, the membrane retains  its  natu-
 ral colour; but if it be either purely fluid
 blood, or blood coagulated and the sub-
ject  young, the colour of the membrane
 is so altered by what lies under it, that
 the nature of the case is always deter-
 minable from this circumstance.
  " Be  the extravasated  fluid  what  it
 may, it  has  no natural outlet; absorp-
 tion  was tlie only chance the patient had
 whereby to get rid of it without an opera-
 tion,  and that we must now suppose to
 have  failed; an artificial opening there-
 fore  must be made, by the division of the
 dura mater, and perhaps of the pia also.
 This  operation, under the circumstances
 and  appearances  already  mentioned,   is
 absolutely necessary,  and  has been sue.
 cessful;  it is performed to give discharge
 to what cannot be got rid of by any other
 means, and consists in a division of the
 membrane or  membranes, made in a cru-
 pial  form with a  point of a lancet.  The 
HEAD.
%x
  Operation in itself is extremely simple and
  e&s},  but Vhe  patient is thereby put  into
  the state  of one whose meninges have
  been wounded, with only this difference,
  that the wound made for this purpose is
  smooth and simple, and inflicted with the
  least  possible violence : whereas an acci-
  dental wound of the same pans may be
  lacerated, contused, and attended with
  circumstances  which must aggravate the
  evil, and may  induce worse  consequen-
  ces."  (Pm.)
    All cases of pressure on the  brain are
  attended with hazard of inflammation of
  this organ, and membranes.   This danger
  must  be averted as much as  possible, by
  the antiphlogistic  means,  recommended
  in speaking of fractures of the skull.

     CONCUSSION, OR  COMMOTION OP  THE
                  BHAIN.

    " Very  alarming symptoms, followed
  sometimes by the most fatal consequences,
  (Pott remarks,) are found to  attend great
  violence offered to  the head;  and, upon
Sthe strictest examination both of  the liv-
  ing and the dead, neither fissure, fracture,
  nor extravasation of any kind can be dis-
  covered.   The  same symptoms, and the
  same event,  are met with, when the head
  has received no injury at all ab externa,
  but has only been violently shaken ; nay,
  when  only the body, or general frame,
  has seemed to have sustained the whole
  violence."  And the  same writer after-
  wards accurately  observes, that  " the
  symptoms attending a concussion are gen-
  erally in proportion to the degree of  vio-
  lence, which the brain itself has  sustained,
  and which, indeed, is cognizable  only by
  tlie symptoms.  If  the concussion  be very
  great, all sense and power of motion are
  immediately abolished, and death follows
  soon : but, between this degree, and that
  slight confusion (or stunning, as it is call-
  ed) which attends  most violences, done
  to the head, there are many stages "  I
  think Mr. Abernethy has particularly ex-
  celled other writers, in his description of
  the symptoms  of concussion, which, he is
  of opinion, may be properly divided into
  three stages.
    " The frst is, that state of insensibility
  and derangement  of the bodily powers,
  which immediately succeeds  the accident.
  While it lasts,  tlie patient scarcely feels
  any injury that may be inflicted on him.
  His breathing is difficult, but in  general
  without stertor; his pulse  intermitting,
  and his extremities cold.   But  such a
  state  cannot last long; it goes off gradu-
  ally, and is. succeeded by another, which
  I consider as the second stage of concus-
  sion.  In  this,  the  pulse and respiration
become better, and, though not regularly
performed, are sufficient to maintain life,
and to diffuse warmth over the extreme
parts of the body.  The  feeling of the
patient is now so far restored, that he i9
sensible  if his skin be pinched;  but he
lies stupid, and inattentive to slight ex-
ternal impressions. As the effects of con-
cussion diminish, he  becomes capable of
replying to questions put to him in a loud
tone of voice, especially when they refer
to his chief suffering at the time,  as pain
in the head, &c.;  otherwise, he answers
incoherently, and  as if his attention was
occupied by something else.  As long as
the stupor remains,  the inflammation of
the brain seems to be moderate ; but as
the former abates, the latter seldom fails
to  increase;  and this constitutes the
third stage, which is the most important
of the series of effects proceeding from'
concussion.
  " These several stages  vary consider-
ably in their degree  and  duration; but
more or less of each will be found to take
place in  every instance where the  brain
has been violently  shaken. Whether they
bear any  certain proportion to each other
or not, I do not know. Indeed this will
depend upon  such a  variety of circum-
stances in the constitution,, the injury, and
the after-treatment, that it must be diffi-
cult to determine.
  " With regard to the treatment of con-
cussion, it would appear, that in the first
stage very little can be done; and per-
haps, what little is done, had better be
omi.ted, as the brain and nerves are pro-
bably insensible to  any stimulants that
can  be employed.  From  a loose, and, I
tlunk, fallacious analogy between the in-
sensibility  in  fainting,  and  that  which
occurs in concussion,  the  more powerful
stimulants,  such  as  wine,  brandy, and
volatile alkali, are commonly had recourse
to, as soon as the patient can be got to
swallow.  The same reasoning which led
to the employment of these remedies in
the first  stage, in  order to recall sensibi-
lity, has  given a kind of sanction to their
repetition in the  second, with a view to
continue and increase it.
  " But  here the  practice becomes  more;
pernicious, and less defensible. The cir-
cumstance of the brain having so  far re-
covered  its powers,  as to carry on the
animal functions in a degree  sufficient to
maintain lite, is surely a strong argument
that it will continue to do  sq, without the
aid of means which probably tend to  ex-
haust parts already weakened, by the vio*
lent ad 'ion they induce.
   " And it seems probable, that  these
stimula ing liquors  will  aggravate that
inflammation Which must  sooner or later 
 .»               I1EA

 ensue."  (Essay on Injuries of the Head,

   The following passage, extracted from
 a writer, who  has already been of mate-
 rial assistance to us in this subject, can-
 not be too deeply impressed on  the me-
 mory of every surgical practitioner .-
   " To  distinguish  between an  extrava-
 sation and a commotion, by the symptoms
 only, is frequently a very difficult matter,
 sometimes an impossible one.   The simi-
 larity of the effects in some cases, and tlie
 very small space of tune which may inter-
 vene between the going off of the one and
 accession of the .other, render this a very
 nice exercise of the judgment.  The first
 stunning or deprivation of sense, whether
 total or  partial, may be from either, and
 no man  can  tell from which; but when
 these first symptoms have been removed,
 or  have spontaneously disappeared ;  if
 such patient is again oppressed with drow-
 siness, or stupidity,  or  total or partial
 loss of sense, it then becomes most pro-
 bable, that the first complaints were from
 commotion, and that the latter are from
 extravasation;  and the greater the dis-
 tance of time between the two, the greater
 is the probability not only that an extra-
 vasation  is the  cause, but that the extra-
 vasation  is of the limpid kind, made gra-
 datim, and within the brain.
   " Whoever seriously reflects  on the
 nature of these two causes of evil within
 the cranium, and considers them as liable
 to frequent combination in tlie same sub-
ject, and at the same time considers, that
 m many instances  no degree of informa-
 tion can be obtained from the only person
 capable  of giving it (the  patient), will
 immediately be sensible, how very difficult
 a part a practitioner has to act in  many
 of these cases,  anel  how very  unjust  it
 must be  to call that ignorance ; which is
 only a just diffidence arising  from the
 obscurity of the subject, aiid the impossi-
 bility of attaining materials to form a clear
judgment.
  "When there is no reason to apprehend
 any  other injui), and  commotion seems
 to be the sole disease, plentiful evacuation
 by phlebotomy and lenient  cathartics, a
 dark room, the most  perfect quietude,
 and  a  very  low regimen,  are  the only
 means in our power ; and are sometimes
 successful."  (Pott)
  The reader, who wishes to acquire the
 most accurate information, concerning in-
juries of the head, may consult, with ad-
 vantage, various dissertations in theJUem.
 de I'Acad. de Chifnrgie; Traite' des Optra-
lions de Chirurgie par Le Dran,- Dease on
 h ounds of the Head; Pott on Injuries of
 tlie Head from  External  Violence;  Hill's
 Cases in Surgery; 0*Halloran on  the dif-
              HEM

 ferent Disorders arising from External In-
 juries of the Head; Some Cases in Desault's
 Parisian  Chirurgical Journal;  Jiltmoire
 sur les Plaies de T£te, in (Euvres Chirurgi-
 cale de Desault, par Bichat, Tom. 2; Las-
 sus, Pathologie Chirurgicale,  Tom. 2, p.
 252, &c. Edit. 1809.)
   HECTIC  FEVER.  See Fevers, Sur-
 gical.
   HEMERALOPIA. According to M.Du-
 jardin, this term  is derived from vtt*.i%ot,
 the day, *'*e>s, blind, and »^, the eye,
 and its right signification is therefore in-
 ferred to be diurna excitudo, or day-blind-
 ness.  (See Journal de Mtdecine, 'Tom. 19,
 p. 348.)  In the same  sense, Dr. Hillary
 (Obs.  on the Diseases of Barbadoes, p. 298,
 Edit.2,) Dr.Heberden (Med. Transactions,
 Vol. 1, Art. 5.) have employed the term.
   Hemeraiopia then, which is of very rare
 occurrence,  stands in  opposition to  the
 nyctalopia, of the ancients, or night-blind-
 tiess.  Moelern writers in general,  how-
 ever,  have used these terms in  the con-
 trary sense; considering the hemeraiopia,
 as  denoting sight during  the  day, and
 blindness in the night, and nyctalopia, as
 expressing night-seeing, owl-sight, as the
 French call it, and blindness during the
 day-time.
   Hemeraiopia, in the meaning of day-
 blindness,  is a very uncommon  affection.
 Dr. Hillary had never met with  but two
 examples.  He mentions a report,  how-
 ever, that there are a people in  Siam, in
 the East Indies, and also in Africa, who
 are subject to the disease of being  blind
 in the day time, and seeing well by night.
 (Mod. Univ. Hist.  Vol. 7.)
  Sauvages affirms, that the hemeraiopia,
 in his nomenclature called amblyopia cre-
 puscularis, had, about two years before,
 been  in  some degree  epidemic in the
 neighbourhood of  Montpellier, in the vil-
 lages,  in  damp situations adjoining the
 rivers, and that it particularly  affected
 the soldiers, who  slept in the open damp
 air.  They were cured, he says, by blis-
 tering, together with emetics and cathar-
 tics, and other evacuants.  (Nosol. Me-
 thod. Class 6, Gen. 3, Spec. 1.)
  See some ingenious observations on this
 subject in Dr. Rees's Cyclopaedia,  Art.
 Hemeraiopia.
  Scarpa, with the generality of modern
 writers, has considered the hemeraiopia,
 as an affection, in which the patient sees
 very well in the day, but, not in the night-
 time.
  The following observations are offered
by this celebrated Professor upon the dis-
ease, in the sense of night-blindness.
  " Hemeraiopia,  or  nocturnal blindness,
(says, Scarpa)  is properly nothing but a 
HEMERALOPIA-                               29
kind of imperfect  periodical  amaurosis,
most commonly sympathetic with the sto-
mach.  Its paroxysms come on towards
the evening, and disappear in the morn-
ing.  The disease  is endemic  in  some
countries, and epidemic, at certain sea-
sons of the year, in others.
  " At sunset, objects appear to persons
affected with the complaint, as if covered
with an ash-coloured veil,  which gradu-
ally changes into a dense cloud, which in-
tervenes between the eyes,  and surround-
ing objects.  Patients with hemeraiopia
bavejthe pupil, both in the day and night-
time7 more  dilated, and  less moveable,
than it usually is in healthy eyes.   The
majority of them, however, have the pupil
more or  less moveable in  the day-time,
and always  expanded and motionless at
night.  When brought into a room faintly
lighted  by a candle, where all the by-
standers can see tolerably well, they can-
not discern at all,  or  in  a very feeble
manner, scarcely any one object; or they
only find themselves able to distinguish
light from darkness ; and  at  moon-light
their sight is still  worse.  At day-break
they recover their sight, which continues
perfect, all  the  rest of the day, tdl sun-
set."
  This disease (according to Scarpa) may
commonly be completely cured, and often-
times in a very short time,  by treating it
on the same  plan by which the imperfect
amaurosis is remedied ; (see Amaurosis,-)
viz. by employing emetics, the resolvent
powders, and pills, and a  blister on the
nape of the  neck ;  and,  topically, the va-
pours of the caustic volatile alkali:  last-
ly, by prescribing, towards  the end of the
treatment, bark conjoined with valerian.
In cases, in which  the disease  has been
preceded by plethora, and suppressed per-
spiration, bleeding and sudorifics are also
indicated.
  In this manner, Scarpa  has  succeeded
in curing three subjects, affected with the
complaint.  The first was a boy, fourteen
years  old, who, for several weeks,  had,
in vain,  made use of the fumigation of a
sheep's liver, which had been fried.   The
second was a waterman ; the third a coun-
tryman, living  in  the rice-fields in the
vicinity of Pavia.  The two last were be-
tween thirty and forty years of  age, and
emaciated, with bloated,  sallow counte-
nances. After the boy had vomited a good
deal, in consequence of taking, at repeat-
ed  doses, in the space of two  hours, a
grain and a half of tartar emetic, dissolved
in four ounces of water, he took on the
following days,  the  resolvent  powders,
mentioned in Amaurosis.  They produced
nausea,  and two or three copious  stools,
ftgularly every  day.   On the evening of
the fifth day, the patient began to discern
surrounding objects by the faintest light
of a lantern.   Even since the emetic was
administered, he continued the topical use
of the vapours of the spirit of sal-ammo-
niac, and, on tlie sixteenth day, was per-
fectly cured. The waterman tiirice  vomit-
ed up a considerable quantity of a yellow-
ish, viscid matter.  Afterwards, he took
the resolvent powders, which made him
vomit  again on the third day, and, in the
day-time, he regularly exposed his eyes,
every  four hours, to the action  of the
ammoniacal vapours.  It was  not till the
eleventh  day, that he began to distinguish
objects in the night-time by a weak can-
dle-light.  The countryman vomited only
once copiously, but afterwards experien-
ced considerable nausea  during the nine
following days, on which he took  the re-
solvent powders, and he  daily discharged
by stool  a considerable quantity of green-
ish matter.  From  the  beginning, this
patient also employed the ammoniacal va-
pours, as  a topical application, and, on
the evening of the fourteenth day,  he be-
gan to see by candle-light.   From this
period, he continued to regain the  faculty
of seeing objects in the night-time regu-
larly  more and more, until he was com-
pletely cured. Towards the conclusion of
the treatment, Scarpa gave these patients
bark and valerian.
   But, the most expeditious cure was that
which Scarpa effected on Mauro Bonini,
a robust husbandman, of Donalasco, aged
two-and-twenty. This man began in March
to perceive, that, at sunset, he could only
distinguish objects very imperfectly. The
complaint increased  to  such  a  degree,
that,  in  the beginning of May, he was
almost totally blind in the evening.  On
the tenth of May, he came to the hospital
at Pavia.  Having examined both his eyes
in the day-light, Scarpa found both the
pupils very  much  dilated,  and  almost
motionless.  In the evening,  he repeated
the examination, and assured himself, that
the patient could not see objects, which
were visible to tlie  by-standers,  conse-
quently, that he was affected  with  hemer-
aiopia.   He also complained of bitterness
in his mouth,  heaviness in his head, and
his tongue was foul.
   On the eleventh, Scarpa ordered him an
emetic,  which did  not produce so much
effect  as was expected, and therefore a
stronger one was prescribed the next day.
It was composed of a dram and a  half of
ipecacuanha,  and   two grains of  tartar
emetic.  This dose made him vomit up a
considerable emantity of" yellow, greenish
matter.  The patient found his head re-
lieved immediately afterwards, and  the
bitterness in his mouth was no longer per- 
30
HEMERALOPIA.
  ceptible; the pupils of his ej es contracted
  a little, and became somewhat moveable
  in a vivid light. The ammoniacal vapours
  were now externally applied.   Tlie s* ne
  evening, tiie patient's sight seemed amend-
  ed,  and,  on  the thirteenth,  all internal
  medicines were discontinued, the vapours
  alone being used.
   On the fourteenth, the patient complain-
  ed again of bitterness in his mouth, and
  his  tongue appeared furred. Scarpa order-
  ed  him  to take the  resolvent powders
  every three hours.  These produced nau
  sea, and some evacuations from the bow-
  els.  The use  of the vapours  was con-
 tinued.  In the evening,  Scarpa exposed
 the patient to  the same degree of* light,
 as when the preceding examinations were
 made, and the patient was able to distin-
 guish all objects which were presented to
 him, exceedingly well.  On the sixteenth,
 the  symptoms of foulness in the stomach
 entirely  disappeared,  and the  pupil  of
 each eye contracted  in a moderate light,
 as in healthy persons.  The man left  the
 hospital,  on the seventeenth,  perfectly
 cured.
   Scarpa notices, that the ancients have
 strongly recommended, for the cure of this
 disease, the fumigations of a sheep's liver
 fried.  These were directed against the
 eyes through a funnel; and the liver, thus
 prepared,  was  also directed to  be eaten.
 Even in  Italy,  according t» Scarpa, this
 remedy in  general obtains confidenpe not
 only with  the vulgar, but also with sur-
 geons.  Some writers add, that  it is pro-
 ductive of wonderful success among the
 Chinese, who are said to  be very liable to
 this  complaint.   Scarpa  says,  he has no
 observations of his own to offer in support
 of this account;  but,  the case of the
 above-mentioned boy seems to be repug-
 nant  to it.  If,  however, the efficacy  of
 this  remedy should be a  matter of fact,
 surgeons will  possess another means  of
 curing noeturnal blindness, besides that
 which we have been explaining.
   Celsus, in the chapter on Mydriasis, has
 the  following words:  Quidam sine  ulld
 manifesto" causd subitd obexcati sunt.  Ex
 quibus nonnulli, cum aliquandiu nihil vidis-
 sent, repentind profusione alvi lumen recu-
perant.   Quo minus alienum videtur, et re-
 centi re,et interposito, tempore medicamentis
 quoquemolvn dejectiones, quxomnem noxiam
 materium per inferior a depellant.  This pas-
 sage, Scarpa thinks, refers not only to the
 J«at-meni of the dilated pupil, but also to
 that  ot the imperfect amaurosis, which
 occurs suddenly; and it  appears to him
 to merit the attention of practitioners.
   Ine first  part of what Celsus has stat-
 ed, viz. that persons who have been for
 some time affected with amaurosis, have
 regained their sight on being attacked by
 a diarrlicc^iHiJeems to Scarpa to t>e corro-
 borated by the case, related by  Doctor
 Pye. (Med. Obs. and Inq. Vol. 1.) A man,
 forty  years of age,  says  he,  had  been
 affected for two months with periodical
 amaurosis, which, for a certain time, had
 occurred regularly every evening,  but af-
 terwards came on irregularly, at different
 intervals,  with  considerable dilatation of
 the pupil,  and such  obscuration of sight
 on the approach of night,  that even the
 light of a candle could not be discerned.
 The man was  seized  with a diarrhoea.
 Doctor I'\ e ordered htm to lake, for eight
 successive  elays,  a potion  with  the kali
 praeparatum; then he prescribed an elec-
 tuary, composed of  bark,  nutmeg,  and
 sirup of orange-peek  The two latter in-
 gredients  were  added to  the  bark, on
 account of the continuance of the diarrhcea.
 The sec >nd day after the  electuary was
 taken, tlie  diarrhoea increased, and  the
 patient vomited copiously; after which he
 suddenly recovered his sight, so as to see
 equally well by day and by night  As the
 diarrhoea  continued,  the electuary  was
 omitted, after having been taken two days.
 A violent fever succeeded  the diarrhcea,
 and, it was remarked that,  during the
 highest stage of the  former,  the  patient
 became rather deaf,  but without losing
 his sight in  the night  or day-time.  Doctor
 Pye does not mention what  steps were
 taken to moderate the fever, which prov-
 ed fatal to the patient. At all events, adds
 Scarpa, it is a fact, that this spontaneous
 laxness of the bowels entirely freed the
 man from the imperfect periodical amau-
 rosis.  Scarpa entertains no doubt, that,
 by looking attentively into the numerous
 collection of medical observations,  one
 might  find  in them a  great many facts
 similar to the preceding one, shewing the
 influence of what he terms  morbific gas-
 tric stimuli over the organ of sight, and,
 consequently,  the great utility of a spon-
 taneous looseness of  the bowels  in  the
 cure of the imperfect amaurosis.
  But, says Scarpa, even if such exam-
 ples of the incomplete amaurosis  being
 dissipated in consequence of spontaneous
 vomiting, or copious evacuations from the
 bowels, produced entirely by nature, were
 rare, and noticed by few, we now have so
 many observations,  evincing the succes
 ful cure of this disease by means of such
 evacuations, artificially produced by eme-
 tics, and  internal resolvents,  that  no
doubt whatever  can be  entertained, con-
cerning the  accuracy  of the second part
of Celsus S  admonition, relative  to  the
present view of the imperfect amaurosis .-
 et  recenti  re,  interposito   tempore,  me-
dicamentis  quoque moliti dejectiones, gnx 
h Am                                  hem             si
ow7i<»i naritm materiam per infrriapa depel-  such as destrov the transparency of only
lant.  Of  this Scarpa remarks,  we  un-  a*certain portion of these parts.
doubtedly  have numerous,  satisfactory    The cure of this species of hemiopia
proofs, in the accurate  observations, re- ^.depends upon the' removal of the partial
lated by Schmucker and Richter; but our  opacity from which it originates.   (Sec
 confidence, says  Scarpa,  in the  above
 method of curing the imperfect and perio-
 dical amaurosis, must increase,  when we
 take notice,  that the most respectable
 practitioners of past times, have, in the
 majority of cases, cured this disease only
 by means of emetics, and internal resolv-
 ents, though, in their writings, they may
 have imputed  the success  of the treat-
 ment to other causes,  or the efficacy of
 other re medies, which they prescribed con-
 jointly  with emetics, and resolvents.
   Scarpa, after several valuable remarks
 on amaurosis in general, refers to the Mer-
 cure de France, for February, 1756, where
 there is an account of tlie cures performed
 by Fournier, on several subjects, affected
 with hemeraiopia.   The first were three
 soldiers, to whom an emetic was adminis-
 tered,  after bleeding   them.  The  next
 day, as they also complained of a heavi-
 ness in  their head, and nausea, the bleed-
 ing and emetic were repeated.  This ex-
 pedient removed all the above symptoms,
 and these three soldiers were no  longer
 unable  to see in the night-time.  Fouimier
 met with equal success, in treating eight
 Other soldiers upon  the same plan, .who
 were affected with the same disease, and
 belonged to the same garrison.
   Scarpa notices, that Pellier (Recueil de
 Mem. et Obs. sur I'CEil. Obs. 132.) cured
 Captain Micetti. of an hemeraiopia by re-
 peated  doses of tartar-emetic, a seton in
 the nape of the neck, and cooling, aperient
 beverages.  Pellier  also assures us, that
 he has several times  cured the recent im-
 perfect  amaurosis, by means of small doses
 of tartar-emetic,  and  topical  aromatic
 fumigations.  (Observ.  136—138.)  (See
 Scarpa  sulle Malattie degli Occhi. Venezia,
 1802)
   HEMIOPIA.   (from t)fucvf,  half, and
 uifz, the eye.)  A certain disorder of the
 eye, in  which the patient cannot see the
 whole of any object, which he is looking
 at, but only a part of it. Sometimes, he
 sees the middle, but not the circumfer-
 ence ; sometimes  the circumference, but
 not the centre;  while, on other occasions,
 it  is only the upper,  or lower half,  which
is  discerned.  Sometimes objects are seen
 thus  imperfectly,  whether distant, or
 near; sometimes, only when they are near,
 and not at a great distance.
   The causes of the hemiopia are divided
by Richter into four  kinds.
  To the first belong  opacities of tlie
rorn'%<  and  crystalline  lens, especially,
 Cataract, and Cornea, Opacities of.)
   Under  certain circumstances, persons,
 whose upper eyelid cannot Jae  properly
 raised, are affected with hemiopia.  They
 can only discern the k»\\ er half of an ob-
ject,  which is near and of large  size^ un-
 less they  go further from, it, draw their
 heads backward, or turn their eyes down-
 ward. The pupil, in particular instances,
 becomes drawn away from the mjddle of
 the iris.   This may also be a cause of he-
 miopia : it is a case, that does not admit
 of a  cure.  The affection may likewise
 proceed from a separation of the  iris from
 the margin of the cornea by external via-
 lence, on  other causes.  Here the cure is
 equally impracticable.
   The foregoing species of hemiopia  are
 merely effects of other diseases. Ttu fimrth
 and last kind is the  most important,  be-
 ing generally regarded as an independent
 disorder.   Sometimes,  it  appears rather
 to be the effect of a sudden and  transient
 irritation,  producing a morbid sensibility
 in the optic nerve.
   The causes of this sort of case,  if we
 can credit Richter, are mostly seated in
 the abdominal viscera.  When the  affec-
 tion is  more durable, forming what  has
 been termed amaurosis dmidiata, the same
 treatment is  indicated, as  in the  paralytic
 affections of the retina and optic nerve,
 in which  last disorders, indeed, it often
 terminates (See Richter's Anfangsgrunde
 der Wundarzn. Band. 3. Kap. 17.)
   HEMORRHAGE,  (from cufut,  blood,
 and pvyvvfii, to break out.)  Mamorrha-
gia, Bleeding.
   This is doubtless one of the most im-
portant subjects in Surgery.  The fear of
hemorrhage in fact retarded the improve-
ment  of our profession for ages; for the
ancients, ignorant how to stop bleeding,
were afraid to cut out the most trivial tu-
mour, or they did so with terror.   They
generally performed operations slowly ant]
imperfectly,  by means  of burning-irons,
or ligatures,  which the  moderns execute
quickly and  safely with a knife.  If tlie
old surgeons ventured to amputate a limb,
they only did so, when it had mortified, by
dividing the dead parts, and so great was
their apprehensions of bleeding, that they
only dared to cut parts which could no
longer bleed.  (John BeWs Principles  of
Surgery, Vol. 1. p. 142.)  But, not only as
a consequence of surgery, is hemorrhage
to be feared; it is also one of tlie most
alarming accidents, which  surgery is call- 
32
HEMORRHAGE.
ed upon to relieve. " Un sentiment naturel
attache a I'id/e de perdre son sang ; un ter-
rcur macliinale, dont I'enfant, qui commence
ti purler, et I'homme le plus dtcid6, stmt
igalement susceptibles. Onnepeutpoint dire,
que cette peur soit chimtrique.  Si I'on comp-
toil ceux, qui per dent la vie dans une bataille,
on verroit, que les trois Quarts out p4ri par
quelque hemorrhagic; et dans les grandes
operations de chirurgie cet accident est pres-
que toujours le plus formidable."  (Morand.
Mem. de  PAcad. Royale de Chirurgie, Vol.
5. &vo.  See Jones on Hemorrhage.)
  As the blood circulates  in the arteries
with much greater impetus and rapidity,
than in the veins, it necessarily follows,
that their wounds are generally  attended
with much more hemorrhage, than  those
of the latter vessels, and that such hemor-
rhage is more  difficult to suppress.  How-
ever, as the blood also flows through veins,
of great  magnitude, with great velocity,
bleedings from them  are frequently highly
dangerous, and sometimes unavoidably
fatal. When  an artery is  wounded, the
blood is  of a brght scarlet colour, and
gushes from the vessel per sal turn, in a very
rapid manner.  The blood issues from  a
vein in an even,  unbroken stream, and is
of a dark purple red colour.  It  is  of
great practical use  to remember,  these
distinguishing differences, between arte-
rial  and  venous hemorrhage,  because,
though the oozing  of blood may  be in
both cases equal in quantity, yet, in the
latter instance, one  is often justified in
bringing the sides of a wound  together,
without taking farther  means to suppress
the bleeding, while it would not be proper
to adopt  the same conduct, were there an
equ.d oozing of arterial blood.
   Dr. Jones has favoured  the world with
a matchless work, on the present subject;
and  as one gr. nd object of this Diction-
ary is to convey a careful  account  of all
the  latest  improvements in surgical sci-
ence, I shall first endeavour to  make the
reader acquainted with the more accurate
ideas, which  this gentleman  has  lately
pubhshed, relative to the doctrines of he-
morrhage. Afterwards, we shall consider
the surgical means to  be practised  in dif-
ferent cases.
   The sides of the arteries are divisible
into three coats.  The internal one is ex-
tremely thin,  and  smooth.   It is elastic,
and firm,  (considering its delicate struc-
ture) in the longitudinal direction, but so
weak in the circular as to be very easily torn
by the slightest force applied in that direction.
Its diseases shew, that it is vascular, and
it is also probably sensible.
   The middle coat is the thickest, and  is
composed of muscular fibres, all arranged
in a circular manner; they differ, how-
 ever, from common muscular fibres in be-
 ing more elastic,by which they alone keep
 a dead artery open, and of a  cylindrical
 form.  As this  middle coat has no longi-
 tudinal fibres, the circular fibres are held to-
 gether by a slender  connexion, which yields
 readily to any force, applied in the circum-
ference of  the artery.
   The external coat is remarkable for its
 whiteness, density, and  great elasticity.
 When an artery is surrounded with a tight
 ligature, its middle and internal coats are as
 completely  divided by it, as they could be by a,
 knife, while the external coat remains entire.
   Besides these proper coats,  all the ar-
 teries, in their natural situations, are con-
 nected, by  means of fine cellular sub-
 stance,  with surrounding, membranous
 sheaths. If an artery be divided, the divided
 parts, owing to their elasticity, recede from
 each other, and the length of the cellular sub-
 stance, connecting the artery with the sheath,,
 admits of in retracting a certain way within
 the sheath.
   Another important fact is : that when an
 artery is divided, its truncated extremities
 contract in c greater, or less, degree, and the
 contraction is generally, if not always,  per-
 manent.
   Arteries are furnished  with  arteries,
 veins, absorbents, and nerves ; a structure,
 which makes them susceptible of every change
 to which livir.g parts are subjected in common;
 enables them to inflame, wlien injured, and to
 pour out coagulating lymph  by which the in-
 jury is  repaired, or  t'e  tube permanently
 closed  (Si e Jones on Hemorrhage.)
    M.  Petit,  the surgt on, was the first,
 who, in 1731, endeavoured to explain the
 means, which nature employs for the  sup-
 pression of Hemorrhage.  He thought, that
 bleeding from a divided artery is  stopped
 by the  formation of a coagulum of blood,
 which is situated partly within, and partly
 without the vessel. The clot,he says, after-
 wards adheres to the inside of the artery,
 to its orifice, and to the surrounding parts;
 and, he adds,  that when  hemorrhage is
 stopped by a ligature, a coagulum is form-
 ed above  the ligature, which  only differs
 in shape,  from  the one, which takes place
 when no ligature  is employed.  His opi-
 nion leads him to recommend compression
 to support the coagulum.
    In 1736,  M. Morand published addi-
 tional interesting  remarks.  He allowed,
 that a coagulum had some effect in stop-
 ping hemorrhage ; but, contended, that a
  corrugation, or plaiting,  of the circular
  fibres of  the  artery which  diminish  its
  canal, and a shortening  and consequent
  thickening of its * longitudinal ones, which
  * Anatomists do not acknowledge that
such exist. 
Hemorrhage.
h?arly rendered it impervious, had some
Share in the process. He thought that the
Cavity of an artery might be obliterated,
by the puckering, or  corrugation, when
Circular pressure, as that of a ligature, is
made.  '
  Morand erred  chiefly in  explanation •
for, the contraction and retraction of divid-
ed arteries are indisputable facts, and, as
Dr. Jones remarks, this does not affect the
truth of his general conclusion,  tliat the
efiange, produced on a divided artery, contri-
butes with the coagulum  to stop tlie flow of
blood.
  Mr. Samuel Sharp (2d. Edit, of Opera-
tions of Surgery,1739,) supported the same
doctrine.  "The blood-vessels,  immedi-
ately upon  their  division,  bleed freely,
and continue bleeding, till they are either
stopped by art, or, at length contracting,
and  withdrawing  themselves, into  the
wound, their extremities are shut up by
coagulated blood."
  Pouteau (Mtlanges de Chirurgie, 1760,)
denied, that a coagulum is always found
after an artery is divided; and,  when it
is, he  thought it only a feeble and subsi-
diary means  towards the suppression of
hemorrhage.   He contended, that the re-
traction of the artery  had not been  de.
monstrated, and could not be more effec-
tual, than  a coagulum.  His theory was,
that  the swelling of tlie cellular mem-
brane, at the circumference of the cut ex-
tremity of the artery, forms the principal
impediment to the flow of blood; and that
a ligature is useful in promoting a more
immediate and extensive induration of the
cellular substance.
  Gooch, White, Aikin, and Kirkland, all
oppose Pelit's doctrine of coagulum.  The
first  blends some of Pouteau's theory with
his own, by observing, that" when p small
artery is totally divided,  its retraction
may  bring it under the surrounding parts,
and  with the natural  contraction of the
diameter of  its mouth,  assisted by  the
compressive  power  of those parts,  in-
creased by their growing tiimid, the ef-
flux  of blood may be stopped.'*
  White was convinced, from what Govich
had  suggested, and  Kirkland confirmed,
that the arteries, by their natural contrac-
tion, coalesce, as  far as their first ramifi-
cation.
  Dr. Jones admits, that an artery con-
tracts  after it has been divided;  and his
experiments  authorize him  to say,  that
the contraction of an  artery is an impor-
tant  means, but, certainly not the only,
nor  even the  chief means, by which he-
morrhage  is  stopped.    The  impetuous
Mowing of the  blood through  the wound
of the artery would resist the contraction
     \oi..ll.
of the vessel in such a degree, that would*
in almost every instance, be attended with
fatal  consequences,  when  the  artery is
above a certain size, were it not for the
formation of a coagulum.   (Jones.)
  Mr. J. Bell thinks, that  when  hemor-
rhage stops of its own accord,  it is  nei-
ther from the  retraction of an artery, nor
the constriction of its fibres, nor the form-
ation of clots, but, by the  cellular sub*
stance, Which surrounds the artery, being
injected with bloocL
  We must refer the reader to Dr. Jones'
Work for a complete exposure of the in-
consistencies and absurdities in Mr. Bell's
account of his own theory.  (See P. 25,
&fc.)
  Dr. Jones very accurately concludes his
criticisms  on  Mr. Bell with observing,
that  if this gentleman really  means to
confine his doctrine of the natural means
of suppressing hemorrhage  to the injec-
tion of the cellular substance, round the
artery, with blood, he dwells improperly
on one of the  attendant circumstances to
the exclusion  of the  retraction,  and con-
traction of an artery,  and the formation
of a distinct clot, all primary parts of the
process.
  The blood,  besides  filling the cellular
substance round the artery,  also fills the
Cellular substance at the mtuth of the ar-
tery in  a particular  manner; for, the di-
vided vessel, by its retraction within its
cellular sheath, leaves a space of a deter-
minate form, which, when all tlie circum-
stances necessary for tlie suppression of
hemorrhage operate, is gradually filled up
by a distinct clot. (Jones.)

MEAHS OF NATCRE IN STOPPIXO  BLEEDINO
         FROM  DIVIDED ARTEniES.

  Dr. Jones has given  a faithful and ac-
curate detail of a series of experiments on
animals, which demonstrate  " that the
blood, the action, and even the structure
of the arteries, their sheath,  and the cel-
lular substance connecting them  with it,'*
are concerned  in stopping bleeding from a
divided artery of moderate size, in t|ie fol-
lowing  manner: " An  impetuous flow of
blood, a sudden and forcible retraction of
tlie artery within its sheath, and a slight
Contraction of its extremity, are the imme-
diate, and almost simultaneous, effects of
its  division.   The natural impulse, how-
ever,  with v hidi the blood  is driven on,
in some measure counteracts the retrac-
tion,  and resists the  contraction of the
artefy.  The blood is effused into the cel-
lular  substance, between the artery and
its sheath, and passing through that canal
of the sheath,  which had been formed bv 
HEMORRHAGE.
the retraction of the artery,  flows  freely
externally, or is extravasated into the sur-
rounding cellular membrane, in propor-
tion to the open, or confined state of the
wound.  The retracting artery leaves the
internal surface of the  sheath  uneven,
by  lacerating,  or stretching the cellular
fibres, that connected them.  These fibres
entangle the blood, as it  flows,  and thus
the foundation is laid for the formation of
a coagulum at the mouth of the artery,
and which appears to be completed  by
the blood, as it passes through this canal
of the sheath, gradually adhering and co-
agulating, around its internal surface, till
it completely fills it up from the circum-
ference to the centre."   (Jones, p. 53.)
  The effusion of blood into the surround-
ing cellular membrane, and  between the
artery and its sheath; but, in particular,
the diminished  force of the circulation
from loss of blood, and a speedy coagu-
lation of  this  fluid in this circumstance,
most   essentially  contribute, says  Dr.
Jones,  to the desirable effect.
  It appears then, that a coagulum, which
Dr. Jones calls the external one, at the
mouth of the artery, and within its sheath,
forms the first  complete obstacle to the
continuance of bleeding, and  though  it
seems  externally like  a continuation of
tlie artery, yek on slitting open this ves-
sel, its termination  can be plainly ob-
served, with the coagulum shutting  up
its  mouth, and contained in its sheath.
(Jones, p. 55.)
  No collateral  branch being very near
the impervious mouth of the artery, the
blood just within it is at rest, and usually
forms a slender conical coagulum,  which
neither fills up the canal of the artery,
nor adheres to its sides, except by a small
portion of the circumference of its base,
near the extremity of the vessel.  This
coagulum is distinct from the former, and
what Dr. Jones calls the internal one.
   The cut end of the  artery next  in-
flames, and tlie vasa vasorum pour out
lymph, which fills up  the extremity  of
the artery, is situated between  the inter-
nal and  external  coagula,  is somewhat
intermingled with  them, or adheres to
them,  and is firmly united  all round to
the internal coat of the vessel.   Dr. Jones
further states, that the  permanent sup-
pression of the hemorrhage chiefly  de-
pends  on this coagulum of lymph; but,
that tlie end of tlie artery is also secured
by a gradual contraction, which it  under-
goes, and by an effusion of lymph between
its tunics, and into the surrounding cellu-
lar substance;  whereby  these  parts be-
come thickened, and so incorporated with
each other, that one cannot  be discerned
from the other.  Should the wound in the
integuments  not heal  by the first inten-
tion, the coagulating lymph, soon effused,
attaches the artery firmly to the subjacent
and lateral parts, gives it a new covering,
and entirely excludes it from the outward
wound.  (Jones, p. 55.)
  The same  circumstances are  also re-
markable in  the portion of  the vessel,
most remote from the  heart.  Its  orifice,
however, is usually more contracted, and
its  external  coagulum smaller, than  the
one, which attaches itself to the other cut
end of the artery.  (Jones on Hemorrhage,
p. 56.)
  The impervious extremity of the arte-
ry, no longer allowing blood to circulate
through it,  the portion, which lies be-
tween it and the first lateral branch gra-
dually contracts, till  its cavity is com-
pletely obliterated, and its tunics assume
a ligamentous appearance.   The external
coagulum, which, in the  first instance,
had stopped  the hemorrhage, is absorbed
in a few days, and the coagulating lymph,
effused around it, and by which the parts
were thickenefl, is gradually removed, so
that they resume again their cellular tex-
ture.  (Jones, p. 57.)
   At a still later period, the ligamentous
portion is reduced to a filamentous state,
so that the artery is, as it were, completely
annihilated from its  cut end to the first
lateral branch.  Long, however,  ere this
final change is accomplished, the  inoscu-
lating branches have become considerably
enlarged, so as to establish a free commu-
nication, between the  disunited  parts of
the main artery.  (Jones, p. 58.)
   When an artery has been divided at some
distance from a lateral branch, three coagula
are formed : one of blood externally, which
shuts up its  mouth; one of lymph, just
within  the extremity of its  canal;  and
one of blood, within its cavity, and conti-
guous to that of lymph.  But, when the
artery  has  been divided near a  lateral
branch,  no internal coagulum of  blood  is
formed.  (Jones, p. 63.)
   The external coagulum is always form-
ed, when the divided artery is  left to na-
ture ; not so, however, if art interferes, for
under the application of the  ligature  it
can never form.  If agaric,  lycoperdon,
or sponge, be used, its formation is doubt-
ful, depending entirely upon the degree of
pressure, that is used; but, the internal
coagulum of blood will be equally formed,
whether the  treatment be left to ait, or
nature, if no collateral branch is near the
truncated  extremity of the artery;  and
lastly, effused lymph, which, when in suf-
ficient quantity, forms a distinct coagu.
lum, just at the mouth of the artery, will 
HEMORRHAGE.
3*
be always found, if tlie hemorrhage is per-
manently suppressed.  (Jones, p. 74.)

hkans,  Which  hature  employs  fob
  suppressing  tue  hemorrhage  from
  pcwctcred  or   partialli   divided
  arteries.

  The suppression of hemorrhage by the
natural means is much more easily accom-
plished, when an artery is completely di-
vided, than when merely punctured,  or
partially divided. Completely dividing a
wounded artery was one means practised
by the ancients in order to stop hemor-
rhage: the  modems  frequently do the
same thing, when bleeding from  the tem-
poral  artery proves troublesome.
  Dr. Jones has  related  many experi-
ments, highly  worthy  of perusal, and
which were undertaken to investigate the
present part of the subject of hemorrhage.
This gentleman, however, owns, that, in
regard to the temporary means by which
bleeding from a punctured artery is stop-
ped, he has but little to add to what Petit
has explained, in his third publication  on
hemorrhage.   (Mem.  de I'Acad.  des Sci-
ences; 1735.)   The blood is effused into
tlie cellular substance,  between the  ar-
tery  and its sheath,  for some distance,
both  above and below the wounded part;
and when the parts  are examined, a short
time after the hemorrhage has completely
stopped, we find a stratum of coagulated
blood between the artery and its sheath, ex-
tending fromafewincb.es belowthe wound-
ed part to two, or three inches above it, and
somewhat thicker,  or more  prominent
over  the wounded part, than elsewhere.
   Hence, rather than say the hemorrhage
 is stopped by a coagulum, it is more  cor-
rect to say, that it is stopped by a thick
lamina of coagulated blood, which, though
somewhat thicker at the wounded part, is
perfectly continuous with the coagulated
blood lying between the artery and its
 sheath.   (Joiws, p. 113.)
   When  an artery is punctured, the he-
 morrhage, immediately following, by  fill-
 ing up the space, between the artery and
 its sheath, with blood, and consequently,
distending the sheath, alters the relative
 situation of the puncture in the sheath to
 that  in the artery, so that they are  not
 exactly  opposite to each other; and by
 that  means a layer of blood is confined by
 the sheath over the puncture in the artery,
 and,  by  coagulating there, prevents  any
 further effusion of blood.
   But,  this coagulated blood, like the
 external coagulum of a divided artery,
 affords  only a temporary barrier to the
 hemorrhage: its permanent  suppression
is effected by a process of reparation, or
of obliteration.
  Dr. Jones's experiments shew, that an
artery, if wounded only to a moderate
extent, is capable of reuniting and heal-
ing so completely, that, after a certain
time, the cicatrization cannot be disco-
vered, either  on its internal, or extefnal
surface;  and that even oblique and trans-
verse wounds  (which gape  most) when
they do not open tlie artery to a greater
extent, than one-fourth  of its circumfer-
ence, are also filled  up and healed by
an  effusion  of coagulating  lymph from
their inflamed lips, so as to  occasion but
little, or no obstruction to the canal of
the artery.  The utmost magnitude of &
wound, which will still allow the  conti-
nuity of the canal to be preserved, is difc
ficult to  be learnt;  for, when the wound
is large, but yet capable of being  united,
such a quantity of coagulating lymph  is
poured out, that the canal of the vessel,
at the wounded part,.is more or less filled
up  by it. And when tlie wound is still
larger, the vessel becomes either torn or
ulcerated completely across, soon after-
wards, by which its complete division^
accomplished.
  The lymph, which  fills up the wound
of an  artery,  is poured out very freely
both from the vessel and the surrounding
parts, and it accumulates around the  ar-
tery, particularly, over the wound, where
it forms a more distinct tumour.  The
exposed surrounding parts at the same
time inflame, and pour out coagulating
lymph, with which  the whole surface  of
the wound becomes covered, and which
completely excludes  the artery from the
external wound.  This lymph granulates,
and tlie wound is filled up and healed  in
tlie usual manner.   (See Jones on Hemorr-
hage, p.  113, &c.)

 SURGICAL MEAKS OF  SUPPRESSING HEMOR-
                 RHAGE.
                                     •
   It must be plain to every one, who  un-
derstands the  course of the circulation,
 that pressure, made on that portion of a
 wounded artery, which adjoins the wound
 towards the heart, must check the effusion
 of blood.  The current of blood in  the
 veins, running in  the opposite direction,
 requires the pressure to be applied to
 that side of the wound, which is most
 remote  from the  heart.  As  pressure is
 the  most rational  means  of impeding
 hemorrhage,  so it  is the most effectual;
 and almost all the  plans,  employed  for
 this purpose, are only modifications of it.
 The tourniquet, tlie  ligature, the applica-
 tion of a roller  and compresses,  even 
36                            HEMORRHAGE.
  agaric itself, only become useful in the
  suppression of hemorrhage, on the prin-
  ciple of pressure, the cautery,  caustics,
  and styptics excepted.

    MEANS EMPLOYED RT THE ANCIE-XTS.

    In order to prevent a wounded person
  from  dying of  hemorrhage, Celsus ad-
  vises the wound to be filled with dry lint,
  over which is to be laid a sponge dipped
  in cold water,  and pressed oh  the part
  with the hand.   If, notwithstanding this,
  the hemorrhage should continue, he re-
  commends repeatedly applying fresh lint,
  wet with vinegar; but, he  is against the
  use of corroding escharotic applications,
  on account of the inflammation, which they
  produce; or only sanctions the  employ-
  ment  of the mildest ones.  When  the
  hemorrhage resists these  methods, he ad-
  iiises two ligatures to be applied to the wound-
 ed part nf the vessel, and then to divide the
 portion .i mated between them:—"  Quod si
 ilia quoque proftuvio vincunter, vend, qux
 sanguinemfundunt. apprehendendx  circaque
 itl, quod ictum est, duobus  locis deligandx,
 intercidendeque sunt, ut et in seipsx co'e'ant,
 el nihilominus oru prxclusa  habeant."  Lib.
 5. cap. 26.  When the ligature is  imprac-
 ticable, he proposes the actual cautery, if
 the wound should bleed sufficiently, and
 there should be no nerves, nor muscles at
 the bleeding part.
   Galen also mentions tying  the vessels
 to  stop the hemorrhage  from wounds;
 and there  are some traces of the same
 information in other authors, who lived
 before him,  as  Archigenes, and  Rufus.
 However, it is more  than  probable, that,
 in their days, the ligature was little used,
 as we must infer from  the  multitude of
 topical  astringents,  caustics, and other
 applications, which  they have  advised
 for stopping bleeding, and in which they
 Would have put lrs3 confidence, had they
 been familiarly acquainted with  the m>e
 of the ligature.   No one can doubt,  that
 they would very soon have  tied the  ves-
 sels after amputations,  had thev  had
 many opportunities of seeing  the  advan-
 tage, of the ligature; but,  so far  were
 they from adopting such practice, that,
 Albucasis, a long while  afterwards, re-
 tused to amputate a wrist, lest he should
 see Ins patient bleed to death.
  Pare passes for Hie first, who employ.
 ed  %he  ligature  after amputation.  H-s
 method having  been  attacked,  he  mo-
 desty defends it in the part of his works
intitled, Apohgie.  He takes gre.t care to
 impute  the ongin of it to  the ancients,
 and cites many of them, who have made
 inent10n  of it.   However, he thinks its
 utility  m  amputations of  such high con-
 sequence, that he considers  himself an
 inspired by  the  Deity  in having first
 adopted this practice.
   The  method, in  which  the ancients
 placed most confidence, for stopping he-
 morrhage after the  amputation of a limb,
 was  the cauterization  of the  cut  vessel,
 and part of the surrounding flesh.  The
 parts, thus  affected by the  heat, formed
 an eschar,  of greater, or less thickness,
 which blocked up the opening of the ves-
 sel, and lundered  the blood from escap-
 ing.   The separation of the eschar, how-
 ever, which frequently  took  place  too
 soon, occasioned a return of the hemor-
 rhage, and  rendered it the  more dange-
 rous, as its suppression  became  more
 difficult, than before the cautery was  ap-
 plied.  The instrument being  too much,
 heated,  even,  sometimes,  immediately
 brought away  with it the eschar,  which
 it had just formed.   At the present time,
 the cautery is never employed, as a means
 of suppressing hemorrhage,  or, at most,
 only in a few very unusual cases, in which
 neither compression, nor the  ligature can
 be made use  of.   In Great Britain, the
 cautery  may be said to be entirely ex-
 ploded ; but, in France, the best hospital
 surgeons now and then employ it to stop
 bleedings  from the antrum, and the
 mouth.
   It was once a practice, to apply pledgets,
 dipped in boiled turpentine, to the mouths
 of the bleeding vessels : of this it is only
 necessary to say, that the method now has,
 long been mpst justly abandoned.


      ASTRINGENTS, STTPTICS,  &C.

   he Dran, in his  treatise on  the opera-
 tions  of surgery, says, that  a  button of
 vitriol, or alum, applied  and  properly
 confined on the extremity of the vessel, is
 sufficient to stop the hemorrhage in am-
 putations.  Heister  recommends the ap-
 plication of  vitriol, in preference to the
 ligature, in  the amputation of the  fore-
 arm.   Great praises have also been con-
 terred on agaric, and sponge, for  their
 styptic properties.  Solutions of iron, and
 all the mineral acids in various forms,
 have been recommended to the publick
 as remedies  of the  same kind, and pus.
 sessing great efficacy.  The ancients,  in-
 deed, had already exhausted this class of
 remedies in such a  degree, that the pre-
 tended  discoveries  of  the moderns,  in
 t»s way, may almost all be met with in
 thnr  writings;  and  the  little success,
 attending their practice, especially, when
 bleeding from a considerable artery was
 to be  suppressed,  clearly  shews what
little reliance we ought to place on means,' 
HEMORRHAGE.
37
of this  description.   (Encyclopedic M6-
thodique; Partie Chirurgicale.) Styptics do,
indeed,  possess  the  power  of stopping
some  hemorrhages from small arteries;
but, they ought never to be trusted, when
large ones are concerned.
  There is no doubt, that cold air has a
styptic property; by which expression 1
mean, it promotes the contraction of the
vessels,  for,  no styptics can contribute to
make  the  blood  coagulate, though  such
an erroneous idea is not uncommon.  We
frequently tie, on the surface of a wound,
every artery, that betrays the least dispo-
sition  to bleed,  as long as the  wound
continues exposed to the air.   We bring
the opposite sides of this  wound into
contact, and put the patient to bed.  Not
an hour elapses, before  the renewal of
hemorrhage  necessitates us to remove the
dressings.  The  wound  is again  exposed
to the air, and again  the bleeding ceases.
This often happens in the scrotum,  after
the removal  of a testicle, and on the chest,
after the removal of a breast. The proper
conduct, in such cases, is not to open the
wound unnecessarily, but, to  apply wet
linen to the  part so as to produce such an
evaporation from, its surface, as shall cre-
ate a sufficient degree of cold to stop the
bleeding.  As all styptics irritate,  judi?
cious  practitioners seldom apply them to
recent wounds. It is sometimes, however,
very proper to employ them tp suppress he-
morrhages from  many diseased surfaces,
where the vessels seem to have lost their
natural disposition to contract.

             COMPRESSION.

  We have   already remarked,  that  all
tlie best means of checking hemorrhage,
operate on the principle of pressure, the
actual and potential cautery,  and  some
styptics excepted ; the two first of which
act by forming a slough, which stops up
fhe mouths of the vessels ;  while the lat-
ter operate  by promoting their  contrac-
tion.  Let us next consider the  various
modifications of  pressure.
  M.  Petit endeavours to shew, in a dis-
sertation on  the manner of stopping he-
morrhage, printed in the Mem. de PAcad.
tie Sciences, anne"e 1731, that the different
things which have  been praised  as  infal-
lible specifics, would seldom, or never,
have succeeded  without compression. It
was always requisite, even when caustics
were  employed, to  apply compresses,
which  were  bound ton  with  sufficient
tigiitness  to resist the impulse of tlie
blood in the artery, and the  premature
separation of the eschar, occasioned by
 he actual or potential cautery. Had this
precaution not  been taken, there would
have been reason to have feared hemor-
rhage, almost invariably, and  which, in-
deed, did recur but too frequently, when
the eschar was  detached, notwithstand-
ing the pains taken to avert it by suitable
compression.   M. Petit has noticed, that
the end of the finger, gently compressing
the mouth of  a vessel, is a  sufficient
means  of stopping  hemorrhage from  it,
and that nothing else would be necessary,
if the  finger  and stump could always be
kept in this  posture.   Hence, he endea-
voured to obviate these difficulties by in-
venting a machine which securely and in-
cessantly executes the office of the finger.
This  instrument  is  a  double tourni-
quet, which, when applied, compresses,
at once, both the extremity of the divided
artery and its  trunk above the wound.
The compression on the end of the  vessel
is to be  permanent; that on the trunk is
only to be made at  the time of dressing
the wound, or when it is necessary to re-
lax the other.   An engraving and parti-
cular description of the instrument are to
be found  in Petit's memoir.
  Surgeons used formerly to  fill the ca-
vities of  the  wounds with lint, and then
make  pressure on  {he bleeding vessels,
by  applying compresses and a tight roller
over the  part.  The practitioners  of tlie
present day are too well acquainted with
the advantages of  not allowing any ex-
traneous substance to intervene between
the opposite  surfaces  of a recent wound,
to persist in the above plan.  They know,
that  the sides  of the  wound may be>
brought  into contact, and  that compres-
sion may yet be adopted, so  as both to
restrain particular hemorrhages, and ra-
ther .promote,  than retard tlie union of
the wound.
  When  the blood does not issue from
any particular vessel, but from numerous
small  ones, compression is preferable to
the ligature.  The employment  of the
latter would  render it necessary to tie the
whole surface of the wound.  The sides
of  the wound are  to he  brought accu-
rately together, and compresses are then
to be placed over tlie part, and a roller to
be  applied with sufficient  tightness to
make  effectual pressure,  but not  so for-
cibly as to produce a danger of the circu-
lation in the  ljmb being completely stop-
ped.
    If  compression  can  ever be  safely
trusted in bleedings  from large arteries,
it is  when these vessels he immediately
over a bone, against which they can be
advantageously  compressed.    Bleedings
from  the radial and temporal arteries
are of this kind. Compression is some- 
38
HEMORRHAGE.
 times tried, when the brachial artery has
 been  wounded in phlebotomy.   Here it
 is occasionally tried, in preference to the
 ligature, because the latter cannot be em-
 ployed  without  an  operation to expose
 the artery.
    When there is a small wound in a large
 artery, the following plan may be tried :
 a tourniquet is to be applied,  so as  to
 command the flow of blood into the ves-
 sel.  The edges of  the external wound
 are next to be brought into  contact.
 Then, a compress, shaped  like  a blunt
 cone, and which is best formed of a series
 of compresses, gradually increasing  in
 size, is to be placed with its apex ex-
 actly  on the situation of the w»und  in
 the artery.  This graduated compress,  as
 it  is termed, is then to be bound on the
 part with a roller.
   In this manner, I lately healed a wound
 of the superficial palmar arch, in a young
 lady  in  Great Pulteney-street.   The out-
 ward wound was very small,  and though
 the hemorrhage was  profuse, I conceiv-
 ed, that it might be permanently stopped,
 if compression could be  so  made as  to
 keep  the  external  wound   incessantly
 and firmly covered for the space of a day
 or two.   At first, I tried  a compress  of
 lint, bound on the part with a roller ; but
 this  proving  ineffectual,  1   took some
 pieces of money, from the size of a far-
 thing to that of a  halfcrown, and, wrap-
 ping  them up in  linen, put the smallest
 One accurately over the wound, so  as
 completely to cover it.  Then the others
•were  arranged,  and  all  of them  were
 firmly confined with a roller,  and the
 arm kept as quiet as  possible  in a sling.
 They were taken oft' after three days, and
 no hemorrhage ensued.
   It is  to be observed, that  the palmar
 fascia,  in this instance,  would prevent
 the compression from operating on the
 vessel;  but  the case shews, that this ar-
 tery, when wounded, is capable of he  J-
 ing, if the blood be completely prevented
 from getting out  of the external wound
 by the  proper application  of compres-
 sion.  Were the outer wound too large
 to admit of this plan, it would probably
 be necessary to dissect for the ends of the
 artery, in order to tie them.  This  ope-
 ration, however, is by no means easy;
 and, perhaps,  upon the whole,  it might
 be better to cut down, at once, to the
 ulnar  artery, and put a  ligature round
 it, though this would only certainly  stop
 the bleeding from one end of the vessel in
 the hand.
   Besides compressing the wounded part
 of the artery, some surgeons also apply a
 longitudinal compress over the  track  of
 tile vessel above the  wound,  with a view
of weakening the flow  of blood  into if.
Whatever good effect it may have in this
way, is more than counterbalanced by the
difficulty which it must  create to the cir-
culation  in  the  arm.  If tlie  graduated
compress  be  properly arranged,  an effu-
sion of blood cannot possibly happen, and
pressure  along the course of the artery
must at all events be unnecessary.
   After  relaxing the tourniquet, if no
blood escape from the artery, the surgeon
(supposing it to be the  brachial artery
wounded) should feel the pulse at_ the
wrist, in order to ascertain, that the com-
pression employed is not so powerful as
entirely to impede the circulation in the
fore-arm  and  hand.   The arm is to be
kept quietly in a sling, and, in forty-eight
hours, if  no  bleeding take place, there
will be great  reason to expect that the
case will  do well.   In another work, I
have given an engraving and description
of an instrument, invented by Plenk, for
making pressure on the wounded brachial
artery, at the bend of the arm, without
pressing upon the whole circumference of
the limb,  and consequently stopping the
circulation.   No one,  however, would
prefer compression , when large arteries
are injured, except in the kind of cases,
to which  we  have just  adverted, or in
those in which the wounded vessel can be
firmly  compressed against  a subjacent
bone.  The compresses  sometimes  slip
off", or the bandages become slack, so that
a fatal hemorrhage  may  arise.   Hence,
when this method is  adopted, the tour-
niquet should  always   remain   loosely
round the limb, ready to be tightened in
an  instant.   Sometimes  the  external
wound heals,  while the opening in the
artery remains unclosed, and an aneurism
is  the consequence.   This is particularly
apt to occur,  when  the pressure has not
been powerful enough; and, when too
great,  mortification is apt to come on:
such are the objections to placing much
confidence in  compression, except when
tlie vessels are not of considerable size.

             TOURNiaUET.

  When  hemorrhage takes place from a
large arteiy in  one of the limbs, where
the vessel can be conveniently compressed
above the wound in it, a tourniquet, ju-
diciously  applied, never fails in  putting
an immediate stop to the bleeding.
  Before the invention of this instrument,
which did not take place till the latter
part of the  17th century, surgery was
really a very defective art.  No important
operation could  be undertaken on the ex-
tremities, without placing the patient in
the most  imminent  peril; and the want 
»
HEMORRHAGE.
39
of tlie aid,  afforded by  the tourniquet,
made many wounds mortal,  which other-
wise would not have been attended with
the least danger.
  As the  first invention  of this instru-
ment has been claimed by different sur-
geons,  and   even different nations,  we
shall net take upon us to determine where
it had its origin.  But whoever was  the
inventor,  it  was first presented to  the
publick in a form exceedingly simple; so
much so,  indeed, that it seems extraor-
dinary, that its invention  did not happen
sooner.  A small pad  being placed  on
the principal artery of a limb,  a band
was applied over it, so  as  to encircle  the
limb twice.   Then a stick was introduced
between the two circles of the band, and
twisted: thus the pad  was made to com-
press with quite power enough  complete-
ly to stop the flow of blood into tlie lower
part of the vessel.
  Although, in the Armamentarium Chirur-
gicum of Scultetus; there is a plate of a
machine, invented by this author for com-
pressing the radial artery, by means of a
screw, M. Petit is universally allowed to
be tlie first, who brought the tourniquet
to perfection, by combining the circular
band with a screw, in such a manner that
the greatest pressure operates on the prin-
cipal artery.
  The advantages of the modern tourni-
quet are, that its pressure can be regulat-
ed with the  utmost exactness;  that it
epcrates chiefly on  the  point  where the
pad is placed, and where  the main artery
lies ;  that it  does not  require  the aid of
an assistant  to keep it tense : that it com-
plexly commands the flow of blood into
a limb ; that  it can be relaxed, or tight-
ened in a moment; and that, when there
is reason to fear a sudden renewal of he-
morrhage, it can be left slackly round the
limb, and,  in case of need, tightened in
an  instant.  Its utility, however, is  con-
fined to the  limbs, and as  the pressure
necessary to stop the flow of blood through
the principal  artery, completely prevents
the return of blood through the veins, its
application  cannot be made very long
without inducing mortification  It is only
of use also in putting a sudden stop to
profuse hemorrhages for  a time, that is,
until the surgeon has put in practice some
means, the effect of which is more perma-
nent.
  The ancients were quite unacquainted
with tlie use of the tourniquet, and though
some of their writers have made mention
of the ligature, they do not seem to have
known how to make proper use of it, nor
to have possessed any other certain means
of suppressing hemorrhage from wounds.
In modern times, it is easily comprehen-
sible, that, when any great operation was
undertaken, while  surgery was  so imper-
fect, there was more likelihood of harm,
than good being done to the patient.  Nor
can it be wondered at,  that the old prac-
titioners  should  have  taken  immense
pains to  invent a great  many topical as-
tringents.  But now that the ligature is
known to be a means which is safe, easy,
and  much less painful  than former me-
thods, we need no longer  search for such
remedies.
  It may, indeed,  be set down,  as  a  rule
in surgery, whenever large arteries  are
wounded, never to trust to any styptic
application whatsoever; but to have  im-
mediate recourse to the ligature, as being,
when properly  applied, the most simple
and safe of all methods.
  In order to ojualify the reader to judge
of tlie best mode of applying ligatures to
arteries,  I  shall first explain to him their
effect on these vessels, as related by Dr.
Jones.
  This  gentleman  learnt  from Mr.  J.
Thomson,  of Edinburgh,  that, in every
instance  in which a ligature is applied
around an artery,  without including .the
surrounding  parts, the internal coat  of
the vessel is torn through  by it, and  that
this  fact had been originally noticed by
Desault.   Mr.  Thomson shewed to  Dr.
Jones, on a portion of artery taken from
the human subject, that the internal and
middle coats are divided by the ligature.
(Jones, p. 126.)
  This led Dr. Jones to make  some  ex-
periments on the  arteries of   dogs  and
horses, shewing, that when a ligature is
applied with sufficient tightness round an
artery, to cut  through  its internal  and
middle coats, although  it be immediately
afterwards removed,  the vessel  always
becomes permanently impervious  at  the
part  which was tied, as  far as the  first
collateral branches above and  below  the
obstructed part.  Dr. Jones thinks it rea-
sonable to expect, that the obstruction
produced  in the  arteries of  dogs  and
horses,  in the manner  he has related,
" might  be effected by the same treat-
ment in  the arteries  of the human  sub-
ject; and, if it should  prove successful,
it might  he employed in some of the most
important cases in surgery.  The success
of the late important improvements which
have been introduced  in  the  operation
for aneurism, may perhaps appear to most
surgeons to have rendered that  operation
sufficiently simple  and safe; but, if it be
possible  to produce obstruction in   the
canal of  an artery  of the  human subject,
in the above-mentioned manner,  may it 
4<j                             HKMORl

Mot be advantageously employed in the
cure of aneurism;  inasmuch as nothing
need be done  to  prevent the immediate
union of the external wound?"   Dr. Jones
next questions, whether this mode of ob-
structing the passage of blood through the
arteries may not  also be advantageously
practised  in cases  of bronchocele > (p.
136.)
  From Dr. Jones's experiments, it ap-
pears,  that the first effects of a ligature
upon  an  artery are, a complete division
of its internal  and middle coats, an appo-
sition of its wounded surfaces,  and  an
obstruction to  the circulation of the blood
through  its canal.  There  must  be  a
small  quantity of  stagnant blood, just
within the extremity of" the artery; but
this does not,  in every instance, immedi-
ately  form a coagulum, capable of filling
up the canal of tlie artery. In most cases,
only a slender coagulunr is  formed at
first, which gradually becomes larger by
successive  coagulations of  the blood;
and hence, the coagulum is always at first
of a tapering form,  with its base at the
extremity  of  the  artery.  But,  as Dr.
Jones  remarks,  the formation  of this
coagulum is not material; for soon after
the ligature has been applied,  the end of
the artery inflames, and the wounded in-
ternal surface of its canal being kept  in
close contact  by the  ligature,  adheres,
:md converts  this  portion of the artery
into an impervious,  and, at first, slightly
conical sac.  ft is  to the effused lymph
that the  base of the coagulum adheres,
when  found to be  adherent.   Lymph is
also effused between the coats Of the ar-
tery,  and among the parts surrounding
its extremity. In  a little time, the liga-
ture makes the part, on Which it  is di"
rectly applied, ulcerate; and, acting as a
 tent, a small  aperture is formed in  the
 layer  of  lymph effused  over  the artery.
 Through this aperture, a small quantity
 df pus is discharged, as long  as the liga-
 ture remains; and, finally, the ligature
 itself also escapes, and the*little cavity,.
 which it has  occasioned, granulates  and
 •ills up,  and  the external  wound  heals,
 leaving the cellular substartce a little be-
 yond  the end  of the artery, much thicken-
 ed and indurated.   (Jones, p. 159, 161.)
   In short, when an artery is properly tied,
 the following are  the effects,  as enume-
 rated by Dr. Jones:
    1.  To cut through  the  internal  and
 middle coats of the artery, and to bring
 the wounded  surfaces  into perfect appo-
 sition.
    2. To occasion a determination of blood
 to the collateral  branches.
    3.  To allow of  the formation of a coa-
 gulum of blood just within the  artery,
provided a collateral branch is not Very
near the ligature.
  4   To excite inflammation on the in-
ternal and middle coats of the artery, by
having  cut  them  through,  and,  conse-
quently, to give rise to an effusion of
Ivmph,  by  which the wounded surfaces
are united, and the canal is rendered im-
pervious; to produce a  simultaneous in-
flammation on the corresponding external
surface  of the artery,  by  which  it be-
comes very mtich thickened with effused
lymph; and, at the same time, from the
exposure and inevitable wottndmg of the
surrounding parts,  to occasion inflamma-
tion in  them,  artd  an effusion  of lymph,
which covers  the  artery, and  forms the
surface  of the wound.
   5. To produce  ulceration in the part
of the artery,  around which the ligature
is immediately applied,  viz. its external
coat.
   6. To produce  indirectly a complete
obliteration; not only of the canal  of the
artery,  but even of the artery itself, to the
collateral branches on both sides of the
part which has been tied.
   7.  To give rise  to an enlargement of
the collateral  branches.  (Jones, p. 163,
 164.)
   Every part  of an artery is organized
 in  a similar  manner  to the  other soft
 parts, and its coats are susceptible of the
 same process of adhesion, ulceration, &c.
 as the  other parts are.   Hence, the pre-
 cautions taken to  secure the adhesion of
 other parts, should  be observed for the
 same purpose, with regard to  aft  artery.
 The vessel is put in a state to admit of ad-
 hesion  by the ligature, Which,  when pro-
 perly applied, cuts through its internal and
 middle coats, keeps their cut surfaces  in
 contact, and affords them an opportunity
 of uniting by  the  adhesive inflammation,
 as other cut surfaces do.   The immediate
 stoppage of the bleeding is merely  the in-
 cipient and temporary part of what the
 ligature has to accomplish ; it has also to
 effect  the  adhesion of the internal and
 middle coats  of the artery, which being
 the thing, on  which the permanent sup-
 pression of hemorrhage depends, is the
 most important.   The size and form  of
 the ligature,  whether completely  flat, or
 irregular, have not been, as Dr. Jones re-
 marks, sufficiently  attended  to;  nor is
 the degree of force employed in tying the
 artery, often considered.  Some surgeons,
 wishing to  guard against  the ligature's
 slipping off,  tie it with very considerable
 force;  while others,   apprehensive  lest
 they should  cut through  the artery, or'
 occasion too  early a separation of the li-
 gature, draw it only sufficiently tight to
 prevent the escape of any blood.  A broad 
HEMORRHAGE.
41
.fiat ligature is not likely to make such a
 wound in the internal and middle coats
 of the artery,  as is most- favourable to ad-
 hesion, because it is scarcely possible to
 tie  it smoothly round the vessel, which is
 very  likely  to be thrown into  folds, or
 puckered by  it, and, consequently, to
 have an irregular bruised wound made In
 its  middle and internal coats.  By cover-
 ing also a considerable  space of the ex-
 ternal coat, it may destroy the very vessels
 which pass on it in their way to the  cut
 surfaces of the inner coats, and  thus ren-
 der them incapable of inflaming.  Even
 supposing the wound to unite, still such
 a ligature  may cover that  part of  tlie
 external coat, which is directly over  the
 newly-united  part, and, consequently, as
 soon as it has produced ulceration through
 the external coat, it will cause  the same
 effect on the newly-united parts, and, of
 course, secondary hemorrhage. (Jones,
 p. 168.)
  When a  ligature  is  of an  irregular
 form, it is apt to cut through the internal
 and middle coats of an artery more com-
 pletely at some parts than  others;  but
 these coats must be perfectly cut through,
 in order to produce an effusion of lymph
 from  the inside of the vessel, which seems
 to adhere only at its cut surfaces.
  Also, when the ligature is not applied
 with sufficient tightness,  the inner coats
 of  the artery will not be properly  cut
 through.  Dr. Jones thinks,  the ligature
 being sometimes put on so as to deviate
 from a circle, has a tendency to produce
 secondary hemorrhage.
   Dr. Jones  thinks  ligatures are  best,
 when they are round, and very firm, and,
 he adds, diat though a very slight force
 is  necessary to cut through the internal
 and middle-coats of an artery, it is better
 to  tie the vessel more  tightly than is
 necessary merely to  cut through its inner
 coats, because the cut surfaces  will thus
 be more certainly kept in contact;  the
 separation of the ligature expedited;  and
 the danger of ulceration spreading  to
 tlie newly cicatrized part diminished.
 The  external coat  will  never  ulcerate
 through,  before the inner ones have ad-
 hered. The.limb, however, should be
 kept in a perfectly quiet state.
   I am sincerely glad to  find, that so ac-
 curate an observer as Dr. Jones, has re-
 futed the idea, that ligatures occasionally
 slip off the vessels, in consequence of the
 violent impulse of the  blood.  In fact,
 the blood does not continue to be  impel-
 led against the  extremity of the  artery
 with  the same impetuosity with  which
 it circulated  through tlie vessel before it
 was tied.  The blood is immediately de-
      Vor, II.
termined into the collateral branches, nor
is there any pulsation for some way above
the ligature.
  Dr.  Jones much  more rationally im-
putes  this occasional occurrence, either
to the clumsiness of the ligature, which
prevents its lying compactly and securely
round the artery;  or to  its not  having
been  applied with sufficient tightness;
or to its having that very insecure hold
of the vessel, which the deviation from
the  circular application must occasion.
(P. 173.)
  Dr. Jones is of opinion, that, in cases of
aneurism, in which the artery has  only
been tied with one ligature, and left un-
divided, and in which secondary hemor-
rhage has arisen, that this has most  pro-
bably  been  owing, either to a  diseased
state of the artery ;  to  various contriv-
ances  for compressing a large portion of
the  vessel,  or  having  a loose  ligature
above  the one, which is tied; or, lastly,
to not tying the artery sufficiently tight
to cut through the internal and middle
coats,  so as  to tit them for adhesion,  but,
so as to cause a gradual ulceration through
them,  and,  of course,  bring on hemor-
rhage,  which returns with  greater vio-
lence, as the  ulceration advances.  (P.
176.)
  Dr. Jones seems to consider, that the
advantage of the retraction of tlie  divided
artery within the cellular membrane, is
compensated, in the case of the undivided
artery, by the speedy and profuse effusion
of  lymph,  which  takes place  over and
round the  vessel,  at the tied  part, and
even covers the  ligature itself.  * How-
ever, he admits the objection,' urged  by
Mr. Abernethy, to using only one ligature,
viz. that the vessel cannot be tied, where
it lies among its  natural connexions,  or
if tied in this manner either at the upper,
j>v  lower part of the wound, the  hemor-
rhage will proceed from that part of the
vessel, which has tlie detached portion of
the artery for its extremity.  This gentle-
man concludes  this point, with allowing
it to be safest and best to apply two liga-
tures,  and to divide the artery between them.
P. 179. See Aneurism.  Another cause of
secondary  hemorrhage  is  by including
other  parts  in the  ligature, together with
the artery,  by doing which, the division
of the inner coats of the vessel  may be
prevented.                     •
   In  the  valuable  publication  of Dr.
Jones's, to  which  we have  so freely  ad-
 verted, some secondary hemorrhages  are
 also imputed to the hidden separation, or
 laceration of the recently united parts 6f
 an artery,  by premature and  extraordi-
 nary exertions of the patient. Hence, he
     F 
42                              BExMOR]

strongly insists on  kecpiflg a  limb,  in
which a large artery has been  tied, per-
fectly at rest.
  We shall conclude our remarks on the
ligature with a few practical rules.
  1. Always tie a large artery, as sepa-
rately as possible, but still let the ligature
be  applied to a part of the vessel, which
is close to where it lies among its natural
connexions.
  Besides the  reasons for this practice,
already specified, we may  observe, that
including other substances in the ligature
causes immense pain, and a larger part of
a wound to  remain disunited.  The liga-
ture  is also apt to become loose, as soon
as the substance between it and the artery
sloughs,  or ulcerates.  Sometimes  the
ligature thus  applied, forms  a circular
furrow in the flesh, and remains a tedious
time, incapable of separation.
   The blood-vessels being thus organized
like other parts, the healing of the wound-
ed artery can only take place favourably,
when that  part of the vessel, which is
immediately contiguous to the  ligature,
 continues to receive a due supply of blood
 through its vasa vasorum, which are rami-
 fications of the collateral arteries.  Hence,
 Wie disadvantage of  putting  a ligatur^
 round the middle of a portion of an artery,
 which  has  been separated  from its sur-
 rounding connexions.   Hence, the utility,
 however, of making the  knot, as closely
 as possible  to that part of the vessel which
 lies undisturbed among the surrounding
 flesh.
    Small arteries neither allow nor require
 these minute  attentions to the  mode of
 tying them.
    2. When a divided artery is  large,
 open-mouthed, and very visible, it is best
 to take hold of it, and raise its extremity,
 a little way above the surface of the wound
  with a pair of forceps.  When  tlie vessel
  is smaller, the tenaculum is the most con-
  venient instrument.
    3. While one surgeon holds the vessel
  in this way, another is to place the noose
  of a lig;.ture round it, and tie it according
  to the above directions.  In order that
  the  noose may not rise too high, and even
  above the mouth of the artery, when it is
  tightened, the ends of the ligature must
  be  drawn  as horizontally as  possible,
  Which is best done with the thu b;>s.  A
  knot is next to be made.
    4. Ligatures always operating in wounds
  as extraneous bodies, and one  end  of each
  being sufficient for its removal, the other
  should alwaj> be cut off close to the knot,
  and taken away.
    5. "VMien a large artery is either par-
  tially divided, or completely divided, two
  ligatures, one to the upper* th* other to
the lower part of the vessel, are common-
ly necessary, in consequence of the anas-
tomosing branches conveying'the blood
so readily into the part of the artery most
remote from the heart, as soon as the first
ligature has been applied.
  6.  When  a large artery is  only punc-
tured ; when compression cannot be judi-
ciously tried; and when the hemorrhage
continues;   the vessel must be first ex-
posed by an incision,  and then a double
ligature  introduced under it, with the aid
of an eye-probe.  One ligature is to be tied
above; the other below the bleeding ori-
fice ; with due attention to the principles
already advanced.
  7.  Ligatures usually  come away  from
the largest  artery ever tied, in about a
fortnight, and from moderate-sized  ones
in six  or seven days.  When they con-
tinue attached  much beyond the  usual
period, it is proper to draw them  very
gently every time the wound is dressed,
for the  purpose of accelerating  their de-
tachment.   Great care, however,  is  re-
quisite  in  doing this;  for, as Dr. Jones
remarks, as long  as  the ligature  seems
firmly attached, pulling it rather strongly
must act, more or less, on the recently
cicatrized extremity of the artery, which
is not only contiguous  to  it, but is  still
united to that portion of the artery, (the
external coat) which detains the ligature.
(Jones, p. 162.)
  For information concerning hemorrhage,
consult  Petit's  Memoirs, among those of
VAcad.  des  Sciences for the years 1731,
 1732—1735.- Morand sur le Changement,
qtri arrive aux Arteres couples, 1736: Pou-
 teau's  Melanges  de  Cfnrurgie:  Gooch's
 Chirurgical Works, Vol. 1:  Kirktand's Es-
say  on the  Metliod of suppressing Hemor-
 rhages from divided Arteries; White's Cases
in Surgery: J. BeWs Principles of Surgery,
 Vol. 1:  Purtie  Chirurgicale  de I'Encycl.
 Meth.f  Larrey's Me"moires  de  Chirurgie
 Militaire, Tom. 2, p. 379.   Pelletan's Clin-
 iqne Chirurgicale, Tom. 2. p 240, &c. Me-
 moire  EUmentaire sur les Henwrrhogies.
 Richerand's  J\i'osographie  Chirurgicale,
 Tom. 4.  Sect, snrles Maladies des Arteres,
 p. 31,  &c. Edit. 2.  Levtilli, JYouvelle
 Doctrine Cliirurgicale,Tom 1, Chap. 9. and,
 particularly, Jones on the Process employed
 by JVature, in suppressing the Hemorrhage
 from divided and punctured Arteries, 1805.
   HEMORRHOIDS,  (from «<V, blood,
 and '%i»,  to flow.)   Hxmorrhoides.  Piles.
 The etymological meaning of the word is
 evidently only a discharge of blood.   Sur-
  geons,  however,  sanctioned by long  cus-
  tom,  always imply  by the term, hemor-
  rhwdi; either a bleeding from the veins of
  the lower part of the rectum, or else a
 considta-able distention of these vessels, 
HEMORRHOIDS.
4-r
so as to form tumours, but quite unattend-
ed with hemorrhage.   When the dilated
veins do  hot bleed,  the  swellings  are
called blind piles;  but, when they are at-
tended  with  occasional  discharges  of
blood, they are named open piles.   These
tumours vary in number, size, form, and
situation : some are external, others inter-
nal  In general, tlie inconvenience which
they occasion, is  very supportable ; but,
sometimes  they  bring on  very  serious
complaints, either by bursting and dis-
charging blood so profusely as dangerous-
ly to reduce the  patient; or by exciting
inflammation of the adjacent parts, and
causing abscesses and fistulae;  or, lastly,
by becoming strangulated by the contrac-
tion of tlie sphincter ani, so as to occasion
very acute  pain.   Piles,  which bleed but
little, are  not of much consequence; but
those which bleed profusely, cause vio-
lent pain, or which induce inflammation,
and all its effects, demand the greatest
attention.    Lieutaud makes mention of a
person, who lost  three quarts of blood
from some  open  piles in the course of a
couple of days;  and  the heretic  Arius,
and the  celebrated philosopher Coperni-
cus are said to have bled to death in this
manner.
  When piles are situated far  up in the
rectum, they are commonly less painful,
than when low down.   In the former case,
the  veins  are  surrounded by soft and
yielding substances, which do  not make
any  painful pressure  on tlie swellings;
but, piles, situated towards the anus, are
apt to suffer a very painful  constriction
from the  action of the sphincter  muscle.
Hence, when such tumours are very high
up in the  rectum, the patient  has some-
times no warning of lus disorder, till he
discharges  blood from the rectum, and,
so violent a bleeding may at  once ensue,
as to prove fatal.
  With regard to the cause of hemor-
rhoids, any thing capable of retarding, the
return of blood through the hemorrhoidal
veins,  may occasion the  disease.  The
pressure of the gravid uterus, costiveness,
and the frequent retention of hardened
feces in the rectum,  are  very frequent
causes.   Persons,  who  lead  sedentary
lives, are  often troubled with the com-
plaint.  From  what has been stated, we
may easily discern the reason, why women
are more  subject to piles,  than men are,
though the disease is so common, that the
Jitter  are also very frequently troubled
with it.
  The pressure of an enlarged liver, or
of water accumulated  in the cavity of the
peritoneum, is said sometimes to be the
occasion of piles.
   When  these tumours are produced by
the pressure of the  gravid uterus, no
cure can be expected till after delivery,
when one generally follows spontaneously.
Also, when piles are an effect of dropsy,
they can only get well, after tlie  pressure
of the  fluid in the abdomen has been re-
moved by tapping. Gently laxative medi-
cines,  and an horizontal position of the
body, commonly alleviate the uneasiness
resulting from hemorrhoids.  The appli-
cation  of an ointment, composed  of equal
parts of the powder of oak-galls,  and of
elder-ointment, or hog*s lard, contribute
to the same beneficial effect. Applying
warm  water  to  the  tumours, by  means
of a bidet, or  semicupium, is also fre-
quently productive of great ease.  When
piles  are constricted  by the sphincter
ani muscle, the pain thus  arising,  may
often be at once removed, by pushing the
swellings  with the  finger a little higher
up the rectum.  Leeches applied  to the
vicinity of the anus, and puncturing the
dilated hemorrhoidal vessels with a lancet,
for the purpose of taking  away  blood,
are  measures occasionally employed to
procure ease. Mr. Ware seems to  give
the preference to leeches;; Petit preferred
the lancet.
  When the  number  and size of hemor-
rhoids are so considerable,  as materially
to obstruct the  discharge  of the  feces;
when  they are very painful, and subject
to profuse bleedings; when the patient is
disabled from following his  usual occu-
pations ; and when all  the above  means
are not  of sufficient avail, the^  surgeon
should recommend the  removal of the
tumours.
  Extirpating piles with the actual  cau-
tery and caustics, as practised by the old
surgeons,  is now very properly altoge-
ther relinquished by  modern practition-
ers.   The only plan ever followed  in the
present state of surgery, is either to cut
tlie tumours off  with a pair of scissars or
knife,  or to apply a tight ligature round
their bases, so as to make  them slough
away.
  When piles are to be cut off, and they
are not sufficiently  visible,  the patient
must first strain, as at  stool, in order to
make the swellings more apparent. With
the aid of a pair of dissecting  forceps,
the skin, covering the  hemorrhoids, is
then  to be separated from them wfyh
the knife,  but not cut away,  and the tu?
mours are to be removed. Sabatier states,
that saving  the skin is very essential;
for,  any hemorrhage  which may arise,
can then be more easily suppressed ;  and,
when there are several hemorrhoids to be
extirpated, the  loss of  substance about
tlie anus will be  less,  and, of course, the
patient will not be so liable to a contrac- 
44
HEMORRHOIDS.
tion of this part,  which is sometimes a
very great affliction.
  Mr. Ware thinks  it unnecessary to re-
move all the swellings, when there are
several of them. He remarks, that though
the  number  of hemorrhoidal tumours,
protruded through the anus, is often con-
siderable, yet the pain which the patient
suffers, is not produced equally by all of
these;  but, that he will point to one, or
at most to two, of the tumours, whence
all his pain proceeds. These will be found
to be much harder  and more  inflamed
than the rest;  but, generally smaller and
less prominent,  protruding only just low
enough to be compressed by the sphincter
muscle.
  Hence,  Mr. Ware  contends, that cut-
ting off the whole number of hemorrhoids
with a  scalpel, or scissars, and  tying a
ligature round them, in order to make
them die and fall off, are unnecessary. He
says, we have only to direct our attention
to the hard inflamed tumour, which is the
cause  of  the  pain,  and  which  is  not
unfrequently situated in the centre of the
rest.  This is often  not larger than the
end of the  little finger, and the removal
of it almost instantly abates the pain, and
soon makes the rest of the tumours, col-
lapse and disappear.  Mr.  Ware operates
as follows : having secured with a com-
mon dissecting-hook, or forceps, the little
hard tumour, which is often in the middle
of the  rest, and much darker coloured,
lie snips it off, as close to its basis as pos-
sible, with a sharp pair of curved scissars.
The pain is trifling,  and the hemorrhage
60 slight, that Mr. Ware  says,  he  has
rarely had occasion to use any application
to check it.  If the hemorrhoids are con-
stantly protruded, the operation  may he
performed at any time; but, if they only
appear  after the  feces are voided,  that
opportunity must be taken.
  When the pain of hemorrhoids is not
violent, but there is  a constant distress-
ing uneasiness, with frequent returns of a
profuse debilitating hemorrhage, Mr.Ware
states,  that his method of operating will
frequently produce a radical cure.
  The  excision of  piles is occasionally
followed by a very dangerous bleeding,
as a case, related by Mr. Petit, confirms.
A patient had some  hemorrhoids, which
were supposed to be external ones, though
in f..ct they were not, and had only be-
come  protruded.  Almost immediately
alter they had been cut off, the skin which
had  supported  them, became drawn in-
ward.   An inward hemorrhage ensued,
which could not be suppressed, and prov!
ed  fatal in less  than five hours.   The
rectum and colon were found full of black
coagulated blood.                    '
   After the operation, Mr. Ware advises
 a thick compress to be applied, wet either
 with  cold brandy and water, or with a
 cold satumine lotion, and retained on the
 part with  the T bandage.' The patient
 should be kept quietly in a cooler tem-
 perature than usual, and be  enjoined to
 eat and  drink nothing of  a stimulating
 quality.
   Certainly, if the bleeding should prove
 troublesome, and  proceed from vessels
 within the rectum,  tlie  best plan would
 be to distend  the  gut  with a  suitable
 piece of  sponge, so as to make  pressure
 on the wound, observing to adopt at the
 same time the means above recommended.
   Tying  hemorrhoids is free  from the
 danger of hemorrhage;  but, still it has
 its inconveniences, though ihey are not
 constant ones.  Petit frequently practised
 this method, without any ill effects.  In
 other instances, he  had  reason to repent
 having adopted it.   A woman, for whom
 he had tied three hemorrhoids with nar-
 row pedicles, which were favourably situ-
 ated  for the operation,  did  not at first
 experience a great  deal of pain.  How-,
 ever, five hours afterwards  he was in-
 formed,  that she  suffered violent  colic
 pains, .which extended along the colon.
 The woman was bled four times, without.
 relief.  At last, Petit cut the ligatures,
 which could not be loosened,  in conse-
 quence of their being concealed so deeply
 in the substance of the swollen parts. The
 pain very soon subsided. "The  ligatures
 had only been  applied four and twenty
 hours, but the piles had become black,
 and the skin covering their bases was cut
 through.   Petit removed them, without
 the least effusion of blood.
   M. Petit also relates a case, in which a
 patient, after having some piles tied, died
 of symptoms resembling those, which take
 place in cases of strangulated hernia, not-
 withstanding the ligatures were  cut as in
 the foregoing instance.   After these two
 cases, Pent abandoned the  plan  of curing
 hemorrhoids by tying them.
   I believe, on the whole,  that it is best
,to remove hemorrhoids with a knife un-
 less they are situated high up the rectum,
 where the veins  are of large size, and
 likely to bleed profusely.  If a tumour so
 situated  should  absolutely  require re-
 moval, a ligature might  be put  round its
 base with the aid of a double cannula,  in
 the  way  we shall relate in speaking  of
 Polypi.   When the  base of the tumour,
 however, is large, admits of being brought
 into view,  and the surgeon prefers  tying
 it, he should pass a  needle, armed with a
 strong double ligature, through the root
 of the hemorrhoid, and tie one part  of
 this ligature firmly over one side of the 
HERNIA.
45
swelling, and the other over the opposite
one.   When the  base  of the tumour  is
narrow, and the ligature is preferred, the
part may be tied at once, without passing
a double ligature through its middle.
  As  piles very seldom  prove fatal, an
opinion has commonly prevailed, that they
are of a salutary, or critical nature.  They
have  not unfrequently been  regarded, as
an evacuation, by which some peccant, or
morbific matter,  is thrown off from the
body  ; and hence, patients have frequently
been taught to submit to all the pain, and
uneasiness, which the disease occasions,
rather than seek  a cure.  This opinion,
however,  is neither founded upon  impar-
tial and mature observation, nor upon
solid  reasoning; for, granting that there
was any morbific matter in the body, it is
impossible to explain why it should be
collected in the blood,  which  fills the
dilated veins about the rectum, more than
any where else.
   For information on  hemorrhoids, con-
sult  VEncyclopidie Methodique;  Partie
 Chirurgicale.  Sabatier, De  la Midecine
 Optratoire, Tom.  2.  Latta's System  of
 Surgery,  Vol. 2.   Ware on  the Treatment
 of Hemorrhoids. Abernethy on Hemorrhoidal
 Diseases in his Surgical Works, VoU 2, p.
 231,  &c.
   HE'RNIA.  (from epm, a branch, from
 its protruding  forward.)   Surgeons un-
 derstand by the term hernia, a tumour,
 formed by the protrusion of some of the
 viscera of the abdomen, out of that cavi-
 ty, into a kind of sac, composed of the
 portion of peritoneum, which is  pushed
 before them. However, there are certainly
 some cases which will not be compre-
 hended in this definition; either because
 the parts are not protruded at all, or have
 no hernial sac, as the reader will  learn in
 the course of this article.

      GENERAL nF-HIAUKS OW  HEimi.E.

   "  The  brilliant progress, which sur-
 gery has  made in  modern times, (says
 Scarpa)  is, properly  speaking, only  the
 results of pathological anatomy, that is to
 say, of exact comparisons of tlie natural
 state of our organs  with their different
 diseases,  which may depend upon  an
 alteration of texture, a derangement of
 functions, a solution of continuity, or a
 change of  situation.  It  is from these
 important results, that the  most  rational
 curative  methods, with which  modern
  surgery is enriched, are deduced as so
  many corollaries; methods, to which we
  are  also  indebted for the  perfection  of
 operations.
    - There arc indeed a certain  number
of surgical operations, for the prompt and
safe execution of which, mere anatomkcal
knowledge  will suffice;  but,  in many
others, the surgeon cannot promise him-
self success, even though he be well ac-
quainted  with anatomy,  unless  he has
particularly studied the numerous changes
of position, and alterations of texture, of
which the parts, upon which he is about
to operate, are susceptible.  If he has not
the requisite information  upon all  these
points, false appearances may deceive his
judgment, and make  him commit  mis-
takes, sometimes of a very serious and
irreparable kind.
  " In order to have a convincing  proof
of this truth, it will be sufficient  to take
a view of the different species of hernix,
and their  numerous complications.  As-
suredly, no anatomist would believe, that
the  intestine caecum, naturally fixed in
tlie right ilium, and the urinary bladder,
situated at  the  bottom  of the  pelvis,
could undergo, without  being torn,  so
considerable a displacement as  to pro-
trude through the  abdominal ring, and
descend even into the scrotum; that the
 same intestine the caecum could pass from
the  right  iliac region  to the  umbilicus,
so  as to protrude at this opening, and
form an umbilical hernia; that the right
 colon could  have been seen  protruding
 from the abdomen at the left  abdominal
 ring, and the left colon through the right
 one ; that the liver, the spleen, and ovary
 could sometimes be the  parts contained
 in the umbilical, inguinal, and  femoral
 herniae; that the caecum could engage
 itself within the colon, and even protrude
 at the anus;  that  the  stomach, forced
 through the diaphragm,  could form a
 hernia within the chest; that the omen-
 turn,  or intestine, or both these parts to-
 gether, could sometimes make their escape
 from the belly through the foramen ovale,
 or  sacro-ischiatic notch, of the pelvis ;
 that a noose of small intestine, after being
 engaged in the abdominal ring, or under
 the femoral arch, could suffer the most
 violent strangulation, without the  course
  of the intestinal matter being intercepted;
 lastly, that, in certain circumstances, the
  intestine and omentum could be  in  im-
  mediate contact with the testicle, within
  the tunica vaginalis, without the least  la-
  ceration of this latter membrane.  These
  and several  other  analogous facts,  says
  Scarpa, are so surprising, that they would
  yet  be regarded as incredible,  had they
  not  been proved by numerous observa-
  tions on  individuals  affected with her-
  nia:  their possibility,  (repeats this ex-
   Eerienced professor) would not even have
   ecu suspected either by the anatomist, 
46

or physiologist.'1
Hernies, Fref)
HERNIA
(Sec Scarpa's TraitC dee
CAUSES OF HERNIS.
  The places, in which these swellings,
most frequently make their appearance,
are the groin,  the  navel, the labia pu-
dendi, and the upper and forepart of the
thigh ; they do also occur at every  point
of the anterior part of the abdomen; and
there are  several less common instances,
in which  hernial tumours present them-
selves at  the foramen ovale in the peri-
naeum,  in the  vagina,  at the ischiatic
notch, &c.  These rarer species of hernia
will  be noticed  in their proper place.
  The parts, which, by being thrust forth
from the cavity, in which they ought na-
turally to remain, mostly produce herniae,
are either a portion of the omentum, or a
part of the intestinal canal, or both toge-
ther. But, the stomach, the liver, spleen,
uterus, ovaries,  bladder, &c.  have  been
known to form the contents of some herni-
al tumours.
   From these two circumstances of situa-
tion and contents, are derived all the dif-
ferent appellations,  by which  herniae are
distinguished.  If a  portion of  intestine
only forms the contents of the tumour,  it
is called enterocele; if a piece of omentum
only, epUplocele; and  if  both  intestine
and  omentum contribute mutually to the
formation of a tumour, it is called entero-
epiplocele.  When the contents of a hernia
are protruded at the abdominal ring, but
only pass as low as the groin, or labium
pudendi,  the case  receives the name  of
bubonocele, or inguinal liernia; when the
parts descend into the scrotum, it is  called
an oscheocele, or scrotal hernia. The crural,
or femora' hernia, is the  name  given  to
that which takes place below Poupart's
ligament.  When the bowels protrude at
the  navel, the  case is named  an  exom-
phalos, or umbilical hernia; and veiUral is
the  epithet given to the swelling, when it
occurs at any  other promiscuous part of
the  front of the abdomen.  The congenital
rupture is a very particular case, in which
the  protruded  viscera  are' not  covered
with  a common hernial  sac of  perito-
neum, but are  lodged in the  cavity of
the  tunica vaginalis, in contact  with the
testicle, and, as must  be  obvious, it is
not named, like herniae in general, from
 its  situation, or contents, but from the
circumstance of its existing from the time
 of birth.
   When the hernial contents lie quietly
 in the sac, and admit of being readily put
back into the abdomen,  it is termed a re-
ducible hernia; and, when they suffer no
constriction, yet cannot be put back, ow-
ing to adhesions, or their large size in rela-
tion to the aperture, through which they
have to pass, the hernia is termed irreduci-
ble. An incarcerated, or strangulated liernia,
signifies one, which not only cannot  be re-
duced, but suffers constriction ; so that, if
apiece of intestine be protruded, the pres-
sure, to wliich it is subjected, stops the
passage of its contents onward towards the
anus, makes the bowel inflame, and brings
on a train of most alarming, and often fatal
consequences.
  The causes of herniae  are either pre-
disposing or exciting.  Of the former kind,
writers mention  a  preternaturally  large
size of the openings, at which the bowels
protrude; a.weakness  and  relaxation of
the margins of these apertures;  a preter-
natural laxity of the peritonaeum ; an unu-
sually  long  mesentery, or omentum, &c.
It is very certain, that, with regard to the
abdominal ring, the transverse tendinous
fibres, which naturally cross and strength-
en its  upper  and outer part, are  much
weaker in some subjects tlian others.  No
idea seems more prevalent in books, than,
that taking a good deal of oil with one's
food, is  conducive to the occurrence  of
ruptures. Some of the alleged pre-dispo-
sing causes, may justly excite scepticism;
but there are several circumstances which
tend to prove, that a natural deficiency of
resistance, in any part  of the parietes  of
the abdomen, is certainly a cause of this
kind.  We need only mention, how very
liable persons are, who have had the peri-
tonaeum wounded, to the present disease ;
and how much more liable  men are than
women to the inguinal liernia, owing evi-
dently to the larger size of  the abdominal
ring in the former, than tlie latter subjects.
These, however,  having a larger space for
the protrusion of the viscera, below Pou-
part's ligament,  are  more  exposed than
men to femoral herniae.
   With regard to the exciting causes, our
knowledge is involved in less doubt.  The
grand cause of this kind, is the  powerful
action of the abdominal muscles and dia-
phragm on the viscera. In feats of agility,
 such as jumping, &c. the pressure which
 the contents of the abdomen must often
 encounter,  sufficiently accounts for their
 protruding  at any part, where  the abdo-
 minal parietes  do  not  make   adequate
 resistance.   The same consideration  ex-
 plains, why herniae very  often take place
 in lifting and  carrying  heavy weights,
 running, vomiting,  straining  at stool,
 parturition,  &c.  and  in people who  in-
 habit mountainous countries. 
HERNIA.
47
  This diminution of the capacity of the
abdomen, by the action of the abdominal
muscles  and diaphragm,  on many occa-
sional exertions, must take place  in every
one, by reason of  the common habits and
necessities of life.   But, as only a certain
number of persons meet with the  disease,
it is fair to infer, that, either the exciting
causes must operate with greater force in
thtm than in the generality of people,  or
else their  abdominal  parietes have not
been  capable  of  the ordinary  degree  of
resistance.   Many patients who meet with
herniae,  in   making violent  efforts and
exertions, may be in the former  circum-
stance;  while others, who  have their
viscera protruded from such trivial things
as coughing, sneezing, crying, &c. must
be considered as being under the influence
of some predisposing cause.  A gentle-
man, who has gained great honour by a
late publication on hernia, remarks,  that,
" herniae, which  originate in predisposi-
tion,  generally come on gradually, and
almost imperceptibly; while those which
are produced  by bodily exertion,  are
formed suddenly, and by ■ the immediate
action of the exciting cause.  The oc-
currence of the complaint is often indi-
cated, in the first instance, by a  fulness,
combined with a  sense of weakness, about
the abdominal ring.   The swelling is  in-
creased by  any action of the respiratory
muscles, and disappears on pressure, and
in the recumbent position of the body.
It gradually finds its  way  through the
 tendon of the external oblique  muscle,
into  the groin,  and afterwards  into the
 scrotum.  When  a hernia  takes  place
 suddenly, it is generally attended with a
 sensation of something giving way at the
 part, and   with  pain."   ^Lawrence on
 Hernia; 1807 ;j&. 11.)
    Upon  the  subject  of  the  immediate
 cau^e of herniae,  it is observed by Scarpa,
 that several of the most celebrated mo-
 dern surgeons, as, for instance,  Warton,
 (Adenograph. cap. 11.) Benevoli, (Disserta-
 zioni Chinirgiche, 1.)  Rossius, (Acta JVaf.
 cur, Tom. 2, Obs. 178.) Brendel (de hemi-
 arum natalibus) and Morgagni, (de sed. et
 cans. morb. epist.  43, art.  13,) consider a
 relaxation  and elongation of the mesen-
 tery, as the principal cause of herniae in
 general, and  of the bubonocele  in parti-
 cular.   Hence it  happens, say they, that
 the whole  mass  of intestines, or  only a
 portion  of  an  intestine, descends against
 the  inner  orifice of  the inguinal ring,
 comes  into  contact  with  this  opening,
 and gradually makes its way out  of the
  abdomen.  In examining  this  patholo-
  gical point  Without  prejudice,  it  flfin-
  contestable,  says Scarpa, that  an intes-
  tine cannot be moved beyond its natural
  limits, unless that part of the mesentery,
which retains and fixes the  bowel in its
proper place, be at the same  time elon-
gated.   But, it does not follow from this,
that a relaxation of the" mesentery must
precede the  displacement of the intes-
tii.e.  It appears to Scarpa much more
probable, that these two events are simul-
taneous, and  depend  upon one and the
same cause.
  '• In  the healthy state, (observes this
interesting writer)  the abdomen, consi-
dered  altogether,  is  submitted to two
opposite forces,  which reciprocally  ba-
lance each other.  One is the pressure  of
the  viscera  against the  abdominal  pa-
rietes ; the other is the reaction of these
same parietes  upon  the  viscera, which
they contain.   If these two forces were
in perfect equilibrium in  all individuals,
and under all the circumstances  of life,
we should not be in the least subject  to
herniae.  tf, when the equilibrium has
been broken, every point  of the  parietes
of the belly were to yield equally to the
impulse of the viscera, an increase of tlie
volume of the whole abdomen would  be
the consequence; but,  a true hernia would
never  happen.  The  cavity  of  tlie ab-
domen is  always completely full.  The
containing  and  contained   parts react
upon, and reciprocally compress one an-
other.  It is by the effect of this moderate,
but equal and unremitting pressure, that-
all the viscera mutually support  each
other.   Without it,  the ligaments of the
liver,  those  of the spleen,  and the va-
rious membranous bands of  the intestines
in  general, would  only be  feeble means
 for fixing such  parts  in their respective
 situations.  But, there are certain points
 of the abdominal parietes, which natu-
 rally present much less  resistance, than
 others, and which  react with much less
 power against the  pressure  made  from
 within outwards by  the abdominal vis-
 cera.  Such is particularly the part, which
 extends from the  pubes  to the anterior
 superior  spinous  process of the ilium.
 This  relative  weakness of some  points
 of the abdominal parietes is very marked
 in certain  individuals, in consequence of
 a defect of organization.  It may also be
 increased by internal  or external causes,
 which are  as various as  they are nume-
 rous.   W hen, in one  of these cases, the
 pressure made by the viscera  is unusually
 increased, as happens in a violent effort,
 a defect in the equilibrium between the
 two forces  above mentioned  is occasion-
 ed; tlu-t is to say,  the reaction of the
 abdominal  parietes is no longer propor-
 tioned,  at  least  at  certain  points, to
 the force  of the  impulse of the  viscera.
 The conjoined powers of the abdominal
 muscles, diaphragm, and levator ani, are
 then  directed'and concentrated against 
46
HERNIA.
the most feeble point of the abdomen, to-
wards  which  they  propel the  nearest
viscus, or  th-t, which,  from its move-
ableness, is the most liable to displace-
ment.  If such viscus should  happen to
be the "noose  of an intestine, it is evi-
dent, that the power, which  tends to
make it protrude from the belly, must at
the same time act upon the corresponding
portion of the  mesentery; and the intes-
tine, in passing  through the parietes of
the abdomen, drags the mesentery after
it, and makes this  membrane yield and
become elongated.   AVhen  the displaced
viscera meet with little resistance on the
part of the parietes of the  abdomen, the
hernia is quickly formed,  and the elon-
gation of  the  mesentery  occurs  with
equal cele/ity.   We have an example of
this  in  the Inguinal  congenital  hernia:
in this  case,  the intestine is, in  some
measure, precipitated  into a  sac previ-
ously prepared for its reception.   On the
contrary, in the ordinary  inguinal her-
nia, a totally different disposition of the
parts renders the progress of the disease
much slower.   In  most instances, the
lieriiia is  not  formed immediately' the
equilibrium between  the impulse of the
viscera and the reaction of the abdominal
parietes, is broken.   But  in  the groin,
a slight elevation is first observed, which
reaches from the anterior superior spinous
process of the ilium to the  inguinal ring.
Some time afterwards, when the intes-
tine has made its appearance on  the out-
their   cause  is  owing  to a  laxity and
weakness of the parietes of the vagina,
which not being capable  of making any
further resistance to the pressure of the
viscera situated in the cavity of the pei-
vis, at length  suffer these parts  to pro-
trude.
  "With respect to  the  second propo-
sition, that  during the  formation of a
hernia,  the  combined  force of  all the
abdominal muscles is, as it were, directed
and concentrated against the most feeble
point  of the parietes, we see a  proof of
it in a fact that occurs to our observation
every day.  In  order to  convince  our-
selves of Nthis, it is  enough  to notice the
individuals afflicted with herniae: if they
cough, or sneeze; in a word, if they make
the slightest  effort,  they instantly find
the size  of  the swelling  increased, and
hasten to support the part with their hand.
During the slightest  shocks,  which ren-
der the herniae  larger, it is also  indis-
putable, that the mesentery is elongated
in  the same proportion as  the  intestine
protrudes.   All the viscera have such a
tendency to be displaced and carried  to-
wards the weakest  point  of the  parietes
of the abdomen, that even  those, which
are naturally  the most distant from  it,
and are the most firmly fixed by the folds
of the mesentery, may  in their turn de-
scend into the herniae. Anatomical know-
ledge alone would never have ledusto have
a suspicion of the possibility of these oc-
currences.  Sandifort  and  Paletta  have
side of the ring, the enlargement of the „ found, in ah umbilical hernia, the caecum,
                                        with  a portion of the  ilium  and colon.
                                        ( Obs.  Pathol, cap. 4, & Nova  Gubernaculi
                                        testis Descriptio.)  Mauchart, Camper, and
                                        Bose,  have met  with the caecum in  an
                                        inguinal hernia  of the left  side.   (De
                                        Hern.  Incarc. in Halleri Disput.  Chirurg.
                                        Tom. 3.  Demonstrat. anat. patholog. lib. 2,
                                        p. 18, & Animadvers. de Iiern.inguin.p. 5.)
                                        Lassus has seen the left colon protrude at
                                        the right inguinal ring.  (M6decine  Opi-
                                        ratoire, Tom. 1, p. 173.)  R* it be proved
                                        by all these facts, that such  viscera; as
                                        are the most closely united to the great
                                        sac of the peritoneum  and neighbouring
                                        parts, are  nevertheless  liable  to  form
                                        herniae; and if such displacements  can-
                                        not happen without a  considerable elon-
                                        gation of the membranous bands fixing
                                        these bowels in their natural situation,
                                        how can we refuse to admit, that a noose
                                        of intestine, pushed by degrees through
                                        the  inguinal ring, drags  along with it
                                        the corresponding portion of the mesen-
                                        tery ?  In order to  explain   this event,
                                        there is  no necessity  for  supposing a
                                         partial  relaxation  of  the  mesentery."
                                         (Traite"  Pratique  des  Hernies, Par A.
                                         Scarpa, trad, de I'ltalien, p. 37-—43.)
hernia, and the elongation of the mesen
tery, make much  more rapid, though al-
ways simultaneous progress.
  "Numerous   practical  observations,
(says Scarpa) concur in proving the fore-
going account, that we must not search
for the immediate cause of herniae in the
relaxation of the  mesentery, but  rather
in  a  want of  equilibrium between the
pressure of the viscera and the resistance
of one or several points of the abdominal
parietes.  Indeed, herniae are  seen occur*
ring from the slightest causes in infants,
in whom the  neck of the tunica vaginalis
is not speedily obliterated, and in indivi-
duals, who, from being fat have all on a
sudden become extremely thi: . Such wo-
men as have had children, are more subject
to the disease than others.  Persons also
of both sexes, who carry considerable bur-
dens, or who play upon wind instruments,
or who have suffered a forcible contusion
of the abdomen, are particularly exposed
to tlie disorder, even though there is not
the least reason for suspecting in them a
relaxation of  the  mesentery.   Vaginal
hernia;, which arises after difficult labours,
afford another proof of the  same truth; 
HERNIA.
49
  The general  symptoms of a  hernia,
which is reducible, and free from stran-
gulation, are, an indolent tumour at some
point of tlie parietes of the  abdomen ;
most frequently descending out of the ab-
dominal ring, or from just below Poupart's
ligament, or else out of the  navel;  but,
occasionally, from  various other situa-
tions,  as  will  be  presently  explained.
The swelling often originates suddenly,
except in the  circumstances above re-
lated,  and,  it is subject to a change of
size, being smaller when the patient lies
down on his back,  and  larger when he
stands up,  or holds his breath.  The tu-
mour frequently diminishes when pressed,
and grows large again when the pressure
is removed.  Its size and tension often
increase after a meal, or when the patient
is flatulent.   Patients  with hernia,  are
apt to be troubled with colic, constipa-
tion, and vomiting, in consequence of the
unnatural situation of the bowels.  Very
often, however, thev functions  of the vis-
cera seem to suffer little or no interruption.
  If the case be an  enterocele,  and the
portion of intestine be small,  the tumour
is small in proportion; but, though small,
yet, if the  gut be distended with wind,
inflamed, or have any degree of stricture
made on it, it will be tense,  resist  the
impression of the finger, and give  pain
upon being  handled.   On  the contrary,
if there be  no  stricture, and the intes-
tine suffers  no  degree  of inflammation,
let the prolapsed piece be of what length
it may, and the tumour of whatever size,
yet the tension will be little, and no  pain
will attend  the  handling  it; upon  the
patient's coughing, it will feel as if it
were blown  into; and, in general,  it  will
be  found very easily returnable.   (Pott.)
A guggling noise is often made when the
bowel is ascending.
  tf the hernia be an epiplocele, or one of
the omental kind, the tumour has a more
flabby, and a more unequal feel; it is in
general perfectly indolent,  is more com-
pressible, and (if in the scrotum) is more
oblong, and less round, than the swelling
occasioned in  the sa|ne situation  by an
intestinal hernia; and, if the quantity be
large, and the patient adult, it is, in some
measure distinguishable by  its  greater
weight  (Pott.)
  If the case be an entero-epiphcele,  that
is,  one consisting of both intestine  and
omentum,  the  characteristic marks  will
be  less clear than in either of the simple
cases; but the disease may easily be dis-
tinguished from every other  one, by any
body in the habit of making tlie examina-
tion.  (Pott, p. 28.)
  On the subject of prognosis, Mr.  Pott
Wmarks,  " that the  same kind  of  rup-
     Vot. II.
ture, in different people, and under dif-
ferent  circumstances, wears  a very vari-
ous face ; the age and constitution of the
subject, the date of the disease, its being
free, or not free from stricture, or inflam-
mation, the  symptoms  which attend it,
and the probability or  improbability of
its being returnable, necessarily producing
much variety; the degree  of hazard at-
tending this complaint will be also more
or less, as it shall happen to be circum-
tanced.
  " If  the subject be an infant, the case
is not often attended with  much diffi-
culty,  or hazard; the softness and duc-
tility of their fibres generally rendering
the reduction easy as well  as the  de-
scent ; and though from neglect, or inat-
tention, it may fall down again, yet it is
as easily replaced, and seldom produces
any mischief;  I say  seldom, because I
have seen an infant, one year old, die of a
strangulated hernia, which had not been
down  two days, with all the symptoms of
mortified intestines.
  " If the patient be adult,  and in the
vigour of life,  the consequences  of neg,
lect, or of mal-treatment, are more to be
feared than at any other time, for reasons
too obvious to need relating.  The great
and principal mischief to be apprehended,
in an  intestinal hernia,  is an inflamma-
tion of the gut, and an obstruction to the
passage of the aliment and feces through
it; which  inflammation  and obstruction
are generally produced by a stricture
made  on the intestine.   In very old  peo-
ple, the symptoms do not usually make
such rapid progress,  both  on account of
the laxity of their frame, and their more
languid circulation ; and also that their
ruptures are most frequently of ancient
date, and the passage a good deal dilated;
but then, on the  other  hand, it should
also be remembered,  that  they are by no
means exempt from inflnmm;.tory symp-
toms ;  and that, if such should come on,
the infirmity of  old age is  no favourable
circumstance in the treatment, which may
become necessary.
   " ft  the disease be recent,  and the pa-
tient young,  immediate reduction,  and
constant care to prevent its pushing out
again,  are the only means  whereby it is
possible to obtain a perfect cure.
   " If the disease be of long standing,
has been neglected, or suffered to be fre-
quently down, and has given little or no
trouble, the aperture in the abdominal
muscle, and the neck of the hernial sac,
may both be presumed to be large; which
circumstances  in general  render  imme-
diate  reduction less  necessary and less
difficult, and also  frustrate all rational
expectation  of a perfect cure-   On the 
Su                                HERNIA.
contrary,  if the rupture be  recent, or,
though old, has generally been kept up,
its immediate  reduction is more abso-
lutely necessary, as the risk of stricture
is greater from the supposed smallness of
the aperture, and narrowness of the neck
of the sac.  If the rupture be  very large
and ancient, tlie patient far advanced in
life, tlie intestine  not  bound  by any de-
gree of stricture, but does its office in the
scrotum regularly, and no other incon-
venience be found  to attend it, but what
proceeds from its weight, it will in gene-
ral be better not to attempt reduction, as
it will, in  these circumstances, most pro-
bably prove fruitless,  and  the handling
the parts  in the attempt, may so bruise
and ii'jure them as to do mischief;  but
this must  be understood to be spoken of
those only in which   there is not  the
smallest degree of stricture, nor any symp-
tom of obstruction in the intestine; such
circumstances  making  reduction  neces-
sary at all times, and in every case.
  " With  regard to the contents of  a
heniia,  if it  be a portion of omentum
only,  and  has  been gradually  formed, it
seldom  occasions  any bad  symptoms,
though  its weight  will sometimes render
it very  troublesome.  But  if  it be pro-
duced suddenly, by effort or violence, that
is,  if a considerable  piece of the caul
by accident slip down  at  once, it will
sometimes prove painful, and cause  very
disagreeable complaints ; the  connexion
between the omentum, stomach, duode-
num,  &c. being such as  to render  tlie
sudden  descent of a large  piece  of the
first sometimes productive of nausea,  vo-
miting,  colic,  and  all  the disagreeable
symptoms arising from the  derangement
of these  viscera.  When   the piece of
caul is engaged in such a degree of stric-
ture as to  prevent the circulation of blood
through it, it will sometimes, by becoming
gangrenous, be tlie occasion of very bad
symptoms, and even of death,  as I* have
more  than once seen; and thus, as  a
mere omental hernia, it may sometimes be
subject to great hazard.  But even though
it should never be liable to the just men-
tioned evil, that is, though' the  portion
of the caul should remain uninjured in
tlie scrotum, yet it renders the patient
constantly liable to hazard  from another
quarter: it makes  it every moment pos-
sible  for a piece of intestine to slip into
tlie same  sac,  and thereby add to  the
case all the trouble and all the danger
arising from an intestinal rupture.  It is
by no means an uncommon thing for  a
piece of gut  to be added to a rupture,
which had for many jears  been merely
omental, and for that piece to be strangu-
lated, and recjLue immediate help.
   " An old omental hernia, is often ren-
dered not reducible, more by an altera-
tion made  in  the  state of the prolapsed
piece of caul, than  by its quantity.  It
is very common for that part of tlie omen-
tum which  passes  through the neck  of
tlie sac,  to  be compressed into a  hard,
smooth body, and lose all appearance  of
caul, while what is below in the scrotum
is  loose and  expanded, and enjoys its
natural  texture ;  in this case, reduction
is often  impossible, from the mere figure
of the part: and 1 have so often seen this,
both in the living and the dead, that I am
satisfied, that for  one omental  rupture,
rendered irreducible by adhesions, m any-
more become  so  from the cause above-
mentioned.
  " In the sac of old omental  ruptures
that have been long  down, and only sus-
pended  by a bag truss, it is no  very un-
common thing to have a pretty consider-
able quantity of fluid collected : this,  in
different slates and circumstances of the
disease, is of different colour and consist-
ence, and seldom so much in quantity  as
to occasion any particular attention  to
it; but  on the other hand, it sometimes
is  so much  in quantity as to  become an
additional disease  to  the original  one
I have more than  once been  obliged  to
let  it out, in order to remove the incon-
venience arising from its weight, and the
distention of the  scrotum, which I have
also seen become gangrenous  by the ne-
glect of this operation.
  " If the  hernia  be  of the intestinal
kind, merely,  and the  portion of gut be
small, the  risk is  greater, strangulation
being more likely to happen in this  case,
and more productive of mischief, when it
has happened:  for the smaller the  por-
tion  of  gut is  which is  engaged, the
tighter  the  tendon  binds, and the  more
hazardous  is  the  consequence.   I  have
seen a fatal gangrene, in a bubonocele,
which had not been formed forty-eight
hours, and in  which the piece  of intes-
tine  was little more than half ah  inch.
There  are  few practitioners,  who  have
^een business, but know the truth of this ;
but perhaps the reason of it is not  suffi-
ciently explained to  the  unknowing:  it
is  this;  when a considerable  portion  of
intestine passes out  from the  belly  in a
hernial sac,  it necessarily and unavoida-
bly carries with it  a proportional quan-
tity of the mesentery, which ew.ry body
knows   is  a strong  double membrane.
When the prolapsed:  part is at all consi-
derable,  this double membrane  is again
in  some measure  folded on  itself,  and
takes off a good deal of the effect of the
stricture on the intestine.  Now although
this  circumstance  will not prevent toe 
HERNIA.                                *l
effect, if the means of relief be totally
neglected, yet it will most  certainly  re-
tard the evil, and give more time  for
assistance; whereas, when there  is little
or none of the mesentery got through the
tendon, and the  thin, tender intestine
bears all the force of the stricture, it is im-
mediately brought into hazard.
  " The practical inference to be drawn
from hence, is too obvious  to need men-
tioning.
  " In the intestinal,  as  in tlie omental
hernia,  they which  have been often or
long down,  are in general more easily re-
turned, and do  not require such imme-
diate assistance, as they which have  sel-
dom  been  down, or  have  recently  de-
scended ;  and in the one kind of hernia,
as well as in the other, the state of  the
hernial sac, with  regard to size, thick-
ness, &c. depends very much on the date
of tlie  disease, and tlie regard  that  has
been paid to it.
   " If the hernia  be caused by a portion
of the intestine ileum only, it is in general
more easily reducible  than if a part of
the colon has descended with it,  which
will also require more  address and more
patience in  the  attempt.  The reductiou
of a  mere intestinal hernia too  (cxteris
paribus) will always remain more practi-
cable than tliat of a mere  omental one,
after it has  attained to a certain  size  and
state, as the part contained  within  the
former is liable to less alteration of form
than  that within the hitter; which altera-
tion has already been mentioned as no un-
 frequent hindrance of the return of an old
 caul rupture.
    ■« Not that the parts within a mere in-
 testinal hernia are absolutely exempt from
 such an alteration as may render their re-
 turn into  the belly  impracticable, even
 where  there is no stricture; for 1 have
 seen that  part of the mesentery, which
 has lain long in  the neck of the sac of an
 old  rupture, so  considerably hardened
 and thickened, as to prove an insuperable
 obstacle to its reduction.
   " Upon the whole, every thing consider-
 ed, I think it may be said, that an intesti-
 nal rupture is  subject to worse symp-
 toms,  and  a greater  degree of hazard,
 than  an  omental one, though  the latter
 is, by no means, so void of either as  it is
 commonly supposed to be; that bad symp-
 toms are more likely to attend  a recent
 rup ure than one of ancient date;  that
 the descent of a very small  piece of in-
 testine is more hazardous  than that  of a
 larger : that the hernia, which consists
 of gut only, is  in general, attended  with
 worse circumstances than that  which is
 made  up both of gut and caul;  and that
 no true judgment can be formed of any
rupture at all, unless every circumstance
relating to it  be taken  into  considera-
tion."  (Pott on Ruptures.)
  Mr. Hey coincides with Pott, in think-
ing  the prognosis more  unfavourable
when the tumour is small.  " I think it
is not a bad general rule,.that the smaller
tlie hernia, tlie less hope there  is of re-
ducing  it by the taxis.  Long-continued
efforts to reduce  a prolapsed intestine,
are most likely to succeed in  old and,
large hernias,  when no adhesions have
taken place."  (Pract.  Observ. in Surgery,
p. 203.)
  " The opening  (says Mr.  Lawrence)
through which the parts protrude, is nar-
rower in some  situations than in others ;
the progress of the case will therefore  be
more rapid* and the danger of the patient
more urgent.   The aperture is generally
very small  in  femoral hernia; this kind
of rupture in men,  and the bubonocele in
women, have  a particularly narrow en-
trance."  (Treatise on Hernia, p. 29.)
GENERAE OBSERVATIONS ON THE TREATMENT
              OF HERNIiB.

1. Treatment of those which are capable  of
  easy and immediate reduction and are not
  attended by any troublesome or bad symp-
  toms.

  " This case,"  says  Pott, " is very fre-
quently met with in infants, and some
times in adults, and is too often neglected
in both.   In the former, as the descent
seldom happens but when the  infant
strains to cry, and the gut is either easily
put up, or returns sud sponte, as soon  as
the child becomes quiet, it often is either
totally unattended to, or an attempt made
to restrain it only by a bandage made of
cloth, or dimity,, and which being inef-
fectual for  such purpose,  lays the foun-
dation for future trouble and mischief.
  •'This  is, in great measure, owing  to
a common opinion, that a  young infant
cannot wear a  steel truss : a generally
prevailing error, and which ought to  be
corrected. There is no age at which such
truss may not be worn, or ought not to be
applied ;  it  is, when well made, and pro-
perly put on, not only perfectly safe and
easy, but the only kind  of bandage that
can be depended upon :  and as a radical
cure  depends greatly on the thinness of
the hernial  sac^ and its  being capable of
being so compressed as possibly to unite,
and  thereby  entirely close  the passage
from the belly,  it must  therefore appear
to  every  one who will  give himself the
trouble of thinking on the subject, that
the   fewer  times the parts have made 
52                                HERi

a descent, and the smaller and  finer tlie
elongation  of the  peritoneum  is,  the
greater the probability of such cure must

  " The  same  method of acting  must,
for the same reasons,  be  good in every
age in which a radical cure  may reason-
ably be expected; that is, the prolapsed
parts  cannot be too soon returned,  nor
too carefully prevented from  falling down
again,  every, new  descent rendering  a
cure both  more distant and  more  un-
certain.
  " As soon as the parts are returned,
the truss should be immediately put on,
and worn without  remission, care being
taken,  especially if the patient  be  an
infant, to keep  the  parts on which it
presses constantly  washed,   to prevent
galling.
  " It  can  hardly  be  necessary to say,
that the surgeon should be careful  to see
that the truss fits,  as his success and re-
putation depend on such care.  A truss
which  does  not  press  enough,  is  worse
than none at all, as it occasions loss«of
time,   and  deceives the patient,  or his
friends; ;.nd one which presses too much,
or on an improper part, gives  pain and
trouble,  by producing  an inflammation
and swelling of the spermatic chord, and
sometines of the testicle.
  " In adults, whose ruptures are of long
standing,  and  accustomed  to  frequent
descent, the hernial sac is generally firm
and thick, and the aperture in the tendon
of the  abdominal muscle large; the free-
dom and ease with which the  parts re-
turn into  the belly, when the patient is
in a supine posture, and  the little pain
which  attends  a rupture of this kind,
often  render the persons who labour un-
der it  careless:  but all such should be
informed, that they are in constant dan-
ger of such alteration  in their complaint,
as may put them  into great hazard, and
perhaps destroy them.  The  passage from
the belly being open,  the quantity of in-
testine in the hernial sac is always liable
to be  increased, and  when  down, to be
bound by  a stricture.  An  inflammation
of that portion  ofthe gut  which is down,
or  such obstruction in it as may distend
and enlarge it, may at all times produce
such complaiuts as may put the  life of
the patient  into imminent danger;  and
therefore,  notwiihstanding this kind of
hernia may have been  borne for a great
length of time, without  having  proved
either  troublesome or hazardous,  yet as
it is alwajs possible to become so,  and
that very suddenly, it  can never be pru-
dent or safe to neglect  it.
  "Even though the  rupture should be
of the omental kind,  (which considered
abstractedly is  not subject to that de-
gree or kind of danger to which the intes-
tinal is liable) yet it may be secondarily,
or by accident, the cause of all the same
mischief;  for while it keeps the mouth  of
the hernial  sac  open,  it renders the de-
scent of a  piece of intestine always possi-
ble,  and  consequently  always likely  to
produce the mischief which may proceed
from thence.
  " They  who  labour  under a  hernia
thus circumstanced, that is,  whose  rup-
tures have been  generally down while
they have been in an erect posture, and
which have either gone up  of themselves,
or have been easily put up  in a  supine
one, should  be  particularly  careful  to
have their truss well made, and properly
fitted; for the mouth of the sac, and tlie
opening in the tendon  being  both large
and  lax,  and  the parts  having been
used to descend through them, if the pad
of the truss be  not  placed  right,  and
there be not a due degree of elasticity in
the spring,  a piece of  intestine will,  in
some posture, slip down behind it, and
render the truss productive of that  very
kind of mischief which it  ought to  pre-
vent.
  " It  is  scarcely credible  how very
small an opening will serve  for a portion
of gut or caul to  insinuate   themselves
into at  some times.   Now,  though  in
persons of mature age it most frequently
proves impracticable so to compress the
mouth of the hernial  sac, as absolutely
to close it, yet  by the constant use  of a
well-made truss, it may be  so lessened, as
to render  the descent of a  piece of intes-
tine into  it much more difficult: from
whence we  may learn  the great  conse-
quence of having the part  completely re-
duced before the truss is applied, and the
danger  that  may  be incurred by laying
such  bandage  aside  after it  has been
worn some  time; since the same  altera-
tion which renders the descent ofthe gut
less easy, will also make  the reduction
more difficult, if a piece should  happen
to  get down :  and hence  also we  may
learn why the bandage should be  long
and unremittingly  worn  by  all  those
whose time  of life makes the expecta-
tions of a perfect cure reasonable, many
of the ruptures  of adults being  owing
to  the negligent manner  in  which  chil-
dren at school are suffered to wear  their
trusses.
  " I know  a gentleman  who has  for
some  years  had an  omental  rupture,
which was neglected while  he was  young,
and he  haying naturally a  lax habit, and
the abdominal  opening  being much di-
lated, he  finds  it extremely  difficult  to
keep it up, even with the best truss  he 
HERNIA.                                53
can get, behind which it will sometimes
slip down: when tlus  happens, it gives
him such  immed ate and acute pain at
his stomach, and makes him  so intole-
rably sick, that he is obliged immediatelj
to. throw himself on his back, and pro-
cure the return of tlie piece of omentum."
(Pott or. Ruptures.)
   When we  have  considered the anatomy
of partcular herniae we shall  begetter
able to judge of  the proper construction
of trusses.  (See Truss.)

treatment of irreducible hernije, free
   from inflammation,  and unattended
   With troublesome, or dangerous symp-
   toms.

   " This incapacity of reduction may be
owing  to  several causes, .but  most fre-
quently arises either from the  largeness
of the quantity of the  contents, from an
alteration made in their form and texture,
or from connexions  and adhesions, which
they have contracted with each fther, or
with their containing bag.
   " I  have already  mentioned  it as my
opinion that ruptures are sometimes ren-
dered difficult to be reduceu, by that por-
tion ofthe intestinal canal which is called
the caecum, or the beginning of the colon,
being contained in  the hernial sac.  Of
which  tact ,1 am as much convinced as
the nature  of such kind of things will
permit;  that is, by observations  made
Both on the living and the dead.
   " When a hernia of this kind (viz, one
containing such a part of the intestinal
tube) has been long neglected, and suf-
fered to remain in the  scrotum without
any bandage  at all to support its weight,
the hernial sac being constantly dragged
down,  and  kept in  a state of distention,
necessarily   becomes  thick,  hard,  and
tough; by this means the diameter of its
neck is lessened, and  the  return  of the
intestine back from the scrotum into the
belly rendered more and more difficult, as
the parts through which it is to pass be-
come harder, and less capable of yielding.
This will, indeed, in time prove an ob-
struction sufficient  to hinder any part of
tlie intestine, or even  of the  omentum,
"from being  returned;  hut the more the
difficult)' is,  which proceeds  from the
mere figure  and size ofthe portion of gut,
the greater will be tlie obstruction when
added to that arising from the  just-men-
tioned cause.
   " An alteration produced by  time, and
constant, though gentle, pressure  in the
form  and consistence, or texture  of the
omentum, is also no infrequent cause, why
neglected omental ruptures become irre-
ducible.
  " The cellular membrane in all parts of
the body, however loose and light its na-
tural texture may be, is capable of becom-
ing hard, firm, and compact, by constant
pressure.  Of this there are so many, and
so well known instances, that it is quite
unnecessary  to produce any.
  " The  omentum, from its  texture, is
liable to the same consequence.   When a
portion of it has  been suffered to remain
for a great length of time in the scrotum,
without having  ever  been returned into
the belly, it often happens that although
that part of it which is in the lower part of
the hernial sac preserves its natural soft,
adipose, expansile state, yet all that part
which passes through  what is called the
neck  of the sac  is, by constant pressure,
formed into a hard, firm, incompressible,
carnous kind of  body,  incapable of being
expanded,  and  taking the form  of the
passage in which it is confined, exactly
filling that passage, and rendering it im-
possible to push  up the loose part  which
fills the scrotum.
   " This is no  theoretic  opinion,  but a
fact, which  I have seen and  proved oft-
en ; and  whoever will reflect on it, will
immediately find in it one  insuperable
objection to the return of some old omen-
tal ruptures.
   " The same reason for incapacity of
reduction is also sometimes met with in
ruptures of the  intestinal  kind, from  an
alteration produced  on that part  of the
mesentery which has been suffered  to lie
quiet for a  great length  of time  in the
neck of an old hernial sac.
   " The other impediment, which I men-
tioned, to the return of old ruptures, is the
connexion and adhesion ofthe parts, either
with each other, or with the bag contain-
ing them.   This is common to both the
intestinal and omental  hernia, and is pro-
duced by slight inflammations of the parts,
which have been permitted to lie long in
contact with each  other,  or pe^iaps in
many cases from the mere contact only.
These adhesions are more or less firm in
different cases, but even the slightest will
almost always be found an invincible  ob-
jection to tlie reduction of the adherent
parts, by the hand only.
   " Many, or perhaps most of these irre-
ducible ruptures become so by mere time
and neglect, and might at first  have been
returned; but when they are got into this
state, they are capable of no relief from
surgery but the application of a sQspen.
sory bag, to take off or lessen the*  incon-
  *  I am not unaware  (says Pott) that
most of these are capable of being cured
by the operation for the bubonocele, as it 
54
HERNIA.
venience arising from the weight of the
scrotum.
  "  People in  this situation should be
particularly careful not  to make any at.
tempts beyond their strength, nor aim at
feats of agility; they should take care to
suspend the loaded scrotum, and to keep
it  out ofthe way of all harm from pres-
sure,  bruise, &c.  When the tumour is
very large, a soft quilted bolster should
be worn at the bottom of the suspensory
to prevent excoriation, and the scrotum
should be  frequently washed for the same
reason;  a  loss of skin in this part, and
in such circumstances, being sometimes
of the utmost importance.  They ought
also  to  be particularly  attentive to  the
office of the intestinal canal, to see  that
they do not by  any irregularity of diet
disorder  it, and keep  themselves from
being costive, for reasons too obv ious to
need relating.  By these means, and with
these  cautions, many people have passed
their  lives for  many years free from dis-
ease,  or complaint,  with very large irre-
ducible ruptures.
  " On the other hand,  it is fit that man-
kind should be apprised, that the quiet,
inoffensive state  of this kind of hernia is
by no means to be depended upon;  many
things may happen to it, by which it may
be so altered, as to become hazardous,
and even  filial:  an inflammation of that
part of the gut  which  is  down, any ob-
steuction to the passage ofthe aliment or
feces through it, a stricture made by the
abdominal tendon, either on what has been
long down, or on  a new  portion which
may at any time be added to it, are always
capable  of so altering tlie state of the
case,  as to  put  tlie life of the patient
into danger.
  " Indeed  the  hazard arising  from  a
stricture made on  a piece of intestine
contained in the  sac of an old irreducible
hernia, is in one respect greater, than that
attending one that  has  been found at
times reducible; since from the nature of
is  called; but as I should never think of
proposing it in any case, in which there
are not symptoms, that threaten the life
of the pati-nt, so  I have not mentioned
it in this place as a means of cure.   I also
am not unapprised what influence a suc-
re-sful operation or two of this sort has
had on the unknowing; but I also know,
that  such accidental successes  have em-
boldened the same operators  to commit
more than one  or two murders, in  similar
cases; and that, from  the  prevalence of
fashion,  some  of  these rupture-doctors
have been largely  rewarded,  when  they
ought to have been hanged
the case it will hardly admit of any aj •
tempt  toward relief,  but the operation,
and that in these circumstances must ne-
cessarily be accompanied with additional
difficulty.
  " Among the ruptures which have been
thought not  reducible,  and treated as
such, there have been some  which, upon
more judicious and more patient attempts,
have been found capable of reduction.
  " When this is suspected to  be  the
case,  the  proper method is by absolute
rest, in a  supine posture, for a consider-
able length of time, by great abstinence,
and the use of evacuants, so  to lessen the
size of the parts in the hernial sac, as to
render them capable of passing back again
into the belly.''  (Pott on Ruptures.)
  Fabricius Hildanus  gives an account
of a man, who was radically cured of a
rupture, of twenty years'  date, by six
months' confinement to  bed.  (Cent. 5,
Obs. 54.)
  Le Dran and Arnaud relate instances of
monstrfcis bubonoceles, which disappear-
ed entirely, after the  patients  had been
long confined to bed, and become much
emaciated, by tedious illnesses.   Some of
the moderns have imitated this operation
of nature, and  by frequent  bleedings,
and repeated purges, have sometimes so
far  reduced the size of  the hernia, that
it has  been returned into the  abdomen.
Mr. Hey has several times succeeded in
this  way.   (P. 219.)   But,  this practice
cannot prove successful, when the viscera
adhere to  the  sac, or to  the peritoneum,
just within the abdomen.  The greatest
objection  to this method of cure, is the
want of an absolute criterion, by which
to distinguish, when the parts do, or do
not  adhere to the hernial  sac, and, in
advanced  years, though  one were sure,
that the viscera were  free from tlie sac,
the possibility of hurting  the body by
the necessary evacuations, is also another
objection.  (Sharp's Critical Enquiry, p.
15)
  Were the plan to be  thought worthy of
trial, keeping up a constant pressure on
the tumour, by means  of  a suspensory
bandage, made to lace  in front, would be
proper for promoting the absorption of
the  tliickened parts in  tlie  hernial sac.
Mr. A. Cooper has reduced  such herniae,
after applying ice to them, the good effects
of which  he imputes to  its producing  a
contraction of the scrotum, which per-
forms the office of a strong and permanent
compression of the tumour.
  Whenever any attempts  of this  kind
succeed, " a truss should be immediately
put  on, and worn  constantly without re-
mission ;  for,  in these people,  the large-
ness ofthe abdominal aperture, the thick- 
HERNIA.                               55
Hess of the hernial sac, and the relaxation
of the mesentery, make a new descent
always to be apprehended, and guarded
against."  (Pott.)
  There are instances,  however, on re-
cord,  in  which the  capacity of the ab-
domen had  become  so  adapted to the
diminished quantity of the viscera, that
when  the contents of the  hernia  were
reduced, serious  complaints  arose  from
their introduction into the belly. Schmuc-
ker has met with several such cases, in
which he has been obliged to  take off
the truss.  Petit  has known  the reduc-
tion of a hernia of this  kind  prove fatal,
the parts not descending again when the
truss was removed, the nausea and vomit-
ing, which  arose, continuing, and  peri-
tonitis taking place. (Chirurgische, Wahr-
nehmungen,  Vol.  2,  p. 243.  Traite" des
Maladies Chirurgicales, Tom. 2, p. 392.)
  Mr. Pott  remarks, that " an omental
rupture,  which has been so long in the
scrotum as to have become irredypible, is
very seldom attended with any bad symp-
toms, considered abstractedly;  but, it is
constantly capable of being the  occasion
Of an  intestinal hernia,  and all its conse-
quences ; neither is that  all, for the omen-
tum,  either  so altered in form and tex-
ture,  or so connected as to be incapable
of reduction,  may  by accident  inflame,
and either beoome gangrenous, or suppu-
rate,  and the  occasion of a great deal of
trouble." In a few instances, epiploceles
produce very bad symptoms indeed,  cases
of which are  to be found in Garengeot,
Dionis, &c.
  Sometimes,  in old cases of entero-epi-
plocele,  the  intestine is reducible, but
the omentum is not, in  which case  some •.
have  advised keeping up the piece of
bowel with a truss, the pad of which must
be  so contrived as riot to press on the
omentum.   Mr. Pott, however, contends,
that this is not often  practicable, and,
should such a truss be  used, he advises
its  being particularly attended to, lest a
small piece of gut slip down, and, being
pressed  on  by the truss,  produce fatal
mischief.
  " Irreducible herniae must of course be
exposed to all the consequences of exter-
nal injury  and violence; hence, various
cases are recorded, in which the bowels
have  been burst by blows, falls," &c.
(Lawrence on Hernia, p. 53.)

STMPTOMS AND TREATMENT OF  A STRAN-
  GULATED, OR  AN  INCARCERATED, HER-
  NIA.—MEANS TO  BE TRIED, BEFORE AN
   OPERATION.

  " Difficulty of reduction  (says  Pott)
may be owing to several causes.  The size
of the piece of omentum, or the inflamed
state of it; the quantity of intestine and
mesentery, an inflammation of tjie gut, or
its distention by feces, or wind; or the
smallness of  the aperture of the tendon,
through  which the hernia passes.   But,
to whatever cause it be owing, if the pro-
lapsed body  cannot be immediately re-
placed, and the patient suffers  pain, or is
prevented thereby from going  to stool, it
is called an incarcerated hernia, a stran-
gidated hernia, or a hernia with stricture.
  " The  symptoms are a swelling  in the
groin,  or scrotum, resisting the impres-
sion of the fingers: if the hernia be of
the intestinal kind, it is generally painful
to the touch,  and the pain is increased by
coughing, sneezing, or standing upright.
These  are the very first  symptoms, and,
if they are not relieved, are soon followed
by others,  viz. a sickness at the stomach,
a frequent retching, or inclination  to vo-
mit, a stoppage of all discharge per anum,
attended with a frequent, hard pulse, and
some degree  of fever."
  A patient,  thus  circumstanced,  is in
some danger, and demands immediate as-
sistance.   A  stricture made on  the pro-
lapsed part of the gut, by the aperture,
through which it passes, is the immediate
cause of all  the bad  symptoms; and of
course, the removal of such  stricture is
the only 'thing, which  can bring  relief.
This object can only be accomplished by
returning the bowel back into the abdo-
men,  or  dividing the parts, which form
the stricture.  The former  plan is  al-
ways  the  most desirable, when practi-
cable.
   We next proceed to notice  the various
measures to be adopted for the relief of a
strangulated  hernia, so as to  obtain tb<
best chance of doing away the necessily
of  an operation.  After treating of the
merits of each plan, a few remarks will
be  offered on  the  order  in  which the
means should be put in practice, a subject
that has  been most lamentably neglected,
even by the latest writers on this interest-
ing disease.
   Taxis.—This is the term applied to.the
operation of reducing a  hernia with the
hand.  It is much  promoted by the posi-
tion of  the  patient's  body; Winslow
thought it advantageous to have it placed
in an inclined plane/and  the thighs bent
towards  the  trunk.  Mr. A. Cooper ad-
vises the same practice,  observing,  that
this posture,  by relaxing the fascia ofthe
thigh,  relaxes  also the aperture, through
which the hernia passes.  Every degree
of tension, and relaxation of the femoral
fascia must undoubtedly  be at tended with
a corresponding change in the abdominal
ring.   But flexion  ofthe  thigh, besides' 
56
HERNIA.
relaxing this fascia, also relaxes the ab-
dominal, internal iliac, and psoas muscles.
The pressure,  which is  made on the tu-
mour by the hinds of the surgeon, should
always be directed upwards and outwards,
in  cases of  inguinal hernia,  along the
course ofthe sperm, it ic cord, and Mr. A.
Cooper advi-es it to be continued from a
quarter to  half an  hour. (On Inguinal
and Congenital Hernia.)
  As the  femoral  hernia passes down-
wards, and then  forwards, the pressure
must  be directed  first  backwards, and
then upwards.   No violence should ever
be used, for, besides being unavailing,  it
must greatly aggravate the inflamed state
of tlie contents of  the hernial sac, and,
it has even made the intestine  burst.—
(See Cooper on  Inguinal Hernia, &c p. 23.)
  Besides bending the thigh, care should
also be taken to rotate it inwards, which
will have great effect in  relaxing the  fe-
moral fascia, and  tendon of the external
oblique muscle.  Suspension of the pa-
tient over  the shoulders of an assistant
has been thought  to facilitate reduction:
"I  have tried  it often, (says Mr. Hey;)
but have not found it to be of such supe-
rior efficacy, as some authors have repre-
sented." (P.  144.)
  The return of a piece  of intestine is ge-
nerally preceded by a peculiar noise,  caus-
ed  by the passage of air through the! stric-
ture.  It recedes  at first gradually, and
then slips  up  suddenly.  The omentum
goes up slowly to the very last  portion,
which must be actually pushed  through
the  opening.  If  the taxis  should  not
succeed at  first, it will often do  so  after
the warm bath, bleeding, or cold applica-
tions.  Small herniae, being attended with
the closest  stricture, are the most difficult
to reduce,  and, for the same reason; cru-
ral  ones do not so often yield to the taxis,
as inguinal ones in the male subject. The
taxis becomes less likely to succeed, the
longer the  inflamed viscera have  been
down, because  adhesions are likely to
have formed.   Mr.  Liwrence  observes,
(p.  63 )  " When the rupture becomes
painful, we are no longer justified in per-
severing in attempts at reduction by the
hand.  A sufficient pressure cannot now
be endured; and the force which is em-
ployed only tends to increase the inflam-
mation, and accelerate  the  approach of
gangrene.  At this period, the operation  is
required, and should be performed without
delay?' Desault even proscribed the  taxis
altogether  in  the inflammatory strangu-
lation, until the  previous use of other
means had produced a change in the state
of  the swelling.  However, 1  should
never advise the reader to lose too much
tin^e in this way, on the supposition, that
he can  diminish the  inflammation  of a
strangulated  hernia  in any other  way,
than by delivering the bowels from the
pressure of the stricture.  Bleeding  may
check, but cannot  stop, much less dinu-
nish, the inflammation, that  prevails.
  That, however, the taxis  is  frequently
abused, and the cause of-serious mischief,
is  a truth, which cannot   be  doubted.
" Strangulated  herniae,  (says   Scarpa)
very frequently mortify from the negli-
gence of the patients,  and their repug-
nance to  submit  to  an operation,  and,
perhaps, still more  frequently from the
effect of the taxis, unskilfully exercised
by uninformed  surgeons, who are deter-
mined,  at  any price whatsoever, to ac-
complish the speedy reduction of the vis-
cera.  The majority  of them make  no
distinction between the acute,  and the
chronic strangulation.   In both cases,  no
sooner are the symptoms of strangulation
evinced, than they begin to handle the
swelling roughly, and to push the viscera
with all their  force,  in order to  make
them  return  into  the abdomen;  whilst,
when the strangulation is acute, and the
patient  young and strong, the taxis ought
never to  be  practised,  before  all the
means proper for diminishing the strength,
calming spasm, and relaxing parts, which
are to be reduced, have been employed
for a  certain time.  These  means, we
know, are bleedings,  fomentations, emol-
lient glysters, and, especially, the warm
bath,  which, next  to  bleeding, holds the
first rank.  At this school  of surgery, I
have frequently had opportunities of ob-
serving the salutary effect  of this  treat-
ment.   My pupils have, more than once,
seen  herniae,  which had been painfully
handled without any good, reduced, as it
were, spontaneously, after a bleeding,  or
whilst tlie patient was in  the bath.  If,
what  I have said upon the subject of the
acute strangulation, and  the  treatment
that it requires, were generally known  by
surgeons, I think, that the  operations  for
strangulated herniae would be  less fre-
quent.  Things  are   different, with re-
gard  to the  chronic strangulation of old
large herniae, in feeble, or aged persons;
for, in these  cases, it is of great import-
ance  to support tlie patient's strength.
Eleedings, the warm  bath,  and  other
weakening means, should also be avoid-
ed, which, in producing a general atony,
might bring on gangrene of the intestine,
either during tlie strangulation,  or  after
the reduction of the viscera.  It is ascer-
tained, that these  kinds of  strangulation
are almost always occasioned by an accu-
mulation of fecal matter, or an  extraor-
dinary quantity of air in the hernia.  No-
thing is more efficacious, than cold  appli- 
HERNIA.
57
   cations, for provoking the action of the
   bowel on the matter, which distends it, or
   for les^Ping the volume of the air.  They
   produce a corrugation of all the scrotum,
   and contractions of the cremaster, which
   alone sometimes suffice  for reducing the
   viscera, in a  much better manner, than
   could be done by the hands of the most
   experienced surgeon."  (Scarpa,  Traite"
   des Hernies, p. 244—247.)
     Bleeding.—The inflammation, which at-
   tacks the protruded viscera, and spreads
   thence over the whole abdomen, and the
   temporary weakness and  often fainting,
   which the sudden loss of blood induces,
   and which is a  peculiarly favourable op-
   portunity for reducing the hernia by the
   hand, are the reasons in  favour of bleed-
   ing in the present disease. Sharp,  Pott,
   B. Bell, Sabatier, Richter, Callisen, and
   Scarpa, names which can never be sur-
   passed in respectability, are all subscribed
   in favour of  bleaflftr. Wilmer, Alanson,
   and  A. Cooper flave published  against
   the practice.  Mr. Hey has related two
   cases, which strongly evince the manner,
   in which  bleeding  facilitates  the return
   of a hernia : the protruded viscera, in one
   instance, went up spontaneously, on blood
   being taken away;  in the other, the taxis
   succeeded immediately afterwards, though
   the  attempt  before  had  been made  in
   vain.   (P. 125, 126.)  Mr. Hey*s expe-
   rience, however, leads him to concur so
   far with Wilmer and Alanson^ as to de-
   clare, that bleeding  has  generally failed
 ■j to procure a reduction of the strangulated
   intestine, though he is persuaded that, in
   many cases, it "may be used with advan-
   tage.  But he cannot agree with Wilmer,
   that it  generally renders the subsequent
   operation more dangerous.  (P. 126 )—
   The majority  of candid practitioners, I
   believe, will allow,  that  bleeding is  al-
   ways proper, when  the  hernia is small
L   and recent; the abdomen tense and pain-
   ful ;  and  the patient young, strong, and
   plethoric.
     Purgative Medicines.—My  experience,
   (says Mr. Hey) leads me to condemn  al-
   most universally the use of  purgatives
   taken  by  the  mouth, while an intestine
   remains firmly strangulated.   In the en-
   tero-epiplocele, when the intestine has
   retired, and  the omentum remains stran-
   gulated ; or in a simple  strangulation of
   the omentum, where the intestine has not
   been prolapsed, purgatives are of great
   utility.  So  likewise  in very large and
   old  hernias,  where  there  is  reason to
   doubt, whether the disease  is not to be
   considered as a morbid  affection  of the
   intestinal canal, rather than the effect of
   strangulation, purgatives may be as use-
   ful  as in  the simple ileus without hernia.
        Vol. II.
While the intestine remains firmly stran-
gulated, they usually increase the vomit-
ing, and add to the distress ofthe patient.
If they are to be tried at any time with
hope of success, the trial would appear to
have the greatest advantage when the vo-
miting has been removed by means of an
opiate; yet I have repeatedly given  them
in vain during such  an  interval  of relief."
(Practical Observations in Surgery, p. 128.)
  Purgatives are supposed to operate by
exciting the peristaltic action ofthe intes-
tine, and thereby extricating it  from the
stricture.  Besides the above eminent sur-
geon, Pott and Richter have  joined in
their condemnation in general, and,  to all
appearances,   with  very   great  reason.
Purgative glysters, certainly have not the
objection of increasing the irritation; but,
their  efficacy  is not  deserving of much
confidence.  Mr. Hey  says, he  has never
seen one case, in which either purgative,
or emollient glysters produced a return of
a strangulated hernia.  Such  injections
will empty the large intestines;  but, they
have seemed to him to do no more.  It is
common also for a natural evacuation to
be the immediate consequence of a stran-
gulation.  (P. 131.)
  Warm  Bath.—" Many instances  (says
Hey) are upon record of the good effect
of warm bathing in procuring the reduc-
tion of a strangulated  hernia.   I have of-
ten seen it useful;  but I have  also often
seen it fail of success.  Whenever it is
used in  this disease, the  patient should
be placed, if possible, in a horizontal  po-
sition.   Gentle efforts  with the hand to
reduce the prolapsed part are perhaps at-
tended with less danger, and with greater
prospect of success, while the patient lies
in the bath, than in any  other position.
The  free  use  of opiates coincides  with
that  of warm bathing,  and under  somet
circumstances, these means deserve  to be
tried  in conjunction."   (P. 132.)
  Cold Bath, and Cold Applications.—The
cold bath, and dashing of cold  water on
the patient are little to be depended upon,
though success seems sometimes to have
been obtained in this manner. (Petit Traite-
des Mai Chir. Tom. 2, p. 325. Hey, p.  136.)
  Wilmer has strongly recommended the
application of cold to the tumour itself,
and this plan has acquired  the approba-
tion of the most celebrated modern sur-
geons.  It is  generally tried in conjunc-
tion with  the  effect of tobacco glysters,
which  will be presently noticed.   Cold
applications, in the form of ice,  were, in-
deed,  particularly  recommended  by B.
Bell.  The best way is to pound tlie ice,
tie it up in a bladder, and place it on the
rupture.  When ice cannot be procured,
Mr. A. Cooper employs a mixture of equal
  H 
58
HERNIA.
parts of nitre and sal-ammonfac.  To one
pint of water, in a bladder, ten ounces of
the mixed salts  are to  be added.  " If,
after four hours,  (says this distinguished
surgeon) the symptoms become mitigated,
and the tumour lessens, this remedy may
be  persevered in, for some time longer;
but, if they continue with unabated vio-
lence, and the tumour resist every attempt
at  reduction, no  farther trial should  be
made of the application."  (On Inguinal
and Congenital Hernia.)  When  ice  has
not been at hand, aether has occasionally
been found a good  substitute, when  al-
lowed to evaporate from the surface of the
swelling.
  Care must be  taken, that the  cold be
not so applied as  to freeze the scrotum,
and bring  on sloughing.  (A.   Cooper,
p. 15.)
   Opiates.—Mr.  Hey has  seen  several
cases, in which opiates, given freely,  (in
athletic persons after bleeding) have pro-
cured a reduction of strangulated liernia.
  He cannot say,  however, that this  re-
medy is generally successful; but, it has
the advantage of removing, for a time,
the pain and vomiting usually attendant
on  strangulation, even  though  it prove
ultimately inefficacious.  Opiates should
be  given in large doses, when it is wished
to try their effect in procuring reduction ;
and whenever the symptoms of strangula-
tion return, after having been removed
by  opiates, the operation should be per-
formed without delay.  (P. 134, 135.)
   Tobacco Glysters.—For this purpose,
some surgeons prefer a decoction of to-
bacco, made by  infusing, or boding, one
dram of the plant, for ten minutes, in  a
pint of water; others employ the smoke,
which is  prepared,  and introduced into
the rectum, by means of a  well-known
apparatus   for  the  purpose. Perhaps,
both methods are equally efficacious ; but,
as  one  requires an apparatus, while  the
otlier does not, and is equally proper,  the
decoction may be entitled to most recom-
mendation.  The machine for the smoke
is  also  frequently found  out of  order.
Tobacco glysters are, next to the opera-
tion, the most certain means of bringing
about the reduction of the strangulated
parts.  They not  only excite the action
of the intestines, they also exert a pecu-
liar depressing  influence  on the whple
 system, reducing the pulse, and  causing
 nausea and sickness, cold  sweats and
 fainting, under which circumstances the
 parts  recede spontaneously,  or  may be
 easily  reduced.   Mr.  A.  Cooper pru-
 dently  advises injecting  half the above
 quantity at first; for he has  seen two
 drams, and  even one,  when  used as an
infusion,  and introduced at once, prove
fatal.   (P- 24)   The  rest  should pre-
sently be injected when it  appears, that
the tobacco does not operate wiljpfhe ex-
traordinary v.olence, with whiclfit does
in a few particular constitutions.
   Poultices  and Fomentations.  We only
mike ment.on of these, to say, they have
not the least confidence of any experienc-
ed, or  intelligent  surgeon.   Whoever
wastes time, in these urgent cases, in try-
ing the effects of such applications, merits
censure for his credulity,  ignorance, and
unfitness to undertake the treatment of a
rapid disease, in which, as Pott remarks,
if we do not get forward, we generally go
backward ; and whatever does no good,
if it be at all depended upon, certainly
does harm, by occasioning an irretrievable
loss of time.
   [Placing the patient on an inclined plane,
with   his  feet   highest.— Winslow  and
Cooper recommended this position of tlie
body  during  the eftbj^«.to reduce the
hernia by taxis.   I  wotft recommend it
however,  to  be  continued longer; from
having seen two cases in  which  this
simple  measure  succeeded  after seve-
ral of those,  already recited,  had been
tried  in  vain.  The  patient  should lie
upon his back, and the foot of the bed
be elevated about  twenty  inches higher
than the  head.   This posture  need not
interrupt  the administration  of  other
remedies, and  in  some  cases  will  be
found powerfully to aid them.]

OF THE ORDER,   IN WHICH  THE  PRECED-
   ING METHODS   AND  REMEDIES  SHOULD
   BE  TRIED,  AND  OF  THE TIME,  WHEN
   THE  OPERATION  SHOULD  NOT  BE  DE-
   LATED.

   In the treatment of a strangulated her-
nia,  a surgeon cannot be too deeply  im-
pressed with the danger of spending tin. -
in the trial of methods of inferior efficacy,
or of such as are evinced to be ineffectual
in the cases before  them.
   The rapidity,  with which gangrenous
mischief sometimes arises, and the patient
loses his life, has been  proved  in a mul-
titude of unfortunate examples, and should
operate as a  warning  to all practitioners
against the  danger of deferring the ope-
ration too  long.  In  the course of my
reading, however, I have not met  with so
remarkable an  instance  of the  sudden
mortification, and  rapidly fatal termina-
tion of an hernia, as the following case re-
corded by Mr. Larrey, in speaking of the
fatiguing and forced  marches  performed
by the French soldiers  in Egypt.   These
marches, he says,  brought on in one of
the mditary " a hernia which formed sud-'
 denly, and became  at the same time str. a- 
HERNIA.
&
gulated.  He  was  immediately brought
to my ambula-ice; but,  a spontaneous
gangrene, which had all on a sudden at-
tacked the  intestine, and extended to the
other abdominal viscera, caused the pa-
tient's death in the space of two hours,
and made it impossible for me to do the
operation for him.  This is  the second
example, that I  have been  acquainted
with, in which the effects of the accident
were thus rapid."   (Larrey, in Me'moires
de Cfururgie Milttaire, Tom. l,p. 196.)
  The taxis is generally among  the  first
things to be  tried, and  Mr. A. Cooper
thinks the attempts should be continued
for a quarter, or half an hour.  When
these have  been ineffectual, the patient,
if the circumstances do not forbid, should
be  immediately  bled, and have a large
opening  made  in  the vein, so  that the
suddenness of the evacuation may be most
likely to  bring  on fainting.   The  taxis
should be tried once more as soon as this
operation is finished.
  In  cases, where the strangulation  is
very  acute, and the patient  young and
strong, perhaps, it may be most advisable
to follow the advice delivered by Scarpa
and Desault, and bleed the patient,.and
put him in the warm bath, before attempt-
ing the taxis.
  If bleeding alone lfas been  practised,
and the manual efforts at reduction should
not now succeed, the warm bath may be
employed, provided it can begot ready in a
very short time, but none should  ever be
lost in  waiting  for it  to  be  prepared.
When the bath is used, the taxis may be
attempted, as the patient lies in  the wa-
ter; a  situation, in  which I  have suc-
ceeded  myself in reducing several her-
niae.
  Certainly not  more   than  one  hour
should ever be  allotted for putting  in
practice  the first attempts at reduction,
bJMding, and the warm bath.
 ™he plan should  be, while the trial of
one thing is going on, another should be
preparing.  So when the preceding  mea-
sure* have been  tried in vain,  the appli-
cation of a bladder filled with ice, or the
solution of salts, and the injection of to-
bacco, m the form of smoke, or decoction,
should never  be  delayed for want of due
previous preparation of all tlie requisites.
Both these measures should be  practised
at the same time,  immediately  after the
failure of the taxis,  bleeding,  and  the
warm bath.  Mr. A.  Cooper states, that
four hourfc  are enough for the trial of the
tobacco glyster, together with cold  appli-
cations.
   In  omental1 herniae, the necessity for
operating may frequently be obviated, by
the  good effects of  bleeding, purgative
medicines, and glysters, and leeches ap-
plied to the tumour. ' Mr. Lawrence had
justly observed, that " when, as it very
frequently happens, the aid of the surgeon
is not required, until the complaint has
lasted for some time, a trial of the tobac-
co, together with the topical use of cold,
should be immediately resorted to, as cir-
cumstances will not admit of delay in the
previous use of less powerful remedies."
(P. 87.)
   Every man who has seen much of her-
niae, will immediately recognize the pro-
priety of the following, sentiments of the
experienced Mr.  Hey:
   " I can scarcely press  in too  strong
terms the  necessity of an early recourse
to the  operation, as the most effectual
method of preserving life.in this danger-
ous disease. ' If  Mr. Pott's opinion be
true, that the operation, when perforrtied
in a proper manner, and  in due  time,
does not prove the  cause of death oftener
than perhaps once in fifty times; it would
undoubtedly preserve the lives  of many,
to perform it almost as soon as the disease
commenced, without increasing the dan-
ger by spending much time in the use of
means, which cannot be depended upon
for a cure.
   " I have twice seen this disease  prove
fatal in about twenty-four hours. In such
cases it  is evident there is little time for
delay.  A surgeon, who  is competent to
perform  the operation,   is  not perhaps
consulted till the intestiie is on the point
of being mortified, or is actually in a state
of  mortification.  The   dilemma  into
which he is then cast, is  painful indeed.
But  when  the fullest opportunity is af-
forded him of using the  best  mode  of
treatment, I am satisfied that his success
will be the greatest when the  operation
is not  long delayed.  This, at least,  has
been my own experience.   When I first
entered upon the profession of surgery, in
the year 1759,  the operation for the stran-
gulated hernia  had  not been performed by
any ofthe surgeons in Leeds.  My seniors
in the profession were very kind in af-
fording me their  assistance, or calling me
into consultation  when such cases occur-
red ; but we considered the  operation as
the last  resource, and as improper until
the danger appeared imminent.  By this
dilatory mode  of practice, 1 lost three pa-
tients in five  upon whom  the  operation
was performed.  Having more experience
of the urgency of  the disease, 1 made  it
my custom, when called to a patient who
had laboured two or three days under the
disease,  to wait only about two  hours,
that I might try the effect of bleeding (if
this evacuation was not forbidden by some
peculiar  circumstances of the case)  and
the tobacco glyster.  In this mode   of
practice  I lost about two patients in nine 
60
HERNIA.
upon  whom I operated.  This compari-
son is drawn from  cases  nearly similar,
leaving out of the account  those cases in
which a gangrene  of the intestine  had
taken place.
  " I have now,  at the time  of writing
this, performed the operation thirty-five
times; and have often had occasion to
lament that I had performed it too late,
but never  that  I had performed  it too
soon.   There are some cases  so urgent,
that it is not advisable to lose any time
ip the trial of means to produce a reduc-
tion.  The delay of a few  hours may cut
off all hope  of success, when a speedy
operation migrht have saved the life of the
patient."  (P. 141, &c.)
  To determine the exact  moment, when
to give up the trial of the  preceding mea-
sures, and to have  immediate recourse
to the operation, is certainly  difficult;
but,  no one can doubt, that this should
rather be  resorted to too  early, than too
late.
  All directions must be general ones,
liable to many r-xceptions :  in rapid cases
little, or no time should be allotted to the
trial of any plan, and tlie operation should
be done without th^ least delay   In other
instances,  we have full time to try tlie ef-
fects  of every thing at all likely to  suc-
ceed.   The symptoms, which  ought to
guide us, in having recourse to the  ope-
ration, arise from an attack of inflamma-
tion in that part ofthe  intestine contained
in the hernial sac, and from its spreading
into the abdominal cavity.  It is in  pro-
portion to their violence,  that we  ought
to urge the performance of the operation.
Mr.  A. Cooper considers  pain on  press-
ing the belly, and tension, as the symp-
toms, which point out its  immediate ne-
cessity.  He adds,  :* Indeed, there  is
scarcely  any period  of  the  symptoms,
which should forbid the  operation;  for,
even  if mortification has  actually begun,
the operation may be the means of saving
life,  by promoting  the ready separation
of gangrenous parts."  (On Inguinal and
Congenital Hernia, p. 27.)
  Whenever the  surgeon has succeeded
in reducing the parts, without having re-
course to the knife, if the  symptoms  of
pain,  inflammation, &c. ran high  before
such  reduction, "they will not always cease
immediately afterwards.   As they  proba-
bly depend on the reduced bowel having
been  inflamed by the stricture, the body
should be kept open, and  tlie diet and re-
gimen should be low and sparing, while
the least degree  of pain  and  tension re-
main; in short,  till all complaint is ab-
solutely removed from the abdomen, and
the  intestines do their office freely  and
without trouble.  (Potf.)         ''
PROGRESS OF THE SYMPTOMS  OF A ST1AN-
           DULATED HERNIA.
  The earliest  symptoms have  been al-
ready related, viz. " tumour in the groin,
or scrotum,  attended with pain, not  only
in the part, but all over the belly, and
creating  a sickness and inclination to vo-
mit, suppression of stools, and some de-
gree of fever.   These are the first symp-
toms, and, if they are not appeased by the
return of the intestine, that is, if the at-
tempts, made  for this  purpose, do  not
succeed; the sickness becomes more trou-
blesome, the vomiting more  frequent, the
pain more  intense,  the tension of  the
belly greater, the fever higher, and a ge-
neral restlessness come on, which is very
terrible to bear. When this is the state of
the patient, no  time  is to be lost; a  very
little delay is now of the utmost conse-
quence,  and if the one single  remedy
which  the disease is now capable of be
not administered immediately,  it will ge-
nerally baffle every other attempt.  This
remedy is the operation, whereby the part*
engaged in the  stricture may be set free.
If this be not now performed, the vomit-
ing is soon  exchanged for  a convulsive
hiccough, and  a  frequent gulping up of
bilious matter; the  tension  of the belly,
the  restlessness  and fever  having been
considerably increased for  a  few hours,
the  patient  suddenly becomes  perfectly
easy, the belly subsides, the  pulse from
having been hard, full, and frequent, be-
comes low, languid, and generally inter-
rupted ; and the skin, especially that of
the limbs, cold and moist; the eyes  have
now a langour and a glassiness, a lack-
lustre  not easy to be described; the tu-
mour of the part disappears,  and the skin
covering it, sometimes changes its natural
colour for a livid hue ; but whether it
keeps or loses its colour, it has an emphy-
sematous  feel,  a crepitus to the touch,
which will easily be conceived by all Jfco
have attended  to it, but is not so easySjto
convey an idea of by words: this crepitus
is the too sure  indicator of gangrenous
mischief within.  In this state,  the  gut
either goes up spontaneously,  or is re-
turned with the  smallest degree of  pres-
sure ;  a discharge is made by  stool,  and
the patient is generally  much  pleased at
the  ease he finds; but this pleasure is of
short duration,  for the hiccough and the
cold  sweats  continuing and increasing,
with the addition of spasmodic rigors and
subsultus tendinum, the  tragedy  soon
finishes."  (Pott)

ANATOMY OF;THE BUBONOCELE, OR INGUI-
              NAL HERNIA.

   This subject must necessarily precede 
                                   HERNIA.                                61

tlie account ofthe operation, which would  ated by Albinus; Gimbernat makes dis-
otherwise be unintelligible.   It is chiefly  tinct mention of it in his Account of a new
in the anatomical information, relative to  Method ofOperating for Femoral Hernia, p.
herniae, and the mode of operating, that  19—32; but, no one, before Mr. A. Coo-
modern surgeons have  a decided  supe-  per, considered the thing with due at-
rioxity over their predecessors; for, be-  tentien.
fore Gimbernat, Camper, Hey,  and A.    The  abdominal ring is then only the
Cooper, published their several works on  outer opening of the  canal,  or passage,
herniae, the anatomy  of the disease was  through which the spermatic cord passes
only imperfectly understood.              before it emerges. The inner one, at which
  The tendinous fibres of the aponeurosis  the viscera in cases of inguinal hernia first
of the external  oblique muscle, as they  protrude, is situated about an inch and a
run downwards and forwards towards the  half from the abdominal ring, in the di-
pubes, separate from each other, so as to  rection  towards the  anterior spinous pro-
leave a  triangular  opening,  called the  cess ofthe ilium.  This inner opening is
abdominal ling.  The upper and  inner  rather nearer the  pubes, than the ilium,
pillar (as it is termed) of this aperture is  and its upper border is formed by the low-
inserted into the symphysis of the pubes;  er edge ofthe internal, oblique, and trans-
the lower and  outer  one, which is only  verse muscles, which  can be plainly felt
the continuation of Poupart's ligament,  with the  finger, introduced upward and
is fixed into the angle and  crista  of the  outward into the abdominal ring.
same bone.  Some  tendinous fibres cross    " The precise point, at which the her-
the upper and outer angle of the ring, so  nia most commonly  commences,  (says
as to diminish the  triangular appearance  Scarpa) is that which corresponds, in the
of the whole aperture: these are said to  foetus, to the communication of the tunica
be very strong in  old  herniae.  The an-  vaginalis with the peritoneum, and, in the
terior and thicker layer ofthe aponeurosis  adult, to the passage ofthe spermatic cord
of  the internal  oblique muscle joins the  under the transverse muscle. In the sound
tendon of the external oblique; the pos-  state, the peritoneum presents at this part
terior  and thinner  one joins  that of the  a small funnel-like depression, the depth
transversalis;  but  the  lower portion  of of  which increases  in proportion as the
this tendon, together with the correspond-  spermatic cord is pulled from above down-
ing part of the transversalis, goes wholly  wards.   It is this small pouch, this sort
in front of the  rectus muscle.  Thus the  of  digital appendage, whose progressive
inferior border of  the  obliquus internus  developement constitutes the hernial sac.
and transversalis, which originates from  Resting upon the anterior surface of the
the upper part of Poupart's ligament, lies  spermatic cord, it first makes  its appear-
behind the outer pillar of the abdominal  ance under the inferior edge of the trans-
ring.  Mr. A. Cooper, was the first, who  verse muscle; thence  it extends itself in
noticed, that a thin fascia proceeded from  the separation of the inferior fleshy fibres
the inner edge of Poupart's ligament, and  ofthe internal oblique muscle, always fol-
spread itself over  the  posterior surface  lowing  the spermatic cord,  in front  of
of the transversalis.  This forms the only  which  it is situated;  and after having in
partition between the peritoneum and the  this manner passed through the  whole of
outer opening of the abdominal ring, and  the canal, which  extends from the  iliac
were it not for its existence, inguinal her-  region  to the pubes, it lastly protrudes at
niae would probably  be much more fire-  its external orifice, which is the inguinal
quent.                                   (or abdominal) ring properly so  called.
   The  spermatic vessels joined by the  In  all this track, the hernial sac, as well
vas deferens, proceed before  the epigas-  as  the  spermatic cord, is situated above
trie artery, very near the place where it  the femoral arcli, the direction of which it
arises.  They then run through the above  follows.  The canal,  which it traverses,
fascia, go under the  edge of the internal  is of a conical shape, the apex of which is
oblique and transverse muscles,  and next  towards the flank,  and the base at the
obliquely downwards and  forwards  be-  external orifice of the ring."  (Scarpa,
tween the above fascia, and  aponeurosis   Trait6  des Hernies, p. 44, 45.)
of the  external oblique to  the opening     The  epigastric artery runs behind the
ofthe ring.                             spermatic cord, along tlie inner margin
   Thus  we see, that the spermatic cord  ofthe internal opening ofthe above canal,
runs through a kind of canal,  before it  \hen upwards and inwards,  so as to  pass
actually emerges at  what is named the   at  the distance of half an inch, or an inch
abdominal ring.  This oblique passage of from the upper extremity  of the  outer
the cord, through the abdominal parietes,  opening, or abdominal ring.
was well known to, and elegantly deline-    In common  cases of inguinal hernia, 
82                                  HERNIA.
the viscera, protruded at  the inner open-
ing, above  described, lie over the sper-
matic cord, and form a tumour on the out-
side of the  abdominal ring.  They may,
however, insinuate themselves into the
inner  opening, without descending suffi-
ciently to protrude through tlie external
one, or abdominal ring.  The stricture
may take place at either of these open-
ings.  In recent and small hernia, accord-
ing to Mr.  A. Cooper, the  strangulation
is  most frequently situated at the inner
opening;  in large old rupture*, at the
abdominal ring.  Even when the parts are
completely protruded out  of  the latter
opening, the strangulation  may exist at
the inner one: but, there may occasionally
be  two strictures, viz. one at each open-
ing.  (Lawrence on Hernia, p. 103.)
  The hernial sac descends through the
abdominal ring over the  spermatic cord,
and is covered by a fascia,  sent off from
the tendon of the external oblique mus-
cle.  Beneath this fascia, the  cremaster
muscle is also situated  over  the sac.
When this has descended a certain way,
it lies on the tunica vaginalis, as well as
the spermatic cord.
  As  the epigastric artery naturally runs
first behind the spermatic cord, and then
along  the  inner margin  of the internal
opening of  the ring,  and as the  viscera
are protruded over the cord,  they must
be situated on the outer side of the artery,
which runs  first behind  the neck of the
sac, and then on its inner  side.   Hence,
the inner margin of the sac, when  in-
spected on the side towards the abdomen,
seems to be formed, as  it were, by the
track of the vessel.  (See  Lawrence, p.
106.)   That this is the ordinary situation
of the epigastric artery, in relation to the
inguinal hernia, is confirmed by the con-
current testimonies of Camper, Chopart,
Desault^Sabatier,  A. Cooper, &c. and by
preparations to be seen  in almost every
museum.
   In recent inguinal herniae, the internal
and external openings of the ring are at
some distance from each other, tlie first
being situated obliquely upwards and out-
wards in relation to the former; but, tbe
pressure of the protruded viscera, gradu-
ally brings them nearer together, so that
in large herniae of long standing, the open-
ing into the  abdomen is almost direct,
and the epigastric artery becomes situated
nearer the pubes, than in the natural state.
   Though such is the ordinary direction,
in  which a bubonocele protrudes,  there
are occasional varieties.  In one of these,
the viscera, instead of descending through
the canal of the ring, are at once thrust
through the abdominal  ring  itself, and
the opening into the belly is then direct:
the hernial sac, instead of passing on tlie
external side of tlie spermatic vessels, as
is usual,  now lies on their inner, or pubic
side;  and the  epigastric artery, which is
commonly situated behind, now pursues
its course, in front of the sac, at its usual
distance from  the upper and outer angle
of the abdominal ring.
  The following is Scarpa's description of
the displacement of the epigastric artery
in the greater number of cases of inguinal
hernia. " This artery, which, in the natu-
ral state, runs about ten lines from the
abdominal ring, has its situation and direc-
tion so changed, in subjects a^-cted with
hernia, that it crosses the  posterior part
of the neck of the hernial  sac, and is
pushed from the  outer  to  the inner side
of the abdominal ring.  In order to com-
prehend the reason of this displacement,
it is necessary to recollect what I have
elsewhere said of the formation of inguinal
hernia, and  of the manner, in which  the
spermatic cord crosses  the epigastric ar-
tery.   The hernia begins to form at  the
very  place, where  the  spermatic  cord
passes under  tlie inferior margin of  the
transverse muscle; and this place is ra-
ther nearer the flank, than that where the
epigastric artery  passes towards the rec-
tus muscle.   In its  progressive develope-
ment,  the hernial sac constantly follows
the same track as  the spermatic  cord,
since it is situated upon its anterior sur-
face.  As has been already explained, this
cord crosses the epigastric artery ; conse-
quently, the hernial sac must necessarily
pass with the cord above this artery, be-
fore protruding  from  the  canal of the
abdominal ring.  At the same time, the
internal  orifice of the hernia becoming
larger, and the inguinal canal shortened
by the approximation of its two orifices to
each other,  it follows, that, at the period,
when  the hernia begins to make its ap-
pearance in  the  groin,  the  epigastric
artery is unavoidably situated behind the
neck  of the  hernial sac, and is pushed
from the outer to the  inner side of the
ring.  Let us suppose a piece of string to
be passed from the inside ofthe abdomen
into the scrotum, all through tlie inguinal
canal, and the middle of the hernia;  and
that  this string  is pulled so as to bring
the internal orifice ofthe hernia,  which is
situated beyond the point where the sper-
 maUc cord  crosses tlie  epigastric artery;
 this artery will immediately be found to
 be earned from the outer to the inner side
 of the neck of the hernial sac.  The same
 thing happens from the effect of the de-
 velopement of the hernia.  The removal
 of" the epigastric artery from one side of
 the ring to the other  (says Scarpa)  is a
 phenomenon, which may be regarded  a.' 
HERNIA.
63
almost constant in the inguinal hernia.  I
have examined the bodies of a great num-
ber of subjects, affected with this species
of hernia; and  it has  been only in a very
few, that I met with the epigastric artery
retaining its natural situation on the outer
side of  the  abdominal ring.  In  investi-
gating the reason of this exception, 1 have
observed, in all the individuals who pre-
sented it, a very  remarkable  weakness
and flaccidity of that part of the abdomi-
nal parietes, which extends from tlie flank
to the pubes. In all the displaced viscera
had passed  through the aponeuroses of
the transverse and internal oblique mus-
cles, not in the  vicinity of the ilium, as is
commonly the case, but, at a little  dis-
tance from the pubes, giving to the upper
pillar of the ring a  curvature that is
extraordinary, and dispropprtioned to the
smallness of the hernia.  I observed, also,
that the neck of the hernial sac did not
pass in an oblique direction from the flank
to the pubes, but, that it protruded from
the abdomen almost in a direct  line from
behind forwards.  In  short, in  these  in-
dividuals, the small cul-de-sac ofthe peri-
toneum, which constitutes the origin of
the'  hernial  sac,  had  not  begun  to  be
formed  under the edge of the transverse
muscle,  at the point where the spermatic
cord  runs outward; but, it  had passed
through the aponeuroses of the internal
oblique  and transverse  muscles, at a
little distance from the pubes, and within
the point, at which the  spermatic cord
crosses  the epigastric artery.   The small
hernial  sac,  having at this  part come
into contact with and united  to the sper-
matic cord, protrudes at the external ori-
fice  of  the  inguinal canal, without  dis-
placing  the  epigastric artery  from  its
natural situation.
  " This species of hernia, properly speak-
ing, is a mixture of the ventral and inguij
nal.  It  resembles  the former,  inasmuch
as the hernial sac. pierces the aponeuroses
of the  transverse  and internal oblique
muscles; the latter, inasmuch as it passes
out at the abdominal ring, conjointly with
the spermatic cord."  (Scarpa, Tndl6 des
Hernies, p.  68, tyc.)  In most  instances,
the spermatic cord  lies behind or under
the hernial sac.  There are cases, however,
iu which the vas deferens is found on  the
outer side of the  sac, while the  rest of
the spermatic cord lies, as it usually does,
on the inner side, or rather under this
part (Cooper.)  Le Dran, Schmucker, and
Blizard, have found the whole cord situ-
ated in  front of the sac.  Sometimes  the
vas deferens has run on the front and in-
ner part, and the rest of the cord on  the
back and external part of the swelling.
(Camper, Hm.)  The cord has been known
to be before, and the vas deferens behind
the sac.  (Camper, Cooper.)
   Upon this part ofthe subject, the reader
may deem the following passage interest.
ing. " While the hernia is of moderate
size (say9 Scarpa) the surrounding cellu-
lar substance  is  not very greatly  com-
pressed, and no change is observed in the
situation of the spermatic vessels.  The
artery and veins of this name always form,
with the vas  deferens, one single cord,
which is intimately adherent to the pos-
terior surface ofthe hernial sac.  But, in
proportion as the tumour increases in size,
the cellular substance, which immediately
surrounds it and unites it to the spermatic
cord, is more and more  distended  and
compressed.  At  length, at a certain pe-
riod, the distention is carried to such a
pitch, that the spermatic vessels are sepa-
rated from one another, and change their
position with respect to the hernial sac.
This kind of gradual decomposition of the
spermatic cord is quite similar to that,
which would be produced by pulling tlic-
surrounding  cellular substance  in  two
opposite directions.  Such is the reason,
why, in scrotal hernix of large  size, the
spermatic artery,  the vas  deferens,  and
the  spermatic veins are  found  separated
upon the posterior surface of the sac.  All
these vessels, instead of being  conjoined
in one cord, are  divided by interspaces.
which  are  sometimes very considerable.
Ordinarily, the vas deferens is  less sepa-
rated from the spermatic artery, than from
tlie vein of this name.   In some subjects,
Camper has seen it situated on one side of
the sac, and the  artery and veins on the
other.   (Icones Herniamm, tab.  5. L.  O.
Tab. 8. 1, 2 )  The displacement and de-
composition of the spermatic cord take
place equally in adults and in children af-
fected with large scrotal herniae.  (Camper,
loco cit.) In general, towards the upper
part and neck of the hernia, the vessels are
not much separated; but, as they proceed
downwards, they diverge more and more.
Sometimes, when the hernia is very old
and voluminous, they are no longer found
at the posterior part, but rather at the
sides, and even on the front surface of the
sac; they shew themselves through the
cremaster muscle, which covers them, and
form a sort of vascular train, which arrests
the hand of the operator at the moment,
when he is about to open the hernial sac.
Le Dran relates, that, m operating upon a
large scrotal hernia, he found the sper-
matic cord on the anterior surface of the
hernial sac.  (Operations de Chir. p. 127.)
This fact has been the cause of numerous
conjectures, and appeared altogether in-
conceivable to such surgeons, as have not
been acquainted  with  the changes,  to 
64                                HERNIA.
% which the spermatic cord is exposed,  in
 cases of large  scrotal herniae.   (Lassus,
 Med Operat. Tom. 1, p.  152, cannot con-
 ceive th\- possibility of the occurrence.)
 The observation of Le Dran is not the
 les.. true and exact: it exemplifies a very
 import ant fact, of which it is easy to give
 a true explanation, when the state of the
 spermatic cord in ordinary inguinal her-
 niae, and in those, which have obtained a
 considerable size, has been comparatively
 examined. In the first, the spermatic cord
 quite entire is always found situated on
 the posterior surface of the hernial sac ;
 but, in the second, the spermatic vessels
 are so separated  from one another, that
 they sometimes extend over the sides and
 even  the forepart  of the  hernial  sac."
 (Scarpa, Traite" des Hernies, p 61, &c.)
   The hernial sac is commonly described
 as an elongation of peritonaeum.  When
 more minutely examined, however, it  is
 found, in cases of inguinal hernia, to con-
 sist of the portion of peritonaeum, pushed
 out with the viscera ;  of a layer of cellu-
 lar substance on the outside of this, which
 becomes more or  less thickened by the
 pressure ofthe rupture in different cases ;
 of a fascia, sent off from the tendon of the
 external oblique muscle; and of the cre-
 master  muscle, which latter parts form
 the exterior covering,  which consisting of
 several layers, often leads the operator to
 fancy he lias opened into the cavity of the
 sac, when, in reality, he has not.
   It  is observed by Professor Scarpa, that
 "the cremas er muscle,  in  cases of old
 large scrotal herniae, acquires a thickness,
 which  is  really surprising.   Its fibres,
 which  are  naturally very thin, become
 from f >ur to six times more considerable.
 Being spread over  the neck  and body of
 the hernial sac, they sometimes present a
 remarkable consistence, and a yellowish
 colour.   Such alteration, however,  does
 not prevent the muscular  texture from
 being discovered, and Haller was not mis-
 taken about it.  ( Opusc. Patholog. p. 317.)
 Pathology furnishes us with several ex-
 amples of similar changes of organization.
 In certain c-ises, the muscular coat ofthe
 bladder, that of the stomach and intes-
 tines, and even the exceedingly delicate
 fleshy fibres of the ligaments of the colon,
 are  "found  to  have become yellow, and
 much thickened.
   " In old scrotal herniae (says Scarpa)
 it is not unusual to find an intimate ad-
 hesion of the fibres of tlie cremaster mus-
 cle to the  edges  of the abdominal ring.
 This may depend on the pressure,  which
 the contents of the hernia  may make on
 those edges, and  perhaps it may also de-
 pend on the union of the cremaster mus-
cle with tlie prolongation of the aponeu-
rosis ofthe fascia lata, which is continued
from tlie margins of the ring to the groin
and scrotum.  Howsoever it may be, cer-
tain it is, that in old large scrotal herniae,
there is much difficulty in introducing a
probe between the fleshy fibres of the cre-
master  and the margin ofthe abdominal
ring; and that, on the contrary, in recent
herniae, a probe passes as easily between
the edges of the ring and the cremaster,
as between  this muscle and  the hernial
sac.
  "Few authors  (according  to  Scarpa)
have spoken ofthe sheath, formed by the
cremaster muscle, in which are enclosed
the hernial  sac, the spermatic cord, and
the tunica vaginalis ofthe testicle. Sharp
(In  Critical Enquiry) and Monro, the fa-
ther, (Anat. and Chirurg. Works, p. 553.)
were the first to dwell  upon this import-
ant pathological point.   Monro had seen
the cremaster muscle covering the hernial
sac; but, he did not believe, that the same
thing occurred in all individuals affected
with inguinal hernia.  In this respect, he
was mistaken; for, this disposition of the
cremaster muscle is  one or the essential
characters of the  disease.  Petit has not
omitted to describe the relations, which
exist between the cremaster and the herni-
al sac.  ((Euvres Post hum. Tom. l.p. 288.)
On  this subject,  he even relates an inter-
esting fact, from which it results, that, in
certain cases, this muscle may by its con-
tractions alone cause a  reduction of the
hernia.   Gunz  explains, with tolerable
perspicuity,  how the cremaster  and  its
aponeurosis  form one of the coverings of
the inguinal and scrotal hernia.  (Libelius
de Herniis,p. 50.)  Morgagni once saw  its
fleshy fibres  extended over the hernial sac;
(De sed. et  caus. morb. epist. 34, art.  9;
epist. 31, art. 15.) andNeubaver positively
assures  us, that he has made the same re-
mark upon the dead body of a man affect-
ed with an entero-epiplocele.   (Dessert de
Epiploo-oscheocele.)  After these facts,  so
positive and accurately observed, I can-
not comprehend (says Scarpa) how in our
time Pott, Richter, and several other au-
thors, should have passed over in silence,
or only mentioned vaguely, this point,  so
important in the history of the inguinal
and  scrotal hernia."   (Scarpa, Traite' des
Hernies, p. 48—50.)
  When surgeons  speak of a  hernial sac
being usually thicker  and stronger,  in
proportion to the magnitude and duration
ofthe hernia, they do not imply, that this
alteration only occurs in the mere perito-
naeum.    '
  In very enormous hernia, the pressure
ofthe contents is so great, that, instead of 
HERNVIA.
65
 thickening the sac, it renders it thinner,
 and  even makes it  ulcerate.  The  pro-
 truded viscera have been met with imme-
 diately beneath  the  integuments, when
 the sac has been burst by a blow. (Cooper;
 J. L. Petit)
   The outer surface of the peritoneal part
 of the hernial sac, is always most closely
 adherent to the other more external cover-
 ing by means of cellular substance.  This
 connexion is formed so soon* after the first
 occurrence of a hernia, that any hopes of
 returning a hernial sac into the abdomen
 are now  generally considered as merely
 chimerical.  There must, however,  be a
 certain space of time, before adhesions
 form, though it is, ho doubt,  exceedingly
 short.
   Upon this point, Scarpa does not adopt
 the opinion commonly received.
   " It has long  been disputed, (observes
 this author) whether it is possible to re-
 duce a hernial sac into the abdomen with
 the intestine.  But, it has happened, as
 in most discussions,  that  every  one has
 endeavoured  rather to support  his  own
 opinion, than appreciate the facts opposed
 to him.   On both sides,  they have neg-
 lected to  consult observation, which alone
 ought to  be the basis of our judgment in
 similar matters.
   " There is no doubt, that, in recent and
 small inguinal herniae, the intestine, stran-
 gulated by the heCk ofthe hernial sac, has
 been known, in more instances than one,
 to. have been reduced by the taxis,  and
 carried with it the Whole of the sac  into
 the abdomen.  Observations,  not less au-
 thentic, inform Us, that,  after the opera-
 tion for hernia,  when the viscera  could
 not be reduced on account of their adhe-
 sions to the sac, they have been seen, not-
 withstanding such adhesions, to get nearer
\o the ring daily, and at length, spontane-
 ously  to  return  into the  belly together
 with  the  hernial sac.  Louis  was wrong
 in denying the possibility of  these facts.
 (Acad. Royalede Chirurgie, Tom. 11 p.486.)
 For my part, (continues Scarpa)  I regard
 them as very correct, according to my own
 experience, and that of several other  sur-
 geons.   It appears, that the illustrious
 secretary  of the academy, only refused to
 put confidence in such well attested cases,
 because they were contrary to an opinion,
 that he had set up with great assurance :
 he pretended that neither art, nor nature,
 could ever accomplish the reduction ofthe
 hernial sac, unless the cellular substance,
 which unites it to the spermatic cord and
 surrounding parts, were torn. Apparently
 he forgot, that, under  certain  circum-
 stances, the  cellular substance will bear,
 without laceration, a considerable elonga-
 tion,  and  afterwards shrink again.  It is
     Vol. 1!
 thus, that we often see a visous, which had
 suffered a considerable displacement, re-
 turn spontaneously into its natural situa-
 tion.   Pathology would furnish us with a
 great number  of similar examples ; but,
 riot to depart from our subject,  daily ex-
 perience proves, that, in the inguinal her-
 nia, the spermatic cord is elongated, and
 descends farther, than in the natural state.
 No laceration of the cellular substance,
 however,  is then occasioned; for,  if the
 hernia be  kept reduced, the spermatic
 cord becomes shorter, daily retracts, and
 at last has only the same length, which it
 had previously to the disease.  When a
 sarcocele  becomes  large and heavy,  tlie
 portion  of the  spermatic cord, naturally
 situated within the belly, is by degrees
 drawn out into  the scrotum; but, after
 the tumour is extirpated,  this portion as-
 cends again, and of itself returns into its
 original situation.
  "The same  thing happens  after  the
 operation  for  the strangulated inguinal
 hernia.  All  practitioners have noticed,
 that the  hernial sac retracts and reas-
 cends  progressively towards the ring.
 That  alone would prove, that the cellu-
 lar substance, Which surrounds  the sper-
 matic cord* and  unites. It t» the hernial
 sac, is highly endued with the property of
 yielding* and afterwards returning to its
 original state.   Can the same property be
 refused to the cellular substance, which
 unites the sac to the cremaster muscle and
 other surrounding parts ?
  " While the inguinal hernia is recent*
 and not of much size, the  cellular sub'
 stance in question possesses all its elasti-
city, and  hence,  the hernial sac and the
 spermatic cord, may easily ascend towards
 the abdominal ring.  I have had occasion
 (says  Scarpa)  to make this observation
 upon the dead body of a man, who had an
 incipient inguinal hernia.  The small her-
 nial sac was capable of being pushed back
 into the ring with the utmost facility; and
 in carefully examining the parts* both
 within and Without the belly, it appeared
 to me, that the cellular substance, which
 united the sac  to the spermatic cord and
 cremaster muscle, was disposed to yield
 equally from without inwards, and in the
 direction  precisely opposite;  that is  to
 say, it made an  equal resistance  to the
 protrusion and the reduction of the her-
 nial sac.   Monteggia has seen a case ex-
 actly  similar s although, according to his
 own expressions, (Instituz. Chirurg. Tom.
 3, sex. 2, p. 249.) the hernial sac was not
 very small, it adhered very loosely to the
 surrounding parts, and it admitted of be-
 ing entirely  reduced into the  abdomen
 with  great facility.  It might indeed  be
 strict!v said, that this is not a true redu.6--
    i" 
66
HERNIA.
tion, because in pushing back the  hernial
sac, we only just squeeze it up behind the
ring, whence it is forced out again by the
slightest effort.  But, whatever we may
please to term this retrocession of the her-
nial sac, it is not the less proved, in  an
evident manner, that, in the small and  re-
cent inguinal hernia, the  hernial sac,  to-
gether with the viscera Which it contains,
may be returned into the abdomen.
  " Tlus is not the case with large old
scrotal herni ae.  In these, the cellular sub-
stance, which unites the sac to  the sper-
matic cord, and cremaster muscle, has  ac-
quired such a density, that it does not op-
pose less resistance  to the further deve-
lopement of the hernia, than to the efforts
of the surgeon, who endeavours to effect
it9 reduction." (Scarpa, TraitS des Hernies,
p. 57, &c.)
  We  shall   conclude  this anatomical
account  of the  inguinal  hernia,  with
ihe following explanation of the parts
as they appear on dissection:  "  the  re-
moval of the integuments  exposes the ex
terior investment of the hernial tumour,
continuous with the  margins of the ring,
and formed of tendinous fibres, from  the
aponeurosis,  the cremaster muscle,  &c.
This is connected by  cellular substance
with the proper hernial sac, formed of  the
peritonaeum.   This  production  of  the
peritonaeum passes through the  ring of
the external oblique, and then goes  up-
wards and outwards.  Behind  and above
the ring, the  inferior margin of  the  ob-
liquus mtemus and  transversalis  Icrosses
the neck ofthe sac.  When these muscles
are reflected towards the linea alba,  the
fascia,  ascending from  Poupart's  liga-
ment, anil  forming  the upper opening of
the ring,  is expo-ed, and the epigastric
artery is discovered  emerging from  the
inner side  of the neck ofthe hernial  sac,
(Camper;) which,  at this precise point,
becomes continuous with the peritonaeum,
lining the  abdomen.  The removal ofthe
hernial sac will disclose the course ofthe
spermatic  cord in its  de cent  towards
the testicle; and  when this is also  ele-
vated, the first part of the course of the
epigastric  artery, and its  origin frr.m the
iliac  trunk, are I.t.d  open."  (Lawrence
onHernia,p  115, 116)
   Iivfemales, the  round ligr.ment of the
uterus bears the same relation to the tu-
mour, as the tpe1 rnatic cord in males.   In
the former subjects, bubonoceles are un-
common.  Mr. f^awrence had a very  rare
instance pointed out to him, in which a
bubonocele in n female was situated on
the inner side of the epigastric artery.

 MARKS OF DISCRIMINATION BETWEEN SOMB
  OTHER i)ISXASES AND INGUINAL HERNI*.
  The disorders in which a mistake may
possibly be made, are the Cirsoeele, Bubo,
Hydrocele and  Hernia Humoralis,  or In-
flamed Testicle.
  For an account of the manner of distuv
guishing the first complaint from a bubo-
nocele, see Cirsoeele.
  " The  circumscribed  incompressible
hardness, the situation of the tumour, and
its being free from all connexion with the
spermatic process, will sufficiently point
out the first, at least while it is  in a re-
cent  state ; and when it  is in  any degree
suppurated, he must have a  very small
share of the tactus eruditus,  who cannot
feel the difference  between matter,  and
either a piece of intestine, or omentum.
  " The perfect equality of the whole tu-
 mour,  the freedom  and smallness of the
spermatic process above it, the power of
feeling the spermatic vessels and the vas
deferens in that process, its being void of
pain  upon being handled, the fluctuation
of  the water,  the gradual formation of
the swelling, its having begun below  and
 proceeded upwards, its not being affected
 by any posture or action of the patient,
 nor increased by  his coughing or  sneez-
 ing, together with the absolute  impossi-
 bility of feeling the testicle at the bottom
 of  the scrotum, will always, to an intel-
ligent person, prove the disease to be a
hydrocele."  Mr. Pott,  however, allows,
 that  there are some exceptions, in which
 the testicle cannot be felt at the bottom of
 the scrotum in cases of hernia.  In re-
 cent bubonoceles, while the hernial sac i9
 thin, has not been  long,  or  very much
 distended, and the scrotum still preserves
 a regularity of figure,  the testicle  may
 almost always  be easily felt  at the infe-
 rior  and posterior  part of*  the tumour.
 But,  in old ruptures,  which have been*
 long down, in which the quantity of con-
 tents is large, the sac considerably thick-
 ened,  and  the  scrotum of an  irregular-
 figure, the testicle frequently cannot be
 felt, neither is it in  general easily  felt  in
 the congenital hernia for obvious reasons."
 (Pott)
    "  In the hernia humoralis,  the pain in
 the  testicle,  its  enlargement, the hard-
 ened state  of the epidydimis, and the
 exemption of the  spermatic cord  from
 all unnatural fulness, are such marks as
 cannot easily  be mistaken;  not to  men-
 tion the generally  preceding gonorrhoea.
 But, if any doubt si^l remains ofthe true
 nature of the  d'sea', the progress  of it
 from above downward,  its different  state
 and size in different postures, particularly
 lying and standing, together  with its de-
 scent and ascent,  will, if duly attended
 to;  put it out of all doubt,  that  the tu-
 mour is a true hernia."   (Pott.) 
HERNIA-                                <£
  When an inguinal hernia does not de-
scend through the abdominal  ring, but
only into the canal tor the spermatic cord,
it is covered  by the aponeurosis of the
external oblique muscle, and the swelling
is sm. 11 and undefined.
  Now  and then, the testicle  does not
descend into the scrotum till a late period.
The first appearance of  this body  at the
ring, in  order to get into its natural si-
tuation, might be mistaken for that  of a
-hernia, were the surgeon  not to pay at-
tention  to the absence ofthe testicle from
the scrotum,  and the peculiar sensation
•ccasioned by pressing  the swelling.

OPERATION FOR  THE STRANGULATED IN-
    GUINAL HERNIA, OR BUBONOCELE.

   This consists in  dividing the integu-
ments ; dissecting down to the sac, and
opening it; removing the stricture; and
replacing the protruded viscera.
   The external  incision should begin an
inch above the external  angle of the ring,
and extend over the middle ofthe tumour
to its lower part. The advantage of be-
ginning the  wound so  high, is to obtain
convenient room for the  incision of the
 stricture.  By this first cut,  the external
pudic branch of the femoral artery may
be divided; it  crosses the  hernial sac
 near the abdominal ring, and  sometimes
bleeds  so freely, that it should be imme-
 diately tied.  In general, however, a hga-
Jnre is  unnecessary.
   When carrying this incision  low down,
 we should always bear in  mind the cau-
 tion  given  by  Camper, that there is a
 possibility of dividing the spermatic ves-
 sels, should they happen to be situated,
 as they sometimes are, in front of the
 hernia.  The division of the integuments
 brings into view the fascia,  which is sent
  off from the teisdon ofthe external oblique
  muscle, and covers the hernial sac.
   The layers of tendinous fibres,  cellular
  substance, &c.  intervening  between the
  skin and sac, should be carefully divided,
  one  after another, with  the knife and
  dissecting forceps, taking care" to incline
  the edge of the instrument horizontally,
  for fear of cutting too deeply at once, and
  injuring the viscera contained in the sac.
    After making a small opening  through
  a  part of tlie fascia  covering the sac,
  some advise introducing  a  director, and
  laying it open  upward and  downward as
  far as the  tumour extends.   The same
  manner of proceeding, they next recom-
  mend in regard to the cremaster muscle.
  Thus  the sac becomes completely  expos-
  ed.   When this method is  followed,  Mr.
  A. Cooper advises the  incisions not to be
  Carried upward, nearer, than one inch, to
the abdominal ring, for reasons which
will be presently explained.
  However it may be rationally doubted,
whether there 1s any good in these regular
and  successive divisions of tlie  whole
length of  the coverings of the sac: and
it is certain, that they protract the  opera-
tion  very much.   As  the  grand object,
after  dividing  tlie  skin, is  to make a
small opening into the  sac, sufficieut  for
the introduction of  a director, dissecting
down  at  one  particular place, answers
every purpose, and  enables us, in the end,
to lay open the whole  of die sac and its
coverings in the shortest time.  Let  the
operator only take care to raise the suc-
cessive layers of  fibres with the forceps,
and divide the  apex of each elevated por-
tion with the  knife  held horizontally.
As there is commonly a quantity of fluid
in the sac, and it gravitates to  the  lower
part, to which place the intestine seldom
quite   descends;  this  is certainly  the
safest situation for  making the  first open-
. ing into the sac.  The operator, however,
relying on the presence  of such fluid,
 should not cut  too boldly;  sometimes
 none at all i»  found, and the  viscera are
in immediate contact with, nay, adherent  ,
to, the inner surface of the sac.
   The circular arrangement of the  ves-
 sels of a piece of intestine, and its smooth
 polished surface, sufficiently distinguish
 it from the hernial sac, which has a rough
 cellular surface, and is always connected
 with the surrounding parts.   (Lawrence,
 p. 125.)
   We have mentioned, that Mr. A. Cooper
 only advises cutting the fascia, and other
 coverings of the sac, under the skin, to
 within an inch  of the abdominal ring:
 he  also recommends,  of course, limiting
  the division of the sac itself to the same
 extent.  His  reasons, for this practice,
  are to avoid  making the closure of the
 wound more difficult, and to lessen the
 danger of peritoneal inflammation.
    Having laid open the hernial sac, with
  a probe-pointed bistoury, guided on a di-
  rector, or tlie fore-finger, introduced into
  the opening, which is made at the lower
  part ofthe sac, the next desideratum is to
  divide the stricture, unless  the  viscera
  admit of being  easily  reduced,  without
  such an incision being made, as occasion-
  ally happens.
    From the  anatomical account we have
  given of the bubonocele,  it appears, that
  the  stricture may either be situcied at
  the abdominal  ring,  and be formed  by
  the margins of this  opening, or else at
  tlie  inner aperture of  tlie  canal, about
  one  inch and a  half, in a direction up-
  ward and outward, from the  outer  open-
  ing in the tendon of  the external oblique 
68
HERNIA.
 muscle.  This  latter  strangulation  is
 caused by the semicircular edge of the
.transversalis muscle and its tendon, which
 pass over the  neck of the hernial sac, and
 by a fascia, arising from Poupart's  liga-
 ment,  the semicircular border of which
 passes under this part of the sac.
   The common,  and probably the best,
 practice is to  divide the hernial  sac, iO-
 gether with the stricture. When this is sir
 tuated at the abdominal ring, the surgeon
 is to introduce the end of a director a
 little way into the neck of the sac, within
 the aperture  in the tendon, and  with a
 {irobe-pointed   bistoury, guided  on the
 atter instrument, he is to cut the stricture
 Upward and outward, or else directly up-
 ward;  a manner,  which Mr.  A. Cooper
 recommends because  it is applicable to
 all Cases, even those  less frequent ones,
 in  which  the hernia  protrudes  on the
 inner side of the epigastric artery.  This
 vessel,  as we  have  already  explained,
 commonly  runs upward round the inner
 side of the neck of the sac ; so that cut-
 ting the stricture upward and  inward
 Would be very apt to divide it.
   Cutting upward and outward is, in or-
 dinary cases,  perfectly safe; and is  only
 objectionable  in  a  few  occasional  in-
 stances, in which  the hernia descends on
 the  inner side of the' artery.  Mr. A.
 Cooper's rule of always cutting  in one
 direction, viz, upward, which is  proper
 in every instance,  is in mv opinion  well
 worthy of universal adoption.  No more
 ofthe parts, forming the stricture, should
 be cut, than is just sufficient for allowing
 the protruded viscera to  be reduced,
 without  bruising  or   otherwise  hurting
 them.   The middle of  the upper margin
 of the r'mg is  the safest place for  making
 tlie necessary  incision.
   Mr. A- Cooper, in his late work on the
 Inguinal Hernia, advises a mode of divid-
 ing  the  stricture,  considerably different
 from the usual method.  He  directs the
 finger of the  operator to be  introduced
 into the sac, (which in his plan, we know
 is left undivided for the space of one inch
 below the ring.)   When the  stricture is
 felt, a probe-pointed bistoury is to be con-
 veyed  over the front  of the sac into the
 ring (between the  two parts,) and the lat-
 ter only Is then to be divided, in the di-
 rection upward,  opposite the  middle of
 the neck ofthe sac, and to an extent just
 sufficiently to  allow the protruded parts to
 he returned into  the  abdemen,  without
 their being hurt.   The two chief advan-
 tages,  which  Mr. A. Cooper  imputes  to
 this method, are, that the danger of peri-
 toneal inflammation will be less, and that
 the epigastric artery,  if wounded, would
 pot  bleed  into the abdomen.  I  am  of
opinion, that what Mr. Lawrence has re*
marked, concerning this  proposal, is ex-
ceedingly judicious :  " An accurate com.
parative trial of both methods  would be
necessary, in order to determine the weight
of the first reason.  The second  circum-
stance cannot be a matter of any import-
ance, if we cut in such a direction  as to
avoid the risk of wounding the artery.
Many circumstances  present themselves
as objections to this proposal.   The ma-
noeuvre  itself,  although perhaps easy to
the  experienced hand of  such an  able
anatomist as Mr. C.  would,  I am  con-
vinced, be found highly  difficult, if not
impracticable,  by the generality of sur-
geons.  This  difficulty  arises  from the
firm manner, in which the sac and sur-
rounding parts are  connected,  we might
almost say, consolidated  together.   The
experience of Richter ('Traitif des ffernies, '
p. 118) shews, that this objection is found-
ed in real it}'.   He once tried to divide the
ring, without cutting ihe sac, but he found
H impracticable.  If the  stricture  is so
tight, as to prevent the Introduction of
tlie finger, there must be great danger of
wounding the protruded parts.  The prac-
tice would still be not advisable, even if
it could be rendered as easy as the com-
mon method of operating.   Mr. C. leaves
an inch of the sac, below the ring,  undi-
vided ; thus  a  bag remains ready to re-
ceive  any future  protrusion,  and the
chance  of a  radical cure  is diminished.
It would be better to follow the advice of
Richter, and scarify the neck of the sac,
in order  to  promote  an  adhesion  of its
sides.   He  has  found this practice so
successful in  accomplishing  a radical
cure, that he advises (p. 191.) its employ.
ment in every operation for strangulat-
ed  hernia."    (Treatise   on  Hernia, p.
144.)
   If'.he stricture should be felt to exist
at the inner opening of the canal for the
spermatic cord, Mr. A, Cooper advises the
operator to introduce  his finger into the
sac, as far as the stricture, and then to
insinuate  a probe-pointed bistoury,  with
the flat part of its blade  turned towards
the  finger, between the  front of the sac
and the abdominal ring, till  it arrives
under the stricture, formed by the  lower
edge ofthe transversalis and obliquus in-
terims.   Then the edge of the instniment
is to be turned forward,  and the stricture
cut in the direction upward.  This plan of
not cutting the neck ofthe sac, is liable to
all the objections stated by Mr. Lawrence,
in regard to the case,  in which the  stran-
gulation takes  place  at  the  abdominal
ring  It should  be mentioned, that Mr
A. Cooper's bistoury  is a very proper one
for dividing the stricture, as it only ha* a 
HERNIA.
69
cutting edge to a certain distance from
the point.  Perhaps, on tiie whole, we may
infer, that it is both most easy and advan-
tageous to divide the neck of the sac,  to-
gether with the stricture, whether this be
situated at the ring,  or more inward.  In
the latter cVise,  cutting upward  and out-
ward would always be perfectly  safe,  be.
cause the hernia "always protrudes on tlie
outer side ofthe epigastric artery; but, as
it is easiest for the memory to adhere to
one rule, making the incision immediately
upward is a very proper plan,
   Room being made for the reduction of
the protruded parts into the abdomen, by
the division ofthe stricture, they are to be
immediately returned, if sound,  and free
from adhesions.   This object is  consider-
ablv facilitated by bending the thigh. The
intestines are to be  reduced before  the
omentum, but, when a portion of mesen-
tery is protruded, it is to be returned be-
fore either of the preceding parts.  The
intestine should always be reduced, unless
it be found  in a state of actual mortifica-
tion. It often appears so altered in colour,
that an uninformed person would deem  It
improper to return  it into  the abdomen.
However, if such alteration should  not
 amount to a real mortification, experience
justifies the reduction ofthe part.  Mr. A.
Cooper has judiciously cautioned the ope-
 rator not to mistake  the  dark chocolate-
 brown discolourations, for a state of gan-
 grene. With these  the protruded part  is
 frequently  found affected;  and, as they
 generally produce no permanent mischief,
 they ought to be carefully discriminated
 from  the black-purple,  of  lead-coloured
 spots, which usually precede mortification.
 To determine  whether  a  discoloured
 portion of  intestine  be positively  morti-
 fied, some  recommend pressing forward
 the blood contained in the veins, and, if
 they fill  again,  it is looked upon as a
 proof, that the bowel is still possessed of
 life.  '
   In  returning a piece of intestine  into
 the abdomen,  the surgeon should first  in-
 troduce the part, nearest  the  ring, into
  this aperture, and hold  it there till an-
  other  portion  has  succeeded  it.   Tins
  method w> to be followed up, till the whole
  ofthe protruded bowel is reduced.
    Writers  on surgery cannot too severely
  reprobate the employment  of  any force,
  or  violence,  in endeavouring  to return
  the contents of a hernia in  the operation:
  a method  the more pernicious,  because
  such parts are commonly more or less in
  a state  of inflammation.   It  is  always
  more  judicious to enlarge the stricture,
  than to pinch and bruise the bowel in
  trying to get it through  an opening which
  U too small.  Distention of the intestine
sometimes prevents the reduction: but,
the bowel can then be generally returned
as soon as its contents are first compress-
ed  into the part of the intestinal canal
within the stricture.  It is better, how-
ever,  to dilate  the  strangulation  a little
more,  than to use any force  in trying to
get the intestine back  into the abdomen
in the manner just suggested.
  Reduction  is  sometimes impeded  by
the  protruded parts  adhering  to each
other, or to  the hernial sac.   The intes-
tines  are not often found very firmly ad-
herent together.  The omentum  and in-
side of the  sac are the parts, which are
most  subject to become intimately con-
nected by adhesions.   The  fingers will
commonly  serve for breaking any recent
slight adhesions  which may have taken
place  between the intestines and inside
of the hernial  sac.  When  these adhe-
sions  are firm,  and  of long standing,
they must be cautiously divided with the
knife; an object, which can be most ea-
sily and safely accomplished, in case they
are long enough to permit the intestine to
 be elevated  a little  way from the surface
 of the sac.   But, provided their firmness
 and shortness  keep the external  coat of
 the bowel and inner surface  of the sac in
 close contact,  the greatest  care is requi-
 site in separating the parts  with a knife,
 so as to avoid  wounding the  intestine.
 In doing this, the most prudent and safe
 method, is not to cut  too near the bowel,
 but rather  to  remove  the adherent parts
 of the sac,  and return them with the in-
 testine into  the abdomen.   Every preter-
 natural connexion should always be  se-
 parated, before the viscera  are reduced :
 Mr.  A. Cooper mentions,  that  a fatal
 obstruction  to the passage  of the  intes-
 tinal matter has arisen from the  mere
 adhesion of the two  sides  of a fold  of
 intestine together.  (P. 31.)  When the
 adhesions,  which prevent reduction,  are
 situated about the neck of the sac, so as
 to be out of the operator's view,  it is  the
 best  to make the wound through the skin
 and  abdominal ring somewhat larger,  io
 as to be able to separate the adhesions
 with more safety.
    Having reduced the parts, the operator
 should introduce his finger, for the pur-
 pose of being sure that they are fairly and
 freely returned into the abdomen, and no
 longer suffer constriction, either from the
  inner opening, from the ring, or the parts
 just  within  the cavity ofthe peritonaeum.

       TREATMENT OF THE OMENTUM.

    In an entero-epiplocele,  this  part, if
  healthy and free from gangrene, is to be
  reduced after the intestine.   When, how- 
70
HERNIA.
 ever, it is much diseased, thickened, and
 indurated, as it frequently is found to be,
 after remaining any considerable time in
 a hernial  sac,  the morbid part should be
 cut off   Its reduction, in this circum-
 stance, would be highly improper, both
 because an immediate enlargement  of the
 wound would be necessary,  in order lo be
 able to put the diseased mass back  into
 the abdomen, and because, when reduced,
 it would, in all probability,  excite inflam-
 mation of the surrounding  parts,  and
 bring on dangerous  symptoms. (See Hey,
p. 172 )
  The diseased omentum  should always
 be cut off with a knife;  and, if any  of its
 arteries should bleed, they ought  to be
 taken up with  a tenaculum, and tied se-
parately with a small ligature.  An un-
reasonable apprehension of hemorrhage
from the cut end of the omentum has led
many  operators  to put a  ligature all
round this part, just above the diseased
portion, which  they are about to remove.
This  practice cannot be reprobated in
terms  too severe;  for, a frequent  effect
of  it is to bring on a fatal inflammation,
and even  mortification of the omentum,
extending within  the abdomen, as  high
as the stomach and transverse  arch of the
colon.  Mr. A. Cooper has remarked with
great truth,  that  it  is  surprising, this
custom should ever have prevailed.   The
very object of the operation is to  extri-
cate the omentum  from  its strangulated
state, arising from  the  pressure of the
surrounding tendon, and no  sooner has
this been done, than the surgeon includes
it in a  ligature, which produces a  more
perfect constriction,  than that  which
existed before the operation was under-
taken.
  " When the omentum   has suffered
strangulation for  a few days  (says Mr.
Lawrence), it  often becomes  of a dark
red, or livid colour; and there is an ap-
pearance,  on cutting it, as if some blood
were extravasated in its substance.  This,
I believe, is the  state,  which surgeons
have generally described under the term
of gangrene."   (P.  167.)
  When  cut in this state, it does  not
bleed.  I  need  hardly observe, that the
dead jiart must be amputated, and  never
reduced.  Some have advised  leaving the
omentum in the wound, especially in cases
of old hernhe, in which it lias been a loog
while protruded.   Hey  mentions  cases,
shewing that granulations form very well,
and the  wound becomes firmly healed,
when this plan is followed.   (P. ISO, &c.)
Every one, however, will acknowledge the
truth of what Mr. Lawrence says on this
sufcject.  The  method " is attended with
no particular advantage, but certainly ex-
poses the patient to the  possibility of ill
consequences.  The omentum, left in the
wound, must  be liable to injurv, jnflam-
mation, or  disease; and  hence arises a
source of danger to the patient.  Unnatu-
ral adhesions, formed by this part, have
greatly impaired  the  functions  of . the
stomach.  Cases are recorded, where the
unfortunate  patient has never been able
to take more  than a certain quantity of
food, without  bringing on instant vomit-
ing: and even where it has been necessary
for all the meals to be taken in the recum-
bent position, with the tnunk curved, and
the thighs bent.  (Gunz.)  To  avoid the
possibility of such afflicting consequences,
we should,  after removing any diseased
portion, carefully replace the sound part
of the omentum in  the abdominal cavity."
(Treatise on Hernia,p. 181.)

  TREATMENT, WHEN THE INTESTINE IN
        TUE SAC MAS MORTIFIED.

  Sometimes,  on opening the hernial sac,
the intestine is found to be in a gangren-
ous, state,  although the occurrence could
not be previously  known, owing to the
integuments and the  hernial  sac itself
not being affected with the same mischief.
In ordinary cases, however, both tlie skio
and sac become gangrenous at the same
time with  the contents of the  hernia.
The tumour, which was before tense and
elastic, now becomes soft, doughy, em-
physematous,  and  of  a purple  colour.
Sometimes the parts now become spon-
taneously reduced;  but, the patient only
survives a few  hours.
  Mr. A. Cooper has accurately remark-
ed,  that,  in other instances,  the  skin,
covering the swelling, sloughs to a con-
siderable extent, the intestine gives way,
and, as the feces find vent at the wound,
the symptoms of strangulation  soon sub-
side. When the patient continues to live
in these circumstances, the living part of
the intestine becomes adherent to the her-
nial sac, the sloughs separate  and come
away, and thus an artificial anus is esta-
blished, through which the feces are com-
monly discharged, during the remainder
of life.  (See Anus, Artificial.)
   However, though when the patient sur-
vives the mortification of an  intestinal
hernia, he  commonly obtains  the bless-
ings of life only combined with the loath-
some affliction of an artificial anus ; yet,
things  sometimes take a still more  pros-
perous  course;  the feces gradually re-
sume their  former rout to the rectum,
and, in proportion  as the artificial anus
becomes unnecessary, it is shut up. Many
instances of this sort have fallen under
my own observation in St. Bartholomew's 
HERNIA.
7V
 hospital.  The  chance of  a favourable
 event is much greater in some kinds of
 hernia,  than in others.  When the su-an-
 gulation only includes a part of the dia-
 meter of the gut, the feces are sometimes
 only  partially  discharged  through  the
 mortified opening.  This quantity lessens,
 as the wound heals, and the patient  gets
 perfectly well.   (Louis; Mem. de tAcad.
 de  Chir. Tom.  3.)   A small gangrenous
 spot, or two, may end in  the  same man-
 ner.  Mortification of  the  csecum  and
 its  appendix,  in a  hernial sac, has hap-
 pened several times, without much dis-
 turbing the usual course of the feces  to
 the anus, and the patients have very soon
 recovered.  (Med.  Obs. and Inq. Vol.  3,
 p. 162, &c.)
  The grand thing, on which tlie esta-
 blishment of tlie continuous state of the
 intestinal canal depends, in all these cases,
 is the adhesion, which the living portion
 ofthe bowel, adjoining the mortified part,
 contracts with the peritonaeum all round.
 In this manner, the escape of the contents
 of the bowels into the cavity of tlie peri-
 tonaeum becomes in general  completely
 prevented.   When the intestine has not
 already burst,  the  stricture  should be
 divided; an opening made  in the  morti-
 fied part to let out the feces, and very
 mild purgatives and glysters administered.
 (Lawrence, p. 186.)
  It is an observation of Mr. A. Cooper's,
 that the degree of danger,  attending an
 artificial anus, depends on tlie vicinity of
 the  sphacelated  part of the intestinal
 canal to the stomach.  Thus, if the open-
 Ing be  in the jejunum, there is such a
 small extent of surface  for  absorption,
 between  it  and the stomach, that the
 patient dies of inanition.
  Let us now suppose, that  the mortified
 state of the intestine has only been  dis-
 covered,  after laying open the hernial sac
 in tlie operation.  The mischief may only
 consist of one,  or more spots; or of the
 Whole diameter of the protruded bowel.
 In the first case, the  proper practice is to
 divide the stricture, and return  the in-
 testine into the abdomen, with tlie mor-
 tified spots towards the  wound.  Mild
 purgatives  and glysters are then to be
 exhibited.  The most  favourable mode,
 in which  a case of this  kind ends, is,
 when the intestinal matter gradually re-
 sumes its  natural   course,  after  being
 either partly, or entirely discharged from
 the wound.  But, sometimes, an artificial
 anus continues for life.
  The repeated observations  of modem
surgeons have now decided,  that no liga-
ture,  passed through the mesentery, to
keep  tlie gangrenous part of the bowel
 uear the wound, is at all necessary.  The
 fiarts, in the neighbourhood of the ring,
 iave all become  adherent  together, in
 consequence of inflammation, at tiie same
 time, that the  parts  in the hernial  sac
 mortify-;  and, of course, the  partially
 gangrenous bowel, when reduced, is me-
 chanically  hindered, by these adhesions,
 from slipping far  from tlie wound.  De-
 sault and  De la Faye, both  confirm  the
 fact, that tlie intestine never recedes far
 from the ring; and, even were  it to do
 so, the adhesions, which it soon contracts
 to  the adjacent surfaces, would,  as Petit
 has explained,  completely  circumscribe
 any matter, which might be effused, and
 hinder it from being  extensively extra-
 vasated  among the convolutions of  the
 viscera.  (Mem. de I'Acad de Chir. Tom.
 land 2.)
   Mr. Lawrence, in his bite very valuable
 Treatise on Hernia, has clearly shewn  the
 impropriety of sewing the ends of  the
 intestinal canal together, introducing one
 within the other, supported by a cylinder
 of isinglass, &c. put in their  cavity, in
 those  cases, in which the whole circle
 of the intestine has mortified,  and been
 cut away,  as is advised  by the majority
 of writers.  "  By drawing  the  intestine
 out of the  cavity, in order to remove  the
 dead partj the adhesion behind the ring,
 on which the prospect of a cure chiefly
 depends,  must be  entirely  destroyed;
 and new irritation and  inflammation must
 be unavoidably produced,  by handling
 and sewing an inflamed part."—(P. 199.)
   Instead  of such  practice,  this gentle-
 man very judiciously recommends dilat-
 ing the stricture,  and leaving the subse-
 quent progress of the cure entirely tn
 nature.  The sloughs  will cast offi and
 the  ends of the gut are  retained by the
 adhesive process in a state of apposition
 to  each  other, the most favourable  for
 their union.  Thus, there is a chance of
 the  continuity of the intestinal  canal  be-
 coming established again.
  However, in  recent wounds of the  ab-
 domen, attended with  a protrusion of a
 portion of  ihe  intestine, cut completely
 across,  the bowel is  as  yet neither  in-
 flamed,  nor adherent  to  the vicinity of
 wound in the  peritonaeum,  so  that, in
 these cases, it may be proper practice to
 connect the ends together, (as advised in
 the  article Abdomen,  Wounds of the  In-
 testines,)  by means of a few stitches with
 silk, or thread, and a small sewing needle;
 and to confine the  wounded  part of the
 intestine, near the breach in the perito-
 naeum, until adhesions have had time to
 form.
  Mr. A. Cooper has  recommended this.
 mode of proceeding in cases of hernia,
attended with mortification of the whole 
n
HERNIA
diameter of the bowel;  but, for reasons,
already stated, and  many facts, referred
to in "Mr. Lawrence's work, it is  to be
hoped, that the plan of sewing the in-
Ustines  in these cases  will be for ever
abandoned.

  OPERATION fOR VERr LARGE INGUINAL
               HEHM.E.

  When the tumour is of very long stand-
ing, is exceedingly large, perhaps extend-
ing half way down to the knees, and its
contents  have never admitted of  being
completely reduced,  the indication is  to
divide the stricture, provided  a strangu-
lation takes place ;  but without laying
open the hernial sac, or  attempting to re-
duce the parts.
  The reasons, against the common plan
of operating,  under such circumstances,
are, the difficulty of separating  all the old
adhesions; the  hazardous inflammation,
which would be excited by laying open
so vast  a tumour,  and the probability
that parts, so long protruded, might even
bring on serious complaints, if reduced.
J. L.  Petit, and afterwards, Dr. Monro,
advised the sac not  to be opened in ope-
rating on certain  cases.   (See  Mai. Chir.
'Tom. 2,  p.  372.   Description  of Bursx
Mucosx.)

orERATION FOR  THE HERNIA, WHEN IT IS
   SO SMALL THAT IT DOES NOT PROTRUDE
   KXTERNALLT THROUGH THE RINO.

   In this kind of  case, there is little ap-
pearance of external tumour; consequent-
ly, the disease is very apt to be overlooked
by the   patient and surgeon,  and some
other cause  assigned for  the series of
symptoms.  The manner of operating, in
this form of the disease, differs from that
in the common scrotal heniia; the incision
is to be  made parallel to the direction of
the spermatic cord, and the stricture will
be found at the internal ring.  (A- Cooper
on Inguinal Hernia.)

    TREATMENT AFTER THE OPERATION.

   Evacuations from the bowels should be
immediately promoted  by means of glys-
ters,  oleum ricini,  or small doses of any
ofthe common salts, dissolved in pepper-
mint-water.  For some  time, tlie patient
must only be allowed a low diet.  When
symptoms of inflammation  of  the bowels
and  peritonaeum  threaten the  patient,
general  bleeding, leeches  applied to the
abdomen, fomentations, the warm bath,
blisters, doses of the oleum  ricini, and
glysters, are the means  deserving of most
dependence,  and should be resorted to,
without the least delay.  When  all the
danger of peritoneal inflammation is past,
and the patient  is very low and  weak,
bark, wine, cordials, and a generous diet,
must be directed. The effervescing saline
draught, with opium, is the best medicine
for quieting sickness,  after the operation.
Opium and cordials are the most eligible
for checking diarrhcea.  As the opera-
tion  does not usually prevent the  parts
from becoming protruded again, a truss
must  be applied before the patient gets
up again,' and  worn  constantly  after-
wards.
PROPOSALS FOR THE RADICAL  CURE OF TRB
              BUBONOCELE.


   We shall  just  mention the principal
plans for this purpose^ some of them are
perfectly absurd and cruel; others  may
deserve more extensivettrial.  Of castrat-
ing the patient, applying caustic, or of
the operation of the punctum  aureum,
With this view, I need only say, that  they
are barbarous, and not at all adapted for
the attainment of the desired end.  A de-
scription of these methods may be found
in Pare, Wiseman, &c.
  The old  operation, termed the  royal
stitch,  seems one of  tlie  most justifiable.
It consisted in putting a ligature, under
the neck of the hernial sac, close to the
abdominal ring, and  then tying it, so  as to
produce an obliteration  of tlie pervious
state of  the part, by the adhesive inflam-
mation thus excited.  An incision, about
two inches  long,  would be  quite large
enough for getting at the neck of tlie sac,
which must next  be separated from the
parts covering it on  each side, with a few
sweeps of the knife.  A single ligature
might then, with the aid of a needle, be
passed immediately under it, and be-
tween it and the spermatic vessels,  close
to the ring, and then firmly tied, just as
surgeons tie an artery.  This operation
is  applicable to reducible hernia.  One
would not expect d priori, that any dan-
gerous constitutional symptoms would be
likely to follow  so small  a wound,  or
 making a ligature on  a part of such little
 importance as a hernial  sac.  After per-
 forming the common operation for the re-
 lief of a strangulated bubonocele,  might
 not this opportunity be taken, to  learn
 whether a radical cure would  not  more
 frequently be accomplished, than  is  at
 present the case ?
   The royal stitch,  performed in this
 manner, has  actually been attended with
 success.  (Heister,  Vol  TT.)  The  umbi-
 lical rupture  was cured by  Saviaid, on
 similar  principles;  and  Desault radically 
HERNIA.
73
 cured nine cases of the ecomphalos in
 children, by tying the hernial sac.
   Schmucker cured two irreducible rup-
 tures, free from strangulation, by cutting
 away the body of tlie sac, after tying its
 neck.   Chirurgische  Wahrnehumgen,  Vol
 2.)   Mr. A. Cooper, found cutting away
 the sac alone  insufficient, in one case.
   Dissecting away the whole hernial sac,
 or even laying it  open, must be a formi-
 dable operation compared with the sim-
 ple  mo*de above  related.  Such severe
 proceedings would also be quite useless,
 if the hernia were reducible, and the neck
 of the sac could be rendered impervious
 by' the  ligature.  Perhaps  the  cases  re-
 corded by Petit, Sharp, Acrell, &c. against
 attempting a radical cure, have no real
 validity  against the royal stitch  done in
 the simple way above described,  as none
 of these surgeons operated in  this man-
 ner.
   Richter recommends scarifying  the neck
 of the sac, with the view of producing an
 adhesion of  its sides to each other ; a
 plan, which he says, he has found very
 successful.  It certainly seems free from
 danger; but perhaps not more  so  than
 tying the part, and one, would expect,
 less likely to be always successful.
   From the account we have given of the
 anatomy of the bubonocele, it is obvious,
 however, that all these  methods  could
 only obliterate tlie sac as high as the ring,
 not more inwardly to the inner opening.
 Hence there would still remain a certain
 portion of the entrance  of its cavity open
 for tlie descent of the viscera.

      CRURAL, 0R  FEMORAL HERNIA.

   Verheyen, who wrote in 1710,  first de-
 monstrated the distinct  formation of cru-
 ral hernia, which was  before generally
 confounded with bubonocele.
   The parts composing this kind of her-
 nia, are  always protruded  under  Pou-
 part's ligament, and the swelling is situa-
 ted towards the inner part of  the bend
of the thigh.  The rupture descends on
the inside of the femoral artery and vein,
between  these vessels  and the os pubis.
Females  are particularly subject to this
kind of rupture, in  consequence of tlie
great breadth  of  their pelvis, while  in
them the inguinal  hernia is rare.  It has
been  computed,  that  nineteen  out  of
twenty  married  women,  afflicted with
hernia, have this kind;  but, that not one
out of a hundred  unmarried females,  or
out of the same number of mep, have this
form of tlie disease.   (Arnaud.)
  " The  crural hernia," says Scarpa, " is
frequently  observed in  women,   who
liave had several  children; it  very sel-
    Vol. II.
 dom afflicts young girls; and still more
 rarely men.  in the latter, tlie viscera can
 more  easily escape through the inguinal
 ring,  by following the spermatic  cord,
 than they can descend along the  crural
 vessels, and raise the margin of  the apo-
 neurosis of the external oblique muscle,
 that forms  the  crural arch.  In women,
 an opposite disposition  prevails, in con-
 sequence of the smallness of the inguinal
 ring, which, in them, only gives passage
 to the round ligament of the uterus, and
 besides is situated lower down, and near-
 er the pubes, than it is in men, whilst, on
 the  contrary, the crural arch is more ex-
 tensive,  by reason  of the  wider  form of
 the  pelvis.   Morgagni  expressly  says,
 that he  has never met  with the  crural
 hernia in the dead body of any male sub-
 ject.  Mini ut verumfatear, nondum nisi in
 fxminis accidit  ut earn videretn.  (De Sed.
 et cous. morb. Epist. 34—15.) Camper gives
 us to understand almost the same thing.
 (Icones Herniarum, in Prxfat.)   Hevin,
 often operated for this kind of hernia io
 females, but only  once in the male sub-
 ject.  (Puthol. et Therap, p. 406.)   Sandi-
 fort and Walter have both seen  but a
 single instance  of it in the dead body of
 the  male  subject.  (Obs. Anat. Pathol.
 cap. 4,p. 72.  Sylloge comment, anat. p. 24.
 obs.  21.)  Arnaud himself, to whom mo-
 dern surgery is highly indebted for many
 important precepts on the operation for
 the  strangulated crural  hernia  in both
 sexes, candidly confesses, that  he never
 had  an opportunity of dissecting a hernia
 of this kind in  the  male subject." (Scar.
 pa Trait£ des Hernies, p. 201.)
   Scarpa happened to have at  his dis-
 posal the dead body of a man  affected
 with a crural  hernia,  and,  he availed
 himself of the  opportunity of examining
 the parts with the utmost care.   He first
 injected the blood-vessels; he afterwards
 attentively  dissected all  the  parts con-
 cerned in the disease, and, in his valu-
 able treatise, he has published  an exact
 description of all ^ie particulars, accom-
 panied with an  engraving.  Plate 8.
   But, though the occasional occurrence
 ofthe crural heniia in men is fully proved,
 it is  chiefly  in  women, that this  form  of
 disease is met with.
   According to the observations of Scar-
 pa, and all the best modern writers upon
 surgery, the crural  hernia forms, both in
 tlie male and female subject, in  the eel-
 lular substance, which accompanies the
 crural  vessels below Poupart's ligament.
 The  swelling follows tlie internal side of
 those vessels, and gradually descends into
 the fold of the thigh, between the  sarto-
 rius,  gracilis,   and  pectinus  muscles.
" Many surgeons believe,  (says   Scarpa) 
74
HERNIA.
that the  hernial sac, and the intestines,
Which it contains, are ordinarily situated
above the crurd vessels and trunk of tlie
vena  saphen3,  and sometimes  between
these vessels and the anterior  superior
spine of the ilitrm.  But,  as far as my
knowledge extends, this assertion is not
supported by  a single accurate descrip-
tion of a crural hernia in the  early stage.
It is  true, that when the tumour has in
time acquired a large size, and its fundus
is inclined in a parallel manner to the
fold of the thigh,  it partly or entirely
covers the crural vessels,  and eVert the
crural nerve, as Walter says he  once ob-
served.  (Sylloge comment, anat. p.  24.)
But, it is not thence to be concluded, that
(he tumour in the beginning descended
over the  crural vessels, much less betwixt
them and the  anterior superior spinous
ptocess ofthe ilium   Neither must it be
imagined, that the heck ofthe hernial sac
becomes removed from the inner  to the
Outer side of these vessels.   If these two
cases ever  happen,  they must  be  very
rare;  and the best authors, who have
treated of the crural  liernia, concur  in
stating,  that in performing the operation,
they  have constantly  found tiie viscera
situated on the inside of the crural ves-
sels,  hut never on thfir outside.  Evm
when the  tumour, after acquiring a con-
siderable size, Was situated transversely
over the crural vessels, the neck of the
hernial sac has always been found upon
their inner side, that is  to say, between
them and  the pubes.   Le Dran, ( Observ.
de Chir.  Tom. 2,p, 2.)   La Faye\ (Cows.
ef Operations de Dionis,  p.  358.)   Petit,
((Euvres Posthumes,  Tom.  2,  p.  219.)
Morgagnl,  (De Sed. et Caus. Morb.  epist.
34—15.) Arnaud, (Mem. de Chir. Tom. 2.
p. 768.). Gunz, (De Herniis Ubellus.p. 78.)
Bertrandi, (Trnttato delle Operazioni, Tom.
 l,annot. p. 218 ) Pott, (Chirurg.  Works,
 Vol. II,p. 152.) Desault,  ('Traite des  Mai.
 Chirurg. p. 191—195.) B. Bell, (A Sys-
 tern of Surgery, Vol I, p. 387)  Richter,
 (Traite des Hernies, chap. 34.) Nessi, (In-
 stitut. Chirurg. Tom. 2, p. 198 )  Lassus,
 (Med.  Oper. Tom. 1, p. 198.) and many
 other writers,  all concur upon this point.
 In support of their opinion  (says Scarpa)
 I could cite a great number of cases of
 my own, which 1  have collected either in
 operating on several individuals for cru-
 ral hernia, or in dissecting the same kind
 of hernia in  the bodies of many female
 subjects, and  in that of the man,  from
 whom I have taken  the  plate.  Lastly,
 also, having had an opportunity  of dis-
 secting  in a female an  enormous crural
 hernia,  which  descended one-third of the
 way down the thigh, 1 observed, that the
 neck of the sac did not encroach at all
upon the crural vessels, but lay entirely
on their inner side."  (Scarpa, Traite des
Hernies, p. 203—206.)
  The situation of the tumonr  makes it
liable to be mistaken for an enlarged in.
guinal  glafnd; and many fatal events are
recorded to have happened from the sur-
geon's  ignorance of the existence of the
disease.  A gland  can only  become en-
larged by fhe gradual  effects of inflam-
mation ; the swelling of a1 crural hernia
coiries  on  in  a  momentary and sudden
manner,  and, when strangulated, occa-
sions the train of symptoms already de-
scribed in  our account of the  inguinal
hernia,  which  symptoms an  enlarged
gland  could  never  occasion.   Such cir-
cumstances seem to bfe sufficiently dis-
criminative ; though the feel  of the two
Kinds of swelling, is often not  of itself
enough to  make the surgeon  decided in
his opinion.   A femoral hernia  may be
mistaken for a bubonocele,, when the ex-
panded part  of  the swelling lies  over
Poupart's  ligament.   As  the taxis and
operation  for  the first  case ought to be
done differently from those for the latter,
the error may lead to  very  bad conse-
quences.  The femoral hernia,  however,
may always be discriminated, by the neck
of the tumour having Poupart's ligament
ab» \e  it.  In the bubonocele, the angle of
the pubes  is  behind and below this part
of the sac  ; but, in the femoral heniia, it
is on the same horizontal level, and a little
on the inside  of it.   (Lawrence, p. 218)
   In the male subject, " the crural her-
nia, in the early stage, (says Scarpa) is
situated so deeply  in  the bend of the
thigh, that it is  difficult, even in the
thinnest persons, to feel its neck, and in
examining is circumference with the ex-
tremity of the finger,  the  tendinous mar-
gin of the opening, through which the
parts  are  protruded,  can only be per-
ceived with  considerable  difficulty.  On
the  contrary, the inguinal herni.i,  h<,w-
ever small it  may be, is always less derp-
ly situated: it is about half.an inch above
 the  bend of the thigh. In carrying the
finger round its neck,  the  tendinous mar-
gin of the inguinal  ring a.', be easily felt
at its circumference; and at the posterior
part of the small tumour, the cord com-
 posed of the  spermatic vessels  is  distin-
 guishable.  When  the crural hernia has
 acquired a considerable size, its neck is
 always deeply situated in the bend ofthe
 thigh  ; but, its body and its fundus have
 a.'sttmed  an  oval  form, and their great
 diameter  is situated transversely in the
 bend of the thigh.   Whatever may be the
 bize of the inguinal herni;., it always pre-
 sents a tumour of a pyramidal  form, the
 ftase or fundus of which,  far from  being 
hekNia,
7*
 directed towards tlie  ilium, follows ex-
 actly the direction of the spermatic cord,
 and descends directly into  tlie scrotum.
 It may also be added, tliat, besides the
 symptoms, common to all hernial swell-
 ings,  the  crural  hernia,  when it- has
 attained  a certain size,  presents  some
 others, which are peculiar to it, such as
 a  sense of stupor  and heaviness in the
 thigh, and oedema  of the leg, and  even,
 of die foot of tlie same side.
   " In women, however, it is less easy to
 distinguish the  crural hernia from the
jnguinal.  In  fact, the absence  of the
 spermatic cord,  and the nearer situation
 of the ring to  the crural arch, may easily
 occasion a mistake.  Sometimes,  a wo-
 man  may even  be supposed to  have a
 double crural hernia of the same  side,
 whilst, of these two  distinct, though
 neighbouring  hernix, one may be ingui-
 nal, and the other crural. Arnaud  (Mem.
 de Chir.  Tom. 2, p. 605.)   relates an  in-
 stance of  such  a  mistake."  (Scarpa,
 Traite des Hernies, p. 207—208.)
   This interesting writer  takes occasion
 to observe further, upon this part of the
 subject, that  the portion  of the inferior
 pillar  of the abdominal ring, which sepa-
 rates this opening from the internal and
 inferior angle  of the  crural  arch,  is so
 slender in  women, that it is sometimes
 hard to distinguish the crural from the
 inguinal hernia,  which is not the case in
 male patients.
   Until very lately, the stricture,.in  cases
 of femoral hernia, was atways supposed
 to be  produced  by tlie lower border of
 the external oblique muscle, or, as it is
 termed,  Poupart s ligament.  A  total
 change of surgical opinion on  this sub-
ject, has, however, latterly taken place, in
 consequence of the accurate observations
 first made  in  1768, by Gimbernat, sur-
 geon to tlie king of Spain.  " In tlie cru-
 ral hernia, (says he) the aperture through
 which tlie parts  issue,  is  nut formed  by
 two bands, (as in the inguinal hernia) but
 it is a foramen almost round, proceeding
 from  the  internal  margin of the crural
arch  (Poupart's ligament,)  near  its in-
sertions into the  branch of the os pubis,
 between this bone and the iliac vein ;  so
that,  in this liernia, the branch of the os
pubis is situated more internally than the
intestine, and  a  little behind; the  vein,
externally,  and behind;  and the internal
border of the arch, before.  Now  it is
this border which always forms the stran-
gulation."  (See A new .Method of Ope-
rating for the Femoral  Hernia, by  Don
Antonio de Gimbernat, p. 6. Trans, by Bed-
does.)
  Mr. Hey, who attempted  to describe
some anatomical circumsunces, relative
 to the femoral hernia, and wrote subse-
 quently to Gimbernat, has certainly rather
 obscured, than thrown any light upon this
 part of the subject.   The inconsistencies
 and perplexities of his description, nave
 been clearly explained by M. Lawrence,
 to whose treatise I shall refer the reader.
 The latter gentleman makes the ligament
 described by Gimbemat,  perfectly intelli-
 gible, in a few  words:  when Poupart's
 ligament approaches the pubes, he states
 that it  becomes suddenly broader; that
 it is fixed by this broad portion, along
 the whole length of the angle and crista
 of the bubes; that it has a rounded and
 strong anterior  edge,  a  thin and sharp
 posterior margin;  and that the former of
 these is nearer to the surface, while the
 latter  is  comparatively  deeply  seated.
 The breadth of this part varies,  in  dif-
 ferent subjects: it is generally from three
 quarters of an inch to an inch.  Some-
 times, as Gimbernat has  stated, it mea-
 sures more than an inch.  Dr. Monro has
 observed, than it is  broader  in the male
 than in the female subject;  and, from
 this structure, he explains  in  part the
 more rare occurrence of this rupture in
 the male."  (P. 220.)
  The great utility of knowing, that it is
 this part, which produces the strangula>
 tion,  in cases of femoral hernia, is im-
 mense ; for  we then know, that  cutting
 the lower and outer border of the exter-
 nal oblique muscle, (in other words, Pou-
 part's ligament) is quite erroneous. This
 proceeding is the more to be  reprobated,
 because the lower pillar ofthe abdominal
 ring, in  both sexes, will be divided by di-
 recting  the incision  upward, or upward
 and inward; and thus the abdominal and
 crural rings, are made into one common
 aperture, large enough to  make the future
 occurrence of hernia very likely to bap-
 pen.  In the male,  also, there is consider-
 able danger of the spermatic  cord being
 cut.  Cutting  Poupart's ligament  ob-
 liquely outwards,  is attended with still
 more danger; for the epigastric artery
 will be  infallibly divided at its  origin.
With all  these  hazards, the cutting of
Poupart's ligament is quite useless, unless
the incision be carried on to the internal
edge ofthe crural arch.- (Gimbernat, p. 16.)
  Mr. B.  Bell, has the  merit of having
proposed the safest plan  of cutting Pou-
part's  ligament,  before  surgeons were
 aware of the part which really  formed
 the  strangulation :  he  introduced  his
 finger below Poupart's ligament, between
 the ligament and the intestine, (an  evi-
 dent proof,  says Gimbernat,  very truly,
 that there was no strangulation there;)
 he  then made a very superficial  incision
 from  above downwards, into the, thickest 
70
HERNIA.
 part of the ligament to its lower edge;
 and,  without cutting quite through  it,
 he 'continued   his  incision  about   an
 inch.  He rested the back of the scalpel
 upon his  finger, which served as a guide
 to the instrument, and, at the same time,
 as a defence to the intestine.  The  in-
 cision, however,  having been  continued
 for  an inch,  would,  as  Gimbernat  re-
 marks, inevitably cut the internal edge of
 the  crural arch.  Now, cutting this,  only
 for a  few lines, gives sufficient room for
 the easy reduction of the parts,  and there
 is no necessity  to touch the ligament,  as
 it  never  occasions  the strangulation.—
 (Gimbernat, p. 27.)
   The ihacus internus muscle is covered
 by a thin  fascia, called by  Mr. A. Cooper,
fascia iliaca. This is closely connected with
 the tendon of the psoas parvus, and is  in-
 serted into the posterior edge of Poupart's
 ligament, as far as where  the crural ves-
 sels pass  under this part.  It is  this fascia
 which prevents any protrusion of the vis-
 cera, on t he outside  of these vessels  But
 between the iliac vein, the thin posterior,
 deep-seated,  edge of Poupart's  ligament,
 and the os pubis, a space exists,  at which
 the  femoral  hernia makes its descent.
 Sometimes, at  this  point is situated a
 lymphatic gland; sometimes only cellular
 substance.
   The fascia lata  is not inserted into the
 w hole length of Poupart's ligament;  that
 is, not nearer the pubes than the femoral
 vessels.   Here  it is  continued  over the
 pectineus muscle;  consequently has  no
 connexion with the thin edge ofthe crural
 arch, nor with Potipart's ligament oppo-
 site the space, left between the vein and
 that thin  margin.  (Lawrence,p. 226)
   Where  the insertion of the fascia lata
 into Poupart's ligament ends,   it forms
 what  Mr. Burns of Glasgow  calls  the
falciform process, the upper part of which
 is attached to the above ligament, while
 the  lower  proceeds further  down the
 thigh.  Its  convexity  faces the pubes.
 This anatomical connexion is  one  chief
 cause,  why extending the  thigh,  and
 rotating it outward,  should make the cru-
 ral arch tense.
   Gimbernat named  the place where the
 femoral hernia protrudes tlie crural; Hey,
 the femoral ring.
   The hernia,  being situated in front  of
 the-pectineus, must  of course be exterior
 to the fascia lata.   In  my opinion,  sur-
 geons  are very much indebted to  Mr.
 Lawrence for his able explanation of this
 fact.   As for myself, I am candid enough
 to own that, until 1 read  his  clear and
 eoncisc account  of  the anatomy of the
 crural  hernia,   1 could never  reap any
 accurate  notions, concerning the relative
 situations* of the hernial sao and fascia of
 the thigh,  from other  more prolix works.
 This gentleman reminds us,  however,
 that  the particular crural  hernia,  con-
 tained in the sheath of the femoral  ves-
 sels,  lies  under the fascia;  p. 230.   Mr.
 Lawrence describes, that, " the falciform
 process ofthe fascia lata,  passes along the
 upper and outer part of the tumour.  Tlie
 iliac  vein  is placed on the outer  side of
 the neck ofthe sac; the pubes is directly
 behind  it; and the upper and inner parts
 are bounded by the thin posterior edge of
 Poupart's ligament."  The falciform pro-
 cess seems to have some inferior share in
 producing the strangidation;  the chief
 part  of which is formed, as  Gimbernat
 first  pointed  out,  by  the thin posterior
 edge of tlie crural arch.
   The sac  of the  femoral liernia is  ex-
 ceedingly narrow at its neck;  and, where
 its body begins, it becomes expanded  in a
 globular form : the sac of the bubonocele
 is generally of an  oblong shape.  The
 body of the sac of the  femoral  hernia,
 makes a right angle with the  neck, by
 being thrown jbrward and upward, a  cir-
 cumstance very necessary  to be known in
 trying to reduce the parts by the taxis.
   The  6ac  of the  femoral hernia is co-
 vered by a kind of membranous  expan-
 sion,  consisting of condensed cellular sub-
 stance,  and named  by Mr. A. Cooper,  the
fascia propria.  According to this gentle-
 man, another covering extends over the
 swelling,  from the superficial  fascia of
 the bend  of the thigh.   It is of infinite
 use to remember these circumstances in
 operating, lest one should think the herni-
 al sac divided, when it is  not so.
   All late  writers on hernia,  have re-
 ma! ked how  very  small  the aperture is,
 through which the viscera protrude in
 the femoral rupture;  how much greater
 the   constriction  generally is, than in
 the bubonocele; consequently, how much
 more rapid the symptoms  are ;  how much
 less  frequently  the taxis succeeds;  and
 how  much more dangerous delay proves
 (See  A. Cooper, Hey, Lawrence, 6}c.)
   Though the crural ring  is almost always
 very  small, yet in a few instances, in which
 the tum<mr is very large,  and of long
 standing,  it becomes very capacious, just
 as the  opening often  becomes, through
 which the inguinal  hernia protrudes.  Dr.
 Thomson,  of Edinburgh,  Mr.  Hey,  and
 Mr. Lawrence, have related examples of
 this kind.
   The  remarks already  made, concern-
 ing the treatment  of  hernia,  before  hav-
 ing recourse  to  the knife, are all appli-
 cable to the present case,  and we need ntt
 repeat them.  In attempting to reduce the
 femoral hernia by tlie taxis, tlie surgeon 
HERNIA.
77
should recollect, however, that relaxing
Poupart's ligament, and the femoral fas-
cia, is of tlie highest consequence. Hence,
the thigh should be bent, and rolled in-
wards.  The pressure ought  also to be
first made downwards and backwards,  in
order to push the  swelling off Poupart's
ligament; and afierwards, the parts should
be propelled upwards, so as to try to get
them through the crural ring.

OPERATION FOR  THE FEMORAL,  OR CRURAL
                HERNIA.

  Mr.  A. Cooper says,  " the incision  of
the integuments is to be begun an inch and
a half above the crural arch, in a line
with the middle of the tumour, and ex-
tended downwards to the center of the
tumour below the arch.  A second  inci-
sion,  nearly  at right  angles  with  the
other, is next made, beginning from the
middle of the inner side of the tumour,
and extending it across  to the outer *side,
sc that tlie  form of this double  incision
will be that of the letter T reversed."  The
angular flaps are,  of course, to be  next
dissected off, and reflected.
  T1, t making of two incisions, however,
is not deemed necessary by the majority
of surgeons; and, in all  the  numerous
operations I  have seen performed by the
surgeons of St. Bartholomew's Hospital,
during a space of nearly fifteen years,  1
never knew them  have any  occasion  to
make any transverse  wound.   The  divi-
sion of the  skin should begin about an
inch above the crural ring,  and be  con-
tinued obliquely  downwards  and  out-
wards.  In tliis  manner, we  cut exactly
over the place,  where the incision of the
stricture should be made.
  " The first  incision  (says  Mr.  A.
Cooper)  exposes  the  superficial  fascia,
which is given off' by the external oblique
muscle,  and which  covers  the anterior
part of tlie hernial sac ; but,  if the patient
is thin, and the hernia ha* not been  long
formed, this fascia escapes observation,
as it is thrn slight and delicate, and ad-
heres closely to the inner side of the
skin.  When this  fascia is  divided, tlie
tumour is  so far  exposed,  that the cir-
cumscribed  form of the hernia may be
distinctly seen; and  a  person,  not  well
acquainted with the anatomy ofthe parts,
would read ly suppose that the sac itself
was now  laid  bare.  This, however,  is
not the case, for it is still enveloped  by a
membrane, which  is the fascia, that the
hernial sac pushes before it, as it passes
through  the  inner  side  of the  crural
sheath.   This membrane,  the fascia pro-
pria, is to be next divided longitudinally
from  the  neck to the fundus of the sac;
and  if  the subject is fat,  an  adipose
membrane lies between it  and the sac,
from which it may be distinguished, by
seeing the  cellular membrane  passing
from its inner side to the surface of the
sac.
  " This  is, in my opinion,  the  most
difficult part of the operation;  for the
fascia propria is  very liable to be  mis-
taken for the sac itself; so that,  when
it is divided, it is  supposed that the sac
is exposed, and the intestine is laid  bare:
following  upon this idea, the stricture is
divided in the outer part of the sac, and
the intestine, still strangulated, is  push-
ed, with the unopened sae, into the cavity
of the abdomen.
  " The hernial sac being exposed, is to
be next opened; ajid,  to divide it with
safety, it  is best to pinch up a small part
of it hetween the finger and thumb; to
move  the thumb  upon the finger,  by
which'the intestine is  distinctly felt, and
may be separated  from the inner side of
the sac ;  and then to cut into the sac, by
placing the blade  of  the knife horizon-
tally. Into this opening, a director should
be passed, and the sac opened from its
fundus to  the crural sheath."  (A. Cooper
on Crural and Umbilical Hernia.)
  Sometimes the contents of the hernia,
thus exposed, admit  of being  returned,
without tlie further use  ofthe knife. When
this  object, however,  cannot be readily
done, the protruded parts should  never
suffer  injury  in  repeating  manual  at-
tempts ; and it is safest to divide the stric-
ture at once.
  Gimbernat's method of dividing the
stricture,  in cases of femoral herniae, may
be regarded as the most effectual, and
safest.   " Introduce, along  the  internal
side  of the intestine,  a cannulated or
grooved sound, with a blunt end, and a
channel of sufficient depth.  This is to
be directed obliquely inwards, till it enter
the crural ring, which  will  be  known by
the increased resistance;  as also  when
its point rests upon tlie branch of tlie os
pubis.  Then suspend  the introduction;
and  keeping the  sound (with  your left
hand, if you are  operating on  the right
side, and  v. v.)  firmly resting  upon the
branch of the os pubis, so \"*r its back
shall  be  turned  towards  the  intestine,
and its canal to the symphysis pubis, in-
troduce gently with  your  other  hand,
into  the groove of the sound, a bistoury,
with a narrow blade and blunt end,  till
it enter the ring.  Its entry will  be known,
as before, by a little increase of resibtance.
C.iutiously "press  the bistoury to the end
of the canal; and employing  your two
hands at  once,  carry  both  instruments
close along the branch  to the body of the 
78                                HERNIA.
 pubis,  drawing them  out at  tlie same
 tune.   By this easy operation, you will
 divide  the internal edge of the crural
 arch at its extremity, and within four or
 five lines of its duplicative; tiie remain-
 der continuing firmly attached, by the  in-
 ferior band, or pillar,  of which it is  the
 continuati^i.   This simple  incision  be-
 ing thus made, without the smallest dan-
 ger,  the internal  border of  the  arch,
 which  forms  the  strangulation,  will  be
 considerably relaxed,  and the parts will
 be reduced with the greatest ease." (Gim-
 bernat,  p. 45,  46.)
   Mr. A. Cooper  recommends the stric-
 ture to be divided "obliquely  inwards
 and upwards, at right angles to  the cru-
 ral arch."
   After advising us to open the  sac of a
 femoral hernia with particular  care,  on
 account of its being much thinner than
 that of a bubonocele,  and (as might  be
 added)  on account of  its seldom  contain-
 ing any fluid,  and  often having no omen-
 tum in it  covering the  intestine,  Mr.
 Hey remarks,  " The stricture made upon
 the  prolapsed  parts is very great, as I
 have already observed; but if tlie tip  of
 the finger  can be  introduced within the
 femoral  ring,  to  guide the bubonocele
 knife, a small incision (for  the  ring  is
 narrow) will be sufficient to set the parts
 at liberty.  If the tip of tlie finger cannot
 be  introduced  at the proper place, a di-
 rector with a deep groove must be used
 instead  of the finger;  but I prefer the
 latter.   The finger, or director, should
 not be  introduced  very near the great
 vessels ; but on that side  of the intestine
 or omentum which is nearest to the sym-
 physis   of  the ossa pubis.  The incision
may then be made directly  upwards.  The
surgeon  must take especial care to  in-
troduce his finger or director within that
 part where he finds the stricture to be the
greatest, which, in this species of hernia,
is  the  most interior part of the wound."
 (P. 155.)
  Gimbernat's mode is preferable to Mr.
 Hey's,  because, were the  operation done
on a male, cutting  directly upward would
endanger the spermatic cord.
  Mr.  L»*rence has noticed,  "an inci-
sion ofthe most interior part of tlie stric-
ture is  free from  all danger, in  the or-
dinary  course of the vessels.  But that
variety, in which  the  obturator artery,
arising from the epigastric, runs along the
inner margin of the sac, seems to preclude
us from cutting  even  in this direction.
A mode of operating has been lately pro-
posed,  (Edinb. Med. and Surg. Journal,
 Vol. 2, p. 205.) with a view of avoiding this
danger.  Wo  are  directed  to  make  an
 incision through the aponeurosis of the
 external oblique muscle, just above the
 crural  arch, and  in  a  direction parallel
 to that part: to introduce a director under
 the stricture from this opening, and to
 divide the tendon to the requisite extent,
 by  means of a curved knife, passed along
 the groove."  (Treatise on the Hernia, p.
 247.)   For reasons which  Mr. Lawrence
 states, tliis plan is certainly not altogether
 eligible, and, upon the whole, Gimbernat's
 method of cutting  the stricture is the
 safest.   Monro computes,  that the obtu-
 rator artery may arise  from the epigas-
 tric, once in twenty-five or thirty subjects.
 But, allowing that it   originates  more
 frequently, it then does not always de-
 viate from its usual course along the out-
 side  of the sac.  Mr.  A  Cooper says:
 " in all  cases, which I have myself dis-
 sected,  where this variety  existed  with
 crural hernia, the obturator has passed
 into the pelvis, on tlie  outer side of the
 neck of the sac, entirely out of the reach
 of any danger of the knife."  ( On Crural
 Hernia, p. 21.)  Mr. Lawrence concludes,
 that the comparative number of instances,
 in which it is found on  the opposite side,
 cannot be more  than one out of eiglit, or
 ten, and consequently  it would  only be
 liable to be wounded once in eighty or one
 hundred operations.   (P. 252.)•
  It is observed  by  professor  Scarpa,
 that " the round ligament  of the uterus,
 in passing through the abdominal muscles,
 follows precisely the same track as the
 spermatic  cord.  It is  equally  situated
 behind  Poupart's ligament, with  the dif-
 ference,  that it  does not become so dis-
 tinct from the internal  extremity of this
 ligament, as the spermatic cord does, be-
 cause it has not so far to run, in order to get
 from that ligament to the  inguinal ring,
 the latter opening being situated lower in
 the female,  than the male  subject..  The
 round ligament, like the spermatic cord,
 also crosses the  epigastric  artery, before
 reaching the inguinal ring.  And as the
 crural hernia always begins at  the in-
 ternal and inferior angle of the  arch  of
 this name,  as well in  the  male as the
 female, it follows,  that  in the two sexe3,
 the  epigastric artery remains in its na-
 tural situation, and invariably  corres-
 ponds to the external side of the  neck  of
 the crural hernia;  whilst  tlie spermatic
 cord, in man, and the  rour.d ligament,
 in women, pass over the extremity of the
 front of the neck of the hernial  sac.  In
 the  operation for  the  crural hernia,  in
 females, the incision of the  neck of the
 hernial  sac,  and crural arch, when di-
rected upward  towards the  linea alba,
 cannot wound the epigastric artery, which
 it is of the most consequence to avoid ; 
HERNIA.   .
79'
but it  always divides,  either  totally or
partially, the round ligament  of the ute-
rus,  Which cannot lead to any  dangerous
hemorrhage; for,  out  of the period of
pregnancy, the arteries  of the round li-
gament are.very small; they are  almost
obliterated in women advanced in years;
and  in general  they are quite capillary
in the  extremity of the  ligament adjoin-
ing  the ring.  Hence, it cannot be sur-
prising, that  so many crural hernia: have
been successfully  operated upon  in wo-
men, by cutting the hernial sac and cru-
ral arch  directly  upward, while  not a
single  instance can be cited  of such an
incision being made in  man without any
ill consequence, altliough in  both sexes,
the  epigastric artery  may  have  been
avoided  in operating  by this process."
(Scarpa, Traite, des Hernies p. 240.)
   In operating for the crural hernia in
males, Scarpa recommends us to follow
a method which he calls new, but which
in fact, is the same  as that advised by
Gimbernat.   " I have found (says Scarpa)
that, in man, the neck of the hernial sac
may be divided without danger, by giving
to the  incision a  direction exactly con-
trary to that, which is practised, in the
female subject.  After having opened the
hernial sac, it is to  be  drawn outward by
one of its sides  sufficiently to allow the
introduction  of a small director between
its neck and  the  strangulated intestine,
the groove of the  instrument being turned
downwards towards the internal and inferior
angle ofthe crural arch.  A probe-pointed
bistoury, the edge of which is also to be di-
rected  downwards  towards  the  point of in-
sertion of Poupart's ligament to the pubes,
is to be pushed along the groove.  By this
means, the neck ofthe hernial sac will be di-
vided its whole length, at its internal and in-
ferior side, and Poupart's ligament will be
cut cose to its attachment to the top of tlie os
pubis.   The epigastric artery  will be cer-
tainly  avoided,  because it  lies upon the
opposite side of tlie hernial sac.  As for
the spermatic cord, I have demonstrated,
that it is situated  on the forepart of the
neck of the hernial sac ; consequently, it
cannot be touched by  an incision made
from above  downwards,. whilst it  is'con-
stantly cut in the ordinary method, since
the knife is carried from below upwards.
In the first case, this part may be the more
easily avoided, as it lies at some distance
from the  internal  and  inferior angle of
the  crural  arch.   In  fact, it is at  this
place,  that it quits,  as we   have  seen,
the  edge of  Poupart's  ligament, in order
to   ascend   towards the   inguinal ring.
The incision, that I propose (says Scarpa)
not  only  has the advantage  of slitting
open  the neck ofthe hernial sac its whole
length,  it also divides  a part of tlie  in-
sertion  of Poupart's  ligament into the
upper part of the os pubis, a thing, that
greatly  contributes  to relax the crural
arch, and facilitate  the reduction of the
viscera ; of tlyjse, at least,  which are not
adherent to the sac."  (Scarpa,  Op. cit.
p. 235.)
  Altliough this accurate anatomist and
surgeon appears to be quite unacquainted
with many of the late valuable publica-
tions  on hernia, which have  made  their
appearance in this country, it is curious
to find,  both  in  his account  of the  in-
guinal and crural hernia, how strongly his
doctrines and observations tend  to con-
firm every thing  that  has  recently been
insisted upon  in modern works, respecting
the place where the bubonocele first pro-
trudes,  its  passing  through  a sort of
canal before it comes out ofthe abdominal
ring,  the advantage of cutting  in  the
crural hernia  the  internal and  inferior
angle of Poupart's ligament,  or, in other
terms,  that part of  the ligament, which
was first  particularly  pointed  out  by
Gimbernat, as causing the principal pan
of the strangulation, and about which so
much has  been said by Mr.  A. Cooper,
Mr. Hey, &c.                   •

          C0NHF.N1TAL REHNIA.

  Before the beginning   of  the  sixth
month  of the foetal state, the testicle  is
situated near the  kidney, where it re-
ceives a covering from the peritonaeum,
just like the  other abdominal  viscera.
Between  the beginning  of  the  sixth
month,  and end of the seventh, the  testi-
cle has  either descended  as  low as just
above the abdominal ring, or else  is pass-
ing through it, or just below it. ( Wrisberg.
Comm. Reg. Societ. Gotting. 1578.)
  When the  testicle passes through the
abdominal ring into the scrotum, it carries
before it a production of the peritonaeum,
which afterwards constitutes the tunica
vaginalis;  while  that  peritoneal invest-
ment, which  was given to the testicle  in
the loins, is closely adherent to this body,
and forms what  is* named  the tunica al-
buginea.
  After the  descent of the testicle into
the scrotum,  the communication between
the cavity of  the tunica vaginalis and that
of the  abdomen,  commonly becomes ob.
literated, which latter event is  usually
effected before  birth, sometimes  not till
afterwards, and in a  few subjects, even as
late as the  adult state.
   In the  pongenital  hernia,  the  pro-
trtaled viscera are situated in the tunica 
80  '
HGRN1.V.
 vaginalis, In contact with the testicle;
 having  descended into  this position  be-
 fore the closure of the communication
 with the abdomen.  Of course, the tunica
 vaginalis  itself is the hernial  sac.  The
 nature of this  case was not understood,
 before it was  elucidated  by  Haller in
 1755, and the two Hunters in 1762 and
 1764.  (See Hunter's  Med.  Comment. :
 Holler's Opuscula Patholog. and Opera Mi-
 nora,  Tom. 3.)  Before that period, sur-
 geons imputed the circumstance of the
 contents of the hernia and testicle being in
 contact, to the former parts having made
 their way, by laceration, through the tu-
 nica vaginalis,  from the ordinary hernial
 sac  of a bubonocele. The old surgeons,
 indeed, frequently cite this instance,  in
 proof of their doctrine, that some herniae
 were attended with  a laceration  of the
 peritonaeum.  (See Sharp's Enquiry.')
   From  the term  congenital,  we might
 suppose, that this hernia always existed
 at the time of birth. The protrusion, how-
 ever, seldom occurs till after this period,
 on  the operation  of the usual exciting
 causes  of herniae in general.   The con-
 genital hernia  does not usually happen
 till some  months after birth ; in some in-
 stances, not till a late period.  Mr. Hey
 relates a«case,  in which a  hernia conge-
 nita was first  formed in  a young  man,
 aged sixteen, whose right testis had, a
 little while before the attack of the dis-
 ease; descended  into the  scrotum.  It
 seems probable, that in the cases of lier-
 nia congenita, which actually take place
 when the testicle descends into the scro-
 tum  before birth,  the  event may com-
 monly be referred to the testicle having
 contracted an adhesion to  a piece of in-
 testine, or of the omentum, in its passage
 to the ring.   Wrisberg found one testicle,
 which had not passed the ring, adhering,
 by means of a  few slender  filaments,  to
 the omentum, just above this aperture,  in
 an infant,  that  died a few  hours after
 birth.
  Excepting the impossibility of feeling
 the testicle in  hernia congenita, as we
 can in most cases of bubonocele, (which
 criterion Mr. Pott should have mention-
 ed,) the  following accent  is very  excel-
 lent.  ** The appearance of a  hernia  in
 very  early infancy,  will always make  it
 probable "that it  is of this kind ;  but,  in
 an adult, there is no reason  for supposing
 his rupture  to be of this sort, but his
 having been afflicted with  it  from his
 infancy ; there  is no external  mark, or
 character, whereby it can be certainly dis-
tinguished from one contained in a com-
 mon hernial sac ; neither would it be of
 any material use in practice, if there was,
   " When  returnable, it ought,  like all
 other kinds of ruptures, to be reduced,
 and constantly kept up by a proper band-
 age ;  and  when  attended  with  symp-
 toms  of stricture, it  requires  the same
 chirurgie assistance as the common hernia
   " In very young  children,  there are
 some  circumstances, relative  to this  kind
 of rupture, which are very  well worth
 attending to, as they may prove  of  very
 material consequence to the patient.
   " A piece  of intestine,  or omentum,
 may get pretty low down in the sac, while
 the testicle is* still in the  groin, or even
 within the abdomen ; both which I have
 seen.  In this  case, the application  of a
 truss/ would be highly  improper ; for in
 the latter, it might prevent the descent
 ofthe testicle from the belly into the scro-
 tum ;  in the former,  it must necessarily
 bruise and injure it, give a great deal of
 unnecessary pain,  and  can prove of no
 real use.  Such bandage, therefore, ought
 never  to be applied  on a rupture in an
 infant, unless the  testicle  can be fairly
 felt in the  scrotum, after the gut or  caul
 is replaced ; and when it can  be so folt, a
 truss can never be put on too soon.
   " As this kind of rupture is subject to
 stricture, with  all  its consequences, as
 much  as that which is contained in * com-
 mon hernial sac, and therefore liable to
 stand in need of the chirurgie  operation;
 it may be very well worth  an operator's
 while to know, that an old rupture, which
 was originally  congenital,  is subject  to a
 stricture made  by the  sac itself, inde
 pendent of the abdominal tendon, as well
 as to that made by the said tendon.
   " Whether this be owing to the weight
 of the testicle  at  the bottom of the  sac,
 and the endeavours which  nature makes
 to close the upper part of the tunica vagi-
 nalis, or to what other  cause, I will not
 pretend to say, but the fact I have seve-
 ral times noticed, both in the dead and in
 the  living.   I have  seen such stricture
 made by the sac of one of these herniae,
 as produced all those bad symptoms which
 render the  operation necessary; and  I
 have  met with two  different  strictures,
 at near an inch distance from each other,
 in the body of a dead boy, about four-
teen, one of which begirt the intestine so
tight, that I could not disengage it with-
out dividing the sac.
  " In this  kind of hernia I  have also
more frequently found  connexions  and
adhesions of the.parts to each other, than
in the common one ; but there is one kind
of connexion sometimes met with in  the
congenital hernia,  which can never be
found in that which is  a  common hernial
sac, and which may  require all the dex- 
HERNIA.                                 81
 terity of an operator to set free,-  I mean
 that  of the  intestine with  the  testicle,
 from which 1 have more than once expe-
 rienced a good deal of trouble.
   " When a common hernial sac has been
 laid open, and the intestine and omentum
 have been  replaced, there can be nothing
 left in it which can require particular re-
 gard from  the surgeon;  but by the divi-
 sion of the sac of a congenital hernia, the
 testicle  is laid  bare, and after  the parts
 composing the hernia have been reduced,
 will require great regard and tenderness,
 in all the future dressings, as it is  a part
 very  irritable,  and  very susceptible of
 pain, inflammation, &c.
   " If a large quantity of fluid should be
 collected in the sac of a congenital heniia,
 and, by adhesions and connexions of the
 parts within, the entrance into it from the
 abdomen should be totally closed, (a case
 which I have twice seen) the tightness of
 the tumour, the difficulty of distinguishing
 the testicle, and the  fluctuation of the
 fluid, may  occasion it to be mistaken for
 a common hydrocele; and if without at-
 tending to other circumstances, but trust-
 ing merely to the feel and look of the scro-
 tum, a puncture be hastily made, it may
 create a great deal of trouble, and possi-
 bly do fatal mischief.
   "By what has fallen within my obser-
 vation, I am inclined  to believe  that the
 sac of a congenital hernia is  very seldom,
 if ever, distended to the degree which a
 common  hernial sac  often  is:  it also,
 from being less dilated,  and rather mos>
 confined by the upper part of the sperma-
 tic process, generally preserves a pyriform
 kind of figure, and, for the same reason,
 is also generally thinner, and will there-
 fore require more attention and dexterity
 in an operator when he is to open it.  To
 which I believe I may add, that common
 ruptures, or those in a common sac, are
generally gradually formed, that is, they
 are first inguinal, and by degrees become
 scrotal; but the congenital are seldom, if
 ever, remembered by the patient to have
 been in the grout only."   (Pott  on Rup-
 tures, Vol. 2.)
  The reader  must  not conclude, how-
ever, from the above  account, that every
rupture in  children is a congenital one.
Mr. Lawrence has related a case of stran-
gulated bubonocele,  which  took  place
in an infant only fourteen  months  old.
(P. 31.)
  The common inguinal hernia, which first
protrudes at the  inner opening of the in-
guinal canal, and which has the epigas-
tric artery on the inner  side  of its  neck,
has been  named  by Hessclbaeh external,
    Vol. II.
 while the less common instance, in  which
 the viscera  pierce  directly through the
 aponeuroses of the  transverse and inter-
 nal oblique muscles, and pass  directly
 out of the  abdominal  ring,  leaving the
 epigastric artery on  tiie outer side  of the
 neck of the  sac, is  distinguished by the
 epithet internal. (Anatomisch. Chirurg. Ab-
 handlung.  uber den Ursprung  der Leisten-
 bruch.)  " The inguinal congenital  hernia
 (says Scarpa) cannot be  divided  into ex-
 ternal and internal;  it is evident, that  it
 must always be external, since the neck
 of the tunica vaginalis  invariably  corre-
 sponds to  the point at which the  sperma-
 tic cord passes  under the margin of the
 transverse muscle.  As for other circum-
 stances, the tunica vaginalis  lies  in its
 whole course in the same manner as the
 sac  of a  common inguinal  hernia .- like
 this, it passes completely through the in-
 guinal canal from one end to the  other,
 resting upon the  anterior  suiface of the
 spermatic  cord.  Consequently, it passes
 between the separation  of  the  inferior
 fibres  of the obliquus internus,  and the
 principal Origin  of the cremaster muscle:
 (See Wrisberg. sylog. comment, anat. p. 23.)
 After coming out ofthe ring, being always
 united to the spermatic cord, it is enclos-
 ed in the muscular and aponeurotic sheath
 of the cremaster  muscle,  which accom-
 panies it to  the bottom  of the scrotum.
 Since  the  tunica vaginalis, including the
 displaced   viscera,  enters  the inguinal
 canal on the outside ofthe point, at which
 the  spermatic cord crosses tf^fepigastric
 artery, it  is manifest, that, s^nt follows
 exactly tlie direction of this cord, it must
 also cross  the artery, and remove  it  from
 the outer  to  the inner side of the  ring,
 according to  the mechanism already ex-
 plained in  speaking of the common in-
 guinal hernia.  Hence, the displacement
 of the epigastric artery  constantly hap-
 pens in the inguinal congenital, just  as it
 does in the  ordinary external inguinal
 hernia.
  " But, if these two species of inguinal
herniae have some analogy to  each other,
 in regard to  the parts which constitute
 them, yet,  they present some remarkable
differences.  1.  The common  inguinal
 liernia,  whether  internal,  or external,
 when it extends into the scrotum, cannot
 descend beyond the point at which flie
spermatic vessels enter the testicle. There
the cellular  substance of the spermatic
cord terminates.   There  the hernial sac
must  unavoidably terminate.  On  the
contrary, in  the congenital  hernia, the
viscera may descend lower, than the testi-
cle,  with  which they are in  immediate
  L 
82                                HERNIA.
contact; and, at length, they even occupy
the situation of this organ, which is then
pushed upward and backward.  2.  In
the case  of a congenital  hernia, the de-
scent of the viscera from the groin to the
scrotum commonly takes place  in a very
short time, and in  some  measure preci-
pitately :  it is  much  slower and  more
gradual in the ordinary  inguinal hernia.
The  reason  of this difference  is very
plain.  In the  first case, the descent of
the testicle, and the formation of the tu-
nica vaginalis, have opened and prepared
tlie route, which the viscera must follow
in forming  a protrusion; while, in the
second, the hernial  sac  cannot descend
into the scrotum, but by gradually elon-
gating the layers of the cellular substance,
which joins it to the surrounding parts.
This fact  is  so  generally  known, that
experienced  practitioners  consider  the
promptitude, with which the viscera have
descended from the groin to the bottom
of the scrotum, as a characteristic sign,
of a scrotal congenital hernia."   (Scarpa,
Traite des Hermes, p. 73,  &c.)
  If circumstances will admit of a truss
being applied and worn, in cases of con-
genital hernia,  in young subjects, there
will be a considerable chance of a radical
cure being effected, in consequence of the
natural propensity of the opening between
the abdomen  and tunica  vaginalis to be-
come closed.
  The only  material difference in the
operation, from that for a bubonocele, is,
that the sdfeon has to lay  open the tu-
nica vagimM^ instead of a common her-
nial sac.   The stricture is to be  divided
on the same principle as that  of an in-
guinal hernia,  and  much  in  the same
manner.   The parts having been reduced,
the edges of the wound are to  be imme-
diately brought together, and retained so
by  means of  one  or two  sutures, and
sticking plaster, which is  much preferable
to the plan of applying the dressing to
the testicle and inside of the tunica vagi-
nalis, so as to heal tlie part by the granu-
lating process.
   A new species of hernia congenita has
lately been described, in which a com-
mon peritoneal hernial. sac,  containing
the viscera, is included in the tunica va-
ginalis.  It arises  from  the parts being
proxruded, alter  the communication be-
tween the abdomen and  tunica vaginalis
is closed, so that the peritonaeum is car-
ried down along with the intestine, and
form* a hernial sac, within the tunica va-
ginalis.  It is evident also, that such a
hernia can only be produced,  while the
original tunica vaginalis  remains, in the
form of a bag, as high as the abdominal
ring.  Operators should be  aware_ of the
possibility of having a sac to divide,  a£
ter laying open the tunica vaginalis.  (See
the accounts of this hernia in Hey's Prac-
tical  Observations, p. 221,  (Jc. and  A.
Cooper's Work o?i Inguinal Hernia, p. 59.)

   UMBILICAL HERNIA, OR EXOMPHALOS.

   "The exomphalos,  or  umbilical rup-
ture, (says Pott) is so called from its situ-
ation, and has (like other herniae) for  its
general contents,  a  portion of intestine
or omentum, or both.  In old umbilical
ruptures,  the  quantity of  omentum is
sometimes very great.
   " Mr. Ranby says, that  he found two
ells and half of intestine in one of these,
with about a tlurd part of the  stomach,
all adhering together.
   " Mr. Gay and  Mr. Nourse found the
liver in the sac of an  umbilical hernia;
and Bohnius says  that he did also.
   " But whatever are the contents, they
are originally contained in the sac, formed
by the protrusion  ofthe peritoneum.
   " In  recent  and small  ruptures, this
sac is very  visible; but in old, and large
ones, it. is broken through at the knot of
the navel, by the pressure and weight of
the contents, and is not always to be dis-
tinguished; which is the reason why it
has by some been  doubted  whether this
kind of rupture has a hernial sac or not.
   " Infants are very  subject to this dis-
ease, in a small degree, from the separa-
tion ofthe funiculus; but in general they
tffther get rid of it as they gather strength,
or are  easily cured by wearing a proper
bandage.  It is of still more consequence
to get this disorder cured in females, even
than in males, that its return, when they
are become adult,  and pregnant, may  be
prevented as   much as possible;  for  at
this time it often  happens, from the  too
great distention of the belly, or from un-
guarded motion when the parts are upon
the stretch.  During gestation, it is often
very troublesome, but  after delivery, if
the contents have contracted no adhesion,
they will often return, and may be kept in
their place by a proper bandage.
'   " If such bandage was always put  on
m time, and worn constantly, the disease
might in general be kept within moderate
bounds, and some ofthe very terrible con-
sequences Which often attend it might be
prevented.   The   woman  who  lias  the
smallest degree of it, and  who from her
age and situation has" reason to expect
children after  its  appearance, should  be
particularly careful to keep it restrained.
   " In some the entrance of the sac is
large,  and  the parts easily reducible;  iu
others they  are difficult, and in some ab- 
HERNIA.
83
 Dolutely irreducible.  Of the last kind
 many have been suspended for years in a
 proper bag,  and have given  little or no
 trouble.  They who are  afflicted with
 this  disorder, who are  advanced in lite,
 and in  whom  it is large, are  generally
 subject to colics,  diarrhoeas, and, if the
 intestinal canal be  at all obstructed, to
 very  troublesome  vomitings.  (Hence,
 patients are often supposed to labour un-
 der a stricture, when they really do not.)
 It  therefore behoves such to take great
 care to keep that tube  as clean  and free
 as possible, and neither to eat, or drink
 any thing likely to  make any disturbance
 in that part "  (Pott on Ruptures, Vol 2.)
   Authors, who have published since the
 time of this.celebrated surgeon, have not
 added much to the stock of information,
 which he has left,  relative to the exora-
 phalos.  The writings of Mr. A. Cooper,
 Scarpa, (Traite des Hernies, p. 327.) and
 of all the most accurate moderns, confirm
 the fact, described by Pott, that, in the
 umbilical rupture, there is a hernial sac,
 just  as in other  instances  of herniae.
 Every - one,  acquainted with anatomy,
 knows,  that  behind the opening in  the
 luiea alba  at the  umbilicus, the perito-
 neum is complete, and consequently must
 be protruded before the viscera,  in cases
 of exomphalos. In the only two cases,
 which Mr.  A. Cooper has seen of a defi-
 ciency of the sac, the membrane had been
 partially absorbed,  or lacerated, so as ,to
 allow the protrusion of its contents, and
 threaten, from  this  cause, a double stric-
 ture. Similar  appearances less  closely
 inspected, probably gave rise to  the opi-
 nion so  firmly  maintained  by Dionis, De
 la Faye, Garengeot, and J.  L.  Petit, that
 in the umbilical hernia, the peritoneum
 was always lacerated, and there was no
 hernial  sac.  It is  observed  by  Bichat,
 that the umbilicus is a kind of cicatrix,
 formed,  in consequence of  the  separa-
 tion of the funis, by the contraction of the
 parts with which it  was  continuous ; and
 that it only gradually acquires the degree
 of firmness which it has in the adult sub-
ject.  As it is  for  a long while weaker
than the rest of the abdominal parietes,
it oidy makes an inferior degree of resist-
ance to  the viscera; but this resistance
increases with  age;  and,  as the  cicatrix
now becomes stronger than the surround-
ing parts, it forms  a more impenetrable
barrier against any escape of  the  bowels.*
From these anatomical facts, the follow-
ing pathological inferences, confirmed by
experience, are deducible :—1.  That in-
fancy is more subject, than any other age,
to the umbilical hernia, strictly so called,
in which the parts protrude through the
navel.   2 That other periods of life are*
 more  subject  than  infancy to false um*
 bilical herniae or to  those which  arise in
 the  vicinity  of the  umbilicus.  ((Euvres
 Chirurgicales de Desault, par Bichat, Tom.
 2, p. 315.)
   Besides a  true hernial sac, the exom-
 phalos is also covered with a more super-
 ficial expansion, consisting of condensed
 cellular  substance.  In   operating,  we
 should always  cut,  however,  with great
 caution,  for, often the integuments and
 hernial sac,  in  front of the tumour, are
 inseparably adherent;  and sometimes,  in
 consequence of the pressure ofthe viscera,
 in large cases,  having  caused an  absorp-
 tion of part of the sac, they are even found
 adherent to the integuments.
   Pregnant" women, and dropsical  and
 corpulent subjects, are peculiarly liable
 to the exomphalos.  In  adults, there  is
 almost always omentum in the  sac  when
 there is  intestine.  The transverse arch
 of the colon is observed to be particularly
 often  contained  in  umbilical  herniae,
 though the small intestines are not unfre-
 quently protruded.   (Lawi-ence, 265.)
  In the true umbilical hernia, the stric-
ture  is made by the tendinous opening in
the linea  alba.  We shall next consider
the umbilical hernia in  the three particu-
lar forms in which it has been noticed  by
the latest writers.
     CONGENITAL UMBILICAL HERNIA


   Dr.  Hamilton has met with about two
 cases of this kind annually, for the space
 of seventeen years; and they strictly de-
 serve  the epithet  congenital, as they ap-
 pear at birth.  The funis ends in a sort
 of bag, containing  some of the viscera,
 which pass out  of the abdomen through
 an aperture in the situation of the navel.
 The swelling is not covered with skin, so
 that the contents of the  hernia  can  be
 seen through the thin distended covering
 of the  cord.  The cLsease is owing to a
 preternatural deficiency in the abdominal
 muscles, and the hope of cure must be re-
 gulated by the size of the malformation,
 and quantity of viscera protruded.
   The plans of cure proposed,  consist of
 the  employment of a  ligature, or of  a
 bandage.   The  latter  seems  preferable,
 and  was practised by Mr. Hey, as fol-
lows :  having reduced  the intestine,  he
 desired an assistant to hold the funis com-
 pressed sufficiently near the abdomen,  to
 keep the bowel from returning into the
 hernial sac.
   "  I  procured (says  he) some plaster
 spread upon  leatlier,  cut into circular
 pieces, and laid  upon  one another in a
 conical form.   This compress  I  placed 
84
HERNIA.
upon the navel, after I had  brought the
skin on each side of the aperture inio
contact, and had laid one of the  lips a
little over the  other.  I then  put  round
the child's abdomen, a linen belt; and
placed upon tiie inn el, a thick, circular,
quilted part,  formed  about two inches
from one extremity of tiv belt.
  "This bandage  kept the  intestine  se-
curely within the abdomen,  and was  re-
newed occasionally.  The funis was  se-
parated about a week after birth; and at
the expiration  of a  fortnight from that
time, the aperture at the navel was  so  far
contracted, that the crying of the  child,
When  the bandage  was removed, did not
cause the least protrusion.   I  thought it
proper, however, to continue  the use of
tlie bandage a little while longer. A small
substance, like fungous  flesh, projected,
after the funis had dropped off, about half
an inch from the bottom  of that depres-
sion which the navel  forms.   A dossil of
lint spread  with cerat. e  lapide calami-
nari, and assisted by  the pressure of the
bandage, brought on a complete cicatriza-
tion."   (P. 227)
  This gentleman has related another ex-
ample, in which the intestines were quite
uncovered, and inflamed, the sac having
burst  in delivery.   The parts were reduc-
ed ; but tiie child died.


    UMBILICAL  HERNIA IN CHILDREN.


  The umbilical  hernia, which is  some-
times formed in the foetus,  from causes
difficult  of explanation,  takes place, in
other   instances, at the moment of de-
livery ; and then, as Sabatier remarks,
should it, by mistake, be tied with the
funis, death would be the consequence.
Most  frequently, however, it is not till
the second, third,  or fourth  month after
birth, that the disease occurs;  and the
numerous cases  collected  by Desault,
prove that, of ten infants  attacked with
this hernia, nine become  afflicted  at the
periods just mentioned.
  The umbilicus, still open, now begins
to contract, so  as to close  the cicatrix,
which, as has been already stated, forms,
in the adult state, an  obstacle  soon  capa-
blcof preventing a protrusion of the vis-
cera, when nothing resists  its  formation.
But,  the  repeated crying  of the child,
propelling  the  viscera outward, pushes
them  through  the opening.  Thus the
cicatrix is forced before them, and they
distend it so powerfully, foifWard, that its
closure is prevented.   Asiheir continued
action gradually dilates it more and more,
the intestines insinuate themselves through
it, increase its natural width, project  be-
yond it, and thus a tumour arises, which,
from being of trivial size at first, becomes
afterwards more considerable; at length,
attains the size of an eeg, or large walnut,
and presents itself with all  the character-
istic marks of a hernia.
  The presence of  a piece  of intestine
and omentum in the  tumour, keeps  the
umbilicus open, and opposes the continual
tendency  which it has to  close.  Such
tendency, however, being sometimes su-
perior to the resistance  of  the protruded
parts, forces them to return back into the
abdomen, obliterates the opening through
which they passed, and thus the sponta-
neous  cure of  the  umbilical  hernia in
children is accomplished.   Two cases il-
lustrative of this fact,  are related  in
(Euvres   Chirurgicales  de  Desault,  par
Bichat, Tom. 2, p. 318.
  Nature, however, does not effect  many
such cures, and when the case Is left to
her alone, she not only fails in bringing
about a radical cure, but gradually ren-
ders it impossible.  In short, the propen-
sity of the opening  to close diminishes,
and is lost, as the subject grows older.
In the adult, it is not the lodgment of the
intestines  in the opening, that prevents
its  obliteration;  it  is its having no
disposition to  undergo this  beneficial
change.
  Hence,  the umbilical hernia of children
seems to be essentially distinguished from
that  of adults, by  the tendency of the
aperture to contract.   Hence the ease of
effecting a radical cure in children,  and
the almost utter impossibility of doing* so
in adults.   In the former, it is enough to
keep the intestines from protruding into
the opening, and it becomes of itself obli-
terated ; in the latter, it always continues,
whether the bowels continue in it or not.
Hence,  the inaccuracy  of  the inferences
deduced by some writers, from the um-
bilical liernia of infants, as  being appli-
cable to that of  adults, and the necessity
of not delaying the assistance of art in the
former cases.
  The means of curing the umbilical her-
nia of children, are of three kinds: exter-
nal applications ;  compression; and tiie
ligature.  The  first  are totally useless;
and, as they occasion  a waste of time, are
improper.  Compression,  and  the  liga-
ture, are the  only rational  plans; and to
these we shall  limit our  observations.
The former is the most modern,  the lat-
ter the most ancient,  as it  was practised
by the Greeks, and then by Celsus.   De-
sault has drawn a most able parallel be-
tween the two modes; he tells us, that
the design both of the ligature  and  com-
nression is the same,  viz. to  prevent the
lodgment  of the protruded viscera in the 
HERNIA
85
opening of the umbilicus, and thus  faci-
litate the approximation of its sides.   To
accomplish this  end, the  ligature  re-
trendies the hernial sac, and skin pushed
before it;  and, by the union of the cut
parts occasions a cicatrix, which hinders
the  protrusion of the viscera.  At  the
same time, the sides ofthe opening, obey-
ing their natural tendency, and affected
by the irritation which they have sustain-
ed, contract, obliterate the opening, and
put the cicatrix in its proper place, though
now it is only  an  accessory means of hin-
dering a protrusion.  "Compression stops
up the aperture by something applied ex-
ternally ; thus, the deficiency, or opening,
in the parietes of the abdomen, hinders
the protrusion of the  bowels, and keep
these parts from resisting the contraction
ofthe sac.  Hence it is clear, that the two
methods are founded on a different basis.
Reason and experience also shew,  that
their results are equally different.
  Though compression occasions no pain,
it causes the child an  irksome inconveni-
ence, during the  great length of time its
employment is necessary.  The ligature
produces momentary  pain;  but there  is
nothing irksome attending its use,  and it
effects in a few days, what  compression,
when successful,  accomplishes in several
months.  In one  plan, continual  atten-
tions are  requisite : should its  employ-
ment be only for a short time neglected,
the previous effect becomes almost de-
stroyed.  The other method always ac-
complishes its  object with certainty, inde-
pendently ofthe crying of the child, and
the care of its attendants.   The first, by
continually compressing the sides  of the
opening, counteracts,  in  this  point  qf
view, its natural  disposition to contract.
The second, by artificially irritating  this
natural  process of the  umbilicus, accele-
rates its contraction.   When compression
is adopted, it is executed either by  means
of a flat compress applied to the opening,
and which  does not enter it, or else by
means of some round or oval body, such
as a ball of wax, a nutmeg,  &c. adapted
to the shape of the aperture, and, as Plat-
ner,  and Richter,  (in his Treatise on Her-
nia) advise, made continually to  enter the
opening.  But, in the  first  case,  if the
bandage be exactly applied,  the skin and
sac,  forming a fold in the aperture  ofthe
navel, will hinder its closure, and operate
in ti»e same manner,  from without, in-
ward,  as the  protruded  intestines  did
from within outward.  In the second case,
the  foreign body, being depressed into
and maintained in the opening, will occa-
sion, notwithstanding what Richter says,
the  same  inconveniences, and, in a more
striking  manner, similar' consequences.
  But, on the contrary, when the ligature
  is employed, tiie sac and skin of the
  tumour are removed, while the opening
  remains free, and nothing prevents  its
  obliteration.  In this method, the omen-
  tum can never protrude  outward; but,
  in the other, if the  compression should
  ever be inexact, the parts slip out again,
  above or below, and tiie disorder prevails
  on one  side  of  the  useless  application.
  Supposing compression successful, both
  plans effect a closure of  the  umbilicus;
  but, while compression only accomplishes
  the latter  object, tlie ligature  has the
  additional advantage of producing an ad-
  hesion ofthe sides of the opening, either
  to each other, or the adjacent parts. This
  adhesive process  arises from  the inflam-
  mation excited, and occasions a degree of
  firmness,  not producible   by any other
  mode of cure.
   To this  parallel, dictated  by reason,
  (continues Desault) let us add that, which
  is the  fruit of experience. On one side,
  we shall  discover,  that  the beneficial
  effects of compression are only reckoned
  in the midst of its want of success, and
  that the children,  on whom it is employ.
  ed, miserably endure for  years its  irk-
  someness and inconveniences.  If we look.
  the other way, we shall  find,  that the
  ligature, which is employed at the Hotel-
  Dieu,  presents an uninterrupted series
  of  well authenticated cures, which,  in
  Desault's practice, amounted to the num-
  ber of fifty.  In the latter years of his
  practice, you might  see  many persons
  bringing to his public consultations their
  cluldren, which were  immediately ope-
  rated on  without any preparation, car-
  ried  home immediately afterwards, and
  brought the next, and every following
  day, to  be dressed,  till  the cure was
 complete.
   To these considerations,  are to be added
 other  motives, which are, perhaps,  not
 immaterial. Tlie children ofthe poor may
  be cured in an hospital, by the ligature,
  in the  space of a  few days.  But, when
 compression is adopted, the parents are
 frequently put to  repeated expence,  as
 tlie bandage wears out; and to additional
 loss' from the time consumed in paying
 the necessary attentions.
   The ancients had different modes of ap-
 plying the ligature ;  but, what they have
  transmitted to us, may be referred to two
 different processes.  One consisted in re-
 ducing the parts, and afterwards tying the
 integuments and sac, without opening the
 latter at all.  In  tlie other,  an  incision
 was made: in the  sac, either before, or
 after tying it, for  the purpose of being
tsure, that no piece of intestine v/as, and
 could  become, strangulated in the liga- 
86
HERNIA.
ture. Celsus adopted the first plan.  Pau-
lus  JEgineta preferred the second, and
was imitated by all the Arabian physicians,
and their successors.  Avicenna, Albu-
casts, and Guy de Chauliac give us proofs
of this in their several works.
  Experience soon decides, which of these
modes of operating ought to be chosen,
One is less painful, and equally safe; for,
we soon become habituated to ascertain-
ing, whether there is still any intestine in
the sac,  by rubbing  the opposite sides of
this bag against each other.  The other,
which is unnecessarily  cruel,  increases
the pain, without  making the method at
all more certainly successful. The latter
has been usually adopted, and Pare, who
has described it, does  not even mention
the former.  Latterly, some variations in
the plan of operating were made.  Some
simply tied  the base  of  the  tumour ;
others passed through it  one,  or two
needles, armed with ligatures for the pur-
pose of fixing such  ligatures in a better
manner,  and even  making, for  this pur-
pose, a circular incision for the lodgment
of them.  It is chiefly'in  the  Arabian
practice,  that we  meet with thi9 cruel
proceeding, which was  also useless, as
the ligature was never known to fadl, when
properly applied.   Par6 also describes  it;
but, Saviard, tlie only modern, who has
practised the ligature,  rejected  it, and
followed the plan long  ago advised  by
Celsus.  Sabatier seems to recommend,
:n his work on the  operations, both plans
indifferently,  with  the exception of the
circular incision. Desault's method, which
much resembles that of Saviard, is simple,
and attended with little  pain : in short, it
is the following:
  The child, on whom the operation is to
be done,  must be placed on its back, with
its thighs a Utile  bent, and its head in-
clined  towards  the chest.  The surgeon
is to reduce tlie protruded parts, forming
the tumour, and to hold them so with his
finger, at the same, time, that  he raises
the hernial sac, and rubs its sides between
his fingers, so as to be sure, that there is
nothing  contained  in it.  Being certain,
that the  parts, which he lifts up, are only
the skin and sac, he  is to direct an assist-
ant to  surround their base several times
with a waxed ligature, of middling size,
each turn being tied with a double knot,
in such a manner as only to occasion little
pain.   The tumour,  thus tied,  is to  be
covered with lint, which is to be support-
ed with  one  or two compresses, and a
circular bandage, secured with a scapu-
lary.  A  slight swelling commonly takes
place in the constricted parts, by the fol-
   No pain accompanies this tumefaction,
which is itself often scarcely perceptible,
as may be seen by referring to the first
case of this operation related in the Pari-
sian Journal.   On  the  second, or third
day, tlie parts shrink, and then tlie liga-
ture becomes loose,  so that a fresh one
must now be applied in the same manner
as the first, taking care to draw it a little
more tightly.  The sensibility of the parts,
increased by the inflammation, which the
constriction of the  ligature has already
produced, usually renders this second h-
gature more painful.  After the operation,
the same dressings, as before,  are  to  be
applied.  The tumour soon becomes dis-
coloured, livid,  and smaller   A third
ligature, put  on in the same way as the
preceding ones, entirely obstructs the cir-
culation in it.  The  part turns  black and
flaccid,  and commonly falls off on the
eighth or tenth day.  A small ulcer is left,
which, being  properly dressed very soon
heals, and  leaves  a cicatrix sufficiently
strong to resist the impulse occasioned  by
coughing, or other efforts of the abdomi-
nal muscles.   For two, or three months,
however, after the operation,  the child
should wear a circular bandage, in order
to prevent, with still more certainty, the
viscera from being  propelled against the
cicatrix,  so as to interrupt the process  of
nature, which  is now producing a gradual
closure of the  umbilical opening.  Nume-
rous cases might  here be  adduced,   in
confirmation of the above practice; but,
several (nine) are already published  in
the Parisian Chirurgical Journal. The re-
lation of others here would only prolong
our observations in  a fruitless manner.
Suffice it to remark, that since those al-
luded to  were published,  Desault has
practised an infinite number of operations
of tins  sort with  equal  success;  that,
every week, many children were brought
by their mothers into the amphitheatre,
where he publicly delivered  his lectures;
that  here  the  ligature was applied in the
presence of all his pupils; and that chil-
dren, thus  operated upon, were carried
home, and  brought back  every day to be
dressed, till the cure was completed.
  But, one  may doubt,  (says  Sabatier)
quoting the article in the journal, where
Desault treats of  the  present disease,
whether the infants got rid of the hernia,
as it might have returned some time after-
wards. Numerous facts remove this dinibt;
for, several of the  subjects were brought
to Desault's public consultation, for their
diseases, a long while after they had been
operated upon, and the great number  of
students, who examined them, all acknow-
lowing day, just as a polypus swells, afterlTledged, that the ring was completely obU-
its base has been tied.                    terated, and there was no impulse of the 
HERNIA.
87
viscera in coughing, sneezing, &c.  Other
children, in the knowledge of the sur-
geons of the Hotel-Dieu, have remained
perfectly cured of their umbilical herniae,
by the operation,  which Desault has  re-
vived.  Bichat  is  acquainted with two
young subjects,  who were operated  on
four years ago,  and have  since had  no
relapse.
  The operation is almost  certainly suc-
cessful in young infants ; but, it becomes
less so,   in proportion as  their age  in-
creases.  Bichat relates three cases, which
tend  to  show,  that success may be com-
pletely obtained at the age  of a year and
a half; that the cure  is difficult, when
the child is four years old; and impossi-
ble, when it" is nine.   Several other ope-
rations,  done   too late, have had   the
same result.  (See QZuvres  Chirurgicales
ik  Desault, par Bichat, Tom. 2, p. 315,
&c.)
  Mr. Pott  notices the plan of curing  the
exomphalos  widi the  ligature,  and  ex-
presses himself strongly against the prac-
tice in general.  To adults* the plan is
 not applicable,  particularly,  when   the
 tumour  is large.  Mr.  Pott was  decid-
 edly  in  favour of compression, and he
 observes, that, in young  subjects,  and
 small hernix, a bandage, worn a proper
 time, generally proves a  perfect  cure,
 {Vol 2.)               '
   Anxious  that  this  work should  be
 strictly impartial, I next proceed to relate
 what has been  recently* urged against  tiie
 employment of tlie ligature for the cure
 of the  umbilical hernia in children,  and
 to  notice the   observations,  which have
 been adduced in favour of the treatment
 by compression.
   The incessant care that a bandage re-
 quires,  either  to keep it clean, or make  it
 always keep up the proper degree of pres-
 sure, renders its employment difficult in
 the children of the poorer  classes.  Scar-
 pa expresses his opinion, that " this  was
 what induced Desault to revive the opera-
 tion for the umbilical hernia by the liga-
 ture, nearly such as  is described  by Cel-
 sus,  an operation  (continues  Scarpa),
 which,  a long while since, and  for good
 reasons, was altogether abandoned.  Cel-
 sus has  sufficiently described the particu-
 lars  of it: (Lib  7,  Cap.  14.)  he  states,
 that the tumour is sometimes to  be sim-
 ply tied, and that, in other instances, its
 base is  to  have a needle and double liga-
 ture introduced through it, in order  that
 it  may  be  embraced almost in  the same
 way as a staphyloma is tied. But, amongst
 the  causes,  which  contra-indicate  this
 operation,  he  mentions so many circum-
 stances, in  relation  to age, constitution,
diseases of the skin, &c. that he seems to
consider the  cases, in which  it may be
practised with success, as very few.  The
same reflections have been made  by seve-
ral other ancient surgical writers, espe-
cially,  by  Fabricius  ab  Aquapendente.
Desault himself has put some restrictions
to the  employment of the ligature, since
he observes, with his usual candour, that
this method does not radically cure the
umbilical hernia of children,  arrived at
the  age of four years; that  it is indis-
pensable, as Celsus inculcates, to employ
a needle and  double  ligature, when the
base of the tumour is very large; and,
lastly, that, even in the youngest children,
a radical cure  cannot be effected  by the
ligature, unless a methodical compression
of the  navel,  by means of a bandage,  be
kept up immediately after the operation,
and for two or  three months. It is per-
haps to the omission  of this last  means,
that a relapse isvto be  ascribed in  several
of the children operated upon by Desault.
" Desault avoit remis en vigueur la ligature
tombee en desuetude.  II s'abusoit sur sa va-
leur,- et il n'est pas difficile (Fen connoitre la
 muse.  Tous les enfans qu'il operoit d I'Ho-
 tel-Dieu sortoient gueris et n'y revenoient
plus: on regardoit alors comme radicale une
guerison momentanee."  (Nosographie Chi-
rurgicale, Tom. 2, p. 453, par Richerand)
I have carefully watched  (says Scarpa)
 the immediate effects, and the more or
 less remote consequences of tying the um-
 bilical hernia,  either simply, or by means
 of a needle and double ligature; and, after
 a considerable number of such cases, I be-
 lieve I can assert, that tins operation, how-
 soever performed, is not always exempt from
grave  and sometimes dangerous accidents.
 I can also add, that it never procures a truly
 radical cure, unless the cicatrix, occasioned
 by it in the umbilical region, be submitted for
 some months to  a methodical and uninterrupt-
 ed compression.  It is  not so uncommon, as
 some surgeons pretend, to see arise after the
 application oftlu; ligature,  a fever attended
 with symptoms  of most violent irritation, and
 acute sufferings,  w/uch cause incessant cry-
 ing, and sometimes convulsions.   The ulcer,
 which is produced by the detachment of the
 swelling, is always very large and difficult to
 heal.   Every now and then it becomes pain-
ful, and emits fungous granulations, even
 though dressed with dry applications.
   " Latterly,  it has been explained by a
 celebrated surgeon, (Paletta Memor. delV
 Instituto, Tom. 2, Part 1.)  that the umbi-
 lical vein and the suspensory  ligament of
 the liver,  being included in the  ligature
 ofthe  umbilical hernia, the inflammation,
 which originates in these parts may, per-
Vhaps, in certain cases, be communicated 
88                                 HERNIA.
  to the liver, so as to put  the  child's life
  in great danger.  When,  in consequence
  of the ligature, symptoms of violent irri-
  tation come on, they are ordinarily attri-
  buted to certain individual circumstances,
  such as extreme sensibility, or a particu-
  lar disposition to spasm.   Hence,  it is
  believed, that they should be  considered
  as exceptions, which do not exclude the
  general  rule, and prove nothing  against
  the utility  of the operation.  But,  how
  (says Scarpa)  can the  surgeon ascertain
  the existence, or non-existence of these
  individual dispositions,  in  the children,
  upon which he is to operate ?   Assuredly,
  those subjects, in which I have had occa-
  sion to  notice the above accidents,   en-
  joyed, before the operation, perfect health
  in every respect.
    u,Whatever  process  be  adopted   for
  tyi^Sig  the umbilical hernia, it is evident,
  that the tumour can only be constricted
  as  far as a little way on this side of the
  aponeurotic ring ofthe umbilicus, whence,
  it follows, that the integuments must al-
  ways remain prominent  and relaxed for a
  certain extent, at the front and circum-
  ference of this opening. Also, after  the
 separation of the strangulated portion,
 there necessarily remains, under the cica-
 trix, a portion of the hernial sac,  and of
 the loose  integuments, which covered it;
 and as the cicatrix itself never acquires
 sufficient firmness to resist the impulse of
 the viscera, which tend to insinuate them-
 selves into the remains of the hernial sac,
 the hernia sooner or later reappears, i-.nd,
 in  a short time, becomes larger, than it
 was before .the operation. If the subject
 is a little girl, it may  be  apprehended,
 that the first pregnancy will cause  a  re-
 currence  of  the heniia;  for,  it  is known,
 that, during gestation, the external cica-
 trix of  the umbilicus, is  considerably dis-
 tended, and much disposed to give way."
   Pott  has seen terrible  accidents caused
 by the rupture of the cicatrix at the na-
 vel, during pregnancy.  (Chirurg. Works,
 Vol. 2, p. 169.)  It is true,  that accord-
 ing  to this writer, tliis  cicatrix was not
 the consequence of a hernia, but rather
 of an abscess  in  the  umbilical region,
 which abscess had formerly been opened
 with  a  bistoury;  yet, observes Scarpa,
 it would not be impossible to raise doubts
 upon this  conjecture.  Lastly,  after the
 separation of the tumour, there always
 remains, between the aponeurotic ring  of
 the navel,  and  the integuments, a  small
 cavity, formed by the neck of the hernial
 sac ; a cavity, into which the viscera be-
gin to insinuate themselves after  the ope-
ration, so as to hinder the complete  con-
traction of the umbdical ring.   The de-
monstration of what 1 have  advanced  is,
   in some measure  to be found, in the old
   method of operating for the inguinal her-
   nia,  not in a strangulated state,  by the
   ligature of the hernial sac and spermatic
  * cord.  It-is well known, that most of the
   hernis, operated upon  by this barbarous
   process, were subject to relapses, because,
   in all probability, the  cicatrix was not
   sufficiently firm to resist the impulse of
   the viscera, which entered the remains of
   the hernial sac.   In  the same manner,
   after the common operation for the stran-r
   gulated inguinal hernia, although the ci-
   catrix is formed very near the ring, there
   is no prudent surgeon,  who does not ad-
   vise the  patient to wear a  bandage the
   rest of his life,  observation having prov-
  ed that the hernia is still liable to recur.
     " An experience of several ages  (ob-
  serves Professor Scarpa) has put  out of
  all doubt,  that  compression  alone is an
  extremely efficacious method of radically
  curing the umbilical hernia of young sub-
  jects.  It is attended  with no risk, and,
  provided  it be executed with the  requi-
  site caution, it is hardly ever necessary
  to continue it longer, than two, or three
  months,  for the purpose of  obtaining a
  complete  cure.  On the  other side, if it
  be clearly proved, by all that I have been
  observing,  that the ligature never accom-
  plishes a  perfect cure without compres-
  sion, it  is manifest, that it cannot  be at
  all advantageous  for the children of the
  poor, since a bandage cannot be dispensed
  with.  It  may hi  said, that,  in  general,
  it  does  not shorten the treatment;  for,
  in  the most successful cases, the ulcer,
  caused by it, is not healed in less than a
  month, and, in order to make the cure
  certain, an exact compression must  after-
  wards be kept up, by means of a bandage,
  two months longer.  It has already been
  stated, that  three months are ordinarily
  sufficient for obtaining  a  radical cure by
  the  mere  employment  of a compressive
  bandage."  (Scarpa, Traite des Hernies, p.
  344—349.)                           r
   It appears from a note,  which M. Cayol
  has inserted  in the French translation of
  Scarpa's  work  on liernia, that M. Girard
  has published in the Journal General  de
  Medecine,  Tom. 41, Cahier  de  Juillet,
  1811, a memoir on  the umbilical hernia
  of children, which was read to the Medi-
 cal  Society of Lyons in May,  1811, and
 the object of which was to recommend
 compression as an effectual means of cure.
 The arguments used were very similar to
 those adduced by Scarpa.  In the course
 of the  discussion,  M.  Cartier  affirmed,
 that he had seen many children operated
 Jipon by Desault,  who were not cured of
Hbeir hernia.
   The  subject  was afterwards taken vf 
HERNIA.                                89
by tttc Medical Society of Paris, and the
result of the debate was, that the employ-
ment of the ligature ought to be rejected.
1. Because the  cure  of umbilical herniae
is very often accomplished by the power
of nature alone.  2. Because compression,
either alone, or aided by tonic  remedies,
always  succeeds.  3. Because the opera.
tion bf the ligature deserves the triple re-
proach of being painful, and not free from
danger, if unfortunately a piece of intes-
tine should chance to be  included in the
ligature;  of not  succeeding  in general,
unlesslwith the assistance of compression;
and of being  sometimes uselessly prac-
tised,  as Desault himself gives  us  in-
stances of.
  It is  farther stated by M. Cayol, that
the majority of judicious surgeons have
long since acknowledged the insufficiency
of the ligature for the radical cure of the
umbilical hernia; Sabatier, Lassus,  Ri-
cherand. &c.

  UMBILICAL HERNIA  IN ADULT SUBJECTS.

  This case is to be treated on the prin-
ciples common to all ruptures.  When
reducible, the  parts  should be kept up
with  a bandage,  or truss; which plan,
however, at this period of iife, affords no
hope  of a radical cure.  Mr.  Hey has
described one of the best trusses for  the
exomphalos, which  is applicable to chil-
dren, when compression is preferred, as
well as to adult subjects.  It was invented
by Mr. Marrison, an ingenious mechanic
at Leeds.
   " It consists of two pieces of thin elas-
tic steel, which surround the sides of the
abdomen, and  nearly meet behind.  At
their anterior  extremity they form con-
jointly  an oval ring,  to one side of which
is fastened a spring of  steel of the form
 represented.  At  the end of  this spring
 is placed the pad or bolster that presses
 upon the hernir..  By  the elasticity of
 this  spring the  hernia  is repressed  in
 every position ofthe body, and is thereby
 retained continually  within the abdomen.
 A piece of calico or jean is fastened to
 each  side of the oval ring,  having a con-
 tinued loop at its edge,  through which a
 piece of tape is put, that may be tied be-
 hind  the body.  This contrivance helps
 to preserve the  instrument steady in  its
 proper situation," (Practical Obs. in Sur-
gery, p. 231.)
   When the  exomphalos  is  irreducible,
 and large, the tumour must be supported
 with bandages.
   It  is observed by Professor. Scarpa,
 that  the umbilical  hernia, and those of
 the linea alba, are less subject to be stran-
 gulated, than the inguinal and  femoral
      Vol  11
hernia:; but that,  when they are unfortu-
nately affected  with strangulation, tiie
symptoms are more intense, and gangren«
comes on  more  rapidly, than in  every
other species of rupture.  If the opera-
tion be performed, the event is frequently
unfavourable, because it is generally done
too late.  This  practical fact is  proved
by tlie experience of the most celebrated
surgeons of every age.   " II est certain
(says Dionis) que de cette operation il en
perit plus qu'il n'en rechappe."   (Court
d'Operation,p.98, Edii.1777, aveclesnotes
de La Faye.)  He also adds, that they,
who have the misfortune to be afflicted
with an exomphalos, should rather dis-
pense  with their shirt, than  a bandage.
Heister says nearly the same thing.  (In-
stit. Chirurg. Tom. 2, Cap. 94.)
   It is further remarked by Scarpa, that
when the omentum alone is strangulated
in the exomphalos, or herniae of the linea
alba, observation proves, that the  symp-
toms are not less intense, than when the
intestine is  also  incarcerated. There is
this difference, however, that when  the
omentum alone is  strangulated, only nau-
sea occurs, and, if vomiting should like-
wise take place,  it is less frequent and
violent than when the bowel itself is stran-
gulated.  In the first case, the stools are
hardly ever entirely  suppressed.   The
proximity of the  stomach  is, no doubt,
the reason, why the strangulation of the
omentum, in the  umbilical hernia, occa-
sions far more  intense symptoms of sym-
pathetic  irritation,  than the  strangula-
tion ofthe same viscus in the inguinal, or
criual hernia.
   Here, says Scarpa, the operation is not
only always necessary, but urgently  re-
quired.   It is  not materially different
from  that, which is  practised  for  the
strangulated inguinal and crural herniae ;
but, in general, it demands  greater cir-
 cumspection, on account ofthe connexion,
 or intimate adhesions,  which  frequently
 exist, between the  integuments  and her-
 nial sac, and also the  adhesions,  which
 often prevail between the latter part and
 the omentum which it contains.  The si-
 tuation  of the intestine, which  is  fre-
 quently covered by, and enveloped in the
 omentum,  is another  circumstance de-
 serving earnest attention. (Scarpa, Traite
 des I ferries, p. 361, 36'2.)
   Mr. Pott is not such an advocate as
 Scarpa, for  the early performance of the
 operation  in  cases"  of exomphalos: —
 " The umbilical, like the inguinal  her-
 nia, becomes the subject of chirurgie ope-
 ration, when the parts  are  irreducible by
 the hand only) and are so bound as to
 Ereduce bad  symptoms.   But though I
   ave  in thje inguinal and  scrotal hernia
     M 
90                                HERNIA
 advised the early use of the  knife, I can-
 not press it so much in this :. the success
 of it  is very rare, and I should  make
 it  the last  remedy.  Indeed I  am much
 inclined to believe, that the bad symptoms
 which attend these cases are most  fre-
 quently owing to  disorders in  the intes-
 tinal canal, and not so often to  a stricture
 made on it at the navel, as  is supposed.
 I do not say that the latter does not some-
 times happen, it certainly does; but it is
 often  believed to be the case  when it is
 not.
   [On this opinion of  Mr. Pott's I take
 the liberty to remark, that no  surgeon
 ought to undertake an operation for tiie
 cure  of hernia, unless certain that  the
 hernia exists   If an umbilical hernia  be
 strangulated, it calls as loudly for  the
 operation as  any other, and  I see no rea-
 son why it should be longer delayed.]
   " When the operation becomes  neces-
 sary,  it consists in dividing the skin and
 hernial sac,  in such manner as shall set
 the intestine free from  stricture,  and en-
 able the surgeon to return it into the ab-
 domen."  (Pott on Ruptures.)
   The rest of the  conduct of the surgeon
 is to be regulated by the usual  principles.
   The division of the stricture is proper-
 ly recommended to be made directly up-
 ward, in the course of the linea alba.
   In eonsequence  of the great fatality of
 the usual operation for the exomphalos, I
 think  the plan suggested, and successfully
 practised by  Mr. A. Cooper in  two in-
 stances, should always be adopted, when-
 ever the tumour is at all large, and free
 from gangrene;  a plan, that has also re-
 ceived the high sanction of that distin-
 guished anatomist and surgeon. Professor
 Scarpa. (Traite des Hernies, p. 362.)   I
 might, perhaps,  safely add, that when the
 parts admit of being reduced, without lay-
 ing open the sac, this  method should al-
 ways  be preferred.  It consists in only
 making an incision sufficient to  divide the
 stricture, without opening the  sac at all,
 or, at  all events no more of it,  than is in-
 evitable.
   In umbilical hernia:, of not a large size,
 Mr. C. recommends the following plan of
 operating: " As the opening into the ab-
 domen is placed towards the upper part
 of the tumour, 1 began the incision a lit-
 tle below it, that is, at the middle ofthe
 swelling, and  extended  it to its  lowest
 part.  I then  made a  second incision at
 the upper part of the first, and at right
 angles with it, so that the double incision
 was  in the form of the letter T,  the top of
 which crossed the middle of the tumour.
 The integuments being thus divided, the
angles  of the  incision were turned down,
which  exposed a considerable portion of
 the hernial sac.  This  being then  care.
 fully opened, tiie finger was p.issed liclow
 the intestines  to  the orifice of the sac at
 the umbilicus, and the probe-pointed bis
 toury being introduced upon it, I directed
 it into the  opening at the navel,  and di-
 vided the  iine» alba downwards, to the
 requisite degree, instead of upwards,  as
 in the former operation.  When the omen-
 tum  and intestine arc returned,  the por-
 tion  of integument and sac, which is left,
 falls  over the opening  at  the  umbilicus,
 covers it, and unites to its edge, and thus
 lessens the risk of peritoneal inflamma-
 tion, by more readily closing the  wound."
 (On  Crural and Umbilical Ifcrtua.)
   [Mr.  Lawrence  remarks  that in old
 umbilical herniae there is generally found
 a considerable portion of omentum ad-
 hering to the sac.  About two years ago
 I operated on a case of umbilical hernia,
 in which the sac differed from any 1 have
 seen  described.   Upon cutting  into  it
 I found a portion  of  ilium,  ten inches  in
 length, strangulated in several places, by
 bands passing in all  directions from the
 sac to  the omentum,  forming a cavity
 much resembling  the  ventricles of the
 heart.  The omentum,  and the  sac  had
 been  blended together  in this way proba-
 bly for  years.  The intestine was net a
 part of the usual contents of the  sac, but
 had been forced into this singular cavity
 and  become strictored  in four  distinct
 places by these productions.  It was ne-
 cessary by  very careful  dissection to di-
 vide, these  bands and liberate the struc-
 tured intestine, which was accomplished,
 and the intestine evidently not being gan-
 grenous was returned into the abdomen.]

    LKSS FUEO.UENT KINDS OF HERNIA.

  The ventral hernia, described by Celsus,
 is not common ; it may appear  at almost
 any point of the anterior part ofthe belly,
 but, is most frequently found between the
 recti  muscles.  The portion  of intestine,
 &c. is always contained in a sac,  made by
 the protrusion of the peritonaeum.  Mr. A
 Cooper  imputes its causes to the dilata-
 tion ofthe natural foramina for the trans-
 mission of  vessels, to congenital deficien-
 cies,  lacerations,  and wounds, of the ab-
 dominal  muscles, or their tendons.  In
 small ventral herniae, a second  fascia  is
 found beneath the superficial one; but, in
 large  ones, the latter is the only one cov-
ering the sac.
  Herniae in the course of  the linea alba
sometimes  occur  so  near the umbilicus,
that  they  are liable to  be mistaken for
true umbilical ruptures.  They may take
place  either above, or below the navel.
TLe first case, however, is more fre:ju.-u^ 
HERNIA.
91
than the  second, and thp following is the
reason of this  circumstance according to
the opinion of Scarpa.   " l he upper half
of the linea aiba, that which extends from
the ensiform cartilage to the umbilicus, is
naturally broader and  weaker, than the
lower halt', the recti muscles becoming
nearei*»and nearer together, as they des-
cend from the navel to the pubes." (Scar-
pa, Traite des Hernies,  p. 333)
   The hernial sac of ruptures at the up-
per part of the linea alba  may contain a
noose of intestine,  and  a piece of the
omentum, though,  in most cases, a por-
tion of the latter membrane alone forms
the contents.  In some subjects, the linea
alba is so disposed to give way, that seve-
ral herniae are observed to be formed suc-
cessively  in the interspace between the
ensiform cartilage and the umbilicus.
   " With respect to the small hernia (says
Scarpa) which is considered as formed  by
the stomach, and concerning which Hoin
and  Garengeot have  written  so much
(without either of  them havmg related,
at least to my knowledge,  a single exam-
ple proved by dissection), it  is at least
unproved, that it was exclusively formed
 by this  viscus.  I  do not  see, why the
 other viscera, particularly the omentum
 and transverse colon, might not also con-
 tribute to it.   In my  judgment, it only
 differs  from  other herniae of  the linea
 alba, in being situated on the left  side of
 the ensiform  cartilage, a  situation, that
 must materially influence  the  symptoms
 of the case.  In fact, whatever may  be
 the viscera, which  form it,  a sympathetic
 irritation of the stomach is  occasioned,
 that is much more intense, than that which
 ordinarily accompanies umbilical herniae,
 those of the lower  part of the linea alba,
 or, in short,  all other herniae, which  are
 more remote from the  stomach."  (Op.
 cit. p. 334.)
   The following are said to  be the cir-
 cumstances, by  which the umbilical her-
 nia,  and that which occurs in  the linea
 alba near the navel, may be discriminated.
   The first, whether in the infant, ofthe
 adult, has a roundish neck, or pedicle, at
 the  circumference of which the aponeu-
 rotic edge of the  umbilical ring can  be
 felt.   Whatever may be its size, its body
 always retains nearly  a spherical s.hape.
  Neither at its apex, or its sides, is  any
 wrinkling of the skin, or any  thing  like
 the cicatrix of the navel,  distinguishable.
 In some points of the surface of the tu-
 mour, the skin is  merely somewhat paler
 and  thinner,  than  elsewhere.
    On the contrary, the hernia ofthe linea
 alba has a  neck,  or pedicle of an oval
 form, like the fissure, through which it
  is protruded.  The body of the tumour
is also constantly oval.  If the finger be
pressed deeply round it s neck, the edges
ofthe ope.iing in  the  tinea alba can be
felt;  and, if  the hernia be situated very
near  the  umbilical ring, the cicatrix of
the navel may be observed upon one  side
of it,  which cicatrix retains its  rugosity
and all  its natural appearance; a certain
indication, that  the viscera are not  pro-
truded through the umbilical ring.  (Scar-
pa,  Traite des Hernies, p. 336.)
  The distinction,  which Scarpa has es-
tablished between  the  umbilical hernia,
properly so called,  and those ofthe linea
alba,  is not useless in regard to practice.
Indeed, when the latter are left to them-
selves,  they make much  slower progress
than tlie former.  On account of their small-
ness, they frequently escape notice, parti-
cularly  in fat persons, and, when situated
at the  side  of the eiisiform  cartilage.
They occasion, however, complaints ofthe
stomach, habitual Colics, especially  after
meals;  and, unfortunately for the patient,
he may be tormented a very long time by
these indispositions, before the true cause
of them is discovered.
  The  umbilical hernia may be known,
from tlie earliest period of its  formation,
by the alteration which it produces in the
cicatrix of the navel, and the rapidity of
its increase.
   In other respects, these two kinds of
 herniae demand  the same means of cure ;
 but,  those of the linea alba,  cxteris pari-
 bus,  are more difficult to cure, than rup-
 tures at the  umbilicus.  This is probably
 owing to the natural tendency, which the
 umbilical ring has to close, when the her-
 nia  is kept well  reduced, whilst acciden-
 tal  openings in the linea  alba, have not
 the same advantage. (Scarpa, p. 340.)
   When a common ventral hernia  is re-
 duced,  it should be kept in its  place by
 means  of a bandage or truss. When stran-
 gulated, it admits, more frequently than
 most other cases, of being  relieved by
  medical treatment. If attended with stric-
  ture, which  cannot otherwise be relieved,
  that stricture must be carefully divided.
  Mr. A. Cooper recommends the valvular
  incision,  and the dilatation  to  be made,
  either upward,  or  downward,  according
  to the relative situation of the tumour and
  epigastric artery, which crosses tlie  lower
  part ofthe linea semilunaris.
    Pudendal  Hernia.— This is the  name
  assigned by Mr. A. Cooper, to that which
  descends between the vagina and ramus
  iscliii,  and  forms an oblong tumour  in
  the labium, traceable  within the pelvis,
  as far as the os uteri,  Mr. C. thinks this
  case has sometimes been mistaken for a
  hernia of the foramen ovale.  When redu-
  cible, a common female bandage,  or the 
92
HERNIA.
truss used for a prolapsus ani, should be
worn  A pessary, unless very large, could
not very well keep the parts from descend-
ing, as the protrusion happens so far f om
the  vagina.  Mr. C  is of opinion,  that,
when strangulated,  this hernia, in conse-
quence of the yielding nature of the parts,
may generally be reduced, by pressing
them with gentle and regular force, against
the inner side ofthe branch ofthe ischium.
If not,  the warm bath,  bleeding, and to-
bacco glysters, are advised. Were an ope-
ration indispunsable, the incjsion should
be made in the labium, the lower part of
the sac carefully opened, and, with a con-
cealed  bistoury, directed by the finger, in
the  vagina, the stricture should  be  cut
directly inward, towards the vagina. The
bladder should be emptied, both before
the  manual  attempts  at reduction,  and
the operation.  (On Crural Hernia,  &c.
p. 64.)
  Vaginal Hernia —A tumour occurs with-
in the os externum.  It is elastic, but not
painful  When compressed,  it readily re-
cedes,  but, is reproduced by  coughing, or
even without this when  the pressure is
removed.   The inconveniences produced
are an inability to undergo much exercise,
or exertion; for, every effort of this sort
brings  on a sense of  bearing down.  The
vaginal hernia protrudes in the space, left
between the uterus and rectum. This
space is bounded below by the peritonaeum,
which  membrane is forced downwards to-
wards  the perinacum ; but, being unable
to protrude further  in that  direction, is
pushed towards the back part of the va-
gina.  Mr. C. advised the use of a pessary
in one case; the plan, however, was neg-
lected.  These cases, probahly, are always
intestinal.
  Some herniae protrude at  the  anterior
part of the vagina. (See Mr  . 1. Cooper on
Crural Hernia, &c. p. 65,' 66.)
  Perineal Hernia.—In men, the parts pro-
trude between  the bladder and rectum ;
in women, between  the  rectum and va-
gina.  The hernia does not project, so as
to form an external tumour, and, in men,
its existence can only be distinguished by
examining in the rectum.  In  women, it
may be detected both from this part,  and
the vagina.
   In case  of strangulation, the hernia
might,  perhaps, be reduced by pressure
from within the rectum.   An interesting
case of jierineal hernia, which took place
from the peritonaeum being wounded with
the gorget in lithotomy is related by Mr.
Bromfield;  Chirurgical Observation,*, f>.
264.                                ^
  The  reducible perineal hernia in women
may be kept from descending, by using a
large pessary.  Both this kind of rupture
 and the vaginal may prove very dangermii
 in cases of pregnancy.  See Smellie's Mid-
 wifern,  Case, 5.
   Tlnjroideal Hernia, or Hernia Foramhiin
 Oralis.  In the  anterior and upper part
 of  the  obturator  ligament,  there  is an
 opening, through which the obturator ar-
 tery, vein, and nerve proceed, and t.^oiv^h
 which, occasionally, a piece of omentum,
 or intestine is  protruded, covered  with a
 part of the peritonaeum, which constitutes
 the hernial sac.
  In the Case, which Mr. A.  Cooper met
 with, the hernia descended above the ob-
 turatoies muscles.  The os pubis w.ts be-
 fore the neck of the sac: three-fourths of*
 it were surrounded by  the obturator liga-
 ment ; anil the fundus of the sac lay be-
 neath  the pectineus and adductor hrevis
 muscles.  The obturator nerve and artery
 were situated behind the neck of the sac,
 a little towards its inner side.  This spe-
 cies of hernia Can  only form an  outward-
 tumour,  when very large.   Garengeot,
 however, met with an  instance,  in which
 there was  not only a  swelling,  but, one
 attended with  symptoms of strangulation;
 he  reduced the hernia, which  went up
 with a guggling  noise;  the symptoms
 were stopped, and stools soon followed.
  The hernia of the foramen  ovale,  when
 reducible,  must be kept up With a suita-
 ble truss; and when strangulated, and not
 capable of reHef from the usual means, an
 operation would be requisite, though at-
 tended with difficulties.  The division of
 the obturator ligament and month ofthe
 sac should be made inwards,  to avoid the
 obturator artery.  This vessel,  however,
 would  even be exposed to  injury by fol-
 lowing this plan, if it should arise in com-
 mon with the  epig-istric artery.  (See a
paper by  Garengeot in  Mem.defAcud.de
 Chir. torn. 1; and A. Cooper on Crural Her-
 nia, &c. p. 70.)
  Cystocefe—As Mr. Pott observes,  "The
 urinary bladder is also liable to be thrust
 forth  from  its proper situation,  either
 through the opening in the oblique mus-
 cle, like the  inguinal hernia, or  under
 Poupart's ligament, in the same manner
 as the femoral.
  " This is not a very frequent species of
 hernia,  but does happen, and has as plain
 and determined a character as any other.
  " It h:..s been  mentioned by Bartholin,
 T. Dom. Sala,  Platerus, Bonetus, Ruysch,
 Petit, Mery, Yerd.cr, &c.  In one  of the
 histories given by the latter, the urachus,
 and impervious  umbilical  artery on  tl: .■
 left side, were drawn through the tei-d'.:i
 into the scrotum,  with the  bladder; in
 another he found four calculi.
  " Ruysch gives an account  of one com-
 plicated  with  a  ir-crt'l!'-.!.  1'".:;-"!'<.tj? 
HERNIA.
23
Mr. Petit says iie feit several calculi in
one>  which were afterwards discharged
through the urethra.
  " Bartholin speaks of T. Dom. Sala as
the first  discoverer of the  disease, and
quotes a case from him,  in which the pa-
tient had all the symptoms  of a stone in
his bladder; the stone could never lie felt
by the sound, but was found in the bladder
(which iiad passed into  the  groin)  after
death.
  " As tlie bladder is only covered in part
by the peritoneum, and must insinuate
itself between  that membrane  and the
oblique muscle, in order to pass the open-
ing in the tendon, it is plain  that the her-
nia cystica can  have no sac, and  that,
when complicated with a bubonocele, that
portion  of the bladder  which forms the
cystic hernia must lie between tjie intes-
tinal hernia and the  spermatic chord, that
is, the intestinal hernia  must be anterior
to the cystic.
  " A cystic hernia may indeed be the
cause of  an intestinal one;  for when so
much of  the bladder has passed the ring,
as to drag  in the upper and hinder part
of it, the peritoneum which covers that
part must  follow, and by that  means a
sac be formed for the reception of a por-
tion of gut or caul.   Hence  the  different
situation of the  two hernix  in the same
subject.
   " While recent* this  kind of hernia is
easily reducible,  and may, like the others,
be kept within by a proper bandage; but
when it is of any date, or has arrived to
any considerable size, the urine cannot be
discharged, without lifting up, and com-
pressing  tlie scrotum ; the outer surface
ofthe bl.idder is now become adherent to
:ne cellular membrane, and the patient
must be contented with a suspensory bag.
   " In case of complication  with a bubo-
nocele, it the  operation becomes neces-
sary, great care must be taken not to open
the bladder instead of the sac, to which
it will always  be found to  be posterior.
And it may also sometimes by  the inat-
tentive be mistaken for a hydrocele, and
by being treated as such, may be the oc-
casion of great  or  even  fatal  mischief."
(Vol 2.)
  The cystocele  is always  easily distin-
guishable by  tlie regular diminutien  of
the swelling, whenever the patient makes
water.
   Verdier  and Sharp have accurately de-
scribed the cystocele.   Pott has offered
two  cases, which fell under his observa-
tion;  Vnl.  3. Pipelet le Jeune mentions
a cystic  hernia  in  perinaeo, and several
crises of  its occurrence in the female;
. lead, de Chir. torn 4.  Pott cut into one
;;;,•».♦.>cHe,  by mistake.  Mention is made
(Edinb. Surg. Jourtt.  vol.  4. p. 512.)  of a
cystic  hernia, which  protruded between
the origins of the levator ani, and obtura-
tor internus muscles: the tumour made
its appearance in the pudendum of an old
woman.  Gunz and Hoin have also treat-
ed of the cystocele.
  Ischiatic Hernia.—The case is probably
very rare.  A case, however, which was
strangulated, and undiscovered till after
death, is related in  Mr. A. Cooper's  se-
cond  part of his  work  on hernia.  It is
communicated by Dr. Jones,  already cele-
brated for his book on hemorrhage.  The
disease happened in  a young man, aged
27.  On opening the abdomen,  the ilium
was found to h:tve descended  on the right
side of the rectum into the  pelvis, and a
fold of it was protruded into a small sac,
which passed out  of the pelvis at  tlie
ischiatic notch.  The intestine was adhe-
rent to the sac at two points: the stran-
gulated part, and about three inches on
each  side, were very black.  The intes-
tines towards the stomach were very much
distended with air, and, here and there,
had a livid spot on them.  A dark spot
was even found on  the stomach  itself just
above  the pylorus.  The  colon was ex-
ceedingly contracted,  as  far as its  sig-
moid flexure.  A small orifice was found
in the side of the pelvis, in front of, but a
little  above, the sciatic nerve, and on the
forepart of the pyriformis muscle.  The
sac lay under the glutaeus maximus mus-
cle, and its orifice was before the internal
iliac artery,  below the  obturator artery,
but above the vein.  Mr. A. Cooper re-
marks, that a reducible case might be kept
up with a spring truss, and, that if an
operation were requisite, tiie orifice of tiie
sac should be dilated directly forwards
(On Crural liernia, Hie.p. 73.)
   Phrenic Hernia. —The abdom inal viscera
are occasionally protruded  through the
diaphragm,  either through some of the
natural apertures in this muscle, or defi
ciencies, or wounds, and lacerations in it.
The second kind of case is the most fre-
quent : Morgagni furnishes an instance of
the first.  Two cases, related by Dr. Ma-
cauley in Med.  Obs.  and Inq. Vol. 1.  and
two others published  by Mr. A. Cooper,
are instances ofthe second sort: and an-
other case has been lately recorded by the
latter-gentleman, affording an example of
the third kind.  Hildanus,  Pare,  Petit,
Schenck, &c. also mentions cases of phre-
nic hernia.  The disease  is quite out of
the reach of art.
   Mesenteric Hernia.—-If one of the layers
of the mesentery be torn by a blow, while
the other remains  in its natural state, the
intestines may insinuate themselves  into
tlie aperture and  form a kind of hernia 
94                                HERNIA.
 The same consequences may result from a
 natural deficiency in one of these layers.
 Mr. A. Cooper records a case, in which
 all the small  intestines, except the duo-
 denum, were  thus  circumstanced. The
 symptoms during life were unknown. (On
' Crural Hernia, &c. p.  82.)
   Mesocolic Hernia.—So named by Mr. A.
 Cooper, when the  bowels glide between
 the  layers of the  mesocolon   There  is a
 specimen of this disease preserved at St.
 Thomas's hospital.
   Every  surgeon should be aware, that
the  intestines may be strangulated within
the abdomen  from the  following causes :
1. Apertures in the omentum, mesentery,
or mesocolon, throngh which  the intestine
protrudes.  2. Adhesions, leaving an aper-
ture, in which a  piece of intestine  be-
comes confined. 3. Membranous bands at
the mouths of hernial sacs, which becom-
ing  elongated, by the frequent protrusion
and  return of the viscera, surround  the
intestine, so as to strangulate them within
the abdomen, when returned from the sac
(See A. Cooper on Crural Hernia, &c. p. 85.)
   Pott remarks;  that " Ruysch  gives an
account of an* impregnated uterus being
found on the outside of  the abdominal
opening; and so  do Hildanus and Sen-
nertus.  Ruysch also gives an account of
an entire spleen having passed the  tendon
ofthe oblique muscle.  And 1 have myself
seen the ovaria removed by incision, after
they had been some months in the groin."
(Vol 2.)
   The best sources of information on her-
nia are the following : Franco, Traite des
Hernies, &c; Lynn,  1561; Bvo. Littre, Ob-
servation sur une .Vouvelle Espece deher-
nie;  Mem. de I'Acad, des Sciences ; 1700.
Mevy; same work; 1701.  Littre, sur une
Hemic Rare; same work;- 1714. Muuchart
de Hernia incarcerate ; Tubing. 1722. Hei-
ster, Instit. Chirurg. et De Hernia  Incar-
cerate! Suppurata nonsemper lethali.Vogel,
abhandlung aller urten der bruche;  Lips.
1738. Peyronie, Observations, &c. sur la
Cure des Hernies avec  Gangrene,  Mem.
de I'Acad, de Chir. torn. 1.  Gunzius, Ob-
servationum Anatomico-chirurgicarum de
Herniis UbeUus; Idps.  1744:   Arnaud on
Hernias, 1748 ,• also his Mem.  de Chir.
Haller de Herniis Congenitis,  1749-   Ga-
rengeot, surplusieursHernies  singulieres;
Mem de I'Acad, de Chir. torn  2.  Moreau
sur les suites d'une Hernie operie ;  .Mem.
de I'Acud. de Chir. torn. 3.  Benevoli, una
Ernia assai particolare;  Firenzo,  1750.
Haller Hemiarum adnotationes; extant.
in  opnscul. pathol. 17.55.  Blanc JVouvelle
Methode d'operer les  Hernies,-  avec  un
essai sur les Hernies, par .11.  Hoin ; Or.
feg.nx) 1767;  8vo.  Lov.h, Reflexions *;/>
 VOperation dela Hernie; Mem.  del'Acad.
 de Chir. torn. 4.   Hoin, Essai sur les Her-
 nies rares et peu  connues;  1767.  Medi-
 cal Observations and Enquiries.  Pott's
 Works, vols. 2. and 3.  Goursaud  sm-  la
 Difference des Causes de Vetranglement
 des Hernies;  Mem. de VAcad. de Chir.
 torn. 4.  Le  Dran, Traite des Operations
 de Chir. et Observations de Chir. obs. 57.
 F. Hildanus,  cent. 5. obs. 54.  J. I,. Petit,
 Traite de  Mai Chir. torn.  2.   Sharp on
 the Operations, and his Critical Enquiry.
 Hertrandi Traite des Operations, et Ex-
 emple d'une Hernie formee  du cute droit
 par Vintestin ileum settlement,  dont une
 portion s'etoit echappee par une des echan-
 crures ischiatiques,  en se glissant sur les
 ligaments sacro-sciatiques ; Mem. de Chir.
 torn. 2.  Saltzmann, Disp. de  Vesicx Vri-
 narix Hernia ; 1712.  Mery sur des Be-
 scentes de la Vessie,- Acad,  de Sciences,
 1713.  J. L. Petit sur les  Hernies de la
 Vessie; Acad, des Sciences,  1717.   Ver-
 dier, Recherches sur la Hernie de la Ves-
 sie ; Mem. de I'Acad,  de Chir. torn.  2.
 Divoux, Disp.de Hernia Vesicx Urinaria;
 Argent. 1732.  Levret-, Obs. s«r la Hernie
 de la  Vessie; Mem. de I'Acad, de  Chir.
 torn. 2.  P. Petit (le jeune) sur les Her-
 nies de la Vessie, et de PEstomac;  Acad.
 de Chir. torn. 4.   Vater de Lienis Prolap-
 sione,- 1746.  Peyronie sur un  etrangle-
 ment de l'intestin,cause interieurement par
 Vadherence de Vepiploon au-dessus ded'an.
 neau;  Mem.de I'Acad, de Chir. torn.  1.
 Tenon in Acad, des Sciences,- 1764.  Gun-
 zius,  Obs. de Entero-epiplocele.  Callisen,
 System Chirurg.  hodiernx, pars posterior.
 Richter Von den Briichen, in 2 vols. 1778,
 1779.- or the French transl. by Rougemont.
 Also  Richter's Bibliothek, and Anfang.
 der Wundarzn.   Wilmer's Pract. Obs. on
 Hemix.   Schmucker's  Chir.  Wahrneh-
 mungen.  Desault's CEuvres Chirurg. par
 Bichat. torn. 2.   Hey's Pract.  Observ. in
 Surgery. Sandifort's Anat. Pathol.   Cam-
per's Demonstrat. Anat.  Pathol 1760;
 and his Icones Herniarum, edit, d  Soem-
 mering.  1801.  Dr. Hunter's Med.  Com-
 ment. 1762,1764.  Monro in Edinb. Med.
 Essays ;  and the edition of his  works by
 his Son.   Gimbernat's Account of a New
 Method of operating for Femoral Hernia.
 . 1. Cooper on Inguinaland Congenital Hernia;
 and  on  Crural  and Umbilical Hernia.
 Monro on Crural Hernia, 1803.  Sabatier;,
 Medecine Operatoire, torn. 1. Chopart and
 Desault,  Traite des Mai.  Chir.  Desault,
Parisian Surgical Journal.  Wrisberg in
 Comment.  Reg.  Societ. Gotting.  1778.
 Schmucker's  Vermischte  Chir. Schriften.
Holler's  Opera Minora,-  and  Dispula*
Hones Chir.   SuWerrde Memorie anatarnt- 
HERNIA.                                95
ro*clarurgiche di Antonio Scarpa,  1809
and 1810 ,• or tlie French transl. by Cayol,
1812.  Hicherand's Nosographie Chirur-
gicale, Tom: 3. p. 354, &c. Edit. 2.  Las-
sus,  Pathologie  Chirurgicale, Tom.  1,
p. 1, &c, Edit. 1809. Pelletdn Clinique
Chirurgicale, Tom. 3.  Travers on  Inju-
ries of the Intestines, &c. 1812. Leveilie,
.Youvelle Doctrine Chirurgicale,  Tom.  3,
p. 170, &c.  1812.    But, above all, the
work, which I feel infinite pleasure in re-
commending, from a conviction of its su-
perior  merit, and practical  utility, is  a
Treatise on Hernia by W. Lawrence ; Svo.
the first edit, of which was published 1807,
the second in 1810, under the title of a
Treatise on Ruptures.
   HERNIA CEREBRI.  (Fungus Cerebri.
Encephalocele.)   This name is given to a
tumour which every now and then  rises
from  the brain,  through  an ulcerated
opening in the dura mater, and protrudes
through a perforation  in  the cranium,
made by  the previous application of the
trephine.  Mr.  Abernethy has made  some
observations on this disease, and related
some cases.   In one of these, the hernia
cerebri arose  on  the tenth  day  after
trephining, and was as large as a pigeon's
egg; the  pia mater, covering it, was  in-
flamed -h and a turbid serum was discharg-
ed at the sides of the swelling, from be-
neath the dura mater.  On the eleventh1
day, the tumour was as large as  a hen's
egg, smooth, and ready to burst.  The
man died the  next day.   On examina-
tion, the swelling was found larger, than
before,  and of a dark colour, with  an  ir-
regularly granulated surface.  This ap-
pearance was owing to coagulated blood,
which adhered to its surface,  as the part
had bled so much, that the  patient's cap
was rendered quite stiff with blood.  The
pia mater was in general much inflamed,
and, as well as the dura mater, was defi-
cient at the  place  of the tumour.  The
deeper part  of the swelling  seemed  to
consist  of fibrous coagulated  blood, and
it was found to originate' about an inch
below the surface of the brain.
   Mr. Abernethy explains the particular
appearance and progress of the disease,
as follows:  " In consequence  of the
brain being  injured  to some depth be-
neath the surface,  disease of the vessels,
^nd consequent effusion  of the blood,
had ensued ;  the effusion was, for a time,
restrained by the superincumbent  brain
and its membranes ;  but, these gradually
yielding to the expansive  force exerted
from within,  and at last giving way alto-
gether, the  fluid  blood oozed  out and
congealed upon the  surface  of the  tu-
mour"   An  organized  fungus  could
hardly be produced so rapidly as these
tumours  are.  (Essay on  injuries of the
Head, p.  37.)
  Mr.  C. Bell contends,  however, that
such swellings are vascular and organized.
(Operative Surgery, Vol. 1.)
  When the bad symptoms disappear,  on
th« tumour  being no longer confined  by
the dura mater, it  is best to i.iterfcre as
little as possible, as the hemorrhage will
probably  cease, and the tumour drop  oft'
in pieces   (See  Edinb. Med.  Comment.
Vol.  I.p. 98. Med. Museum, Vol. 4. p. 463.)
The mildest dressings alone  should  be
employed, and all pressure avoided.
  When  the tumour acquires a very great
size, it may be pared off* with a kniie, as
Mr. Hill did several  times, with success.
(Cases in Stergery.)
  Should the  swelling still increase, and
bad symptoms prevail,  in consequence of
the  irritation and pressure on tlie brain,
the opening- in the  bone ought to ha en-
larged.  Were the bleeding to continue
in a dangerous degree, Mr.  Abernethy
suggests removing the  coagulum, to try
whether  exposure of  the cavity  would
stop  the effusion? of  blood.   Quesnay
mentions an instance, in which a patient
tore off"  the coagulum himself, and the
cavity healed up; Mem. ded'Acad. de Chir.
torn. 1.  The danger of applying styptics,
and irritating applications  is shewn  by
Hildanus, Obs. 14, and Mr. Hill, p. 198.
(See Abernethy on Injuries of the Head.)
  One would suppose,  that cases of this
kind would generally require the employ-
ment of every thing at all likely to keep
off,  and  diminish,  inflammation  of the
brain.
  [The American Editor has recently wit-
nessed the recovery of a patient with her-
nia cerebri—he does not venture to call it
a cure.—During the existence  of the  tu-
mour  vomiting  took  place, which was
followed by  a copious discharge of blood,
and an amelioration of the  symptoms.—
The patient, aged about 12 years, is now
in good health]
  HERNIA HUMORALIS.   (Inflamma-
tio Testis. Swelled Testicle.)  A very com-
mon symptom, attending a gonorrhea, is
a swelling of the testicle, which is only
sympathetic, and  not  venereal, because
the same symptoms follow every kind of
irritation on the urethra, whether pro-
duced by strictures, injections, or bougies
Such symptoms  are not similar to the  ac
tions arising from the  application  of ve-
nereal matter, for  suppuration  seldom
occurs, and when it does, the matter is
not  venereal.   The swelling and inflam-
mation appear suddenly, and as suddenly
disappear, or go from one testicle to the
other. The epididymis remains swelled, 
«6                                 HERNIA.
however,  even  for a considerable  time
afterwards.   (/. Hunter.)
  The first appearance of swelling is ge-
nerally a soft pulpy fulness of the body of
the testicle, which is tender to the touch;
this increases to a hard swelling, accom-
panied with considerable pain.  The epi-
didymis, towards  the  lower end of the
testicle,  is  generally  the hardest  part.
The  hardness  and  swelling,  however,
often pervade the* whole of the epididy-
mis.  The spermatic chord, and especi-
ally, the vas deferens, are often thickened
and sore to the touch.  The spermatic
veins sometimes become varicose.  A pain
in the loins, and sense of weakness there,
and, in the pelvis, are other casual symp-
toms.  Cholicky pains; uneasiness in the
stomach and bowels ;   flatulence;  sick-
ness ;  and even vomiting; are not unfre-
quent.  The whole  testicle is  swelled,
and not  merely the epididymis, as has
been asserted.   (J. Hunter.)
  The inflammation of the part most pro-
bably arises from its sympathizing with the
urethra.   The  swelling of the  testicle
coming on, either  removes the pain in
making  water,  and suspends   the dis-
charge, which  do  not  return,  till  such
swelling begins to subside; or else the
irritation in the urethra, first ceasing, pro-
duces a swelling of the testicle,  which
continues till the pain and discharge  re-
turn ;  thus  rendering it doubtful, which
is the cause, and which the effect.  Occa-
sionally,  however, the  discharge has  be-
come  more violent, though the  testicle
has swelled; and such swelling has even
been known to occur after the discharge
has ceased;  yet, the latter  has returned
with  violence,  and  remained as long as
the hernia humoralis.  (/. Hunter.)
  Irritation at the mouth of the vasa de-
ferentia has been mentione d as  a cause ;
but,  were this true, both testicles would
usually be affected at the same time, and
the complaint would occur more frequent-
ly,  when  the irritation  of  the  urethra
extends  far towards the bladder, than
when it only reaches about an inch  and a
halt; or two inches, from the orifice ofthe
passage.   (/. Hunter.)
  Hernia humoralis, with  stoppage of
the discharge, is apt to be attended with
strangury.   A  very singular  thing is,
that  the  inflammation more  frequently
comes on when  the irritation in the ure-
thra  is going off,  than when it is at its
height. (J. Hunter.)
  The enlargements ofthe testicle, from
rancer and scrophula, are generally slow in
their progress -, that of a hernia humoralis
very quick. (J.  Hunter.')
  Rest is the best remedy, and  the hori-
zontal position ofthe body is easiest. \.t
all events, the testicle must be well su»«
pended;  to which expedient the  patient
will readily have  recourse as soon as he
knows the ease it affords.  The case  is
treated as inflammation in general, by
bleeding and purging, and applying fo-
mentations and poultices."  Leeches have
often proved  serviceable.  The swelling
not being venereal,  mercury is only  use-
ful in removing the induration,  continuing
after  the  inflammation  has  subsided.
Vomits have  been  recommended,  and
found  beneficial.  They  have  even been
known to cure the complaint in a siirpri-
singly sudden manner.  Opiates are use-
ful.  When  suppuration occurs, no mer-
cury  is requisite,  only  common  treat-
ment.
  As the hernia humoralis often appears
to depend on  the cessation of the  dis-
charge, some  (Bromfield) have  advised
irritating the urethra with  bougies to
bring on the gonorrhoea again;  but the
practice  is not followed by the expected
good.  The introduction of venereal mat-
ter into the urethra has also been most ab-
surdly suggested.
  A hernia humoralis is at first very quick
in subsiding; but, some of the swelling
remains a long while, and the hardness
and swelling of" the epididymis even con-
tinue for years, nay,  for life.  However,
no inconvenience attends the mere indu-
ration. In such instances, the vas deferens
may occasionally be rendered impervious,
though the  occurrence must  be  by no
means frequent. (J. Hunter.)
  Frictions with camphorated mercuri-
al ointment;  fumigations with aromatic
herbs ; and electricity ; arethe  best means
for promoting the absorption ofthe super-
fluous particles, causing the induration in
question.  (J. Hunter.)
  The signs, distinguishing a hernia hu-
moralis from a scrotal rupture, are ex-
plained in the article Hernia.
  John Hunter has  undoubtedly given
the best account of hernia humoralis.
  HERPES, (from i$na, to creep.)   Se-
veral cutaneous,  superficial kinds of ul-
cerations, having a  great propensity  to
creep, or spread over the skin,  are  so
named.  Cullen places this disease in the
class  locales, and order dyalyses ;  and de-
fines it, phlyctenae,  or a great number of
small ulcers, crowding together, creeping,
and difficult to heal.  For  an  account of
one disease, usually  considered as a spe-
cies of herpes, see Noli me tangere. Refer
also to Tinea  Capitis, which some have
classed with herpes.
   The tetter, ring-worm, serpigo, or darta,
consists of clusters  of sharp-pointed pus-
tules, of a yellowish white colour,  with
inflamed bases.  The di-ense  is atter^td 
                  II OR

Svith more or less smarting and itching,
is  sometimes difficult of cure, and apt to
recur.   When the disorder is connected
with constitutional causes,  small doses of*
mercury are useful.  One of the best local
applications, is a solution  of the hydrar-
gyrus muriatus in lime-water.
  Shingles, zona aurea, or herpes zoster, is
a disease, which appears in large clusters
on the neck, breast, loins, hips, or thighs,
and sometimes spreads all round the body,
or limbs.  The heads of the little pustules
have  at first a white watery appearance,
and then a small round scab, resembling
a  millet-seed.  .Hence the names  herpes
miliaris.  The complaint is often attended
with  febrile symptoms   The treatment
should  resemble that of erysipelas;  but,
bark and camphor are particularly recom-
mended as useful internal medicines.  The
lotion of lime-water,  and muriated mer-
cury is also said to be frequently an effica-
cious application. Old persons are subject
to a more inveterate, obstinate, and dan-
  fsrous species of shingles. All the other
  inds of herpes, enumerated by writers,
are medical cases, as, indeed, some may
consider the two latter affections: we shall
therefore, not  enlarge on the  subject in
this work.
   HORDEOLUM, (dim. of hordeum, bar-
ley.)  A  little  tumour on the eye-lid,
resembling  a barley-corn.  A  Stye.  As
Scarpa  remarks, the stye is strictly only a
little boil, which projects  from the edge
of the  eye-lids,  particularly  often  near
the great angle  of the eye.  This little
tumour, like the f'urunculus, is of  a dark
red colour,  much inflamed, and a great
deal more painful, than might be expect-
ed, considering its small size.  The latter
circumstance is partly owing to the vehe-
mence of the inflammation producing the
stye, and partly to the exquisite sensibi-
lity and tension of the skin, which covers
the edge of the eyelids.  On this account,
the  hordeolum very  often  excites fever
 and restlessness in delicate, irritable con-
 stitutions;  it suppurates slowly and im-
 perfectly ; and, when suppurated, has no
 tendency to burst.
   'I'iie  stye,  like other  fVrunculous in-
 flammations,  forms an exception  to the
 general rule, that the best mode, in which
 inflammatory swellings can end,  is reso-
 lution.   For,  whenever, a furunculous in-
 flammation extends  so deeply as  to de-
 stroy  any of"  the cellular substance, the
 little tumour  can never  be' resolved, or
 onh imperfectly so.  This event,  indeed,
 woiild  rather be  hurtful,  since there
 would  still remain behind a greater or
 smaller portion of dead cellular mem-
 hra.ie,  which, sooner or later, might bring
 on a renewal ofthe stve in the same place
     Vol. II.
                HOB               9P

as before, or else become inverted into a
hard indolent body, deforming the edge
ofthe eyelid.
  The resolution of the incipient  hor-
deolum may  be effected in that stage of
it, in which the inflammation only inte-
rests the  skin, and not the cellular sub-
stance underneath, as is the case  on the
first appearance of the disease.   Now
repellent, cold  applications  are  useful;
particularly  ice.  But when the  hordeo-
lum has affected, and destroyed,  any of
the cellular membrane underneath, every
topical repellent application is absolutely
useless, and even hurtful;  and the  pa-
tient  should have recourse to emollient
anodyne  remedies.  The hordeolum and
eyelids  should  be  covered  with a warm
soft bread and milk poultice, which ought
to be renewed very often. When a white
'point makes its appearance on  the apex of
the little tumour, Scarpa says, the sur-
geon should not be in a hurry to  let out
the  small quantity  of serous  matter,
which exists between the skin and dead
portion of cellular membrane.  It is bet-
ter, that  he  should wait till the skin,
within this white point,  has  become still
somewhat thinner, so as to burst of itself,
and give  a ready vent, not merely to the
little serous  matter, but, to all  the dead
cellular membrane, which constitutes the
chief part of the disease. When the con-
tents of  the little tumour  are slow in
making  their way outward, through the
opening,  the surgeon, gently compressing
the base of the stye,  ought to force them
out.  After this, all the symptoms of the
disease  will disappear, and  the  cavity,
left by the  dead  cellular membrane, in
tlie centre of the little tumour,  will be
found quite  filled up, and healed, in the
course of twenty-four huurs.
   Sometimes,  though seldom, this pro-
cess  of  nature, destined to  detach the
dead from the living cellular membrane,
 only  takes  place incompletely,  and  a
 small fragment of yellow dead cellular
 substance still  continues fixed in the ca-
 vity , and hinders the cure.   In  this  cir-
 cumstance,  the further employment of
 emollient poultices is of little or no ser-
 vice.  The surgeon should dip the point
 of a camel-hair pencil in sulphuric acid,
 and touch the inside of the stye with it,
 one or more times, until the sloughy cel-
 lular membrane comes away.  After this.
 the small cavity remaining will soon close.
 Should the  eyelid continue afterwards a
 little swollen and edematous, this affec-
 tion  may be  removed  by  applying the
 lotio aquae  litharg.  acet.,  containing a
 little spirit of wine.  Some  persons are
 very often  annoyed with  this   disease-
 Scarpa imputes this most frequently to a 
98           HYL)
II Y1)
disordered state of the primx vix, often
met with in persons who live  on acrid ir-
ritating food, and drink too much spirits.
(See Scarpa suite  Mnlattie degli Occhi,
cap. 2)
  HYDARTHRUS. (from vd»pt  water,
and «?^ov,  ajoint.) The white swelling.
(See Joint a.  )
 "HYDRARGYRIA.  A  peculiar erup-
tion  occasioned by the use of mercury.
(See Mercury.)
  HYDRARGYRUS. (from vbttp, water,
and «fyt>f«s, silver.)  Quicksilver;  mer-
cury.  (See Mercury.)
  HYDROCELE, (from vfrap, water, and
kjjAjj, a tumour.)  The term  hydrocele, if
used in a literal sense, means  an>  tumour
produced by water; but  surgeons  have
always confined it to those,  which pos-
sess either the membranes of the scrotum^
or the coats of the testicle and its  vessels.
The first of these, viz. that which has its
seat in the membranes ofthe scrotum,  is
common to the whole bag, and to all the
cellular substance, which loosely enve-
lopes both the testes. It is, strictly speak-
ing,  only a  symptom of a  disease,  in
which the wh61e habit is most frequently
more or less concerned, and very  seldom
affects this part  only.   The latter,  or
those which  occupy the coats  immedi-
ately investing the testicle and its vessels,
are absolutely  local, very seldom affect
the common  membrane of the scrotum,
generally attack one side only;  and are
frequently found in persons, who are per-
fectly free from all other complaints.
  Dr.  Monro,  the father, professor  of
anatomy  at Edinburgh, and  Mr.  Samuel
Sharpe, were almost the only writers,
before Mr. Pott, who sensibly awl ration-
ally  explained the true  nature of  these
diseases.

   AXASARCOUS TUMOUR OF THE SCROTUM.

  It is most frequently only  a symptom
of a  dropsical habit, and very often  ac-
companies both the general anasarca, and
the particular  collection  within  the  ab-
domen, called  the ascites.   This being
the case,  and the  true method  of cure
consisting in an internal medical process,
it has been improperly ranked among the
species of hydrocele, though  the nature
of the contents will certainly admit the
use ofthe word.
  " It is (says Pott) an  equal, soft  tu-
mour, possessing every part of the cellu-
lar membrane, in which both the testicles
are enveloped, and consequently is gene-
rally as large on one side as on the other;
it leaves  the skin  of its natural colour;
oi'j  to speak  more properly,  it does not
 redden or  inflame it;  if the  quantity of
 water be  not  large, nor the  detention
 gieat, the skin preserves some degree of
 rugosity :  the tumour has a doughy kind
 of  feel: easily receives, and for  a while
 retains, tiie  impression of the  fingers;
 tlie raphe, or  seam, of the  serotum di-
 vides  the swelling nearly equally; the
 spermatic  process is j>erfectly free, and of
 its natural size;  and the testicles seem to
' be in the middle of the loaded membrane.
 This  is the appearance, when the  dis-
 ease is in a moderate degree.   But if tlie
 quantity of extravasated serum be large,
 or the disease farther advanced, the skin,
 instead  of being  wrinkled,  is  smooth,
 tense, and plainly shews# the limped state
 of the fluid underneath :* it is cold to the
 touch, does not so long retain the impres-
 sion of the finger,  and  is always  accom-
 panied with a similar distention of the
 skin of the penis; the preputium of which
 is sometimes  so  enlarged, and so twist-
 ed, and distorted, as to  make a very
 disagreeable appearance.  These  are the
 local symptoms : to which it may be add-
 ed, that a yellow countenance, a loss of
 appetite, a deficiency  of urinary  secre-
 tion, swelled legs, a hard belly,  and mu-
 cous stools, are  its very frequent compa-
 nions.
   " The  cure of the  original   disease
 comes within the province  of the  physi-
 cian,  and  requires a  course of internal
 medicine : but sometimes.the loaded scro-
 tum and penis are so troublesome to the
 patient, and in such danger of mortifica-
 tion, that a  reduction of their  size be-
 comes absolutely necessary; and at other
 times a derivation, or  discharge,  of the
 redundant extravasated serum from  this
 part is ordered as an assistant to the in-
 ternal regimen.
    " The chirurgical means in use for this
 end is called  in general scarification; a
 term,  whose  precise  sense  has  by no
 means been settled ;  by which it has now
 and then  happened, that a general order
 being given,  and  che particular  method
 of executing it being left to the choice of
 those who have  not been  sufficiently ac-
 quainted  with  this  kind  of business,
 much hazard has been incurred,  and con-
 siderable mischief done, which might have
 been avoided.
    " The means of making this discharge
 are two,  viz. ptmctiire and  incision: the
 former is made with the point of a lancet;
 the latter with the same instrument, or
 with a knife.
    "The  generality  of writers   on  this
 subject have spoken on the two methods
 in  such  a manner,  that  a practitioner,
 who had  seen but little of either, woul«°.
 be inclined to  think,  that it was  a n»at'.i\ 
HYDROCELE.                               99
of great indifference, which we should
make use  of: and  that the safety  and
utility of each were equal: which is by no
means the case
  " The intention of the use of either is,
by a discharge of extravasated serum, to
alleviate the present  uneasiness; and, by
reducing the size ofthe scrotum, t<» render
it le^s  troublesome, and less  likely to
mortify.  In some few  instance,  it has
indeed  happened  that   this drain  has
provad a radical cure of the  original  dis-
ease ; but that has been  accidental,  and
is not in general  to  be expected.  The
intention is  generally palliative;  and, if
the patient lives, is most likely to require
repetition:   therefore,  if there be  any
difference between the two methods, with
regard either to ease or safety,  there can
be no doubt which ought to be preferred.
  " All wounds of membranous parts, in
anasarcous or dropsical habits, are neces-
sarily both  painful and  hazardous; they
are apt to  inflame,  are very difficultly
brought to suppuration, and will often
prove  gangrenous in spite of all endea-
vours to the contrary.   But the  larger
and  deeper tlie  wounds are, the more
probable are  these  bad consequences.
Simple  punctures, with the  point of a
lancet, are much less  liable to be attended
by them, than any other kind of wound ;
they generally leave  the skin easy, soft,
cool, uninflamed,  and in a state to admit
a repetition of  the same operation,  if
necessary.   Incisions create a • painful,
crude, hazardous sore, requiring constant
care  Punctures seldom produce any un-
easiness at all; and stand in  need of only
a superficial pledget, for dressing.
  " Now, although there is  so very ma-
terial a difference in  the symptoms  and
trouble attending the two methods, yet is
there none in their effect: the communi-
cation ofthe cells of the dartos  with each
other is so free, through every part of it,
that punctures made  with the fine point
of a bleeding-lancet,  into the  most  super-
ficial of them, will,  as  certainly  and as
freely,  drain oft'all the water, as a large
incision,  without any  of its inconveni-
ences or its hazard.   Neither the  one
nor the  other will cure  the  original  dis-
ease, unless by mere accident: they are
both made, with a design to cure only .the
focal one.   The same habit and constitu-
tion  remaining, the  same effect will in
general follow, and  the same  relief be
again necessary.   The ease,  the freedom
from bad symptoms,  or from danger,  and
the state  iu which  the parts are left,
render  one  method practicable   at  all
times,  and capable of being  repeated as
often as may be  thought necessary: the
fatigue, pain,  confinement and Hazard,
 which most frequently attend the other,
 make one experiment in general as much
 as most people choose  to submit to, or in-
 deed have an opportunity  of complying
 with."
   Mr.  Pott afterwards remarks;  " If we
 consider tlie preceding complaint as mere-
 ly symptomatic, and do not rank itfamong
 the different kinds of  hydrocele, there
 will then remain only three, viz.
   " 1.  That which consists of a  collec-
 tion of water in the cells  of the tunica
 communis, or cellular membrane, enve-
 loping  and connecting the spermatic ves-
 sels.
   " 2.  That which is  formed by  tlie ex-
 travasation of a fluid, in the same coat
 as the former, but which, instead of being
 diffused through   the  general  cellular
 structure of it, is confined to one cavity
 or cyst, in which all the water constitut-
 ing this species of disease  is contained ;
 the rest of the membrane being in its na-
 tural state.
   " 3.  That which is produced by the ac-
 cumulation of a quantity of water, in the
 cavity ofthe tunica vaginalis testis.
   "These three are distinct, local,  and
 truly within  the  province  Qf surgery.
 They may  accidentally be combined or
 connected with other  disorders, but not
 necessarily; and are frequently found in
 persons whose general habit is good, and
 who are perfectly free  from all other com-
^plaints."

 THE HTDUOCELE OF THE CEIXS OF THE TUNI-
              CA COMMUNIS.

   " The spermatic vessels from their ori-
 gin quite down to the insertion  into the
 testicle, are enveloped in, and connected
 together by, a membrane, called formerly
 tunica  vaginalis vasorum spermaticorum,
 but now (more properly) tunica commu-
 nis.  This membrane, so enveloping the
 spermatic vessels,  has no one particular
 cavity, (as its old  name  would seem to
 imply;) but is merely cellular, as either
 the Inflation of air or the  extravasation
 of a fluid, will always prove   While  it
 is within the cavity of the belly, its cells
 are lax and large;  and when  it has pass-
 ed out  from thence, and has formed a part
 of the  spermatic process, by enveloping
 its  vessels,  its cells are rather smaller,
 and  the  membrane  composing  them,
 firmer. It is included  within  that thin
 expansion of muscular fibres, called  the
 cremaster.   And a great number  of lym-
 phatics, passing from  the testicle to the
 receptaculum chyli,  are always  to be
 found in it.
   " An attentive consideration of these
 cireumstances in the structure of this part 
100                            HYDROCELE
will shew us, (continues Pott) why either
obstruction  or breach of the lymphatic
vessels, considerable pressure by  means
of diseased  indurations within the abdo-
men, or a morbid state ofthe parts which
should receive the lymph from the vessels
ofthe spermatic cord, may induce the dis-
ease in question; and also, when it  is
produced, that  its  appearance,  and the
nature of the  extravasation, must make
the term cellular a very proper one, as ex-
pressive of its true state.
  " When the disease is simple,  it is per-
fectly local; that is, it is confined entire-,
ly to the  membrane forming the  tunica
communis; and does not at all affect, either
the scrotum, the tunica vaginalis  testis, or
any other part."
  According to  Pott, it does not give a
great deal of trouble,  unless it arrives to
a considerable size;  and, being  by  no
means so frequent as either  of the other
two kinds  of hydrocele,   it is in ge-
ner..l  but little known or  attended  to.
With some, it passes  for a varix of the
spermatic cord; with others, for the de-
scent of a  portion  of omentum, which,
having contracted an adhesion, cannot be
returned.  Thus, its true nature not being
in general rightly'understood, and  it giv-
ing but little trouble or uneasiness while
it is within moderate bounds, and neither
hindering any necessary action or faculty,
they who have it are most frequently ad-
vised to be  contented with  a suspensory
bandage, and find very little inconvenience
from it.
  " Sometimes it arises to so large a size,
and gets into such a state,  as to become
an object of surgery,  and  to require our
very serious attention.
  " In general, (says Pott,) while it is of
moderate size,  the  state of it is as fol-
lows.   The  scrotal bag  is free  from  all
appearance of disease; except that when
J he skin is not corrugated, it seems rather
 iller,  and hangs rather  lower  on that
side than on the other, and if suspended
lightly on the  palm of the  hand,  feels
heavier:  the testicle, with its epididymis,
is to be felt  perfectly distinct below this
fulness, neither enlarged, nor in any man-
ner altered  from its  natural state: the
spermatic process is considerably  larger
than it ought to be, and feels like a varix,
or like an omental  hernia,  according to
the different size ofthe tumour;  it has a
pyramidal kind of form, broader at the
bottom than at the top: by gentle and
continued pressure it  seems gradually to
recede or go  up, but drops down again
immediately upon removing the pressure,
and that as  freely in  a supine,  as in an
erect, posture; it is attended with  a very '
gmall degree of pam or uneasiness ;  which
uneasiness  is not felt  in  the scrotum,
where the tumefaction is, but in the loins
  " If the  extravasation be confined  to
what is called the spermatic process, the
opening in the tendon of the abdominal
muscle is not at all dilated,  and the pro-
cess passing through it  may be very dis-
tinctly fell; but if the cellular membrane,
which invests  the speimatic vessels with-
in the abdomen, be affected,  the tendin-
ous aperture  is  enlarged;  and the in-
creased size of the distended membrane
passing through it, produces to the touch,
a sensation, not  very  unlike  that  of an
omental rupture.
  " While it is small, it is hardly an ob-
ject of surgery-; the  pain  or inconveni-
ence  which it produces being  so little,
that few people would chuse to submit to
an operation to get rid of it; and it  is
very  seldom   radically cured without
one:  but when  it is large  or  affects the
membrane within the  cavity, as well as
without, it becomes an apparent deformi-
ty, is very inconvenient both  from size
and weight,  and the only method of cure
which it admits is far from being void  of
hazard.  The plan  is to make a free in-
cision into the  swelling."   (See Pott on
Hydrocele.)

THE ENCYSTED  HYDROCELE OP  THE TUNICA
               COMMUNIS.

  "This species of hydrocele (Pott re-
marks) has its seat in the same part as the
preceding,  viz. the tunica communis^, or
cellular membrane, which  invests the
spermatic vessels; with this difference,
that, in the former, the water is diffused
in general through all  the cells  of the
membrane;  whereas,  in this, it is con-
tained in one cavity only.  If any  of the
three  kinds  of hydrocele  deserves the
name  of encysted, it is this.   The water,
which constitutes it, being all contained
in a bag,  formed in the same manner as
all the coats of all encysted tumours are,
viz. by  mere  pressure  and condensation
of the common membrane.
  " It is a complaint by no means infre-
quent, especially  in  children.   It was
very well known to many ofthe  ancients,
and has been very accurately described
by Albucasis,  Celsus,  Paulus, JEgineta,
&c.; but  later writers have often mista-
ken it for, and represented  it as, a species
of wind-rupture,  or  pneumatocele;   a
disease  existing in  their  imaginations
only.  It most  frequently  possesses the
middle part of the process,  between the
testicle and groin, and is generally of an
oblong figure; whence it has by  some
people been compared to an egg, by others
t'i a fi-h's  bladder.  Whether it be large 
HYDROCELE.                             101
or small, it is generally pretty tense,  and
consequently the fluctuation of the water
within  it,  not  always  immediately or
easily  perceptible; for  which  reason  it
has been supposed to  contain air only.
It gives  no  pain, nor (unless it  be very
Urge indeed) does it hinder any necessa-
ry action. It is perfectly circumscribed ;
and  has  no communication, either with
the cavity of the belly above, or that  of
tie vaginal coat of the testicle below it.
The testis and  its epididymis, avc  per-
fectly and distinctly to be felt  below the
tumour,  and are absolutely independent
of it.  The  upper part of the spermatic
process  in the groin  is  most frequently
very distinguishable.  The swelling does
not  retain the impression of the fin: ers;
and when lightly struck upon, sounds as
if it contained wind only.' It  undergoes
no. alteration from change of the patient's
posture ; nor is affected by his coughing,
sneezing, &c. and has  no  effect on  the
 discharge per anum.
   " These  marks (while the  disease is
 simple and  uncombined with  any other)
 are sufficient to distinguish it by, from all
 others which may affect the same part;
 but it sometimes happens, that  the pre-
 sent complaint is found connected either
 with a true hernia, or  with  a hydrocele
 of the  tunica vaginalis; by  which  the
 case is  rendered complex, and less easy
 to be understood.
   " In this, as in every other case where,
 from a complication of symptoms and ap-
 pearances,  a combination of diseases may
 be suspected, there is but one method of
 investigating the truth ; which is, to con-
 sider carefully  what disorders  the part
 aggrieved  is naturally liable  to;  what
«t,hc distinct symptoms and appearances of
 t ucli of those are ; and what are the effects
 of the  present  complaint.  The two dis-
 eases with which this kind of hydrocele
  is most likely to be combined are, an  hy-
 drocele of the tunica vaginalis testis, and,
 a true hernia; the parts within the groin,
  the spermatic process, and  the scrotum
  being the seat of all three.
   " One mark,  or characteristic  of an hy-
  drocele of the tunica vaginalis  testis is,
  that, it possesses and distends the inferior
  part of the scrotum ; and that the testicle
  being nearly (though not absolutely) sur-
  rounded by the water, it very seldom hap-
  pens, that the  former can be clearly and
  plainly  distinguished by the fingers of an
  examiner ;  whereas, in the encysted col-
  lection, in the membranes of the cord, the
  tumour is  always  above the  testicle,
  which is obvious and plain to be felt be-
  low it.
    " A nother circumstance worth attend-
 •ing to  is,  that although the fluid in a hy-
drocele ofthe vaginal coat does so nearly
surround the testis as to render it often
not very easy to be distinguished, yet the
different parts of the tumour have always
a very different  feel: for  instance, in all
those points  where the vaginal tunic  is
loose, and unconnected with the tunica
albuginea, the tumour is  soft and  com-
pressible, and  gives a clear idea of the
contained fluid; but when these two coats
are continuous, or make one and the same
membrane, and have  no cavity between
them (which is the case on the middle and
posterior part) there will always be found
a hardness and  firmness very unlike  to
what is to be found in  all those places,
where the distance between the two  tu-
nics  leaves room for the  collection of a
fluid .- now the hydrocele of the cord be-
ing formed in the mere cellular membrane
of it, is the  same to the  touch in all the
parts  of the tumour,  and feels like  a
distended bladder through  every  point
of it.
   " The free state of the upper  part of
the spermatic  process, while the tumour
is  forming below ; the gradual accumu-
lation of the fluid,  and consequently  the
gradual growth of the swelling; the in-
dolent  and  unaltering state of it;   its
being incapable of reduction, or  return
 into the  belly from the first; its  being
always unaffected by the  patients cough-
ing, or sneezing; and the uninterrupted
freedom of the fecal discharge per anum,
will always distinguish it  from an intes-
 tinal hernia; and he who mistakes it for
 an omental one, must be very ignorant, or
 very heedless.
   " Now, although there may not always
 be such external  marks as may, to  the
 eye, explain the combination of these dis-
 eases with each other;  yet the particular
 seat and  symptom of each being known,
 and the sensations which  they produce to
 the fingers  of an  intelligent examiner
 being well understood, when such mixed
 characteristics are found in the same sub-
 ject, we may reasonably conclude the case
 to be complex, and act accordingly.
    " I have indeed seen an encysted hy-
 drocele,situated so high toward the groin,
 as to render the perception of the sper-
 matic  vessels very obscure, or even  im-
 practicable ; but  then, the state and ap-
 pearance of the testicle,  and the absence
 of every symptom proceeding from con-
 finement of the 'intestinal canal, were suf-
 ficient marks of the true nature of  the
 complaint.
    " Infants are much more subject to this
  disease than adults; though it  often af-
  fects the latter.
    « In young children, it frequently dis--
  sipates in a short time,  especially if as 
102        "                   HYDROCELE
 sisted by warm fomentation, and an open
 belly.
   " If it does not disperse, that is, if it
 be not absorbed, the point of a lancet will
 give discharge to  the  water;  and,  in
 young children, will most frequently pro-
 duce a cure:  but in adults, the cyst form-
 ed by the pressure of the fluid does some-
 times become so thick, as to require divi-
 sion  through its  whole length; which
 operation may  in general be performed
 with great ease, and perfect safety."  Mr.
 Pott says,  in  general, because it is most
 frequently  so : though he has  seen  even
 this, slight as it may seem, prove trouble-
 some, hazardous, and fatal.  (See Pott on
 Hydrocele.)
   Sir James  Earle has proposed  curing
 this case, in  the same way as the hydro-
 cele of the tunica vaginalis, viz. by an in-
 jection  of red  wine and  water.  This
 gentleman has succeeded in this manner
 himself.  (See  Earle  on Hydrocele, p. 194,
 edit. 2.)

  HYDROCELE  OF  THE  TUNICA VAGINALIS
                TESTIS.

   " The third species of this disease, (as
 Pott describes)  is that which is confined
 to the vaginal coat, or bag, which loosely
 envelopes  the  testicle.    In  a natural,
 healthy state, its cavity always contains a
 small quantity  of a  fine fluid, exhaled
 from capillary  arteries, and  constantly
 absorbed by vessels appointed  for  that
 purpose.
   " This fluid, in the natural small quan-
 tity,  serves to keep  the  tunica albuginea
 moist, and to prevent a cohesion between
 it and  the  vaginalis;  a consequence,
 which almost necessarily follows any such
 diseased state of these parts, as prevents
 the due secretion of it.  On the contrary,
 if the quantity deposited be  too large, or
 if the regular absorption of it be by any
 means prevented, it will be gradually ac-
 cumulated, and, by  distending the  con-
 taining bag, will form the disease m ques-
 tion."
   It is a disease from which  no time of
 life is exempt; not only adults  are  sub-
ject to  it,  but young children are  fre-
 quently'afflicted with  it;  and infants
 sometimes born with it.  What is the im-
 mediately producing cause, Mr. Pott will
 not take upon  him to  affirm.   Ruysch
 is of opinion, that  it proceeds from a va-
 ricose state   of  the spermatic vessels.
 What real  foundation there may be for
 such  conjecture, Mr. Pott  cannot say;
 certain it is, that the spermatic vessels are
 very frequently  found varicose,  in  per.
 sons afflicted with this kind of hydrocele ;
 hut  whether such state of these parts
 ought to be regarded as a cause, or as an
 effect of  the  disease, is a matter  worth
 enquirirg into.
   " In Morgagni,  are  some observations
 on the state of the parts concerned, parti-
 cularly the inside of the tunica vaginalis,
 and outside of the albuginea; which, if
 repeated and confirmed, may possibly lead
 us on to farther information.
   " Whatever tends  to  increase the se-
 cretion of the fluid into the sacculus, be-
 yond the due and necessary quantity, or
 to prevent its being taken up, and carried
 oft,  by the proper absorbent vessels, must
 contribute to its production ;  which is *o
 slow, and gradual, and at the same time
 so  void  of pain,  that  the patient sel-
 dom attends to • it, until  it has arrived to
 some size.  Not but that it* sometimes is
 produced very suddenly; and in a very
 short space  of time attains considerable .
 magnitude.
   " The size  and figure of the tumour
 (continues Pott) are various in  different
 people, and under different circumstances.
 In general, at its first beginning,  it is ra-
 ther round;  but  as it  increases, it fie-
 quently assumes a pyriform  kind  of fi.
 gure, with its larger extremity downward:
 sometimes it is hard, and almost  incom-
 pressible ; so much so, that,  in some few
 instances, it has been mistaken for an in-
 duration of the  testicle: at other times,
 it is so soft and lax, that both the testicle,
 and the fluid surrounding it, are  easily
 discoverable.  It is perfectly  indolent, in
 itself; though its weight does sometimes
 produce some small degree of uneasiness
 in the back.  The transparency of  the
 tumour, the great characteristic  (as it is
 called) of this disease, and on which al-
 most all writers  have agreed to  lay  the-
 greatest stress, and to rest their proof of
 the nature of the disorder, is, according
 to Pott, the most fallible, and uncertain
 sign belonging it: it  is a circumstance
 whieh does not depend upon the quantity,
colour, or consistence of the  fluid consti-
 tuting the disease, so much as on the un-
certain thickness, or thinness of the con-
taining bag,  and of the  common  mem-
branes of the scrotum.
  " If (adds this celebrated writer) they
are thin,  the fluid limpid, and the accu-
mulation made so quick as not to give the
tunica vaginalis time  to thicken  much,
 the rays of light may sometimes be seen
 to pass through  the tumour: but this is
 accidental, and by no means to be depend-
ed upon.  Whoever would be acquainted
 with  this disorder, must learn to distin-
 guish it by other, and those more certain
 marks; or he will be apt to fall into very
 disgraceful, as well as pernicious  blun-
 ders. The colour of the fluid is very dif- 
HYDROCELE.                            103-
.fcrent and uncertain; sometimes it is of
 a pale yellow, or  straw-colour;  some-
 times it i-> inclined to a greenish cast; some-
 times it is dark, turbid; and bloody ;  and
 sometimes it is perfectly thin and limped-
   " In the  beginning of the disease,  if
.the water be accumulated slowly, and the
 tunica vaginalis thin and lax, the testicle
 may easily be perceived ;  but if the said
 tunic be firm,  or the water accumulated
 in  any considerable quantity, the  testis
 cannot be felt at all;  and  other  symp-
 toms, or marks must be attended to.  In
 most cases, the spermatic vessels may be
 distinctly felt  at their exit from the ab-
 dominal muscle, or in the groin ;  which
 will  always  distinguish  this  complaint
 from  an intestinal hernia,  the disease
 which it is most likely to be confounded
 with.  It does indeed now and then hap-
 pen, that the vaginal coat is distended so
 high, and is  so full, that it is  extremely
 difficult,  nay, almost impossible, to feel
 the spermatic process: and it also  some-
 times happens, that the same kind of" ob-
 scurity is occasioned by the addition of
 an encysted  collection of water  in the
 membrane of the cord; or by  the case
 being combined with a true enterocele.
 These circumstances are  not  very fre-
 quent, but yet do occur often enough to
 render it  well worth While to mention
 them; and to signify that, when they are
 met with,  recourse  must be had to other
 marks.
   " The two coats of the testicle, the tu-
 nica vaginalis  and tunica  albuginea, are
 so inseparably united at the   posterior
 and superior, or rather the posterior and
 middle part of the  tumour,  that no fluid
 can collect between them ; and, in  opera-
 ting, a puncture, or incision, made here,
 cannot only   do  no service, as it cannot
 reach the water, but must injure the tes-
 ticle, or epididymis, and do  great mis-
 chief.
   " This natural connexion,  between the
 two tunics, at the upper and hinder part,
 is the reason (says Pott) why, in a simple
 hydrocele, that part of the tumour feels
 so very unlike to every other.   In that,
 the tunica albuginea, and vaginalis,  being
 immediately  continuous, no water can get
 between them ; and therefore, the fingers
 of an intelligent examiner must immedi-
 ately discover the firmness and hardness
 arising from  the  union of these  parts:
 in all others,  the  two membranes  being
 unconnected, and affording  a void space
 for the collection  of water,  the fluctu-
 ation of it will always be distinguishable.
   " This must for ever discriminate the
 simple hydrocele of the tunica  vaginalis,
 from the amis^-cous swelling of the scro-
 ti'.!!);  from the encysted hydrocele  of the
 cord;  and from   the  intestinal hernia.
 The first is every where equal, tumid and
 soft; and every" where equally receives
 and retains the impression of the fingers :
 the second,  though circumscribed,  uot
 very compressible,  and affording the sen-
 sation of fluctuation, yet does not pit, and
 is alike to the touch in all parts of it: and
 in the third,  if the testicle be distinguish-
 able at all, it is found at the inferior part
 of the whole tumour.
   ." An  indurated  or  scirrhous testicle
 (continues this author) /has indeed, very
 frequently, a quantity of fluid lodged in
 its vaginal coat  (hydro-sarcocele;)  which
 is a  circumstance  (says  Pott) not to be
 wondered at; the  diseased state  of th«
 gland being sufficient to account for the
 non-execution of the  absorbent faculty,
 and consequently,  for  the collection of
 the water.  But although part of this
 mixed tumour is undoubtedly owing to a
 fluid, and such fluid as is lodged within
 the vaginal coat, yet it is a very different
 disease  from the. true simple hydrocele,
 and ought not  to be confounded with it;
 one of these marks of the latter being the
 natural, soft, healthy state of the testicle;
 and  the characteristic  of the  former,
 being its diseased and indurated enlarge«
 ment."
   Mr. Pott does not mean that, in a true
 simple hydrocele, the testicle is never al-
 tered from the natural state.  He knows
 the contrary, and that it is often enlarged
 in size, and relaxed in structure, and that
 the spermatic vessels are frequently vari-
 cose. But, the testicle is never indurated.
 These two diseases are extremely unlike
 each  other,  and require very different.
 treatment.   That  which  would cure a
 simple  hydrocele  would  dangerously ag.-
 gravate the hydro-sarcocele.
   Mr. Pott observes, that " it may, and
 does  sometimes become necessary  to  let
 out the  water from the vaginal coat of a
 testicle,  in some  degree diseased; hut
 this should always be  done with caution,
 and under a guarded prognostic; lest the
 patient  be not only disappointed,  by not
 having  that permanent  relief, which,  for
 want of better infoi niation, he may be in-
 duced to expect; but  be  also (possibly)
 subjected to other unexpected inconve-
 niences  from the attempt.
   " When the  disease  is a perfect, true,
 simple hydrocele, the testicle, though fre-
quently somewhat enlarged, and perhaps
 loosened in its vascular texture, is nevei-
 theless sound, healthy, and capable of exe-
 cuting  its proper  office; neither  is the
 spermatic cord, any way  altered from ■<■.
 natural state, except that its  vessels are
 generally somewhat dilated;  neither of
 which circumstances are objections either 
10*4
HYDROCELE.
to the palliative or radical cure of the
disease.  But  in those disorders, which
in some degree resemble this, the case is
different; either tlie testicle, or sperma-
tic cord,  or both, bearing evident marks
of a diseased state.

METHODS OF CURING THE HYDROCELE OF THE
            VAGINA! COAT.

  " The  methods of cure  (says  Pott)
though various, are reducible to  two,
(viz.) the palliative, or that which  pre-
tends only to relieve the disease in pre-
sent,  by  discharging the  fluid; and the
radical, or that  which aims at a perfect
cure, without leaving a  possibility of re-
lapse.  The end of the former is accom-
plished by merely  opening  the contain-
ing bag in such manner  as to let out the
water •• that of the latter cannot be ob-
tained, unless the cavity of that bag be
abolished, and no receptacle for a future
accumulation  left.  One  may be  prac-
tised at all times of the patient's life, and
in almost any state  of health and habit:
the other lies under some restraints and
prohibitions;  arising from  the circum-
stances of age, constitution,  state of the
parts, &c.
  " The  operation by which the fluid  is
let out, is  a very simple one.  The only
circumstances requiring our attention in
it,  are,  the  instrument  wherewith  we
would perform it; and the place  or part
of the tumour,  into which  such instru-
ment should he passed.
  " The two instruments in  use,  are the
common bleeding-lancet, and the trocar.
  " The former having  the finer point,
may possibly  pass  in rather the easier,
(though  tlie difference  is hardly percep-
tible)  but  is liable  to   inconveniences,
to which the latter  is not. The trocar, by
means of its cannuli, secures the exit of
the  whole fluid without a possibility  of
prevention ;   the  lancet cannot.   And
therefore it frequently happens when this
instrument is used, either, that some of the
water is  left behind; or that some degree
of handling and squeezing is required for
its expulsion; or,  that  the  introduction
of a probe, or a director, or some such in-
strument, becomes necessary for the same
purpose.   The  former  of these  may in
some habits be productive of inflamma-
tion :  the latter  prolongs  what  would
otherwise be a short operation, and mul-
tiplies the necessary instruments ;  which,
in every operation  in surgery, is wrong.
 To which  it may be added,  that if  any of
the  fluid be left in the vaginal  coat, or
 insinuates itself into the cells of tlie scro-
 tum, the patient will have reason to think
 the operation imperfect,  and to fear that
he shall not  reap even tlie temporary aft*
vantage which  he expected.' The place
where this puncture ought to be made,  h
a circumstance of much more real  const*
quence;  the success of the  attempt, the
ease, and even sometimes the safety of the
patient, depending upon  it.
  " All the anterior  and lateral parts  of
the vaginal  coat are  loose and detached
from the albuginea; in its posterior and
superior part, those two tunics make onei
consequently the testicle is, as  it were,
affixed to the posterior and superior  part
of the cavity of the sac of an hydrocele;
and consequently, the water or  fluid can
never get quite round it.   This being the
state of the  case, the operation ought al-
ways to be performed on that part of the
tumour, where the two coats are at the
greatest distance from  each other, and
where the fluid must therefore  be accu-
mulated in  the largest quantity;  anil
never on that  part of  it  where the fluid
cannot possibly be.   The consequence  of
acting otherwise, must not  only produce
a  disappointment, by not  reaching the
said fluid; but may prove, and has proved,
highly  and  even fatally mischievous  to
the patient.
  " After performing this operation,  pre-
sent practitioners content themselves with
a  bit of lint, and a  plaster; and  if the
scrotum has been considerably distended,
they suspend it in a bag truss; and give
the patient no farther trouble.
   " In most people,  (continues Pott) the
orifice  thus  made heals in a few hour",,
(like that made for blood-letting;)  but in
some  habits and  circumstances,  it in-
flames and  festers;  this festering is ge-
nerally superficial only, and is soon quiet-
ed by any simple  dressing; but it some-
times is so considerable, and extends so
deep, as to affect the vaginal coat, and by
accident produce a  radical cure.  Mr.
Pott  has also .seen  it  prove still more
troublesome,  and even  fatal:  but  then
the circumstances both ofthe patient, and
ofthe case, have been particular.
   " Wiseman and others have advised de-
ferring the  puncture, till a pint of  Huid
has collected.   When there is a sufficient
quantity, however,  to keep the testicle
 from the instrument, there  can be no rea-
 son for deferring the  discharge; and the
 single  point  on  which this  argument
 ought  to rest, is this:  Whether the ab-
 sorbent vessels, by which the extrava-
 sation  should  be  prevented,  are  more
 likely to reassume their office, while the
 vaginal coat  is thin, and has  suffered
 but little violence  from distention;  or
 after it has  been stretched  and distended
 to ten or perhaps twenty times its natu-
 ral  capacity;  and by such distention is- 
HYDROCELE.
105
(like all other membranes) become thick,
hard, and tough ?  Mr. Pott  thinks the
probability so much more on the side of
the former, that he should never hesitate
a moment about letting out the water, as
soon as he found,  that the puncture could
be  made securely.  And  from what has
happened within  the  small  circle of  his
own experience, he is inclined to believe,
that if it  was performed more early than
it generally is, it might sometimes prevent
the return of the disease."
  The palliative  cure shoidd in general
be performed at least once on those, who
determine to undergo a radical one, as it
gives an opportunity of  examining the
state ofthe testis, and also of permitting
the cavity to be filled again only to  such
a size, as may be thought to be best cal-
culated  to insure success in  any future
operation.  (~Sir James Earle on the Hydro-
cele, p. 13, edit. 2.J
  Upon the  subject of  performing the
operation  of tapping  hydroceles,  Pro-
fessor Scarpa gives us some usefid cau-
tions. The analogy, which exists between
large scrotal herniae and hydroceles of
considerable size, led this writer to sus-
pect, that, in the latter disease, the dis-
placement and  separation of the vessels
of the spermatic  cord from  each other
might  also  happen.  Careful  investiga-
tions, made upon  the dead subject, fully
justified the conjecture.   In  all consider-
able hydroceles, he found the spermatic
vessels so displaced and  separated, that
the artery and  vas deferens were ordina-
rily situated on  one side  of the tumour,
and the veins on  the other.   Sometimes
these vessels all extended over the lateral
parts of the tumour, as far as its anterior
surface, principally towards the bottom.
  It is well known, that, in many instances,
the operation of punctoring a  hydrocele
has, been followed by a large extravasa-
tion of blood within the tunica vaginalis ;
but, Scarpa informs us, that until lately,
he was unacquainted with any case of this
kind, which  was  well detailed  and au-
thentic enough, to be cited as an example
of injury of  the spermatic artery in the
puncture of a  hydrocele.  This learned
Professor, however, has had such a fact
recently communicated to him by liaspa-
rnli, a distinguished surgeon of Pallaiiza,
who, in  introducing the trocar into the
lower part of the swelling, had the mis-
fortune  to injure the  spermatic artery,
and the patient  was afterwards castrated.
The wound of this vessel was most clear-
ly proved by the  part iculars of the case,
as detailed in Scarpa's work,  to which  I
must refer the reader.
  " From the accurate knowledge,  (says
Scarpa) which  we now have  upon  this
     Vol. II.
pathological pohit,  such an accident may
be avoided, by observing the rules, which
are elsewhere given for opening the sac
of a  very  large scrotal hernia. In this
last  operation, as well  as that "of punc-
turing an old and voluminous hydrocele,
care must  be taken to  introduce the in-
strument at a considerable  distance from
the bottom of the tumour,  that is to say,
a little below its middle part, and on a
line, which would  divide the swelling
longitudinally into  two perfectly   tqual
parts.  Experience  proves, that,  for the
purpose of completely  emptying an hy-
drocele, it is  unnecessary to make the
puncture very near  the bottom of the tu-
mour. The corrugation of the scrotum,
and a slight pressure, made by the sur-
geon's hand, will suffice for discharging
all the fluid  contained  in  the tunica va-
ginalis, even when the puncture is  made
at the middle part of the swelling.  (Scar-
pa,  Traite des Hernies, p. 64—68.)

    RADICAL CURE Or THE HYDROCELE.

  Six  different  operations  have  beem
practised  for this purpose; viz. the in-
cision, the excision,  the application of
caustic, the introduction of a tent, the
employment  of  a  seton,  and injecting
some stimulating fluid into the cavity of
the tunica vaginalis.
  The principle,  on which the  success of
every plan of this  kind depends, is the
excitement of such a degree of inflamma-
tion in the tunica  vaginalis, and  tunica
albuginea,  forming  the cavity which con-
tains the water,  as shall end  in a mutual
and  general  concretion  of those  mem-
branes with each other, by which, it  is
evident, the  receptacle  for a  future ac-
cumulation of fluid is completely obli-
terated.
  All the above  plans are not equally eli-
gible  Some of them, indeed, are now
quite exploded: some, which are still
practised by a few,  are not more success-
ful, though certainly more severe, than
one, which will be presently recommend.
ed; others are  very  uncertain  in their
effect, as well as painful.

                Incision.

  Making an incision,  so as to lay open
the cavity containing the fluid, is the most
ancient method,  being described by Cel-
sus.  Paulus -Tigineta says, the incision
is to  commence at  the middle of the tu-
mour, and be carried to the upper part of
it, in a line parallel to the raphe.   This
incision is only to go through the integu-
ments , the bag, which contains the wa-
ter,  is then to be opened, and part of the
    O- 
106
HYDROCELE.
 sides of the sac taken away.  A  director
 is next to be introduced,  and a division
 of the tunica vaginalis made to  the bot-
 tom  of the swelling.  The cavity is after-
 wards to be dressed with lint, and healed
 by granulations.   Hildanus,  Dodonaeus,
 Wiseman, C'ucsclden, Ileister, and Sharp,
 all coincide in stating the dangerous and
 even fatal consequences sometimes  fol-
 lowing this mode.  Mr. B. Bell, who pre-
 ferred this operation to  every other one,
 acknowledges that he has seen it produce
 great pain and tension  ofthe abdomen,
 inflammation and  fever.   Pott observes,
 that  it can never be said to be totally void
 of danger, and  that it bears  the appear-
 ance of an  operation of some  severity.
 This eminent surgeon abandoned tlie me-
 thod, during the last twenty-six  years of
 his life.  Severe as it is, it has also been
 known to fail, as Sabatier and Earle have
 confirmed.

                Excision.

   Albucasis  gives the first clear  account
 of this operation, though Celsus  has cer-
 tainly mentioned removing some of the
 sac.  White  and Douglas used to  adopt
 this method.  The latter advises making
 two  incisions,  so as to  form  an oval,
 from the upper to the lower  part of" the
 tumour;  dissecting off'the oval  piece of
 the scrotum, and then making an opening
 into the sac,  and enlarging it with scis-
 sars.   The  tunica  vaginalis was  next  to
 be entirely cut away, close to where it is
 connected with  the spermatic  vessels.
 The  cavity  was afterwards  filled with
 lint.   Sir James  Earle justly  notices,
 that  this plan must  have  been  tedious,
 exquisitely painful in the  performance,
 and,  as subsequently treated, attended
 with  violent and dangerous symptoms.

                Caustic.

   Paulus ^Egineta advises destroying the
 skin with a cautery of a particular form,
 dissecting off the eschar, and then caute-
 rizing the exposed membrane.  Guido de
 Cauliaco  is,  perhaps, the  first who de-
 scribed the application of caustic for the
 cure  of the  hydrocele   Wiseman  .prac-
 tised  this  method.   Dionis  advises  it;
 but, De la Faye and Gareugeot make ob-
jections to it.  Mr. Else has left the best
 account of the manner of using  caustic.
 He recommends laying " a small caustic
 upon  the anterior and inferior part of the
 scrotum, which is intended to affect, and,
 if possible, penetrate through the tunica
 vaginalis."
  The objections to  the employment of
caustic  are, its  causing  an unnecessary
 destruction of parts, and producing a tedi-
 ous painful sore.   The action oicaustic
 can never be so regulated as to make an
 opening with certainty through the tunica
 vaginalis,  so that  either its application
 must sometimes be  repeated, or else a
 lancet, or trocar used  after all.  Its suc-
 cess is also less sure, than that of an  in-
 jection; but it is  preferable to  all the
 other  methods, except this latter, and,
 perhaps, the seton.

                 Tent.

   This is first  mentioned  by  Franco.
 The operation  consists  in  making  an
 opening into the  tunica vaginalis, and
 keeping the wound open with  a tent of
 lint, linen, or sponge,  so as  to make the
 cavity suppurate, in which the water was
 contained.  Pare,  Guillemau,  Covillard,
 Ruysch, Heister, and  Marini, have all de-
 scribed the  plan,  with some variations,
 one of which consisted in smearing the
 tents with irritating substances.   The fa-
 mous Monro devised the plan of keeping
 a cannula in the tunica vaginalis; so as
 to bring  on a cohesiou  of the parts,
 without suppuration.   Fabricius ab Aqua-
 pendente,  however, has made allusion to
 some surgeons before him, who used to
 keep the  wound open a few days with a
 cannula.   Mr. Pott tried the cannula, but
 found it very inconvenient, as its inflexi-
 bility hurt the testis whenever the patient
 moved with inattention, and, consequent-
 ly, he preferred a tent, or bougie, though
 he speaks of the plan as a very uncertain
 one.
   Of late, M. Larrey,  in consequence of
 having  seen  several  instances,  in which
 the symptoms,  follgwing the use of an in-
jection, were violent, and one  case,  in
 which  a  fatal  peritonitis was produced
 by this mode  of treatment, has  recom-
 mended, exciting the necessary degree of
 inflammation by keeping  a short piece of
 an elastic  gum catheter in the puncture,
 which instrument also  serves afterwards
 to let any  fluid escape from the tunica
 vaginalis.   (Mem. de Chirurgie Militaire,
 Tom. 3,p. 409, &c.) This author, of course,
 speaks of  the plan as having fully answer-
 ed his expectations; but, 1 much doubt,
 whether it has  any  particular superiority
over several of the former  methods  of
employing the tent; methods, which the
wisdom, arising  from  past  experience,
has long since rejected.

                 Seton

Is first mentioned by Cuido de Cauliaco,
1363, as a  means of curing the hydrocele.
In  modem times,  Pott preferred it to 
HYDROCELE.
107
 every other method, if we except injection,
 of which, according to Sir J. Earle, he
 expressed his  approbation before his de-
 cease.   Mr. Pott  found,  that the  best
 mode of making the seton was, as follows.
 He employed three instruments: the first
 was a trocar, the cannula of which was
 about one-fourth of an inch broad.   The
 second  was what  he called  the  seton-
 cannula, which was made of silver, was
 just  small  enough to  pass with easa
 through  the cannula of the trocar, and
 five inches  long.   The third instrument
 was, a probe 6 1-2 inches long, having at
 one end a fine  steel trocar point, and, at
 the other,  an  eye,  which  carried  the
 seton.  The seton  consisted of so  much
 white sewing-silk,   as  would  just pass
 easily through the cannula, and vet fill it.
 The  thickness  of  the  seton, "however,
 was not so great in the latter part of his
 practice.  Having  pierced  the  inferior
 and anterior part of the tumour with the
 trocar, withdrawn the perforator,  and dis-
 charged the water,  Mr Pott used to pass
 the seton-cannula  through' that  of  the
 trocar, to the upper part of the tunica
 vaginalis, so as to be  felt  there.   The
 probe, armed with  the seton, was  next
 conveyed through the latter cannula, and
 its point  pushed through the upper  part
 ofthe tunica vaginalis and scrotum.   The
 silk was then drawn through the  cannula
 until a sufficient quantity was brought out
 of the upper orifice.  The  two cannula
 being1 withdrawn,  the  operation   was
 finished.

                Injection.

   Dr.  Monro attributes the  first use of
 injections for the radical cure of hydro-
 celes to an army-surgeon of his own name,
 who first used spirits of wine.  This pro-
 duced a cure, but,  the inflammation was
 so  violent, that he afterwards  tried a
 milder injection, which consisted of wine.
 However, M. Lambert, above a century
 ago, in his GSuvres Chirurgicales, publish-
 ed at Marseilles, advised injecting a solu-
 tion of sublimate and lime-water, and he
 has related cases of success.   Mr. Sharp
 also made trial of spirit of  wine, which
 cured the hydrocele, but, not without caus-
 ing dangerous symptoms, and two subse-
 quent abscesses in the scrotum. ( Opera-
 tions of  Surgery.J   Douglas, Le  Dran,
 and Pott,  all disapprove of injections, in
 their  works; though Sir James Earle in-
 forms us, that the latter lived to alter his
opinion on the subject
  The violenee of the inflammatory symp-
toms, consequent to the first employment
of injections for the radical cure  of hy-
droceles, arose from the fluids used being
  too irritating.  Sir James Earle, at last,
  preferred wine for several reasons.   He
  found, that it had been used with suc-
  cess in France;  its strength is never so
  great as  to render it unsafe: and it may
  be readily  weakened.  This injection, in
  short, produces  less pain, than any other
  mode  of  eure, does nothing more  than
  is intended, and  is as  certain  as  any
  plan.
   " I have  commonly used  (says Sir
  James Earle) about two-thirds of wine to
  one-third of water; if the parts appeared
  insensible,  and no pain  at all was pro-
  duced by  the first quantity  thrown in, I
  have withdrawn  the syringe, and added
  to the proportion  of wine,- on the  con-
  trary,  if the complaint was  recent, and
  the parts irritable, I have increased the
  proportion  of  water, so that I have hi-
  therto been principally  guided by the de-
  gree of sensation,  which the patient has
  expressed.   I have lately used pure water
  mixed with wine, and found it answer as
 well  as when astringents were added."
 (P. 103. Treatise on the Hydrocele, Edit. 2 J
 In the preface, the author says, that he
 has long disused the pipe with  a stop-
 cock,  which he  once  employed, on  ac-
 count of  not being well able to  spare a
 hand,  during the  operation, to turn  it,
 and its consequently  being  found awk-
 ward.   A pipe, one end of which is made
 to fit into the cannula of a trocar, the
 other  adapted  to receive the neck of an
 elastic bottle,  with • a  valve, or ball,  in
 the centre of the pipe  to permit the en-
 trance, and prevent the exit, of the  in-
 jection, will be  found infinitely more
 convenient and useful,   f Earle. J   When
 the hydrocele is very large, Sir James re-
 commends simply- letting out the fluid, and
 waiting, till the tumour acquires a more
 moderate  size,  before attempting the rar
 dieal cure by injection.
   It appears  from  Sir James  Earle's in-
 teresting cases, that a cure may be accom-
 plished in this manner, even  when  the
 tunica  vaginalis  is considerably thick-
 ened.   The  following  is  the common
 mode  of operating: the hydrocele is to
 be tapped  with a  trocar at its anterior
 and inferior part, and, when the whole of
 the fluid is evacuated, the cavity  of the
 tunica  vaginalis is to be distended to its
former dimensions  with  the above  injec-
tion.   This is to be allowed to remain in
the part about five minutes,  upon  the
average, after which it is to be discharged
through the cannula.  The patient  usu-
ally feels  some pain  in the  groin, and
about the kidneys, on the injection being
introduced; which  symptoms  are rather
desirable,  as they evince, that the  sti-
 mulus  of the fluid is likely to have the 
108
HID
HYD
      wished for effect of exciting the necessary
      degree of inflammation.  This plan, now
      brought to so high a pitch of perfection
      by Sir James Earle, may be deemed al-
      most  an  infallible means of obtaining a
      permanent cure; and being the  mildest
      method,  also, is, of course, universally
      preferred.
        The treatment after the operation  is
      exactly like that of the common  swelled
      testicle (see Hernia Humoralis J, consisting
      ofthe use of fomentations, poultices, saline
      purges,  and,  above all,  of a bag truss for
      keeping up the scrotum.
        There  is a particular case,  that has
      been  called the congenital hydrocele, by
      which is implied a collection of water in
      the tunica vaginalis, in consequence  of
      there being a preternatural communica-
      tion  between  it and the cavity  of the
      peritonaeum.  Desault used to  cure this
      disease by a  red-wine  injection.    Any
      protruded viscera being returned into the
      belly, and the opening between that and
      the inside of the tunica vaginalis being
      carefully compressed and closed  by  a
      trusty assistant, this celebrated surgeon,
      after letting out the water in tlie common
      way, used to  throw in the injection.  The
      method is said to succeed,  without caus-
      ing a perilous  circumstance, one might
      d priori expect, viz. inflammation of tlie
      peritonaeiun. (See Desault par Bichat. J
        This kind of by drocele,  has  not been
      described by most writers.  The  case  is
      easy of discrimination from the fluid be-
      ing capable  of being pushed  into the
      belly.  The French state,  that this  dis-
      ease admits of a cure by injections,  first
      taking care to press the upper part of the
      cord,  so  as  to keep the  injection from
      coming into contact into the peritunxum.
      A successful  instance of this practice is
      related,  by which a  boy was cured both
      of a congenital hydrocele and  hernia.
      The patient was nine years old, and had
      in his  scrotum,  ever  since he was born,
      a fluctuating  semi-transparent tumour,
      which was free from pain,  of  the  size  of
      a large egg, and disappeared, when com-
      pressed, and  in  a  horizontal posture.—
      (See (Euvres Chir. de Desault, Tom. 2,  p.
      4-42.)
        The success of the vinous injection  in
      hydroceles of the tunica vaginalis, in en-
      crysted ones  of the chord, and in other
      cases, in which Sir James Earle has tried
      it,  particularly in a large ganglion, and a
      collection of the patella, makes  it  pro-
      bable, that it will  be found extensively
      useful in  all cavities, where we wish to
      procure an adhesion,  without destruction
      of parts. (Ei.rle.p  158, ,-at. 2. J
«*■•      One caut'.u it is nece.ss.uy to offer, be-
     fore taking our  leave of this  .subject;  it
 has sometimes happened, during the ope-
 ration,  that the  cannula has slipped out
 of the  tunica  vaginalis,  and  its  inner
 mouth  become situated in  the substance*
 of the scrotum, in which event, the ope-
 rator, if he persists in  propelling in the
 injection, will fill the cellular  texture of
 the part with a stimulating fluid, which
 may cause sloughing,  and  other unplea-
 sant symptoms, without entering the ca-
 vity of tlie tunica vaginalis, or affording
 the least prospect of a radical cure of the
 hydrocele.  When such an accident hap-
 pens, it is best to defer the operation, till
 a sufficient quantity of fluid lias collected
 again.  Hydroceles  have been cured by
 applying to the scrotum a solution of sal
 ammoniac in vinegar and water.  ("Aeate.J
 But, the application frequently creates a
 good deal of pain and irritation, and does
 not ofteu succeed, to say the   best of it
 CEarte.J
   For information, relative to  the hydro-
 cele, the reader is  particularly referred
 to Monro on the Tumours ofthe Scrotum, in
 tlie Edinb. Med. Essuys, Vol. 5..  Pott on
 the  Hydrocele;  El*;e  on tlie  Hydrocele;
 Keate ;  B. Bell; Douglas ;  and Sir James
 Earle on (he same.  Memoire sur VHydrocele
par Bcrtrundi, in Mem. d» VAcad. de Chi-
 rurgie,  Torn. 3.   Also  the  same author in
 Trattato  delle  Operazioni  di   Cliirurgta.
 Nizza,  1763.   Remarques,  &c. sur diver-
 ses especes d'Hydrocele, en QZuvres Chirur-
gicales  de  Desault, Tom.  2.    Sharpe's
 Treatise on the Operations,  and his Critical
 Enquiry.  Also Sabatier  in Medecine  Ope-.
 ratoire,  Tom.  1.  Scarpa, Traite des Her-
 nies, p.  64, &c.  Lurrey, in Memoires de
 Chirurgie Militure,  Tom. 3, p. 409, Ire.
 Practical Observations on tlie Sclerocele, &c.
 by T. Ramsden, surgeon to  thrift's  Hos-
pital, £jc.
  The mode  of distinguishing a hydro-
 cele from a scrotal  hernia, as  explained
 by  Pott, is described in the article  Her-
 nia.
  HYDROPHOBIA, (from  o$up, wuter,
 and <Po$eu,  to fear )  A dread of water.
 This being a  striking symptom  of  that
 species  of madness, which results  from
 the  bite of a  mad dog, and some other
 animals  affected  in the same wav, the
 disease  itself has  been named  Hydro-
phobia.  Some have used the more general
 term, hygrophobia, from  oy^ot,  liquid.
  Both  these terms  are highly   objection-
 able, because they  are  derived  from a
 symptom,  which  'does  not exclusively
 belong to the  disease,  nor constantly ex-
 ist in it.
  The old writers, as we learn from Cx-
 Uus Aurelianus, used the  terms aerophobia,
o; a dread ./ air, ard pantophobia, or, a 
HYDROPHOBIA.
169
fear of all things, as appropriate names for
the disease, since  the impression of cold
air sometimes excited terror, and the dis-
order is  marked by a singular degree of
general  timidity  and  distrust.   Others
called it phobodipson (oir»9t  signifying
thirst,) because the patient is thirsty, yet
J'ears to drink.  Several modern  authors,
however, objecting to an appellation ex-
pressive only of one symptom, hai'e more
correctly denominated-the disease  rabies,
and rabies  canina,  or  canine madness,
The French call it la rage.  (Reesl Cy-
clopxdia, art. Hydrophobia.J  Aristotle is
the  first writer, that  expressly mentions
this disorder; but, he appears  to have
had a very  imperfect idea of it,-since he
 sets down man as exempt from the danger
 of being affected by it.
   Animals of the dog kind,  including the
 wolf and the fox, are most frequently the
 subjects of rabies; and some writers have
 maintained, that,  although it may be re-
 ceived and propagated by other  animals,
 yet it always originates with some of the
 canine race.  (Hillary on Diseases of Bar-
 badoes,  p. 246 )  Wrong notions, of a very
 dangerous tendency, have been generally
 entertained,  in regard to the  disease,
 as it appears  in  the canine  race.   The
 writer  of  the article Dog, in Dr Rees'
 Cyclopaedia, appears to  have  had most
 extensive  opportunities of  observing the
 disorder in dogs,  having paid attention
 to more than two hundred  cases.  From
 his remarks,  I have collected the follow-
 ing information.
   The  peculiar symptom,  which charac-
 terises the complaint in  the human  sub-
 ject, has been applied to the disease  in
 the dog, and has  occasioned it to be call-
 ed by the same name, hydrophobia.   This
 is a p.dp.ible misnomer;  for, in  no in-
 stance, does  there ever exist  any dread
 of  water;  on the contrary, dogs are in
 general very greedy after  it.  Such un-
 founded supposition has  often conduced
 to a very fatal error; for, it being the re-
 ceived  opinion, that  no dog is mad,  who
 can lap water,  many persons  have  been
 lulled  into a dangerous security.  An-
 other equally false  and fatal idea  has
 prevailed, that every  mad dog must of
 course be   wild and furious ; but,  this is
 so far from being true,  that, in the great-
 er number  of instances, there is very  little
 of  that wild savage fury, that,  is ex-
 pected  by tlie  generality of  persons.
 "Hence,"  says this author,  "as  it  is
 evident, that the term hydrophobia, cha-
 racterising the affection in the dog, is a
 misnomer, so it is evident, that the term
 madness is equally  so.  In no  instance,
 bave 1 ever observed a total alienation of
 the mind; in very few,  have the  mental
faculties been  disturbed.  The disposi-
tion to do mischief is rather an increased
irritability, than  absence of sense; for,
in most instances, even those  that are
furious, they acknowledge  the master's
voice, and are obedient."  The symptom,
which is most frequently first observable
in a rabid dog,  is a certain peculiarity in
his manner;  some  strange  departure
from his usual  habits.  In a very  great
number of instances,  the peculiarity con-
sists in a disposition  to pick up straws,
bits of paper, rag, threads,  or tlie small-
est objects, which may happen to be on
the floor  This is said to be particularly
common in  small dogs.   " Others again
shew an early peculiarity by licking the
parts of another dog.  In one instance,
the approach of the disease was foretold,
by  our  observing  a  very uncommon at-
tachment in  a  pug puppy,  towards  a
kitten,  which he was  constantly licking;
and  likewise the cold nose of a healthy
pug, that was with him.   An attachment
to the  sensation of cold appears in many
cases,  it being  very  common to  observe
them (the dogs) licking the  cold iron,
cold stones, &c.  Some dogs, early in the
disease, will eat  their own excrement,
and  lap their own  urine."  An early an-
tipathy to strange dogs  and cats  is very
commonly  observed,  but, particularly to
cats.   As the disease  advances, the affect-
ed dogs bite those with which they are
domesticated,  and,  lastly,  the  persons
around; but, except  in a moment of irri*
tability they seldom attack the human
subject. The  irritability,  that  induces
them to bite is  very  strong; but, is  de-
void of wildness.   It  is more like peevish-
ness, than fury.  A stick held up at them
always  excites their  anger in a  violent
degree, and, throughout the disease, there
is generally a  wonderful impatience  of
controul, and the animals are  with great
difficulty frightened. (See  art. Dog in
Rees' Cyclopxdiu J
   For  additional details, relating to the
disease as it appears  in  the dog,  I must
refer to the  paper, which has  been just
now quoted.  Enough, I hope, has been
said to make the reader  aware, that mad
dogs are not particularly characterised
by an  inability  to lap water, or  any de-
gree of  fury.  These animals, when ac-
tually  affected with  rabies,  from their
quiet manner, have even not been suspect.
ed of having the disorder, and have even
been allowed to  run  about, fondled, and
even slept with.   (See Mem.  of Swedish
 Acad.  1777.)
   The causes of this peculiar distemper
 in dogs are at present in much obscurity,
 and we  have little more, than conjecture
 upon the subject.  We  do not positively" 
110                            HYDROPHOBIA.
 know, whether  rabies sometimes origi-
 nates spontaneously in these animals, or,
 whether,  like small pox, in  the / human
 species, it is propagated only by conta-
 gion.  That  th% disease is frequently im-
 parted in consequence of one dog biting
 another,  every body  well knows.   But,
 still, there are many instances, in  which
 it is certain, that no such cause can be
 suspected  Several facts  tend to shew,
 that among dogs the disease is often com-
 municated by contagion.   It is observed,
 that, in insular  situations, dogs are sel-
 dom  affected, and this circumstance  is
 ascribed to such animals being in a kind
 of quarantine.   The celebrated sports-
 man, Mr.  Meynell, secured his dogs from
 the maLdy, by making every new hound
 perform a quarantine before he was suf-
 fered to join the pack.  (See Trans, of a
 Society for the Improvement of Med.  and
 Cldr. Knowledge,  Vol  1, art. 17.)  Great
 heat is very commonly  supposed to be an
 exciting  cause of the  disease in  dogs;
 but, without much foundation.  •' A very
 hot  climate,  or  one exposed to the ex-
 tremes of heat and cold; a very hot and
 dry  season;  feeding upon putrid, stink-
 ing  and maggotty flesh; want of water;
 worms in the kidneys, intestines,  brain,
 or cavities of the nose," are set down by
 Boerhaave as causes  of  the  disease.—
 CAphorism, 1134.)  We learn  from Dr.
 J. Hunter,  that in the hot island of Ja-
 maica, where degs are exceedingly nu-
 merous, not  one  was  known  to go mad
 during forty years.  (Transactions of a
 Society for the Improvement of Medical
 Knowledge, loc cit.)
  "  Although (say s M. Larrey) hydropho-
 bia is more frequent in warm, than tem-
 perate climates, it is  not observed in
 Egypt, and the natives assured  us,  that
 they knew of no instance,  in  which  this
 disease had manifested itself either in
 man, or   animals.   No  doubt, this is
 owing to  the  species and character of the
 dogs of this  country,  and  their manner
 of living.
  " It is  remarked, that the  Egyptian
 dogs are almost continually in a state of
 inaction: during the day,  they lie down
 in the shade, near vessels, full of fresh
 water, prepared by  the  natives.  They
 only run about in  the  night time;  they
 evince the signs and effects of their love
 but once  a year, and only for a few in-
stants. They are  seldom seen coupled.
 On  our arrival, there Was  a vast number
 of these animals in Egypt, because, they
 were held, like many others, in great ve-
 neration,  and  were never put  to death.
 They do  not  go into the houses: in the
 day time,  they remain at the sides of the
 streets, and they only wander into  the
 country  at night, in order  to find  any
 dead animals,  which happen  to  be  un-
 buried.  Their disposition is  meek  and
 peaceable, and  they rarely fight with each
 other.  Possibly,  all  these  causes may-
 exempt them from rabies."  (Larrey, in
 Mem. de Chir. Militaire, Tom. 2, p. 226.)
   In  Mr.  Meynell's  account, which  was
 communicated  to him by a physician, it
 is asserted,  that the  complaint  never
 arises from hot weather, nor putrid pro-
 visions, nor  from any cause except  the
 bite; for, however dogs have  been c»u-
 fined, however fed,  or, whatever may
 have  been the heat of the season, the  dis-
 order never commenced, without a possi-
 bility of tracing it to the preceding cause,
 nor was it ever introduced  into the ken-
 nel,  except by the bite of a  mail dog.
 This  malady is also  stated to be rare in
 the northern parts of Turkey,  more rare
 in the southern provinces of that empire,
 and totally unknown under  the burning
 sky of Egypt.  At  Aleppo,  where these
 animals perish in great numbers, for want
 of food and water, and  the  heat  of  the
 climate, this disorder was never known.
 In other  parts  of Africa, and in the hot-
 test zone of America, dogs are said to be
 never attacked  with madness.  (See  art.
 Dog,  in Rees' Cyclopxdia.)
  Mr. Gillntan endeavours to prove, that
 the disease in dogs  is probably produced
 independently of particular climates, of
 putrid aliment, of deficiency of water, of
 want  of  perspiration, or, of the worm
 under the tongue, to which it has been at
 different times ascribed, and he expresses
 his belief, that it originates somewhat like
 typhus in the human  subject, and is  not
 always  produced  by   inoculation  by
 means of a bite.  He thinks,  that  it may
 be occasionally brought on  by  the con-
finement  of dogs,  without exercise,   in
close  and  filthy kennels; and that  the
success of Mr.  Trevalyan, as related by
Dr. Bardsley, in clearing his kennel  of
the disease,  by changing even the pave-
ment,'after other means of  purification
had failed, affords presumptive  evidence
in favour  of the  opinion;  and,  conse-
quently, this author thinks,  that the me-
thod of quarantine, adopted by Mr. Mey-
nell, and recommended by Dr. Bardsley,
on the supposition, that  the disease ori-
ginates exch'sively from contagion, will
not be a sufficient preventive alone; and
he shews, from some facts, reported by
 Mr. Daniel, that  the poison  sometimes
 lies dormant in dogs four, five, and  six
 months;  and,  consequently, he  infers,
 that  the period of two months is not a
 sufficient quarantine, before a new  dog is
 introduced into a pack.  (See Gillman'a
 Diss,  on the Bite of a Rabid Animal. J 
HYDROPHOBIA.                            Ill
  It is observed by the late Dr. J. Hunter,
that all domestic animals, birds, as well as
beasts, are susceptible of the poison of
the mad dog; and,  indeed, our expe-
rience has not yet taught us that there is
any race of animals exempted from its ef-
fects.   Whether every animal labouring
under the disease is capable of infecting
others, or whether this power is  confined
to a few only, we are yet to learn
  The disease has been communicated to
the human species by dogs,  cats, wolves,
and foxes.   The  dog, the wolf", and the
jackal, have, by the late mquiries of na-
turalists, (Mr. Hunter's paper, Phil. Trans.
Vol. 77, p- 253.) been ascertained to be of
the same species; and therefore it is pro-
bable, from analogy, that the latter is ca-
pable of communicating the infection as
well as the two  former.  The fox also
has a strong affinity to the dog, and is by
Linnaeus counted of the same genus ; but
the distinctions of natural  history will
not avail us  here; for the cat, an animal
of a very different genus, has often pro-
duced the hydrophobia in the human spe-
cies.  Many other animals  are  reported
to have the power of infecting others, by
biting them while labouring under the
disease themselves; but the facts hitherto
collected are very vague, and lead to no-
thing conclusive on this head.  Were we
to judge from analogy,  from seeing two
animals so  different from each other as
the dog and the cat, capable of infecting
others,  we  might be led to infer, that
every animal susceptible of the disease
had the power of communicating it, pro-
vided their natural habits led them to bite
and tear with their teeth such animals as
came in their  way while in an enraged
state.  But, though  there  are instances
of  men labouring under hydrophobia bit-
ing some of those employed in taking
care  «f them,  no ill consequences have
been known to follow.   .From this,  how-
ever, we can draw  no positive  inference,
for it is but a  small proportion of such
persons as  are bit by dogs undoubtedly
mad, who are infected with the poison.
   The bite  only  serving the purpose of
inoculation, the danger arising  from  it
will he various, as it happens to be in a
part  more  or less  vascular; or as the
teeth are more or less  loaded with the
poison.   There  is the  greatest danger
from  bites in the face, and  the symptoms
come on soonest;  bites  in the hands also,
which are generally bare, are full of dan-
ger.  In other parts of the  human body
the clothing, by wiping the teeth, greatly
lessens the danger of infection.   The bite
is not essentially- necessary for the appli-
cation of the poison :  a dog, by  licking a
sore, produced the hydrophobia; but he
licked it till it bled, so thaV the poison
came in contact with the newly divided
blood-vessels.  This circumstance, if we
may judge from the analogy of other poi-
sons, is probably  of importance in giving
efficacy to the poison, yet it is  not  clear
that it is essential j for there are two cases
of the  disease mentioned in the Philoso-
phical Transactions, (Phil. Trans. Vol. 23,
p. 1074.) which arose from putting the
hands in the mouth of a puppy that was
mad, but  when there was  no bite; and
there is a similar case in the Memoirs of
the Royal Academy of Sciences of Swe-
den.  (Anno 1777.)  It  is  true,  various
other modes  of infection are narrated by
writers, but in all of them there is much
appearance of fabulous credulity.   There
is good reason to think that tetanus has
sometimes been mistaken for hydropho-
bia, and given rise to the accounts of the
diseases  proceeding from  the  bite of a
cock,  the claw of a cat, and similar hist-
tories.
   Dogs are much more susceptible of the
infection than the  human species.  Four
men  and  twelve  dogs  were bit by the
same mad dog, and every one of the dogs
died ofthe disease, while all the four men
escaped, though they used no other means
of prevention, but such as we  see every
day to fail.  There is also  an instance of
twenty persons Ibeing bit by  the same
mad dog, of whom only one had the dis=-
ease.
   There  is  a question  which »aturally
presents itself here; does the disease ever
arise spontaneously in  the human spe-^
cies ? The facts relating to this question
involve many doubts.  Francis  Stannier
died in November 1787, with the symp-
toms of hydrophobia, though it was not
known that he had ever  been bitten by  a
mad dog; (London Med. Journal, Vol. 9.
p. 256.) and  similar cases are related by
writers.  Yet as  a large  bite is no way
necessary to  communicate the  infection,
the patient  above-mentioned  may have
been slightly bit,  without knowing it, as
he was often drunk, and frequently .in the
streets at night.  There is good reason to
believe that  the difficulty of swallowing,
which sometimes  occurs in tetanus, has
been mistaken for hydrophobia in soro?
cases ; and  there may  be other spasms
about the throat  and   the oesophagus,
which may so far resemble hydrophobia,
as to give rise to errors on this subject.
Something of this kind occurred once to
Dr. John Hunter, in  an hysteric woman.
 Were we to  be guided by analogy in de-
ciding the present question, we should be
led to deny  the existence of spontaneous
hydrophobia; for where  is  there  an ex-
 ample of ar.v  of those diseases  which  de-t 
112                           HYDROPHOBIA
 pend npon a specific poison, as the small-
 pox,  the venereal disease, or the measles,
 arising spontaneously ?  But the full deci-
 sion of this question must be left to future
 experience and observation.  (Dr. J. Hun-
 ter in Trans, of a Society for the Improve-
 ment of Med. and Chirurgical Knowledge,
 Vol. l,p.  299—303.)
   Dr Heysham has defined hydrophobia
 to be an  aversion and horror at  liquids,
 exciting a painfitl convulsion of the pha-
 rynx, and occurring at an  intermediate
 period  after the canine virus has been re-
 ceived into the system.  Dr. Cullen places
 it in the class neuroses, and order spasmi,
 and defines it a loathing and great dread
 of drinking any liquids,  from their creat-
 ing a painful  convulsion of  the pharynx,
 occasioned most commonly by the bite of
 a mad animal.   Others have suggested the
 following  definition., as  more  complete:
 melancholy, dread of cold air; of any thing
 shining, and particularly of  water; often
 arising  from the bite of  a mad  animal.
 (Parr's Med.  Diet. J However, the latter
 definition  is, perhaps, equally objection-
 able,  because  there  is  not invariably a
 dread 0/ shining bodies.  (See Dr. Powell's
 Case, p. B.J
   Writers in general have divided hydro-
 phobia into two stages, viz. the melancholy,
 and the raving;  the hydrophobia simplex,
 and rabiosa, of Cullen. In many instances,
 however,  the latter stages of the disorder
 are not preceded by any condition, to
 which the epithet melancholy is applica-
 ble.
   With regard to the symptoms of hydro-
 phobia, they are generally tardy in  making
 their appearance, a  considerable, but a
 very variable space of time usually elaps-
 ing between their commencement and the
 receipt of the bite.  This interval in the
 greater number of instances appears to
 be  about  six weeks.  Out of a  table of
 131 cases, none ofthe patients became ill
 before the eleventh day after the bite, and
 only three  before the  eighteenth.  Dr.
 Hamilton  thinks  nineteen  months  the
 longest interval, to which any credit can
 be given. (On Hydrophobia, Vol. 1. p. 113.)
 On the other hand, Dr. Bardsley, of Man-
 chester, has recorded a case, in which the
 most  careful enquiries  tended to prove,
 that the^ patient  had never  suffered the
 least  injury from any animal, except the
 bite, inflicted twelve years previous to the
 commencement ofthe hydrophobia, by a
 dog apparently mad.  (Mem. of Liter, and
 Phil. Society of Manchester, Vol 4,  Part 2,
p. 431.)  The  wound, if treated by com-
 mon methods,  usually heals  up at first in
 a favourable manner.' At some indefinite
 period,  and, occasionally,  long after  the
 S;tte;i part seems quite well, a slight pain
begins to  be felt in it,  now and then at-
tended with itching, but generally resent-
bling a rheumatic pain  It soon extends
from the wound  up the arm,  and affects
the situation of the trepezius muscle, and
the  neck,  on the same side as the bite.
The cicatrix, in tlie  mean while, begins
to  swell,  inflames, and, at length, dis-
charges an  ichorous matter.   There are
often pains of a  more flying,  convulsive
kind, felt in various  parts  of the  body.
As the disease advances, the patient com-
plains of the pain shooting, from the si-
tuation of the bite, towards the region of
the heart.  A lassitude, a dull pain in the
head, and a vertigo, soon  come on : the
patient is commonly  melancholy, though
not  always,  mutters,  is  forgetful, and
drowsy ; his mind seems disordered; his
temper irritable and irregular; his slum-
bers disturbed, and convulsive agitations
immediately follow his waking: a  deaf-
ness is sometimes complained of; the eyes
are watery; the aspect sorrowful; the
face pale and contracted ;  sweat  breaks
out upon the temples;  and an  unusual
discharge of saliva is made from the mouth.
From the beginning, a peculiar stricture
and heaviness  on the  breast, occasional
involuntary  sighing,  and  nausea,  take
place.  There is often a bilious vomiting.
The idea of drinking any kind of  fluids
creates considerable  alarm and agitation,
and the attempt to do so generally brings
on most  afflicting pains and convulsions,
attended with a dreadful sense of suffoca-
tion, and choaking.  Dr. Marcet, in re-
lating the case of a patient affected with
hydrophobia, observes, that " on our pro-
posing to him to drink, he started up, and
recovered his breath by a deep convulsive
inspiration : yet, he expressed much re-
gret,  that he could not drink,  as he con-
ceived, it would  give  him  great  relief,
his mouth being  extremely parched and
clammy.  On being  urged to try,  how-
eyer,  he took up a cup of water  in one
hand, and a tea-spoon in the other.  The
thought of drinking out of the cup ap-
peared to him intolerable; but, he seemed
determined to drink with the spoon. With
an expression of terror, yet,  with  great
resolution,  he filled the spoon, and pro-
ceeded to carry it to his lips;  but, before
it reached his mouth, his courage forsook
him,  and he was forced to desist. He re-
peatedly renewed the attempt; but, with
no more success.   His arm became  rigid
and immoveable, whenever he tried to raise
it towards his mouth, and  he  struggled
in  vain against  this spasmodic resistance.
At last, shutting his eves, and, with  a
kind  of convulsive effort, he suddenly
threw into his mouth  a few drops of the
fluid, which he actually swallowed.  But, 
HYDROPHOBIA.                           US
at the same instant, he jumped up from
his chair, and flew to the end ofthe room
panting tor breath, and in a state of inde-
scribable terror."   (See Medico-Chirurgi-
cal  Transactions, Vol. 1, p.  138.)  Even
the  splashing, or running, of any liquid
causes  a great deal of inconvenience.  As
the  system  becomes more  and more af-
fected, the patient loses his sleep entirely,
and has frequent and violent fi.sot" anxiety
and loud  screaming from slight causes.
The woman, whom Dr.  Powell attended,
was often attacked in this  way, in conse-
  auence of so trivial a circumstance as a
  y  settling on  her  face.  The noise of
tea-cups, or the mention  of any sort of
drink greatly disturbed her, though  she
was not at all agitated by the sound of
her urine. The currents  of air entering
her room, whenever the door opened, be-
came very distressing to  her, and this
more and more so.  The pain in her neck
became so great, that she could  scarcely
bear it to be touched; but she made  use
of  a looking-glass  without  the inconve-
nience which hydrophobic patients usually
suffer from the sight of shining bodies.
Dr.  Powell states,  that the paroxysms
which  this poor woman suffered, resem-
bled those of hysteria, and increased in
duration as the disorder  lasted.  "She
described their commencement  to be in
the stomach,  with a working and fulness
there,  and that a pricking substance pass-
ed  up  into her throat and  choaked  her;
she screamed  suddenly,   and  grasped
firmly  hold of her attendants, as  if volun-
tarily; and muscular convulsions  came
on, which were  sometimes  more, some-
times  less general and  violent.   The
causes from which these paroxysms arose,
were extremely slight; the passage of a
 fly near her  face, the attempt to swallow
a pill,  a stream of air, the sight of oil or
 wine,  or any  other liquids,  even  the
sound  of water, and other  such circum-
 stances,  were  sufficient;  she  now  also
complained of inconvenience from light,
 which was accordingly moderated.  The
 effects of sounds was peculiar; for, though
 in the  subsequent  stages,  their influence
 became more general, at this period the
effect  was  rather  proportionate to  the
 ideas they excited  in her mind, than  to
 their  violence.  Bells, and other strong
 noises, did not agitate her, but the clatter
 of  earthen ware,  the  noise of a distant
 pump, or any  thing connected with  li-
 quids, produced the paroxysms in all their
 violence."  She could swallow fresh cur-
 rants  with less resistance than any  thing
 else, taking care that they were perfectly
 dry.   Her mind had, till now, been quite
 calm and composed, and her conversation
     vox. n.
and  behaviour proper, during the inter-
vals of the convulsive  attacks.   Bui Dr.
Powell was  ooliged  to discontinue  the
pills of  argentum  nitratum,  in conse-
quence ofthe sufferings which the attempt
to swallow them regularly  brought on.
Fifteen grains  of this substance had been
given without any sensible  effect.  The
fits and irritability  to  external objects,
increased.  The pain shot from the back
of the neck, round to the angles of the
jaws, the chin,  and  throat.   At  length,
the paroxysms  became  more  frequent,
and, indeed, might be said  to  come  on
spontaneously:  seven  occurred  in  one
hour.  She  looked  pale  and exhausted,
and a tremor and blueness of her lips and
fingers  were  observable; her pulse be.
came weaker and  more  rapid,  and her
scalp so tender,  that touching it brought
on convulsions.  She had, latterly,  eruc
tations of wind, and spit up some  thick
viscid saliva.  Her urine  now came away
involuntarily, and she was more and more
irritable  and  uncontrollable.   She now
passed two hours in almost constant con-
vulsions ;  became extremely irritable and
impatient of every thing about her,  com-
plained of failure of her sight; wished
to be bled to death; her words were fewer
and  interrupted; she struck, and threat-
ened to bite, her attendants; had copious
eructations of air; discharged an increas-
ed  quantity of viscid saliva with much
convulsive effort; said the  affection of
her  throat  and stomach  had quite left
her; and continued in  a  general perspir*
ation,  with a weak pulse from 140 to 150.
She  afterwards  bit  some of the  attend-
ants, and was therefore confined with a
waistcoat.  From  this period,  she had
lost all control over her  mind,  and con-
tinued  for  almost  four  hours in a  pa-
roxysm of  furious  insanity.   She  now
swallowed, with an effort, near half a pint
of water: but this was, in a few seconds,
vomited  up, with some  mucus, and  a
greenish  fluid.   In  this violent raving
state,  she continued till within  two hours
of her death, which took place forty-seven
hours after the first marked occurrence of
hydrophobia.  , In the course of  the case,
she swallowed, once or twice, a little por-
ter ; and also  some cinnamon-water, with
tinct opii; but they were always vomited
up.  On opening the body,  tiie most re-
 markable appearances were,  a  turgid
 state of the vessels  of tlie  hrain ;  great
 distentions of the iutestines  with air; the
 oesophagus rather  redder  than natural,
 and covered with a thin layer of coagulat-
 ing lymph ; nearly halt a pint of greenish
 fluid in the stomach,  which was rather
 redder than  natural, and had under its
     P 
114                            HYDROPHOBIA.
      internal coat,  new the cardia, a few spots
«     of extravasated blood.  (Dr. Powell's Case
      of Hydrophobia.)
         The dread  of  swallowing  liquids,
      though the most singular symptom of the
      disease, constitutes but a small part of the
      malady.  It is true, that  none, or very
      few recover, who have this  symptom, yet,
      tiiey certainly do not die, in consequence
      of the  difficulty of swallowing liquids;
      for, the human  body  could  easily exist
      double the time, in which the disease usu-
      ally proves fatal, without food, or drink.
      Besides, the sick can often swallow sub-
      stances, that are  nourishing, in a pulpy
      s|Ute, without, however, having their life
      ttiereby at all prolonged. It is not, there-
      fore, the  difficulty,  or impossibility of
      swallowing liquids ; but the effects ofthe
     poison  upon  the constitution  at  large,
      which occasions death.  (Dr J. Hunter iu.
      Trans, of a Society for the Improvement of
     Med. Knowledge, Vol. 1, p.305.)
       The extreme sensibility of tlie sick to
     all  impressions, appears in the displea-
     sure which they  express at even the air
     blowing upon them ;  iu their dislike to a
     strong light;  in their aversion to new
     feces,  or even  the  sight of their  friends
     and relations ;  and in the terror they ex-
     press  at being  touched, which  almost
     threatens to throw them into convulsions.
     As the disease advances, the mind is more
     and more filled with  dreadful  fears and
     apprehensions. (Dp. ci:. p. 307.)
       The duration o* life,  from the appear-
     ance of the hydrophobia till  death, varies
     from thirty-six hours to tour or five days :
     the most common  period is from two to
     three days. (Op. cit. p.  308.)
       The dread of water is said to  be some-
     times a symptom of certain fevers, from
     topical inflammations  of the  thorax, or
     neighbouring  parts. (Edinburgh Medical
     Commentaries.  Vol  2, p. 331.)  A species
     Of hydrophobia has been knows  to origi-
     nate from an inflammation  of  the  sto-
     mach.   (Med. Essays, Vol 1.)  Also from
     the bite of an epileptic patient, or of per-
     sons in viblent fits of passion; and from
     the accession of epilepsy.  An inferior de-
     gree of it is said to be observable in some
     hysteric cases,  when,  from the difficulty
     of swallowing, patients are fearful of tak-
     ing liquids. In the latter cases, musk and
    opium are recommended.
      With respect to the  treatment of hy-
    drophobia, arising from the canine  poi-
    son, little is necessary .to be said in  this
    work, because the subject is rather medi-
    cal than  surgical.   The reader will re-
    gret my brevity the less, when he is in-
    formed, that, after hydrophobia has once
    begun,  it has always pursued its dreadful
    course  to a fatal  termination,  without
 anyone well authenticated instance to tit*
 contrary,  notwithstanding  the  trial  of
 every medicine, and  method,  which the
 a!4est practitioners have suggested.  The
 only case, that I have ever periled, which
 seemed really to be one, in which hy dro-
 phobia  was  cured, was published  iji a
 Calcutta paper, of December, 1811.  The
 treatment, if my memory  fails me  r.n',
 consisted  in  mercurial frictions, and co-
 pious and repeated bleedings.   The par-
 ticulars, I believe, however, are likely to
 be made public in one of the  periodical
 works, long  before  this  edition of the
 dictionary will  be completed.  If this
 were a true case of hydrophobia,  it is ex-
 traordinary, that a  method, which has
 been often and often  tried in  other in-
 stances, should have  answered  in  this
 particular one.   The  same observation,
 in regard to the inefficacy, of every mode
 of treatment hitherto known, might,  per-
 haps, be accurately extended to every in-
 ternal remedy, mercurial frictions, plung-
 ing the patient for a considerable time
 under water, &c. as preventives.  The in-
 stances, in which a prevention  has  been
 inferred to have taken place by  different
 writers, in consequence of such means,
 may all be<( very rationally ascribed to
 other circumstances   It is well  known,
 that, out ofthe great number of persons,
 f. equently bitten by the same  dog, only a
 few are commonly affected.  The hydro-
 phobic poison is known to reside in the
 saliva of the animal; consequently,  the
 chance of being affected must greatly de-
 pend upon the quantity of this fluid, which
 may be insinuated into the wound; and,
 if the teeth of  the animal should have
 previously pierced a thick  boot, or other
 clothing, before entering  the  skin,  the
 danger must obviously be in general much
 diminished.   Many patients  Wash  and
 suck the wound, immediately after its oc-
 currence, and thus, no doubt, very often
 {?et  rid of  the poison.  Even when it lias
 odgedin  the wound, it  may not be di-
 rectly absorbed, but be thrown off with
 the discharge   All prudent patients sub-
 mit  to excision of the  bitten part.  Now,
 under each of the  above  circumstances,
 escapes have frequentlv occurred, while
 internal  medicines, half drowning, or sa-
 livating  the patients,  h id also  not been
 neglected,  so that all the efficacy of pre-
 ventives has too often been most unjustly
 ascribed to means, which probably never
 yet had, nor ever will have, any beneficial
 effect whatever.  What confirms the truth
 ofthe preceding  statement are these feels;
 that persons  bitten by  the  same animal
have  sometimes been treated exactly on
the same plan;  some  of them  have es-
caped having  the disease; others have 
                  HYD

had it, and, of course, perished:  on other
occasions, some of the patients, bitten by
the same animal, have  been treated in a
particular way, and  have escaped hydro-
phobia,  while others bitten at the same
time by  the animal, also never had any
constitutional effects, altliough they took
no medicines, nor followed any other par-
ticular plan.
  Happily,  there is,  in  surgery,  one
means of preventing hydrophobia, when
it is practised in time,  and in a complete
manner.   Every reader will know,  that
the excision ofthe bitten parts is the ope-
ration to which I allude.  Indeed, as hy-
drophobia is often several months before
it begins,  the wounded parts should, per-
haps, always be  cut out,   even though
they are healed,  and some  weeks have
elapsed  since the accident,  provided no
incipient  symptoms of hydrophobia have
already   commenced.   The   operation
should be done completely; for a timor-
ous surgeon, who should tear-to cut deeply
enough,  or to cut a  sufficient quantity of
the surrounding  flesh  away, would be a
most dangerous one  for the patient.  All
hopes of life depend on tlie  prevention of
the disorder : for, in the present state of
medical  knowledge, none can rest upon
the efficacy of any plan, except the extir-
pation of the part. This some have done
with caustics.  However, as  their action
can never be regulated with the same pre-
cision as  that of die knife,  and, conse-
quently, they will not always destroy the
flesh to a sufficient depth, excision should
always be preferred.   The latter method
is also the safest, for another important
reason,  viz. the part, and poison lodged
in it,  are removed from the body at once;
but,  when caustic  is  used, tlie  slough
will not be thrown off for some  days af-
terwards.
  Some surgeons of  the present  day are
not  content  with cutting  out the part;
they  recommend,  after  the operation,
filling the wound with the  aqua  ammo-
nix  purs, so as to produce a  general
sloughing ofthe surface, by way of greater
security.
  I shall conclude this article with  re-
ferring the reader to  the following works,
for  farther information on  hydrophobia:
Sauvages sur la Rage ; James on Canine
Madness; Mead on the Bite of a J fad-dog;
Seleg, Augent, and Hamilton, on Hydropho-
bia; Medical Museum,  Vol. 2; London Me-
dical  Transactions, Vol 2; Med. Obs and
Inq. Vol.3;  Edinb.Med Comment. Vol. 5,
p. 42/ Vaughan's  Two  Cases of'" Hydropho-
bia ; Dr. PowelTs Case of Hydrophobia;
Lotto's  System of Surgery, Vol.3; Cullen'b
First Lilies,  Vol 4,-  Memoirs of the Med.
Society of London, Vol. I, p. 243/  Medical
               HYD              115

Communications, Vol. 1; Mem. ofthe Royal
Society of Medicine in Paris, Supplement to
Vol. 4. Ferriar's Med. Facts and Observa-
tions.Richerand'sJVbsographie Chirurgicale,
Tom.  1, p. 251, &c.  Edit. 2. Marcet,  in
Medico-Chirurgical  Transactions,   Vol.  1,
p. 132, &c. Lassus,Pathologie Chirurgicale,
Tom.  2, p. 239, SJc. Edit.  1809.  A valua-
ble paper by Dr. John Hunter in Trans, of a
Society for the Improvement of Me d.and Chi-
rurgical Knowledge,  Vol. 1, Art. 17.  Gill-
man's Dissertation on the Bite of a Rabid An-
imal.  Leveilie, JVouvelle Doctrine Chirurgi-
cale, Tom 2,p- 341, &c.   Bardsley in Sle-
moirs  of the Literary and Philosopldcal So-
ciety  of Mancfiester, Vol. 4,  Part  2.  Ba-
bington, in the Medical Records and Re-
searches, liond. 1T98.
  HYDROPHTHALM1A.   (from  u^t
water;  and oty6xXp.oct the eye.)   Dropsy
of tlie eye.  In all the cavities of  the ani-
mal body, (says Scarpa)  which  are conti-
nually moistened by a serous vapour,  as
well as in those destined to  contain a de-
terminate quantity of an  aqueous, limpid
fluid, there is such a reciprocalness of ac-
tion,  between the secerning extremities
ofthe arteries, and the minute mouths of
the absorbent vessels, that the fluid effused
in these  cavities is always in circulation,
being incessantly renovated,  but  never
accumulating beyond a certain degree and
determinate measure. When this mutual
action, existing between these two vascu-
lar systems, is interrupted, in consequence
of a  general or local indisposition, the
above cavities, being no longer moistened
by a  serous vapour, shrivel and  become
obliterated;  or, on  the  contrary,  being
unusually  distended by the  excessive
quantity of fluid, they acquire an enor-
mous  magnitude, much  beyond  what a
person,  unacquainted with  these things,
would suppose
  As  Scarpa continues, the eye, considered
simply as a cavity destined to contain a
certain quantity cif limpid fluid,  is occa-
sionally subject to both these infirmities.
The first is  termed atrophy ; the sec md,
dropsy of the eye, or hydrophthalmia.  In
the first case, the globe of the  eye gra-
dually becomes smaller;  and, as  the ab-
sorbent  system  does not cease acting,
when there  is no  more  fluid to be ab-
sorbed,  it gradually consumes the solid
parts  of this organ, which  it insensibly
diminishes, and in time destroys.  In the
second  case, the eye assumes a greater
bulk  than is  natural  to it; sometimes ac-
quiring such an e vtraordinary magnitude,
that it propcts out of the eyelids, at first
with great weakness, and afterwards with
total  loss of  sight.
  Surgeons generally state, that  the im-
mediate causs ofthe dropsy ofthe eye, is 
116                         H YDROPHTHALMIA
 sometimes an increase of tlie vitrous hu-
 mour, sometimes ofthe aqueous.  In every
 case of this kind, on which Scarpa has
 performed the operation, and in other ex-
 aminations of the different  stages of the
 disease, made on the dead subject, he has
 constantly  found the vitreous humour,
 more or less, altered in its organization,
 liquified,  and  converted into  water, ac-
 cording as the  disease  was ancient,  or
 recent.  In some  instances, he could not
 distinguish whether the increased quan-
 tity ofthe vitreous or the aqueous humour
 had most share in  the formation of the
 disease.  Some  of  the  most  celebrated
 modern oculists  believe, that  the princi-
 pal cause of this complaint is referrible
. to  the closure of the  inorganic pores of
 the cornea, through which the  aqueous
 humour can no longer transude, and con-
 sequently collects in the interior of the
 eye, so as  to occasion dropsy.  By this
 assertion, they evince, that they are not
 sufficiently  acquainted with the activity
 ofthe  absorbent system in the animal eco-
 nomy ; and they do  not seem to have ad-
 verted that,  in  conformity  with their
 theory, the dropsy of the eye ought inva-
 riably  to follow  a thickening of the con-
junctiva spread  over the organ, as well
 as  the leucoma and extensive scars  of
 the whole cornea; a thing that is  con-
 tradicted  by  daily  observation and  ex-
 perience.
   Scarpa  has also dissected a dropsical
 eye, taken from the body of a child, three
 years and a half old, who died  of maras-
 mus.  The vitreous  humour was not only
 wanting in  this  eye, and the cavity des-
 tined  for its  reception filled with water;
 but the  vitreous tunic  was  converted
 into  a substance,  partly of  a  spongy,
 partly of a  lippomatous nature.  This
 dropsical  eye  was one-third larger  than
 the sound one.   The sclerotica was not
 thinner than that of the other  eyej but,
 in consequence of being yielding^flaccid,
 and separated from the choroides, it had
 lost its plumpness, and globular shape.
 The cornea formed a  disk,  one-third
 larger than that of this membrane in a
 sound  state ; it  did  not retain  its natural
 pulpousness, and was obviously thinner
 than the cornea of the healthy eye. There
 was a  considerable quantity of an aque-
 ous, reddish  fluid,  between the  cornea
 and iris.  The crystalline  lens, with its
 opaque capsule, had been pushed forward
 a little way into the anterior chamber,
 but could not  advance  further on  ac-
 count  of a firm adhesion, which the cap-
 sule had contracted with the iris, around
 the edge  of the pupil.  As soon as the
 capsule was opened, the lens issued from
 it, half dissolved, the rest exceedingly
soft.  It was  impossible  to detach  the
whole of the posteriour layer of the cap-
sule from a hard substance, which seemed
to be the altered membrane ofthe vitreous
humour.  Scarpa, therefore, slit open the
choroides, from the ciliary  ligament to
the bottom of the eye,  when a consider-
able  quantity of a reddish aqueous fluid
gushed out,  without, however, one parti-
cle of the vitreous humour.  In lieu of the
latter body, there was found a  small cy-
linder of a substance, partly of a fungous,
partly of a lippomatus nature,  surround-
ed with a good deal of water, which was
effused in the longitudinal  axis of  the
eye, from the entrance of the optic nerve,
as  far as  the  ciliary  ligament, or  that
hard substance  to which the posteriour
layer of the capsule firmly adhered.  This
little cylinder was covered, for the extent
of two lines and a half forwards from the
entrance of the optic nerve,  by a stratum
of whitish matter, reflected on itself, like
the  epiploon, when raised towards  the
fundus of the  stomach.  Scarpa conceiv-
ed that this stratum  of  whitish matter
was  nothing else than the relics of  the
unorganized retina; for, on pouring rec-
tified spirits of  wine on the whole  inner
surface of the choroides, and.the  little
cylindrical body, he found no vestiges  of
the  retina on this membrane, and Ihat
the whitish substance, which was reflected
on itself, became very firm, just as  the
retina does when  immersed in spirit of
wine.  Both the cylinder and the  indu-
rated substance, occupying the place of
the ciliary body, were  manifestly nothing
else  than the  membrane  of the vitreous
humour destitute of water, and converted,
as was described, into a substance, partly
of a  spongy, partly of a lippomatous  na-
ture. It is not easy to  determine whe-
ther this fungous and  lippomatous dege-
neration  of the  vitreous  tunic had pre-
ceded, or was a consequence ofthe dropsy
of the eye. _ However,  it may  be,  this
fact,  in conjunction with  several other
similar  ones, that Scarpa has met  with,
in which he found no vitreous humour in
the posteriour cavity ofthe eye, but only
water, or  a bloody lymph, tends  very
much to confirm that this disease princi-
pally consists of a  morbific secretion  of
the  vitreous humour,, and  occasionally,
also,  of a strange degeneration of the al-
yeolary  membrane, bv which this humour
is formed   Scarpa refers to a  similar
case  in Medical  Obs. and Inquiries, Vol. 3,
Art.  14.
  The augmentation  in the  secretion of
the aqueous fluid, both in the cells ofthe
vitreous  humour and  out of them, after
they have been  ruptured from  excessive
distention; together with a debilitated 
HYDROPHTHALMIA.                         117
    action of the absorbent system of the eye
    affected; are, most probably, continues
    Scarpa,  the  causes  of every species of
    dropsy, and, consequently, of the morbific
    accumulation  of  humours  in  the  eye.
    From such  a lodgment and successive
    increase of the vitreous and aqueous hu-
    mours,  the  eye-ball  at first necessarily
    assumes an oval shape, ending at the point
  -  of the cornea; then, as  the organ en-
    larges in all  dimensions,  it acquires a
    larger size  than  that of  its fellow; so
    that, in the end, it projects from the orbit
    in such a manner, that it cannot  be co-
    vered by the eyelids, and disfigures the
    patient's face as much as  if an ox's eye
    were placed  in the orbit, instead of his
    own natural one.
      This disease (says Scarpa) is sometimes
•   preceded by blows on the  eye, or adjoin-
    ing  temple;  sometimes by an  obstinate
    internal ophthalmy.   In other instanc-s,
    it is preceded by no other inconvenience
    except an uneasy sensation of tumefaction
    and distention in the orbit, a difficulty
    of moving the eye-ball, and a considerable
    impairment of sight.  Lastly, it is some-
    times preceded by  none of these causes,
    or  no other obvious one whatever, espe-
    cially when the complaint occurs in  chil-
    dren, of very tender age, from whom no
    information can be obtained.  As soon as
    the eye has assumed an oval form, and
    the anteriour chamber has become pre-
    ternaturally capacious, the iris seems si-
    tuated further backward than usual, and
    tremulates, in a very singular way, on the
    slightest motion of the eye-ball.  The pu-
    pil  remains  dilated  in every degree  of
    light,  while the crystalline is sometimes
    brcvnish from the very beginning of the
    disease; and sometimes it does not be-
    come cloudy till the  affection has arrived
    at its highest pitch.  The complaint tliea
     becomes stationary;  and, as the crystal-
     line is not deeply opaque, the patient can
     distinguish light from darkness, and,  in
     some degree, the contour of objects, and
     brilliant colours.  But, when the eye has
     acquired a larger volume, and the whole
     crystalline has become opaque, the retina
     at last remains  in  a state of  paralysis,
     from the excessive distention, and, conse-
     quently,  is no  longer sensible to  such
     few rays of light as  reach the bottom of
     the eye, by insinuating themselves at the
     sides of the lens.
       In the  last stage of the disease,  (con-
     tinues the above celebrated surgeon) when
     the dropsical eye projects from the orbit,
     so as not to  admit of being covered by
     t he eyelids, with the  inconveniences al-
     ready enumerated, others associate them-
     selves, arising from  the friction  of  the
     cilia:, the secretion  of gum, the flux of
tears, the ulceration of the lower eyelid-,
on which the eye  rests, and the excoria-
tion  of the eye itself.  Hence, the drop-
sical eye is gradually attacked by violent
ophthalmies,  attended with  intolerable
pains ofthe part affected, and of the whole
head.  The ulceration, also does not al-
ways confine  itself within certain limits;
but  continues  to spread,  first depriving
the cornea of  its  transparency, next con-
suming the sclerotica, and lastly, destroy-
ing  progressively the other component
parts of the eye-ball.
   At the first appearance of the dropsy
of the eye,  the masters of the art recom-
mend the internal administration of  mer-
curials, the extract of cicuta, and of Pul-
satilla nigricans; and   the external em-
ployment of astringent and  corroborant
collyria, making a  seton  in  the nape of
the neck, and compressing the eye, which
forms a  preternatural  projection out of
the  orbit.  As far, however, as Scarpa
can judge, from the events of observations
made  by the  best  practitioners on this
point, he has never yet met with a single
well-detailed  history of a dropsy of the
eve  cured by means  of  the above-men-
tioned  internal medicines.  With regard
to externals, he has learnt, from his own
experience, that, when the disorder is
manifest, astringent, and corroborant col-
lyria, as  well  as compression on the pro-
tuberant eye, are highly prejudicial.  In
such circumstances, making a seton in the
nape of the neck, frequently  bathing the
eye in a lotion of mallows, and  applying
to it a plaster composed ofthe same plant,
have enabled  him to  calm, for a time,
that disagreeable sense of distention in
the orbit, and over the  forehead,   and
temple ofthe same side, of which patients
in this state make so much complaint,
especially when they are  affected with a
 recurrence  of ophthalmy. But, as  soon
 as the eye-ball begins to protrude  from
 the orbit, and project beyond the eyelids,
 there is  no means of opposing the very
 grievous dangers, which the dropsy ofthe
 eye threatens, except  an operation", which
 consists in evacuating, by an incision, the
 superabundant humours from  the  eye,
 then exciting gentle inflammation of the
 membrane, and  suppuration on the inte-
 riour of this organ, so as to  make it con-
 tract, and shrink into the bottom of the
 orbit.  To defer the operation any longer,
 would be abandoning the patient to the
 constant inconvenience  of  an habitual
 ophthalmy, the danger of an ulceration
 of the eye-ball and subjacent eyelid, and,
 what is worse, of carcinoma of the whole
 eye, with great peril to tha patient.
   Scarpa next states, that, in  order to
 fulfil the preceding indication, of evacu- 
113
HYDR0PHTHALM1A.
 ating the superabundance of aqueous hu-
 mours lodged in the eye, the paracentesis
 of the ey e-ball has been greatly extolled
 iii past times —Nuck, one of the promo-
 ters of this operation, punctured the eye
 with a trocar, exactly in the centre of the
 cornea.  (De Duct. OcuL Aquos, p.  120.)
 It has since been thought better to punc-
 ture the eye-ball  in the sclerotica,  at
 about two lines from the junction of this
 membrane  with the cornea,  that such a
 small quantity of the vitreous humour
 may be more easily discharged  at the
 same time with the aqueous, as may  be
 deemed adequate to effect a  diminution
 in the  morbific enlargement  of the eye-
 ball.
   Notwithstanding the approbation, says
 Scarpa, which the most celebrated sur-
 geons have conferred on this method of
 operating  for  the dropsy  of the eye, it
 has at present fallen into disuse, as in-
 sufficient, and ineffectual for the purpose.
 This will not appear surprising to  such
 as are acquainted with our present know-
 ledge of the  animal economy, particu-
 larly in regard to the lymphatics, and are
 not ignorant how  little reliance can be
 put in paracentesis, as a means of curing
 chronic dropsy in general, especially that
 of the tunica vaginalis, termed hydrocele.
 Indeed, the radical cure of the latter is
 never accomplished, except when the ad-
 hesive inflammation  takes  place  in the
 tunica  vaginalis and  albuginea, after the
 evacuation  of the  fluid, or  when  these
 membranes suppurate, ulcerate, or con-
 tract an intimate adhesion together, which
 remove every  opportunity, every possi-
 bility of a fresh accumulation of water in
 the scrotum.  If it has sometimes  hap-
 pened, that  the puncture has  radically
 cured the hydrocele, it is because it has,
 by some unexpected incident,  excited in-
 flammation of the vaginalis and albuginea,
'so as to produce a coalescence of these
 two membranes.
   In consequence of these principles, (con-
 tinues Scarpa) the paracentesis of the eye,
 directed wholly for the discharge of the
 superfluity of humours in this  organ, can
 never be a means of curing the dropsy of
 the part, unless the puncture, made by the
 trocar, excite, at  the  same time, inflam-
 mation and suppuration, and afterwards
 a concretion of the membranes composing
 the  eye-ball.  Indeed Nuck relates,  that
 in a young man at Breda, on  whom he
 had operated, he was obliged to puncture
 the  eye five several times ; that, on the
 fifth time of doing this, it was necessary
 to suck through the  cannula of the tro-
 car, in order to evacuate the greatest pos-
 sible quantity  of the vitreous  humour;
 and, lastly, that it seemed proper to intro-
 duce a plate of lead, between the eyelids
 and eye-ball, for the purpose of making a
 continual pressure on the eye, in its empty,
 shrivelled  state.   In  a  woman of  the
 Hague, he mentionstthat he twice punc-
 tured the eye in vain; and that this per-
 son submitted,  two or three other times,
 to the same operation, but he omits  add-
 ing with what degree of success.  Scarpa
 has no  difficulty in believing,  that a ra-
 dical cure of" the dropsy has sometimes
 been accomplished by means of the punc-
 ture,  after the  trocar, and other similar
 hard substances, have been repeatedly in-
 troduced into the eye, through the  can-
 nula of that instrument; but this success
 can never be attributed to the mere eva-
 cuation of  the superabundance of the vi-
 treous and aqueous humour;  tnough it
 may be referred to that,  conjoined with
 the  irritation produced by the cannula,
 and, consequently, to the adhesive inflam-
 mation or suppuration excited in tlie in-
 ternal membrat-.es of the eye.  It is by no
 means unlikely,  that,  after having learnt
 this practical point  from experience, and
 wishing to  insure the success of the para-
 centesis in  the radical cure of the dropsy
 of tiie eye.  Woolhouse may have directed
 that, when the cannula is introduced in
 the eye,  it should be rolled at least  six
 times  between   the  fingers;  and   that
 Platner,  following the  same steps,  may
 have proposed  to  inject  a  warm  fluid
 through the cannula into the cavity of the
 eye,  after having evacuted. the humours,
 by means of a trocar; and that Mauchart
 may have directed keeping open the wound
 made in the eye by the trocar,  by means
 of a small tent of  lint. If all  these cir-
 cumstances prove,  on one side,  the ineffi-
 cacy of  the paracentesis  in the radical
 cure of tlie dropsy of the eye, they  evi-
 dently shew, on the other,  that the perfect
 cure of this infirmity can only be achieved
 by evacuating tiie humours contained in
 the eye; and exciting, at the same time,
 a  certain degree  of  inflammation,  and
 suppuration, of the  internal membranes
 of the organ
  The most easy and expeditious  way
 hitherto known, of obtaining all these ad-
 vantages,  is  undoubtedly  that which is
 explained in tlie  account of the radical
 cure of the  inveterate staphyloma, pro-
 truding out of the eye-lids.  (See Stafthy-
 loma.)   With  respect to this subject,
 Scarpa cannot refrain from repeating, at
 this opportunity,  that it  is exceedingly
disadvantageous, and even dangerous, to
 make the circular section ofthe dropsical
eye-ball in  the  sclerotica.  In  fact,  this
circular recision, when  performed in the
 sclerotica, is constantly followed by the
 most aggravated symptoms, particularly, 
HYDltOPH I" HALMIA.
119
 frequent  hemorrhages, an accumulation
 of grumous blood  at the bottom of  the
 eye-ball,  \ciiement inflammation of  the
 eye, eyehu>, and head, obstinate vomit-
 ings, convulsions, delirium,  and the most
 imminent danger  to  the  patient's  life.
 Such modern surgeons, as have faithfully
 published the results of their practice on
 this point, among whom, Marchan (Jour-
 rial de Med. de Paris. Janvier,  1770.  Sur
 ileux Exophthalmies, on grosseurs contre na-
 ture du  Globe de I'QSU.J and Terras, (Ibi-
 dem; Mars. 1776.  Sur  I'Hydrophthalmie.
 next to Louis,  (Memoires de Chirurg, t.
 13, p.  2»9, 290.)  merit infinite praises,
 have ingenuously declared that, after per-
 forming the circular recision of dropsical
 eyes in  the sclerotica,  they have  had the
 greatest  motives for  repenting of what
 they had done
   The circular section, as broad, or rather
 broader than a  large  lentil-seed, is per-
 formed at the  summit or centre of  the
 cornea  of the dropsical eye,  according to
 Celsus's direction relative to the staphy-
 loma, is exempt from the serious conse-
 quential symptoms  that Scarpa has just
 mentioned.  By means of this operation,
 which is by no means painful, an opening
 is made for the evacuation ofthe humours
 ofthe eye, and internal inflammation  is,
 at  the  sums  time, excited.  These  ob-
 jects are accomplished, also, without oc-
 casioning such a sudden  subsidence,  and
 emptiness, of the membranes of the  whole
 eye, as  necessarily happen when a circular
 incision is made in the  sclerotica,  and
 gi*eatly affect the nerves of this organ,
 and  the parts sympathizing with it, par-
 ticularly  the head  and  stomach.  This
' intimate  sympathy, perhaps, is  not  the
 least of  the causes producing the fatal
 consequences  above   specified;  besides
 those very serious  ones, which necessa-
 rily  result from  the almost sudden expo-
 sure of a large surface  of the deeper part
 of the eye to the contact of the air,  and
 from the  lotions which are,  in these  cir-
 cumstances, often employed.
  With regard to the manual of the ope-
 ration,  it  is exactly the same as what is
 detailed in the article Staphyloma.  In  the
 dropsical  eye,   whether the  cornea  be
 transparent or not,  since the function of
 the immediate organ of sight is irrevoca-
 bly lost, as Scarpa has  already stated,  the
 surgeon must  introduce a small bistoury
 across the apex, or middle ofthe cornea,
 at one  line and a  half from its central
 point; and  then, by pushing the instru-
 ment from one towards the other canthus
 of the eye, he will cut  the lower part of
 tlie crtrnea in a semicircular manner. The
 segment of the cornea being next elevated
 with the forceps, the operator is to turn
 the edge of the knife upward, and com •
 plete the work by a circular removal of as
 much of the centre of the cornea as is
 equal, in size, to a large lentil-seed,  or
 three  lines in diameter, supposing  the
 patient to be in the adult state.  Through
 this circular opening, made in the centre
 ofthe cornea, the surgeon may, by means
 of gentle pressure,  discharge as much of
 the superabundant humours in the eye,
 as is requisite to  make the eye-ball dimi-
 nish, and return into the orbit,  so  as to,
 be covered,with the eyelids.  As for the
 rest of the humour lodged in the eye, it
 will gradually escape of itself, through
 the circular opening in the cornea,  with-
 out any more pressure being made.
   Until the appearance  of the inflamma-
 tion, that  is, until the third  or fifth day
 after the operation,  the dressings are  to
 consist of the application of a pledget of
 dry lint, supported  by a retentive band-
 age.   As soon as the inflammation and
 tumefaction  invade the eye operated on,
 and theeye lids, the surgeon is to employ
 such internal remedies as are calculated
 to moderate the progress of inflammation;
 and he is  to cover the  eyelids with  a
 bread and milk poultice, which must be
 renewed at least once every two hours. It
 is a  very frequent phenomenon, both in
 the staphyloma and dropsy of the eye,
 that, on the first appearance of inflamma-
 tion, the eye-ball o* which the operation
 has been done,  augments, and protrudes
 again  from the eyelids,  in the same way
 as before the operation.   In this circum-
stance, it is proper to cover the projecting
 f»art of the eye-ball with a  piece of fine
 inen,  smeared with a liniment of oil and
 wax, or the  yolk of an  egg,  and  oleum
 hyperici; the application  of  the   bread
 and milk poultice being continued,  as be-
 fore-mentioned, over this other  dressing.
 Scarpa next states, that, when suppuration
 of the  interiour of the  eye manifests it-
 self, the swelling of the eyelids at  the
 same time decreases, and the eye-ball di-
 minishes in size, returns gradually into
 the orbit, and continues to contract itself.
 This state of suppuration may be known
 by observing, that  the dressings  are
 smeared with a viscid  lymph, blended
 with a portion ofthe humours  of the eye,
 which incessantly issue  from  the  centre
 of the cornea; and  by noticing the ap-
 pearance of the  margin  of the recision,
 which is changed into a circle of a whitish
 substance,  resembling the rind of bacon.
 In the progress of the case, this whitish
 circle,surrounding the place ofthe recisiorr
 of the cornea, becomes  detached,  like a
 slough, so as to leave a small  ulcer, of a
 very healthy colour.  This ulcer, as welt
 as the whole eye-ball, contracts, so  as  to 
  120           H Y M

  become  entirely  closed, and cicatrized,
  leaving every opportunity  for the placing
  of an artificial eye between the eyelids and
  the stump of the eye-ball.
    Although, in the majority of cases, the
  circular recision of the centre of the cor-
  nea, equal in size to a large lentil-seed,
  proves sufficient to excite a mild inflam-
  mation, and suppuration, in the interior
  of the eye of  an  adult  subject, yet^ if
  this occurrence does not take  place on
  the fifth day, it is useful  to expose the
  eye, on which the  operation has  been
  done, to the  air;  or, as is stated in the
  article Staphyloma, it is useful to remove
  a  circular portion of the cornea, halt a
  line in breadth, or little more, by means
  of the forceps  and curved scissars.   This
  gives the patient  neither  pain  nor any
  other inconvenience,  and produces the
 desired effect,  viz. it makes the interior
 cf the eye, at length, inflame and suppu-
 rate mildly, without  which it is  impossi-
 ble to effect a perfect cure.  (Scarpa sulle
 Principali Malattie degli Occhi, cap. 13.)
   HY'DROPS.  (from ofy,  water)  A
 dropsy, or morbid accumulation of water.
 For hydrops articuli, refer to Articulation.
 With regard to hydrops pectoris, Ivydrotho-
 rax, or dropsy of the chest, as it is altoge-
 ther a medical case, an  account of its
 symptoms and  treatment will hardly be
 required  in this Dictionary.   The  only
 concern which a surgeon  has with  the
 disease, is being occasionally required to
 make an opening for the discharge of the
 water: this operation is described in Pa-
 racentesis Thoracis.
    HYDROSARCOCELE.   (from cJ^wf,
 water: «•«£|} flesh ; and *j>Aj}, a tumour.)
 A morbid enlargement of the testicle, at-
 tended with a  collection of fluid in  the
 tunica vaginalis.
   HYMEN IMPERFORATE. The incon-
 veniences brought on by such a cause and
 the mode of relief, are explained in the
 article Vagina.
   A  continuation  of the  hymen over a
 part of the orifice of the meatus urinarius
 may produce great pain and difficulty in
 making water, aid symptoms, which  may
 give rise  to  suspicion of there being a
 stone in the bladder.
  The following case  illustrates  this ob-
 servation.   "In  the  year  1740, (says
 Mr. Warner) I was consulted in the  case
 of a httle girl, about three years old,  who
 had long  laboured  under  such severe
 symptoms in voiding her urine, as to make
 it suspected by her physician, that she had
a stone in  her  bladder.  L'pon enquiry,
I was  informed, that her  urine came
away by drops,  that she was  inclined to
put her hand to the pudendum when she
              H Y P

 made water, and that, at that time, she
 could not help crying and stamping  with
 her feet.  These symptoms  so nearly re-
 sembled thofce of the stone, that I thought
 proper to propose the passing a stall uito
 the  bladder that we might be  satisfied,
 whether there was a stone, or any other
 disease  of the urethra, or  bladder;  but,
 upon endeavouring to  do it, I observed,
 that the urethra was at least half covered
 over with a  continuation of the hymen,
 which appeared  imperforated;  for  this
 reason, 1 could with difficulty execute my
 design.   However, I effected  the intro-
 duction  of the instrument into the blad-
 der,  without using much violence;  but,
 there was no stone, nor any other preter-
 natural  appearance to be discovered in
 the  bladder, or  the urethra.  For  this
 reason, I  pronounced, that  the difficul-
 ties and pains, which arose in discharging
 the urine, probably proceeded  from  the
 size  and  situation  of this membrane;
 which I  divided by incision  with a small
 knite," &c.  The  patient was cured in a
 few days.  (See Wanteds Cases in. Surgeiy,
 p. 276, edit. 4.)
   HYPOPYON, or HYPOPIUM.  (from
 u7ro, under;  and zrt/ov, pus.)
   By hypopium (says  Scarpa) I imply,
 with  all surgeons,  that accumulation of a
 glutinous, yellowish fluid, like pus, which
 take place in the anterior ehamber of the
 aqueous  humour,  and, frequently, also in
 the posterior one,  in  consequence of se-
 vere, acute ophthalmy,  particularly  the
 internal  species.    I  have explained, in
 speaking of  inflammation of  the eyes,
 that,  though the severe, acute oplithalmy
 particularly affects the externtd parts of
 the eye, in the majority of instances; yet,
 it  occasionally invades,  with equal vio-
 lenee, both  the external  and  internal
 coats of this  organ, especially  the cho-
 roides and uvea.   In this last  circum-
 stance, if  the inflammatory diathesis, af-
 fecting the interior of the  eye, be  not
 promptly checked  and subdued, by  the
 most  effectual chirurgical means, coagu-
 lating lymph  is extravasated  from  the
 highly inflamed choroides and uvea, and
 gradually,  as it is effused into  the cavity
 of the eye, it passes through the pupil,
 into the chambers ofthe aqueous humour,
 and descends to the bottom  of the ante-
 riour  one, so as  to  fill  sometimes  one
 third, sometimes one half of this space;
 and, occasionally, to occupy it to such a
 height, as totally to conceal the iris and
pupil.
  This viscid matter of the hypopium is
commonly  called pus; but Scarpa con-
tends that it is only coagulating lymph.
The  symptoms portending  an extrava-
sation of coagulating  lymph in the eye, 
HYPOPIUM.
121
r* Sth hypopium, are the same as those
which occur in  the  highest stage of vio-
lent acute ophthalmy:  viz.  prodigious
tumefaction ofthe eye-lids ; the same red-
ness and swelling of the conjunctiva, as
in chemosis; burning heat and pain in
the eye; pains in tlie  eye-brow  and nape
of the neck ; fever,  restlessness, aversion
to the faintest light, and a  contracted
state ofthe pupil.
  As soon as the hypopium  begins to
form, (says Scarpa)  a  yellowish semi-
lunar streak makes its appearance at the
bottom of the anterior chamber, and, re-
gularly, as the glutinous fluid is secreted
from the inflamed internal membranes of
the eye, so as to pass through the  pupil,
and fall  into the aqueous humour, it in-
creases  in  all dimensions, and gradually
obscures the iris, first at its inferior part,
next, where it forms the pupil, and last-
ly, the whole circumference of this mem-
brane.   As long as the inflammatory stage
of the violent ophthalmy lasts, the hypo-
pium never fails to enlarge ; but,  imme-
diately  this stage ceases, and  the oph-
thalmy  enters its second period, or that
dependent  on local weakness, the quan-
tity  of coagulating  lymph, forming the
hypopium,  leaves  off  increasing,  and,
from that moment,  is disposed to dimi-
nish.
  This fact sufficiently evinces (continues
this eminent Professor)  how important it
is,  in order to check the progress  of the
hypopium,  to  employ  with  the  utmost
care, the most effectual means for check-
ing and resolving the attack of  violent
ophthalmy, in  its  first stage.  Copious
evacuations of blood,  both generally  and
topically, ought to  be  speedily put into
practice; and when  chemosis exists, the
conjunctiva should be divided; mild ape-
rients, blisters  to the nape of the neck,
little bags of emollient  herbs, applied to
the eye,  and other measures of this kind,
described on the subject of the first stage
of severe acute ophthalmy, ought to be
employed.  It  will  be  known that they
have fulfilled the indica'tion,  by noticing
that, solne days after the adoption of such
treatment, though there may still he red-
ness, ofthe conjunctiva and eyelids, the
lancinating pains in the eye abate, the
heat considerably diminishes, the fever
subsides, quietude and sleep are restored,
the motion of the eye becomes  free, and,
lastly,  the collection  of viscid  matter
forming the hypopium, becomes station-
ary.  It is not unfiequent to  see, espe-
cially among the lower orders of the peo-
ple, persons affected with the second stage
of severe acute  ophthalmy, bearing this
collection of  coagulating  lymph, in the
chambers  of the aqueous humour, with
    Vol. 11.
the greatest indifference,  and  without
complaining  of any of those  symptoms
which characterize the acute stage of oph-
thalmy.  It is only at this crisis, or at the
termination of the acute stage of violent
inflammation of tlie eye, that the enlarge-
ment ofthe hypopium ceases, and the co-
agulating lymph begins to be, absorbed,
provided this salutary  operation  of na-
ture be not impeded, nor retarded, by any
injudicious regimen.
  Scarpa states, that persons, little vers-
ed in the treatment of diseases of the eyes,
would  fancy  that  the  most expeditious
and efficacious mode of curing an hypo'
piuwi, after  it has become stationary  in
the second stage of severe acute ophthal-
my, would be that of opening the cornea
at its  most depending part, in order  to
procure a speedy exit for the matter col-
lected in the chambers  of the aqueous hu-
mour;  especially, as this is also the com-
mon doctrine.   But experience  shews,
that dividing the cornea, in such circum-
stances, is  seldom  successful, and most
frequently gives rise to evils, worse, than
the hypopium. itself,  notwithstanding the
modification suggested by Richter, (Obs.
C/iir. Fasc. 1, 'Chap. 12.) not to evacuate
the whole of the matter at once,  nor to
promote its discharge by repeated pres-
sure, and injections, but to allow it to flow
slowly  out of  itself.  The wound made
at the lower part of the cornea,  for eva-
cuating the matter of the hypopium, how
small  soever the incision may be, most
commonly reproduces  the severe  acute
ophthalmy,  and occasions a greater effu-
sion of  coagulating lymph in the  cham-
bers of the aqueous humour, than existed
before.  Besides, after  opening the cor-
nea, the matter of  the hypopium,  if al-
lowed to escape gradually, and  in drops,
of its own accord, would be several days
in becoming completely discharged, on
account of  its  viscid  quality.   During
this space of time, the  glutinous lymph
would keep the edges ofthe wound ofthe
cornea dilated, and make them suppurate.
Thus  the  incision  would  be cor.wrted
into an  ulcer, through which the aqueous
humour, situated behind the coagula t inn;
lymph,  would escape,   and r.ew even  a
told of the  iris.  Opening the conea,
therefore, only converts  the  hypopium
into an ulcer of that membrane, attended
with a prolapsus  of the  iris, and i cca-
sionally ofthe crystalline itself.  No:- can
any inference be. drawn in favour of mak-
ing an  artificial opening during  tlie.st.^
tionary  state of an  hypopium in the se-
cond stage of severe acute ophthaiiiiy.f.om
the matter of the hypopium having some-
times made its way spontaneously through
a narrow aperture in the cgmea, with  a 
122
HYPOPIUM.
successful result*  For, there is a wide
difference, between the effects of a spon-
taneous opening into a natural, or pre-
ternatural cavity of the animal body, or
of one made with caustic, and the conse-
quences of an opening, made  with  a cut-
ting instrument.  In  the  two  first  me-
thods,  the subsequent symptoms are con-
stantly milder than in the  last.  Besides,
even in the  instance, in which  a sponta-
neous  exit of the hypopium  takes place
through  the  cornea, an  escape of the
aqueous humour, and a prolapsus of the
iris not unfrequently ensue;  consequent-
ly,  the spontaneous evacuation of the hy-
popium cannot justly form a  rule for the
treatment of the disease.  There is only
one case, in  which dividing  the cornea,
in < • der to discharge an hypopium, is not
only useful, but indispensable: this is,
when there is  such an immense quantity
of coagulating lymph, extravasated in the
eye, that the excessive distention,  which
it produces of all the coats of this organ,
occasions  such  vehement symptoms, as
not only  threaten  the entire destruction
of the eye, but even endanger the life of
the patient.  But,  this  particular case
cannot serve  (says Scarpa) as  a model,
for the treatment of the  hypopium, usu-
ally met with in practice.
  Besides, if it be  certain, that blood ex-
travasated in the eye in consequence of
blows, and what is still more  remarkable,
that even the membranous flakes of the
capsular cataract,  pushed by the needle
from the posterior  into the anterior cham-
ber, are  insensibly  dissolved, and, at
length, entirely absorbed, if it  be the
same with milky, and caseous  cataracts,
that have been iacerated as much as pos-
sible;  and even  with the crystalline  lens
itseltj  when deprived of its capsule, and
depressed into  the  vitreous humour by
the operation; (see Cataract/)  there'ean-
not be a doubt, as  Scarpa states, that ab-
sorption will take  place,  in  the case of
coagulating  lymph extravasated into the
chambers ofthe aqueous humour, as soon
as the source of this extravasation of glu-
tinous  fluid   no longer  exists, and the
lymphatics of the eye have recovered their
original  energy.
  Hence the resolution of the hypopium,
by  means of absorption, forms the pri-
mary  indication, at which  the surgeon
should aim  in the treatment of the com-
plaint.  We have already observed, that,
in  order to  stop  its progress, the only
truly efficacious method is to subdue the
first shock  of the inflammation, and .to
shorten the acute stage of the severe oph-
thalmy, by  the free  employment  of the
antiphlogistic treatment, and the  use of
mild*  emollient, topical remedies.
  If this plan of treatment  answer the
wishes of  the practitioner,   (continue*
Scarpa) as  in the  majority  of cases it
does, the incipient collection of coagulat-
ing lympK, at the bottom of the anterior
chamber of-the aqueous humour, not only
ceases to augment,  but, also, in propor-
tion as the severe ophthalmy disappears,
the absorbent system takes up the hetero-
geneous  fluid extravasated in the eye,
and the white, or yellow speck, shaped
like a crescent, situated at the bettoin of
the  anterior chamber, gradually dimin-
ishes, and  is at  last  entirely dispersed.
Janin  considered  the  infusion  of the
flowers of  mallows, applied  to the eye
that is inflamed and affected with this dis-
ease, as a specific resolvent  in these cir-
cumstances.  (Jlfem. et Obs.  suri'CEil, p.
405;) but, it  is  now  known, that every
topical  emolient  application,  provided it
be conjoined with such internal antiphlo-
gistic treatment, as  is the most proper for
repelling  the  ficute stage of the severe
ophthalmy,  produces quite as good  an
effect as  this  infusion.    Simple  warm
water produces  the same - benefit.   " A
young girl, (writes the celebrated  prac-
titioner Nannoni) was struck in the eye by
an ear of corn.  An inflammation was the
consequence,  which produced  a  white
pus of a  semilunar shape, apparently be-
hind the cornea, without  a possibility of
judging, whether the matter was actual-
ly  situated  between the  laminae of that
membrane,  or in the  anterior chamber.
Hence, I was asked whether  it might not
be evacuated by an  incision, particularly,
as the patient complained of great pam
in the eye,  and eye-brow.  She  was in
the hospital; and in the presence of Dr.
Lulli, and several students in surgery,  I
saiii that  the  pain  of which the patient
complained, was  not  occasioned by the
pus itself, but the cause which produced
it.   This cause was inflammation, which
probably  would  be increased by making
a larger opening for the external air, than
what it has to the  internal  parts,  while
the external ones remain  entire.  By fo-
menting the eye and forehead with warm
water, the  inflammation  subsided, and
the pus disappeared.  We have so often
witnessed the fact subsequently, that we
can idso extol the simplicity of the treat-
ment.'   Such, in short is the happy ter-
mination of an hypopium, whenever the
disease  is properly  treated at its com-
mencement, and  the acute stage of the
severe  ophthalmy   has  been promptly
checked,  and  repelled by  internal anti-
phlogistic meaiib,  and eniolient applica-
tive* to the eye.  But, in consequence of
the inflammatory period  of the  severe
ophthalmy  having  resisted  in  an un- 
                                     HYPOPIUM                              123

   common manner the best means, or be-  intervals, the vapours of the spir. ammon.
   cause such  means have  been employed  comp. mentioned in the article Ophthalmy,
   too late, it sometimes happens, that the  may be applied, and recourse had again
   coagulating  lymph, effused  in the eye,  to  a blister on the nape of the neck.
   and collected in the anterior chamber,  is  When the extreme sensibility  of the eye
   so abundant, even after the acute stage of  is overcome, the simple vitriolic collyriura
   the ophthalmy, that it  continues *for a  must be used again, strengthening it after-
   long time to cloud the eye, and intercept  wards by the addition of a few drops of
   vision.  Scarpa  has often  seen patients,  camphorated spirit of wine.   Under such
   especially  paupers,  who  from indolence,  treatment,  proceeds Scarpa, the surgeon
   negligence, or ill treatment, have remain-  may observe, that,  in proportion  as the
   ed, a long time after the cessation of the  chronic ophthalmy  disappears, and the
   inflammatory stage of  ophthalmy, with  action of the absorbents is re-excited, the
   the anterior chamber almost entirely fill-  tenacious matter of the hypopium divides
   ed  with the  glutinous  matter of hypo-  first into several small masses; then dis-
   pium.   When  the inflammation  cease*,  solves still  further; and, afterwards, de-
   these unhappy persons wander about the  creases in  quantity; depending towards
   streets almost quite indifferent, and with-  the inferior segment of the cornea ; and,
   out complaining of pain,  or any other in-  finally, vanishing altogether.  But Scar-
   convenience, than the difficulty of seeing  pa accurately observes, that the surgeon
   with the eye  affected.   In this  second  cannot always  expect to be  equally suc-
   stage of the ophthalmy, the resolution of  cessful, whether the disease occur during
   the hypopium obviously  cannot  be ac-  the first,  or second stage of violent acute
   complished by the same means, nor with  ophthalmy, if the tenacious lymph, sud-
   equal celerity, as in the first   At this cri-  denly extravasated in the interior  of the
   sis, the  great quantity, arid density 'of the  eye, prevail in such quantity, as not only
   glutinous matter extravasated, and the  to fill, but strongly distend, the two cham-
   atony of the vascular system of the eye,  bers of the  aqueous  humour, and the cor-
   make it necessary to give nature  suffi-  nea  in particular.   Notwithstanding the
   cient time, to dissipate the  thick,  tenaci-  most skilful treatment, in this state of the
   ous matter ofthe hypopium, and, at length,  complaint,  the unpleasant complication
   to dispose it to be insensibly absorbed  is  often followed by another inconveni-
   with the aqueous humour which  is con-  ence, still worse than the  hypopium it-
   tinually  undergoing a renovation.  Hence,  self; viz. ulceration, opacity, and burst-
   it is right, (says Scarpa) to adopt these  ing of the cornea, at that point of its cir-
   means, which are best calculated to invi-  cumference, or centre opposite the pupil,
   gorate the debilitated tone of the vascular  where there is the smallest resistance to
   system of the eye,  more especially the  the pressure.
   lymphatics.  This requires  more or less    The ulceration of the cornea ordinarily-
   time, according as the patient is advanc-  takes place  with  such celerity, that the
\   ed in years, of a relaxed fibre, and weak;  surgeon seldom  has  time to prevent it.
   or a young man of good constitution.       As soon as  an aperture has formed, the
     However, in the second stage of violent  excessive abundance of coagulating lymph,
   acute ophthalmy, complicated with hypo-  contained in the  eye, (sometimes named
   pium, the  surgeon,  according to Scarpa,  empyema oculi) begins to escape through
   should limit his efforts to the removal of  it, and a degree of relief  is experienced.
   every thing, which may  irritate the eye,  But, this melioration  is not of long con*
   or be  likely to renew the inflammation;   tinuance ; for, scarcely is  the glutinous
   and he should only employ such means, as  fluid e^cuated, that distended the whole
   are conducive to the resolution of the se-  eye, and especially the cornea, when it is
   cond inflammatory  stage, depending on  followed by a-portion of tlie iris,  which
   relaxation of the conjunctiva and its ves-   glides through  the  ulcerated aperture,
   sels, and such  remedies   as tend, at the   protrudes externally, and constitutes the
   same time, to invigorate the action ofthe   disease termed,  prolapsus  of the  iris.
   absorbents.  Therefore, in this state, he   (See Iris,  Prolapsus of)   But, if  in such
   ought first to examine carefully the de-   an emergency, the  cornea already  ulce-
   gree of irritability in the eyeaffected with   rated, opaque, and  greatly  deranged  in
   the  hypopium, by  introducing, between   its organization, should not immediately
   the eye and eyelids,  a few drops of vitri-   burst, the surgeon is then constrained by
   olic collyrium, containing the mucilage  the violence of the symptoms, depending
   of quince-seeds.   Should the eye seem too   on the prodigious distention of the  eye-
   itrongly  stimulated  by  this application,   ball,  to make an artificial opening in this
   it must not be used, and little bags of  membrane,  in order to relieve the im-
   warm mallows with a few grains of cam-   roense constriction, and even the danger
   phor are  to be  substituted for it.  In fee   in which life is placed.  The practitioner 
124            I X C
IXC
Will do this the more readily,  as, in such
circumstances,  there is little hope of pre-
serving the organ of vision. Scarpa adds,
that the pain" in the eye, and whole head,
is often so severe in this case, as to cause
delirium.
  Were there the least chance of restor-
ing, in  any degree, the transparency of
the cornea, and the functions of the or-
gans of vision, after opening the cornea,
it would certainly be more prudent to
make the opening at the lower part of
this membrane, as is practised in the ex-
traction of the cataract.  But, in the  case
of empyema of the eye, now considered,
in which  the cornea is universally  me-
naced  with ulceration and opacity,  and
seems ready to  slough, there is no hope of
its resuming its transparency at any point.
The best, and most expeditious, method
of relieving the patient from the terrible
pain, which he suffers, is, according to
Scarpa, to divide  the centre of the cor-
nea withti small bistoury to the extent of
a line and  a  half; then to raise with  a
pair of forceps the little flap, and  cut it
away all round with one  stroke of  the
scissars, so as to  make in  the  middle of
this membrane an  opening of about the
size of a lentil-seed.
  The most fluid  part of the matter, dis-
tending  the eye,  immediately  escapes
through this  opening, the lips of which
cannot  close, like  those of  a simple in-
cision.  Successively  afterwards, the co-
agulating lymph, and the chrystalline lens,
take the same course, and also, in a few
days, the vitreous humour.  The surgeon
should  refrain from promoting the escape
of  the latter by strong pressure  on the
eyeball; experience proves, that, msuch
cases, it  is best to allow it to  flow out
spontaneously.                  .
  Immediately  after the operation, the
surgeon must cover the eye with a bread
and milk poultice, which is to be  renew-
ed every  two hours, not neglecting tlie
ut,e of such general remedies, as are cal-
culated, to check the  progress of acute
inflammation,  and to  quiet the alarm of
the nervous  system.  In proportion as
the interior of  the eye suppurates, the
eye-ball gradually diminishes, shrinks into
tne orbit, and at length cicatrizes, leaving
things in a favourable state for the appli-
cation of an artificial eye.
  However, Scarpa infers from the whole
of what has just been said, that making
an incision into the  cornea is as danger-
ous, and useless, in the  case of hypopium
ordinarily met with in  practice, as it is
necessary in the instance of empyema of
the eye, attended with  the  aggravating
symptoms  above-mentioned,  and irreme-
diable opacity of the cornea.
  The foregoing remarks, which are some
of  the best ever offered on the subject,
were first published  by Professor Scarpa
in Saggio di Osservazioni e d* Experience,
sulle PrincipaU Mallattie degli Occhi;  Ve-
nezia, 1802.  Another excellent writer on
hypopium is Richter :  see Anfangsgrtmcle
der 'IVwidarzneykunst, Band. 3.1795. Con-
sult also Essays on the morbid Anatomy of
the Human Eye: by J.  Wardrop, Chap. 6.
Edinb. 1808.
   HYSTEROTOMIA. (from *a-Tt%*t the
womb, and rtfMot, to cut.) See Cesarean
 Operation.
I.
    rIPERFORATE HYMEN.   See  Va-
    gina.
  INCARCERATION,  (from incarcero,
to  confine.)  This  term  is usually.ap-
plied to cases of hernia,  in the same sense
as strangulatiou.  When the viscera are
pressed  upon  either . by  the  opening
through which they protrude, or  by the
parts themselves  within the hernial  sac,
in such a degree, that the course of the
intestinal matter to the  anus is obstruct-
ed, and nausea, sickness,  pain, and  ten-
sion of the swelling and  abdomen, &c.
are occasioned, the rupture is said to be
affected with incarceration, or strangula-
tion.
  According to Professor Scarpa, how-
ever,  an incarcerated, and a strangulated
hernia, do not  imply exactly the  same
tiling.   In the first  case,  says  he, the
course of the intestinal  matter is  inter-
rupted,  without  any  considerable im-
pairment ofthe texture, *or vitality of ihe
bowel   On the contrary, in the strangu-
lated hernia, besides  the obstruction to
the course of the fecal matter, there  is
organic injury of the coats of the intestine,
with loss of its vitality.   The bowel, that
is merely incarcerated, resumes its func-
tions immediately  it  is replaced in the
abdomen ; while  that, which  is  truly
strangulated, never returns to its natural
state.  (See  Scarpa's Traite des Hernies,
p. 251.)
  This distinction, however,  which Scar-
pa has drawn, is  by no means  generally 
INC
IN F
125
adopted, incarceration, and strangulation
being used as synonymous terms.
  INCISION, (from  incido, to  cut.)  A
wound made with a sharp cutting instru-
ment.
  INCONTINENCE  OF  URINE.  An
inability of the bladder to retain this fluid,
which should not be discharged without
the concurrence of  the will.  See  Urine,
Incontinence of.
  INDURATION,  (from induro, to har-
den.)  A morbid hardness of any part.
  INFLAMMATION,  (from  inflammo,
to burn.)  By the term,, inflammation,  is
generally understood, the state of a part,
iii which it is painful, hotter, redder, and
somewhat more turgid, than it naturally
is; which topical symptoms, when pre-
sent in any considerable degree, or when
they affect very sensible parts, are attend-
ed with fever, or a general  diseased ac-
tion of the system. (Burns.)
   The susceptibility of the  body  for in-
flammation is of two kinds;  the one ori-
ginal, constituting a  part of the  animal
economy, and beyond the reach of human
investigation ; the other ucquired from the
influence of climate,  habits  of life, and
state of the mind over  the  constitution.
 (Hunter.)   The first kind of susceptibi-
lity,  being innate, cannot be diminished.
by art; tlie  second may  be lessened by
 the  mere  avoidance of  the  particular
 causes, upon which it depends.
   Inflammation may, with great proprie-
 ty, be divided  into the  healthy and un-
 healthy.  Ofthe  first, there  can only be
 one kind; ofthe second, there must be
 an infinite number of species,  according
 to the peculiarities of different constitu-
 tions, and the nature of diseases, which
 are numberless.  (Hunter.)  Inflammation
 may also  be divided into the acute and
 chronic.   This  division of the  subject  is
 one of the most ancient, and seems  to
 have obtained the sanction of all the best
 surgical  writers.  Healthy inflammation
 is invariably quick  in  its  progress, for
 which reason,  it must always rank as an
 acute species of the affection.  However,
 there are numerous inflammations, con-
 trolled by a diseased principle, which are
 quick in their  progress, and are, there-
 fore to Ixj considered as  acute.  Chronic
 inflammation,  which we shall  treat  of,
 when we come  to the subject of tumours,
 is always  accompanied  with  a diseased
 action.

       PRINCIPLES OF INFLAMMATION.

    There is much foundation for believing,
 that  healthy  inflammation  is invariably
 an homogeneous process, obedient to  or-
 dained principles,  and,  in similar Consti-
tutions*,  similar structures,  and  similar
situations, uniformly assuming the same
features.   If  experience reveals to us,
that he~e  it is commonly productive  of
certain  effects, and there  it  ordinarily
produces different ones, the  same  un-
bounded  source of wisdom communicates
to the mind a knowledge,  that  there is-
some difference in the tone of the consti-
tution, 9r in the structure or situation of
the parts affected,  assignable as the cause
of this variety.   The nature of the excit-
ing cause can have no share in modifying
the appearances of phlegmonous inflam-
mation, whether this be occasioned by the
application of heat, or of mechanical vio-
lence to the body.   Healthy inflammation
is always the same in  its nature,  and  all
the influence, which the  exciting causes
can have, is proportioning the degree of
inflammation to their own  violence.  A
modern author  (Dr. Smith, in Med. Com-
munications, Vol. 2.) makes the  nature of
the exciting cause one principal  ground
of the specific  distinctions in inflamma-
tion,  and, with  good  reason,  when  he
takes into the account the actions of mor-
bid poisons, and the  qualities of disease
in general.
   The  attentive  observation of experi-
ence, the only solid basis of all medical,
as well as other, knowledge, has inform-
ed the practitioner, that parts, which from
their vicinity to the source of the circula-*
tion, enjoy  a   vigorous circulation  of
blood through  them, undergo inflamma-
tion more favourably and  resist disease
better, than other parts, of similar struc-
ture, more remote from the heart.  The
lower extremities are more prone to  in-
flammation, and disease in  general, than
parts about  the  chest; when inflamed,
they are longer in getting well; and the
circumstance  of  their   being depending
parts, which retards the return of blood
through the veins, must also increase the
backwardness  of  such parts in any salu-
tary  process. (Hunter.)  Wealthy inflani--
 ination is of a pale red; when less healthy,
 it is of a darker colour; but, the inflam-
 ed parts will, in every constitution, par-
 take more of the  healthy red, the nearer
 they are to the  source of the circulation.
 (Hunter.)
   Inilammation, when situated in highly
 organized and very  vascular  parts,  is
 more disposed to take a prosperous course,
 and is more  governable by art,  than  in
   * Here strength and  weakness are al-
 luded to; for, it is impossible that heal-
 thy inflammation should prevail in a dis-
' cased constitution.
• 
126
INFLAMMATION.
parts of an opposite texture.   The nearer
also such vascular parts are to the heart,
the greater will be their tendency to do
well  in inflammation.  (Hunter.)  Hence,
inflammation of  the  skin, cellular  sub-
stance, muscles, &c. more frequently ends
favourably, than  the  same  affection of
bones,  tendons,  fasciae,  ligaments, &c.
It is also more manageable by surgery;
for those parts of  the body, wtufh are not
what anatomists  term  vascular, seem to
enjoy only inferior powers of life,  and,
consequently, when excited in a preterna-
tural degree, frequently mortify.
   But, inflammation of vital parts, though
these may be  exceedingly  vascular,  can-
not go on so favourably, as in other parts
of resembling structure, but, of different
functions; because,  the  natural  opera-
tions of universal health depend so much
upon the sound condition of such organs.
(Hunter.) The trutli of  this observation
is illustrated in cases of  gastritis, perip-
neuinony, £e.
   All new-formed parts,  not originally
entering into the  fabric of the body, such
as tumours,  both  of the encysted and sar-
comatous kinds, excrescences, &c. cannot
endure  the  disturbance  of inflammation
long, nor in  a great  degree.  The vital
powers of such parts are weak, and when
irritated by the pressure of inflammation,
these adventitious substances are some-
times removed by the lymphatics,  but
more commonly  slough.    This   remark
applies  also  to substances generated as
substitutes for the original  matter of the
body; for instance, granulations  and cal-
lus.   The knowledge of this fact, leads
us to a rational principle of  cure  in the
treatment of several  surgical diseases.
Do we not here perceive the cause,  why
very large wens are occasionally  dispers-
ed by the application of urine, brine,  and
similar  things, which  are  now in great
repute, on this account, with almost every
one out of the profession ?  How many
verrucx, wrongly suspected  to originate
from  a  syphilitic cause, are diminished
and cured by a course of mercury !   It is
the  stimulus of this mineral upon the
whole system, that accomplishes the de-
struction of these  adventitious substances
—not its antivenereal quality.  Topical
stimulants would fulfil the-same  object,
not only with greater expedition, but with
no injury to the g- neral health.
  In  strong constitutions,  inflammation,
cxteris paribus, always proceeds more pro-
pitiously, than in   weak ones; for, when
there is much strength, there is little ir-
ritability.   In weak  constitutions,  the
operations of inflammations  are backward,
notwithstanding   the part,  in which  it is
seated, may, comparatively  speakiug, pos-
 sess considerable organization, and  pow-
 ers of life. (Hunter.)
   Healthy inflammation,  wherever situ-
 ated, is always most violent on  that side
 of the  point  of inflammation,  which, is
 next to the external surface of the body.
 When  inflammation attacks the socket
 of a tooth, it does not take  place on the
 inside of the  alveolary process, but to-
 wards the  cheek.  When  inflammation
 attacks the  cellular substance, surround-
 ing the rectum, near the  anus,  the affec-
 tion usually extends itself to the skin of
 the buttock, leaving the intestine perfect-
 ly sound,  though  in contact with tiie  in-
 flamed part.  (Hunter.)
   We may  observe the influence of this
 law in the fistula lachrymalis, in diseases
 of the frontal  sinuses, and  antrum, and,
 particularly, in  gun-shot wounds.  Sup-
 pose a ball were to pass into the thigh, to
 within an inch of the opposite side of the
 limb, we  should not find, that inflamma-
 tion should be excited along the  track of
 the  ball,  but, on the  side next  the skin
 which had not been hurt   If a ball should
 pass quite through a limb, and carry into
 the wound a piece of cloth,  which lodges
 in the middle, equidistant from the two
 orifices, the  skin, immediately  over the
 extraneous  body, would  inflame, if the
 passage of  the ball  were superficial.—
 (Hunter.)  Mr. Hunter compared  this law
 with the principle, by which vegetables
 approach the surface of the earth; but,
 the solution of it  was even  too arduous
 for his strong genius and penetration.
   We  see three very remarkable effects
 follow the prevalence of inflammation;
 viz. adhesions of parts of the body to each
 other; the formation of pus, or suppura-
 tion ; and ulceration, a process, in which
 the lymphatics are  more concerned than
 the blood-vessels.   Hence, Mr. Hunter
 termed the different stages of inflamma-
 tion, the adhesive, the suppurative, and the
 ulcerative.
  All parts of the body  are not equally
 liable  to  each of  the preceding conse-
quences. (Hunter.)
  In the cellular membrane, and  in  the
circumscribed cavities, the adhesive stage
takes place more readily, than the others
suppuration may be said to follow next in
order of frequency; and lastly ulceration.
  In internal canals, on the inner surfaces
of the eyelids, nose, mouth, and trachea,
in the air-cells of the lungs, in the oeso-
phagus, stomach, intestines, pelvis of the
kidneys, ureters,-bladder, urethra, and in
all the ducts and outlets of the organs of
secretion,  being what are termed  mucous
membranes, the suppurative inflammation
comes  on more readily,  than either  the
adhesive, or the ulcerative stage,  Adhe-
• 
INFLAMMATION.
 1 "**
■ lz<
Rions, which originate from the slightest
degree of inflammation in other situations
and structures, can only be produced by a
violent kind in the above-mentioned parts.
Ulceration  is more frequently met with
upon  mucous surfaces,  than  adhesions.
(Hunter.)   The  cellular membrane ap-
pears to be much more susceptible of the
adhesive inflammation, than the  adipose,
and  much more readily passes into the
suppurative.  (Hunter.y Thus we see the
cellular substance, connecting the muscles
together, and the adipose membrane  to
the muscles,  inflaming,  suppurating, and
the matter separating the muscles from
their lateral connexions,  and even the  fat
from  the muscles, while the latter sub-
stance and the  skin are oidy  highly  in-
flamed.  (Hunter.)   But,  it must be al-
lowed, that in situations where fat abounds
we very frequently meet with abscesses.
This  is so much the case, that fat has been
accounted  a more frequent nidus for col-
lections of matter, than the cellular sub-
stance.  (Bromfleld.) Abscesses are par-
ticularly liable to  form in the neighbour-
hood of the anus, mamma, 8cc.  We have
mentioned above  the fat's  being  highly
inflamed; an expression not strictly true.
Fat has no vessels, principle of life, nor
action of its own; consequently, we can-
not suppose it can itself either inflame, or
suppurate.   We know, that it is itself a
secretion,  and  when an  abscess forms in
it, we understand, that the mode of action
in the vessels,  naturally destined  to  de-
posit fat, has been altered to that adapted
to the formation of pus.   When we speak
of the fat being inflamed; we imply, that
the membranous cells, in which it is con-
tained, and by  which it is  secreted,  are
thus affected.
   The deeply-situated parts of the body,
more especially the vital ones, very readily
admit of the adhesive stage of inflamma-
tion.   The circifmstance of deeply seated
parts not so readily taking on the suppu-
rative stage of inflammation, as the super-
ficial ones do, is strikingly  illustrated in
cases of extraneous bodies,which, if deeply
lodged, only produce the adhesive inflam-
mation  By this process a cyst is formed,
in which they  lie' without much incon-
venience, and they  may even gradually
change their situation, without disturbing
the parts, through which they pass. But,
no sooner do these same bodies approach
the skin, than abscesses immediately arise.
 (Hunter.)
   All inflammations, attended with dis-
ease.partake of some specific quality, from
which  simple  inflammation is entirely
free.   When the  constitution allows the
true  adhesive and suppurative stages to
occur,  it is to be  regarded  as the most
Jjealthy.  Were  it in an opposite state,
 we should see the very same irritation ex-
 cite some  other kind  of inflammation,
 such  as  the erysipelatous, scrophulous,
 &c.  (Hunter.)
   In specific inflammations, the position,
 structure, and distance ofthe part affect-
 ed from the source of the circulation, as
 well as from the surface ofthe body, seem,
 also to have as much  influence as in cases
 of common  intkimmation.  Upon this point,
 I feel conscious of being a little at variance
 with what Mr  Hunter has stated; but the
 undecided manner  in which he expresses
 himself, not less  than the following  reflec-
 tions, encourages me.not to desert my own
 ideas.  We see  that venereal eruptions
 sooner make  their appearance upon the
 chest and face, than upon the extremities.
 No organized part can be deemed exempt
 from the attack of common inflammation ;
 many  appear to he totally insusceptible of
 the venereal.  We know, that scrophulous
 diseases ofthe superior extremities take a
 more favourable course, require amputa-
 tion less frequently, andget well oftener
 than when  situated  in !€ne inferior ones
 (Ford.) The venereal disease makes more
 rapid  advances in  the skin  and throat,
 than in the bones and tendons;  we often
 see it producing a  specific inflammation,
 and an enlargement  of the superficial
 parts of the tibia, ulna, clavicle, cranium,
 8cc. while other bones,  which are covered
 with a considerable quantity of flesh, are
 very rarely affected.  Gouty inflammation
 is prone to invade  the small joints, tiie
 rheumatic the large ones.

 SYMPTOMS AND NATURE OP HEALTHY INHA^
         MATION, OK PHLEGMON.

   Redness, swelling, heat, and pain,  the
 four principal symptoms of phlegmonous
 inflammation,  have  been accurately no-
 ticed  by  Celsus*   If we refer to  any
 writer on this interesting point of surgery,
 we shall And the  above symptoms enu-
 merated as characterizing phlegmon.  In
 short,  this term is usually applied to a
 circumscribed tumour .attended with heat,
 redness, tension, and a throbbing pain.
 These are the first appearances observed
 in every case of the phlegmon; and when
 they are slight, and the part affected is oi
 no great extent, they are commonly very-
 little, and sometimes no apparent, influ-
 ence on the general  system.  But, when
 they are more considerable, and the inflam-
 mation becomes  extensive, a  full,  quick.


   * Notx verd  inflammationis sunt qua-
 tuor, rubor, et tumor, cum ca^ore  et do-
 lore,  lib. 3. cap.  10. 
128
INFLAMMATION.
and generally a hard pulse,  takes place,
and the patient, at the same time, com-
plains of universal heat,  thirst, and other
symptoms of fever.  (B.  Bell.) While the
inflamed part becomes red,  painful, and
swelled,  its functions are also impaired.
The same degree of inflammation is said
to produce  more swelling in soft parts,
and lees in  harder ones.   (Burns.)
  Though  the  redness, swelling, throb-
bing,  tension,  and  other symptoms of
phlegmonous inflammation, are less mani-
fest, when the affection is deeply situated,
yet they certainly exist   When persons
die of peripneumony, or inflammation of
the lungs, the air-cells of these organs are
found crowded with a larger number of
turgid blood-vessels, than in the healthy
state, and of course the parts must appear
preternaturally red.  Coagulating lymph,
and even blood,  are  extravasated in the
substance of the viscera, which become
heavier, and feel more solid.   (Baillie.)
  The extravasation of coagulating lymph
which is one of the chief causes of the
swelling, is also  one of the most charac-
teristic signs of phlegmonous inflamma-
tion.
  Some writers (Smith,  Med. Common.)
have confined the seat of phlegmon to the.
cellular membrane; but, this idea is pro-
bably an erroneous one. Had such authors
duly discriminated the nature of common
inflammation, they  would have  allowed,
that this affection existed, wherever the
blood vessels appeared to  be more nume-
rous, and enlarged,  than in the natural
state, accompanied  with an effusion of
coagulating lymph, whether upon the sur-
face of a membrane, or a bone, or into the
interstices  of the cellular substarce, and
attended with acute pain, and a throbbing
pulsation in the part affected.
  Before proceeding further into the con-
sideration of inflammation, it seems pro-
per to treat oi causes.

            ME MOTE CAUSES.

  The remote causes of inflammation are
infinite in number; but, very easy of com-
prehension, because only divisible  into
two general classes.  The first  includes
all such agents as operate by their stimu-
lant or  chemical qualities;  for  instance,
cantharides, heat, &c  The second  class
of causes are those, which act mechanical-
ly, such as bruises, wounds, &c.  After
this statement, it seems quite unnecessary
to give a detail  of each particular remote
cause.*
  * Those,  who  are curious, may see  a
list of remote causes in Pearson's Princi-
pies of Surgery, p. 15.
  Fevers often sqem to become tlie remote
causes of local  inflammation.  In other
instances, inflammation  appears  to  arise
spontaneously, or, as 1 should rather say,
without any perceptible  exciting cause.
  The principle  on which the application
of cold to a part becomes the remote cause
of inflammation, is not decidedly known.
A modern author offers  the  following ex-
planation, in lieu of those founded on the
doctrines of cold being a stimulus,  and
a sedative cold may operate on a part in
three  different ways.  First, it  may be
applied in such a degree,  and for such a
length of time,  as to destroy the vitality
of tnepart directly;  in which case, sloughs
are formed.  Secondly, it may be applied
in a  less degree, or for a shorter time;
and afterwards a stimulant,  such as heat,
may be applied,  which will excite inflam-
mation.  The production of inflammation
by any agent,  depends in  a great degree
upon  the suddenness of the operation of
the ageat, which excites it; for a quantity
of stimulus, which, if  suddenly applied,
would produce inflammation, may be ap-
plied   slowly with  impunity. Hence, it
results, that any give*  stimulant  must
more   easily produce  inflammation in a
part, which has  a low action, &c. than in
one having a vigorous action, &c. Hence,
very slight stimuli will  induce inflamma-
tion in parts which have been weakened by
cold.   Thirdly,  a part  sympathises very
much with the contiguous ones.  If a part
be weakened by having its action reduced,
and if then the debilitating  cause be re-
moved, the action of the  part will be in-
creased  from sympathy with the neigh-
bouring acting parts.  But,  as the action
ought to be *ery little, the power being
small, inflammation must arise  from the
action being increased beyond the power.
We ought, therefore,  in this case, to di-
minish the  action  of  the  neighbouring
parts,  in order to prevent their extending
their  action to a part,  which is not able
to bear it  without becoming  diseased.
(Burns.)

           PBOXIMATE CAUSE.

  Numerous opinions have  been enter-
tained upon this   subject;  but, almost
every theory has been built upon the sup-!
position of there being  some kind of ob-
struction ip the inflamed part.
  While the circulation of the blood was
unknown, and'the hypothetical notions of
the power of the liver, in preparing and
sending forth,  this fluid,  continued  to
prevail,  it  is not  astonishing  that tiie
theories of physic should be exceedingly
imperfect.   So fully persuaded were phy-
sicians of the existence and influence of 
INFLAMMATION.                           129
different humours and spirits, and so little
did-they know of the regubr and constant
motion of the blood, that they believed in
the possibility  of depositions  and con-
gestions of the blood, the bile, or lymph ;
and acknowledged these as the  cause of
inflammation.   Their anatomists taught
tliecn, and their professors of physic sup-
ported the opinion, that the liver was the
centre ofthe vaseular system, from which
the blood  went forth by day to the ex-
tremities,  and returned again by  night.
If then any peccant matter  irritated the
liver, the  blood was sent out more forci-
bly ; and if, at the same time, any part of
the body were weakened, or otherwise dis-
posed to receive a greater quantity of flWd
than the rest, then a swelling was produ-
ced by the flow of humours to this place.
Fluxions,  or flows of humour to a place,
might happen either from weakness ofthe
part which allowed the humours to enter
more abundantly, or from  the place at-
tracting the humours, in consequence of
the application of heat or other agents.
(Burns.)
   The peculiar nature of  the  swelling
thus occasioned was supposed, by the an-
cients, to depend upon the kind of humour.
Blood produced the true phlegmon, bile,
erysipelas, Sec.
   The ancient physicians also entertained
an idea, that the blood and humours might
slowly stagnate  in^a part, from want of
expulsive  power, and this  affection was
termed a congestion,  while the expression
fluxion or defluxion was used to denote any
swelling arising  from the sudden flow of
humours from  a distent part.   The first
was formed gradually without much pain,
or the feeling  of pulsation, and run its
course slowly: the second appeared sud-
denly, was very painful, had a pulsatory
feel,  and was rapid in its progress. The
ancients, who supposed that the blood had
very little motion, and that its course could
be easily  directed or changed, recom-
mended bleeding from some part which
was remote from a recent inflammation,
by which  they imagined  that the current
of blood was altered, and a revulsion made.
A revulsion was also made, by raising  a
tumour in some other part,  by  means ^ of
ligatures,  cupping-glasses, &e. or by {jiv-
ing nature an opportunity of discharging
the humours from distant parts,  by  ap-
plying leeches  or blisters.   Hence si-
napisms were  applied to the feet, in dis-
ease of the superior  parts.  (Burns.)
   When blood was drawn from the vicinity
ofthe fluxion, or congestion, the mode was
called derivation which only differed from
revtdsion in the distance to* which the hu-
mour was drawn being less.   ( Burns )
   I shall not enter further into an account
     Vol.  II.
ofthe practice of the ancients in the treat.
ment of inflammation ;  but shall refer the
reader to what Mr. Burns has written on
the subject.  Our present object is only to
trace the leading doctrines, which have at
different times prevailed, respecting the
proximate causes of inflammation.
  From  the theories of fluxion and con-
gestion, which  were quite  incompatible
with the haws of the  circulation  of the
blood, we turn our attention to the doc-
trine of obstruction.
  Boerrhaave inculcated. (Aph 375  et seq.)
that inflammation was caused by an ob-
struction  to the free  circulation  of the
blood  in the minute vessels, and this ob-
struction, he supposed.might he caused by
heat, diarrhoea, too copious flow of urine,
and sweat, or whatever  could dissipate the
thinner parts of the blood,  and produce a
thickness or viscidity of that fluid.  When
the lentor did not exist before the produc-
tion of inflammation, he imagined, that
the larger globules of  the blood, got into
the small vessels, and thus plugged them
up.  When, for instance, the perspiration
was stopped, the fluid, being  retained,
dilated the  vessels, and allowed some of
these mischievous globules to enter, and
produce  a-  more permanent obstruction.
This circumstance was  termed an error
loci, and was one ofthe chief causes  assign-
ed  for inflammation.  The obstruction,
whether caused by viscidity or an error loci,
was imagined to occasion a resistance to
the circulation in the part affected; hence
increased it in the other vessels, proving
an  irritation to the heart, and augment-
ing the force or attraction of the blood in
that part of the vessel  which was  behind
the obstruction.  This caused  heat and
pain, while the aecumul. t on ofthe blood
produced redness;  which three symptoms
are the essence of  the disease.  Besides
obstruction,  Boerrhaave also brought into
the account an acrimonious state of tlie funds,
which rendered resolution out ofthe quesJ
tion, and gangrene likely to follow. (Aph.
388.)
  The viscidity of the blood cannot be ad-
mitted as the proximate cause of  inflam-
mation ;  because we have no proof; that
this state ever exists; or, granting that
it did, it  would  not   explain  the  phe-
nomena.  Were a  viscidity to  occur, it
would exist in the whole mass of blood,
would affect every part of the body alike,
and could not be supposed to produce only
a local disorder.  How also could such a
lentor be produced by  causes which bring
on inflammation suddenly, without there
being time  for changes  of the fluids  to
 take place?  (Burns.)
   With regard to the doctrine of error loci,
or of red globules going into vessels,which
     R 
130
INFLAMMATION.
 did not formerly  transmit them,  the fact
 must be admitted, at the same time, that
 the conclusion is denied.   When the eye
 becomes inflamed,  the tunica conjunctiva
 is seen with its vessels full of red blood,
 which in health is not the case;  but this
 redness never appears until the inflamma-
 tion has commenced, and must, therefore,
 be considered as  an effect, not a cause
 Nor  can  this error loci  occasion  any ob-
 struction in these vessels ; for, if they be
 divided, the  blood flows  freely, which
 shews, that they are lar,<e enough to allow
 an easy circulation.  (Buiiis.)
   Boerrhaave's theory 01 obstruction was
 too circumseribed,  and too  mechanical;
 it reduced all inflammations to one spe-
 cies.   The only distinctions wh.ch  could
 have arisen, must have proceeded from the
 nature of the obstruction itself. This doc-
 trine couid never account for the action of
 many  specific  diseases and morbid poi-
 sons.   (Hunter.)
   As for the supposition of the co-opera-
 tion of" an acrimony of the fluids, the pro-
 portion of the saline matter of the blood
 has never been proved to be greater in
 this,  than in any  other state of the body.
 (Burns.)  Even were a general disorder
 of  tins kind  to be  admitted, no rational
 explanation of the proximate cause of lo-
 cal inflammation could be deduced from it.
   Dr.  Cullen attributed  the proximate
 cause of inflammation to a " spasm ofthe
 extreme arteries supporting an increased
 action in  the  course of  them."  This
 theory only differs from that of Boerrhaave
 in the cause which is assigned for the  ob-
 struoiion.  Some  causes of inequality in
 the distribution ofl the blood,  may throw
 an unusual quantity of it upon particular
 vessels, to which it must necessarily prove
a stimulus.  But, farther, it is probable,
 that to relieve the congestion, the vis me-
dicatrix naturae increases  still more the
 action of the vessels; and which, as in all
Other febrile  diseases, it  affects, by the
formation of a spasm on  their extremi-
ties."  " A spasm ofthe extreme arteries,
 supporting an  ir-creased  action  in the
eourse of them, may, therefore,  be con-
 sidered as the proximate cause of inflam-
mation; at least,  in all  cases not arising
from direct stimuli applied; and, even in
this case, the stimuli may  be supposed to
produce a spasm of the extreme vessels."
 (Cullen.)
  The inconsistencies in Cullen's theory
 are very glaring.  The congestion or ac-
cumulation of blood, which is  only an
 effector consequence of inflammation,  is
 set down as the cause ofthe spasm ofthe
vessels, to which spasmodic constrictions,
Cullen, strangely enough,  assigns  the
name  of proximate cause. The spasmodic
contraction ofthe extremities of the ves-
sels, instead of propelling the accumulated
quantity of blood, would render the pas-
sage of the blood from the arterial into the
venous system still more difficult.   Spas-
modic constriction of the small vessels is
so  far from being a satisfactory explana-
tion ofthe proximate cause of inflamma-
tion,  that even tying a large  vessel docs
not of itself bring on tiie affection.  I 'lile^-
mdn  is also attended with an effusion into
the cellular substance from the extremi-
ties of the arteries;  a  circumstance  not
easily explained upon the principle of ob-
structed circulation.  (Burns.)
   We shall now notice the celebrated, and
very  original, opinions, promulgated on
this subject by the famous John Hunter.
According to  him  inflammation is to be
considered only  as  a disturbed state of
parts, which requires a  new, but salutary
mode of action, to restore them  to that
state, wherein a natural mode of" action
alone is necessary.  From  such  a view of
the subject, therefore, inflammation in it-
self, is not to  be considered as a disease,
but as a salutary operation,  consequent
either to some violence, or some disease.
Elsewhere, the author remarks, the act of
inflammation is to be considered as an in-
creased action of the vessels, which, at
first,  consists  simply in an increase or
distention beyond their natural size  This
increase seems to depend upon a diminu-
tion ofthe muscular p"bwer of the vessels,
at the same time that the elastic power of
the artery  must  be  dilated in tlie same
proportion.  This is, therefore, something
more  than simply a  common  relaxation:
we must suppose it an action in the parts
to produce an  increase of size, to answer
particular purposes,  and this Mr. Hunter
would call  an act of  dilatation.  The
whole is to be considered  as  a necessary
operation of nature.   Owing to this dila-
tation, there is a greater quantity of blood
circulating in the part, which is according
to  the common  rules of the animal eco-
nomy ; for,  whenever a part has more to
do than simply to support itself, the blood
is there collected in larger quantity. The
swelling is produced by an extravasation of
coagulable lymph, with some serum ; but,
this lymph differs from the common lymph,
in consequence of passing through inflam-
ed vessels.  It  is this lymph which  be-
comes the uniting medium  of inflamed
parts ; vessels shoot  into  it; and it has
even the power of becoming vascular itself.
The pain proceeds from spasm.  The red-
ness is produced either by  the arteries
being more dilated than  the veins,  or  be-
cause the blood  is  not changed  in the
veins.  When  a  part cannot be restored
to health, after  injury,  by  inflammation 
INFLAMMATION.                          ,.J31
alone, or by adhesion, tlien suppuration,
as a preparatory  step  to the formation of
granulations, and the consequent restora-
tion  of the  part takes place.  The ves-
sels are nearly in the  same  state as in
inflammation ; but  they are more quies-
cent, and  have acquired a new mode of
action
  An increased action of the vessels is now
almost universally regarded as the proxi-
mate cause of inflammation. This opinion
is greatly supported from a review of the
several exciting  causes of the  affection,
which, being  in general  of an irritating
nature, must,  when applied to any living
or sensible parts, occasion a preternatural
exertion of the  vessels.  The method of*
cure, as we  shall presently see, tends  also
to confirm the general doctrine with re-
spect to the cause of inflammation.

StMPTOMS or  PHLEGMONOUS INFLAMMATION
          FURTHER CONSIDERED.

  The essential  symptoms are  redness,
swelling, heat, and pain.
  Redness.—This is manifestly  owing to
the increased quantity of blood in the in-
flamed part.   More blood must necessa-
rily be contained there, because the  ves-
sels, which previously conveyed this fluid,
are preternaturally distended,   and  the
small vessels,  which naturally contained"
only lymph,  are  now so enlarged as to be
capable of  receiving  red blood.  Many
have supposed, that the redness of com-
mon inflammation is partly occasioned by
the generation of new vessels.  This doc-
trine, however, seems  very questionable.
When coagulating lymph is extravasated
upon the surface of a wound,  an inflamed
membrane, Sec I think no one can doubt,
that the lymph often becomes  vascular, in
other words, furnished with new vessels.
But, in the extravasated lymph of a phleg-
monous  tumour, we  have no  evidence
shewing, that there is any generation of
new vessels.   Were the lymph to be  ren-
dered organized and vascular, the swell-
ing and redness  would probably be more
permanent,  and not admit, at least so ea-
sily, of resolution.   When adhesions form
between  two  inflamed surfaces, the or-
ganized substance, forming the connexion,
lives after tlie subsidence ofthe inflamma-
tion, and is a  permanent  effect.  It  was
probably  the enlargement of the small
vessels, which led to the  theory, that new
vessels are  formed in inflammation. It
has, however, been justly observed,  that
the  supposition  easily admits  of refuta-
tion ; for  heat, and many other  causes of
inflammation, operate  so  quickly,  that
there can  be no time for  the formation of
any new vessels; and, yet the redness is
as great, and the inflammation as pi rfect
in a  minute as in an hour or a day  after
the  application of the  exciting cause.
(Bums.)  Another reason, assigned for
the redness of inflammation, is that the
blood, after it has become venous, retains,
more or  less, its bright scarlet  colour.
(Hunter.)
  Swelling.—This effect arises from several
causes.  1. The increased quantity of blood
in the vessels.  2 The  effusion of coagu-
lating lymph, and deposition of new mat-
ter.   3. The interruption of absorption,
of late particularly noticed. (Soemmering
de Morb. Vas. Absorb.)
   Pain.—This  is observed  to be greatest
during  the diastole of  the arteries.  The
affection is probably owing to the unna-
tural state ofthe nerves, and not to mere
distention, as many have asserted.  Were
the latter cause a real one, the pain would
always be proportioned to it.
   Heat.—It  was formerly imagined  by
many,( Boerrhaave, Savage,&c.)who wrote
after the discovery of the circulation of
the blood,  that the heat was produced by
the attraction ofthe red globules, against
the sides of the vessels.  Modern philoso-
phy,  now,  however,  teaches  us,  that  a
fluid may flow, with the utmost velocity,
through a pipe, for  a thousand  years,
without producing a single degree of heat.
The most commonly received opinion now
is, that the production of animal heat de-
pends upon the difference in  the capacity
of arterial and venous  blood  for combin-
ing with caloric; and that in the minute
arteries, the blood is combined with cer-
tain substances, in consequence of which
its capacity is diminished,  and heat  is
given out.  But, when  the venous  blood
has been  freed from such substances  in
the lungs,  its capacity is increased, and
the heat, which  is given out by the de-
composition  of the air which we inspire,
is absorbed.  Now, if these things be ad-
mitted as facts,  the augmented heat of in-
flammation may be conceived  to  arise
from the increased velocity of the circula-
tion in  the p:u-t affected.   More blood is
transmitted into the minute arteries; the
capacity of  a  greater quantity  of this
fluid for heat is of course there necessa-
rily diminished, and more caloric is ex-
tracted.

APPEARANCES  OF THE  BLOOD IN  INFLAM-
                MATION.

   The blood, when taken out of the living
vessels, spontaneously  separates into two
distinct parts,  the serum and the crassa-
mentum.  The last is  a compound  sub-
stance, consisting chiefly of coagulating
lymph, and red globules, the most heavy 
132
INFLAMMATION.
ingredients in the blood.   Blood,  taken
away from persons affected with mfl.m-
mation, is longer in coagulating, and co-
agulates  more firmly, than  in otln-r in-
stances.  Hence, the  red  globules,  not
being so soon entangled in the lymph, de-
scend, by their gravity, more deeply from
its surface, which, being more or less di-
vested of the red colouring matter,~is from
its appearance termed the huffy coat, or
inflammatory crust.   The firmer and more
compact coagulation of  the lymph com-
presses out an unusual quantity of serum
from it, and the surface of the sizy blood
is often  formed into a hollow,  the edges
being  drawn inward.  (Hunter.)   These
changes in the blood are, in some cases, a
more infallible proof of the existence of
inflammation, than the state of the pulse
itself,  At the same time, it is probably
only a criterion of some unusual, operation
  going oii'in the system; for the blood taken
  om pregnant women is always found to
exhibit the above appearances. In peri-
toneal inflammation, the patient sometimes
seems to be  in the most feeble state, and
the pulse, abstractly  considered,  would
rather induce the practitioner to employ
tonics and stimulants,  than evacuations;
but, should the continuance or  exaspera-
tion of the disorder, or any other reason,
lead the surgeon  to use the lancet, then
the buffy coat, and the concave surface of
the blood, clear away all doubt concerning
the existence of inflammation.
  In  a few anomalous constitutions, the
blood, when  drawn, always exhibits the
above peculiarities.

    TERMINATIONS OF INFLAMMATION.

  Inflammation is  said to have three dif-
ferent terminations  or, in more  correct
language, we may say, that,  after this
process has  continued a certain time, it
either subsides  entirely,  induces  a dis-
position  in the  vessels to  form pus, or
completely destroys the vitality of the
part.
   When the  inflammation is to end in the
first manner, which is the most favourable,
the pain becomes less, the swelling  sub-
 sides, tlie fever, and every other symptom,
 gradually  abate,, till at last  the  part is
 wholly restored to its  natural size and
 colour.  There  is no formation  of pus,
 nor any  permanent injury  of structure.
 This termination of inflammation is term-
 ed by surgeons resolution.  It is fortunately
 the most common, as well as the most de-
 sirable manner,  in which  the affection
 ends.
   If however, notwithstanding the appli-
 cation of the usual remedies, the  several
 symptoms of heat, pain, and redness, in-
stead of diminishing, rather increase; if the
febrile symptom* are likewise augmented,
and the tumour gradually acquires a larger
size, turns soft, somewhat prominent in
the middle, or towards its most depending
part; if it should next  acquire a clear
shining appearance,  and  become  less
painful, the different symptoms of fever
being at the same time diminished, and a
fluctuation perceptible in the tumour, the
inflammation has ended in suppuration.
  The worst, but, happily,  the  least fre-
quent consequence of common inflamma-
tion,  is the death, or mortification, of the
part affected. The signs of this disastrous
event are a change  of colour in  the part,
•which, from being of a bright red, becomes
of a livid  hue ; small vesicles, filled with a
thin fetid serum, arise on its surface, and
air is plainly felt to exist in the disordered
situation.   The pain is, indeed, diminish-
ed; but the pulse sinks, while the tumour
is gradually changed  into a black,  fibrous
mass.
   These  are  the three most usual termi-
nations of inflammation. By many authors,
however,  anothe&disorder has been treated
of, as one in which inflammation is apt to
end,  viz.  scirrhus.   But, although  that
complaint may, perhaps, in,  a lew in-
stances, follow inflammation;  yet, it is far
from being a common consequence of it.
•Hence, although inflammatory  affections
may justly enough be mentioned as one of
the many exciting causes of scirrhus, yet
the consideration of this  disorder can
never with propriety, it is presumed, be
introduced into an account of inflamma-
tion. (B  Bell)
    Common  inflammation,  particularly
 when it affe<- .s glandular parts,  is  often
 observed  to leave  an induration  in the
 part.   We know very well,  that, when
 the testis has been  inflamed, a hardness
 of the epididymis frequently  remains af-
 terwards during life.  Such  indurations,
 however, are not  at all malignant, and,
 consequently ^ are very different iir  their
 nature, from what  is  implied  by a real
 scirrhus.

      TREATMENT OF  INFLAMMATION.

 Removal of the Exciting, or Remote Cause.

   After the description,  which we  have
 given  of inflammation, the reader may
 easily guess, that  the  grand principle to
 be observed in the treatment, is to endea-
 vour to lessen that immoderate action of
 the arteries, which is now  commonly set
 down as the proximate cause.
•"   The first circumstances to be attended
 to in all cases, in which resolution is to
 be attempted,  is the removal of all suxV 
INFLAMMATION.
233 .
exciting causes of the disorder as may
happen to  present themselves.   If the ir-
ritation of a splinter should excite phleg-
monous inflammation, who would not of
his own  accord extract the extraneous
body?
  Foreign substances in wounds frequent-
ly excite inflammation, and ought  to  be
taken away as speedily as possible; splin-
tered pieces of bone often give rise to the
affection,  and require removal: the head
of a  bone, being out of its place, may
press and inflame the part on which  it
lies;  and  who does not immediately see
Uhe propriety of putting it back into its
natural situation P  Such exciting causes
as these may oftentimes be detected and
removed at once, and this is doing a great
deal  towards the cure  of the inflamma-
tion.   Many of the e xciting causes of this
affection are only  of momentary  appli-
cation ; yet,  though they no longer exist,
the process of  inflammation must  follow
the  violence and irritation, which were
suddenly   produced,  and  still remain.
Hence, besides taking away, if possible,
the remote cause, it is proper to moderate,
 by other  means, the increased action of
 the vessels.

                Bleeding.

   If the doctrine which we have advanced
 be true, viz. that inflammation depends
 upon an  increased action of the vessels,
 and that  a greater quantity  of blood is
 impelled  into,  and circulates,through the
 inflamed part,  than  in the natural state;
 it follows that bleeding must be a prin-
 cipal  means of  relieving inflammation;
 because it lessens the action of the whole
 arterial system, and, of course, of that
 part which is undergoing  inflammation;
 and  because it  diminishes the quantity
 of blood transmitted to  the part affected,
 by lessening the whole mass in the circu-
 lation.
   Bleeding,  however,  is  often  misem-
 ployed, especially, when regarded as the
 only remedy for inflammation,  and  other
 steps are neglected.   The obstinacy and
 vehemence of the  process in weak con-
 stitutions  prove, that bleeding is not in-
 variably  proper.  When inflammation is
 complicated with  an unhealthy state of
 the alimentary canal,  blood should  be
 taken away  with great circumspection.
 A great  deal  of induration, with little
 pain and heat in the inflamed part; the
 probability of a long and copious  suppu-
 ration, as is tlie base in  many compound
 fracuires; and the dependence of the in-
 flammation  on  local weakness; are par-
 ticular instances, in which the practitioner
 should  be  sparing  of this  evacuation.
Bleeding is quite unnecessary when  the    ,
focal inflammation and symptomatic fever
are trivial,  when the patient is feeble or
very  old, and  when the  cause of  the
affection can be entirely removed.  (Rich-
ter.)
  On  the other hand, bleeding is highly
beneficial  in  all cases, in  which the  in-
flammation is uncomplicated with a mor-
bid state of the gastric system, is  consi-
derable in extent and degree, and attend-
ed with a good deal of ebrile disturbance.
The same is also strongly indicated, when
the part affected is  very sensible,  and
highly important, in regard to its office in
the system.  Hence, ophthalmy,  or  in-
flammation of the eye,  which is a most
sensible part, particularly requires  a free
evacuation of*  blood.  Hence, inflamma.
tion  of the  lungs, brain,  or stomach,
which  are  organs, the sound state of
which is  intimately essential  to the  re-
gular continuance of all the various ope-
rations in the  animal machine, particu-
larly  demands the employment of the
lancet; for, if,a successful effort  be not
promptly made to stop such inflammation,
death itself will, in  all probability,  be the
result.
   Bleeding is  likewise indicated, when
the  patient is young, robust, and  ple-
thoric ; when the cause of the .disorder
can neither be removed nor diminished,
and when there is a very strong motive
for wishing  to avoid the formation of
matter.  Inflammation of  the eye affords
an instance  illustrative  of the  truth of
the last observation; for, if suppuration
be allowed to take place in this  organ,
the common consequence is so serious a
destruction of  its internal structure and
organization, that the future  restoration
of sight is totally impossible.  Under such
circumstances as  we have specified, it is
frequently necessary to repeat  bleeding
several times.
   The efficacy of bleeding is greater, the
sooner it is practised, and the more sud-
denly the  blood is  evacuated.  Bleeding
near  the  part  affected  is  usually  more
effectual-  than when done in a remote
situation.  Hence, in inflammation  of the
eye or brain, it is deemed  most advanta-
geous  to take blood from the temporal
artery.
   The preceding remarks chiefly relate to
general bleeding; for, in phlegmonous in-
flammation, topical bleeding is scarcely
ever  improper. It is always a point highly
 worthy of the surgeon's  consideration,
 whether bleeding in or near tlie part will
 answer better,  than taking the blood from   i
 the general habit; for, certainly less may
 be removed in this  way, so as to have
 equal effect upon the part inflamed, and 
134                          INFLAMMATION.
 probably, upon every other disease that is
 relieved by  bleeding, and yet affect tlie
 constitution less. Although, in many cases,
 the general habit may be elieved by bleed-
 ing, vet the part affected will always re-
 quire  this evacuation  most.  That local
 bleeding has very considerable  effects on
 the inflamed part, is proved by the sudden
 relief, which leeches, applied in cases  of
 gout, produce. Bleeding by leeches, alone
 will also remove a tumour in  the  breast,
 haying all  the appearance of a scirrhus,
 which cannot be considered as  inflamma-
 tory,  so that topical bleeding extends its
 power further than the mere checking of
 inflammation.   Some part of its effect has
 been  imputed  to  sympathy.  (Hunter.)
 There are three modes of performing to-
 pical  bleeding; by cupping; by leeches ;
 and by dividing, or scarifying die dilated
 vessels leading to  the  inflamed part.
 Upon the head and fiice, leeches are com-
 monly employed; upon the  chest, either
 leeches or cupping; upon the abdomen,
 leeches; and upon the joints, either cup-
 ping  or leeches.  When  the  eye is in-
 flamed, leeches may either be applied to
 the adjoining temple ; or the dilated ves-
 sels of the conjunctiva may be scarified;
 or both methods may be adopted.   When
 the inflammation extends quite to the sur-
 face of the body, leeches are always most
 eligible, as their bite causes less irritation
 in inflamed  parts,  than the punctures of
 the scarificator, or the pressure  of the
 cupping glasses.

               Purging.

  The exhibition of mild laxative medi-
 cines,  and  saline purgatives,  is a prin-
 cipal means of diminishing inflammation.
 Purging doe* not produce  such  lasting
 weakness as is the consequence of  bleed-
 ing, and, consequently,  it is scarcely ever
 omitted, even when taking away blood  is
 deemed  improper.   Saline purges must
 lessen the quantity  of  circulating  blood,
 inasmuch as they increase the secretion
 from the intest'uial arteries.  Hence, they
 must  operate  beneficially  in the cure of
 local inflammation,  much  upon  the same
 principle as bleeding does.  Mr. Hunter
 was of opinion that purging lowers ac-
 tion,  without  diminishing strength,  by
 which we  are  probably to understand,
 without producing a very  lasting or per-
 manent loss of strength.  With respect to
mild  laxative medicines, none are supe-
rior to manna, rhubarb,  oleum ricini, and
the like; and of the saline purgatives,
which  are  in  general  preferable  to the
former ones, the natron vitriolatum, kali
tartarizatum, soda phosphorata, and mag-
nesia vitriolata, are  the best.   We mav
here  remark,  that besides  the  benefit,
which the local inflammation derives from
the judicious administration  of  purga-
tives,  the costiveness and  heat,  which
usually attend the symptomatic fever, are
also relieved by the same means.

         Nauseating Medicines.

   Medicines, which have the power  of
producing sickness, lessen for a time, the
action,  and even the general powers of
life.  This is in consequence of every part
of the body  sympathizing with the sto-
mach ;  and the effect may be very quickly
excited. Sickness lowers the pulse, makes
the small vessels contract, and rather dis-
poses the skin for perspiration.   But no-
thing more than nausea should be caused:
for vomiting  rather rouses than depresses.
(Hunter.)  Nauseating  medicines, em-
ployed after bleeding, has been practised
once  or twice, are often productive  of
considerable  benefit; but there are some
affections, in which they cannot be used,
such as inflammation of the stomach and
intestines.  In  all  superficial inflamma-
tions, however, they may be safely and
advantageously exhibited,  as well as in
most inflammatory affections  internally
situated.  In inflammation  of the dura
mater and brain, and,  indeed, in  every
instance, in which there is an urgent rea-
son for putting as sudden a check as pos-
sible to the continuance of the affection,
the employment  of nauseating doses  of
antimonium tartarizatum, (emetic tartar)
is the one, on which practitioners place
the greatest  reliance, and it is to be pre-
scribed for the purpose of exciting nausea,
as directed below.*

                 Opium.

  The majority  of  surgeons  entertain an
insuperable objection to the administra-
tion of  opiates in almost all  c ases  of  in-
flammation, and the aversion to this prac-
tice is for the  most part deducible from the
recollection of opium being a potent  sti-
mulant.  The plan, however,  has its  ad-
vocates.  (B. Bell, Richter.)   One  of  its
strongest partisans  tells us,  that  opium
particularly lessens  the disturbance of in-
flammation, and it allays pain, which is at
once a principal symptom of the process,
and a cause  of its augmentation, as well
as that of the  fever  Opium also quiets
the inordinate action of the  solids,  the
  • 9r. Antimonii tartarisati  grana duo;
Aquse  distillate uncias quatuor.  Misco
et cola.   Dosis.  Uncia  dimidia  sexta
quaque hora. 
INFLAMMATION.
135
mental' agitation,  and restlessness  so
powerfully, that it well deserves the name
of lie grand antiphlogistic remedy.  It like-
wise occasions a moisture on the surface
of the body, which experience shews is
eminently serviceable in all inflammations
affecting the skin.   When given with this
view, it  :s usually conjoined with anti-
mony, camphor, calomel, or ipecacuanha.
The administration of opium is a gene-
ral practice in all  painful inflammations
arising from external causes,  and it is
attended with perfect  safety when evacua-
tions from the  bowels and bleeding have
been previously  put  in  practice.  Care
must only be taken to give it in sufficient
doses; for small  quantities not only fail
in fulfilling the object, but frequently pro-
duce quite an opposite effect.  During its
employment, the bowels  should be kept
open by  glysters.  The efficacy of opium
chiefly manifests itself in  the early stage
of the affection ;  for,  as soon as the in-
flammatory fever has  extended itself to
the  whole  system,  it loses its beneficial
virtues.  Hence,  in cases  of external in-
juries, it is to  be given the two first days,
immediately after bleeding.  It is to be
given as soon  after the accident as  pos-
sible,  in order to tranquillize the mental
alarm, Jul, if convenient,  towards  the
evening, for the sake of procuring for the
patient a quiet night  (Richter.)  Evacua-
tions being premised,  says the other advo-
cate tor  this medicine, the next object of
importance is to procure ease and quiet-
ness to  the patient,  which, in  cases of
inflammation,  are often of more real  ser-
vice, than any other  circumstance what-
ever.  The most effectual remedy for  this
pu'.pose is opium, which, when the pain
and irritation are  considerable, as very
frequently happens in extensile inflam-
mations, shoutd  never be  omitted.   In
large  wounds, especially  after  amputa-
tions, and other capital  operations,  and
 in punctures of all kinds, large  doses of
opium are always attended with remark-
ably good effects.   In  all such cases,
however, opium, in order to have a pro-
per influence, should be  administered in
very large doses; otherwise, instead of
proving serviceable,  it seems  rather to
have the contrary effect.  This circum-
 stance is, perhaps, the chief reason why
opiates in general have-been very unjustly
condemned in every case of inflammation.
 {B. Bell.)
   On the contrary, they who are averse to
 the use of opium, remark, that, in acute
 inflammation, daily experience shews, in-
 dependently of every theory, that the exhi-
 bition of this medicine increases the ge-
 neral fever,  and  aggravates the local
 action.  Even given  as  a preventive of
inflammation, after operations, anodynes
are almost universally hui tfid, producing
restlessness, heat, thirst, and  afterwards
head-ach, sickness, and frequently, trou-
blesome vomiting.  (Burns.)
  Upon the whole, candour obliges me
to own, that the votes of the majority  of
surgeons in  this  country are decidedly
against the  general use  of opnim  in in-
flammation ; but, after  the performance
of severe operations, and in  all instances,
attended with excessive pain, truth, I be-
lieve,  will justify my saying, that the
voice of most practitioners is in favour  of
the exhibition of this remedy.

          MET ANI) REGIMEN.

  In all cases, the surgeon is to forbid
taking wine and spirits,  and, when the
inflammation is in  the least considerable,
the  same prohibition is  to be made  in
regard to animal food. Watery, cooling,
mucilaginous drinks,  taken  in  a luke-
warm state,  are proper;  for they keep off
thirst  and  heat, and tend to sooth the,
increased action  of  the  whole  arterial
system.  For this purpose,  whey, butter-
milk,  barley-water,   decoction of dried
fruits,  water-gruel, &c. are the best.
  The chamber,   in  which the  patient
lies, should not be kept warmer than his
comfort requires;  for, of all things, heat
keeps up  an increased action in the body,
in the most powerful manner.   For the
same reason, the patient should not  be
covered  with a superfluous quantity  of
bed-clothes.
  The whole body, but  more especially
the inflamed part,  should be preserved  as
free as  possible from every kind of mo-
tion.  Every one knows, that all  motion,
exercise, and muscular exertion,  accele-
rate the circulation, and hence they must
have a pernicious effect on inflammation,
by determining a larger quantity of blood
to the  part affected.

     TOPICAL APPLICATIONS—COLD ONES.

  With the exception of what has been
stated, concerning topical  bleeding,  all
the foregoing remarks relate to the general
treatment of inflammation:  we shall next
consider the local.   A'
   It  has been already   observed,  that
phlegmon is attended with an increase of
heat in the part affected,  and it is an ac-
knowledged and well  known fact,  that the
action of the  arteries, as well as every
other  operation in the animal economy,
is  promoted and increased  by  the  in-
fluence  of  heat.   For  this  reason  an
obvious indication arises, viz. to, reduce
the temperature ofthe inflamed part,by the 
136                           INFLAMMATION
topical application of cold,  and, in parti-
cular, by continually abstracting the heat
generated in the part,  by  keeping up a
constant evaporation from its surface.
  Preparations  of lead, and other  seda-
tive  and astringent substances, are such
as are in the greatest repute for bringing
ab»ut the resolution of inflammation.
  I am decidedly averse to  entering into
minute discussions, concerning the modus
operandi of such medicines  as  are recom-
mended.  These disquisitions would only
extend our  remarks  to an unnecessary
length, and probably fail  in  conveying
satisfactory  information to the  reader.
However, I am firmly of the same senti-
ment with a  preceding systematic writer
(B. Bell) that,  in some circumstances, it
may not  be  improper to deviate so  far
from the general plan, as to render, as  ob-
vious as possible, the propriety of what, at
any  tinw may  be advanced;  for  mere
practical assertions, unsupported by some
foundation  in  reason, can  never  prove
either so useful or agreeable as they might
otherwise be  rendered.
  We have remarked, that the cold  ap-
 Slications, used in the  resolution of in-
 animation, are commonly  such as are of
an astringent and sedative quality. But the
whole class of medicines, which are found
to possess these properties, can never be
recommended  as topical  remedies  for
phlegmonous  inflammation.   Opium   is
one  of the most  powerful of all  seda-
tives; yet,  when  applied to  the surface
of the human body,  (if the cuticle  inter-
vene,) it has little  virtue; and, if  the
part lie excoriated, it is always productive
of some degree of irritation. Hence, how-
ever useful opium may be as  a topical
application to some particular species of
inflammatory affections, which will  be
specified in the course of this  work,  we
may certainly conclude, that it will  never
come  into general  use, as an  external
local application  in  inflammatory cases.
Similar  objections  might,  perhaps,  be
made to  the employment of nearly all se-
dati.es,  in cases  of acute  inflammation
The zincum  vitriolatum, cerussa acetata
(sugar or acetite of fead,) and vinegar, are
the only  medicines of* the astringent and
sedative  class, which seem  to have  ac-
quired permanent celebrity for their effi-
cacy in resolving inflammation
  Extensive experience, and  long estab-
lished trials,  have now  fully   confirmed
the virtue of all those local remedies, in
which the acetite  of lead  is  the active
ingredient.   M. Goulard, and  numerous
other French surgeons, found,  that  the
objections  to the employment  of  many
other sedative  applications in the  treat-
ment of inflammation, did  not  exist
against the use  of the  preparation  of
lead.   The universal  assent of  moderti
practitioners   proves,  indeed,  that the
acetite  of lead, as  a local application
for genuine phlegmonous  inflammation,
is certainly unsurpassed, if not unrivalled,
in point of efficacy.
  Although M.  Goulard, in extolling a
favourite  remedy, has been induced to
assert its  effects to  be more general and
considerable  than  they  properly  will
ever be found  to be;  yet  the world  is
much  indebted  to him; not,  however,
for a new medicine, as every preparation
of lead, recommended by him, was for-
merry, in  some form or other,  known to
every  practitioner; but, for introducing
into more  general use a very  effectual re-
medy for  the discussion of  inflammatory
swellings'. (B. Bell.)
   The preparations  of  lead  certainly
merit the appellation of sedatives.  When
taken internally,  many of the most strik-
ing effects of this mineral are of  a sedative
kind.  The propriety of the term, how-
ever, is more particularly evinced by the
immediate and obvious operation of lead,
when  any of its  preparations are  out-
wardly applied to the surface of an in-
flamed part.  An abatement ofthe differ-
ent symptoms of  pain, and  tension, and
the communication of an agreeable sooth-
ing sensation  to the  part, are  almost al-
ways its direct palpable effects.
  The preparations  of lead are recom-
mended by M. Goulard, as almost equally
applicable to every stage of inflammation.
When swellings  have fully  suppurated,
the employment of, what he calls, the ex-
tractum Saturni, will almost always render
it unnecessary to open them. Even in gan-
grene, the solution of lead is represented
by this zealous writer, as  a remedy, de-
serving the greatest confidence.
  But, notwithstanding,  the  above ex-
aggeration, every man of experience and
observation will allow, that, while there
is a  chance  of accomplishing resolution,
no local applications to phlegmonous in-
flammation, are in general so proper, as
c->ld  lotions,  containing  the acetite of
lead.
  From the poisonous qualities of lead,
when taken into the system, and from the
possibility of this mineral being absorbed
from the surface of the body,  objections
have  arisen against the free  use of its
preparations, even as  outward remedies
in cases of inflammation.  Certain  it is,
however,  that though the  possibility  of
such  absorption  is  proved  by the  oc-
currence of the disorder called  the colica
pictorum, which originates in painters from
the white  lead absorbed  into the system,
yet,  any ill effects from the use of lead, 
INFLAMMATION                           13T
as- an application to inflamed parts, are so
exceedingly rare,  that  they can  hardly
form a serious objection to the  practice.
It is a fact, that,  in inflamed parts, there
is an impediment to  absorption, and this
circumstance  may  tend  to render  the
employment of lead  a  matter  of safety.
Mr. B.  Bell observes, that in all the  ex-
perience he has  had,  of  the  external
application of lead and its preparations,
and in many cases, particularly of burns,
he has known the greatest part of  the
surface of the body covered with them for
days, nay, for weeks together, he does not
rec»llect a single instance of any disagree-
able symptom being ever  produced by
them.
   A lotion composed of cerussa acetata
(sugar of lead), vinegar and water, is one
very commonly employed.*  Occasionally,
bread-crumb  is  moistened in the fluid,
and applied to the part affected, in  the
form of a poultice; but, linen wet in  the
lotion, and kept constantly so, is now al-
most always preferred.  Thus a continual
evaporation is maintained, and  of course
a continual abstraction of heat.
   The aqua lithargyri acetati is preferred
by most .surgeons.
   About a tea-spoonful of this  prepara-
tion, mixed with a pint of water,  makes
a  very  proper lotion  for  all  ordinary
oases.
   When the surgeon is afraid to employ a
solution of lead, he may try one containing
the zincum vitriolatum.  For this purpose
one dram of this  metallic  salt  is to be
dissolved in a pint of  water, and linen
well wet with the lotion, is to be applied
to the inflamed part.
   Many practitioners impute very little
real efficacy either to the acetite of lead,
or sulphate of zinc, contained in the above
applications; and, they attribute all  the
good, that is produced, entirely  to  the
evaporation kept up  from the surface of
the inflamed part,  and to the coldness of
the fluid, in which the metallic salts are
dissolved.   Those, who entertain these
sentiments, think the application of cold
water alone quite as efficacious, as that of
any medicated lotion whatsoever.
   There are particular cases of inflamma-
tion, in which the extravasation of blood
and lymph, into the interstices of the in-
flamed part, is exceedingly copious, while
* $,.   Cerussae Acetata: 33s.
      Solve in Acet.  pur. £iv.
      Et  adde Aq.   Fontanae  distill.
      ibij-
The vinegar  makes the solution more
             complete.
 /Vot. IT.
the swelling is considerable,  and the pain
and  redness not particularly  great.  In
such instances, it is a grand  indication to.
rouse  the action of the absorbents, in
order to remove the extravasated fluid,
and  with this view, a more powerful tlit-
cutient lotion,  than  the  saturnine one,
should  be employed. Sometimes,, it is
better to use embrocations and liniments,
than any sort of lotion.  A very excellent
discutient lotion is  one  of those men-
tioned below.*
  When the part affected  with inflamma-
tion  is  not  very tender,  or when it lies
deep, applications of the vegetable acid
are often had recourse to with consider-
able  advantage;  and the  most effectual
form  of using it seems to be a poultice
made with  vinegar and crumb of bread.
In such cases, it has been thought, that an
alternate use of this  remedy, and the sa-
turnine lotion, has produced more benefi-
cial effects,  than are  commonly observed
from  a continued use of  one of them.
(B. Bell.)  However, surgeons ofthe pre-
sent day seem to think, that vinegar can
be as advantageously applied in the form
of a  lotion,  as in that of a poultice, and,
certainly,  with less trouble
  Alcohol and xtber have acquired some
celebrity,  as local remedies for inflamma-
tion.   Perhaps,  one  great  reason,  why
they are not more extensively used in this
way, is the expence attending such treat-
ment, as these fluids evaporate with great
rapidity  Alcohol may possible prove use-
ful from its  astringent qualities; but, it
seems much more rational to impute both
its virtue, and that of aether, to the power-
ful manner,  in which the  evaporation of
such fluids deprive the inflamed part of its
heat.

WARM APPLICATIONS,  EMOLLIENT TOCLTICES
           AND FOMENTATIONS.

  The absurdity  of  attempting to recon-
cile every useful practice  with a philoso-
phical theory, is, in no  instance, more
strikingly shewn, than  in the opposite
sorts of local  applications, which are of
service in inflammation.   The  generality
of cases undoubtedly receive most relief
* £.  Ammoniac Muriatst 5SS.
     Aceti;
     Spiritus Vini rectificati; sing. ibj.
     M.
  gj.  Aq. Ammon. Acet.
     Spir. Yinirectif.;
    Aq. Distillatae ;  sing. 3"iv. M.
The Aqua  Ammoniac Acet.  alone also
          does very welL 
138
INFLAMMATION.
from the use of cold sedative astringent
lotions; but, there  are  constitutions and
parts,  which derive most service from the
local employment of warm emollient re-
medies.
  Were I to endeavour to  define the par-
ticular instances, in which the latter ap-
plications avail most, I should take upon
me a task, which has baffled all the most
able surgical vvriters.'  The first stage of
the acute ophthalmy, and the hernia hu-
moralis, or inflamed testicle, may be speci-
fied, however, as examples, in which, ge-
nerally speaking,  warm emollient applica-
tions  are  better, than cold  astringent
ones.   If we may judge by the feelings of
certain patients,  there  are  undoubtedly
particular constitutions, in which the lo-
cal use of warm remedies, produces great-
er relief,  than that of cold ones. This cir-
cumstance, however, does not generally
happen;   and,  as  warm  emollient  ap-
plications  of  all kinds have  the most
powerful influence in promoting suppura-
tion, a fact admitted by  every experienced
practitioner, the  use of such  remedies,
while the resolution of inflammation is
practicable,  must  be highly censurable.
But, I am ready to grant, that in all cases
of inflammation, which manifestly cannot
be cured without suppuration, the emolli-
ent plan of treatment ought to be at once
adopted;  for,  the sooner the  matter is
formed, the sooner the inflammation it-
self is  stopped.   The  inflammation at-
tending contused and  gun-shot wounds,
and that accompanying boils and carbun-
cles, are  of this  description.   The in-
flammation,  originating in fevers, com-
monly ends in suppuration, and, perhaps,
it  might  be advantageous, in such in-
stances, also, to  employ at  once  the
emollient treatment.
  Warmth and moisture together, in other
words  fomentations, are commonly had
recourse to in cases of inflammation; but,
when the warmth is as much as the sensi-
tive principle can bear, it  excites action.
Whether it is the action of inflammation,
or the action of the contraction of the ves-
sels, is unknown.  We see that many pa-
tients cannot bear warmth, and, therefore,
it might be supposed to increase the action
of dilatation, and do harm.  But, if the
pain should  arise from the contraction of
the inflamed vessels, benefit would be the
result; though we must  doubt that this
change is produced, as making the vessels
contract would probably give ease. (Hun-
ter.)
  From the preceding   observations, we
must perceive how vain it is to theorize
on this subject, whichever, puzzled  the
genius  and penetration of a  hunter.   In
addition to  what has been already  ob-
served,  I feel totally incapable of gn ing
any useful practical advice,  with respect
to "those cases,  in which warm  emollient
applications should be used in preference
to cold astringent ones.  1 can, however,
with confidence remark, that the surgeon,
who consults the feelings and comfort of
the patient on   this point,  will  seldom.
commit any serious error.  Hence, in all
eases, in which  the first kind of topical
applications seem  not to produce  the
wonted  degree of relief^ let the second
sort be tried.  From  the  opportunity of
comparison, aright judgment may  then
be easily formed.
  The poultice made of  the powder of
linseed is so easily prepared,  th.tt the old
bread and  milk poultice is  now  seldom
made.   As mtich hot water is to be  put
into a basin, as the size ofthe poultice re-
quires, and then the linseed powder is to
be gradually mixed with the water, till the
mass  is of a proper  consistence. Very
frequently, a little sweet oil is also adiicd
to keep the apjHication longer soft  and
moist.
  Fomentations are only to be considered
as temporary applications, while the emol-
lient poultices are  tlie permanent ones.
The former are, at most, never used more
than three times a  day, for the space of
about half  an hour each time.   Two of
the best are directed below.*
  By pursuing the  treatment,  recom-
mended above, the resolution of the in-
flammation will in general begin to  take
place, either in the course of three or four
days, or in a shorter space of time.  At all
events, it  may   usually be known before
the expiration  of  this period, how  the
disorder will terminate. If the heat, pair,
and other attending symptoms abate; and,
especially,  if the tumour begins to de-
crease, without  the occurrence  of  any
gangrenous appearances ; we may then lie
almost certain,  that, by a continuance of
the same plan,  a total resolution will in
time be effected.
  On the other hand, when all the differ-
ent symptoms increase, and,  particularly
when the tumour becomes  larger,  anil
sottish, attended with  a  more violent
throbbing pain, we may conclude, that the
case will proceed to suppuration.  Hence,
an immediate change  of treatment is in-
dicated, and such applications, as were pi o-
* g<.  Lini contusi  Sj.
     Chamaemeli ^ij.
     Aq.  Distill'. ' ILvj.   Paulisper
     coque et cola.
or &. Papaveris albi exsiccati 3'iv.
     Aq.  Purse U.vj.  Coque  usque
     rcmaneuiit Hij.'tt cola. 
LXJ
INT
133
*.cr, while resolution seemed practicable,
are to be left off,  and others  substituted.
This remark relates to the employment of
cold astringent remedies,  which,  wlien
suppuration is inevitable, only do harm,
by retarding what cannot be avoided, and
affording no relief of the pain and  other
symptoms.  If the inflammation, however,
should already be treated with emollients,
no alteration of the topical applications is
requisite,  in consequence of  the  inevita-
bility ofthe formation of matter.   Indeed,
emollient poultices, and fomentations, are
the chief local means both of promoting
suppuration, and  diminishing the pain,
violent throbbing, &c.  which always pre-
cede this termination of phlegmonous in-
flammation.
  But, besides the  substitution of warm
emollient applications for cold astringent
cues, to the  part itself; practitioners have
decided, that it is also prudent, as soon as
the certainty is manifest, to relinquish the
free employment of evacuations,  particu-
larly, blood-letting, and to allow  the  pa-
tient a more generous diet.  When  the
system is too much reduced by the injudi-
cious continuance of the rigorous antiphlo-
gistic treatment, the progress  of the ensu-
ing suppuration is always retarded in a
disadvantageous manner, and the patient
is rendered too weak to support,  either a
long continued, or  a profuse discharge,
which, it may not be possible to avoid.
  On the subject of inflammation, the
best works for perusal are;  Van Swieten's
Commentaries on Boerhaave; Cullen's First
Lines on the Practice of Physic, Vol.  1; John
Hunter on Inflammation, &c; Burns's Dis-
sertations on the same.
  INGUINAL ANEURISMS. See Aneu-
rism.
  INGUINAL HERNIA.  See Hernia.
  INJECTION, (from  injicio, to  cast
into.)  A  fluid, intended to  be  thrown
into a part of the  body by  means of a
syringe.   Thus  port  wine  and  water
form an injection, which is used  by sur-
geons for radically curing the hydrocele,
and, for this purpose, it is introduced into
the cavity ofthe tunica vaginalis, where it
excites  the  degree of inflammation  ne-
cessary to produce  an universal adhesion
between this membrane and the albuginea.
  Thus many fluid remedies are intro-
duced  into  the urethra and vagina  for
curing  the  gonorrhoea.  In  the  article
Gonorrhoea,  will  be  found  an  account
of the  best injections  employed  for  its
relief.  We  here subjoin a few particular
ones not there noticed.
   INJECTIO  ACIOI   MURIATICI.—
9c. Aquae distil, ^iv.   Acid.  Mur.  gutt.
viij. Misce.—Useful when the scalding is
a very troublesome symptom.
  INJECTIO ALUMIXIS.  *. Alum  51.
Aq. pur. §vj.  Misce.—Successfully  em-
ployed by Dr. Cheston, as an injection in
affections of the rectum, either when the
internal coat is simply relaxed,  and dis-
posed to prolapsus,  or when it is studded
with loose fungated  tumours.   In  such
cases, camphor is also  of  service.  The
quantity of* alum may be increased, if the
parts will bear it.
  INJECTIO  CUPRI AMMONIATI.—
£.  Liquoris  Cupri  ammon.  gutt.  xx.
Aquae  rosse  3iv.  Misce.—Strongly  re-
commended by Mr. Foot.
  INJECTIO   QUERCUS—*.  Decocti
quercus  tbj. Aluminis  purificati §ss.
Misce.—Maybe used, when the rectum, or
vagina,  is disposed to a prolapsus  from
relaxation, or in cases of" gleet.
   INTERRUPTED  SUTURES.   See
Sutures.
  INTESTINES WOUNDED.   See  Ab-
domen, Wounds of.
  INTROSUSCEPTION, or Intussuscep-
tion, (from intus, within, and suscipio, to
receive.)  Called also Volvulus.   Is a dis-
ease, produced by the passing of one por-
tion of an intestine into another, and it is
commonly  from the upper passing  into
the lower part.  (J. Hunter.)
  Mr. G. Langstaff has published an inte-
resting paper,  on this subject,  in  the
Edinb. Surg. Journal, No.  XI.; which I
shall take the liberty of freely quoting.
  This gentleman remarks,  that the small
intestines of children are so often affected
with introsusception, in a slight degree^
that most  practitioners  must have had
opportunities of observing the form ofthe
complaint.   The greatest  part of three
hundred  children,  who died either of
worms,  or during  dentition, a the Hos-
pital de la Saltpetriere, and came under
the examination of M.  Louis, had two,
three, four, and even more volvuli, with-
out any inflammation ofthe parts, or any
circumstances leading to a suspicion, that
these affections had  been injurious during
life.  " These cases (says M. Louis) seem
to prove, that introsusception may  be
formed, and destroyed agaiivby the mere
action ofthe intestines." (Mem. del'Acad.
de C/ururg. 4to. torn. 4. p. 222.)  This opi-
nion is confirmed by the authority of Dr.
Baillie, (Morbid Anatomy, 2d edit. p. 162.)
who observes, that^  " in opening bodies,
particularly of* infants, an intussusceptio
is not unfrequently found, which had been
attended with no mischief;  the parts ap-
pear perfectly free from  inflammation,
and they would probably have been easily
disentangled from each other by their na-
tural peristaltic motion."
  The disease, continues  Mr. Langstaff,
assumes  a more dangerous, and,   hjdeed, 
140                         INTROSUSCEPTION.
generally a fatal form, when it occurs at
the termination of the small intestines in
the ccccum. A contracted state ofthe part
to be introsuscepted,  and a dilatation of
that portion of the canal, into which this
part must pass, are essential conditions 10
the formation  of a volvulus; and those
exist no where so completely as in the
situation here alluded to.  The extent, to
which the affection proceeds in this situa-
tion, would appear almost incredible, if it
were  not  proved by  well authenticated
facts.  A person,  who considered the na-
tural situation and connexion ofthe parts,
would of course require the strongest evi-
dence, before he would  believe,  that the
ilium, ccecum, ascending, and transverse
portions of the  colon, may descend into
the sigmoid flexure ofthe latter intestine;
nay more, that they may pass through the
rectum, and be protruded in the form of a
procidentia ani.  Such cases, however, are
recorded.  (Langstaff, in Edinb. Med. and
Surg Journal,  No. XI.)
  This gentleman next relates the case of
a child three .months old, the  body of
which he inspected after death, and found
to confirm the truth of the preceding ac-
count.  The example, was particular in
there being in addition to an extensive in?
trosusception in the usual way, a smaller
invagination in the opposite direction, like
what probably occurred in the case related
by Mr. <Spry;  Med. and Physical Journal,
No. XI  Mr. Home,  in  the Med. and
Chirurg. Trans. Vol. 1. mentions an exam-
ple of  a  retrograde  introsusception, in
which a worm was found coiled up round
the introsuscepted part  The disease took
place in a boy who had swallowed some
arsenic.
  If the following mode of accounting for
introsusception,  be just, it will most fre-
quently  happen  downwards,  although
there is no reason why it  may not take
place in a contrary direction; in  which
case, the chance of a cure will be increased
by the  natural actions  of the intestinal
canal tending to replace  the intestine;
and probably  from this circumstance it
may oftener occur than commonly appears.
(/. Hunter.)
   When the introsusception is downwards,
it may be called progressive,  and when it
happens upwards, retrograde.  The man-
ner in which it may take place is, by one
portion of" a loose intestine being con-
tracted, and the part immediately below
relaxed and dilated;  under which circum-
stances, it might very readily happen by
the contracted portion slipping a little
way into that which  is dilated,  not from
any action in  either portion of  intestine,
but from  some additional  weight  in the
gut above.  How far the peristaltic mo»
tion, by pushing  the contents on  to the
contracted parts,  may  force  these  into
the relaxed, Mr.  Hunter will  not  deter-
mine, but is inclined to suppose that it
will not.  (J. Hunter)
  By this mode of accounting for an acci-
dental introsusception, it may take place
either upwards or  downwards; but if a
continuance or an increase  of it arises
from the action of the intestines, it must
be when it is downwards, as we actually
find to be the case; yet this does not ex-
plain those  in which a considerable  por-
tion of  intestine  appears  to  have been
carried into the gut below : to understand
these, we must  consider the  different
parts which form the introsusception.  It
is made up of three folds of intestine ; the
inner, which passes down, and being re-
flected upwards,  forms the second or in-
verted portion, which being reflected down
again, makes the third or containing part,
that is the outermost, which is always in
the natural position.  (J Hunter.)
  The outward fold is the only one which
is active,  the inverted portion being per-
fectly passive, and squeezed down by the
outer, which inverts more of itself, so that
the angle of inversion in this case is always
at the angle of reflection of the outer into
the  middle portion or  inverted  one,
while the innermost is drawn in.  From
this we  can readily see how an introsus-
ception, once begun, may have any length
of gut drawn in.  (J. Hunter.)
  The external portion  acting upon the
other folds in the same way as upon any
extraneous  matter, will by its peristaltic
motion  urge them  further; and, if any
extraneous  substance is detained  in the
cavity of the inner portion, that part will
become a fixed point for the outer or con-
taining  intestine to  act upon.  Thus it
will be squeezed on, till at last the mesen-
tery preventing more ofthe innermost part
from being drawn  in, will act as a kind
of stay, yet  without entirely hindering the
inverted outer fold  from going «till fur-
ther. For it being the middle fold that is
acted upon by the outer, and  this action
continuing after the inner portion becomes
fixed, the gut is thrown into  folds upon
itself; so that a foot in length of intestine
shall form an introsusception not more
than three inches long.  (/. Hunter.)
  The outer portion  of intestine is alone
active in  augmenting the disease when
once begun; but  if  the inner one  were
capable of equal action  in its natural di-
rection, the effect would be the same, that
of  endeavouring to invert  itself, as in a
prolapsus ani; the outer and inner por-
tions, by  their action, would tend to draw 
INTROSUSCEPTION.
i<U
in more of tlie gut, while the intermediate
part only would, by its action, have a con-
trary tendency.  (/. Hunter.)
  The action of  the abdominal muscles
cannot assist in either forming, or continu-
ing this disease, as it  must  compress
equally  both above and  below,  although
it is capable of producing the  prolapsus
ani.   (J Hunter.)
  When an introsusception begins at the
valve ofthe colon, and Inverts that intes-
tine,  we find the  ilium  is not at all af-
fected ;  which proves that the mesentery,
by acting as a stay, prevents its inversion.
if. Hunter.)
  From the natural  attachment of the
 mesentery to the intestines, one would, at
 the first view of the subject, conceive  it
 impossible for any one portion of gut to
 get far within  another;  as the greater
 extent of mesentery that is carried in along
 with it would render its further entrance
 more and  more difficult, and we should
 expect this difficulty to be greater in the
 Large intestines  than in the  small, as be-
 ing more closely confined to their  situa-
 tion ; yet one of the largest introsuscep-
  tions of any known  was in  the colon,
  as related by Mr. Whateley.  (Vid. Phil.
  Tram. Vol 76. p. 305.)
  . The introsusception  appeared to  have
  begun  at the insertion of the  ilium into
  the colon, and to have carried in the cce-
  cum with its appendix.  The ilium passed
  on into tiie colon, till the whole of the as-
  cending colon, the transverse arch, and
  descending colon, were  carried into the
  sigmoid flexure and rectum..  The  valve
  of the  colon being the leading part, it at
  last got as low as the anus;  and when the
  person went to stool he only emptied the
  ilium, for one half of the large intestines
  being  filled  up by the  other, the  ilium
  alone,  which passed through the centre,
  discharged its  Contents.  (/. Hunter.)
    Two questions of considerable import-
  ance  present themselves to  the  mind
  in considering this   subject ;  whether
  there  are any symptoms, by which tlie ex-
  istence ofthe affection can be ascertained
  during life ?  And whether we possess any
  means of relieving it,  supposing, that its
  existence could be discovered ? The symp-
  toms  attending an  introsusception,   are
  common to inflammation ofthe intestines,
  hernia, and obstruction of the canal, from
  whatever  cause,  and a volvulus  is  the
  least  frequent  cause  of such symptoms.
  (iMugstaff.)  In the   case, published by
  this gentleman, and  in those related by
  Mr. Hunter and Mr  Spry,  the seat of the
  disease was clearly  denoted by  a hard
  tumour on the left side of the abdomen.
  This  circumstance, together with the un-
  p-is.-ibilitv of throwing "P mare  than a
very small quantity of fluid in clysters,
(Hevin, Spry, Langstaff;) and tlie pi esence
of the other symptoms,  would lead us to
suspect the nature of  the disorder.   If
the invaginated portion  descended so low
as to protrude through  the anus,  and  we
could ascertain, that it  was not an inver-
sion of the  gut, the cause might be con-
sidered as clear,  and we should  have no
hesitation   in  delivering  a   prognosis,
which, by preparing the friends for  the
fatal  termination,  would exonerate  us
from all blame on its occurrence.  (Lang-
staff)
   In the treatment of this disease, bleed-
ing, to lessen the inflammation that might
be brought on, and quicksilver to remove
the cause have been recommended.
   Quicksilver  would   have little  effect
either in one way or the other, if the in-
 trosusception were downward; for it is to
 be supposed that it would easily  make its
 way through  the innermost contained
 gut, and,  if it should  be stopped in its
 passage, it would, by increasing its size,
 become a cause (as before observed) of
 assisting the disease.   In cases of the re-
 trograde kind, quicksilver, assisted by the
 peristaltic  motion, might be expected to
 press the introsusception back;  but even
 under such circumstances it  might get
 between the containing and  inverted gut
 into the angle of reflection, and,  by push-
 ing it further on, increase the. disease it
 is intended to cure..  (/. Hunter.)
    Every thing that can increase^ the ac-
 tion of the intestine downwards  is to be
 particularly  avoided,  as tending to in-
 crease the peristaltic motion of  the outer
 containing gut, and thus to continue the
 disease.   Medicines can never  come in
 contact with the outer fold, and, having
 passed  the inner, can only  act on  the
 outer below, therefore cannot immediately
 affect that portion ofthe outer which con-
 tains the  introsusception; but  we must
 suppose that whatever affects, or comes
 in contact with the larger portion ofthe
 canal, so as  to throw  it into action,  will
 also  affect by  sympathy any  part  that
 may escape such application.  Mr.  Hun-
 ter therefore advises giving vomits,  with
  a view to invert the peristaltic motion of
  the containing gut, which will have a ten-
  dency to bring the intestines  into  their
  natural situation.
    If this practice should not  succeed, it
  might be proper to consider it as  a re-
  trograde  introsusception, and  by admi-
  nistering  purges endeavour to increase
  the  peristaltic motion  downwards. (J.
  Hunter.)
     I cannot agree with Mr. Langstaff, that
  it is to be regretted, Hunter's name should
  be affiled to the preceding proposal, or 
142              IN V
1RI
that it is an absurd one; for purgatives
y,nd emetics were only  recommended  to
increase the peristaltic action, the former
downward, the latter upward, according
as the supposed nature of the case might
require,  and this effect they  certainly
would have, notwithstanding vomiting is
an early and  constant  symptom of the
disease, and an insuperable constipation
an  equally invariable   attendant.  The
method,  I  allow, however,  is  not  very
hopeful,  on account of the  existence of
adhesions.   Mr. Langstaff remarks, that
the Recherclies Historiques sur la Gastroto-
nde dans le cos de  Volvulus, par M. Hevin,
(Mem. del'Acad, de Chirurgie, Tom 4, 4to.)
contain many interesting facts and much
sound reasoning.  There we find a  very
ample discussion of the question, concern-
ing the propriety of opening  the abdo-
men,  in  order to disentangle  the intro-
suscepted  intestine;  a proposal which
M Hevin condemns.
   If the  equivocal and uncertain nature
of the symptoms  of volvulus,  were not
sufficient  to deter us  from undertaking
an operation, which, under  the most fa-
vourable circumstances, could  not fail to
be extremely difficult, and imminently
hazardous to the  patient, the state of the
invaginated parts will  entirely banish all
thoughts of such an imprudent attempt.
 The different folds  of the  intestine  be-
come agglutinated to each other, so  that
they can hardly be withdrawn after death;
(Simpson, Edinburgh Med. Essays, Vol. 6.
/levin's 4th Obs.  Malcolm,  Physical and
 Lit. Essays, Vol. 2, p. 360   Hunter,  Med.
and Cidr. Trans, and Soemmering in Trans.
of BuiUie's Morb. Anat.) the stricture on
the introsuscepted part, causes  it to in-
flame, and even  mortify.   (Soemmering.)
It is very clear, that, in this state of parts,
the  operation of gastrotomy  would be
totally inadmissible, even  if the symp-
toms could clearly indicate the nature of
the case, and  the affected part could be
easily reached and examined. (Langstaff,
in Edinburgh Medical and Surgical Jour-
 nal.)
   The forcible injection of clysters was
found useless  by Dr.  Monro, and  the
agglutination of the parts  must  produce
 an insuperable obstacle to the bowels be-
 ing pushed back  by this means.  (Lang-
 staff.)  Some have proposed the employ-
 ment of a long bougie, or a piece of whale-
 bone, to  push back  the  intestine;  and
 this  proposal may be adopted, when we
 are furnished with an instrument, adapted
 to follow the windings of the large intes-
tine to its origin in the right ilium,  with-
 out any risk of perforating the gut  in its
 course.  (Langstaff.)
   We most confess,  both surgery and
medicine are almost totally  unavailing -n
the present disease.   Yet  here,  as in
many other instances,  the resources of
nature are exhibited in a most wonderful
and astonishing manner, while  those of
art  completely fail.   The  invaginated
portion  of intestine sometimes  sloughs,
and is discharged per anum,  while the ag-
glutination  of  the  parts preserves  the
continuity  of the intestinal canal.   The
annals of medicine furnish numerous in-
stances, in which long pieces of gut have
been discharged in this manner, and the
patient  has  recovered.   Hence,  some
hope may be allowed under the  most un-
promising circumstances  In a  case, re-
lated in Duncan's Commentaries, eighteen
inches of small intestines were voided per
anum, Vol.  9,  p. 278.   Three similar in-
stances  occur  in M.  Hevin's  Memoir;
twenty-three inches of colon came away
in one of these, and twenty-eight of small
intestines in another.   Other cases occur
in the   Physical and   Literary  Essays,
Vol.  2, p. 361; in  Duncan's  Essays,
Vol. 6,  p.  298; in  the Medical and Chi-
rurgical Transactions,  Vol. 2; where Dr.
Baillie  states,  that  a yard of intestine
was  voided.  The/patients did not, how-
ever, ultimately  survive in every one of
these instances.   (Langstaff, in  Edinb.
Med and Surgical Journal.)
   For  information  concerning  intussus-
ceptio,   I  would particularly  refer  the
reader  to M. Hevin, in Mem. de I'Acad, de
 Chir.   Hunter's Observations, in the Medi-
cal and Chirurgical Transactions.  L'En-
cyclopedic Methodique,Partie Chirurgicale;
Art.  Gastrotomie.  And Langstaff's Re-
marks in the Edinburgh Med. and Surgical
Journal, No. II.
   INVERSION  OF  THE  UTERUS.
See Uterus, Inversion of.
   IRIS, PROLAPSUS OF.  As long-as
the humours, which fill the cavity of the
eye,  and in which the iris  is immersed
and suspended,  remain in perfect equili-
brium  with respect  to each other,  that
 membrane retains  its  natural position,
and a  suitable distance from the cornea.
 While  such an equilibrium continues, the
 iris,  although of  a  very delicate and
yielding texture, contracts, and relaxes
itself, without ever forming any irregular
fold.  But,  when  the aqueous humour
has  escaped through an accidental, or ar-
 tificial  opening in the cornea, the iris is
pressed forward  by the humours situated
 behind it; and is urged gradually towards
 the  cornea, until a portion of it  protrudes
from the eye, at the same opening, through'
 which  the aqueous  humour made its es-
cape.   Thus  a small tumour of the same
colour  as  the iris forms on the  cornea,
and is named, by the majority of surgeons, 
IRIS.                                 143
staphyloma of the iris; but, for the sake
of distinguishing the disease more parti-
cularly from another, to which the term,
staphyloma is more properly applicable,
Scarpa prefers  calling  it "with  Galen,
procidentia, or prolfsus of the iris.
  The causes of this complaint are such
wounds and ulcers  of the comea, as make
an 0|>emng of a certain extent into the
anterior chamber of the  aqueous humour,
and  such  violent contusions  of the eye-
ball, as occasion a  rupture of the cornea.
If the edges of a wound in this situation,
whether accidental, made for the purpose
of extracting the cataract, or evacuating
the matter  of an  hypopium (as is the
practice of some), be not  brought imme-
diately  afterwards into reciprocal con-
tact, or continue, not sufficiently aggluti-
nated together to  prevent  the escape  of
the aqueous humour  from  the anterior
chamber, regularly as this fluid is repro-
duced ;  the iris, drawn by its continual
flux towards the cornea, glides between
the lips of the wound, becomes elongated,
and a portion of it gradually protrudes,
beyond the cornea, in the form of a small
tumour.   The  same thing  takes place,
whenever the eye-ball  unfortunately re-
ceives a blow, or is too much compressed
by bandages, during the  existence of a
 recent wound ofthe cornea.  Also, if the
patient should be affected, in this circum-
 stance,  with a spasm of the muscles  of
 the eye, with violent and repeated vomit-
 ing, or with strong and frequent cough-
 ing, a prolapsus of the iris may be caused.
 When an ulcer of the cornea penetrates
 the anterior chamber  of  the aqueous
 humour, the same inconvenience happens
 more frequently, than when there is a re-
 cent wound of that membrane;  for, the
 solution of continuity in the cornea, wis-
 ing from an ulcer, is attended with loss of
 substance, and in  a membrane so tense,
 and compact, as this is, the edges of  an
 ulcer do not admit of being brought into
 mutual contact.
   The little tumour  is likewise  necessa-
 rily of  the same colour as the iris, viz.
 brown, or  greyish, being surrounded  at
 its base  by an  opaque circle of  the cor-
 nea, on  which membrane there is an  ul-
 cer, or a wound of not a very recent de-
 r>cription.
   As it usually happens, that the cornea
 is only penetrated at one  part of its  cir-
 cumference by a  wound, or ulcer, so in
 practice we commonly meet with only one
 prolapsus of  the  iris  in  the  same eye.
 tyut, if  tha cornea should happen to  be
 wounded, or ulcerated, at several distinct
 points, the iris may protrude at several
 different places of the same  eye, forming
 an equal number of  small projecting  tu-
mours on the surface of tlie cornea. Scar-
pa has seen a patient, who had three very
distinct protrusions of the iris on the same
cornea, in consequence of three separate
ulcers, penetrating  the  anterior cham-
ber of the aqueous humour; one in  the
upper, and two in  the lower segment of
the cornea.
  If we  reflect  a little on the delicate
structure of the  iris; the great quantity
of blood-vessels which enter it, ;.nd the
numerous nervous filaments,  which pro-
ceed to be distributed to it, as a common .
centre;  we shall easily conceive the na-
ture,  and severity of those   symptoms,
which are wont to attend this disease,
how small soever tiie portion  of the iris •
projecting from  the cornea may be, even
if no larger than  a  fly's head.  The hard
and continual  frictions, to which  this
delicate  membrane  is then exposed, in
consequence of the motions ofthe eyelids;
together with the access of air, tears and
gum to  it, are causes  quite adequate to
the production  of continual  irritation;
and the  blood,  which tends to the point
of  the greatest  irritation, cannot iiiil to
render the projecting portion  of the iris
much larger, almost directly after its pro-
trusion, than it was at the moment of its
first passing through the cornea.  Hence,
it becomes, soon after the prolapsus, more
incarcerated and irritated, than it was at
first.  In the incipient state of the com-
plaint, the patient  complains  of a pain,
similar to what would arise from a. pin
penetrating the  eye ; next he begins to
experience, at the same time,  an oppres-
sive sensation of a tightness,  or constric-
tion,  over the whole eye-ball.  Inflamma-
tion of the conjunctiva,  and  eyelids,  a
burning effusion of tears, and an absolute
inability to endure the light, successively
take place.  As the protruded portion of
the iris drags after  it all the rest of this
membrane, the pupil assumes of mechani-
cal necessity of an oval shape, and deviates
from the centre of the iris, towards the
seat of the  prolapsus.   The intensity of
the pain, produced by the inflammation,
and  other symptoms, attendant  on the
prolapsus of the iris, does not,' however,
always continue to increase.
   Indeed, in practice, cases of old protru-
sions of the iris often occur, where, after
the disease has been left to itself, the pain
and inflammation spontaneously subside,
 and the tumour of the iris becomes almost
 completely  insensible.  Scarpa mentions
 his having seen a man, fifty years of age,
who  had had a prolapsus ofthe iris in the
 right eye ten  weeks; it was as large as
 two  grains  of millet  seed;   the patient
 bore it with the greatest indifference, and
 without any other inconvenience, than  a 
144
IRIS.
little chronic redness of the conjunctiva,
and  a difficulty  of moving  the  eye-ball
freelv, hi consequence  of the friction of
the lower eyelid against the tumour formed
bv tie  ;ris.  When the extremity of the
finger was  applied,  the little  tumour
seemed hard and callous to the touch.
  This  phenomenon was partly owing to
the  constriction, which the base of the
tumour of the iris  suffered  between the
lips  of the wound, or ulcer of the cornea.
The protruded portion of the iris loses its
natural  exquisite sensibility,  in conse-
quence of such compression, or strangu-
lation.  The phenomenon was also partly
ascribable to the iris being deprived of its
vitality  by the induration, and callosity,
which were occasioned by the long expo-
sure  of this membrane to the air,  and
tears.
  In the early stage of this disease, some
direct the iris to be replaced in its proper
situation by means of a whalebone-probe ;
and, in case of difficulty, to make  a dilata-
tion of the wound, or ulcer, of the cornea,
by an incision, proportioned to  the  exi-
gency of the case, as we are accustomed
to do, in order to return a  strangulated
intestinal hernia.   Others  only  recom-
mend strangulating the  prolapsed portion
of the iris, with  a view of making it con-
tract and shrink into the  eye;  or sud-
denly exposing the eye  affected to a very
vivid light,  in the belief, that, as the pu-
pil then forcibly  contracts,  the  piece of
the  iris, engaged between the lips of the
wound,  or  ulcer of the cornea, will  rise
to its  proper place.  However,  Scarpa
strongly contends that  all such methods
are absolutely useless, and even danger-
ous.  Supposing  it were possible, by such
attempts, to reduce the iris to its proper
situation, without  tearing, or injuring  it
in any manner whatever, still tiie aqueous
humour would escape as  before,  through
the'  wound, or uicer of the cornea, so that
the  iris, when replaced, w ould fall down,
the  moment afterwards, and project from
the  cornea,  in the same way as before the
operation.
   It cannot be denied, that the prolapsus
of the iris is  an afflicting accident: but,
when it is remembered, that surgery has
no means of suppi essmg at once, or, at
least, of suspending  the escape of  the
aqueous humour  through a wound,  much
less through an ulcer of the cornea, when
either exceeds certain limits, the prolap-
sus of the iris, far  from being an evil in
such unfavourable circumstances, will be
found rather useful,  and, perhaps,  the
only means of preventing the  total loss of
the  oigan of sight; for, the flap of the
iris  insinuates itself, like a plug, between
the edges of the  wound, or ulcer ofthe
cornea, and thus completely prevents tlie
exit of tiie aqueous humour.
  In  consequence  of this  fluid  being
quickly regenerated, and unable to escape
any  longer  through the cornea ;  it pre-
vents the further  protrusion  of the iris,
removes the rest of this membrane  to a
greater distance from the cornea, and, by
re-establishing the equilibrium between
it and the humours of the eye, resists the
total loss of sight.  If this be evident of
itself, it  is 'equally  obvious, that every
known method, adapted to replace the
prolapsus of the iris, must be useless, or
dangerous.
  In  conformity to such principles, there
are two principal indications for the sur-
geon to accomplish,  in the treatment of
the recent prolapsus ofthe  iris.  The first
is, to  diminish,  as speedily as possible,
the excess of exquisite  sensibility in the
protruded part of the  iris;  the other is
gradually to destroy  the projecting por-
tion of this membrane,  to  such a depth,
as. shall be sufficient to  prevent the httlp
tumour from keeping  the edges of the
wound, or ulcer of the cornea, too much
asunder,  and, at length,  retarding  the
cicatrization.   The  adhesion,  however,
which connects the iris with the inside of
the cornea, must not be destroyed.
  To  fulfil these indications, nothing is
more  effectual than touching the portion
of the iris  projecting from  the cornea,
with the oxygenated muriate of antimony
(butter of antimony), or with what is more
expeditious and convenient, the argentum
nitratum,*so as to form an eschar of such
a depth as occasion  may  require.  That
this operation may be effected with quick-
ness and precision, it is necessary that an
assistant, standing behind the patient's
head, should support  the upper eyelid
with Peltier's elevator;  and that the pa-
tient, if endued with reason, should keep
his eye steadily fixed on one object.
  While the assistant  gently  raises the
upper  eyelid, the surgeon must depress
the lower one, With the index and middle
fingers of his left hand; while, with the
right, he is to be ready to touch the little
prominence formed by the iris, with the
argentum  nitratum,  scraped to a point
like a crayon. This  is  to be  applied to
the centre of the  little tumour,  until an
eschar of sufficient depth is formed. The
pain which the patient experiences at this
moment, is very acute;  but,  it subsides
as soon as the eye is bathed with warm
milk.   The  caustic,  in  destroying the
projecting portion  of the iris, destroys
the principal organ of sensibility, bv co-
vering it with  an eschar, of  sufficient
depth to protect the part affected from the
effecjt of the  friction of tlie eyelids,  and 
IRIS.                                 H>
from ooming into contact with the air and
tears. This is the precise reason, not only
why the sense of pricking and constric-
tion in tiie eye, of which such patients
complain so  much, abates after  the  ap-
plication of the caustic, but also why  the
inflammation  of the conjunctiva under-
goes a considerable diminution, as well
as th* burning  and copious effusion of
tears.
  As in the ease of ulcer of  the cornea,
these advantages only last while the eschar
remains adherent  to   the  little tumour
formed by the iris;  when  it falls off, as
it usually  does two or three days  after
the use of the caustic,  all the above-men-
tioned symptoms are rekindled, with this
difference, that they are less intense and
acute, than they  were previously, and  the
tumour of the iris is not so prominent as
it was before the caustic was applied.
When  these  symptoms make  their  ap-
pearance, the  surgeon   must once  more
have recourse  to the argentum nitratum,
with the  precautions  explained  above;
and he is to employ it a third, and even a
fourth time, as occasion may require,  un-
til  the prominent portion  of the iris is
sufficiently reduced to a level with  the
edges of the wound, or ulcer of the cor-
nea, and no obstacle to the  granulating
process, and complete  cicatrization con-
tinues.
  There is a certain period, (as was stated
in the article, Cornea,  Ulcers of)  beyond
which the  application  ot  caustic to  the
protruded iris, becomes exceedingly dan-
gerous, though at  first ft may have been
highly beneficial; beyond  which,  the es-
char, which previously  soothed the pain,
exasperates it, and re-produces the  in-
flammation of the conjunctiva  in almost
as vehement a degree as in the beginning
of the disease.   This appears to  Scarpa
to be the case, whenever the surgeon con-
tinues  to  employ  the  caustic, after  the
little tumour ofthe iris  has been destroyed
to a level with the external edges of  tlie
wound, or ulcer of the cornea, and  the
application begins to destroy the granu-
lations just  as  they   are   originating.
Hence, in the treatment of this disease,
as soou as the surgeon  perceives, that  the
part of the iris, projecting from the cor-
nea, is sufficiently  lowered, and that  the
application of the  argentum  nitratum,
far  from allaying,  only irritates the dis-
ease, he  must desist entirely from  using
the caustic, and be content with introduc-
ing  between  the eye  and eyelids,  every
two hours, a  vitriolic collyrium with  the
mucilage  of quince-seeds,  or  one  com-
posed of the  sulphate  of  zinc and  white
of egg.  He  is  to employ,  successively
every morning and evening,  Janin's ophf
    Vol,  II.
thalmic ointment, qualified with a dou-
ble, or triple proportion of lard.  If the
stimulus of such  local remedies should
not disturb the work of nature, the ulcer
is constantly seen to diminish gradually in
size, and, in the course of a fortnight, to
become covered with a cicatrix.
  The adhesion, which the projecting part
of the iris contracts to  the internal mar-
gin of the wound, or ulcer of the cornea,
during the treatment,  continues the same
after the perfection of the external  cica-
trix, and of course during the rest of the
patient's life.   Hence,   even   after  the
most successful treatment of the prolapsus
of the iris, the pupil remains  a little in-
clined towards  the place of the cicatrix
in the cornea, and of an oval figure.   The
change in the situation and shape  of the
pupil causes, however,  little or  no dimi-
nution of the patient's faculty of discern-
ing distinctly the smallest objects; and
is much less detrimental to 'the sight,
than one,  inexperienced in these matters
might conceive; provided the scar on the
cornea be not tooextensive, aor situated
exactly in the centre of this membrane.
In the first case, the sight is the less ob-
structed, as the pupil, which, on the first
occurrence of the prolapsus, was narrow,
oblong,  and drawn considerably towards
the wound, or ulcer, gradually  enlarges,
and  forms a less contracted oval.  As
soon as the wound is  completely healed,
the pupil tends, in some degree,  to oc-
cupy its former situation in the centre of
the cornea.   Richter  has, also, noticed
this fact.
  The mode of treating  the prolapsus of
the iris  here explained, is what Scarpa
has found to  be the safest,  and  most ef-
fectual of all  other  methods, that  have
hitherto  been  proposed ; not excepting
that of removing the little tumour, formed
by the iris on the surface of the cornea,
by a stroke of the scissars.
  Certainly, if tiie success of such a reci-
sion were "to correspond, in  all  cases,
with the promises, which some surgeons
have made, nothing would contribute in a
greater degree to exjiedite the cure of the
prolapsus of  the  iris.   But, experience
lias informed Scarpa, that  this recision
can only be practised with a hope of suc-
cess, when the iris has contracted a  firm
adhesion to the internal edge of the, wound,
or ulcer of the  cornea;  and, more espe-
cially in that ancient  prolapsus of the
iris, in which the projecting portion ofthe
iris has become with time almost insensi-
ble, hard,  and callous, w th its base stran-
gulated between the edges of the wound,
or ulcer of the. cornea,  and besides being
adherent to ihem, having also the shape
of a slender pedicle.   Scarpa adds, he
    T 
146                                  IRIS.
   has seen an incarcerated  one fall off of
   itself.
      In such circumstances,  the recision of
   the old prolapsus ofthe iris is not attend-
   ed with  the  least danger; for,  after re-
   moving with a stroke of the scissars, that
   prominent  portion of the iris, which has
   already contracted internal  adhesions to
   the ulcerated margin of the f.ornea, so as
   to reduce it to  a level with  the external
   edges  of the ulcer, there is no hazard of
   renewing the effusion of the  aqueous hu-
   mour,  or giving an opportunity for an-
   other  piece of the iris to be protruded.
   One, or two applications of "the argentum
   nitratum suffice afterwards for the pro-
   duction  of granulations on the  ulcer of
   the cornea, and the formation of a cica-
   trix.   But, it is not so, in the treatment
   of the recent prolapsus of the iris, which
   has no adhesions to the internal edges of
   the wound, or ulcer of the cornea.
      In four subjects recently  affected with
   prolapsus  of the iris, after  Scarpa  had
   removed,  with a pair of convex-edged
   scissars, a portion of that membrane pro-
   jecting beyond the cornea,  of" about the
   size ofa fly's head, it was with regret that
   he found on the ensuing day, that a new
   portion of the iris, not less than the first,
   had made its  way through the ulcer of
   the cornea, and that the pupil  Was very
--> much  contracted, and drawn considerably
   further towards the ulcer of the cornea.
   These circumstances took place, notwith-
   standing  he touched  the won rid imme-
   diately afterwards with the  argentum ni-
   tratum, as well as the edges of the ulcer
   ofthe  cornea.  He has therefore cause to
   fear, should  he ever have occasion to di-
   vide such  a  little tumour again, that it
   would reappear, and always with an ad-
   ditional protrusion of the iris, and a fur-
   ther distortion of the pupil.  Hence, the
   first lesson has made him content to treat
   the disease with caustic, in  the manner
   explained  above; and all the  four sub-
   jects in question were successfully cured,
   > excepting  that their pupils, in conse-
   quence of being drawn too much towards
   tlie situation of the  ulcer of the cornea,
   were  more covered than they ought to
   have been, by the cicatrix.
      Before concluding this article, we beg
   the  attention of surgeons, to a particular
   species of prolapsus, much less frequent,
   indeed,  than that of the iris; but,  which
   does occur in  practice, and, in Scarpa's
   opinion, is very  improperly  termed by-
    mode.]! oculists, " prolapsus ofthe tunic of
    the aqueous humour." (Junin, Pellier, Gue-
    rin, Glci-e, £Jc.)
      This disease consists of  a transparent
   vesicle,  tilled with an  aqueous fluid, and
    composed of a very delicate membrane,
which  projects from the wound, or ulcer
of the  cornea, much in the same  way as
the iris does under similar circumstances.
Scarpa has several times seen this trans-
parent vesicle  full of water, elongating
itself beyond the cornea,  shortly after
the  operation for the  extraction of the
cataract, and sometimes,  also, in conse-
quence of an ulcer of the  cornea, espe-
cially after rescinding a prolapsed  portion
of" the/iris.
  Oculists are, for the most part, of opi-
nion, that this little transparent tumour
consists  of the delicate, elastic, diapha-
nous membrane,  which invests  the inner
surface of the cornea, and is described by
Descemet and Demours.   "  As soon as
the  membrane lining the  cornea (they
say) is exposed by the wound, or ulcer of
the  latter, and the  delicate  pellicle can
no longer resist  the impulse  of the  hu-
mours pressing  behind it, it is necessi-
tated to  yield gradually, to become elon-
gated, and to project from the wound, op-
ulcer of the  cornea, exactly in  the form
of a pellucid vesicle."  But, how remote
this theory is from  the truth,  must be      .
manifest to every one, who reflects at all
on the following circumstances:  1. The
delicate and elastic pellicle, described by
Descemet and  Demours, is not  separable  **
by any artifice from the inner surface of
the  corhea, except near where the cornea
and sclerotica unite.  Since these pro-
truded vesicles make their appearance in
practice  at every  point of the cornea, and
even at its very centre, where the above
pellicle is certainly neither separable, nor
distinct from the  compact texture of the      j
cornea;  it may at least  be asserted, that
the  tunic or the aqueous humour  does
not, in   every instance,  constitute  the      |
transparent  vesicle  in  question.  2. It is
a well known fact,  that  this  vesicular,      \
pellucid  prolapsus   happens more  fre-
quently  after the extraction  of the cata-
ract, than on any other occasion.  In this
case, since the tunic of the aqueous hu-
mour has certainly been divided to afford
an  exit to the crystalline, no one-can be
of opinion, that  the  transparent  vesicle,      ,
which protrudes from the  come?  after      '
this operation, ought  to be attr"' .ted to      i
the  distention and protrusion of the tunic
of the aqueous humour.  3.  If, in cases
of ulcers of the cornea,  the t transparent
vesicle should sometimes appear after the   (•  i
recision  of the prolapsus of the iris, it is    ,
obvious,  that if  it consisted of the tunic
of the aqueous humour, it ought invaria-     i
bly  to appear before the prolapsus of the     J
iris. 4.  Should the surgeon remove the
protruded vesicle to a level with the cor-
nea by a stroke of the scissars,  a small
quantity of limpid  water is seen to ooze
_r 
IRIS.                                 147
out, at the moment when the incision is
made, without any part of the  aqueous
humour escaping from the anterior cham-
ber.   This inconvenience would be in-
evitable',  were the protruded  vesicle in
question  formed by  the delicate elastic
pellicle,  which is said to invest the inner
surface of the cornea.  Besides, the little
transparent tumour disappears when the
incision is made ; but  oftentimes another
one, exactly similar to what was cut off,
is  found in the very  same place on the
following day.  Had the little transparent
tumour been composed of the tunic of the
aqueous  humour, elongated out  of  the
wound,  or ulcer of the cornea,  it could
not at all events have been reproduced at
the same part of the cornea.
  Actuated by such reflections, it is clear
to Scarpa,  that the pretended  prolapsus,
of the tunic  of the aqueous humour, is
not what  it  is  imagined  to be; but,
strictly  speaking,  nothing more  than  a
forcible protrusion of  a portion of the vi-
treous humour, which, from  too much
pressure  being made on the eye, either at
the time of the operation, or afterwards,
or from a spasm of the muscles of the eye,
insinuates itself between the edges of* the
wound after  the extraction of the cata-
ract, and projects in the form of a trans-
 arent vesicle.   The  same thing  also
 appens after ulcers of the cornea, when-
ever the aqueous  humour has. escaped,
and a portion of the  vitreous  humour is
urged by forcible pressure towards  the
ulcer  facing the pupil; or whenever an
elongated piece of the vitreous humour,
after the recision of  a prolapsed portion
ofthe iris, passes by a shorter route, than
through  the  pupil, between the  lips of
the ulcer of the cornea.  At  length, we
understand, why in both these instances a
transparent vesicle forms,  even after the
recision of the  tunic of the aqueous hu-
mour, or ulceration of  the cornea;  and
why it very often reapjsears in the same
place, though it has been cut  away to a
level  with the cornea.  It is because one
or more cells  of  the vitreous humour,
constituting the transparent vesicle, are
succeeded  after their removal by other
cells ofthe same humour, which glide be-
tween the lips of the  wound,  or ulcer of
the cornea, into the situation of the re-
ceding ones.
  The treatment of this species of pro-
lapsus consists in removing the transpar-
ent vesicle, projecting from the wound,
or ulcer, by  means of  a cutting instru-
ment, and  bringing  the  edges  of  the
wound of tha  cornea immediately after-
wards into  perfect apposition,  in order
that they may  unite together as exactly
as possible.   But,  when there  is an ulcer
ofthe cornea, as soon as the vesicle is re-
moved,  the sore must be touched with
the argentum nitratum, so that the eschar
may resist  any  new prolapsus  of" the vi-
treous humour, and at the same time dis-
pose the ulcer of the cornea  to granalate
and heal.
  In this kind of prolapsus,  what pro-
trudes through the cornea is only a subtile
little membrane, tilled with water, and
quite destitute of sensibility    Its detach-
ment from  the rest of the eye,  is a matter
of trivial importance; while, on the con-
trary, its presence occasions all the incon-
veniences of all extraneous substance, that
would prevent a wound from uniting, and
an ulcer from  healing.   Hence, the de-
tachment of the protruded vesicle is very
justly indicated, and the success of the
plan is confirmed by practice; doubtless,
because  the  little transparent  tumour
can, in  general, be expeditiously remov-
ed, by  a stroke  of the curved convex-
edged scissars.   But  if, in some particu-
lar cases,  the vesicle should not pfoject
sufficiently from the  wound, or ulcer of
the cornea, to be included in the scissars,
the  same object may  be accomplished by
puncturing the tumour with a lancet, or
couching-needle; for, when  the  limpid
fluid which  Tit contains  is  discharged,
the  membrane forming it shrinks  with-
in the edges of tlie  wound, or ulcer of
the  cornea, and no longer  hinders the
union of the  former, or the cicatrizatioa
ofthe latter.
   Should the transparent tumour  reap-
pear in the same situation, the day after
its recision, or puncture, it is right to re-
peat one of these operations,  and to adopt
further  measures   for  maintaining the
wound of the cornea in contact; or, if it
should  be  an ulcer, the eschar must be
made to adhere more deeply to its bottom
and  sides,  so as to form a greater obsta-
cle than before  to the escape of the vitre-
ous humour.  In such circumstances, the
surgeon must take all possible care to ob-
viate such  causes  as  have a tendency to
propel the vitreous humour towards the
wound,  or  ulcer, of the cornea; particu-
larly too much pressure on  the eyelids,
spasms of the muscles of the eye, cough^
ing, sneezing, efforts at  stool, and other
similar  ones; and care must also  be
taken to check the progress of inflamma-
tion.
   Pellier's  two cases (Obs.  stir  I'QUil,
p. 350.) on the treatment of this species
of transparent vesicular  prolapsus, de-
serve perusal.  To these, if it were re-
quisite, Scarpa says he could add several
other similar ones, which  have  fallen
under his  own observation, in cases of
ulcer of the  cornea penetrating the ante- 
»   148          ISC
1SS
rior  chamber of the aqueous  humour,
and  which were attended  with as much
success as those  related by the  French
oculist.
  The choroid coat is,  likewise,  not ex-
empt from prolapsus.  Scarpa has  seen
and  cured this complaint  in M.  Bressa-
nir.i, an apothecary at Bescape.  A small
abscess, formed between  the sclerotica
and  choroid coats, at the distance of two
lines from the union of the cornea  with
the sclerotica, in the inferior  hemisphere
ofthe globe ofthe eye,  in consequence of
a severe internal and external ophthalmy,
which had been treated, in its incipient
state, with repellent remedies.  The ab-
scess burst, and discharged a small quan-
tity  of thick viscid lymph; then a  small
blackish body, composed of the choroid
coat, presented itself on the  outside  of
the  little  ulcer of the sclerotica.   The
treatment  consisted in  applying  tiie ar-
gentum nitratum several times to the pro-
jecting portion of the choroides, until it
was consumed, and reduced to a lexel with
the  bottom  of the  ulcer of the cornea.
Then the place healed.   The eye remain-
ed,  however, considerably weakened, and
the  pupil  became afterwards, so  much
contracted, that it  was almost  entirely
closed.  (Scarpa sulle Principali Malattie
degli Occlii. Venezia. 1802.)'
   Consult also Richter's Afangsgrunde der
 Wundarzneykunst, Band 3.  Von dent Vor-
falle der Regenbogenhaut.
   For a description ofthe manner of di-
viding the iris, in order to  make an artifi-
cial pupil, when the natural one is closed,
refer to Pupil, Closure  of
   A wound of the iris is one of the things
most to be feared  in extracting a cataract.
No  sooner does any instrument penetrate
the  eye, than the muscles of this organ
usually contract in a spasmodic manner,
so as to make great pressure on the part,
and to urge forward the cataract and the
iris.  In  this circumstance,  we cannot
wonder that  the  latter should  now and
then be injured by the edge of the instru-
 ment.  When the iris becomes entangled
 under the knife, Wenzel  asserts, that it
 may be invariably disengaged without in-
jury, by gently touching the cornea with
the  finger.  Richter justly observes,  how-
 ever, (Anfdngsgr. der Wundarzn ) that this
 artifice is  not unattended  with some risk
 of pressing out the aqueous humour;  es-
 pecially,  if the irritation of touching the
 eye should make it  move, or the opera-
tor  in the least disturb  the knife.  See
 Cataract.
   ISCHU'RIA.  (from   i<ry,u,  to restrain;
 and «£«v,  the urine.)   A  suppression, or
 stoppage of the urine.
  The distinction between a suppression
and retention of urine,  is practical and ju-
dicious.  The former most properly points
out a defect in the secretion of the kid-
neys ; the latter, an inability of* expelling
the urine when secreted. (Hey )
  The first disease is not very common,
is named ischuria renalis, or suppression of
urine, and belongs to the province of the
physician;  the second is an exceedingly
frequent disorder, is  named ischuria vesi-
calis, or retention of  urine, and its treat-
ment is altogether surgical. Every thing
relative to it will be found in the articles
 Catheter, and Urine,  Retention of.
  ISSUE signifies an  ulcer made design-
edly by the practitioner, and kept  open
a certain time, or even the patient s whole
 lite,  for the cure, or  prevention of a va-
riety of diseases.
  The physician,  in his practice, has fre-
quent occasion to recommend the makir.g
 of  an issue,  and the surgeon  finds it  a
 principal means  of relief  in several im-
 portant cases,  as, for instance, the white
 swelling, the  disease  of  the  hip-joint,
 caries of the vertebrae, &,c.   Many per-
 sons are  never  in  health, or, at least,
 fancy themselves always ill, unless they
 have an issue formed in some part of their
 body or another.  The making of  an is-
 sue,  indeed, is  not  unfrequently  con-
 sidered as  an imitation of nature, who,
 of her own accord, often forms ulcers and
 abscesses in various parts of the body (as
 is not uncommonly conjectured) for the
 purpose of  discharging pernicious hu-
 mours, whereby people are  supposed to
 be  freed from grievous disorders,  and
 have their health preserved.  The hu-
 moral pathologists were excessively par-
 tial to these notions, which, at the  pre-
 sent time, will be found by every  expe-
 rienced practitioner to influence the mass
 of mankind, and render the formation  of
 issues more common,  than  perhaps  is
 consistent  with  the better established
 principles of  medical science.   Few old
 subjects will  allow a sore of long stand-
 ing to be dried up (as the expression is),
 without requiring the surgeon immediate-
 ly afterwards to make an issue for  them.
 When an ulcer has existed a great length
 of time, the constitution may possibly be-
 come so habituated to it,  that the health
 may  really suffer from its being healed.
 Asthmatic complaints,  and  severe head-
 aebs are frequently observed to follow the
 cicatrization of  an old  ulcer; but, whe-
 ther  they  would have  happened,  if  an
 issue had been made in time, is a question
 difficult  of positive determination; for,
 many persons  with old  ulcers are  not
 prevented from suffering from  asthma,
 and headach.  The  plan  of making  an 
ISSUE.
149
Issue, however, is commendable  both as
rational and exempt from danger.  What-
ever may be the solidity* of the theories,
which have been offered by  medical  wri-
ters, in regard to issues, the practitioner,
who has his eyes open, cannot fail to see
the benefit often derived from such means;
and if there be  any unquestionable facts
in  medicine and surgery,  we may confi-
dently set  down  amongst  them  the fre-
quent  possibility of relieving one disease
by exciting  another of a  less grievous
and more curable nature.
   There are two  ways of  making an is-
si>e; one is with a lancet, or scalpel; the
other, with caustic.
   The place for the issue being fixed
upon,  the surgeon and his assistant are to
pinch up a fold of the integuments,  and,
 with a lancet or  knife, make in  them an
 incision of sufficient size to hold a pea, or
 as many peas  as may be thought proper.
 The pea, or peas are then to be placed in
 the cut,  and covered with a piece of adhe-
 sive plaster, a compress, and a bandage.
 The peas, first inserted, need not be re-
 moved for three or four days,  when  sup-
 puration will have begun ;  but, the  issue
 is afterwards to be  cleaned and dressed
 every day, and  have fresh peas  put  into
 it.  The  preceding is the ordinary me-
 thod of making  such issues, as are in-
 tended to contain only one or two peas.
    When the issue is "to be  larger, which
 is generally proper, in cases of  diseased
 vertebrae,  white  swellings, &c. the  best
 plan is to destroy a portion of the inte-
 guments with caustic.  The kali purum,
 blended with quicklime,  is mostly  pre-
 ferred for  this purpose.  The  situation
 and size of the issue having been deter-
 mined, the surgeon is to take care,  that
 the caustic does not extend its action to
 the surrounding parts.  With this view,
 lie is to take a piece  of adhesive plaster,
 and having cut a hole in it, of the exact
 shape and size of the issue  intended to
 be made, he is  to  apply  it to  the part.
 Thus the plaster will defend the adjacent
 skin from the effects ofthe caustic, while
 the uncovered  portion of integuments,
 corresponding to the  hole in the  plas-
 ter, is that which is to be destroyed.  The
 caustic is  to  be taken hold i>f with  a bit
 of lint, or tow, and, its end, having been
 a little  moistened  with water,  is to be
 steadily rubbed upon the part of the skin,
 where" the issue is to be  formed.   The
 frictions are to be  continued,  till the
 whole surface, intended to  be destroyed,
 assumes a darkish corroded  appearance.
  The caustic matter may now be  carefully
 washed  off'  with some  wet  tow.   The
 plaster is to be  removed,  and a linseed
 poultice applied.   As 60on as the eschar
is  detached, or  any part of it  is loose
enough to be cut away, without pain, or
bleeding, the peas are to be inserted and
confined in their proper place with a piece
of adhesive plaster.  Some use beans for
the purpose;  others beads;  which an-
swer very well,  and have the advantage
of serving  for any length of time, when
washed and cleaned every  day.  If the
issue is at all of a longitudinal shape, the
peas, beans, or beads, may be more easily
kept in their places,  when strung upon a
thread.
   Issues ought always to be made, if pos-
sible, in a situation,  where the peas  will
not be much disturbed  in the  ordinary
motions of the  body,  nor interfere with
the actions of muscles.  The interspaces,
between  the margins  and  insertions of
muscles, are deemed  the most  eligible
places. Thus, issues in the arms are usu-
ally made just at the inferior angle of the
deltoid muscle, by the side of the external
edge  of  the biceps.  In the lower extre-
mities, issues are often made at  the inner
side ofthe thigh,  immediately above the
knee,  in a cavity tiut  mo/be readily felt
there with the fingers.  Sometimes, issues
are made upon the inside of tlie  leg,  just
below the knee.  For the relief of any
affections of the head, or eye, the nape of
the neck is commonly selected as  a good
situation.  In caries of the vertebrae,  they
are'made on each side of the spinous pro-
cesses. In  cases of diseased hips,  they
are formed in  a depression just behind
and below the trochanter major.  When
the nature of the disorder does not parti-
cularly indicate the situation for the issue,
the arm should be preferred to  the leg,
as issues u). mi the upper extremities, es-
pecially the left arm, are much less an-
noying,than upon either of the lower limbs.
   The great art of keeping an issue open
for a long while, consists in maintaining
un equal and effectual pressure upon the
peas,  by which means, they are confined
in their places, little depressions are made
for them, and the granulations  hindered
from  rising.  Compresses of pasteboard
and sheet-lead will often be found highly
useful.  This plan is  the surest one  of
preventing  the   issue  from healing, and
the most likely to save the patient all the
severe and repeated suffering, which the
fresh  application of the  caustic, or the
use of stimulating powders, in order to
renew the sore  and repress tlie fungous
 flesh, unavoidably occasion.
   There  is  a  method of making issues
 with the caustic made in a sort  of paste,
 which is laid upon the part left uncovered
 by the adhesive plaster.  It seems to me
 to be a more tedious  and painful plan,
 and I do not recommend it. 
150
jei
  [Dr. Wistar has contrived a method of
forming issues, which is extremely sim-
ple  am', expeditious.—It consists in blis-
tering the skin, and rubbing it for two or
three minutes  with common  caustic.—
The caustic acts on the blistered surface
with great rapidity.]
  It has been suspected, that the  pain,
caused by the caustic  might be lessened,
by mixing opium with the application;
                JOI

but, the idea seems not at all probable;
tiie destruction of a part of the skin must
inevitably caus*;  considerable pain, with
whatever substance it  is  produced,  and
opium itself,  so  far from being likely to
diminish the agony, is  itself a violent sti-
mulus, whenever it comes  into contact
with  the  exposed extremities of  the
nerves.
1
J.
   JOINTS, DISEASES OF.  The joints
     are subject  to  numerous diseases,
which are more, or less, alarming, accord-
ing to their nature.   Like all other parts,
they are liable  to inflammation  and ab-
scesses ; their capsules frequently become
distended with an aqueous secretion, and
the disease termed hydrops articuli, is pro-
duced ;  but,  the  most important of all
their morbid affections,  are,  what  are
called,  white swellings, and  the disease of
the Hp-joint.

          WOUNDS OF JOINTS.

  Wounds ofthe large joints, made either
by puncture or incision, are of a very dan-
gerous  nature,  as these  parts are  sur-
rounded with tendinous and membranous
structures, which, though not very sensi-
ble in a sound state,  yet, when inflamed,
become  exquisitely   sensible, often at-
tended  with  vehement pain and fever,
and sometimes  with  delirious symptoms,
(SeeHunter's Commentaries, Parti,p.69.)
  Superficial  wounds of the  joints  are
often disagreeable cases;  but the danger
is always increased, when the injury pene-
trates the capsular ligament.  This event
may  be detected by the introduction of a
probe,  and often by a discharge of the sy-
novia, which is secreted by glands in the
joint to facilitate its motion.  But, as a
discharge of a similar kind,  may proceed
from mere wounds of such  bursx mucosx,
as he under the  tendons of muscles, in the
vicinity of joints,  our judgment might be
deceived, were  we unacquainted  with
the situation of these little  membranous
bags.  Wounds which  penetrate large
joints, must be looked upon as much more
dangerous,  than  those,  in Which  only
these bunsse are opened.
  When the large joints,  particularly the
knee, are wounded,  the  stomach is fre-
quently very much affected.   I remember
being shewn by  Mr.  Best of Newbury,  a
man, who,  in  his occupation as a wheel-
wright, happened to give  himself a wound
on one side ofthe knee:  a  good deal of
inflammation  and  suppuration ensued;.
but, what particularly struck me, was the
manner in  which the man complained of
the affection' of his stomach.
  In speaking of cartilaginous substances
in the joints,  we shall have occasion to
advert again to the  danger  attendant on
wounds of these parts.

        INFLAMMATION OP JOISTS.

  Idiopathic cases  of this  kind are 'not
common.   The  complaint ordinarily ori-
ginates, in consequence  of  a contusion,
sprain,  wound, or some other kind of in-
jury, done to the part affected-
  The inflamed joint shews the common
symptoms of  inflammation ; viz. preter-
natural redness, increased  heat, throb-
bing, pain, and swelling, while the con-
stitution is also disturbed   by  the  usual
symptoms of the inflammatory  fever.  It
is highly deserving notice,  however, that
in these cases, such symptoms are often
exceedingly severe, and the pulse is more
frequent, and  less  full and strong, than
when parts, more disposed to return to a
state of health, are affected.   The inflam-
mation first attacks some part of the cap-
sular ligaments, and  very quickly diffuses
itself universally over their whole extent,
as usually  happens  in all  inflammations
of smooth membranes.
  The capsules of the joints are naturally
not very sensible; but, Uke many  other
parts similarly  circumstanced, they be-
come  acutely painful,-  when  inflamed.
The complaint is accompanied with an in- 
JOINTS.
151
creased secretion of the synovia, which
becomes of a more aqueous, and of a less
albuminous  quality, than  it  is  in the
healthy state.  Hence, this  fluid is not so
well calculated for lubricating the particu-
lar surfaces, and preventing the effects of
friction, as  it is in the natural condition
of the joint.  This circumstance may ex-
plain, why a grating sensation is  often
perceived on moving the patella, when the
knee is inflamed.
  The  capsular ligaments,  like  other
parts, are  frequently  thickened  by  in-
flammation, and, sometimes,  coagulating
lymph, being effused on their  internal sur-
faces, organized.cartilaginous, or  osseous
bodies, are formed in their cavities.
  When-the inflammation  attains a high-
er pitch, an  abscess  may  occur in the
capsular ligament.  This  part at length
ulcerate's, and   the  pus makes  its way
beneath  the skin,  and  is  sooner, or
later, discharged through ulcerated open-
ings.
  An abscess rarely takes place in an im-
portant articulation,  in consequence of
acute inflammation, without the  system
being, also, so  deranged,  that life itself
is imminently endangered.  In the vio-
lent stage of tiie inflammation, just before
the abscess forms, very severe symptoms '
of  inflammatory fever afflict the  patient,
and, occasionally, delirium and coma tak«
ing place,  death itself ensues.
  In these cases, the inflammatory fever
is very quickly converted into the hectic;
indeed, when the abscess has taken place
in a large joint, in consequence of acute
inflammation,  hectic  symptoms  almost
immediately begin to shew  themselves,
and the strong actions of the common in-
flammatory fever suddenly  subside.
  Local consequences, even  worse than
those above described* may follow inflam-
mation of a .joint.  As the layer of the
capsular ligament, reflected over  the car-
tilages of  the  articulation is  often  in-
flamed, the cartilages themselves  are very
apt to  have tlie inflammation  communi-
cated to them.   Parts partaking of a car-
tilaginous  structure,  being very incapa-
ble or" bearing   the irritation  of  disease,
often  ulcerate,  or, in other   words, are
absorbed,  so as to leave a portion, or, the
whole, of the   articular surface  of the
bones, completely denuded of its natural
covering.  At length, the heads of the
bones themselves inflame, and become ca-
rious ;  or the consequence may be an an-
chylosjs.
   Sometimes, only such parts, as are ex-
terior to the capsular ligament, are affect-
ed, and,  in this case, tiie symptoms are
never so  severe, (Russell on  the  Knee, p.
60.) nor s«> obstinate, as when the com-
plaint  interests  the  capsular ligament,
and parts contained in it.  Even when an
abscess takes place on the outside of the)
capsular  ligament, the  case  cannot  be
considered as dangerous,  provided the
cavity of the joint be not involved in the
inflammatory  attack.  Every  inflamma-
tion of a large joint may be deemed a case
of considerable  importance.   I  do not
mean to assert, that  cases, in which the
inflammation is mild in degree, and sim-
ple in  its  nature,  are  dangerous •  no—I
only wish  to inculcate,  that  though the
inflammation  be originally genuine, it is
always very likely to be converted into
one of a specific nature, whenever there
is a tendency in  the system to scrofulous
disorder    A person, whose  constitution
is scrofulous, may sometimes continue,
during life, exempt from any1* local disease
of this specific  nature,  provided  he  be
fortunate  enough  to  avoid all irritation
of parts, on which scrofula is most par-
ticularly  disposed to make its attack.
Among such  parts we  must class the
joints,  especially  the  knee, hip,  elbow,
and  ankle.  Hence, when a joint  is  in-
flamed, how mild soever the affection may-
be, we ought  never to forget, that, when
there is  a tendency  to scrofula  in the
system, the original case of simple inflam-
mation is  very  apt  to  be the exciting
cause  of the white swelling, one of the
most  severe  and intractable diseases,
which  increase  the catalogue of  human
miseries.
  Hence,  the  curative  means should be
most rigorously put in execution, not.
merely on account of an abstract view of
the present state of the case;, but, also,
on account of the opportunity, which is
now afforded for a terrible disease to
arise,  which  often  remains  previously
dormant.
  It will considerably  shorten what  we
have to say concerning the treatment  of
inflamed joints,  to observe, that the anti-
phlogistic  plan, in the full sense  of the
expression, is to be strictly adopted. But,
as  there is a variety  of means,  often
adapted to the  same purpose, it  seems
necessary to offer a tew remarks on those,
which  lay  the greatest claim  to our com-
mendations.   The treatment of  an  in-
flamed knee  will serve to illustrate that
of all other large joints.
   There are few other surgical cases,  in
which general,  and,  especially  topical
bleeding is more strongly indicated.
   The violence  of the inflammation, and
the strength,  age, and   pulse of the pa-
tient,  must determine, with regard to the
use ofthe  lancet; but,  the topical  appli-
cation of  leeches may  be said to be inva
 riably proper.   When the leeches fall c*\ 
152                                JOINTS.
the'bleeding is to be  promoted by  fo-
menting the  part   The  surgeon should
daily  persist in this  practice, until the
acute stage of  the inflammation has sub-
sided-   But,  in conjunction  vyith  this
treatment, we  are to keep the joint con-
tinually surrounded with  linen wet with
the saturnine lotion.
  In a few instances, however, the pa-
tient seems to  derive more ease and be-
nefit  from the  employment of fomenta-
tions  and  emollient poultices, and the
feelings of the afflicted should always be
consulted ; for, if the pain be materially
alleviated by this,  or that application, its
employment will hardly ever be wrong.
  Nothing more need be said,  concerning
the rest of the  treatment, proper during
the vehemence ofthe inflammation, as the
duty of the surgeon is not materially dif-
ferent from what it is in other inflamma-
tory cases.
  As soon as the acute stage ofthe affec-
tion has subsided, the grand object is to
remove the effects, which have been left.
These are a thickened  state of the cap-
sular ligament, and parts surrounding the
articulations; a stiffness of the joint, and
pain,  when it is moved ;  a collection of
fluid in the capsule,  &c.   This state of
the complaint,  when neglected, and there
is a tendency to scrofula, may prove ex-
ceedingly obstinate; and  even terminate
in an  irremediable, specific distemper of
the joint.
  When this second stage of the disorder
seems tardy in going off, the  application
of  a blister  is  proper,  and it should be
kept open for a few days, by means  of the
savin cerate.
  In other cases, in which the inflamma-
tion has been more trivial, and the effects,
which it has left, are slight; lotions, com-
posed  of vinegar and sal-ammoniac, suf-
fice for tiie removal of  the chronic com-
plaints, continuing after tlie abatement of
the acute stage of the disorder.
  The severity of the constitutional symp-
toms  is mostly, if not  always, greater,
when  the  inflammation of a large joint
arises  from  a  wound,  than  when it is
the consequence  of a  bruise, or  sprain.
(See Treatise on the Diseases of the Joints,
1807.)

       LOOSE CAIITIIAGES IN JOINTS.

  The existence of extraneous  bodies in
the articulations is by  no means  a rare
occurrence, though unknown to the an-
cients.
  Pare is the first who speaks of this dis-
order:  he  says, that   a  hard, polished,
white body, of the  size ofanahnond, was
discharged from the knee of a patient, in
the year 1558, in which he had made an
incision for an aqueous aposteme, (without
doubt  an  hydrops articuli.)   Liv. 25,
.chap. 15.
  One  of  these  extraneous bodies was
found  on dissection in  a knee joint, by
Dr. Alexander Monro.  Mr. Simpson ex-
tracted  one of these some years   after-
wards, which at first  he did not suppose
was in  the cavity of the articulation, not-
withstanding its  mobility, and the  pain
it occasioned. (Edinb. Med Essays.) Since
these periods, examples have  been mul-
tiplied of this disease.
  Such detached and moveable cartilages
are not peculiar to the joint of the knee,
they oceasionally  occur in other joints of
the body;  but they  are most  frequently
met  with  in the  knee, and it is  in that
joint that they produce symptoms which
render them the  object of a  chirurgical
operation.   Morgagni has seen them in
the ankle ; Haller in the joint  of the jaw;
and Hey in the elbow.
   These substances, m their structure,
are,  as Mr. Home remarks, analagous to
bone;  but, in their external appearance,
bear a greater resemblance to cartilage.
They  are  not, however, always exactly
of the same structure,  being in some in
stances  softer,  than in others.   Their
external surface is smooth and polished,
which, being lubricated by the synovia,
allows them to  be moved readily from
one part ofthe joint  to another;  seldom
remaining  long at rest,  while the  limb is
in motion; when  they  happen to  be in
such  situations  as to  be pressed upon
with force by the different parts  of the
joint,  they  occasion considerable pain,
and  materially interfere with its  neces-
sary motions.
   The circumstance of their being loose,
and  having no remains of a visible at-
tachment,  made  it difficult to form con-
jectures respecting their formation; and
according  to  Mr. Home, no  satisfactory
account  of their  origin had  been given,
till Mr. Hunter's observations  threw light
upon  the  subject.   The  circumstances,
which led him  to  the investigation  of
this subject, appear  at first sight so fo-
reign  to the purpose, that they require
some explanation.
   In the course  of his experiments and
observations, instituted with  a view  to
establish a living principle in the blood,
Mr. Hunter was naturally induced  to at-
tend  to  the phenomena, which  took
place, when that  fluid  was extravasated,
whether in consequence of accidental vio-
lence, or other circumstances.  The first
change  which took place he  found to be
coagulation;  and the  coagulum  thus
formed,  if jn contact with living parts, 
JOINTS.
l5o
 •ml not produce  an irritation similar  to
 extraneous  matter, nor was it  absorbed
 and  taken  back into the constitution,
 but,  in many instances, preserved its liv-
 ing principle,  and became vascular, re-
 ceiving  branches  from the neighbouring
 blood-vessels for its  support;  it  after-
 wards underwent changes, rendering it
 similar to the parts to which it was at-
 tached,, and  which supplied it  with nou-
 rishment.
   In  attending to cases of this kind, he
 found that where a coagulum adhered to
 a  surface,  which varied  its  position,
 adapting it to the motions  of some other
 part ; tiie attachment  was necessarily di-
 minished by  the  friction,  rendering it in
 some instances pendulous; and  in others
 breaking it off entirely.
   Hence it was easy to  explain the mode
 in  which  those  pendulous bodies are
 formed,  which arc sometimes attached to
 the inside of circumscribed cavities, and
 the principle being established,  it became
 equally easy for Mr.  Hunter to apply it
 under other circumstances,  since it is evi-
 dent  from  a  known  law  in the animal
 economy, that  extravasated blood, when
 rendered an  organized part of  the body,
 ean assume  the nature of the parts into
 which it is effused, and consequently, tiie
 same coagulum which in  another situa-
 tion might form  a soft tumour, would
 when situated on a bone, or in the neigh-
 bourhood of bone,  often form a hard one.
 The  cartilages found  in  the knee-joint,
 therefore, appeared to  him to  originate
 from a deposit of coagulated blood upon
 the end of one of the  bones, which had
 acquired the nature of cartilage, and had
 afterwards been separated.   This opinion
 was further  confirmed  by  the  examina-
 tion of joints which had  been  violently
 strained, or otherwise injured, where the
 patients had died at different periods af-
 ter the accident.  In some of these there
 were small projecting  parts, preternatu-
 rally  formed, as hard  as  cartilage, and
 so situated, as to  be readily knocked off
 by any sudden,  or  violent motion of the
joint. ( Transactions of a Society for tlie Im-
provementof Medical and Chirurgical Know-
ledge, Vol  1 )
  One or more of these preternatural bo-
dies may be formed  in the same joint.
 Mr. Home mentions one instance  in which
there were three; they are commonly
about the  size  of  a horse-bean, often
much smaller, and sometimes considera-
bly larger; when very large, they do not
give so much trouble to the patient as tlie
smaller  kind.  A soldier in the 56th re-
giment  has one nearly as  big  as the pa-
tella,  which  occasions  little uneasiness,
being too barge to insinuate itself into the
    Voi. ir.
 moving parts of the joint.  Morgagni has
 seen twenty-five in one joint.
   If we except making an  incision into
 the joint, tor the purpose of extracting the
 cartilaginous tumours, we  are not  ac-
 quainted with any certain means of free-
 ing a .patient from the inconvenience of
 this complaint.  To  this plan, the dan-
 ger attendant on all  wounds of so large
 an articulation as the knee, is a very se-
 rious objection.  Middleton and  Gooph
 endeavoured to  conduct the extraneous
 body into a situation, where it produced
 no pain,  and to retain it in that  position,
 a long time,  by bandages, under the idea,
 that the cartilaginous  substance  would
 adhere to the contiguous parts, and  oc-
 casion no future trouble.  Some will be
 inclined  to think,  that no  positive con-
 clusion ought to be drawn from the cases
 brought forward by these gentlemen,  be-
 cause they had no opportunity of  seeing
 their patients again at the end of a rea-
 sonable  length of  time, and  we  know,
 that loose cartilages in the joints, some-
 times disappear for half a year, and then
 make their appearance again.   Yet, per-
 haps, the very  circumstance  of the pa-
 tients not applying  again, may  appear to
 many to justify the inference, that suffi-
 cient relief had been obtained.  _
   Mr. Hey, impressed with a just sense
 ofthe dangerous symptoms, which have
 occasionally resulted from the  most sim-
 ple  wounds  penetrating the knee-joint,
 very laudably tried the efficacy of a laced
 knee-cap, and tlie  cases, which  he has
 adduced, clearly demonstrate,  that the
 benefit,  thus  obtained, is not temporary,
 at least,  as long as the patient cont :nues
 to wear  the  bandage.  In one  case, the
 method had been tried for ten years, with
 all the success,  which the. patient  could
 desire.
  Contemplating the evidence, which we
 have upon this point, and  the  perilous
 symptoms,  sometimes  following wounds
 ofthe knee-joint, I am decidedly of opi-
 nion, that the effect of a knee-cap,  or of
 a roller and  compress, applied over the
 loose cartilage, when  this body is  so si-
 tuated as not to create pain, and to ad-
 mit of being compressed, ought generally
 to be tried, before having recourse to ex-
 cision.   1 say generally, because the con-
 duct of the surgeon ought, in such cases,
 to be adapted to the condition, and  in-
 clination of the patient,  ff a man be de-
 prived of his livelihood by not being able
 to use his knee;  if he  cannot, or will not
 take the trouble of wearing a bandage;
if he be urgently desirous of running the
risk of the operation after things nave
been impartially explained to  him; if a
bandage should not be productive of sut-
    U 
154                                JOINTS
 ficient relief;  and, lastly,  if excessive
 pain,  severe inflammation  of the joint,
 and lameness,  should  frequently be pro-
 duced by the  complaint; I think  it is
 the duty  of  a  surgeon to operate.  It is
 very certain, that success has generally
 attended the operation ; but small  as the
 chance is  of losing the  limb, and even
 life, in the attempt to get rid of  the dis-
 ease ; yet, since the inconveniences ofthe
 complaint are, in most cases, very bear-
 able,  and are  even capable  of palliation
 by means  of a bandage, endangering the
 limb and life  in any degree, must  seem
 to many persons contrary to the  dictates
 Of prudence.   I am ready  to  allow, with
 M. Brochier, that the danger, attendant
 on wounds ofthe large joints, has always
 been exaggerated  in  consequence of An-
 cient prejudices.  (Desault's Journal, Vol.
 2.) But,  making every allowance for the
 influence  of  prejudice, a  man must  be
 very sceptical indeed,  who does not con-
 sider the wound of so  large a joint as the
 knee, attended with real cause for the ap-
 prehension of  danger.  See Case  2, in
 my Treatise on the Diseases  of the Joints.
 At the end of Mr. Ford's case, (Med Obs.
 and Inquiries, Vol. 5.) we read on the sub-
ject of cutting loose cartilages out of the
 knee: " The society have been informed
 of several  cases, in  which the operation
 has been  performed; some, like  this,
 have healed  up, without any  trouble;
others have  been  followed with violent
 Inflammation, fever, and death itself."
   As the disorder is often attended with
 a degree of heat and tenderness in the ar-
 ticulation ; as the danger of the operation
 is, in  a great  measure,  proportioned  to
 the subsequent  inflammation;  and,  as
 mueh  of  the danger is at once removed,
if the wound unite by  the first intention  :
 the advice, to  keep the patient in bed, a
few days before operating, to apply leech-
es, and cold  saturnine  lotions to the knee
during the same time,  and to exhibit be-
forehand  a  saline purgative, is  highly
prudent.
   I shall next introduce an account of the
plan of operating, as described by several
 of the best modern surgeons.
   " As these loose bodies cannot  always
be found,  no time can be fixed  for the
operation ; but the patient, who will soon
become familiar with his own complaint,
must arrest thenr when  in a favourable
situation,  and  retain them there till the
surgeon can be sent for.
   " Before the operation, the limb should
be extended upon a table in an horizontal
position, and secured by means of assist-
ants ; the loose cartilages  are to be push-
ed into the upper part of the joint above
the patella, and then   to  one side; the
 inner side  is  to be preferred, as in that
 situation only the vastus internus muscle
 will be divided in the operation.  Should
 there be  several  of these bodies, they
 must be all secured, or  the  operation
 should be postponed  till some more fa-
 vourable opportunity, since the leaving of
 one will subject  the patient to the  repe-
 tition of an  operation, not only painful,
 but attended with some degree of danger.
   " The loose  bodies are to be secured in
 the situation above-mentioned  by an as-
 sistant,  a task not easily performed while
sthey are cut upon, from their beir.g lu-
 bricated by the synovia; and if allowed to
 escape into the general cavitv, they may
 not readily, if  at all, be brought back into
 the same situation.
   " The operation consists in making an
 incision upon  the loose  cartilage, which
 it  will be best to do in the direction of
 the thigh, as the wound will more readily
 be healed  by the first intention. If  the
 skin is drawn  to one side,  previously to
 making the incision, the wound through
 the parts uiaderneath will not correspond
 with that made in the skin, which circum-
 stance  will favour their union.  The  in-
 cision upon the cartilage must be made
 with caution, as it will with difficulty be
 retained in its  situation if much force is
 applied.  The  assistant  is  to endeavour
 to push the loose body through the open-
 ing, which must be made sufficiently large
 for that purpose; but as thi s cannot al-
 ways be done, the broad end of  an eyed
  firobe may be  passed under  it, so as to
  ift it out, or a sharp-pointed instrument
 may be stuck into it, which  will fix it to
 its situation, and bring it more within the
 management ofthe surgeon.
   " The cartilages being  all extracted,
 the cut edges of  the wound are to  be
 brought together, and, by means of a com-
 press of lint, not only pressed close to one
 another, but also to the parts underneath,
 in  which situation they are to be retained
 by sticking plaster,  and the uniting band-
 age.
   " As  union by the first intention  is of
 the utmost consequence after this opera-
 tion, to prevent an inflammation of the
 joint, the  patient  should  remain in bed
 with the leg extended, till  the wound is
 perfectly united,  or at least all chance of
 inflammation at an end,."  (Home,  in Med.
 and Chir. Transactions, Vol 1, p. 239, &c)
   fn  one instance, Desault proceeded in
 the following manner : the surgeon,  after
 relaxing the capsular ligament  by ex-
 tending  the leg,  brought the extraneous
 body on the inside  of  the articulation
 against the attachment of  the capsular
 ligament, and secured it in this situation
 between the m.lex  finger and  thumb-yj 
JOINTS.                               165,
the left hand, whilst an assistant drew
the integuments forwards towaids the pa-
tella.   All the parts that covered this ex-
traneous body  were  now divided  by a
longitudinal incision, one inch in  length,
and its extraction accomplished by push-
ing it from above downwards, and raising
it inferiorly with  the end of the  knife.
This  substance,  on  examination  was
found similar in colour to  the cartilages
that cover the articular surfaces:  it was
three  quarters of an inch in  length, six
lines  and an half in width,  and three
lines  in thickness;   its surfaces  were
smooth, one concave and the other  con-
vex;  its circumference  irregular, disse-
minated with red points, forming small
depressions;  the inside  was ossified, the
outside of a cartilaginous texture.  As
soon as the substance "ways  extracted, the
assistant let go the integuments which he
had drawn forwards; they consequently
returned to their natural situation, on the
inner   side of the knee-joint, in such a
manner, that  the external  wound in the
integuments  was situated  more inwards
than  the one in the capsular ligament.
Two  advantages were procured  by this
means:  on the one  hand, air was  pre-
vented from  penetrating into the articu-
lation; and on the  other,  the  floating
portion of capsular ligament, retained in-
wards by the skin, was more  likely to at-
tach itself  to the condyle, in case it did
not unite to the other portion of the cap-
sule divided near its attachment.  The
edges of the wound  were brought in con-
tact by means of a uniting bandage; dry
 lint and compresses were applied, and
retained on tiie part  by  a slight bandage;
the limb was kept in a state of extension.
 (Desault's Plan, as described by Brothier in
 Desault's Journal, Tom. 2.)
   The  inner  surface  of  the  internal
condyle of the os  femoris presents an ex-
tensive and nearly plain  surface, which
 terminates in front and  at its upper part
 by an edge  which forms a  portion of a
 circle.   If the points  of the finger be
 firmly  pressed upon this edge so as to
 form  a kind  of  line of circumvallation
 round these ^cartilaginous)  bodies, they
 cannot pass into the joint in this direction,
 nor can they recede in any other, on ac-
 countof the tense  state of the.  internal
 lateral ligament.  Here these substances
 are near the  surface,  and  may  be dis-
 tinctly felt;  and there is  nothing to be
 divided in order  to expose them, but the
 integuments, fascia, and the capsule of
 the joint.
   In an interesting case, which Mr, Aber-
 nethy relates,  he observes:  " The opera-
 tion  was done in the  following manner.
 Sir  Charles  Blicke,  who  assisted me,
 pressed the  integuments  of the  knee,
 gently towards the internal condyle, and!
 then applied his fingers  in the manner I
 have described, round the circular edge
 ofthe bone.  I also drew the integuments
gently towards the inner ham-string, and
 divided them longitudinally, immediately
 over the loose substance, to the extent of
 an inch and  an half.  This withdrawing
 of the integuments from their natural  si-
 tuation was designed to prevent a direct
 correspondence in the situation of the ex-
 ternal wound, and that of the capsule of
 tlie joint; for when-the integuments were
 suffered to regain  their natural position,
 the wound in them was nearer to the pa-
,tella, than the wound which was made in,
 the capsule.   The fascia which covers the
 joint  being  exposed  by the division of
 the integuments, it was divided in a simi-
 lar direction, and nearly to the same ex-
 tent.   The capsule  was now laid  bare,
 and I gently divided it to the extent of
 half an inch, where it covered one of the
 hard  substances,  which suddenly flipped
 through the opening, and  by pressing
 gently upon the other, it also came through
 at  the  same part.  The  bodies  which
 were thus removed,  were about  three
 quarters of an inch in length, and half an
 inch in breadth.  They had a highly po-
 lished surface, and were hard like carti-
 lage.  The  fluid  contained in  the joint
 was pressed towards the wound, and about
 two olhnces  of synovia were  discharged.
 I then drew the wound of the integuments
 gently  towards the patella, pressed the
 two sides together, and closed it accurate-
 ly  with  sticking plaster, enjoining  the
 patient to keep the limb as free from mo-
 tion as possible."   (Surgical Observations,
 1804.)
 •  On the preceding subject some  obser-
 vations have been lately published by  M.
 Larrey. (See Memoires de Chirurgerie Mi-
 litaire, torn. 2, p. 421, fcfe.)  With  the ex-
 ception of a few  wrong theories, he ap-
 pears to have given a very fair account of
 the disease.

            HYDROPS ARTICCTI.

   This  signifies  a collection of  serous
 fluid in the capsular ligament of a joint.
 The complaint is attended  with more or
 less swelling, and a fluctuation, but, there
 is, in  general, but little pain.  The af-
 fection is sometimes situated in the burs?e
 mucosae.  The knee is more subject, than
 other joints, to  dropsical disease.  The
 complaint is frequently preceded by severe
  rheumatic affections,  and a local injury of
  tiie part.  When the fluid is not so copious
  as to produce very great distention of thp
  capsule, a fluctuation is easily distinguish- 
156                               JOINTS.
able.  Also, if the 1 imb be extended, so as
to relax the ligament of the patella, press-
ing the collection of fluid causes a rising
of that bone, and a fulness on each side
of it.  The  disease, though unattended
With  much  pain, produces  a degree of
rigidity in the joint.               _ _
  Mr- Russell  has  adopted the opinion,
that some cases of this kind are venereal,
and others scrophulous; but, he has not
supported the doctrine on any solid foun-
dation.  Hydrops articuli sometimes fol-
low fevers.
  The cure of the above described drop-
sical affection of the joints, depends upon
the absorption of the effused fluid. Such
absorption is sometimes  altogether spon-
taneous,  and the event may always be ex-
cited, and promoted, by mere friction, by
rubbing the joint with camphorated mer-
curial ointment, by repeatedly  applying
leeches, and particularly,  by the employ-
ment of a perpetual blister.
  The operation of a blister may always
be very, materially assisted by a bandage^
applied with moderate tightness.  Among
other effectual means of cure, we  may
enumerate  frictions with flannel  impreg-
nated with the fumes of vinegar; electri-
city ; and tiie exhibition of mercurial me-
dicines to open the bowels. When"hydrops
articuli occurs during the debility, conse-
quent to typhoid, and  other fevers,  the
complaint can hardly be expected to get
well before  the patient has regained some
degree of strength.               j
   Circumstances do not often justify mak-
ing an opening imo the joint; but, exces-
sive  distention, in some neglected cases,
might certainly be an urgent reason for
performing such an  operation.  Also,  if
the complaint should resist all other plans
of treatment,  and the irritation of the tu-
mour greatly impair a weak constitution,
the practice would be justifiable.  An in-
teresting example of this kind is related
by Mr. Latta.   (System of Surgery, Vol. 2.
p. 490.)
   It is best to make the opening in such a
 way, that the wound in the capsular liga-
ment after the operation, will not remain
directly  opposite the  wound in the skin.
For this purpose, the integuments are to
 be pushed to one side, before the surgeon
 m ikes an incision through them.  (Ency-
clopedic  Method. Part. Chir. Art Hydro-
pisie des Jointures.)

     COLLECTIONS OF UL00D IN JOINTS.

   Most  systematic writers  speak of this
 kind of case, though it is certainly a very
 uncommon one.   Tumours,  about  the
joints,  composed of blood, and set down
in numerous surgical works, as extravasa-
tions within  tlie capsular  ligament, are
gen .rally on the outside of them.
  Certainly, were a collection of  fluid to
take place in a joint very suddenly, after
a sprain/or contusion, and to continue to
increase  gradually, for some time after-
wards, there would be reason for  believ-
ing, t^at most of the contents of the tu-
mour was blood.  The production of an
abscess,  and the  secretion of any fluid,
would have required a longer time.
   Were blood known to be  undoubtedly
effused in  a  large articulation,  no  man
would be justified in making an  opening
for its discharge.  No bad  symptoms are
likely  to result from its mere presence,
and the absorbents will,  in the end,  take
it away.   Should an incision be made into
the joint, the coagulated state of the ex-
travasated blood  would frequently not
allow -such blood to be discharged.
   The best plan is to apply discutient re-
medies ;  a lotion of vinegar  and  sal am-
moniac is the best application for the first
three or four days, and, afterwards  fric-
tions with  camphorated  liniments may be
safely had recourse to.
   Mr. Hey has related a case, in which
the  kqee-joint  was  wounded, and blood
insinuated itself into the capsular  liga-
ment ; yet, though the occurrence could
not be hindered, no  harm resulted  from
tiie extravasation which was absorbed,
without having created the smallest incon-
venience.  (Practical Observations in Sur-
gery^. 354.)


            WHITE SWELLING.

   The white swelling, or spina ventosa,as
 it is  not unfrequently called, in imitation
 ofthe Arabian  writers,  Hhazes and Avi-
 cenna,  is  in this country,  a peculiarly
 common, and an exceedingly terribledis-
 ease.  As I have stated in my Treatise on
 tlie Diseases of tlie Joints, the people ofthe
 continent are, unquestionably, as subject
 as we are to chronic enlargements of the
 knee-joint.  Foreign  surgeons  describe
 numerous varieties  of a  disease, which
 mai<y English  writers would term,  rheu-
 matic  white swellings, but they  acknow-
 ledge, that the scrophulous species of this
 disorder does not commonly  occur to their
 nctice.  (Kortum de*Vitio Scrophuhso, Vol
 2 p. 333.   BrambiUa in Acta Acatl. Med.
 C/ur. Vindobonensis, Vol 1. p. 20.  Petit sur
 les Maladies des Os,  Vol. 2. p. 359.  Edit.
 1749.)
   Wiseman was the first who used the
 term White-Swelling; and the expression
 is not very  unapt, because it conveys an
 idea of one mark of the  distemper, which
 is, that notwithstanding the increase  tft 
JOINTS.
U?
size in tiie joint, tlie skin is not inflamed,
but retains its natural colour.  (Pott.)
  The varieties ol white-swellings are very
numerous, and might usefully receive par-
ticular appellations.  Systematic writers
have  generally been content with a dis-
tinction into two kinds, viz. rheumatic, and
scrophulous.
  The last species of the disease they  al-
so distinguish into  such tumours as pri-
marily affect the bones, and then the liga-
ments and soft parts; and into other cases
in which the ligaments and soft parts be-
come diseased, before there is any morbid
affection of the bones
   These  divisions of the subject appear
hardly comprehensive enough  and  the
propriety of  using the  term,  rheumatic,
seems very questionable.
   Sometimes  the bones, ligaments, and
cartilages, are hardly at all diseased. The
whole disease of the joint appears to arise
from  an extravasation of  glutinous lymph,
 which is intimately radherent to the most
subtile layers of the cellular  substance,
and to the surface of the tendons, liga-
ments, and capsule of  the  articulation.
This distemper  has been named by Bram-
billa, Fungus Articulationis.  Acta Acad.
 Medico-Chirurg:  Vindob  p. 1.
 ♦  Sometimes, the  bones are not in the
least diseased,, though the ligaments and
 cartilages are much altered, the joint is
 immensely enlarged, and the severity  of
 the disease has even rendered amputation
 indispensable.
   Sometimes, the  ligaments,  cartilages,
 and bones are not  the  parts,  which are
 chiefly distempered.  In the instances, al-
 luded to, the articulation is greatly  in-
 creased in size, but, most of tlie swelling
 originates  from a  diseased  state of the
 parts on the outside of the capsular liga-
 ment.  The disease does not consist of a
 thick kind of lymph, diffused throughout
 the structure  of the parts  on the outside
 of the joint;  but, of a morbid change,  in
 which such parts become at once enlarged,
 thickened, and bereft of all their original
 firmness   Very frequently, the texture of
 the heads of the  bones is softened, the
 ligaments are distempered, the cartilages
 absorbed, and the  bones carious.
   Sometimes, the surface of the diseased
 bones are rendered  rough and irregular
 by tlie secretion of a kind of substance like
 spermaceti in appearance, but, containing
 a proportion of phosphate of lime.
   It  has  been too commonly inculcated,
 that  the bones are  always carious  in this
 disease   But, as I have explained, caries
 only comes on in an advanced stage of  the
 malady.  The idea of there  being  invari-
 ably  a carious  affection of the bones led
 the old surgeons into the most unwarrapt-
able practices, with a view of promoting
the process of exfoliation.
  In numerous cases, in which the articu-
lation is considerably enlarged, the heads
of" the bones are entirely  fee from dis-
temper. Mr. Russell has noticedhow much
the soft parts frequently contribute to the
swelling.  He describes the  appearances
on dissection thus :  " The  great  mass of
the swelling appears to arise from an af-
fection of the parts, exterior to the cavity
of the joint, and which, besides! an en-
largement  in size, seem also to have un-
dergone a material  change  in structure.
There is a larger, than natural,  jfropor
tion of a viscid fluid, intermixed With the
cellular substance;  and the cellular sub-
stance itself has  become thicker, softer,
and of a less firm consistence, than in a
state of health." (On  the Morbid Affec*
tions ofthe Knee, p. 30.)
  We may infer from  what  Mr. Russell
states, that he is inclined to believe, that
the disease always begins in the ligaments
and membranes  of tlie articulation, and
he even asserts, that lie had never heard nor
known of an instance, in which tlie tibia was
enlarged from an attack of white siuelling.
P. 37.  It is still a very prevailing notion,
that, in white swellings, the heads of the
bones are preternalurally enlarged.
  Deceived by the feel  of many diseased
joints, and influenced by general opinion,
1 once imbibed  the idea, that there is very
frequently a regular  expansion  of  the
heads . of scrophulous bones.  But,  ex-
cepting an occasional enlargement, which
arises from spiculz of bony matter, depo*
sited on the outside ofthe tibia, ulna, &c.
and which alteration cannot be called  an
expansion of those  bones,  I have  never
been an eye-witness of the head of a bone
being of preternaturally large dimensions,
in consequence  of the disease known  b.y
the name of white swelling.   I have often
been in the habit of inspecting the state cf
the numerous diseased joints, which are
every  year amputated  at St. Bartholo-
mew's Hospital, and though 1 have long
been attentive to this point,  my searches
after a really enlarged scrophulous bone
have always been in vain.   The  change,
which the head of the tibia undergoes in
many  cases, is first a partial absorption
of  the phosphate of lime throughout  its
texture, while a soft kind of matter seems
to  be secreted  into its substance.  In a
more advanced stage, and, indeed, in that
stage, which most frequently takes place
before a joint is  amputated, the head o*r*
the bone  has deep excavations  in conse-
quence of caries, and its structure is now
so  softened, that when an  instrument ia
pustied against the carious part,  it easily
penetrates deeply into the bone. 
158
JOINT*.
  A cursory examination of  a diseased
joint, even when it is cut open, will not
suffice to shew, that the heads of the bones
.have iot acquired an increase of size.  In
making a dissection of this kind, in the
presence of a medical friend, I found, that,
even after the joint had been opened, the
swelling had every appearance of arising
from  an actual  expansion  of  the  bones.
iThe gentleman with me felt the ends of
the bones after the  integuments had been
removt$l, and he coincided with me, that
the feel, which  was even now communi-
cated, seemed to be caused by a swelling
ofthe bones themselves. But, on cleaning
them, the enlargement was demonstrated
to arise entirely from a thickening of the
soft parts.  I  am  glad to find, that Mr.
Crowther is among those, who now disbe-
lieve in the doctrine of expanded scrophu-
lous bones.  (See Practical Observations on
White  Swelling, &c. Edit. 2. p. 14.1808.)
  The  soft parts  undergo  a material
change; they are both thickened and sof-
tened, and there is a large quantity of  a
viscid fluid, intermixed with the cellular
substance.  In short,  the  whole texture
of tlie cellular membrane becomes thicker
and softer, than in the healthy state.
  In the cavity of the joint,  we sometimes
find a quantity of curdy matter, and the
cartilages absorbed in various places, but,
more particularly round the edges ofthe
articular surfaces.
   The  knee, ankle, wrist, and elbow,  are
the joints most subject to white swellings.
As the  name of the disease implies,  the
skin is  not at all  altered  in  colour.  In
some instances  the swelling  yields  in  a
certain degree to pressure; but it never
pits,  and  is  almost always  sufficiently
firm to make an uninformed examiner be-
lieve, that the Ajones contribute to the tu-
 mour.  The pain is sometimes vehement
from the very  first;  in other instances
there is hardly the least pain in the be-
ginning of the disease.  In the majority
of scrophulous white-swellings,  let  the
pain  be trivial, or violent, it is particu-
larly situated in  one  part of the joint;
viz. either the centre of the articulation,
or  the head of the tibia. Sometimes,  the
pain  continues  without   interruption;
 sometimes there are intermissions ;  and,
 in other instances,  the pain recurs at re-
 gular times, so as  to have been called by
 some writers, periodical.  Almost all au-
 thors  describe  the patient, as suffering
 more uneasiness in the diseased part, when
 he is warm, and, particularly, when he  is
in this condition in bed
   At the commencement ofthe disease  in
 the majority of instances,  the swelling is
 very inconsiderable, or there is even no
 visible  enlargement whatever. InthelittJr
depressions,  naturally seated  on  eacl4'
side ofthe patella,  a fulness first shewn
itself, and gradually spreads all over the
affected joint.
  The patient,  unable to bear the weight
of his body on  the disordered joint,  iii
consequence  of the great increase of pain,
thus created, gets  into the habit of only
touching the ground with  his  toes, and
the  knee  being  generally kept  a little
bent in this manner, soon loses the capa-
city of becoming  completely  extended
again.  When white swellings have lasted
a good while, the knee is almost  always
found in a permanent state  of flexion.  In
scrophulous cases of this kind, pain con-
stantly precedes any appearance of swell*
ing;  but  the  interval between the two
symptoms differs very much in different
subjects.
  The morbid joint, in the course of time,
acquires a vast magnitude.  Still the in-
teguments retain their natural colour, and
remain  unaffected.   The enlargement  of
the articulation,  however,  always  seems
greater than' it really is, in consequence of
the emaciation of the limb both above and
below the disease.
   An appearance of blue distended veins,
and a shining smoothness, are the only al-
terations to be noticed in the skin covering
the enlarged joint.  The shining smooth-
ness seems attributable to the  distention,
which obliterates the natural furrows and
wrinkles  ofthe cutis.  When the joint is
thus swollen, the integuments cannot be
pinched up  into a fold,  as they could in
the state of health, and even in the be-
ginning of the disease.
   As the distemper of the articulation ad-
 vances, collections of matter form around
 the part, and at length burst  The ulcer- •
 ated openings  sometimes  heal up ; but,
 such abscesses are generally followed by
 other collections, which pursue the same
 course.  In some cases, these  abscesses
 form a few months after the first affection
 of the joint; on other occasions,  several
 years elapse, and no suppuration of this
 kind makes its appearance.
   Such terrible local mischief must neces-
 sarily produce constitutional disturbance.
 The patient's health  becomes gradually
 impaired, he loses both his appetite and
 natural rest  and sleep ;  his pulse is small
 and frequent;  an obstinate  debilitating
 diarrhoea, and profuse nocturnal sweats,
 ensue.   Such complaints are, sooner or
 later, followed by dissolution, unless the
 constitution  be relieved in  time, either by
 the amendment, or removal of the diseased
 part.   In different patients, however, the
 course of the disease, and  its effects upon
 the system,  vary very much in relation to
 the rapidity with whiqh they occur. 
JORtfTft
159
   Rheumatic  White-Swellings  are very
 distinct  diseases from  the  scrophulous
 distemper of the large joints. In the first,
 the pain is  said never to occur without
 being attended with swelling.   Scrophu-
 lous white-swellings, on the other hand,
 are always preceded by a pain, which is
 particularly confined to one point of  the
 articulation.   In  rheumatic  cases,  the
 pain is more general, and diffused over
 the whole joint.
   It seems  probable,  that  all cases, in
 which  the structure of the bones is found
 quite  undiseased, and  in  which all  the
 mass of disease seems  to be confined to
 the soft parts,  are not scrophulous white-
 swellings.  Few  persons, who  have  at-
 tained  the age of five and twenty, without
 having  had the least  symptom  of scro-
 phula,  ever experience, after this period
 of life, a first attack of the white-swelling
 ofthe  strumous kind. All cases, in which
 the internal structure of the heads of  the
 bones becomes softened, are probably scro-
 phulous.
    Mr.  Russell has noticed the frequent en-
 largement of the lymphatic glands in the
 groin,  in consequence of the irritation of
 the disease when  in the knee; but, he
 justly adds, that this secondary affection
 never proves long troublesome.
    When the bones are diseased, the head
 ofthe  tibia always  suffers more than the
 condyles  of the  thigh bone.  (Russell.)
 The articular surface of the femur some-
 times  has not  a single rough  or carious
 point,  notwiihstanding  that of  the tibia
 may have suffered a great deal.   The car-
 tilaginous coverings of the  heads of  the
 bones are generally eroded  first at their
 edges; and, in the knee, the cartilage of
 the tibia is always more affected than that
 covering the condyles of the thigh bone.
 Indeed, when white-swellings  have their
 origin  in the bones, and the knee is  the
 seat of the disorder, there is some ground
 for supposing,  that it is in the tibia, that
 Jthe morbid mischief first commences.
   The ligaments of the knee are occasion-
 ally so much weakened,  or destroyed, by
 this terrible malady, that the  tibia  and
 fibula  become, more  or less, dislocated
 backward, and drawn towards the tube-
v rosity ofthe ischium, by the powerful ac-
 tion of the flexor muscles of the leg.
   I have seen a curious species  of white-
 swelling, in which the leg  could be bent
 to each side in a very  considerable  dis-
 tance,  both when the knee was extended
 and bent.  Such a state implies a preter-
 natural looseness of the ligaments of the
 articulation.
    With respect to the particular causes of
 all such white-swellings, as come within
 the class of rheumatic opes, little is known.
External irritation,  either by exposure to
damp  or  cold, or by the application of
violence,  is often concerned in bringing
on  the disease; but, very frequently, no
cause of this kind can be assigned for the
complaint.  As  for scrophulous white-
swellings, there can be no doubt, that they
are under the  influence of  a particular
kind of constitution, termed a scrophulous
or strumous habit.   In this  sort of tem-
perament, every cause capable of exciting
inflammation, or any morbid and irritable
state of a large joint, may bring on such
disorder as may end in the severe disease
of which  we are now speaking.
  In a man of a sound constitution, an ir-
ritation ofthe kind  alluded to, might only
induce common  healthy  inflammatioft of
the affected joint.
  In  scrophulous   habits, it also  seems
probable, that the irritation of a joint is
much  more easily produced than in other
constitutions,; and no one can doubt, that
when once excited  in the former class of
subjects,  it is much more dangerous, and
difficult   of  removal, than in  other pa-
tients.
  The doctrine of particular white-swell-
ings, being scrophulous  diseases, is sup-
ported by many weighty reasons, the opi-
nions of the most accurate obseVvers, and
the evidence of daily experience.  Wise-
man (Book 4,  chap.  4.) calls the spina ven-
tosa a species  of scrophula, and tells us,
that infants  and children are generally
the subjects of this  disease. The disorder
is said by Severinus to be exceedingly
frequent in young  subjects.  Petrus de
Marchettis  has  observed both male and
female subjects affected  with  what are
called strumous diseases of the joints, as
late as the age of five and  twenty ; but
not afterwards, unless they  had suffered
from scrophula before that period of life,
and had not been completely cured.  R.
Lowerus also maintains a similar opinion.
Even   though a  few persons may have
scrophulous diseases of the joints, for the
first time, after the age of twenty-five, this
occurrence, like the first attack of scro-
phula after this period, must be consider-
ed as extremely uncommon.
  Another argument, in favour of the doc-
trine, which sets down particular kinds of
white-swellings as scrophulous, is founded
on the hereditary nature of such forms of
disease.
  Numerous continental surgeons, parti-
cularly Petit and Brambilla,  have noticed
how very subject the English are both to
scrophula  and  white-swellings  of the
joints.   We every day see, that yoong per-
sons afflicted with the present disease, are
generally  manifestly scrophulous, or have
once been  so.  Very often enlarged ly m-' 
160
JOINTS.
phatic glands in the neck denote this fatal
peculiarity of constitution;  very often the
parents  are known to have  descended
from parents who had strumous disorders.
(Crowther.)
  Besides the general emblems of a scro-
phulous constitution, which we shall no-
tice in tiie article Scrophula, we may often
observe a shining,  coagulated, flaky sub-
stance,  like white  of egg,  blended with
the contents of such abscesses as occur in
the progress ofthe disease.  This kind of
matter  is almost peculiar to scrophulous
abscesses, and forms another argument in
support of  the foregoing observations re-
lative to the share, which  scrophula fre-
quently has in the origin and  course of
many white-swellings.

    TREATMENT OF WHITE-SWELLINGS.

  In practice we meet with  all these cases
both scrophulous and rheumatic ones, in
two very opposite states; sometimes the
diseased joint is at the same time affected
with a degree of acute inflammation; in
other instances, the malady is entirely
chronic.
  The imprudence of patients  in walking
about, and disturbing the  diseased part,
is very  often the occasion of a degree of
acute inflammation, which  is denoted by
the tenderness of the joint when handled
by the surgeon, and also by the  integu-
ments feeling hotter  than those of the
healthy knee.  Acute inflammation is it-
self a frequent  forerunner of the most in-
veterate diseases of the joints.
  When such state exists, there can be no
doubt, that topical bleeding, and cold sa-
turnine  lotions, are means  which may be
eminently serviceable. The  antiphlogistic
regimen is now strongly indicated.  Cool-
ing purges of the saline kind should  also
be exhibited.  Blood maybe taken from
the  diseased part, either  by  means of
leeches  or cupping.  Mr. Latta gives the
preference to the Tatter method, whenever
it can be employed; and he very properly
remarks, that little advantages can be ex-
pected from topical bleeding of any kind,
unless the quantity of  blood taken away
be considerable.  Ten  or twelve  ounces
by cupping should be taken away at a
time, and the operation should be repeated
at proper intervals, till the tenderness and
heat of the skin have  entirely subsided
When leeches are used, the number ought
to be considerable, and Mr. Latta recom-
mends the  application  of at least sixteen
or twenty.  (System of Surgery, Vol.  I.
chap. 6.)
  When the diseased joint is very tense,
painful, and inflamed, the pressure  of
cupping glasses is too  irritating.
  Though such antiphlogistic means  are
judiciously put into practice,  when acute
inflammation  prevails; yet such  practi.
tioners as lose weeks and  months in the
adoption of  this  treatment,  are  highly
censurable.   While  the skin  is hot  and
tender,  while the joint is affected with
very acute and general pain,  and  while
the  patient is indisposed  with the usual
symptoms  of inflammatory fever, great
benefit may be rationally  expected from
the  above  plan.   When,  however,  this
stage of the disorder is over, and the dis-
ease is  a truly chronic one, the  method
becomes ridiculously inert, and, as pre-
venting the employment of a proper plan
of treatment  may be considered, in a cer-
tain degree,  conducive to the  augmenta-
tion of a most cruel  distemper.  Every
conscientious surgeon  would  shudder to
be guilty of recommending inactive mea-
sures to  oppose an  inveterate  disease,
were he only to have a proper  idea of  the
vast number  of lives and limbs which  are
continually falling sacrifices to such  slo-
venly practice.
  Although I am not fortunate enough to
coincide with Mr. Crowther on this point,
who employs bleeding for a much longer
time, than seems tome advantageous,yet
I am content to let general experience de-
termine which of us is right.  There  are
some cases, I know, (and one  such I  had
lately under my care in private practice,)
which require topical bleeding and cold
applications  much  longer than  others.
There are other instances,  which will
never bear the irritation of blisters  and
the savine cerate, but are exasperated by
this treatment.  Such, however,  is  not
the nature ofthe disease in general, when
the acute inflammation, accidentally pre-
sent, has been removed by antiphlogistic
means.   Having  seen  numerous white-
swellings in  St. Bartholomew's Hospital,
invariably unretarded by a  long recourse
to that universal panacea, white wash, aided
by topical bleeding, I must feel satisfied
that the censures I have passed on delay-
ing the application  of perpetual blisters,
or  issues, are not altogether unfounded.
It is curious, that, after criticising my ad-
vice  not to  lose weeks and  months in
trusting to such treatment, when the acute
symptoms have  ceased,  Mr. Crowther
should remark; " If Mr.  Cooper means
by really efficacious measures, the  appli-
cation of blistering plaster, and dressing
the surface,  after the cuticle  is removed,
with the savine cerate, or establishing
caustic issues on each side of the diseased
joint, I congratulate myself, as having been
the means of ascertaining the salutary effect
of this treatment ! /" P. 63.
  Some other passages of my works are 
JOINTS.
161
noticed  by this  unfortunate critic, with
similar inconsistency, as  I, shall take fu-
ture opportunities of explaining.
  ft is quite unnecessary to expatiate fur-
ther on  the mode of treating white-swel-
lings complicated  with  acute inflamma-
tion.  The most eligible pLn of arresting
the morbid  process in the hpnes, liga-
ments,  cartilages,  and  soft parts  sur-
rounding the articulation, and the  most
successful method of lessening the chronic
enlargement of the joint, are subjects now
demanding our earnest investigation.
  The works of  Hippocrates, Celsus,
Rhazcs, Hieron, Fabricii*t^ &c. compared
with modern  surgical books, Will soon
convince us, that the practice of the an-
cients, in  the  treatment  of diseased en-
larged joints,  does not much differ  from
the plan now  pursued by the best modern
9urgeons.  Mr. Crowther remarks, that
the ancients used local and general blood-
letting,  the actual and potential  cautery,
with vesicating and  stimulating applica-
tions  to the  skin.  They further  main-
tained,  that  sores,  produced  by  these
means, should have their discharge pro-
moted, and continued for a considerable
length of  time.
  Topical applications,  consisting  of
strong astringents of the mineral and ve-
getable  kingdom, suffice for the cure of
some mild descriptions of white-swellings.
A decoction of oak bark, containing alum,
is what is  recommended  for this purpose
by Mr. Russell.
   My own experience will not allow me
to say much in favour of electricity, as an
application for the  relief of white-swel-
lings.  Upon the whole, 1 must rank elec-
tricity  among inactive  measures;  for,
though, in a few cases, it has appeared to
do good;  in others  it has done harm, by
making the disease  more irritable and
rapid in its progress; while in most in-
stances, its eff'ects have been so  insignifi-
cant,  as to make it difficult  to decide,
whether they were of a favourable or an
unfavourable nature.
   " If the tumour is quite indolent, (says
Richerand) the application of galvanism
may  be proposed.;  it  is  not,  however,
exempt from  danger, and on one occa-
sion,  where I employed  it, lancinating
  Eains  and swelling  of the joint were
  rought on by it."  (Nosographie Chirur-
fieale, torn. 3. p. 174, Edit. 2.)
   Cases occur, in which a lotion composed
of sea-water  is  productive of benefit.   I
mean to  say, that this  application fre-
quently diminishes the enlargement of the
joint; but it hardly  ever accomplishes a
perfect cure.
   The conjoined operation of sea-air and
Bfia-bathing  has  undoubtedly  a  most
     Vol. If.
powerful influence over scrophulous dis-
eases of the joints, as well as most other
strumous disorders; but  the  application
of sea-water alone, in the form of a lotion,
cannot be greatly praised, because it pre-'
vents the surgeon from having recourse to
a better plan of treatment. Even the trial
of sea-air and bathing unitedly can only
be recommended as an auxiliary plan, to
be adopted  in  conjunction with  other
more certainly efficacious measures.
  Poultices, made of sea-weeds, deserve
the  same kind of praise as has been given
to the sea-water lotion.
  Every one is well acquainted with the
efficacy of friction in exciting the action of
the  absorbents.  To this principle we are
to impute the great benefit, which  arises
from what is termed, dry nibbing, in cases
of white-swellings.  This kind of friction
is performed  by the mere hands of an at-
tendant, without using at the same time
any kind of liniment, or other application
whatsoever, and the rubbing is continued
for  several  hours every day.  At Oxford,
many poor persons earn their livelihood
by devoting themselves to this species, of
labour,  for which they are paid a stipu-
lated sum per hour.
  1 look upon all  mere emollient applica-
tions, such as fomentations and poultices,
as quite destitute of real efficacy, and,
though they serve to amuse the patient,
they ought not to be recommended.  That
surgeon, who merely strives to please his
patient's fancy, without  doing any  real
good to him, in regard to his  affliction,
may be considered as doing harm, because
the semblance of something  being done
too often hinders other really  useful steps
from being pursued.  The  French  sur-
geons  are  particularly   liberal  in the
praises which they bestow on such" warm
emollient remedies, as poultices, steam of
hot water, fomentations,  &c.  and they
adduce instances of white-swellings Lsing
cured iu this manner.  But, whoever has
had opportunities,  of observing  the in-
veterate nature  of the  disease  in this
country, will hardly  be  inclined  to re-
commend the, imitation of French prac-
tice.
  The only method of treatment, which
my own  personal experience enables me!
strongly to recommend, consists in keeping
up  a discharge from the surface  of the
diseased joint.  1'he opportunities which
I have  had  of observing the  effects  of
blisters, and caustic issues, rather incline
me, however, to prefer the former to the
latter.  I have  seen great good derived
from both; but more from blisters,  than
the other kind of issue.  There  are in-
stances in which I should  employ vesi-
 cating applications; there are others in
     X 
162
JOINTS.
which I should prefer making an eschar
with caustic.  I have seen many instances
in  which  the  application of a  blister
could  never be endured, in consequence
of  the general  inflammatory  affection,
which it occasioned throughout  the dis-
eased joint
  The  blister - should always be  large.
Many  surgeons, instead of following Mr.
Crowther's plan,  prefer  blistering  first
one side of the joint, and then the other
alternately, for a  considerable length  of
time.  " Blisters,  (says  Mr  Latta)  may
be put upon each side of the patella, and
ought to be of such a size and shape,  as
to cover the whole ofthe swelling,  on the
inside, from the hinder part of the joint,
at the edge of the  hollow of the thigh,  to
the edge of the patella, over the  whole
extent of the swelling above  and below.
As  soon as  the blister is  taken off from
one side, it ought to be  applied  to the
other, and thus repeated alternately, until
both swelling and pain be completely re-
moved.  When this is the case, the pa-
tient ought to be directed to rub the joint
well with a liniment, composed of half
an  ounce  of  camphor, dissolved in two
ounces of oil, with the addition of half an
ounce  of spir. sal-ammon. caust.  or, as  it
is now  called, aqua ammoniac.  This  is
to be used  three times a day; and in this
way, (continues Mr. Latta) 1 have success-
fully  treated many cases of white-swel-
lings."  (Syst. of Surgery,  Vol. 1, chap. 6.)
  In the beginning,  caustic  issues are
even more  painful,  than  blisters;  but
they afterwards become more  like indo-
lent sores, and are more easily kept open,
for  a length of time, than blisters.  Such
issues  are commonly  made on each side
of the  diseased joint, and of about the
size of a  half-crown.  The manner of
making the eschars, and  keeping  those
issues open, is explained,  in  the article
Issue.
  The question has been contested, among
surgical writers  and  practitioners, whe-
ther blisters and issues produce benefit,
upon the principle of counter-irritation,
or in consequence of the discharge, which
they occasion.  They  probably  operate
efficaciously in both ways; for there  is
no doubt, that mere rubefacients possess
the power of rousing the action of the
absorbents, and they also may modify the
vascular action of diseased parts.  These
applications can  obviously only act upon
the  principle  of  counter-irritation, and,
they have  not  been here recommended
particularly for white-swellings, because,
it seems to me, that whenever some good
might  be derived from their employment,
much  more benefit could  always  be ob-
tained from  blisters   and issues.   This
sentiment is confirmed by experience, and
we must, therefore, impute a  great de-
gree of efficacy to the maintenance of a
purulent discharge from the vicinity of
the diseased part.
   We have noticed the efficacy of friction,
in exciting the action of the' absorbents,
by which the  thickened state  of parts,
around the affected joints,  may be consi-
derably lessened, and, on this  principle,
the  utility  of dry-rubbing-arises.   We
have  now  to  notice the method of  pro-
ducing the same effect by pressure, a plan,
which vet  seems to merit a more  exten-
sive trial.   1  liave seen in St. Bartholo-
mew's Hospital,  a few  cases,  in  which
the swelling of the joints was  most ma-
terially  diminished,   by encircling the
morbid articulations  with  strips  of ad-
hesive  plaster, applied with  moderatr
tightness.
   A somewhat similar plan, though its
modus operandi  is differently accounted
for, appears also to  have  been tried in
France.  " J'ai dans  quelques occasions
(says Richerand) obtenu les plus grands
avantages de  I'appli cation d'un taffetas
cire autour de  rarticulation  tumefiee.
On coupe  un  morceau de  cette etoffe,
assez large pour envelopper la totalite de
la tumeur ; on enduit les  bords d'une
gomme dissoute dans la vinaigre, et sus-
ceptible de le  faire adherer ihtimement a
la peau; on l'applique  ensuite de  ma-
niere que tout l'acces soit inderdit a l'air
entre lui et les tegumens.  Lorsqu'au bout
de quelques jours on leve cet appareil, on
trouve la peau humide, ramollie par  I'hu-
meur de la transpiration  condensee en
goutelettes  a  la  surface  inteneure du
taffetas.  Dans ce procede, on etablit un
espece de bain de vapeur autonr de l'ar-
ticulation malade.   (Nosographie Chirur-
gicale, Tom. 3, p. 175, Edit. 2.)
   My  particular friend,  Mr.   Clement
Wilson Cruttwell. of Bath, sent me, some
time ago, a very excellent case, illustra-
tive of the efficacy of treatment by pres-
sure.   He  remarks, that,  " After  cup-
ping the part,  and endeavouring to quiet
the inflammation, I used  blisters;  but
they excited such  intolerable  pain,  and
produced so great a degree of swelling
and  inflammation, that I was  under the
necessity of healing  them  immediately.  ,
After two months strict  confinement to
bed, and the use of leeches and refrige-
rant  washes,   the  infiamination  having
again  subsided,  and the pain  being re-
moved, I again  ventured to  apply one
small blister, and again a similar attack
of pain, swelling, and inflammation, was
produced.   The joint  became  distended
with fluid, of  which it  had always con-
tained a large  quantity, and the  irrita- 
JOINTS
163
tim  of tlie  constitution was excessive.
By the libera) use of opium, I once more
succeeded  in quieting the  disturbance,
and, convinced of  the  hazard  of using
blisters in such a subject, I applied  mo-
derate pressure, by means of a roller, to-
gether with a  wash, containing a large
proportion of spirit, in order to keep up
a constant evaporation.  The skin, which
was before much inflamed, and hard, has
become natural and flaccid, the pain has
ceased, the swelling has diminished, and
I have every prospect of  effecting a cure,
with  the  preservation of tolerably  free
motion in the joint."
  Mr. Cruttwell tells me, in a late letter;
that this case got completely well, by the
treatment with pressure,  and has remain-
ed so for upwards of six months, under
full and fiee exercise.
  This example clearly  evinces  the im-
propriety of using blisters in certain con-
stitutions.  In some remarks, annexed to
the above case, Mr. Cruttwell expresses
his conviction, that absolute rest,  cold
applications,  and pressure, would  suc-
ceed in very many cases, without local
counter-irritation.   Pressure,  he adds,
succeeds best, when fluid is effused, and
the disease is  indolent; but,  he is  con-
vinced that it may be used with advantage
in later stages, when abscesses have form-
ed, and sinuses already exist.  Mr. Crutt-
well,  with his usual accuracy of observa-
tion,  next reminds me, how very service-
able continued pressure is to the scrophu-
lous finger-joints of children.
  From what has been stated, I am firm-
ly of opinion, that all  impartial practi-
tioners will be disposed to give pressure
a more extensive trial, as a means of re-
lieving a disease which too frequently foils
every effort of the most skilful surgeon.
  We have noticed, that when the knee
is affected, there is a great tendency in
the limb to become  permanently bent. It
might undoubtedly be very judicious to
op|>ose the  occurrence of this  position,
by  means  of splints, which would  also
serve to prevent all  motion of tiie diseased
joint, an object of the very highest  im-
portance.   Were  the disease  to end in
anchylosis, the advantage of having the
limb in a state of extension need scarcely
be mentioned.
  Numerous diseased joints are undoubt-
edly connected with a kind of  constitu-
tion, called scrophulous.  Hence, it seems
rational to combine, with the local treat-
ment, the  employment of such  internal
remedies, as have been known to do good
in other  scrophulous diseases.   Hectic
symptoms are those, which we commonly
have  to palliate in these cases.  When
the appetite is impaired, and the stomach
will bear bark, this  medicine should  be
given  with  the  aromatic  confection.
Above all internal remedies, opium claims
tlie highest recommendation, as it at once
tends to keep off and relieve a debilitat-
ing diarrhcea, which  too frequently pre-
vails, at  the same time that it  alleviates
pain, and procures sleep.  The objection,
made against  its   exhibition,  on  the
ground  that  it  increases perspiration,
seems exceedingly frivolous,  when  the
above important  benefits are taken into
consideration-
  Too often, however,  the terrible dis-
ease of which we are now treating baffles
all  human skill  and judgment, and the
unhappy patient's health having declined
to the lowest state,  he  is necessitated to
submit to amputation, as the  only chance
of preserving life.  It has been explained
in the article Amputation that the condi-
tion  of the patient's health,  and not of
the  diseased joint,  can form  the only
solid reason tor recurring to the severe
operation of removing  the limb.  If the
patient's constitution be equal to a longer
struggle, no man can  pronounce,  that
every prospect of saving the limb is at an
end.  Many diseased joints,  apparently
in the most hopeless  condition, frequently
take  a  favourable turn, and,  after all,
allow the limb to be saved.  The state of
tlie health  is the chief consideration, in
forming a judgment respecting the pro-
priety of amputation.
  The proposal  of cutting out  diseased
joints has been considered in the article
Amputation.

        DISEASE OF THE HIP-JOINT.

  This complaint is very analogous in its
nature to the white-swelling of other ar-
ticulations.  In  the  same  way, as  the
latter disorder, it seems probable that tiie
disease ofthe hip has its varieties, some
of which may  be connected with scro-
phula, while others cannot be suspected
to have  any concern  with a strumous ha-
bit.   The "present complaint is most fre-
quently seen attacking children under the
age of" fourteen; but, image, no sex, no
rank, nor  condition of life  is exempt
from  the possibility of being afflicted, so
that though children form a large propor-
tion  of those subjects,  who are attacked;
yet the number of adults, and even of old
persons,  is cons idem ble.
  The approach  of  the disease of  the
hip-joint is much more insidious, than
that  of a  white-swelling.  Severe pains
generally precede  the latter  affection;
but, the only forerunner of the former  is
frequently  a slight weakness,  and limping
of  the  affected  limb.    These trivial 
164
JOINTS.
symptoms are very often  not  sufficiently
urgent to excite much notice, and, when
observed by  superficial practitioners, are
commonly neither understood, nor treated
according to the dictates of surgical sci-
ence.  As  there  is, also, very often an
uneasiness in  tlie knee, when the hip is
affected, careless practitioners frequently
mistake the seat of disease,  and I  have
many  times  seen patients, on  their en-
trance into an hospital, having a poultice
on their knee, vhiie the  wrong state of
tlie hip was not at all suspected.
  This mistake is extremely detrimental
to the patient, not on account of any bad
effect, resulting  from ,the applications so
applied ; but, because  it is  only in the
incipient period of the complaint, that a
favourable  prognosis can be  made.  In
this stage of  the  disease,  mere rest and
repeated topical  bleeding, will  do  more
good in the  course of a  fortnight, than
large painful  issues will afterwards  gene-
rally accomplish  in the long space of a
twelvemonth.
  The  symptoms of the  disease of  the
hip-joint, when  only looked for in  the
situation of  that articulation,  are  not
very  obvious  to  die  surgical  examiner.
Though the attention of  the surgeon is,
in some instances, soon called to the right
situation of the disease, by the existence
of a fixed  pain behind  the trochanter
major; yet, it is too often the  case, that
mere pain about  an articulation, entirely
destitute  of  visible enlargement* and ex-
ternal alteration  of colour, is  quite dis-
regarded, as a complaint of no importance
iu young  subjects, and as a  mere  rheu-
matic, or gouty  affection, in adults.  Pa-
tients frequently complain of most of their
painful sensaions being in the groin,  and
all accurate  observers  have-  remarked,
that, in  the  hip-disease, the pain is  not
confined to the  real seat of disease, but
shoots down the limb, in the course  ofthe
vastus externus  muscle to the knee.
   Tue early symptoms of disease  in the
hip-joint are only strongly delineated to
such practitioners, as have acquired  the
necessary information relative to t'.iis part
of surgery, from careful study, and ex-
tensive experience.
   We shall next trace those characters of
the  present  disease, which  serve  to de-
note its existence.
   It is a curious circumstance,  that when
the  functions of a limb are obstructed by
disease, the bulk of the member generally
diminishes, and  the muscles become ema-
ciated.  Nearly as soon as the least  de-
gree of lameness can  be perceived, the
leg  and thigh have actually wasted,  and
their circumlereuce has become less.
   If the  surgeon make pressure on the
front ofthe joint, a little on the outside of
the femoral artery, after it has descended
below the os pubis, great pains will be
experienced.
  The limping of the patient is  a clear
proof that something about the limb is
wrong, and, if  such  limping cannot be<
imputed  to diseased vertebrae, or some
recent accident, and if,  at the same time,
tiie above-mentioned emaciation of  the
limb exists, there is a great cause to sus-
pect,  that the hip is diseased, particular-
ly, when the pain is augmented by press-
ing the front of the acetabulum.        ,
   Diseased vertebrae,  perhaps,  always
produce a paralytic affection of both legs
at once, and  they  do not cause painiul
sensations about the knee, as the hip-dis-
ease does.
  The increased length of the  limb, a
symptom  that has been noticed  by all
practitioners since De  Haen,  is a  very
remarkable and curious occurrence, in
the early  stage of the present  disease.
1'his symptom  is easily detected by a com-
parison of' the condyles of the os femoris,
tlie trochanter  major, and malleoli, ofthe
diseased  limb, with  those  parts of the
opposite  member,  taking  care that the
patient's  pelvis is evenly  situated.  The
thing is the more striking,  as the increas-
ed length of the member is frequently as
much  as  four inches.  The  rationale of,
this fact, John Hunter  used to explain
by the  diseased  side of  the pelvis be-
coming lower,  than the other.  ( Crowther,
p. 266.)
   The same  thing was noticed by Fal-
coner, before Mr. Crowther. (On Jschias,
p. 9.)
   An  appearance of  elongation  of the
 limb  is  not exclusively confined to the
early^stage of the  morbus  coxarius; it
 may  attend other cases.   1  remember
 seeing in one of  the wards of St, Bar-
tholomew's Hospital, a little girl, with  a
diseased  knee, whose  pelvis  was consi-
derably distorted in this manner, so that
the limb ofthe same side appeared much
elongated. .  Her  hip-joint  was  quite
 sound.  This case was pointed out to Mr.
 Lawrence and myself by Mr. Cother, of
 Gloucester.
   Mr.  Ford  has very accurately  called
 tlie  attention  of surgeons  to the altera-
 tion, with respect to the  natural fulness
 and convexity of the nates, that part ap-
 pearing  flattened,  which is usually  most
 prominent.  The  gluteus  magnus be-
 comes emaciated, and its edge no longer
 forms so bold a line, as it naturally does
 at the upper and back part of the thigh,
 in the sound state ofthe limb.
   Though there may be more pain about
 the knee, than tfle hip, at some periods 
JOINTS.
165
of tlie malady  in its incipient state, yet,
the former articulation may be bent and
eitended, without any increase of unea-
siness ;  but,  the  os  femoris cannot  be
moved about, without putting the patient
to immense torture.
  The patient soon gets into the habit of
bearing the  weight of  his body chiefly
upon the opposite limb,  while  tiie thigh
of the affected  side is bent a little for-
ward,  that  tiie ground  may  only  be
partially  touched  with  the foot.  This
position  is found  to be  the most com-
fortable,  and every attempt to extend the
limb occasions an increase of pain.
   This is the first stage ofthe disease,' or
the one, wliicli is unaccompanied with
suppuration.                    ,
   The symptoms which precede the form-
ation of  pus, vary in different cases,  ac-
cording as  there is acute, or chronic in-
flammation present.   When tiie diseased
joint is affected with acute inflammation,
the surrounding parts become tense and
extremely  painful; the  skin is even red-
dish;  and  symptoms  of inflammatory
fever prevad.  When the severity of  the
pain  abates, a  swelling occurs in  the
vicinity of the joint, and a pointing quick-
ly follows.
   When the abscess is a chronic one,
there is no particular increase of pain pre-
ceding the collection of matter.
   Startings and catchings during sleep
are said  to be among the most certain
signs  of the formation of matter, in this
stage of the disease.
   We have noticed the lengthened state
of the limb, in the first periods of tiie hip-
disease.  This  condition is not of very
long duration, and% sooner*, or later suc-
ceeded by a shortening of the affected
member.  The  toes are  turned inwards;
the great trochanter  is approximated to
the crista of tlie os ilium; the leg is  in a
state of flexion; and all the symptom?
of a luxation of the thigh upwards  and
outwards,  may be  observed, 'the head of
the  bone indeed  being  actually  drawn
into the external iliac fossa, and carried
betwixt  the os  innominatum and gluteus
minimus, which is raised up by it.  (See
hk/terand's  Nosographie   Cldrurgicale,
Tom. 3, p 171,  172,  Edit. 2.)
   When the  retraction  is  very consider.
able, it arises from nothing less,  than an
actual dislocation of  the head  of  the
thigh-bone, in  consequence  of the  de-
struction of the  cartilages,  ligaments,
and  articular  cavity.    This  retraction
sometimes comes on long before any sup-
puration takes  place.  The head of  the
bone is  sometimes dislocated,  and  the
disease terminates in anchylosis, without
any absciss whatever.
  It is worthy of particalar notice, that
the head of "the bone is always luxated
upwards and outwards ; and the only ex-
ception to this observation, upon record, is
a case related  by the celebrated Italian
practitioner Cocchi, in which a spontane-
ous dislocation of the thigh-bone, as it is
termed,  happened »upwards,  forwards,
and a little inwards.  (See Leveilies. Nou-
velle Doctrine Chirurgicale, Tom. 2,p- 595.)
On a egalement vu la tete du femur luxee
en dedans et en bas, et placee sur le trou
obturateur, mais ce mode de deplacemeut
consecutif,   dans lequel le roembre  est
alonge,  est  infiniment rare.  (Richerand,
Nosographie Chirttrgicule, Tom. 3,p. 172.)
  The hip-disease generally induces hec-
tic symptoms, after it has existed a cer-
tain tune.  In some subjects, such symp-
toms  soon come on; in others, the health
remains  unaffected a  very considerable
time.
  When abscesses of the  above descrip-
tion burst,  they continue, in general, to
emit  an unhealthy thin kind  of matter
for a long time afterwards.
   With respect  to the morbid anatomy of
tlie disease  in its  incipient state, little is
known.   Two dissections  related by Mr.
Ford are, perhaps, the only ones throwing
light upon this point.   In  one,  there was
a tea-spoonful of matter in the cavity of
the hip-joint.  The  head  of the thigh-
bone  was a  httle inflamed, the capsular
ligament a little thickened,  and the liga-
mc-ntum teres united in its natural way to
the acetabulum.  The cartilage lining the
cotyloid cavity was eroded in  one place,
with  a  small aperture,  through which a
probe might be passed, underneath  the
cartilage, into the internal surface of  the
os pubis, on one side, and, on the other,
into the os  ischii; the opposite, or  ex-
ternal part  of the os  innominatum shew-
ing more appearance of disease, than  the
cotyloid cavity.  In the other  instance,
the disease  was more advanced.  These
examples  are  important,  inasmuch  as
they prove that  the hip-complaint prima-
rily  affects  the cartilages, ligaments, and
bones, and not the surrounding soft parts
as De Haen, and some others would ie^d.
one to believe.
   As the disorder advances,  the portions
of the os ischium, os ilium, and os pubis,
composing the acetabulum, together with
tiie   investing   cartilage,  and synovial
gland, are destroyed.  The cartilage  co-
vering  the  head of tlie os  femoris,  the
ligamehtum teres, and  capsule  of  the
joint, suffer tlie same fate, anil caries  fre-
quently affects not only the adjacent parts
of the os innoniinata, but also the head
and neck of the thigh-boue.   The bonev
of the pelvis, however, are always mote 
166
JOINTS.
 diseased  than  the thigh-bone,  a  fact,
 which  displays  the aosurdity  of ever
 thinking  of  amputation  in these cases-
 Mr. For. observes,  "In every case  of
 disease of ihe hip-joint, which has termi-
 nated fatally, I  have remarked,  that the
 os tnnominatu n has  been affected by the
 caries  in a more extensive degree, than
 tlie thigh-bone  itself."  (Observations  on
 the Disease of the Hip-joint, p. 107.)
   Sometimes, however, the head and neck
 of the thigh-bone are annihilated, as well
 as the  acetabulum.
   External violence; laying down on the
 damp  ground in summer time; and  all
 kinds of exposure, to damp and cold; are
 the causes to which the disease may some-
 times be referred.  Scrophula, no doubt,
 has, frequently,  some  concern in  tlie
 origin  of the malady;  but, oftentimes,
 no rational cause of tlie complaint can be
 assigned.

   THEATMBNT OF THE DISEASE OF THE HIF-
                 JOINT.

   Hippocrates,  Celsus,  Cxlius  Aurelia-
 nus, &c. convince us in their writings,
 that the ancients treated the present dis-
 ease much, in the same way  as  the mo-
 derns*.   Forming an eschar, and  keeping
 the sore open; topical bleeding; cupping;
 fomenting the part, &c. were all proceed-
 ings adopted in the  earliest periods of
 surgery.  Drs.  Charlton,  Oliver, and
 Falconer,  have extolled Bath water, as a
 most efficacious application to diseased
 hip-joints,  previous  to the suppurative
 stage.   However, had not their accounts
 been exaggerated, all patients of this kind
 would  long ago have flocked to Bath, and
 the surgeons  in other  places would never
 have had further  occasion  to adopt  a
 more painful mode of treatment.
   The plan pursued at Bath, is to put the
 patient in a  warm  bath, two  or three
 times a week, for fifteen or twenty.five
 minutes.
   In the early period of the disease, en-
 tire rest, the  application of fomentations,
 and the employment of topical bleeding,
 particularly cupping, are highly proper.
 Such practice, also, is invariably judici-
 ous, whenever the case is attended with
 symptoms of  acute inflammation.  When
 the fomentations are  not applied,  the
 fotio aquae lithargyri acetati may  be used.
   This method of treatment ought never
 to be employed unless there are manifest
 marks  of active inflammation  present.
 When no such state exists, this plan can
 only be regarded as preventing the adop-
 tion of a more efficacious one,  and, there-
, fore, censurable.
   As far as morbid anatomy can inform
 us, the hip-disease consists  of tlie same
 alteration  of the bones, ligaments,  and
 cartilages, as takes place in  tiie majority
 of white-swellings..  Hence, both diseases
 should be treated on the same principles.
 Quibus diulurno dolore, says  Hippocrates,
 ischiadico vexatis coxaecccidit, Usfemur con-
 tabescit et claudicant, nisi urantur. Form ing
 an eschar, or issue, is the most efficacious
 plan of treating the disease  even now
 known.
   A caustic issue seems to be more bene-
 ficial than a blister, in cases of diseased
 hips.  The depression,  just  before  and
 below  the trochanter major  is the  situa-
 tion, in which surgeons usually make  the
 issue,  and the size of the eschar should
 be nearly as  large  as  a crown-piece.  It
 is, in general, necessary to keep the issue
 open a very long time.  When the thigh-
 bone is dislocated, the case mostly ends
 in anchylosis.

   FBNOIJS HJBMATODES OF THE  HIP-JOINT.

   Mr.  Bums,  in the second volume of his
 " Dissertations on inflammation," p. 311,
 has recorded a  remarkable  instance,  in
 whj.ch  this joint was  affected  with that
 intractable and fatal distemper, the fun-
 gus hasmatodes.  The  case was at first
 supposed to be the disease, of which  we
 have just been speaking in the preceding
 section.  The limb seemed to be elongat-
 ed, and  issues were employed, without
 any material benefit.   The upper part of
 the thigh swelled, while the lower wasted
 away.  The patient lost his appetite, had
 a quick pulse, and passed sleepless nights.
 The part was rubbed with anodyne bal-
 sam, and laudanum given every night;
 but, these means were only productive of
 temporary benefit.  After some months, a
 difficulty of making water came on, which
 ended  in a  complete retention.  It being
 found  impracticable  to  introduce a  ca-
 theter, and a  large elastic tumour, sup-
 posed'to be the distended bladder, being
 felt within the rectum, a trocar was push-
 ed into  the  swelling.   A good deal of
 bloody fluid was thus discharged.  After-
 wards  a considerable quantity of  high-
 coloured fetid urine continued to escape
 from the urethra.  In about a week from
 this operation, the patient died.
   On  dissection,  Mr.  Burns  found  the
 hip-joint completely surrounded with a
 soft matter, resembling brain, inclosed in
 thin cells, and here and there other cavi-
 ties, full of thin bloody water, presented
 themselves.  The acetabulum and head
 of the os femoris were both carious.  The
muscles were  quite pale, and almost like
boiled  liver, having lost their fibrous ap-
pearance.   The same  kind of substance 
KAL
KNE
16?
was found in the pelvis, and most of the
inside  of the  affected bones carious.
Large  cells, containing  bloody  water,
were  observed in the diseased substance,
and it was into one of such cavities that
the trocar had entered  when the attempt
was made to tap the bladder.  See " Trea-
tise on the Diseases of the Joints" being the
obsenuti oris for which the prize for 1806 was
adjudged by the Royal College of Surgeons,
I/mdon. Ford's Observations on the Disease
of the Hip-Joint are particularly excellent.
See also  Crowtlier on White-Swelling, &c.
Edit. 2, 1808.  Latta's System of Surgery.
B. BelPs  Surgery.  Falconer  on  Ischias.
Burns  on Inflammation,  Vol.  2,  p.  311.
The authors quoted throughout  this article,
both ancient and modern, may all be consulted
with advantage.
  JUGULAR.  VEIN,  how to bleed in.
See Bleeding.
K.
    KALI  JERATUM.—v,.  Kali  praepa-
     rati 3ss. Aq. distillate gv. Ammon.
praeparatae 3J.  Dissolve the kali  in a
water-bath ;   add  the  ammonia 1  and,
when the effervescence has ceased, let the
fluid crystallize.  Two  drams  are given
as a litliOHtriptic, in  a  pint  of distilled
water, twice a day, at St. Bartholomew's
Hospital. (Pharmacopeia Chirurg.)
  KALI  ARSENICATUM— *. Arseni-
ci albi, Nitri  purif., sing.  ^j.  Cruci-
bulo amplo igne  candenti injice nitrum,
et liquefacto adde gradatim arsenicum  in
frustulis donee vapores  nitrosi  oriri  ces-
saverint.  Solve materiam  in aquae  dis-
tillate  libris quatuor, et  post idoneam
evaporationem sepone ut fiant crystalli.
  These  crystals may  be  given in the
dose of one tenth of a grain, thrice a day.
(Pharm.  Sancti   Barthol. 1799.)  Justa-
mond strongly recommended  the internal
exhibition of arsenic  in cases of cancer.
See Cancer'.
  KALI  PURUM.—This  is one of the
most useful caustics for  destroying  fun-
guses, making issues, in cases of diseased
vertebrae, white swellings, &c.; and  it is
recommended  to be used in  a particular
manner, by Mr. Whately, for the cure of
strictures in the urethra. When surgeons
prefer  opening buboes, or any other ab-
scesses, with  caustic, the kali piirum is
very commonly employed.   When  sur-
geons used to care hydroceles, by destroy-
ing a  part of the scrotum and  tunica
vaginalis with  caustic, the kali  purum,
either  alone, or mixed with  quicklime,
was made use of.   (See particularly  Ver-
tebrx,  Diseased;  Urethra, Strictures of,
Uc.)
  KALI SULPHURATUM. Two drams
of this, dissolved in a pint of lime  or dis-
tilled water, make an excellent lotion for
the cure of the tinea capitis. Many other
cutaneous  affections  yield, also,  to  the
same remedy.  When arsenic  has been
swallowed as a poison, it is best to give
first, twenty grains of zincum vitriola-
tum, as an emetic the quickest in its ope-
ration ; and, after keeping up the vomit-
ing by  drinking  warm water, and, what
is better, sweet oil, it is recommended to
make the patient drink as much  as  pos-
sible of a solution of the kali  suj.phura-
tum, the sulphur of  which is  known to
blunt the activity ofthe mineral.
  KNEE,  DISEASES OF.  See Joints.
  KNEE-CAP, its effects in relieving the
inconveniences  resulting  from cartilagi-
nous substances in the knee. See Joints. 
168
LAB
LEU
L.
    LABIA LEPORINA. See Harelip.
        LAGOPHTHALMIA,  OR  LA-
GOPHTHALMOS. (from A*y<>5, a hare;
and «<p6xXf*.o(, an eye ) The Hare's Eye. A
disease, in which the eye Cannot be shut.
The following complaints may arise from
it; a constant weeping of the organ,  in
consequence  of the  interruption of the
alternate closure and opening of the eye-
lids,  which motions so  materially  con-
tribute to propelling the tears into the
nose; blindness  in  a  strong light,  in
consequence of the inability to  moderate
the rays,  which  fall on the eye ; on the
s-'ine account,  the sight becomes gradu-
ally very  much weakened;  incapacity
to  sleep where there is  any light; ir-
ritation, pain, and redness  of the  eye,
from this  organ being exposed to  the
extraneous substances in the atmosphere,
without the eye-lids having the power of
washing them away,  in the  natural man-
ner.
  An enlargement, or protrusion of the
whole eye, or a staphyloma, may obvious-
ly produce lagophthalmos. But, affections
of  the upper eye-lids are  the common
causes.  Heister says, he has  seen  the
complaint originate from a disease of the
lower one.  Now and then lagophthalmos
depends  on paralysis of the orbicularis
muscle.  A cicatrix,  after a wound, ulcer,
or burn,  is the most  frequent cause.
  When lagophthalmos arises from a pa-
ralytic affection  of"  the orbicularis  pal-
pebrarum, let the eye-lids be rubbed  with
the tinctura cantharidum, and  cold  wa-
ter, or the linimeirtum camphorae.  Elec-
tricity is also considered as a principal
means of cure,  (Chandler) together with
the exhibition  of bark, the use of the
shower-bath,  &c.
  When  the  affection arises from  spasm
of the levator  palpebrae superioris, elec-
tricity, a small blister on the neighbour-
ing temple, and rubbing the eye-lid and
eye-brow with the tinctura opii," are good
means.   Internal anti-spasmodic  medi-
cines may also be tried.
  When  lagophthalmos arises from the
contraction of a cicatrix, its relief is  to
be attempted  precisely on the same prin-
ciples as the ectropium. (See Ectropium.)
In some cases,  it will not  be amiss, es-
pecially at night, to  lay plasters, drawing
in contrary directions Upon each lid, and
 to assist them by a compress and bandage,
 (Chandler.)
   The inconveniences, depending on the
 eye being unable to shelter itself from the
 light, are to be  obviated by wearing a
 green shade, till the disorder is cured.
   Whoever  is acquainted with German
 and  is desirous of more  minute informa-
 tion  on this subject,  may find an excel-
 lent account of fagophthalmos  in  Rich-
 er's Anfangsgr. der Wundarzn. Band2,
 Von dem Hassenauge.  See also Chandler
 on the Diseases of*-the Eye. Chap. 2.
   LARYNGOTOMY.  (from  A«fvy{, the
 larynx ; and rtfMot, to  cut.)   The cutting
 an opening into the larynx.   (See Bron-
 chotomy.)
   LATERAL OPERATION.  One mode
 of cutting for the stone is  so termed.  (See
 Lithotomy.)
   LENS   CRYSTALLINE   OPAQUE.
 (See Cataract.)
   LENTICULAR.    (from  knticulaire,
 doubly convex.)  An instrument,  con-
 tained in every trephining case, and em-
 ployed for removing the jagged particles
 of bone from the edge of the perforation,
 made in  the cranium  with  the trephine.
 One side of its blade is convex,  the other
 concave ; and  one of  its edges is sharp.
 On the end of the blade is fixed a  little
 shallow cup, with its concavity towards
 the handle of the instrument.   This part
 serves the purposes of receiving the little
 pieces of bone, when detached, keeping
 the end of  the blade from hurting the
 dura mater, and, when applied under the
 margin of the opening, enables the ope-
 rator to  guide the edge of the instru-
 ment all  round it, with steadiness and se-
 curity.
   LEUCOMA. (from Atuxe?, white.) Leu-
 coma and albugo are  often  used synony-
 mously, to denote a white opacity of the
 cornea.   Both of  them, as Scarpa re-
' marks, are essentially different from the
 nebula of the cornea; for,  they  are not
 the  consequence  of chronic ophthalmy,
 attended with varicose veins, and an effu-
 sion of a milky serum into the texture of
 the delicate continuation of  the conjunc-
 tiva over the cornea;  but, are the result
 of violent acute ophthalmy. In this stage,
 a dense coagulating lymph is extravasat-
 ed from the arteries ;  sometimes superfi-
 cially, at other times deeply into the sub- 
L£ U                                 LIG               169
stance of the  cornea.  On other occa-
sions, tiie  disease consists of a firm cal-
lous cicatrix on this membrane, the effect
of an ulcer, or  wound, with  loss of sub-
stance.  The term albugo, strictly belongs
to the first form of the disease;  leucoma
to the last, more particularly when the
opacity occupies the  whole,  or the chief
part,  of the cornea.
  The recent albugo, remaining after the
cure of a severe acute ophthalmy, is of a
clear  milky colour;  but, when of ancient
date,  it becomes pearl-coloured.  Some
cases, which have existed a considerable
time, do not seem to have  any connexion
with the vascularity of the cornea;  for they
continue insulated  in the  middle of the
transparent portion  of this membrane,
without occasioning the least uneasiness
to the patient, the least disturbance ofthe
rest of the eye, or any attempt of the ab-
sorbents toTremove them.
  The recent  albugo, provided the orga-
nization of the cornea  be not destroyed
may generally be dispersed by the means
employed for  the relief of the  first and
second stages  of acute ophthalmy;  viz.
general and topical  blood-letting with in-
ternal antiphlogistic medicines, and topi-
cal emollients for the first; slightly  irri-
tating and  corroborant applications  for
the second.  As soon as the inflammation
has subsided, the latter should be employ-
ed ; for, by making the absorbents remove
the coagulating lymph, deposited in  the
cornea, they restore the transparency of
this membrane.
  But,  though this may often be accom-
plished in the recent state of albugo, it is
not so easy to  be done,  when the long du-
ration of the  disease has paralized  the
absorbents ofthe affected part of the cor-
nea ;  or when the deposition of  a dense
tenacious substance into its intimate tex-
ture, has subverted its organization.  In
one instance, the matter forming the al-
 bugo cannot be absorbed ; in the other, it
 leaves the cornea so much injured, after
 its absorption, that  it  continues opaque.
 (Scarpa.)
   The  recent condition  of  the  disease,
 without disorganization of the structure
 of the cornea; its  occurrence in young
 subjects, whose  absorbents  are  readily,
 roused by external  stimulants;  are  cir-
 cumstances very  favourable to the cure.
 The opacity of albugo in children, arising
 from severe ophthalmy after the small-
 pox,  and remainingrinsulated in the centre
 of the transparent cornea, very often dis-
 appears in the course of a few months,
 even  without the  interference of  art.
 Heister,  Langguth,  and  Riehter,  have
 made the  same observation.  The event
 can  only  be  imputed to the  vigorous
     Vol. II.
action of  the  lymphatics in children
and to the organisation of the cornea not
being destroyed. To promote this absorp-
tion, Scarpa has found the following col-
lyrium a most  efficacious  one:  9,.  Am-
man, muriatx. ^ij.  Cupri acetati gr. iv.
Aqux Calcis Sviij. Misce.   To be filtered,
after standing twenty-four hours.
  He praises also this ointment: £. Tutix
prxpar ^j.Aloes, s pgr ij. calomelanosgr.
ij. Adipis suillet. ^ss. Misce. And the un-
guentum ophtlialmicum of Janin.  He men-
tions the gall of the ox, sheep, pike, and
barbel, applied to the cornea, two or three
times a day, with a small hair pencil, if
too much irritation  should not be pro-
duced.  In some subjects, when the eye3
are very irritable^ and cannot bear the lat-
ter applications, Scarpa has found the od
of walnuts, when rather rancid, very bene-
ficial ; two or three drops being insinuated
into the  eye,  every two hours, for soma
months.  In others, he  has  found the
juice of the lesser centaury,  mixed with
honey, of service
  It is generally necessary to persevere
very strictly, for at least  three  or four
months, before the case  can be reckoned
incurable.
  All  the  expedients, proposed for the
inveterate  albugo or  leucoma  from a
cicatrix, consisting of scraping or  perfo-
rating the layers ofthe cornea, and  excit-
ing ulceration there, are unavailing. For,
though, the enlargement  of the cornea,
should be lessened by such means, its dia-
phanous state could not be restored;  or
should the patient perceive a ray or two of
light immediately after the operation, the
benefit would only  be transient; for, as
soon as the wound'had healed, the opacity
would recur.  The formation of an artifi-
cial ulcer might prove useful, did leucoma
depend on a mere extravasation of lymph;
but, the fact is, the disease arises from the
deposition of an opaque  substance, and
the disorganization of the textore of  the
cornea, conjointly;  in this lies the differ-
ence between albugo and leucoma.
  See Scarpa sulle Malattie  degli  Occld.
 Venezia; 1802.  Richter's Anfangsgrunde
der Wundarnz. Band 3. Essays on the Mor-
bid Anatomy of the eye, by J. Wardrop ;
Edinb. 1808: 'chap. 11.
  LIGATURE, (from ago, to bind.)   In
the article Hemorrhage, we have noticed,
that the immediate  effect of a tight liga-
ture on the  artery,  is to cut  through its
middle and  internal coats, a circumstance,
that tends very much  to promote the ad-
hesion of the opposite sides of the  vessel
to each other. Hence, the form and mode
 of applying  a  ligature to an artery should
be such as are most certain of dividing
 the above coats of the vessel,  in the most
     Y 
iro              LIN                                 -lip
favourable manner.  A broad flat ligature   or three minutes  together, morning and
does not promise  to answer this purpose   evening, on the outside and edges of the
in the best manner; because it is scarcely   e^e l.ils. (Phwm. Chirurgica.)
possible to tie it smoothlv round die arte-    ' L.1NTMKNTLM HYDRARGYRl COM-
ry, which is very  likely to be thrown into   POS1TUM.—*.  Ung hydrargyri tortio-
folds, or to be puckered bv it, and, conse-   ris,  Ad.pis  suills,  sing.  3J.  Camph.
quentlv, to  have  an irregular bruised   §ij Spirit, vinos, rectif. 31J. Aq. amnion.
wound made  in  its middle and internal   pur. 3j.—The  camphor being dissolved in
coats. (Jones.) A ligature of an irregu-   the spirit of wine, add the aq.  amnion, and
lar form is  likely to cut through these   the ointment previously blended with hogs
coats more completely at some parts than  lard   (Fhami. Sancti Barthol.)  A  truly
others; and  if it does not perfectly divide  excellent formula for all surgical cases, in
them, no adhesion can take place, and se-  which the object  is to quicken the action
condary hemorrhage will follow.  A tear  ofthe absorbents, and gently stimulate
of tying the ligature too tight may often  the surfaces of parts.  It is a capital ap-
lead to the same consequences.  These,  plication for  diminishing the  indurated
and many other impbrtant circumstances,  state of particular muscles, a peculiar af-
are noticed  in the article Hemorrhage.     fection every  now and then met with in
   Ligatures are commonly made of inkle,  practice ; and  it is particularly well calcu-
waxed together with white wax.  They  lated  for  lessening the  stiffness  and
should  be round, and very firm, so as to  chronic thickening  often noticed in the
allow being  t ied with some force, without  joints.
risk of breaking. (See Jones on Hemorrhage,     L1NTMENTUM  SAPONIS  COMPO-
p. 172.)                                S1TUM.—5,.  Sapon. giij.  Camph. |j.
   LINIMENT, (from lino, to anoint.) A  Spirit, rorismar. Ibj. Dissolve  the soap
very  soft  kind  of  ointment,  not much  in  spirit,  and then  add the camphors-
thicker than oil, and intended to be smear-  Uses the same as those of the linimentuni
ed, or rubbed on parts.                  camph.
   We  shall  only  mention  here, a few     LINIMENTUM SAPONIS CUM OPIO.
 of the most useful ones for surgical  pur-  &■  Lin. sapon.  comp.  §vj. "ilinct.  opii
poses.                                  §ij. Misce.—For  dispersing indurations
   LIN1MENTUM  AMMON1JE  FOR-  and swellings  attended  with pain, but no
TIUS.—fy.  Aq.  ammon. pur. ^j.  Olei  acute inflammation.
olivae gij. Misce.  Used for stimulating      L1NIMENTUM TEREBINTH IN &.
the surfaces of parts in which it is wished  5<-  Ung. resmae flavae 3*iv. 01. terebintlii-
to excite the  action of the absorbents.  It  nae, q s. Misce.   The celebrated applica-
is  serviceable in removing  indurations,  tion tor bums, recommended by Kentish.
 stiffness ofthe joints, "&c.                 (See Burns.)
   LIN1MENTUM  CALCIS— *.  Aqua:       LIN1MENTUM TEREBINTHlX.fi
 calcis, Olei  olivae, sing, gviij. Spirit, vinosi  V1TR10L1CUM.—$,. Olei olivae Jx. 01.
 rectificati^j. Misce.—A common applica-   terebinth,  3*iv. Acidi vitriol, ^iij. Misce.
 tion to burns and scalds.                 —Said to  be  efficacious in chronic  afl'ec-
   L1N1MENTUM CAMPHOR JE  COM-   tions of the joints, and in the removal of
 POSITCM.—%.  Camp.  ?ij.  Aq.   am-   long existing  effects of sprains and bruis-
 mon. §vj.  Spirit lavend. 3XVJ.  Sixteen   es.   (Pharrn.  Chirurgica.)
 ounces are to be distilled of  the two last     LIP, CANCER  OF.  The  lips  are
 ingredients, from a glass retort, and the   subject to  ulcers, which  put  on a very
 camphor then dissolved in the distilled   malignant aspect, although they are not in
 fluid—For bruises, sprains, rigidities of • reality malignant;  and many  of  these,
 the joints,  incipient chilblains, &c.        occurring just on the inside of these parts,
     LINIMENTUM     CAMPHORS   wjll be found  to depend on the  bad state
■jCTHEREUM.—fc. Camphorae drach. j.   of the constitution,  and the irritation and
 .fitheris une. ss. Olei viperarum  drach.   disturbance which the sores are continual-
 ij. Misce.  The camphor is  to be  dis-j ly suffering from the incessant motion of
 solved in the  aether, and the oil afterwards   the parts, and their rubbing against a pro-
incorporated  with it.                    jecting, or rough tooth.
   This formula, communicated by  Mr.     When cancer takes place, it is usually
 Ware, is adapted to those obscure aff'ec-  in the lower,  and very  seldom in the up-
 tionsof the eye,  in which it is not easy to  per lip.
 determine,  whether the imperfection of    The disease sometimes puts on the ap-
 the sight proceeds from an incipient-cata-  pearance of  an ulcerated, wart-like ex-
 ract,  or a defect of sensibility in the op-   crescence,  occasionally acquiring a consi-
 tic nerve,                               durable size.   Sometimes it  is seen in the
   The mode of applying it is to moisten  form of a very destructive  ulcer,  which
 the finger with  it, and  to rub it for two  consumes the surrounding substance ofthe 
LIP
LIT
171
lip*; and, in other examples, the disease re-
sembles a hard lump, which, at length, ul-
cerates.  The  disease, in  its  infancy, is
often no more than a pimple,  which gra-
dually  becomes malignant.   Whenever
there is reason to believe, that the disease
is of an unyielding cancerous nature, the
sooner it is extirpated the better   For
this purpose, some surgeons  admit the
propriety of using caustic, when the whole
disease can be completely destroyed by
Hey never rejects a patient on this ac-
count, provided such  state is habitual.
(Practical  Observations, p.  51.)  Scarpa,
however, recommends  relieving the liip-
pitudo before undertaking the operation,
as we  have explained  in the article Ca-
taract.
  See  Chandler on the diseases of the Eyes,
chap. 8 Scarpa sullc Malattie degli Occhi,
p. 244.
  LITHONTRIPTICS.  (from a<0«* a
one application.  But,  as  the action of  stone; and B-^vttu, to break.)  Medicines
caustic is not capable of being regulated
with so much precision as the extent of a
wound can be, and as caustic will not al-
low the parts to be united again, the knife
is the only justifiable means, especially as
it occasions also less pain.  Two incisions
are to be made, meeting at an angle below,
(supposing it to be the lower lip) and in-
cluding the  whole of the disease.  The
sides of the  wound are then to be united
with the twisted suture.   (See Hare-lip.)
When the affection is extensive, however,
the .surgeon  is frequently  necessitated to
remove the whole of the lip, or too much
of it to admit of the above plan being fol-
lowed.  This circumstance is particularly
unpleasant,  as the  patient's spittle can
for dissolving stones in the bladder, (See
Urinary Calculi.)
  LITHOTOMY  (from  Xttot, a stone;
and  TefMor, to  cut.)   The  operation of
cutting into tlie bladder, in order to ex-
tract a stone.
  It has been correctly remarked, that no
single operation of surgery has attracted
so much notice, or had so much written
upon it, as that of lithotomy.  A full and
minute account of the sentiments of every
writer, who has treated of" the subject, and
a detail of the infinite variety of particular
modes of making an opening  into the
bladder, would occupy as many pages as
are allotted to  the whole of this diction-
ary. It must be my endeavour, therefore,
only be prevented from continually running  ^  tQ descvihe what is most'interesting
over his chin by  some artificial contriv-
ance.  The deformity also is very  great,
and pronunciation and  swallowing  can
only be imperfectly performed.
  LIPP1TUDO (from lippus, blear-eyed.)
Blearedness.  The ciliary glands, and lin-
ing of the eyelids, only secrete, in the
sound state, a mere sufficiency of a seba-
ceous fluid to lubricate the parts in their
continual  motions.  But,  it  sometimes
happens, from disease, that this sebacious
matter is secreted in too great a quantity,
                                        and important, than pretend to offer an
                                        article which  is  to comprehend  every
                                        thing.
                                          May I be allowed  to  premise,  that
                                        throughout the following columns,  I sup-
                                        pose the reader well informed of all that
                                        relates to the anatomy of the bladder and
                                        adjacent  parts,  and  of  the  perineum.
                                        Without correct knowledge of this kind,
                                        a man must be presumptuous, indeed I
                                        who will set himself up for a good lithoto-
                                        mist; and if he distinguishes himself at
and glues the  eyelids  together* during  all, it will only be by the murders, which
sleep, so that, on Making, they cannot be  he commits, while his successful feats, if
easily separated.  Hence, the margin of  he achieve any at all,  will redound little
the eye-lids becomes red all round,  and
the sight itself even weakened.
  The best remedies are  the unguentum
hydrargyri nitrati,  smeared, at night, on
tile edges and inside of the eye-lid with a
hair pencil, after being melted in a spoon ;
the unguentum tutise, applied in the same
to his honour, since every young student
will soon find out, that they are not the
effect of science, but of mechanical habit
and imitation.  I  would  particularly re-
commend every one, who would wish to
become well acquainted with the anatomy
of the pelvis viscera and  perinaeum,  with
way; and acollyrium, composed of 9j. of  a view to lithotomy, in the  first place to
zincum vitriolatum in "jviij. of aquae rosae* dissect these parts himself, and then avail
  When alterative medicines are requisite,  himself of the valuable instructions to be
and two of guaiacum, put together with  Deuxieme  Recueil, planche 5 et 6; Hal-
soap,                                    ler's Inst Med. of Boerhaave, and Elem
  Persons who have lippitudo and cata-  Physiol.  Tom. 5; Morgagni, Adversar,
r.icls together, bear couching much better,  Anat 3, p. 82,97:  Camper's plates; Saba-
than one would expect from the'appear-  tier's Anatomy; John Bell's  Principles of
ance of the eyes in that disease ;  and Mr.  Surgery; Deschamp's Traite Historique, 
172
LITHOTOMY.
 &e.  de POperation de la Taille, Tom. 1,
 p. 7, &c.
   A few subjects which  are closely con-
 nected with the present,  will be found in
 other  parts of this  dictionary.  For  in-
 stance, the nature of stones in the bladder
 will  be  considered  under  the head  of
 Urinary  Calculi, where also will be seen
 some observations on lithontriptics. The
 manner of searching  for the stone, or as it
 is now more   commonly expressed,   of
 Sounding, will be explained in  the article
 Sounding
   Here 1 shall principally confine  myself
 to the symptoms of  the disease, and  the
 chief methods of executing the much di-
 versified operation of lithotomy.

         SYMPTOMS OF THF. STONE.

   The symptoms of a stone in the bladder
 are,  a sort of itching along the penis, par-
 ticularly at the extremity ofthe glans; and
 hence the patient frequently gets a habit
 of pulling the prepuce,  which becomes
 elongated; frequent  propensities to make
 water, and  go to stool; great  pain in
 voiding the urine, and difficulty of retain.
 ing it, and often of keeping the feces from
 being discharged at  the  same  time;  the
 stream of urine is liable to stop suddenly,
 while flowing  in a full current, although
 the bladder is  not empty, so that the fluid
 is expelled by fits, as it were ;  the painjs
 greatest towards the  end of, and just after,
 the evacuation; there is a dull pain about
 the neck of the bladder,  together  with a
 sense of weight, or pressure, at the lower
 part ofthe pelvis; and a  large quantity of
 mucus is mixed with  the urine; and,
 sometimes, the latter is tinged with blood,
 especially, after exercise.  (Sharp, Earle,
 Sabatier.)
  Frequently (says Deschamps) a patient
 will  have a stone in his  bladder a long
 while without  the occurrence being indi-
 cated by any symptom, or accident.  Most
 commonly, however, the presence of  the
 stone is  announced by pain in the kid-
 neys, more especially in • adults and  old
 persons, children scarcely ever suffering in
 this way,  because in them  the stone is
 hardly at all detained in the kidneys and
 ureters, but descends immediately into  the
 bladder,  the preceding  tubes  being  in
 them more dilatable,  and the rudiment, or
nucleus of the stone  smaller.
  It  seldom happens, that calculous  pa-
tients void blood with their urine,  before
the  symptoms  and  accidents,  usually
eaused by the stone, have  taken  place
It is not  till  after the foreign body has
descended into the bladder, acquired'some
$\ze, and presented itself at the oniice of
that viscus,  that pain is,occasioncd, par-
ticularly, when the surface ofthe stone is
unequal.  The patient then  experiences
frequent inclination  to  make water,  at-
tended  with pain. The jolting of a car-
riage,  riding  on horseback,  and much
walking,  render the pain more acute.
The  urine  appears  bloody,  and  its
course is frequently  interrupted,  and sa-
bulous  matter and particles of stone  are
sometimes discharged with it. The want
to make  water becomes  more  frequent
and  more  insupportable.  The  bladder
is irritated, and inflames ; its parieies be-
come thickened  and indurated; and its
diameter  is lessened.  A  viscid more or
less tenacious matter   is observed, in
greater or lesser quantity, in the mine,
and is precipitated to the  bottom of  the
vessel.  The urine becomes black and  pu-
trid, and  exhales an intolerable alkales-
cent smell which is perceived at the very
moment of the evacuation, and  is much
stronger a little while afterwards,  the
patient  can no longer use any  exercise,
without all his complaints being redoubled.
Whenever he walks in the least,  the urine
becomes bloody;  the pain about the hypo-
chondria, which was dull in the beginning,
grows more and more acute;  the ureters
and kidneys participate  in the  irritation
with the bladder; they  inflame  and sup-
purate,  and very soon the urine brings
away with it purulent matter.   The fe-
ver  increases, and changes  into one of
a slow type ; the patient loses  his sleep
and appetite;  becomes emaciated and  ex-
hausted; and death at length puts a period
to his misery.   (See  Traite  Historique et
Dogmatique de I'Operation de  'a Tuille par
J. F. L. Deschamps, Tom. 1, p. 163 ; Puns,
1796.)                       -
  It is acknowledged by all the  most  ex-
perienced surgeons, and judicious writers
upon the present subject, that the symp-
toms of a stone in the bladder, are exceed-
ingly equivocal, and  may be produced by
several  other  disorders!  " Pain in mak-
ing water, and not being able to discharge
the urine without the feces,  are common
consequences of irritation  of parts about
the neck of the bladder,  from a diseased
prostate gland, and  other causes.  The
urine stopping in a full stream is frequent-
ly caused by a stone "altering its situation,
so as to obstruct the passage;  but  tlie
same thing may happen from a tumour, or
fungus  in the'bladder.   I have  seen an
instance of this, where atuniour,  hanging
by a small pedicle, would sometimes cause
obstruction, and by altering the  posture,
would  retire,  and give  a free  passage.
The dull pain at the neck of the  bladder,
and tiie sensation of pressure on   the rec-
tum, are frequently owing to the weight
of the stone, &c; bin these may  proceed 
LITHOTOMY.
17*
from a diseased  enlargement of the pro-
slate  gland.   Children  generally,  and
grown persons frequently, are subject to a
profapsus ani,  from the irritation of a
stone  in the bladder; but it will likewise
be produced  by  an irritation  in  those
parts." (Earle)   The  rest of the symp-
toms are equally fallacious; a scirrhous
enlargement of the os  tincae, and disease
of the kidneys, may occasion a copious
quantity  of mucus in the urine, with pain,
irritation, &c.  "  The  least fallible sign
(says  Sir James Earle) which I  have re-
marked,  is tlie patient making  the first
portion of urine  with ease, and complain-
ing of great pain coming on when the last
drops are excelled.  This may readily be
accounted tor, f> om the bladder being at
first  defended from  contact  with  the
stone by the  urine; and,  at last,  being
pressed  naked against it.   But, to  put
the matter out of  all doubt, and actually
to prove the  existence of  a stone  in the
bLdder, we  must have recourse to the
operation of ,sounding."
   A stone in the ureter,  or kidneys, or an
inflammation  in  the  bladder, from  any
other cause,  will sometimes produce the
same effects; but if the patient cannot
Urine, except in a certain  posture, it is
almost a sure sign the orifice is obstructed
by a stone.  If he finds ease by pressing
against the perinaeum with his fingers, or
sitting with that part  upon a hard  body,
there is little doubt the ease is  procured
by taking off the weight ofthe stone ; or,
lastly,  if, with the other symptoms, he
tli inks  he can feel it roll in his bladder,
it is   hardly  possible  to   be mistaken;
however,. .the only sure judgment is to
be formed from searching.  (Sharp on the
 Operations )
   An enlarged prostate gland is  attended
wi'h  symptoms  resembling those  of" a
stoue in the bladder; but,  with this diP
fererice, that the  motion of a coach, or
horse, does not increase the  grievances,
when the prostate is  affected,  while it
does  so  in at* intolerable degree in cases
of stone.  It also generally happens, that
the fits of tiie stone come on at intervals;
whereas, the pain from a diseased prostate
is  neither so unequal,  nor so  acute.—
(Sfiarp in Critical Eiujiury,p. 165, Edit.4.)
   Though,  from a consideration  of all
the circumstances above related, the sur-
geon may form a probable opinion of there
being a stoue in tlie bladder, yet he must
never presume to  deliver a positive one,
nor ever he so rash as  to undertake litho-
tomy, without  having greater reason for
being certain  that there is a stone to  be
extracted.  Indeed, all prudent surgeons,
for centuries past, have laid it down as
an invariable maxim,  never to  deliver a
decisive judgment, nor undertake litho-
tomy,  without-having  previously intro-
duced  a metallic   instrument, called a
sound, into the bladder, and plainly felt
the stone.
  However, were the symptoms most un-
equivocal, there is one circumstance which
would always  render  it  satisfactory  to
touch the stone with an instrument,  just
before venturing to  operate;  I  mean the
possibility of there actually being a stone
in the  bladder  to-day,  and not  to-morrow.
It is now a  well-known fact, that stones
are occasionally  forced,  by the violent
contractions ofthe bladder, during fits of
the complaint, between the fasciculi  of
the muscular coat of tlus viscus, together
with a portion  of the membranous lining
of the part, so as to become what is termed
encysted.   The opening into the cyst is
frequently very narrow, so that the  stone
is much bigger than  the  orifice  of the
cvst, in consequence of which it is impos-
sible to lay hold of the extraneous body
with the forceps, and the operation would
necessarily  become fruitless.   {Sharp's
Critical Enquiry, p. 228, Edit 4.)
   In the article Urinary  Calculi, I  have
noticed the probability of this  having oc-
curred in some of the instances, in which
Mrs. Stevens's  medicine was supposed to
have  actually  dissolved the  stone in the
bladder ; for,  an encysted stone is not
likely  to  be hit with  the  sound, nor  to
cause any  inconvenience, compared with
what, a calculus, rolling about in the blad-
der, usually occasions
   It is noticed by  Deschamps,  that when
the stone is lodged in an excavated corner
ofthe bladder, in a particular cyst, or de-
pression ; when it projects but  very little^
when it cannot shift its situation in the
bladder, so as to fall against the orifice of
this viscus ; and when it  is also  smooth,
polished, and light; the patient may then
have it a long while, without experiencing
any  afflicting symptoms.   He  may  even
live to  an advanced age, if not  without
some degree of suffering,  at most  with
such  pain  as is very supportable.  Daily
experience proves,  that persons may live
a considerable time,  with one,  two, or
even  three stones  in  the bladder,  and,
during the whole of their lives, have not
the  least suspicion of the existence of
these foreign bodies.
   According to  Deschamps,  this  must
have  been  the case of M.  Portalieu, a
taylor, in the  street Sepulchre. This in-
dividual,  eighty years  old, was frequently
attacked  with  a retention  of urine  from
paralysis,  and had consulted Deschamps
two years previously. This surgeon intro-
duced a  sound several times, and dis-
tinctly felt a stone in  the bladder.  The. 
174
LITHOTOMY.
 patient, however, never had any symptom
 ofthe disorder,  not even up to the period
 when Deschamps was writing down the
 case in his excellent treatise.  Very large
 and exceedingly rough stones have  also
 been found in tiie dead bodies of certain
 persons, who had never complained ofthe
 symptoms of the disease.  But, cases of
 this kind must be extremely rare, because
 it is well known,  that the pain, which a
 stone produces, is  less in a ratio to its
 size, than to its shape and situation.  A
 small stone, owing to its  situation, may
 be more painful, than an enormous calcu-
 lus, which fills the bladder,  as  is proved
 by the  following  case,  cited  by  De-
 schamps.                             4
   Pochet, a watchmaker, until the age of
 45, had never had any infirmity, except
 that of not being able to-retain his water
 a  long  while.   One day,  while he  was
 carrying a very heavy pendulum, he made
 some exertion, which, probably by chang-
 ing the situation of the calculus,' caused
 at the instant an acute pain  in the hypo-
 gastric region   Symptoms  of the stone
 soon came on;  the pain became intoler-
 able;  and the patient  went into the* H6-
 pital de la  Charite".   He  was sounded;
 the stone was  felt,  and judged to be of
 considerable  size.  The  incision in  the
 heck of the bladder not sufficing for  its
 extraction, the  patient was put to  bed
 again.  The next morning, he was ope-
 rated  upon  above the pubes by  Frere
 Come, who  extracted  an  oval calculus,
 that weighed twenty-four ounces.  The
 patient died four and twenty hours after
 this second operation.  This case proves
 then, that very large stones may lie a long
 while in the bladder without occasioning
 any serious complaints, since the preced-
 ing patient apparently had such a calculus
 a long time,  without suffering  inconve-
 nience from  it,  and  it seems likely that
 he might have continued well still longer,
 had it not been for the accidental effort,
 which first excited the symptoms. (De-
schamps, in  Traite Historique, &c. de la
 Taille,  Tom. 1, p. 166,  167.)
   With perfect impartiality, I shall next
concisely describe the various methods of
cutting for the stone,  beginning with the
most ancient, called the apparatus minor,
and ending with  the modern proposal of
employing a knife in  preference to a gor-
get.


 OF THE APPARATUS MIJJOJl, CLTTIKG OX THE
      GHirE, Oil CELSUS's METHOD.


  The most  ancient  kind of lithotomy
 was that practised upwards of two thou-
sand years  ago, by  Ammonius, at Alex-
andria, in  the  time of  Merophilus  and
Erasistratus, and  by  Meges,  at Rome,
during the reign of Augustus;  and, being
described hy Celsus, is named, Lithotomia
Celsiana.  From cutting directly on the
stone, fixed by the pressure ofthe fingers
in the anus, it has beeft called,  cutting on
the gripe, a knife and a hook  being the
only instruments used.  The appellation
of the lesser apparatus, was given to it
by Marianus, to distinguish it from a me-
thod which he described, called the appa-
ratus major, from the many instruments
employed.
  The operation was done in the  follow-
ing way.  The rectum  was emptied by a
glyster, a few hours previously ; and, im-
mediately before cutting, the patient was
desired  to  walk  about his  chamber, to
bring the stone down  to  the neck of the
bladder; he  was then placed in the lap
of an assistant, or secured as now,  in the
lateral operation.   The  surgeon then in-
troduced the fore  and middle  fingers of
his left  hand, well oiled, into  the anus;
while he,atthe same timejiressed with the
palm of his right hand on the lower part
of the abdomen, above tlie pubes, to assist
in bringing down  the stone.   With  the
fingers, it is next to be griped, pushed
forward toward the neck of the bladder,
made to protrude,  and form a tumour on
the left side of the  perinaeum.  The ope-
rator then took a scalpel,  and  made a lu-
nated incision through the skin and cellu-
lar substance, directly on the stone,  and
near the auns, down to the neck of the
bladder, with the horns towards the hips.
Then, in the deeper and narrower part
of the wound, is to be made a second in-
cision, also transverse, into the neck of
the bladder itself, till the flowing out of
the iirine shews the incision to  exceed in
some degree, the size ofthe stone.  The
calculus,being strongly pressed upon with
the fingers, next started out of itself, or
was extracted with a hook  for the pur-
pose.   (Celsus, lib  7,'  cap. 26.  J. Bell's
Principles,  Vol 2, p. 42.  Allan on Litho-
tomy, p. 10.
  The objections to cutting  on  the gripe,
are, the impossibility of  always dividing
the same parts;  for, those which are cut
will vary, according to the degree of form
employed in making the stone  project in
the perinaeum.   When little exertion is
made, if the incision be begun just behind
the scrotum, the urethra may be  altoge-
ther detached from the prostate ; if the
stone be much pushed out, the bladder
may be entered beyond tiie prostate,  and
both the vesiculz seminales  and vasa de-
ferentia inevitably suffer.  Lastly,  if the 
LITHOTOMY.                            175
parts are just sufficiently protruded, the
bladder will be cut upon its neck, through
the substance of the prostate gland. (Al-
lan on  lithotomy.  Bums, in  Edinburgh
Surgical Journal, No. XIII.  J. Bell, Vol.
2, p 59.)
  The  preceding dangers were known to
Fabricius  Hildanus,  who attempted to
obviate them by cutting on a staff, intro-
duced  along the urethra into the bladder.
He began  his incision in ,the perinaeum,
about half an inch on the side of the raphe;
and he continued the cut,  inclining the
knife,  as he proceeded, towards the hip.
He continued to divide the parts till he
reached the staff;  after which, he enlarg-
ed the wound to such an extent, as to per-
mit him easily to extract the stone, which
he had previously brought  into the neck
of tiie bladder, by pressure with the fin-
gers in the rectum.  He employed a hook
to extract  the  stone.  (Burns )  In this
way Mr. C. Bell has operated with suc-
cess. (/. Bell.)
    The apparatus minor,  as  practised by
 Fabricius,  with the aid of  a staff, is cer-
 tainly  so simple and safe an operation for
 children, that we  must lament its present
 utter neglected state.  You cut, says an
 eminent writer, upon  the stone, and cut
 of course, with perfect security, an incision
 exactly proportioned  to its size.  There
 is no  difficult nor dangerous  dissection;
 no gorget, nor otlw dangerous  instru-
 ment,  thrust into the bladder, with the
 risk of its passing betwixt that and the
 rectum; you are performing, expressly,
 tlie lateral incision of Raw and Chesel-
 den, in the most simple and favourable
 way.   (/.  Bell)  The  prisca simplicitas
 instrumentwum seems, indeed, as the latter
 gentleman remarks, to have been forsaken,
 for the sake of inventing more ingenious
 and complicated operations.
    Celsus  has delivered one  memorable
 precept in  his description of  lithotomy,
 utplagapaulo major, qudm calculus sit; and
 he seems to have  known very well, that
 there  is  more  danger  from lacerating,
 than cutting the parts.
    The simplicity of the operation embol-
 dened every quack, to undertake  its per-
 formance ; and thus,  by diminishing the
 emolument  of regular  practitioners, be-
  came  the  grand cause of  its downfall.
  ^See  Heister on this subject.)  It was long-
 er practised, however, than all the other
  methods; and  was performed  at  Bour-
  deaux, Paris, and other places in  France,
 on patients of all ages, by  Raoux, even
  as late as 140 years ago.  Frere Jacques
  occasionally  had recourse to it; and it
  was  successfully executed  by   Heister.
  {/'art 2,  cf&p. 140.)  A  modern author
recommends it always to be preferred on
boys,  under fourteen.  (Allan, p. 12.)

           APPARATCS MAJOB.

  So named from the multiplicity of instru-
ments employed; or the  Marian method,
from having been first published by  Ma-
rianus Sanctus, in 1524, as the invention
of his master, Johannes de Romanis. (See
J\Ua-ianus de lapide Vesicx per incisionem
exlrahendo )
  This operation, which came into vogue,
as  we  have  noticed,  from  avaricious
causes,  was rude and painful in its  per-
formance, and very  fatal  in its  conse-
quences.  The apology for its  introduc-
tion, was the declaration of Hippocrates,
that wounds of membranous parts are mortal.
It  was  coin ended, however, that such
parts might  be  dilated  with impunity;
and, on this principle of dilatation, Ro»
manis invented a complex and dangerous
plan of operating; one very incompetent
to  fulfil the end proposed;  one, which,
though supp6sed only to dilate, really la*
cerated tlie parts. (Burns )
   The operator, kneeling  on one knee,
made an  incision, with his razor, along
the perinaeum, on one  side of the raphe ;
and,  feeling with his  little finger for the
curve of the staff, he opened the membra-
nous part of the urethra; and,  fixing the
point  of the knife in the groove of his
staff, gave it to an assistant to hold, while
he passed a probe along the knife into the
groove of  the  staff", and  thus into the
bladder.  The urine now flowed out, and
the staff  was withdrawn.  The operator
next took two conductors, a sort of strong
 iron probes; one, named the female  con-
ductor, Iiaving in it a groove, like one of
 our  common directors; the other, the
 male conductor, having a  probe point,
 corresponding with  that groove.  The
 grooved, or female conductor, being in-
 troduced along  the probe into the  blad-
 der,  the  probe was  withdrawn, lind the
 male conductor passed along the groove
 of the female one, into the bladder.  Then
 commenced the operation  of dilating.
 The lithotomist took a conductor in  each
 hand, and, by making their shafts diverge,
 dilated, or, in plain language, tore  open
 the prostate gland. (/. Bell)
    It would be absurd  in us to trace the
 various  dilating instruments, contrived
 for the  improvement of  this barbarous
 operation, by the CoHots, Le Dran,  Pare,
 &c.  Among the numerous glaring objec-
 tions to  the apparatus major, we  need
 only notice the cutting the  bulb of the
 urethra,  not  dividing the  membranous
 part of the urethra, nor the transversalis 
176                             LITHOTOMY.
 perinei muscle, which forms a kind of bar
 across the place where the stone  should
 be extracted;  the laceration of  the neck
 of the  bladder; frequent  impotency af-
 terwards,  and extensive  fatality.—Pare,
 Le Dran, Le Cat, Mery,  Morand,  Mare-
 schal, Raw, and all tlie best surgeons in
 Europe, most strangely practised this
 rash method, for two hundred years, till
 Frere Jacques, in 1697,  taught at Paris
 the original model of  lithotomy, as com-
jmonly adopted at the present day.

         OF THE HIGH OPERATION.

   This method of cutting for the  stone,
 was first published  in  1561, by Pierre
 Franco, who,  in his  Treatise on Hernia,
 says, he once performed it on a child, with
 very good  success, but discourages  the
 farther practice of it.   After him, Rosse-
 tus  recommended it, with great  zeal, in
 his book intitled Partus Cxsarius, printed
 in  1591; but  he  never performed the
 operation himself.—Monseur Tolet makes
 mention of its Iiaving been tried in  the
 MoteUDieu, but without entering into the
 particular  causes of  its  discontinuance,
 says only, that it was found inconvenient
 About the  year 1719,  it was first done  in
England, by  Mr.  Douglas;  and after
him, practised by others.  (Sharp's  Ope-
rations.)
  The patient  being laid on a square ta-
ble, with his legs hanging  off, and fas-
tened to the sides of it by a ligature, pass-
ed above the knee, his head and body lift-
ed up a little  by pillows, so as  to relax
the  abdominal muscles, and  his  hands
held  steady by  some assistants; inject
through a  catheter, into the bladder,  as
much barley-water as he can bear, which,
In a man, is often about eight ounces, and
sometimes  twelve.
  The bladder being filled, an assistant,
in order to prevent the reflux of the wa-
ter,  must grasp the penis, the moment the
catheter is  withdrawn, holding it on one
side, in such a manner as not  to  stretch
the  skin of the abdomen; then, with a
round-edged knife, make an incision about
four inches long, between the  recti and
pyramidal   muscles, through  the mem-
brana  adiposa, as deep as the  bladder,
bringing its extremity almost down to the
penis;  after this, taking a crooked knife,
continue the incision  into the  bladder,
carrying it a little under the os pubis;
and  immediately upon the  water's flow-
ing out, introduce the fore-finger of your
left hand, which will direct the forceps to
the stone. (Sharp's Operations.)
  Although this is one of the easiest, and,
to all appearance, the  safest method of
 operating, several objections soon brought
 it^into disuse.  1. The irritation of a stone
 often causes such  a thickened and con-
 tracted state of the bladder, that this vis-
 cus will not admit of being distended so
 as to rise above the pubes.  2.  If the ope-
 rator should  break  the stone, the frag.
 ments cannot be easily washed  away,  and
 remaining behind  would form a nucleus
 for a future stone.  3. The urine may be-
 come  extravasated.  4- The   danger of
 exciting inflammation of the peritona:uni.
 5. The  injection  itself  is  exceedingly
 painful, and, however slow the fluid be in-
 jected, the bladder can seldom  be dilated
 enough to make the  operation  absolutely
 secure; and,  when hastily  dilated, it is
 sometimes  even  burst, or, at least, its
 tone destroyed.  We need not  enumerate
 other inconveniences. (See  Sharp, Allan,
 &c)
   Some of the objections, however, da
 not  apply to certain  instances.  In many
 men, we  know by searching,  that their
 bladder is very large, so that we can  nin
 no risk of meeting with it in a contracted
 state, and therefore, the objection is of
 no weight,  when we are certain, that  the
 bladder extends itself a considerable way
 above  the pubes, and will admit  a large
 quantity  of injection.  Stones are some-
 times known to be of large size, and they
 are  less likely to be broken in  this, than
 any other kind of lithotomy, so that  the
 objection  of the  difficulty  of extracting
 small ones and fragments,  is   less  forci-
 ble.   The excoriations,  from the effusion
 of urine all over the skin near the wound,
 may be prevented by  embrocations, oint-
 ments, &c.  The abscesses and gangrenes,
 arising  from the extravasation of urine in
 the cellular substance, may  be very much
 prevented by the introduction  of  a can-
 nula, as practised in the puncture of  tlie
 bladder above  the os pubis.   (Sharp in
 Critical Enquiry.)
   This  celebrated  surgeon remarks, in
 the same  chap. I,  that he should  not be
 surprised,, if hereafter, on particular occa-
 sions, the high operation should be reviv-
 ed and practised with success.

          LATERAL OPERATION.

   So named from the prostate  gland,
 and neck  of the bladder, being laterally
 cut.
  It was invented by  an ecclesiastic, who
 called  himself Frere Jacques: he came
 to Paris in 1697, bringing with him abun-
 dance of  certificates of his  dexterity in
operating; and making his history known
to the court and magistrates of  the city,
 he got an  order to cut at the Hotel-Dieu, 
LITHOTOMY.                             177
»;.;1 the Charite, where he performed this
operation  on  about  fifty persons.  His
success did  not answer the promises  he
had made, .and from that time his reputa-
tion seems to have declined in the world,
if we may give credit to Dionis, who has
furnished us  with  these particulars.—
(S/iarp's Operations.)
  Fi ere Jacques used  a big round staff
without a groove,  and when it was intro-
duced into the bladder, he depressed  its
handle,  with an intention of  making the
portion of this viscus, which he wished to
cut,  approach the  perina:um.  He  then
dunged a long dagger-shaped knife into
the left hip, near the  tuber  isch'n, two
fingers breadth from the perinaeum, and
[lushing it towards the bladder, opened it
in its body, or as near the neck as  he
could, directing his incision upward from
the anus.  He  never withdrew his knife,
till a sufficient  opening was made for the
extraction of the  stone.  He  used some-
times a conductor to guide the forceps,
hut more commonly, directed them  with
his finger, which  he  passed into the
wound  after   withdrawing   the  knife.
When  he  got hold  of the stone,  he
used to draw it out in a quick  rough man-
ner, heedless  of  the bad consequences.
His only object was to get the stone ex-
tracted, and he disregarded every thing
else; all preparatory  means,  all dress-
ings, all alter treatment. (Allan, p. 23.)
  Totally ignorant of  anatomy, and thus
rude and indiscriminate in practice, Frere
Jacques soon sunk into disrepute.  How-
ever, there were several eminent surgeons,
who conceived,  from  considering the
parts, which  he  cut,  that  his  metliod
might  be converted into a  most useful
operation.  (Sharp's  Operations.)
  The  principal defect, in his first man-
ner of cutting,  was the want of a groove
in his staff, w hich made it difficult to carry
the knife into   the  bladder.   At length,
Frere  Jacques was prevailed upon  to
study anatomy, by  which his judgment
being improved, he readily embraced se-
veral improvements, which were suggest-
ed to him. Indeed, we are informed, that
he now succeeded better, and knew more,
than is generally imagined.  Mr. Sharp
i:iys, that when he himself was in  Fiance
in 1702, he  saw a pamphlet, published by
this celebrated character, in which his
metliod of  operating appeared so much
improved, that it  scarcely differed  from
the practice  of that time.  Frere Jacques
had learnt tiie necessity  of dressing the
wound after the operation, and had pro-
fited so much from the criticisms of Mery,
l'agon, Felix, and Hunauld, that he then
used a staff  with  a groove, and, what is
more extraordinarv, had cut thirty-eight
    Vol.  If.
patients successively, without losing one.
(Sharp's Operations.)
  In short, as a modem writer  has ob-
served, he lost fewer patients, than we do
at the present day, in operating with  a
gorget.  He is  said to  have cut nearly
5000 patients in the course  of his  life,
and, though  persecuted by the regular
lithotomists, he  was imitated by Mare-
schal at Paris,  Raw in  Holland, and by
Bamber  and  Cheseldon in  England,
where  his operation   was  perfected.—
(Allan.)
   For  a   particular  history  of |Frere
Jacques, and his operations,  Allan refers
us to Bussiere's  Letter to Sir Hans Shane,
Philos. Trans. 1699.  Observations sur la
Muniere de tailferdans les deux Sexes, pour
I' Extraction dela Pierre, pratiquee par F.
Jacques, par J. Mery.   Lister's Journey to
Paris in  1698.   Cours cF Operations  de
Chirurgie, par Dionis.  Garengeot's Traite
des Operations, Tom. 2. Morand, Opuscules
lie Cldrurgie,  Part 2.
  Among   the  many,  who saw Frere
Jacques operate, was the famous Professor
Raw, who  carried his method into Hol-
land, and practised it with amazing suc-
cess.  He never published any account of
it himself, though  he admitted several to
his operations; but, after his death, his
successor Albinus,  gave the world a very
circumstantial detail of all the processes,
and mentions, as one of Raw's improve-
ments, that he used to open  the bladder,
between the  neck and the ureter. But,
either  Albinus, in  his  relation, or Raw
himself in  supposition, was mistaken;
since it is  almost impossible to cut the
bladder in that part upon the common
staff', without also wounding the neck.
(Sharp in  Operations,  and  Critical En-
quiry.)
  Raw's method was objectionable, even
when accomplished, as the  urine could
not  readily escape, and became extrava-
sated around the rectum, so as to produce
terrible mischief.   There  is little doubt,
that Raw's really  successful plan, was
only imitative of Frere Jacques' second
improved one, though he had not the ho-
nour to confess it.   (See Ferhius de Cal-
cuh Vesicx.)
  Dr. B amber was the first man  in Eng-
land, who made a trial of Raw's metliod
on the living subject, which he did in St.
Bartholomew's Hospital.  Cheselden, who
had been in the habit of  practising  the
high operation, gladly abandoned it,  on
receiving the account  of Raw's plan and
success, and, a few days after Bamber, he
began to cut in tins way in St. Thomas's
Hospital.
  Cheselden  used  at  first to operate m
the following manner.   The patient  be*
    Z 
178
LITHOTOMY.
     ing placed,  and tied much irt the  s:,me
     way, as is done at this diy, the operator
     introduces a hollow grooved steel catheter
     into  the bladder, and with  a syringe,
     mounted with  an  ox's ureter,  injects as
     much warm water into it,vus  he  patient
     can bear without pain.  The water being
     kept from running out by a slip of flannel
     tied round the penis, the end of  the ca-
     theter is to be held by an assistant, whose
     principal care is to keep  it from  rising,
     but  not at all  to  direct the groove to
     the  place, where  the  incision is to be
     made.?
       With  a  pointed convex-edged knife,
     the  operator beginning  about an  inch
     above the anus, on  the left side  of the
     raphe, between the accelerator urinae, and
     erector penis, makes an  incision down-
     wards, by the side of the sphincter ani, a
     little obliquely outwards as it descends,
     from two and  a  half* to  four inches in
     length, according to the age of the  patient,
     or size and structure of the parts.  This
    incision,  he endeavours to make all at one
    stroke, so as to cut through the skin, fat,
    and all, or part, of the levator ani, which
    lies in his way.  This done, he passes his
    left forefinger into  the  middle  of the
    wound,  in order to press the rectum to
    one side, that it may be in less danger of
    being cut; and taking a crooked knife in
    his other hand, with  the edge on the con
    cave side, he thrusts the point of it through
    the wound,  close by his  finger, into the
    bladder,  between the vesicula seminalis
    and os ischium of  the same  side.  This
    second incision is continued upwards, till
    the point of the knife comes out at the
    upper part of the first.  The incision be-
    ing completed, the  operator  passes his
    left  fore-finger through  the  wound into
    the bladder, and having felt, and secured
    the stone, he introduces the forceps, pulls
    out his finger, and extracts the stone.
      As the bladder was distended,  Chesel-
    den thought it unnecessary to cut on the
    groove ofthe staff, and that, as  this viscus
    was sufficiently pressed down  by  the in-
    strument, the forceps could be very well
    introduced, without the use of any direc-
    tor, except the finger. (Postscript to Dou-
*  glas's History of the  Lateral  Operation.
    1726.)
      W ith respect to this first of Cheselden's
    plans, Sharp  says, the  operations  were
    exceedingly dexterous; but the wound of
    the  bladder  retiring  back,  when  it was
    empty, did not leave a  ready issue for
    the urine, which, insinuating itself among
    the  neighbouring muscles and cellular
    substance, destroyed four of the ten that
    he practised it upon, and some  of the
    •thers narrowly escaped.   (Sharp's Ope-
    rations.)
  Cheselden, finding that he lost so many
of his patients, in imitating Haw, as Al-
binus directed, Deg.m  to  adopt a  new
manner of operating, founded on the ana-
tomy of the parts, which he  thus  de-
scribes : " I first  make as long an ircision
as 1  well can, beginning near the place,
where the old operation ends, and cutting
down between the tmiscmus accelerator
urinae and erector penis, and by the side
ofthe inlestinum rectum ;  I then feel for
the staff", and cut upon it the length ot the
prostate gland  straight on to the bladder,
holding down the gut all the  while with
one, or two fingers of my left hand." (Ana-
tomy of the Human Body, Edit. 1~30.)
  It deserves  to  be remarked,  it was
Cheselden's  second manner of cutting, >>
that has been described in the Opuscule*
de Chirurgie of M. Morand, who was de-
puted, and had his expences defrayed, by
the Royal Academy of Sciences in Paris,
to con.e over to England,  Mid learn from
Mr.  Cheselden himself,  his way of operat-
ing for  the  stone; and,  accordingly  we
find, that most  French authors, taking
their account from M.  Morand, describe
Mr.  Cheselden's  second,  not  his  third
operation, as that which he invented, and
bears his name.  But, that Mr. Chesel-
den  never resumed his  second manner of
cutting,  may  be presumed from his con-
tinuing  to describe the third only in all
the editions of his anatomy published af-
ter 1730.  (See a note by J. Thomson, M. I).
annexed to hisitew edition of Douglas s Ap-
pendix.   Edinburgh, 1808.)
  The instruments, which Cheselden em-
ployed  in his third, and most improved,
mode  of cutting for  the stone, were a
staff, an incision knife, a  gorget, a pair
of forceps, and a crooked needle carrying
a waxed  thread.   The   patient  being
placed on a table, his wrists are brought
down to the  outsides of his ankles, and
secured  there  by proper  bandages, his
knees  having first been  bent, and his
beds brought back near his buttocks.
  Mr. Cheselden used then to ti.ke  a ca-
theter, first dipped in  oil,  and  introduce
it into the bladder, where having searched
for,  and discovered the stone, he used to
give the instrument  to one of his col-
leagues, whom he desired to satisfy him-
self, whether there be a  stone, or not.
The assistant, standing on his right hand,
held the handle of tiie staff" between his
fingers and thumb, inclined it a little to-
wards the patient's right thigh, and drew
the convex side close up to the  os pubis,
in order to remove the urethra as far as
possible from the rectum.
  The  groove of the  staff' being  thus
turned outwardly and laterally,  Chesel-
den used to sit down in a low chair, and,   * 
LITHOTOMY.
179
keeping tlie skin of tiie perinaeum  steady
with the thumb and forefinger of his left
hand, he made the  first, or outward inci-
sion, through the integuments, from above
downwards, beginning on tiie .eft  side of
the raphe, between the scrotum and verge
of tlie anus, almost as high up as where
the skin of the perinaeum begins to form
the bag conta'niing tlie testicles.  Thence,
he continued  tiie wound obliquely out-
vv.u-ds, as low down as the middle  of the
margin of the anus, at about half an inch
distant from it near the skin, and,  conse-
quently,  beyond the tuberosity of  the is-
chium.  He was always caiefiil to make
tli is outward wound as large  as he could
with safety.   Having  cut the fat  rather
deeply,  especially near  the rectum, he
used to  put  his left forefinger into the
wound,  and keep it there till the internal
incision  was quite finished; first to direct
the point of his knife  into the groove of
his staff, which he,  now felt with the end
of his finger, and likewise to hold down
the rectum, by the side of which his knife
was to  pass, and so  prevent, its being
wounded.  This inward incision Chesel-
den i made with  more caution, than the
former.   His knife first entered the groove
of the rostrated,  or straight part  of the
catheter, through the  sides  of the blad-
der, immediately above tiie prostate, and,
afterwards, the /point of it continuing to
run In  the same  groove  in a direction
downwards,  and forwards,  or towards
himself, he divided that part of the sphinc-
ter of the  bladder, which lies upon that
gland, and then he cut the outside of one
halfofit obliquely, according to the direc-
tion and whole  length  of the urethra,
that ran within it, and finished his  inter-
nal incision,  by  dividing the muscular
portion of. the urethra on the convex part
of his staff.
  A sufficient opening being made, Che-
selden used to rise from his chair, his fin-
ger still remaining in  the wound.   Next
he put the beak of his gorget in the groove
of the staff, and then thrust it  into the
bladder.   The staff" was now  withdrawn,
and, while he. held  tlie  gorget with his
left hand, he introduced the forceps with
the flat side uppermost, sliding them with
great caution along the concavity of the
gorget   When they were in the bladder,
he  withdrew  the latter  instrument, and
taking hold  of the two  branches  of the
forceps with  both his hands, he searched
gently  for the stone,  having them still
shut.  As soon as this was felt, he used
to open them, and  try to get the tower
blade under the stone, that  it may fall
more conveniently into their chops, and
be laid  hold  of.  This  being done, the
stone was extracted with a very slow mo-
tion, in order to give the parts time to
stretch and dilate,  turning the forceps
gently in all directions
  When the stone was very small,  and
did not lie well in the forceps, Cheselden
used to withdraw them, and introduce his
finger into the bladder, in order to tiy
to turn the stone,  and disengage it from
the folds ofthe  lining of the bladder, in
which  it  is sometimes entangled.  Then
the gorget was passed in again on the up-
per side of his finger, and turned as  soon
as the  latter was pulled out;  the for-
ceps were introduced, and the stone ex-
tracted.
  To preserve a soft stone from breaking,
during its extraction, he used to put one
or  more  of  his  fingers  between  the
branches of his  forceps, to prevent any
greater pressure upon it than  what  was
just necessary to hold it together.   But,
when it did break,  or  there were more
than one,  he used to extract the single
stones,  or  fragments, one  after another,
repeating  the introduction of  his  fingers
and forceps, as often as there  was occa-
sion.  Cheselden took care not to thrust
the forceps so far into the bladder as to
bruise,  or  wound its opposite side; and
he was equally careful not to pinch any
folds of" its inner coat.  In this way,  Che-
selden saved 50 patients out of 52, whom
he  cut successively  in St Thomas's  Hos-
pital.   (Appendix to the  History of the La-
teral Operation, by J. Douglas.  1731.)
  Cheselden, with all the enthusiasm of
an inventor, believed, that he had disco-
vered an operation, which was not suscep-
tible of improvement;   yet, he  himself
changed the manner of his  incision no
less, than three times in the course of a
few years.   1st,  He  cut into the body of
the bladder, behind the prostate, when he
imitated  Raw.   2dly,   He cut  another
part ofthe bladder, viz. the neck" and the
thick substance of the prostate;  tins is
his lateral  mode of incision.  3diy, He
changed a third time, not the  essential
form of the incision, but,  the direction,
in which he moved the knife;  for, in his
first operation, when imitating  the  sup-
posed operation of Raw and Frere Jacques,  ^
he struck his knife into the body  of the
bladder, betwixt the tuber ischii and the
vesiculae seminales,  and all his  incision
lay behind  the  prostate gland.   In his
second operation, he struck his knife into
the membranous part of the urethra, im-
mediately behind the bulb,  and  ran it
down through the substance of the gland;
but, his incision stopped at the membra-
nous part, or body, of the bladder   But,
in his third operation, he, af er very large
external incisions, struck his knife deeply
into the great hollow  under the tuber 
-180                            LITHOTOMV
ischii,  entered it into the  body of the
bladder,  immediately behind  the gland,
and, drawing the knife towards him, cut
through the whole substance of the gland,
and even a part of the urethra, " cutting
the same  parts the  co/itrary  way." * By
carrying the forefinger of the left hand
before the knife, in dissecting towards
tiie body ofthe bladder, he protected the
rectum more perfectly, than he could do
in running the knife backwards along the
groove of the staff"; and by  striking his
knife into the body  of the  bladder, and
drawing it towards him, through the whole
thickness of the  gland, he  was sure  to
make an ample wound.  (J. Bell's Princi-
ples of Surgery, Vol.2, Part 1, p. 152.)

LATrllAL 0PERATIOX  AS rF.KFOUMED - AT THE
   PKESENT DAY WITH CUTTING GlinOKTS.

   The gorget is  the same instrument  as
the conductor  used  by  Hildanus; but,
having a cutting edge;  and  it was used
in the Marian operation as  a dilator and
conductor  for the  forceps.   Sir  Cxsar
Hawkins thought, that,  when its "fight
side was sharpened  into  a cutting edge,
it might be pushed safely ifito the bladder,
guided by the staff, and make tiie true
lateral incision,  in  the  left  side  of the
prostate gland, more easily, and with less
risk of injuring  the adjacent parts, than
 Cheselden could  do with the  knife,  and
 surgeons were pleased with a contrivance,
 which saved them from the responsibility
 of dissecting parts, with the anatomy of
 which all were not equally  well acquaint-
 ed.  (J. Bell. Allan.)
   When the patient is of a plethoric ha-
■fcit, 16, or 20 ounces of blood should be
 taken from his arm two  days before the
 operation;  a brisk purge  administered
 the day before;  and a clyster injected a
 couple of hours before cutting, in order
 to empty  the rectum, and render it less
 liable to be wounded.  It is to be lament-
 ed, that these prudent steps are so often
 neglected.
    As it is advantageous to have the blad-
 der  somewhat distended with urine,  they
 patient should be requested  to retain it a
 certain time before being cut.  When this
 cannot be done,  as in children, some ad-
 vise tying a ligature round the peuie,  or
 applying, what is called,  a j.igum, to pre-
 vent the patient from making the evacua:
 tion.  The best practitioners in London,
 however, do not commonly adopt tins me-
 thod.
    Before the operation, the  following in-
 struments should  all be arranged ready
  on a table: three grooved  stall's, of va-
 rious sizes ; a sharp gorget  with  a beak
nicely  anil  accurately  adapted  to UV
grooves of the staffs, so as to glide easily
and securely;  a large scalpel for  making
the  first  incisions; forceps,  of  various
sizes,  for extracting the stone ; a blunt-
pointed bistoury for enlarging the wound
in the  prostate, if the incision of the gor-
get is  not sufficiently large, as the parts
should never be lacerated : a pair of Le
Cut's  forceps with  teeth for breaking the
stone,  if  too large  to  come through any
wound reasonably  dilated ;  a syringe for
injecting   the  bladder, if" necessary,  ti»
wash out  clots of blood,  or particles ot
the stone  ; a scoop for the latter purpose;
two garters to tie the  patient's hands  to
his feet.
   After introducing the staff, and feeling
that the stone is certainly  in the bladder,
the  patient is to be secured in  the same
position,  as we described in the  account
of Cheselden's latest method of operating.
   The assistant, holding up the scrotum,
with his  left hand,  is  with his right  to
hold  the  staff", inclining  its handle  to-
 wards the right  groin,  to  make the
 grooved convexity of the_.instrument turn
 towards  the  left side of the  perinaeum.
 Some operators, also, like the assistant
 to depress the handle of the staff towards
 the patient's  abdomen, in order to make
 its  convexity project in  the perinaeum,
 while others condemn this plan, asserting,
 that it withdraws the  instrument from  the
 bladder.   (Allan, &c)
   The first incision should always com-
 mence, below the bulb of the urethra, over
 the membranous part of this canal, at  the
 place, where the operator means to make
 his first cut into the  groove  of  the staff,
 and the  cut  should extend  about three
 inches, obliquely downward, to the left of
 the raphe  of the perinaeum, at equal  dis-
 tances from the tuberosity of the ischium
 and the anus.  In a large man, the*fii st cut
 should pass the  anus an  inch and a  half
 or more  ; for, it is a general rule in sur-
 gery  to  make free external  incisions, by
 winch the surgeon.is enabled to conduit
 the remaining steps, of his operation with
 greater facility,  and no where is  it so ne-
 cessary as where a stone is to be extract-
 ed.   {Allan.) Tiie next object is to di-
 vide  the  transversales perinaei  muscles,
  which stand,  like a bar,  across  the trian-
  gular hollow, out of which alone the stone
  can  be  easily extracted.  An opening is
  next  to be made into the membranous  part
  of the urethra,  and now the operator has
  to  accomplish  a very important object,
  and one  which is, for the most part,  very
  much neglected;  1 allude to dividing the
  urethra, with the knife, as far as possible
  along the groove of the staff*, towards tlie 
LITHOTOMY.                            181
  Madder.   When this is  properly done,
  very little remains-to be effected  by that
  rougher instrument, the gorget.
     Having placed the beak of the gorget
  in the groove  of the  staff, the operator
  takes hold of the  latter instrument him-
  self; raises its handle from the right groin,
  wi that it may form nearly a  right angle
  with the body, and he stands up. " Before
  attempting to push  the  gorget onwards
  into the bladder, he should slide it back-
  wards and forwards,  with a wriggling
  motion,  that he may be sure its beak is in
  the groove of  the  staff".  The bringing
  forward  the handle of the latter instru-
  ment, so as to elevate its point, before in-
»• traducing the gorget into the bladder, is
  also of immense importance, for,  it is by
  this means, that the gorget,  is  introduced,
  along the groove of the staff in the axis
  of the bladder, the only direction, unat-
  tended with  risk of wounding the rec-
  tum.  In fact, the gorget should be intro-
  duced nearly in a direction, correspond-
  ing to a  line drawn from the  os coccygis
  to the umbilicus.
    As soon as the gorget is introduced, the
  staff" is to be withdrawn.  Some operators
  next pass the forceps,  along the  concave
  surface of the gorget, into  the bladder;
  while others, with every appearance of be-
  ing right, recommend the cutting gorget
  to be withdrawn immediately it has com-
  pleted the wound; for, then the bladder
  contracts violently, and its  fundus would
  be very apt to be cut, if the gorget were
  not withdrawn. This should be done in
  the same direction, in which it entered,
  pressing  it towards the right  side to pre-
  vent its making a second wound incoming
  [»it.  If the operator should prefer pass-
  ing the  Keeps into the bladder, along
  the gorget, the  latter instrument must be
  kept quite motionless, lest its sharp edge
  should do mischief;  and, at  all  events,
  immediately  the forceps  is in the blad-
  der, the  cutting gorget is to be with-
  drawn*
    Some  operators withdraw the  cutting
  [Jorge t, -and introduce a blunt  one  for the
  guidance of the forceps; a step certainly
  unnecessary,  as the latter instrument, will
  easily  pass, when the  incision into  the
  bladder is ample and direct, as it ought
  always to be.
    The operator has next to  grasp the
  stone with the blades of the forceps;  for
  which purpose,  he is not to expand the
  instrument, as  soon  as it has arrived in
  tlie  bladder;  but, he should  first  make
  use ot  the instrument as a kind of probe,
  lor ascertaining  the exact situation of the
  stone.   If this body  should  be lodged at
  the lower part ofthe bladder, just  behind
  its neck,  the operator is to  open the in-
 strument immediately over the stone, and,
 after depressing the blades a little, is to
 shut them, so as to  grasp it.  Certainly,
 it is much more scientific to use the for-
 ceps at first, merely to ascertain the posi-
 tion ofthe stone ; for, when this is known,
 he is much more able to grasp the extra-
 neous  body in a skilful  manner, than if
 he were to open the blades of the instru-
 ment  immediately  without   knowing
 where they ought  next to be placed, or
 when shut.  No man can doubt,  that the
 injury which the  bladder frequently suf-
 fers,  from rough, reiterated, awkward
 movements  of the forceps, is not  an un-
 common cause of such inflammation of this
 viscus, as too  often extends to  the peri-
 tonaeum, and occasions death. -
   When the  surgeon  cannot readily get
 hold of the stone  with  the forceps,  he
 should  introduce   his  fore and middle
, fingers into the rectum,  and raise the ex-
 traneous body  up,  when it may generally
 be easily grasped.   The stone should be
 held with  moderate firmness  to keep  it
 from slipping from the blades,  but, not
 so forcibly as  to  incur the  risk  of  its
 breaking.
   Sometimes,  the  extraction of the stone
 is attended with difficulty, owing to the
 operator having chanced  to grasp  it in a
 transverse  position, in  which  circum-
 stance, it is better  to try to change  its di-
 rection, or let  it go altogether, and take
 hold of it in another  manner.  When the
 stone is  so large,  that it cannot be ex-
 tracted from the wound, without violence
 and  laceration,  the  surgeon may  either
 break the stone  with a strong pair of for-
 ceps, with teeth constructed for the pur-
 pose ; or he may enlarge the  wound with
 a probe-pointed crooked bistourv,  intro
 duced  uuder the guidance of the forefin-
 ger of the left hand.  The  latter plan is
 generally the best ofthe two; for, break-
 ing  the  stone is an exceedingly unplea-
 sant circumstance, as  it creates such  a
 clanger of  calculous fragments remaining
 behind.
   However,  as nothing  can justify the
 exertion of force in  puliing out a stone, if
 the operator should be afraid of making
 the wound more ample, (its being already
 large and direct) he must break the stone,
 as above described.   As many ofthe frag.
 ments are then to be extracted with the
 common  lithotomy forceps,  as can be
 taken away in  this" method,  after which
 the  surgeon should introduce his finger,
 in order to feel, whether any pieces  of
 the stone still  remain behind.  Perhaps,
 some of these may  be most conveniently
 taken out  with  the scoop;  but, if they
 are very small,  it is best  to  inject  luke-
 warm water with moderate force into the 
182
LITHOTOMY.
wound, for the purpose of washing them
out.
  The stone should always be examined
immediately it is extracted; because,  its
appearance  conveys  some  information,
though not  positive, concerning the  ex-
istence of others.   If the stone is smooth
on one surface, the smoothness is gene-
rally-found to arise from the friction of
other stones still  in  the bladder; but,
when it is uniformly rough, it  is  a pre-
sumptive sign,  that there is no other one
remaining  behind.   In  every   instance,
however,  the  surgeon should introduce
his forefinger, tor the purpose of examin-
ing ;  for, it would be  an inexcusable ne-
glect to put the patient to bed,  with an-
other stone in his bladder.
  After the  operation, a simple pledget
should be laid  on the wound, and sup-
ported with a  T  bandage;  the patient
should lie in bed on  bis back,  with his
thighs closed; folded cloths should be
laid under him to receive the urine ;  and
a large opiate  administered, as after all
grand operations.

 OF SOME  PARTICULAR  METHODS  AND IN-
              STRUMENTS.

  M. Foubert,  a very eminent surgeon at
Paris, devised and practised a plan of  his
own,  which however, has not been con-
sidered by others,  as worthy of being imi-
tated.  The patient,  having retained his
urine,  so  as to distend  his  bladder, an
assistant, with a convenient bolster, presses
the abdomen a little below the navel, in
such a manner, that by pushing tlie blad-
der forwards, he  may make' that part of
it  protuberate, which lies between  the
neck and  the  ureter.   The  operator, at
the same time,  introduces the fore-finger
ot his left hand up the rectum, and draw-
ing it down towards  the right  buttock,
pushes in a trocar on  the left side of* the
perinaeum, near the great tuberosity of
the ischium, and about an inch above the
anus.  Then  the trocar is to be carried
on parallel to the rectum, exactly between
the erector  penis and accelerator urinae
muscles, so as to enter the bladder on one
side of its neck.  As soon as the bladder
is wounded, the operator withdraws  his
fore-finger from the anus.
  In the upper part of the cannula of the
trocar, there is a groove, the use of which
is  to allow some urine to escape,  imme-
diately the instrument enters the bladder,
that  the trocar  may not be pushed  in any
further; but, it£ principal use is  for guid-
ing the incision.  As  soon as the urine
began  to flow, Foubert, retracting the
trocar a  little, without  drawing it quite
out of the cannula,  introduced  the point
of a slender knife  into the groove in the
cannula; and, by the •guidance oF  th.s
groove, he ran  it onwards into the bind.
der,  and was aware of  the knife having
actually entered this viscus, by the  urine
flowing still  more  freely   Then raising
the knife  from the  groove, he made his
incision, about an  inch  and a half in
length, through the neck of the bladder,
by moving the knife from  that point, at
which it had entered upwards towards
the pubes.  And, finally, by moving the
handle  more  largely,  than  the point of
the knife, he opened the outer part of the
wound to whatever extent the size of the
stone seemed to require, and then,  with-
drawing the knife,  he introduced a blunt
gorget to guide the forceps.
  An effort was made by Thomas to im-
prove this method ; but,  he failed ; and
it was  never much adopted.  The inabi-
lity of many bladders to allow being dis-
tended, is  an insuperable objection j for,
without this, the trocar is liable to pass
between the bladder  and rectum,  and
even  through the bladder into the pelvis.
{Memoires de I'Acad, tie Chir. 663, vol. 1.
Le Dran's Paraliele.  Sharp's Critical In-
quiry.  J BelPs Principles, vol. 2.)
  About the middle of the  last century,
Frere Cosme constructed for lithotomy, a
knife, concealed in  a sheath, out of which
it started  on  touching a  lever.   This
instrument is entitled  to  particular at-
tention,  because  it is still used in seve-
ral parts of the continent, and even in
this country, by the surgeons of the West-
minster  Hospital.   Frere Cosme  made
the same external incisions, as in the la-
teral  operation, and, after dividing the
membranous part of the  urethra,  he in-
serted  into the groove of the  staff the
point of" his lithotome,  or bistowrie cachee,
and pushed it into the bladder, after which
the staff'  was  withdrawn.  The edge of
the knife was then  turned sideways, and
the lever in the handle being touched, the
blade started from  its sheath, and,1 being
drawn out, divided the  prostate and neck
of the bladder. The  danger of wound-
ing  the pudic artery;  of injuring the
bladder in more places than one,  if col-
lapsed ; and of cutting the rectum, if the *
edge ofthe instrument should be inclined
too much downward ; are the objections,
which have  been urged against tiie em-
ployment ofthe lithotome of Frere Cosme.
The second is the only one, that has much
validity, and even  it might be done away,
by not introducing the instrument too far,
and yet carrying on the incision just as
far laterally, as would  be the effect  of
having more of the instrument to with-
draw from the  bladder.   If this were not
done, the wound would be  too small to 
LITHOTOMY.                              183
  admit of the stone being extracted, with-
  out laceration.
    Le  Cat, a surgeon, of Rouen, in Nor-
  mandy, devised  a mode  of  lithotomy,
  which would be too absurd to be describ-
  ed, were  it not so much renowned.  He
  thought the neck of the bladder might be
  dilated, like that of the wound, and his
  operation  was  deformed with all  the
  cruelty of the Marian method, and every
  error attendant on the infant state of the
  lateral operation  He first  introduced  a
  long big staff'; he cut forward with a com-
  mon scalpel, through the skin and fat, till
  he could distinguish the bulb, tlie  naked
  urethra, and the prostate gland.  Second-
  ly, with  another knife, called  urethro-
  tome, Iiaving a groove  on one  side,  he
  opened the urethra, just before the pro-
  state,  and, fixing the urethrotome  in the
 , groove of the staff", and holding it steady,
  rose from the kneeling posture, in  which
  he  performed  the  outward  incision.—
  Thirdly, holding  the urethrotome  in the
  left hand, he  passes  another knife, the
  cystotome, along the groove of the urethro-
  tome, and the beak of the cystotome being
  lodged in the groove  of  the urethrotome,
  it was pushed forwards,  through the sub-
  stance of the prostate gland into the blad-
  der.   Fourthly, drawing the cystotome a
  little»backwards, he gives the staff to  an
  assistant  to  hold steadily,  and  lifting
  a  blunt gorget  in  the right hand,  he
  places the beak of it in the groove  of the
  cystotome, and  runs  it onwards,  till  it
  glides from the groove of the cystotome,
  along the groove of  the staff  into the
  bladder.  Then, true  to the principles of
  the apparatus  major, and,  never forget-
  ting his own peculiar theory, little incision,
  and much dilatation, he forced his fingers
  along the gorget, dilated the  neck  of the
  bladder, and so made way for the forceps.
  (J. Bell's Principles,  Vol. 2.)
    In  1741, Le Dran described an  opera-
  tion, the introduction of which has been
  cla.med by  several  since his time.  A
  staff being introduced, and two assistants
  keeping open the patient's knees, while a
  third stands on one side of him on a chair,
  (Le Dran  says,) «• I  then  raise up the
  scrotum,  and directing the last assistant
r to support  it with both hands,  so as to
  avoid bruising  it, by  pressing it  either
  against the staff, or the os pubis, 1  place
  his two forefingers on each side of the
  part,  where the incision is to be  made;
  one of the fingers being laid exactly along
  that branch  of thj| ischium, which rises
  towards the pubes, and  the  other pres-
  sed upon the  raphe,  that  the skin may
  be kept '..xed and tight.  While  I thus
  place the fingers  of the assistant, who
  supports tiie scrotum, I  still keep hold of
the handle of the staff, and direct it so as
to form a right angle with the patient's
body;  at  the  same  time,  taking  care,
that the end of it is in the bladder.  This
position is the  more essential, as all  the
other instruments are  to  be conducted
along the groove of  this   If tlie handle
of the  staff  were kept inclined towards
tho  belly, the end of it would come out
of the bladder,  and the gorget,  missing
its guide, would slip between that and the
rectum.
  " The staff being rightly placed, I take
the knife  from  the assistant,  who  holds
the  instruments,  and  put  it into  my
mouth; then pressing the beak of the staff*
against'the rectum,  I f el  the curvature
of  it  through the  perinaeum.  The in-
cision  ought to terminate, an iuch  and
a half,  below where we  feel the bottom of
the  curvature.  If we  do not carry  this
incision sufficiently  low, it may happen
not to be of a size to allow the extraction
of a large stone, and  might lay us under
the necessity of extending it further after-
wards,  for the .skin will  not lacerate here,
nor easily give way for the passage ofthe
Stone.  I therefore begin the incision from
the lower part of the os pubis, continuing
it down to the place, that I before direct-
ed for its-termination ; after which I pass
the point of the knife into the groove of
the staff', and cutting from below upwards,
without taking the point out ofthe groove,
I  open tiie anterior part of  the urethra,
as  far as  the  incision, that is in  the
skin.
   " The  beak of the  staff, which   was
pressed upon the rectum, must now be
raised  and pressed against the os pubis.
At the  same  time, 1  turn  the handle to-
wards  the right groin,  that  the  groove,
which is at the  beak of  the staff, may face
the space, between the anus and the tu-
berculum ischii on  the left side.  Then
carrying the point of the knife down  the
groove, I slide it along the beak,  turning
the edge, that it may face the space, be-
tween  the  anus and  tuberosity of  the
ischium.  By this incision, I  exactly di-
vide the bulb of the urethra, and by do-
ing this on its side, \ve  are sure to  avoid
wounding the rectum, which, for want of
.this precaution, has  been often cut. This
first incision being  made, I again  pass
the point .of the knife into the curvature
of the staff" to  the part,  where  it bears
against the perinjeum, and direct it to be
held there by the assistant,  who supports
the  scrotum.   This  done,  I  take a large
director,  the end of which is  made with a
beak, like that of a gorget, and conveying
this beak, upon the blade of the knife,
into the groove of tlie staff, I draw the
knife out.  I then slide the  beak of this 
184                             LITHOTOMY.
director, along the groove of \he  staff',
into the bladder, and 1 withdraw the staff
by  turning  the handle  towards  the pa-
tient's  belly.   The  following  circum-
stances will sufficiently  satisfy  us, that
the director is introduced into  the blad-
der ;  first, if it 6trikes against the end of
the staff, which is closed; secondly, if
the urine runs along  the groove. I next
feel tor the stone with this director, and,
having found it, endeavour to distinguish
its size and surface,  in order  to  make
choice of a proper pair  of forceps;  that
is, one of a stronger,  or  weaker make, or
of a large or small size, agreeably to that
of the stone;  after  which I  turn the
groove, towards the space, between the
anus and tuberosity of the ischium, and,
resting it there,  convey a bistoury  along
the groove,  the blade of which is half an
inch broad,  and about three  quarters of
an inch long.   I  continue the  incision,
made by the knife in the urethra, and en-
tirely divide the prostate gland laterally,
as also the orifice of the bladder; and, I
am very certain, that the introducing the
use of these two instruments, which are not
employed by other lithotomists,  does not
prolong the operation a quarter  of  a mi-
nute,  but,  rather shortens the time, both
by facilitating the dilatation,  that  is af-
terwards to be made with the finger, and
by rendering the extraction of the  stone
more  easy.  The  bistoury being with-
drawn,  the groove of the director serves
to guide the gorget into the bladder.  I
then introduce  my forefinger  along the
gorget  (which is now easily done, as the
urethra and prostate, being divided,  do
not oppose its entrance) and with it I di-
late the passage for the  stone,  in propor-
tion to the size,  of which 1 discover it to
be.  This dilatation being made, I with-
draw  my finger, and  use the proper for-
ceps "   (Le Dran's  Operations, edit. 6,
1784, London.)
  The high operation, which we have al-
ready described, was introduced by  Fran-
co, in 1561, and was again   revived in
1658,  by Frere Cosme,  with  what were
supposed to be some improvements.  Tlie
latter  proposed  to open the bladder in
perinaeo, and then, through an  opening
made just above  the  pubis,  he  intro-
duced a ssalpel with a button-point, with
which he slit up,  for  an inch or  two, the
linea  alba, the knob on the  end of the
knife  pushing aside   the  peritoneum.
After this, he introduced, by the aperture
in perinaeo, a staff,  with which he pro-
jected the bladder through the  opening,
between the recti muscles: this done, he
cut  into the front of  the bladder, and
either with his finger and thumb, or with
a pair of forceps, he took out the  stone.
In this way, he extracted a calculus from
the bladder,  weighing 2\ ounces.  Wtrr
it not for the danger attendant on the
double incision into the bladder, and the
protraction  of the operation by the dis-
section  about the perinaeum,  this plan
might, with  propriety, be adopted.  In-
deed, as modified by Deschamps, who, in
place of  the  puncture in perinaeo, perfo-
rates the bladder from the Tectum, it has
met with the approbation  of Dr. Thom-
son, of  Edinburgh, who considers tiiis,
on particular occasions,  to  be the most
advisable mode  of operating.  It is evi-
dent, however, that if the  bladder  be
thickened and indurated,  it will be im-
possible  to raise it above the pubes with
the cannula,  and, consequently, the plan
is only admissible when we have reason
to suppose that the stone is too large to
be removed from the perinaeum, and the
bladder is healthy.   The puncture from
the rectum is simple,  attended with no
increase of danger, allows  the bladder to
be elevated by the cannula, and secures a
depending outlet for the urine.  We avoid
thus the necessity of any discha- ge by the
wound above the pubes, we run no risk
of the urine  insinuating  itself into the
cellular membrane;  no inflammation is
excited; no sinuses are formed.  (Burns,
in Edinb. Surg. Journal, No. 13.)
  The danger of the beak  of the gorget
slipping out of the groove of the staff, is
one of the chief objections uiged against
the employment of the first of these in-
struments. To obviate this, Sir Charles
Blicke had the groove of the  staff, and
the beak of  the  gorget, so constructed
that they locked into each other, and con-
tinued fixed till near the extremity of tlie
staff'. The contrivance, though plausible
and  ingenious, is not much used; the
point of contact of the beak and body of
the  instrument  is mecessarily  so  small,
that it is liable to break.   It is allowed,
however,  that this objection might be re-
moved; but  another  one  is still urged,
viz. the beak and groove catching on each
other, so as to resist the efforts made to
introduce the gorget  into the bladder.
Every operator knows, that much of the
safety of the lateral  operation,  as. per-
formed at present, depends on the ease \
with which the beak of the gorget  slides
along the groove of the  staff.  Le Cat,
in 1747,  is said  to have devised a similar
instrument.
   Some operators seem to have a good
deal  of  trouble in  dissecting into  the
groove of the staff'.   Sir James Earle in-
vented an instrument to render this more
eas5-.' It consists of a  short sUjT, with an
open groove, connec ed by a hinge, with
the  handle  of another staff of the usual 
LITHOTOMY.                     ,        185
size,  shape, curvature, and length, which
may be called the long staff.  The hinge,
by means of a pin, is capable of being dis-
jointed at  pleasure.,  The  short  staff is
sufficiently curved  to  go over tiie penis
and scrotum,  and long enough to reach
to that part of the long staff' which is just
below the beginning of  its  curvature.
The end of the  short  staff, made some-
what  like  a pen, with the sides  sharp-
ened  and  finely pointed, is  adapted to
shut into the groove of the long staff, and
its cutting edges are defended from being
injured by  a proper receptacle  which is
prepared for it in the groove  of the long
staff   When the instrument is shut, the
groove ofthe short staff leads into that of
the long one, so  as to form  one connected
and continued groove.  The short staff' is
rendered steady by the segment of an
arch projecting from the long one through
it.
   The long staff, separated from the short
one, is first introduced in the usual man-
ner, and,  the  stone having  been felt, the
short staff is to be put on the other at the
hinge.  The incision is then to  be made
in the usual  manner, through tlie skin
and cellular membrane, and a second  in-
cision through the muscles, so as nearly
to lay bare the  urethra,   The operator
then being perfectly convinced, that tiie
extremity of the long staff is sufficiently
within the bladder, must bring the end
of  the short staff down,  and press  it
against the urethra, which it will readily
pierce,  and pass into tlie  cavity prepared
for it  in the groove of the long staff. The
two staffs being  now firmly held together
by the operator's left hand, nothing  re-
mains to be  done, except  applying the
beak  of the gorget, to the groove of the
short  staff, and  push it on till  it  be  re-
ceived in the groove of the long one; and
if this latter be  made with a contracted
  Soove, it will just enter where the con-
  action begins,  and thus must be safely
conducted into the bladder.  {Earle on  the
Stone,- Appendix;  Edit. 2, 1796;)  Des-
champs describes an instrument,  invent-
ed by Jarda,  a  surgeon  of Montpelier,
which bears  a  resemblance to  Earle's
double staff, but was more complicated,
being designed  to support the scrotum,
and also press  the rectum out of the way.
  With respect to  the method of using
the double staff",  would it be proper, im-
mediately after piercing the urethra with
the point of the short staff,  to plunge tlie
gorget into the bladder,  without  having
previously divided with a knife the mem-
branous part of the urethra ? The reader
will hardly approve of this plan, what-
ever opinion he may entertain of the uti-
lity of the  instrument.
    Vol. II
  The  late Mr. Dease, of Dublin, and
Mr. Muhy of Glasgow, considering that
the gorget was  more apt to slip from the
staff in  consequence of the latter being
curved, and that its beak never slips from
the groove  of  the staff in operating on
women,  proposed, like Le Dran,  to con-
vert the male  into the  female urethra.
They introduce, as usual, a curved grooved
staff' into the bladder, make the common
incision, and open tiie  membranous part
of  the  urethra;  but,  instead of intro-
ducing a gorget on the  curved staff, they
conduct along the groove  a  female one
into the bladder,  and immediately with-
draw the odier.  The  gorget is then in-
troduced.  This, method  certainly  re-
moves the dangej? arising  from the slip-
ping of the latter instrument.

LITHOTOMT,  AS  PBHFOBMED WITH A KXIFE,
  INSTEAD OF A  CUTTING GORGET, BY SEVE-
  RAL OF THE MOHKRXS.

  We have already described,  how Frere
Jacques and Cheselden used to operate
with a knife, without any cutting gorget,
in the early state  of the lateral operation.
The success, which attended the  excel-
lent practice of the latter surgeon, cer-
tainly far exceeds what attends the prer
sent employment of the gorget, for, out of
52 patients, whom he cut successively for
the stone, he only lost two;  and  out of
213, of all ages,  constitutions, &c. only
20.   These facts are strongly in  favour
of abandoning the use of tiie gorget, and
doing its office with a knife.
  The objections'to the gorget are nume-
rous and well founded.   In the hands of
many skilful operators, its beak has slip-
ped out of the groove of the staff, and the
instrument has been driven either between
the rectum and the bladder, or into the
intestine instead of the latter viscus.   Sir
James   Earle remarks:  " I  have more
than once known a gorget, though passed
in the right direction,  pushed on  so far,
and with such violence,  as to  go through
the opposite side ofthe bladder."  Brom-
field, even  when  operating with a blunt
gorget,  burst through the bladder and pe-
ritonaeum, so that the  abdominal  viscera
came out ofthe wound.  (F. 270.) I knew of
one instance in which the gorget, slipping
from the  staffi  completely severed the
urethra from the  bladder; the stone was
not taken out, and the  child-died.
  We  will  suppose, however, that the
preceding dangers of the gorget are sur-
mounted, as they certainly may  be,  by
particular dexterity, seconded by the con-
fidence of experience.   The gorget is  in-
troduced, but whatever kind of one has
been used, the wound is never sufficiently
    A a 
189                             L1T1I0T0.ATV.
 large for the easy passage of any stone,
 except one below the ordinary size. Cam-
 per has noticed this tact:  " Hawkensius
 solo conductore, cujus maigo dexter in
 aciem assurgit, idem praestat: omnes pia-
 gam dilatant, ut calculum extrahant:  dila-
 cerentur igitur semper vesicx ostium et pro-
 stata." (P.  114.)  Dease says:  " In  all
 the trials that I have  made with the gor-
 get on the  dead subject, I have never
 found the  opening into the bladder suffi-
 ciently large for the extraction of a stone
 of a middling size,  without a considerable
 laceration of the parts. I have frequent-
 ly taken  the largest-sized  gorget,  and
 could not find, in the adult subject, I ever
 entirely divided the prostate gland,  if it
 was any  way  large;  End in  the opera-
 tions that were performed here on the
 living subject, if the stone was large,  the
 extraction was painfully tedious, and  ef-
 fected with great difficulty, and,  in some
 cases, not at all."            '
   I shall dismiss this part of the subject
 with referring the reader to the  spirited
 and correct remarks on the objections  to
 the gorget in Mr. John Bell's Principles,
 Vol. 2, Part 2.
   The latter author recommends the ex-
 ternal incision, in a large man,  to com-
 mence about an inch behind the scrotum,
 and to be carried downwards three inches
 and a half, midway  between the anus and
 tuberosity  of the ischium.  The fingers
 ofthe left hand, which at first kept the
 skin tense, are now applied to other  pur-
 poses.  The  fore finger now  guides the
 knife, and the  operator proceeds  to dis-
 sect through fat  and  cellular  substance,
 and muscular and ligamentous fibres, till
 the  wound is free and open, till all sense
 of stricture is gone; for it is only by feel-
 ing opposition and stricture, that  we re-
 cognize  the transverse muscle   When
 this hollow is fairly laid open, the exter-
 nal incision, which relates merely to the free
 extraction ofthe stone,  is completed.  If it
 were the surgeon's design to operate only
 with the knife, he would  now  push  his
 fingers deeply into the wound, and, by the
 help of the fore-finger, dissect from the
 urethra along the body of the gland, till  he
 distinguished its thickness and solidity,
 and reached its back part.  Then plung-
 ing his  knife through  the posterior por-
 tion of the gland, and settling it  in the
 groove ofthe staff, he would draw it firm-
 ly and steadily towards him, at the same
 time pressing it into the groove  of  this
 instrument, and then the free discharge
of the urine,  assuring  him that the  pro-
 state and neck of tlie bladder were divid-
 ed, he would lay aside his knife, pass the
 left  fore-finger into the  bladder, with-
 draw the staff, and introduce the forceps.,
 {John  Bell,p. 197.) .
   Mr. Charles  Bell describes the  follow
 ing method of  operating with a knife, in-
 stead ot a gorget.   A staff' grooved on the
 right side,, a scalpel with a straight back,
 and the common lithotomy  forceps,  are
 the indispensable  instruments   The staff'
 is kept m the centre,  and well home  into
 the bladder. The surgeon making his in-
 cision under the arch of the pubes,  and
 by the side of  the anus, carries it  deeper
 towards the  face ot  the prostate  gland:
 cutting near to the staff", but yet not cut-
 ting into it, and avoiding  the rectum  by
 pressing it down with the finger.  Now
 cai ry ing the knife along  the staff',  the
 prostate gland  is felt. The  point of  the
 knife is run somewhat obliquely into the
 urethra, and into the lateral groove of
 the staflj just  before the  prostate gland.
 It is run on, until the urine  flows." The
 fore-finger  follows the  knife, and it is
 slipped along the back of it, until it is in
 the bladder.   Having carried the fore-
 finger into the  bladder, it is kept there,
 and the  knife  is  withdrawn.  Then  the
 forceps, directed by the finger, are intro-
 duced.  (C. Bell's Operative Surgery,  IV
 l,p. 361.)
   Mr. Allan Burns, of Glasgow,  recom-,
 mends the following  plan:  " The plan,
 says  he, introduced  by  Cheselden,-and
 revived by Mr.  J. Bell, 1 would assume,
 as  tlie basis  of the operation; hut still,
 along  with their  mode,  I would blend
 that of Mr. Dease, by which, I imagine,
 we may overcome  some  of the disadvan-
 tages  attendant on each considered indi-
 vidually.
   " For more than twelve  months, I have
 been in  the habit of shewing such an
 operation, which is as simple in its per-
 formance, as the  one in  general  use, is
 attended with  less danger to the patient,
 permits  of an incision varying in size, ac-
 cording  to the  wish of the operator,  and
 completely prevents injury of the rectum,
 or pudic artery. -To  perform  this oper-
 ation,  I introduce into the urethra a com-
 mon curved staff', then make the usual in-
 cision  into the perinaeum,  divide fully
 and freely the levator ani,  so as to expose
 the whole extent of the membranous pari
 of the urethra,  the complete extent of the
 prostate gland, and a portion of the side
 of the neck of the bladder.   When  this
Wrt of the operation is  finished,  I open
 the membranous part  of the urethra,  and
 introduce through the slit, a straight or
 female staff', with  which I  feel the stone,
 and then withdraw the curved staff. This
 done, I grasp the handle ofthe staff firm-
 ly in my  left hand, and with  the right hw
V 
LITHOTOMY.
187
hold of the knife.  Having ascertained,
that the two instruments  are in fair con-
tact, I rest the one hand upon the other,
pressing  them  together, and  then by a
steady extraction, 1 pull out the knife and
staff together, which is preferable to draw-
ing the knife along  tiie staff',  it prevents
the risk of the one slipping  from  the
other ;  it guards the bulb of the urethra,
and every  other  part  from injury; for,
between them and the cutting instrument,
the staff is interposed;" &c.   " When in-
troducing the knife, the side of the blade
must be laid  fiat along the fore-finger  of
the right hand, which is to project a little
beyond the point. In this state the finger
and knife  are to enter the wound, oppo-
site the tuber-ischii; but, in  proportion
as they pass along,  they are to be inclin-
ed forward, till at last, with the point of i
the finger, the staff >s  to be felt through
the coats of the bladder, a little beyond
the prostate, and rather  higher than the
orifice of  the urethra.  Here the knife is
to be pushed, with  the  finger,  through
the bladder, and when the point is fairly
fixed in the groove  of the staff the oper-
ation is to  be finished by the steady ex-
traction  of both  instruments."  (Allan
Burns, in Edinburgh Surgical Journal, No.
13.)
   The knife of Cheselden does  not  re-
quire so much violence to divide the parts
as the gorget does; cannot slip in some
instances  before, in others  behind the
bladder;  and it will make a wound suffi-
ciently  ample for the  easy extraction of
the  stone, without the  least laceration.
The possibility of its wounding the rec-
tum,  Mr.  Thomson thinks might be  ob-
viated by employing it as follows :  " Af-
ter having made the  external incisions,
and divided the membranous part of the
urethra, in the way that is usually done
for the introduction of the beak of  the
gorget, a straight-grooved- staff is to be
introduced into the g-roove of the curved
staff, and  pushed along it into the  blad-
der.  The curved staff' is then to be with-
drawn,  and the surgeon, laying  hold of
the handle of the straight staff with his
left hand, and turning  the  groove  up-
wards and a little outwards, presses the
back of It downwards towards the right
tuber ischii, and holds it steadily in that
position.  The point of a straight-backed
scalpel -being now  introduced  into  the
groove ofthe staff",  with its cutting edge
inclined upwards and a  little outwards,
is to be pushed gently forwards into the
bladder.  The  size of the scalpel need
only be such as will make a wound in the
prostate gland and  neck of the bladder,
sufficiently large to admit the fore-finger
of the  left hand.  The scalpel bejng re-
moved, this finger is  to be introduced
into  the bladder,  through  the  wound
which has been made,  and the staff may
then be withdrawn.  With the finger the
surgeon endeavours to  ascertain the size
and situation of the  stone.  If,  after this
examination,  he judges  the  incision in
the neck of the bladder  to be  too small
for the easy extraction of  the  stone, he
next introduces into the bladder a straight
probe-pointed bistoury, with its  side close
to the fore part of his finger,  and its cut-
ting edge upwards. By turning this edge
towards the left side, and by  keeping the
point  of his fiftger always  beyond the
point of  the bistoury,  he .may  safely  di-
vide; in the direction of  the  first incision
as much of the prostate gland, and  neck
of the  bladder, as he shall deem necessa-
ry."  See Observations  on Lithotomy, &c.
with a  Proposal for aNew Manner of Cut-
ting for the Stone, by J. Thomson, M. D.
one ofthe Surgeons ofthe Royal  Infirmary,
&c. Edinb.  1808.   In  this  small  work,
the reader will  find  additional particu-
lars.
   Mr.  Allan, who is a  strenuous advocate
for using the knife instead of the gorget,
directs us, after laying bare the urethra,
and  bringing  the staff'  so as  to form a
right angle with  the  patient's body, to
feel that the instrument is fairly lodged
in the  bladder.   The  operator is to use
the fore-finger of his  left hand as  a  di-
rector in feeling  for  the groove in the
staff, and in distinguishing the prostate
gland ; and, with this finger, he is to de-
press the rectum, and  direct the deeper
part of his dissection.   " Feeling* the
gland, with the point  of the fore-finger
of the left hand,  and  the groove of the
staff in the upper part  of the wound, the
assistant is  desired  to steady  his  hand,
and the operator, holding his knife as he
does a writing pen, his fingers an inch
and a half from  the  point,  turns up its
edge  towards  the staff", and strikes its
point  through the  membranous part  of
the urethra into its  groove,  half an inch
before the prostate gland.  He  now turns
the back of the knife to  the staff", slides
it a little backwards and forwards in the
groove, that he may be sure he has fairly
entered; then shifts the  fore-finger, with
which lie  guides the  incision, places  it
under the  knife,  and  carries always  be-
fore the point  of it, to prevent tiie rectum
being wounded;  he then  lateralizes the
knife,  enters  the substance of the pro-
state, is conscious of running the scalpel
through its  solid and fleshy  substance,
and judges, by the finger, of the extent of
the incision, which  he now makes.   The
urine  flows out; he  slips in  the finger
into the opening, withdraws the scalpel, 
188
LITHOTOMY
and gives  it to an  assistant, who hands
him the forceps, which he passes into the
bladder, using the  fore-finger of his  left
hand, which is still within the wound, as
a conductor.   The  forceps  instantly en-
counter the staff, which serves to conduct
them safely into the  bladder, while  the
finger guides them through the wound;"
&c.   (Allan on Lithotomy,  p.  48, Edinb.
1808.)
  I leave the reader to judge,  which of
the foregoing modes of operating with a
knife,  claims  the  preference.    Perhaps
Cheselden's manner, which is  also  Mr.
John Bell's, is  as deserving of recommen-
dation as any.
  Mr. Lawrence has, very obligingly, al-
lowed me to insert  in this  work the fol-
lowing case, in which he  performed li-
thotomy with a common knife, and with-
out any  gorget.  He describes the me-
thod  which he  took, as follows:  " On
the first of December, 1808, I performed
the operation  of lithotomy on  Mr.  Ri-
chard Cooper,  aged 63, in  the presence
of Mr. Crowther,  surgeon  to Bridewell
and  Bethlem  Hospitals,  Air.  Barnes, a
pupil of  St.   Bartholomew's,  and some
other gentlemen.  The patient  was very
fat, particularly  about the  nates and pe-
rinaeum, so that my  tore-finger was buried
beyond the middle joint before I had laid
bare the groove ofthe staff, which I made
a point of doing behind  the bulb of the
urethra, having  always   considered  any
division ofthe bulb to be perfectly useless,
and  even  prejudicial.   I continued the
incision through the prostate, and neck
ofthe bladder, with the same instrument
that was used  for making  the  first  cut,
(a common scalpel,) carried horizontally,
with its back in  the groove of the staff,
until it reached the bladder,  and then
moved  obliquely  outwards  and  down-
wards, so  as to obtain a cut of the requi-
site size in the neck of that viscus.  The
quantity of fat was so considerable, that
I could barely feel the stone with the end
of my fore-finger pushed as high  up as
possible.  I employed the left fore-finger
as a conductor for the forceps, and  ex-
tracted, without the least violence, a stone
measuring five inches in its greatest, and
four in its least, circumference.  Xo un-
pleasant symptom followed the operation,
not the slightest mark  of inflammation,
nor  the least pain, nor tension of the ab-
domen.
  " I have publicly demonstrated to the
pupils of  St. Bartholomew's the mode of
operating with an  ordinary knife,  and
have repeatedly practised  it in  the dead
subject, without  ever experiencing  the
slightest difficulty  in making an open-
ing of any extent that  I wished  into the
bladder.*"                 .
  [It  is not  my intention  in this place
to decide whether the gorget ought to
be renounced in the operation of litho-
tomy and  the scalpel substituted or not;
but I wish  to declare  my  opinion, that
many of  the  accidents which  have oc-
curred  in  this  operation are owing to
the construction of the gorget, the beak
of which prevents the  possibility of ha-
ving an  edge, perfectly  keen,  contigu-
ous to the  beak.  The consequences of
the gorget being dull  at this place,  are,
first,  That the  urethra  is sometimes
thrown into  folds  before  the  blade  of
the instrument, and in this manner  the
beak  is forced out of  the groove in the
staff".   Secondly,  When the  gorget en-
ters tlie  bladder,  it enters  with a jirk
and with more violence  than  the sur-
geon  intended.  A gorget has been con:
structed by Dr. Physlck, in  which this
objection  is entirely obviated, by having
the blade  separable from the beak.  This
instrument is described in the Med. Mu-
seum,  vol. 1 ]

         LITHOTOMY IX WOMEN.

  Women suffer much  less from the stone
than men, and far less frequently stand in
need of the operation of lithotomy.  It is
not, however, that their urine will not so
readily produce the concretions, which
are termed urinary calculi.   The reason
is altogether owing to the shortness, large-
ness,  and very dilatable nature of the fe-
male  urethra; circumstances,  which in
general render the expulsion of the stone
with the urine almost a  matter of certainty.
The records of surgery present us with
numerous instances, where calculi of vast
size  have  been  spontaneously voided
through the meatus urinarius, either sud-
denly without pain,  or after more or less
time  and  suffering.   Heister mentions
several well authenticated examples of
this kind.  Middleton has also related a
case, where a stone, weighing four ounces,
was expelled  in a fit  of coughing, after
lodging in  the passage a week.  Collot
speaks of another instance, where a stone
about as large as a goose's egg, after lying
in  the meatus urinarius  seven  or  eight
days,  and causing a  retention  of urine,
was voided in a paroxysm of pain.  A re-
markable case is related by Dr. Molineux
  • The above patient afterwards died in
a kind of fit; but to all appearances, from
a cause, which had id connexion with the
operation! 
LITHOTOMY.
189
in the early part of the Philosophical
Transactions : a woman voided a  stone,
" the circumference of which measured
the longest way  seven  inches and six-
lenths, and round about, where  it was
thickest five inches  and three-quarters;
its  weight near two ounces  and a-half
troy.
  Sometimes, after the passage of large
calculi, the patient has been afflicted with
an incontinence of urine; but, in general,
this grievance lasts only a short time.
 • The naturally large size and dilatable
nature of the female urethra, have sug-
gested the plan of endeavouring to expand
this passage by various means, so that a
stone in  the bladder may be taken out
with  a pair of forceps, without  having
occasion to employ  any cutting  instru-
ment whatsoever.  This metliod was pro-
posed by Douglas nearly a century  ago,
who  not  only  recommended the use of
sponge for the purpose, but also dried
gentian root, as being more gradual in its ex-
pansion, and better adapted  to the object.
   Mr Broinfield has published the case
of a young girl, in whom he effected the
 necessary dilatation  by  introducing into
 the  meatus urinarius,  the  appendicula
 cocci of .a  small  animal  in a collapsed
 state, and  then filling  it with water  by
 means of a syringe.  The  piece of gut,
 thus distended, was drawn out, in propor-
 tion as the cervix vesicae opened,  and, in
 a few hours, the dilatation  was so far ac-
 complished, that the calculus had room to
 pass out.  (See Chirurgical Obs. and Cases,
  Vol. 2, p. 276.)
    Mr. Thomas very recently- met with a
 case, in which, after dilating the meatus
  urinarius with sponge tents he succeeded
  in  extracting  an  earpicker which lay
  across the neck of the bladder.  The pas-
 sage was so much enlarged, that the left
  fore-finger  was most easily  introduced,
  and  (says this gentleman)  " I believe had
  the case required it, both thumb and fin-
  ger would  have passed into the  bladder,
  without the smallest difficulty." After ad-
  verting to  this, and other  facts,  proving
  the ease, with which the female  urethra
  canrbe  dilated, Mr.  Thomas  remarks:
  " If these relations can be credited, and
  there is no reason why they should not, I
  can hardly conceive any case, in a young
  and healthy female subject, and where
  the bladder is free from disease,  where a
  very large stone may  not  be extracted,
  without the use of  any other instrument,
  than the forceps,  the urethra having first
  been sufficiently dilated by  means of the
  sponge tents.  For this purpose, the blades
  of the forceps need not be so  thick and
  strong, :xi those commonly employed. (See
Medico Chirurgical Transactions, Vol. 1, p.
123—129.)
  Some surgeons  have extracted stones
from the female  bladder in the following
manner:  the patient having been placed
in the position commonly adopted in the
lateral operation, a straight staff, with a
blunt end, is introduced into the  bladdjgr,
through the meatus urinarius.  The anr.
geon then passes along the groove of the
instrument  the  beak of a blunt gorget,
which instrument becoming wider towards
the handle, effects a part of the necessary
dilatation.  The staff' being withdrawn,  \
and the handle of the gorget  taken hold
of with the left,hand, the right fore-finger
with  the nail turned downwards, is now
introduced slowly along the concavity of
the instrument.  When the urethra and
neck of the bladder have thus been sufiir
 ciently dilated,  the finger  is withdrawn,
and a small pair oi' forceps passed into
 the bladder. The gorget is now removed,
 and the stone taken hold of, and extract-
 ed.  (See Sabatier s Medccine Operatoire,
 torn. 2. p. 103.)
   Notwithstanding these  favourable ac-
 counts ofthe practice of dilating the fe-
 male urethra, for the purpose of renloving
 calculi from the bladder, tlie generality of
 surgeons prefer the  plan of  making  an
 incision.  It is certain,  that some patients
 have found the method  insufferably te-
 dious and painful.  But  the strongest ob-
 jection to the practice has arisen from the
 incontinence of urine, which occasional-
 ly follows  any  great  distention  of the
 urethra and neck of the bladder.  Mr.
 Thomas believes, however, that this un-
 pleasant symptom is quite as often a con-
 sequence ofthe operation of lithotomy, as
 now usually performed.   (.Medico  Chirur-
 gical Transactions, Vol. 1, p. 127 )
    Lithotomy on females is much moie easy
 of execution, and less dangerous than the
 same operation  on the male  subject.   It
 may be done in various ways ; but, the sur-
 geons of the present time constantly follow
 the mode of making the requisite opening
 by dividing the urethra and  neck of the
 bladder.   A straight staff,  or director, is
 introduced through the meatus urinarius;
 the groove is turned obliquely downwards
 and  outwards, in a direction parallel to the
 ramus of the left os pubis ; and a gorget,
 or knife, is thus conducted into the blad-
 der,  and makes the  necessary  incision.-
  Some operators prefer the lithotome cache,
  which,  after being introduced,  is opened
  as far as  is deemed proper, and then drawn
  out  with its edge  turned obliquely out-
  wards and downwards.
    The  French surgeons Louis and Flu
  rant, were the invfcntors of particular bis- 
lyO                             LITHOTOMY.
  touries for dividing  both sides of  the
%female urethra at  once. *  The instrument
  of the former effected this purpose, in
  passing from without inwards; that of the
  latter, in passing from  within  outwards.
  Flurant's bistoury bears some resemblance
  in principle  to Frere Come's  lithotome
  cache*, or to the  cutting forceps,  with
  which Franco used to divide the neck of
  the bladder.   The reason, assigned in re-
  commendation of these bistouries, is, that
  they serve to make a freer opening for the
  passage of large stones, than can be safely
  made by cutting only in one direction. At
  present,  however,  they  are never used.
  Were the stone known to be very large,
  Sabatierseems to prefer the apparatus altus.
    A case may present itself, in which the
  posterior part of the bladder drawn down-
  wards by the weight of the stone,  may
  displace  a portion of the  vagina,  and
  make it protrude at the vulva in the form
  of a  swelling.. Here, there would be no
  doubt ofthe propriety of cutting into the
  tumour, and taking out the foreign body
  contained in it. Rousset performed such an
  operation.and Fabricius Hildanus in a case,
  where the stone had partly made its  way
  into the vagina,enlarged the opening, and
  successfully extracted the foreign body.
    M.  Mery  once made  the proposal of
  cutting into the  posterior part  of the
  bladder,  through  the  vagina, after intro-
  ducing a common curved staff; but the
  apprehension of urinary fistulae made him
  abandon the project.
    The existence of extraordinary circum-
  stances may always render a  deviation
  from  the common modes of operating not
  only justifiable, but absolutely necessary.
  Thus, Tolet met  with a case,  where a
  woman had  a prolapsus of the  uterus,
  with  which  the  bladder was  also dis-
  placed.  In the latter viscus, several cal-
  culi  were felt.   An  incision  was  made
  into  it, and  the  stones  extracted,  after
  which operation, the displaced parts  were
  reduced, and a  speedy  cure  followed.
  (Sabutier's Medecine Operatoire, torn. 2,p.
  107.)

      TREATMENT AFTER THE OPERATION.

    If  the internal pudental artery should
  have  been cut, and bleed profusely, the
  best plan is to introduce into the wound
  a piece of firm sponge, with a large can-
  nula passed through its centre.  The ex-
  panding  property of the sponge, on its
  becoming wet, will  make  the necessary
  degree of compression of* the vessel, which
  lies too deeply to be  tied.   The coagula
  should be washed out of the bladder, if
  they should appear to  have lodged in  it,
  by mjenting luke-warm water.
    ' I cannot sav, that it has  fallen  to my
lot to sec many  cases (out of  the  great
number  which I have seen in Bartholo-
mew's Hospital), in which death  could
be imputed to hemorrhage, notwithstand-
ing the bleeding has often been  so pro-
fuse, and from so deep a source, just after
the operation, as to leave no doubt, that
it proceeded  from the internal pudental
artery.   Such hemorrhage generally stop-
ped before the patient was put to bed.
   The majority  of patients who die after
lithotomy, perish of peritoneal inflamma-
tion.  Hence, on  the least occurrence of
tenderness over  the abdomen,  copious ve-
nesection should be put in practice.  At
the same time, eight or ten leeches should
be applied  to  the hypogastric  region.
-The belly should be  fomented, and the
bpwels kept open  with the oleum ricini.
The  feebleness  of  the pulse   should not
deter  the practitioner  from   using  the
lancet;  this symptom is only  fallacious;
and it is attendant on  all inflammation
within the abdomen.  Together with the
above measures, the warm bath, a  blister
on the lower part of the abdomen,  and
emollient  glysters, are highly proper.  I
have seen several old subjects  die of the
irritation of a diseased thickened bladder,
Continuing after the stone was extracted. I
They had not the acute symptoms, the in-
flammatory fever,  the general tenderness
and tension of the abdomen, as in cases of
peritonitis; but they referred  their unea-
siness to the lower part of tlie pelvis; and
 instead of dying in the course of  two or
 three  days, as  those  usually do,  who
 perisht of peritoneal  inflammation, they,
 for the  most part,  lingered for  two or
 three weeks after the operation.  In these
 cases,  opiate  glysters, and blistering
 the  hypogastric  region, are  the  best
 measures.  In  some  instances  of  this
 kind, abscesses form about the  neck of
• the bladder.
    Whoever wishes to acquire a perfect
 knowledge of  the history of lithotomy
 should consult the following works: Celsus
 tie Re Medicd.  lib. 7. cap. 26.   Remarques
 sur la Chirurgie de Chauliac, par M. Simon
 de Mingelouzeaux,  torn. 2;   Bourdeaux,
 1663.  La Legende du Gascon par  Drelin-
 court; Paris, 1665. Van Home's Opuscuia
 Marianus de Lapide Vesicx per Incisionem
 extrahendo; 1552. Paralleledes Differentes
 Manieres de tirer la Pierre hors de la Vessie;
 1730. Sharp's Operations.  Sharp's  Critical
 Enquiry.  Le Dr-an's Operations, Edit. 5;
 London, 1781. Franco's Traite des Hernies;
 1561.  Rosetus  de Partu Cxsario.   Traite
 de la Litholomie, par Tolet.  Heister's Sicr-
 gery,  Part 2.  Lilhotomia Douglassiana;
 1723.  Morand de alto Apparatu. Observa-
 tions sur Id Maniire de Tail/er,&c. pratiquee
 par Frere Jacques;par J. Mery. CourstTO-
perations de Chirurgie par Dionis. Traite de? 
                  LOT

Operations par Garengeot, torn. 2. Morand
Opuscules de Chirurgie.  Bertrandi Truite
den Operations.  Iiulex  SupeUectiiis  Ana-
tomicx Ravianx; Leitlx,  1725.   Le Cat,
liecueildePieces sur I'Operation delaTaille,
Part I.; Rouen, 1749.  Cosme, Recueil de
Pifces Arialomiqy.es importantes sur V Ope-
ration de la Taille;  Paris, 1751—1753. J.
Douglas,  Postscript to Hist, ofthe Lateral
Oper-ation;  1726.   Cheselden'^  Anatomy,
1730; i.ndsubsequent editions.  J. Douglas,
Appendix  to Hist, of the Lateral Operation;
1781. A sfiort Historical Account of Cutting
for the Stone, by W. Cheselden, im his own
last edition of his  Anatomy.  Falconet in
Thes. Chirurg. Halleri ; thes.  103, t. 4, p.
196.  Hartiniceil. Tractatusde Vesicx Uri-
narix calculo, &c. 1785.  Traite Historique
et Dogmatique de I' Operational la Taille par
J.F.L. Descluimps, in four tomes 8vo, Paris,
1796. This last work is a very complete and
full account of tlie subject up to tlie time of its
publication,and well merits a careful perusal.
Richerand's  Nosographie Cliirurgicale,tom.
3, p. 500, &c. Edit. 2.  Levedie's Nouvelle
Doctrine Chirurgicale, torn. 3, p. 533.  John
BelPs Principles of Surgery, Vol. 2. Part 1.
Burns, in Edinb. Med. and Surg. Journal,
January,  1808.  C. Bell's  Operative Sur-
gery, Vol. 1.  1807. Sabatier, de la Medicine
Operatoire, torn. 2,  1796.   Thomson's  Ob-
servations on Lithotomy ; Edinb. 1808.  Al-
lan's Treatise on Lithotomy ; Edinb.  1808.
Earle's Practical Observations on the Stone;
1796. Edit. 2.  (Euvres Chirurgicales de
Desault par Bichat; torn. 2.—For a minute
description and delineations of the parts
concerned in the operation, see  Camper's
Demonstration's  Anatomico -patholoricx,
Ub.2.                             S
   LOTION,  (from lavo, to wash.)  Lotio.
An external fluid  application.   Lotions
are usually  applied by wetting  linen in
them, and  keeping it  on tiie  part af-
fected.
   The following are some of the most
useful in the practice of surgery.
   LOTIO  ALUMINIS.—*.  Aluminis
purif. ^ss.  Aquae distillatae lbj. Misco.—
Sometimes used as an astringent  injec-
tion ; sometimes as an application  to in-
flamed parts.
  LOTIO AMMON1JE  ACETATiE.—
iy. Aquae  ammon.   acetatae;  Spirit, vin.
rectif.; Aquae distillatae; sing. giv. Miscev
—Properties discutient.
  LOTIO  AMMONLfi  MURIATE.—
fy. Amnion, iiiuriatae ^j.  Spirit,  rorisma-
rini lbj.—Has  the same  virtues as  toe
preceding.  Justamond recommended, it
m the early stage of the milk-breast.
   LOTIO  AMMONUE   MURIATVE
CUM ACETO.—y. Ammon. Mur. :§ss.
Aceti,  Spirit,  vinos, rectif.  sing.  Itij.
Misce. This is one of tlie most efficacious
                LOT              191

 discutient  lotions.   It is, perhaps, the
 best application for  promoting the ab-
 sorption of extravasated  blood, in cases
 of ecchymosis, contusions, sprains, &c.
   LOTIO  AMMON LE  OPIATA—9,.
 Spiritus ammon. comp. ^iiiss.  Aquae dis-
 tillatae  ^iv.  Tinct.  Opii gss. Misce.—
 Applied  by Kirkland to  some suspicious
 swellings in  the  breast, soda and bark
 being also given internally.
   LOTIO  CALCIS  COMPOS1TA.—9,.
•Aquae calcis ibj. Hydrargyri  muriati 3J.
 Misce.— Properties  strongly  astringent.
 Ring-worms,  tetters, and some other cu-
 taneous  affections yield to this applica-
 tion, which, however, should generally be
 diluted.   In the latter state, it may occa-
 sionally be used as an injection for various
 purposes.
   LOTIO  GALL^:— *. Gallarum con-
 tusarum  t^ij.  Aquae ferventis  lbj.  To
 be macerated one  hour,  and strained.—
 This astringent lotion is sometimes used
 with a view of removing the relaxed state
 of the parts,  in cases of prolapsus ani,
 prolapsus uteri, &c.
   LOTIO  HYDRARGYRI   AMYGDA-
 LINA.—%.  Amygdalarum amararum 2ij.
 Aquae distill, fbij.   Hydrarg.  mur. £j.
 Rub down the almonds with water, which
 is to be gradually poured on them; strain
 the liquor, and  then  add the  muriated
 mercury.  This will cure several cutane-
 ous herpetic affections.
   LOTIO  HYDRARGYRI   MURIATI.
 8<. Hydrargyri  muriati g.  ijss.  Arabici
 gummi gss. Aquae distillatae  ibj. Misce.
 —This is the  injection of corrosive subli-
 mate in use at St. Bartholomew's Hospital. -
    LOTIO  HYDRARGYRI  MURIATI
 COMPOSITA.—*.  Hydrarg.  mur. g. x.
 Aq. distillat.  bullientis 3iss.  Tinct. can-
 thar. 3"ss. Misce.—This was  ordered by
 Dr, H. Smith, to  be applied every night
 to scrophulous swellings.
   LOTIO HELLEBORI  ALBI— *. De-
 cocti hellebori albi tbj.  Kali sulphura-
 ri  3ss.   Misce.—This  is  occasionally
 employed as  an  application  for curing
 tinea capitis,  and  some  other cutaneous
 diseases.
    LOTIO  KALI   SULPHURATI.—j,.
 Kali sulph.  sjij.   Aqux distill, ibj. Misce
 —It is used in the same cases as the pre-
 ceding  one.
   LOTIO  LITHARGYRI  ACETATI —
 tje. Aquae litharg. acet. Jij.  Aq. distill.
 Ibij. Spirit, vinos, tenuioris 31J.  The first
 and the last ingredients are to  be mixed
 before the water is  added.
   This is the  common  whitewash,  an ap-
 plication that is so universally known as
 the usual saturnine application  in cases
 of inflammation, &c. that  we  need say
 nothing  more concerning it. 
192              L U M                               L U M
   LOTIO  OPrf.-—*. Opii  purif.  3JSS.
 Aquae distillatae tbjA Misce.—A very ex-
 cellent application to irritable painful ul-
 cers  of every  description.  It is best to
 dilute it, especially  at first.
   LOTIO  FICIS.—9t. Picis liquids  giv.
 Calcis gvj. Aquae ferventis ibhj —To be
 boiled till half the  water  is evaporated.
 The rest is then to be poured off for use.
 This  application is sometimes employed
for the cure of tinea  capitis ; it is also of
 singular service in removing an extensive
 scorbutic redness, frequently seen on the
 legs,  together with old ulcers.
   LOTItf   ZINCI   VITRIOLATI.—*.
 Zinci  Vitriolati  3j.  Aq. ferventi lbj.
 Misce.  This is sometimes used by  prac-
 titioners in lieu of the  lotio aq. litharg.
 acet.  The free  external  application of
 lead  has sometimes been  suspected of
 bringing on bad  effects, in consequence
 of absorption; and some surgeons, there-
 fore, advise the employment of this lotion
 instead  of it,  which in all probability,'
 also, is equally efficacious. When diluted,
 by adding two pints  more water, it forms
 the common injection, so  much recom-
 mended iu  cases of gonorrhoea,
   LUES VENEREA.  Venereal disease.—
 Sec this sirticlc
   LUMBAR ABSCESS.   Psoas Abscess.
 By these terms are  understood chronic
collections  of matter, which form in the
 cellular substance of the loins, behind the
peritonaeum, and descend in the course
ofthe psoas muscle.  Patients in the in-
 cipient stage ofthe disease, cannot  walk
 so well as  usual; they  feel a degree of
 uneasiness about the lumbar region; but
 in general,  there has been no acute  pain,
even  when the  abscess   has  acquired
 such a size as to form a large  tumour,
 protruding externally. In short, the psoas
 abscess  is the best  instance,  which can
possibly be adduced, in order to illustrate
 the nature  of those collections of matter,
which are called chronic, and which form
 in an insidious manner,  without; serious
 pain,  or any other attendant of acute in-
 flammation.
   The abscess sometimes forms a swelling
 jLuve Poupart's ligament;  sometimes be-
 low it; and frequently the matter glides
 under the fascia of the thigh.  Occasion-
ally,  it makes its way through tlie sacro-
ischiatic foramen, and assumes rather the
appearance of a fistula in ano.  When the
matter gravitates into the thigh, beneath
the fascia, Mr.  Hunter would have term-
ed it a disease in, not of, the part.   Tlie
 uneasiness  in the loins, and the  impulse
communicated to the tumour by coughing,
evince, that the disease arises in the lum-
 bar region ; but, it must be confessed, that
 '.v can hardly ever know the existence of
the disorder, before the tumour, by pre.
senting itself externally, leads us to such
information. The lumbar abscess is some-
times connected with diseased vertebrw,
which may either be a cause,  or an effect,
ofthe collection of  matter.—The disease,
however, is frequently  unattended  with
this complication.
  The disease of the spine, we may infer,
is not of the same  nature as  that treated
of by  Pott, as there  is usually  no paralysis.
When the bodies of patients with lumbar
abscesses  are  opened, it  is  found, that
the matter is  completely  enclosed in a
cyst, which, in many cases, is ef course,
very extensive.  If the contents of such
abscesses were not circumscribed  by a
membranous boundary in this manner, -we
should have them spreading among the
cells of the cellular substance, just  like
the water  in  anasarca.   The cysts are
both secreting and absorbing surfaces, as
is proved by the great quantity of matter,
which soon collects  again after the ab-
scess  has been emptied, and by the occa-
sional disappearance  of large  palpable
collections of matter of this kind, either
spontaneously, or in consequence of means
which are known to operate  by exciting
tlie action of the absorbents. ' In short,
the cyst becomes the suppurating surface,
and suppuration is  now well ascertained
to be  a process,  similar to glandular se-
cretion.  While the abscess  remains'un-
opened, its contents are always undergoing
a change ;  fresh  matter»is  continually
forming, and a portion of what was in the
cyst  before, is undergoing an incessant
removal  by the absorbents.   This is not
peculiar  to lumbar abscesses; it is com-
mon to alt  both chronic and acute, bu-
boes  and suppurations in general.  It is
true,  that, in acute abscesses, there often
has not been time for the formation of so
distinct a membrane as the cyst of a large
chronic abscess; but its matter is equally
circumscribed by the cavities of the cel-
lular  substance being filled with  a dense
coagulating lymph;  and  though it ge-
nerally soon makes way to the surface, it
also is occasionally  absorbed.,
  The best modern surgeons, make it a
common maxim  to open  very few acute
abscesses ; for, the  matter naturally tends
with great celerity  to the  surface of  the
body,  where ulceration allows  it to es-
cape  spontaneously;  after  which,   the
case generally goes on better,  than if it
had been opened by art.   But, in chronic
abscesses,  the matter has not that strong
tendency to make  its way outward; its
quantity is  considerably increasing;  the
cyst  is,  of course, incessantly growing
larger and larger;  in short,  the matter,
from one ounce, often gradually increases 
LUMBAR ABSCESS
193
to die quantity of a gallon.   When tlie
disease is at length opened,  or bursts by
ulceration,  the surface  of the cysts, irri-
tated by  the change,  inflames; and  its
great extent,  in this circumstance,   is
enough to account for the terrible consti-
tutional disorder, and fatal consequences,
which  too   frequently  soon follow the
evacuation of the contents of such an ab-
Bcess.  Hence, in cases of chronic suppu-
rations of every kind, and not merely  in
lumbar ones, it  is tiie surgeon's duty  to
observe the opposite rule to  that appli-
cable to  acute cases;  and he  is called
upon to open the collection of matter,   as
soon as he is aware of its existence, and
its situation will ullow'it to be done.
 . Certainly, it would  be highly advan-
tageous to have some means of ascertain-
ing whether the vertebrae are  also dis-
eased ; tor,  as in this instance, tlie morbid
bones would keep up  suppuration,  until
their affection,  had ceased,  and there
would be no  reasonable  hope of curing
the abscess sooner, it might be better  to
avoid puncturing it under such circum-
stances.  The  propriety of this conduct
teems the more obvious, as issues, which
are the means  most likely to stop and re-
move the disease of the  spine, are also
such as afford most chance of  bringing
about the absorption of the abscess itself.
However, if the collection cannot be pre-
vented from discharging itself, and  ul-
ceration  is at  hand, it is  best to meet the
danger,  make an opening with a lancet,
in a place at some distance from where
the pointing threatens,  and afterwards
heal it, in the  way we shall presently de-
tail.
  Though  we have praised tiie prudence
of opening all chronic  abscesses while
small,  the deep  situation of the lumbar
one, and the degree of doubt always  in-
volving its early state, unfortunately pre-
vent us from taking this beneficial step
in the present case.  But, still the prin-
ciple is equally praiseworthy, and should
urge us to  open the tumour as soon  as
the fluctuation of the matter is  distinct,
and  tlie  nature  of the case is  evident.
For this purpose, Mr. Abernethy employs
an abscess  lancet,  which will make an
opening large  enough for the discharge
of those  flaky  substances so  frequently
found blended  with the matter of lumbar
abscesses, and  by some conceived to be an
emblem of the disease being scrophulous.
Such flakes seem to consist of" a part  of
the coagulating matter  of the blood, and
are very commonly secreted by the pecu-
liar cysts of scrophulous abscesses.  The
puncture must also be of a certain size, to
allow the  clots of  blood,  occasionally
mixed with the  matter, to escape.   Mr.
     Vol. If.
Abernethy considers  the opening  of a
lumbar abscess, a very delicate operation.
Former surgeons used to make large open-
ings in these cases; let out the contents;
leave the wound open;  the  usual conse-
quences of which were, great irritation
and inflammation of the cyst; immense
disturbance  of the constitution;  pui re-
faction of the contents of the abscess, in
consequence of the entrance of air  into
its cavity, and, too often, death.  While
such practice prevailed,  very few afflict-
ed with lumbal- abscesses, were fortunate
enough to escape.  Tlie same alarming
eff'ects resulted from allowing the abscess
to attain its utmost magnitude, and then
burst by ulceration.  If then a more hap-
py train of events depend upon the man-
ner, in which lumbar abscesses are punc-
tured,  tiie operation is certainly a matter
of great delicacy.
  Until  the  collection is  opened,  or
bursts, the patients health  is usually
little, or not at all impaired; indeed, we
see in  the faces  of many  persons  with
such abscesses, what  is usually under-
stood by the  picture of health.   Hence,
how likely our professional conduct is to
be arraigned,  when great changes for the
worse, and even death,  occur very soon
after we have  let out the matter,  seem-
ingly,  and truly, in  consequence of the
operation.  Every plan,  therefore, which
is most likely to prevent these alarming
effects, is entitled to infinite praise;  and
such, I conceive, is the practice recom-
mended by Mr. Abernethy.
  This gentleman's method is to let out
the matter,  and heal the Wound immedi-
ately afterwards by the  first intention.
He justly  condemns all introductions of
probes, and   other instruments, which
only irritate the edges of the puncture,
and render them  unlikely to grow toge-
ther again.  The wound is to be  care-
fully closed with sticking plaster, and it
will almost always heal.
  Doing this,  does not  put a stop to the
secretion of matter within the cavity of
the abscess.   Of course,  a fresh accumu-
lation  takes  place; but, it  is  obvious
that the matter, as fast as it is produced,
will gravitate to the lowest part of the
cyst, and, consequently, the upper part
will remain  for a certain  time undis-
tended, and liave an opportunity of con.
tracting.
  When a certain quantity of  matter has
again accumulated, and  presents itself in
the groin, or elsewhere,  which may  be in
about a fortnight after tlie first puncture,
the abscess is to be punctured again, in
tlie  same manner as before,  and  the
wound  healed m the  same  way.  The
quantity  of matter will  now be  found
     B « 
194
LUMBAR ABSCESS.
much less, than  what was at first dis-
charged   Thus the abscess is to  be re-
peatedly punctured  at  intervals, and the
wounds' as regularly healed by the first
intention,  by  which  method,  irritation
and inflammation of the cyst will not be
induced, the  cavity of the  matter will
never be allowed to  become  distended,
and it will be rendered  smaller and small-
er, till the cure is complete.
  In a few instances, you may, perhaps,
be unable to persevere  in  healing the  re-
peated punctures it may be necessary to
make ; but,  after  succeeding once  or
twice, the cyst will probably have enjoyed
sufficient opportunity to have  contracted
itself so much, that its surface will not
now  be of alarming  extent.  It is also a
fact, that  the  cyst loses  its irritability,
and becomes more indolent,  and less apt
to inflame, after the contents have been
once or twice  evacuated,  in  the  above
way.  Its disposition to absorb becomes
also stronger.
  The knowledge  of the fact, that the
cysts of all  abscesses  are absorbing sur-
faces, should  lead  us never to neglect
other means,  which Mr. Abernethy sug-
gests, as likely to promote the dispersion
of the abscess, by quickening the action
of the absorbents.   Blisters kept  open
with savine cerate, issues,  electricity, oc-
casional vomits of*  zincum  vitriolatum,
are the means most  conducive to this ob-
ject.  When the vertebrae are diseased,
issues are doubly indicated*
  In the latter  complication,  the case is
always dangerous.  If  an opening should
have been made in the abscess, the cyst is
at first more likely  to  be  irritated, than
when the bones are  not diseased, and the
affection of tiie spine  is rendered much
less  likely to undergo  any improvement,
in consequence of the mere formation of
an outward  communication.  The same
bad  effect attends   necrosis;  in which
case, the  absorption  of the dead  bone
is always retarded by tite presence of un-
healed fistulae and sores, which lead down
to the, disease.
  Mr.  Crowther  has  succeeded  in dis-
persing some large lumbar abscesses with-
out opening them Large blisters, applied
to the integuments covering the swelling,
and  kept  open with the  savine  cerate,
effected the cure.  When this  gentleman
punctures such collections of matter,  he
uses a small trocar, which he introduces
at the same place as often as  necessary.
He observes,  that the aperture so made
dpes not ulcerate, and allows no matter
to escape after  being dressed.   I cannot,
however, discover any  reason for his pre-
ferring the trocar to the  bscess  lancet,
except that the cannula enables  the sur-
geon to push back with a probe any flakes
of lymph,  &c  which  may obstruct  its
inner orifice.  But,  this is scarcely a rea-
son, when   Mr. Abernethy informs us,
that the  opening, made with  an abscess
lancet, is  large  enough to allow  such
flakes to  be discharged; and,  when they
stop up the aperture, a probe might also
be employed   to push them   back.  A
wound made with a cutting instrument
will, cxteris paribus, always more certain-
ly unite, by the first intention,  than one
made  with such an  instrument as a tro-
car.  Mr. Crowther may have succeeded
in always healing the aperture;  but, 1 do
not  believe,   that  other   practitioners
would  experience equal success.  Were
the tumour  not  very prominent,  from
the quantity of matter  being small, sud-
denly   plunging in  a trocar might even
endanger parts, which should,  on no ac-
count, be injured.
  Some writers recommend opening lum-
bar abscesses with a seton.  Tiie matter
being made to form as  prominent a swell-
ing as possible, by pressing the abdomen,
and putting  the patient  in a position,
which will  make the contents of the ab-
scess gravitate towards the part where the
seton  is to be introduced, a transverse cut
is first to be made  in  the integuments
down  to  the fascia.   A flat trocar is next
to be introduced  within   the  incision,
which  should only be just  large enough
to allow  the instrument to pass  freely
up  under the  skin, for at least  three
quarters  of an inch;  when  the   hand
is to be  raised, and the  trocar pushed
obliquely and  gently  upwards, till the
cannula  is  within the lower part of the
sac.  The  trocar must  now   be   with-
drawn, and the matter allowed to flow
out gently,  stopping it  every now and
then for some minutes.  The  assistant
must  now  withdraw  his hand, to take
away the pressure, and the thumb of his
left hand upon the  opening of the can-
nula,  holding  it  between  his  fore and
middle fingers.  It must then be pushed
upward,  nearly to the top of the tumour,
where its end may be distinctly felt with
the fore-finger  of  the  right hand.  As
soon as it can be  plainly felt,  it must be
held steadily  in the same  position, and
the trocar  is to  be introduced into  it
again,  and pushed  through the skin,  ?t
the place where it is felt, and the cannula
along with it.  The trocar being next
withdrawn,  a probe, with a skein of fine
soft silk,  dipped in  oil, must  be passed
through  the cannula,  which being now
taken away leaves the seton in its place.
A pledget of a  mild  ointment  is then to
be applied  over  the two  openings, tLi
more  completely to exclude the s.ir   A 
MAM
MAM
195
Ircsh piece of the silk is to be drawn into
the abscess, and that which was in before,
cutoff, as ot'u.n as necessary.  (See Latta's
System of Surgery, Vol. 3. p, 307.)
  Mr.  Crowther states,  that  Deckers,
who  wrote in 1696, discharged  a large
abscess, in a  gradual manner,   with  a
trocar, the cannula of which was not with-
drawn, but was stopped up  with a cork,
and  the latter  let  out at intervals.   B.
Bell  also  advises the cannula not to  be
taken out.
  1 cannot quit this  subject without men-
tioning a remarkable case of lurnoar ab-
scess, which I  lately saw in Christ's Hos-
pital, under the  care of  Mr. Ramsden.
The tumour extended from the ilium and
sacrum below, as high  up  as the ribs.
The diameter  of the swelling, from  be-
hind forward, might  be   about  six   or
eight inches.  It was attended with  so
strong  a pulsation, corresponding with
that  Of the  other arteries, that  several
eminent surgeons in this city considered
tlie case  as an  aneurism of the  aorta
After some  weeks, as the  tumour   in-
creased in size,  the throbbing of  the
whole  tumour gradually  became fainter
and  fainter, and, at length, could not be
felt at all.  The tumour  was nearly on
the point of bursting.'  Mr. Ramsden sus-
pected, that it was an abscess, and deter-
mined to make a  small puncture in it.
The  experiment verified the accuracy of
his opinion ; a large quantity of pus was
evacuated at  intervals;  but,  the  boy's
health suffering, he went to his friends at
Newbury, and I have not yet heard the
event.  I have never  seen any popliteal
aneurism, whose pulsations could be more
plainly seen and strongly felt,  than  those
ofthe abscess we have just been describ-
ing.   The  rationale I must leave to the
speculative reader.
   I  shall conclude with  expressing my
decided preference to  Mr. Abernethy's
plan of treating lumbar abscesses.
   Consult Abernethy's  Surgical and Physio-
logical Essays, Part 1. and 2.  CrowtIter's
Observations on White Swelling, He  1808.
Lotto's System of Surgerv,  Vol. 3.
   LUNAR CAUSTIC. "  See  Argentum
Nitratum.
   LUXATION, (from luxo, to put out of
joint.)  A dislocation. See this word.
M.
     MAMMA,  REMOVAL  OF.   The
       operation of cutting  away a dis-
 eased  breast, is done nearly  in the same
 manner as the removal of tumours in gene-
 ral,  and is indicated whenever the part is
affected with an incurable disease, which
 admits, however, of being  entirely  re-
 moved with the knife.   When the breast
 is affected  with scirrhus, or ulcerated
 cancer, the  imprudence of tampering
 with the  disease cannot be  too severely
 censured.  Were the disorder unattend-
 ed with a continual tendency to increase,
 some time might properly be dedicated to
 the  trial  of. the internal remedies, and
 external  applications,  wh^ch, have  ac-
  auired any  character for  doing good in
  lese unpromising  cases.  But, unfortu-
 nately, by endeavouring to cure  the dis-
 ease by medicine, we only afford time for
 it to  increase  in   magnitude,  and, at
 length, to attain a condition, in which
 even the  knife cannot be employed so as
 to take away  the whole of the diseased
 parts.  When the case is marked by those
 characteristic features, of scirrhus, which
 are  noticed  in the article  Cancer,  the
 sooner the tumour is cut  out, the better.
There are also  some malignant kinds ot
sarcoma, to which  the female breast is
subject, (as will be explained in the ar-
ticle Tumour^  which cannot be removed
at too early a period after their nature is
suspected,  or  known.  Indeed,  though
there is not  equal urgency for the opera-
tion when the tumour is only an indolent,
simple,  fatty, or sarcomatous disease, yet,
as all these tumours are continually grow-"
ing larger, and  little success attends the
attempt to disperse them, the practitioner
should never devote  much time to the
trial of unavailing  medicines and appli-
cations, and let  the swelling attain a size,
which would require a formidable opera-
tion  for  its excision.   Besides,  every
simple, fleshy, or fatty tumour, is always
accompanied with  a certain  hazard of
changing into a malignant, or cancerous
one.
   Certainly, there   are many  swellings
and  indurations of the breast, which it
would  be  highly  injudicious and unne-
cessary to extirpate, because they  gene-
rally admit of  being discussed.   Such
are many tumours, which are called schro-
phulous, from  their affecting patients of 
196
MAMMA.
this peculiar constitution; such are near-
ly all  those  indurations,  which remain
after a sudden and general inflammatory
enlargement of the mamma;  such  are
most other tumours, which acquire their
fuil size in a few days,atte.ided with pain,
redness,  &c; and, of this kind, also, are
the hardness in the breast, occasioned by
the mammary abscess.
  In the  removal of all  tumours, their
malignant or cancerou* nature makes it
nece>sary to observe one important cau-
tion in the operation, vii. not to rest sa-
tisfied with cutting away the  tumours
just at their  circumference;  but to take
away also a considerable portion of the
substance, in  which they lie, and with
which they are surrounded.   In  cutting
out  a cancerous breast,  if the operator
were to be content with merely dissecting
out  the disease, just where his eyes  and
fingers might  equally  lead him  to sup-
pose  its  boundary  to be  situated, there
would still be left behind white diseased
bands, which  radiate   from  the  tumour
into the surrounding fat, and which would
inevitably occasion  a relapse.   In a vast
proportion of  the  cases  also, in  which
cancer of the breast unfortunately recurs
after the operation, it is  found, that the
skin is the  part, in which  the disease
makes  its  reappearance.   Hence,  the
great prudence of  taking away a good
deal of it in every case suspected to be a
truly  scirrhous or  cancerous  disease.
This may also  be done so as not to pre-
vent the important objects of uniting the
wound  by the first intention, and cover-
ing  the  whole  of its surface with sound
integuments.  So frequently  does cancer
recur in  the nipple, whenever it does  re-
cur any where,  that many of the best mo-
dern operators always  make a point of
removing this part  in   every instance, in
which it is judged expedient to take away
any portion of the skin  at all.  The  sur-
geon, indeed, would be  inexcusable, were
he to neglect to take away such portion
ofthe integuments covering scirrhous tu-
mours, as is evidently affected,  appearing
to be discoloured, puckered, and closely
attached  to the diseased lump beneath.
Nor should any  gland,  in the axilla, at all
diseased, nor any fibres of the pectoral
muscle,  in the same state, be ever left be-
hind.  There is no  doubt, that nothing
has  stamped operations for cancers with
disrepute, so much as the neglect to make
a free removal 0$ the skin, and parts sur-
rounding every side of }he tumour. Hence
the  disease has 'frequently  appeared  to
recur, when, in fact,  it  had uever been
thoroughly extirpated; the disea-e, though
entirely a local affection,  has been deem-
ed a constitutional one:  and the operation
frequently rejected as ineffectual and use-
less.
  But, strongly as 1 have urged the pru-
dence, the necessity of making a free re-
mova) of  the skin covering, and of the
parts  surrounding, every  cancerous or
malignant .tumour, the same  plan  may
certainly be regarded as  unnecessary,
and, therefore, unscientific, in most oj*'-
rations for the  removal of simple,  fatty,
or fleshy tumours.  However, even in the
latter  cases, when the swelling is very
large, it is better  to take away a portion
of skin;  for, otherwise, after tiie excision
of the tumour, there would be a redund-
ance of integuments, the cavity of which
would only  serve for  the lodgment of
matter.  The loose superfluous skin also
would lie in folds, and not apply  itself
evenly to the parts beneath, so aa to unite
favourably by tiie first intention; nor could
the line of the  cicatrix itself be arranged
with such  nice evenness as it  might be,
were a part of the redundant skin  taken
away at the time of operating.
   The best method  <>f removing a di$-<
eased  breast is as  follow?: The patient
is usually placed in a sitting posture, well
supported by pillows and assistants; but
the  operator would find  it equally con-
venient,  if not  more so, to remove the tu-
mour  with  bis patient in  a recumbent
position ; and it certainly is better  when*
ever the operation is likely to be long, or
much blood to be lost,  which circum-
stances are  very apt to bring on fainting.
1 remember, that Mr. Abernethy,  in his
lectures, used to recommend the latter
plan;  which, however, without the sanc-
tion of any great name, or authority, pos-
sesses such obvious advantages, as will
always entitle it to approbation.
   The arms should be confined back, by •
placing  a  stick  between them and the
body, by which means, the fibres of the
great pectoral  muscle will be kept  on the
stretch,, a state most  favourable for the
dissection of the  tumour off its surface.
The stick also prevents the patient from
moving her arm about, and interrupting
the progress of the operation.
   When the  tumour  is not large, and
only a simple sarcoma, free from  malig-
nancy, it will  be quite unnecessary to re-
move any  of  the  skin, and,  of course,
this need only be divided by one incision,
of a length proportionate to the tumour.
The cut must be made with a common
dissecting  knife;  and, as the division of
 the parts is chiefly accomplished with the
part of  the edge towards the point, the
instrument will be  found to do its  office
best when  the extremity of the edge  is
made of a  convex shape, and this part of
the blade is turned  a little back,  in the 
MAMMA.                              197
way in  which dissecting knives are now
often constructed.   The direction of the
incision  through the skin should be made
according to toe greatest diameter of the
tumour  to be removed, by which means it
will be most easily dissected out.
  The direction of the incision is various
with ditfereut practitioners; some making
it perpendicular, others transverse.  In
grneral, the shape of the tumour must de-
termine which is the best.  In France,  it
h%s been said, that  when the  incision fol-
lows the second direction,  it heals more
expeditiously, because the skin is more
extensible from above downward, than la-
terally,  particularly  towards the sternum,
and, consequently allows the sides of the
wound the more readily to he  placed in
contact; and that the action of the pecto-
ral muscle tends to  separate the edges of
the wound when it is perpendicular.  On
the other  hand,  it is  allowed, that the
wound,  made in the latter  manner, is the
most  favourable for the escape of the dis-
charge,  if suppuration should occur. (See
Default  fiar Bichat,  p. 312. Tarn. 2.)
  The cut through the  skin should always
be somewhat longer than the tumour; and
as it is,  perhaps, the most painful part of
the operation, and one attended with  no
danger  whatever, it should be executed
with the utmost celerity. Pain is certainly
more or less to be dreaded, according to
its duration.  The fear, however, of giv-
ing pain has probably led many operators
to err,  by not making  their first  incision
through the integuments  large enough,
tlie consequence of which has often been,
that there was not room enough to get at
the tumour so as to dissect it out with fa-
cility ;  the patient has been kept nearly
an hour in the operating room,  instead of
five minutes, and the surgeon censured by
tlie spectators, as awkward and  tedious.
It is  clear, also, that, besides the great
deal more bkiod lost, from this error, than
would otlierwise happen, the vessels being
commonly  not tied  till all  the cutting is
finished, the  avoidance of pain, that fear,
which led to the blunder, is not effected,
and tlie patient suffers much  more, and
for a  much longer  time, in consequence
of the embarrassment and obstacles in the
way of the whole operation.
  When the disease is of  a scirrhous or
malignant nature, the  skin covering the
tumour  should, at all events,  he  in part
removed.   As I have said before, all that
portion  which is  discoloured, puckered,
tubci-cutated, or otherwise altered, should
be taken away.  Some must also be re-
moved,  in order to preveut a redundance,
in all  c;is-s in which the tumour is1 large.
We h;as -aid too, that  in cases of scirrhus
and cancer of the breast, the nipple is con-
sidered a dangerous part to be left behind.
For the purpose of removing the neces-
sary portion of skin, the surgeon must ob-
viously pursue a different mode from that
above  described; and, instead  of one
straight incision, he is to make two semi-
circular ones, one immediately after the
other,  and which are to meet at their ex-
tremities.  The size of these wounds must
be determined by that of the disease to be
removed,  and by  the quautity of skin,
wh^ch  it is deemed prudent to take away ;
for the part, which is included in the two
semicircular cuts,  is that which  is not to
be separated from the upper surface of
the swelling, but taken away with it. The
shape, of the two cuts  together may ap-
proach that either of a circle or  oval, as
the figure of the tumour itself may indi-
cate, as most convenient.  The direction
of the  incisions is to be regulated by the
same consideration.
  In the above ways, the first division of
the integuments is to be made in removing
tumours of every description, covered with
skin.   The same principles and  practice
should prevail in all these operations; and,
whether tlie swelling is the mamma, or any
other diseased mass, whether situated on
the chest, the  back, the head, or extremi-
ties,  the same considerations  should al-
ways guide the operator's hand.
  The  incision, or incisions, in the  skin
having been made, the next object is to
detach every side of the tumour  from its
connexions, and the separation of its base
will  then be  the  last  and  only thing re-
maining to be done.  When the tumour
is a scirrhus, or other malignant disease,
the operator must not dissect close to the
swelling, but make his incisions on  each
side, at a prudent distance from it, so as
to be sure to.  remove, with the diseased
mass, every atom of morbid mischief in its
vicinity.  But, when the tumour is only a
mere fatty, or other mass,  perfectly free
from malignancy, the  cellular bands and
vessels  forming its connexions, may  be
divided close to its circumference.  It is
astonishing with what ease fatty tumours
are removed, after the necessary  division
is made in the  skin ; they may almost  be
turned out with the fingers, without  any
cutting at all.   When they have been in-
flamed, however, they are then more ad
herent  to the surrounding parts.
  Thus we see, that the first 6tage ofthe
operation of removing a tumour, is the di-
vision of the skin ; the second, the sepatj
ration of the swelling from  the surround-
ing parts on every side; the  third and last
stage is the division ofthe parts to which
its under surface, or base,-is attached. 
198
MAMMA
 The latter object should be accomplished
 by cutting  regularly  from above  down-
 ward, till every part is divided.
    It is a common thing to see many ope-
 rators  constantly  embarrassed  and con-
 fused,  whenever they have to remove a
 large tumour, on account of their having
 no particular method in their proceedings.
^ They first cut a  few  fibres on  one side,
 'then on another; and, turning the mass of
 disease now to this side, now to that, with-
 out  any fixed design, they both prolong
 the operation very tediously,  and present
 to the bystanders a complete specimen of
 surgical awkwardness.  On the contrary,
 when the practitioner divides the cutting
 part ofthe operation into the three method-
 ical stages, above recommended, in each of
 which there is a distinct object to be ful-
 filled,  he proceeds with  a confidence of
 knowing what he is about, and soon effects
 what is to be done, with equal expedition
 and adroitness.
    Having taken out the tumour, the ope-
 rator is immediately to tie such large ves-
 sels as may be pouring  out their  blood ;
 indeed, when the removal ofthe swelling
 wjll necessarily  occupy more than three,
 or four minutes, it is better to tie  all the
 large arteries as soon as they are divided,
 and then proceed  with their dissection.
 This was the celebrated  Desault's plan,
 and it is highly deserving of imitation in
 this country, not only because many sub-
 ejects cannot afford  to lose much blood,
 but also because  the profuse effusion of
 this fluid keeps the operator from seeing
 what parts  he is dividing^
    The  largest  arteries being  tied,  the
  surgeon should  not be immediately solici-
  tous' about tying  every  bleeding point
  which may  be observed.  Instead of this,
  let him  employ a little while in examining
  every part ofthe surface of the wound, in
  order to ascertain that no portion of the
  swelling, no hardened lump, nor diseased
  fibres  remain behind.  Even if any part of
  the surface of the pectoral muscle should
  present a morbid feel,  or appearance, it
  must, on every account,  be  cut away.
  Also, if any ofthe axillary glands are dis-
  eased, the operator should now proceed to
  remove  them.   After  the time spent in
  such measures', many of the small vessels,
  which bled just after the excision of  the
  swelling, will now have stopped, the  ne-
  cessity for  several ligatures  will be done
  away, and, of course, the patient saved
  a great  deal of  pain,  and more of  the
  wound be likely to heal by the first inten-
  tion.
    Some information  may be derived, re-
  specting whether any of the tumour is
  left behind,  by examining its surfaces,
  when taken out, and  observing whether
any part of them is cut oft'; for, if it is, it
may always be found in the corresponding
part of tlie wound.
  The axillary glands  may  always  be-
taken out, without  the least risk, if the
plan pursued by  Desault in France, and
Sir Charles  Bhcke, and  other  eminent
surgeons in this country, be adopted. The
method alluded to, is,  after dividing the
skin covering the gland, and freeing- the
indurated part  from  its lateral  connex-
ions,  to tie its root, or  base, with which
it is connected with the parts on  the side
towards the cavity of the axilla. Then the
indurated gland itself may be  safely cut
off,  just  above the ligature.  Were the
gland cut off in the first instance, the ar-
tery which supplies it with blood, would
be exceeding difficult to tie, on account of
its deep situation; and, by reason of its
shortness and  vicinity to the heart,  it
would bleed  almost like a wound of the
thoracic artery  itself.   In this way,  there
is also not the least hazard of injuring the
latter ves.'-l   It would be a great im-
provement in the mode of operating  lor
the removal of these glands, if surgeons
were always to make the patient lie down,
with the arm placed in such a position as
would let the  light fall  into the axilla.
How much  the  steps of the operation
would be facilitated in this way, I need
not attempt to  explain.
   The above directions will enable a sur-
geon to remove tumours in general.  They
apply also in a  great  measure to encysted
lumours ,■  but,  a few particular rules how
to  operate in  the latter  cases, will  be
 found in that article.   One half of each
 ligature is always  to be cut  off before
 dressing the wound.   The edges of the
 incision are to  be brought together with
 strips of  adhesive plaster; and,  before
 this can be done with ease, the stick con-'
 fining the arm back must be removed, and
 the os brachii  brought forward,  so as to
 relax the  pectoral  muscle, and integu-
 ments of the breast.  No sutures should
 ever be employed, as they are useless,
 painful, and irritating. The wound being
 closed with sticking plaster, and  a pledget
 of simple  cerate, a compress of folded
 linen, or flannel, may be put over the dress-
 ings ; these arato be secured with a broad
 piece of linen, which is to encircle  the
 chest, be fastened with pins, or stitches,
 and  kept  from slipping down by  two
 tapes, one of which is to go from  behind
 forward,  over  each  shoulder,  and  be
 stitched to the upper part of the bandage,
 both in front  and behind.  The arm  on
 the same side as that on which the opera-
 tion has been done, should be  kept per-
 fectly motionless,  in a sling;  every  mo-
  tion bf the limb must evidently disturb the 
MAMMARY ABSCESS.                       199
 wound, by putting the great pectoral mus-
 cle into action, or rendering  its fibres
 sometimes tense, sometimes relaxed.   It
 is scarcely necessary to say, that, after so
 considerable an operation as the removal
 of a large breast, or any other tumour of
 magnitude,  the patient should  be given
 about thirty drops ofthe tinctura opii.  A
 smaller dose always creates restlessness,
 head-ach, and fever, after operations, in-
 stead of having the  desired effect.
   Here it becomes me to state,  that as I
 could not find in any surgical book, with
 which  I am acquainted, what I conceived
 to be a proper description of the mode of
 removing a diseased breast, and tumours
 in  general,  the  foregoing  remarks  are
 given  chiefly on  my  own  authority
 Whether  they are just, or not,  must be
 decided by the profession.
  The  principal writers on the removal of
 the mamma  are, Garengeot,  Dionis,  Le
 Dran, Bertrandi, Sharp, and Sabatier, in
 their respective treatises  on the opera-
 tions.  B. Bell,  Latta,  &c. have also
 treated of the subject in their Systems of
 Surgery ; and there is a memoir SurPOpe-
 ation du Cancer au  Sein, in Les (Euvres
 Chirurgicales de Desault par Bichat. torn. 2.
  MAMMARY  ABSCESS. Milk Abscess.
 Women who suckle, are particularly sub-
ject to inflammation and suppuration in
 the breast.  The part enlarges, becomes
 tense,  heavy, and painful.   The iategu-
 ments  of the breast sometimes  assume an
 uniform  redness;   sometimes they  are
 only red  in particular places.   Tiie  in-
 flammation may affect the mammary gland
 itself,  or be confined to the skin and sur-
 rounding cellular substance. In the latter
 case, the inflamed part is equally tense ;
 but, when the glandular structure of the
 breast  is also affected, the enlargement is
 irregular, and seems to consist of one or
 more large tumours, situated in the sub-
 stance  of the part. The pain often extends
 to the  axillary glands.  The secretion of
 the milk is not always suppressed, When
 the inflammation is confined to the inte-
 guments,  and suppuration is said to come
 On more quickly, than in affections of the
 mammary gland itself.  When the symp-
 toms of inflammation continue to increase
 for four or fire days, suppuration may be
expected; unless the progress  of tiie  in-
 flammation be slow, and its degree mode-
rate, in which circumstances,  resolution
 may often be obtained, even as late as
a fortnight after the first attack.  Inflam-
mations in the breast are  almost always
attended with  symptoms  of  the  sym-
pathetic inflammatory fever.  (See Fevers,
 Surgical.)  I think  authors err,  who de-
scribe  the febrile disorder as generally
preceding tl,-. focal  complaint.
   Women are most liable to mammary ab-
 scesses within the first three months after
 parturition; but they are also very much
 exposed to the disorder as  luiijj as they
 continue to suckle.
   The most common causes occasioning
 the mammary abscess, as enumerated by
 writers in general, are, repressing the se-
 cretion of milk at an early period, ment: J
 disturbance, fright, &c.; exposure to cold,
 moving the arms too much while the
 breasts are  very  large  and  distended,
 bruises, and other external injuries.  The
 causes are not always assignable.
   The matter is sometimes contained in
 one cyst, or cavity, sometimes in several;
 but the abscess«generally breaks near the
 nipple.
   As all inflammations of the mamma are
 attended  with  considerable induration,
 these cases should be carefully distinguish-
 ed from other swellings of a more incura-
 ble kind.  It is said, that scrophulous tu-
 mours ofthe mamma,  which  have existed
 along while, often disappear after the oc-
 currence of a milk-abscess.  Women who
 have never been  pregnant, are sometimes
 affected with suppurations in the breast,
 not essentially different from  those above
 described. Even men are said to be liable
 to similar  complaints.
   In the early period of tlie affection, re-
 solution should be attempted.  The fol-
 lowing are the principal means for thi9
 purpose :—topical blood-letting,  saline
 purges, low diet, keeping the inflamed
 breast from hanging  down, gentle fric-
 tion ofthe breast, with a soft sponge, wet
 with some warm emollient liquor, having
 the milk tenderly sucked out at proper in-
 tervals ; saturnine applications, or lotions
 containing sal  ammoniac.
   When matter cannot be prevented from
 forming, an emollient  poultice is the best
 application, and the abscess should in ge-
 neral  be allowed to break of itself, unless
 of a somewhat chronic nature,  in which
 case,  it should be  opened in a depending
 part,  with a lancet.   Sinuses sometimes
form, in consequence of abscesses in the
 breast, and will not heal till freely open-
ed with a director and curved bistoury
 When the cavity of the abscess begins ic
fill up with granulations, the poultice m:.
 be left off", and superficial dressings ap
plied
  The indurations, often remaining in the
 breast, in consequence of acute inflamma-
tion  and abscesses, generally  yieid  to
 frictions   with  camphorated  mercurial
ointment,  the application of a piece of
 soap plaster, and giving calomel, cicuta,
and,  as some advise, emetics.
  Mr. Hey describes a very  deep seatc;
abscess of the breast,  not of frequent oc- 
200              MEL

currence, and not confined to pregnant nor
suckling women.   Its situation renders
all  superficial applications  ineffectual.
The inhamniatory stage is tedious; and
when the matter "has  made its way out-
ward, the discharge continues,  and there
is no tendency to  healing.  Sometimes
tiie matter lodges behind the mamma, as
well as in the substance of the gland, and
breaks out in different places,  the inter-
mediate  parts of the breast feeling as if
affected with a scirrhous hardness  There
are numerous  sinuses  running  in  differ-
ent directions, and, when opened, a soft
purple fungus appears within them.  The
disease  goes on in this state, for a long
while, keeping up hectic -symptoms.
  Mr. Hey's practice is to trace the course
of all the numerous sinuses, and lay them
open, and unless this is done, with respect
to every one of them,  the  cure cannot be
accomplished.  If he finds any two sinuses
running  in  such directions, that  when
fully opened, they leave  a small  part of
the mamma in  a pendulous state, he re-
moves such part entirely.  As the sinuses
are filled with fungus, their continuations
present no visible cavity, and can only be
detected by the greater softness of parts
ofthe  wound, where, on breaking down
the fungus, the orifice of the collateral
sinus may be found.   Mr. Hey has found,
that even in the most unfavourable sub-
jects, the  wounds heal quickly, and the
natural shape ofthe breast is preserved.
  Consult  Pearson's Principles of Surge-
ry,  Chap. 3.   Hey's  Practical   Observa-
tions, p.  504.  Kirkland has also  treated
«if several kinds of abscesses ofthe breast,
in his Enquiry into the present state of
Medical  Surgery,  Vol.  2. p. 161;   The
German  reader  may  refer to Richter's
Anfangsgr.  der   Wundarzn.   Band. 4,
Chap. 16.
  MARASMUS,  (from fiugtuva, to grow
lean.)  An atrophy, or wasting  of the
bulk and strength.
  MATURANTIA.   (from  maturo, to
ripen.)   Medicines for  promoting  sup-
puration.
  MATURATION.   (Same derivation.)
Maturatio. The old surgeons were accus-
tomed to call the completion of the suppu-
rative  process in  inflammatory tumours
their maturation, in which state they were
deemed fit to be opened.   The word is
still frequently found in modern surgical
works.
  MELICERIS.  (from peto, honey, and
r-vpos, wax.)   A tumour of the encysted
kind, filled with a substance resembling
wax and honey in consistence.  (See Tu-
^syrs, Encysted.)
              M E R

  MENINGES,  (from ^v*,  to remain.)
The membranes covering tlir  brain.
  MENLNGOPini.AX.   (from i*.r,uy\t
a membrane, and <pv\z.e-*a, to guard.) An
instrument used by the ancients for guard-
ing the dura mater and brain  from injury,
in their mode of trepanning  It seems tu
have been something like the lenticular,
only its blade was completely round, with-
out an edge.   It  ended  in  a  letitif'orm
cup, like the latter.  (Encyclopedic Me-
thodique,  Partie Chirurgicale.)  Pott gives
a little engraving of a meningophylax,
which resembles a common elevator. (See
Vol. 1, of his Works.)
  MERCURY.  (Quicksilver. Mercurius.
Hydrargyrus.)   The medicinal virtues of
this mineral were almost totally unknown
to  the ancients, who considered it as a
poison.   It was  first employed for pur-
poses of medicine by the Arabians, who
made Use of it in the form of ointments
for the cure of certain diseases of the skin
and the  killing of  vermin.  In modern
times, mercury is one of the most import-
ant articles of the materia medica.  It has
an advantage over all  others in being a
specific remedy for a disease, which tends
more, than any other, to the destruction
of the human species, and which, without
this inestimable discovery, would proba-
bly  have continued incurable to the pre-
sent day.
  Mercury,  taken into the stomach in its
metallic state, has no action on the body,
except what arises from its weight, or
bulk. It is not poisonous,  as was vul-
garly supposed, but perfectly  inert.  But,
in its various states  of combination,  it
produces  certain  sensible  effects.   It
quickens the  circulation,  and  increases
all the secretions and excretions.
  According to circumstances, the habit
ofthe body ofthe patient, the  temperature
in which he is kept, the  nature of the pre-
paration, and the quantity in which it is
exhibited, its effects are, indeed, various.
Sometimes, it more particularly increases
one  secretion; sometimes  another; but,
its most characteristic effect is the increas-
ed flow of saliva, which it generally ex-
cites, if  given   in  sufficient quantity.
(Edinb. Dispensatory.)

FIRST ATTEMPTS TO ADMINISTER MERCURY.

  It has  been said, that the efficacy  of
mercury in curing the  venereal  disease
was an accidental discovery.; but, it seems
more probable,  that  the good  effects,
which it  produced in cutaneous diseases,
first led physicians to make trial of it in
the venereal one, which, frequently coming 
MERCURY.                              2<Jl
on with eruptions on the skin, ulcers, &c.
seemed to present an amdogy to the affec-
tions, in which mercury had already been
found successful.
  In the times immediately following the
first origin of the venereal disease, prac-
titioners only ventured to  employ this re-
medy with timorous  caution, so that, of
several of their formulae, mercury scarcely
composed a fourteenth part, and few cures
were  effected.  On the other hand, the
empirics,  who noticed the little efficacy
of these small doses, ran  into the oppo-
site extreme, and exhibited  mercury in
such large quantities, and with such little
care,  that most of their patients became
suddenly attacked with a most violent sa-
livation, frequently  attended  with very
dangerous, and even fatal symptoms ; or
such, as after making them lose their
teeth, left them pale, emaciated, exhaust-
ed, and subject, tor the rest of their lives,
to tremblings, or other more or less dan-
gerous affections.  From these  two very
opposite modes of practice, there originat-
ed such uncertainty, respecting what could
be expected from mercury, and such fears
of the consequences, which might result
from its employment, that every plan was
eagerly adopted,  which offered the least
chance  of cure, without having recourse
to this  mineral.
  A medicine, however, so powerful, and
whose salutary effects were seen by atten-
tive  practitioners amid all  its  inconve-
niences, could  not  sink  into oblivion.
After efforts had been made to discover a
substitute for it, and  it was seen, how
little confidence those means deserved, on
Which the highest praises had  been la-
vislied,  the attempts to extend  its utility
were renewed.  A medium was pursued,
between the too timid methods of those
physicians, who had first administered it,
and the inconsiderate boldness ofthe on-
 irics.  Thus  the causes,  from  which
 oth  parties  failed,  were  avoided;  the
character of the medicine was revived in
a more durable way, and,  from this  pe-
riod, its reputation has always been main-
tained.
  It was only about this epoch,  that mer-
cury  began  to be internally given: hi-
therto,  it had  only  been externally em-
ployed,  which  was done  in three man-
ners.  The first was  in the  form of an
ointment or  liniment:  the second, as  a
plaster; and tlie  third, as a fumigation.
  The basis ofthe ointmen-,  or liniment,
Was quicksilver, which was  blended, by
means of trituration,  with  hog's lard,
goose's  fat, &c.  and composed  scarcely
one-sixth or one-eighth of the whole ;  a
proportion, however, much greater, than
what had been  at first  employed   But,
    Vol  II.
from a fear, that the mineral might prove
hurtful to the  nerves, by tiie cold pro-
perty,  which they fancied  it possessed,
and  that  it  might  occasion  numbness,
tremblings, or pabies,  they combined
with it a multitude  of ingredients  of a
warm, aromatic nature, or supposed to
possess such •  for  example, oil of camo-;
mile, sesame-seeds,  ani-seeds, the roots
of zedoary, and the florentine iris, and a
thousand other substances, which  were
incorporated with  the ointment.  The
members, joints,  and  the  whole of the
body, except the head, belly, and chest,
were rubbed with this conoposition;  and
the frictions were repeated, at  suitable
intervals, until obvious signs of salivation
appeared.
  The ingredients  of the plasters resem-
bled those ofthe ointments; only they con-
tained less fat, for which was substituted
a sufficient quantity of wax, to give them
a proper consistence.   This  composition
was applied to the skin, and they covered
the whole body with  it,  excepting the
same parts, on which they feared to put
the ointments.  The plasters  were kept
on, till salivation  began to make its ap-
pearance.
  The fumigations were made with quick-
silver,  triturated  with turpentine, or sa-
liva, or else with  cinnabar.   These sub-
stances were mixed with fatty, or resin-
ous ones, such as myrrh, nutmeg, &c. and,
all the ingredients being reduced to pow-
der, were made into a paste, with a suffi-
cient quantity of turpentine,  or gum tra-
gacahth.   The  patient  was then placed
in a box made on purpose, or under a lit-
tle kind of tent,  out of which tiie head
was  generally  allowed to  protrude.  A
chafing-dish, containing hunting coals,
was placed near his feet, and,  every now
and  then,  bits of mercurial paste  were
thrown into the vessel.  The patient was
left  e.tposed to the  fumes,  which arose,
until he broke out into a profuse perspi-
ration, which they took great pains to keep
up and increase, by putting him in a warm
bed, loading him with bedding, for about
two  hours,  after  which he was  rubbed
quite dry,  and given  some food.  This
plan was persisted in every day, till a sa-
livation was  produced, which was kept
up as long  as  necessary.  The  method
by fumigation is described in Astrue, and
particular preparations, and apparatuses
tor the purpose, have been  since recom-
mended by Lalonette in France,  and,
more recently,  by  Abernethy in England.
  Of the three methods,  which we  have
just described,  only the first is at present
much in use, and even this is  very mpch
altered.  Experience evinced, not only.
that the  employment of mercurial plas-
    C c 
202                               MERCURY.
 ters  caused heat, redness,  itching, and
 disagreeable eruptions, but, that the me-
 thod  was exceedingly slow and  uncer-
 tain.  Mercurial  plasters are now only
 used as topical discutient applications to
 tumours, and indurations.
   Fumigations, considered  as  the only
 means of cure, fell also into discredit,
 because, although they formed a method
 of applying mercury in a  very active man-
 ner, they  were,  as  anciently managed,
 liable to several objections.  In  this way
 it w:is next to impossible .0 regulate the
 quantity of mercury used, which will ne-
 cessarily vary,  according to the greater,
 or lesser activity of the fire employed for
 making- the fumigation, according to the
 position of the patient during the opera-
 tion, and other circumstances.  The  ef-
 fect of the vapour on the organs  of respi-
 ration w.is often  very  hurtful, and mer-
 cury,  applied in  the way of fumigation,
 more  frequently  occasioned tremblings,
 palsies,  &.c. than in any other  manner.
 In Mr. Abernethy's mode, however, fumi-
 gation  is,  under  certain circumstances,
 not only an eligible, but, the very best,
 way of affecting the constitution, as  we
 shall presently  notice.
   Frictions with  ointment  have always
 been regarded  as the most efficacious.
 They have undergone considerable change,
 and, by being rendered more simple, have
 been  greatly perfected.  All  the warm
 aromatic substances have been retrenched
 from the ointment,  not only as  useless,
 but, as  irritating  and  inflaming to the
 skin   In modern  times,  the  proportion
 of mercury to the  fat has  been  very much
 increased.

 GENERAL R I.MARKS  OX THE ADMINISTRATION
  OF  MERCLM1T, ITS  OCCASIONAL CONSE-
   QUENCES,  &.C.

  With regard to  the preparations of the
 medicine, and  the modes of applying it,
 we are  to consider two things ; first, the
 preparation and mode attended with the
 least  trouble,   or  inconvenience, to the
 patient;  and secondly, the  preparation,
 and mode of administering it, that most
 readily conveys  the  necessary  quality
 into the constitution.  Mercury'is carried
 into  the constitution in the same way as
 other  substances, either  by  being ab-
 sorbed from the surface of "the body,  or
 that  ofthe alimentary  canal.  It cannot,
 however, in all  cases be  taken  into the
constitution in both ways; for, sometimes
 the absorbents ofthe skin  will not readily
 receive it, at least, no effect is  produced,
 either  on the  disease, or  constitution,
 from this mode of  application.   In this
circumstance, mercury must be given  by
 the mouth, although the plan may be very
 improper in other respects, and often in-
 convenient.  On  the other  hand, the  in-
 ternal absorbents sometimes will not take
 up the  medicine, or, at least,  no effect
 is^roduced oirthe disease, or the consti-
 tution.
   In such cases, all the different prepara-
 tions of  the  medicine should  be tried;
 for,  sometimes one  succeeds,  when an-
 other will not.  In some cases, mercury
 seems  to have no  effect, either  applied
 outwardly, or taken into  the stomach.
 Many  surfaces seem  to absorb mercury
 better, than  others;  such are probably
 all internal surfaces and sores.  Thirty
 grains of calomel, rubbed in on the  skin,
 have not more effect, than three, or four,
 taken  by  the mouth.   Dressing small
 ulcers  with   red  precipitate sometimes
 causes a salivation.   (See Hunter on the
 Venereal Disease, p. 335, 336.)
   Besides the practicableness of  getting
 the  medicine into  the  constitution  in
 either  way, it is proper  to consider the
 easiest for the patient, each mode having
 its convenience  and inconvenience, de-
 pending on the nature  of  the  parts,  to
 which   it is applied,  or on  certain situa-
 tions of life at the time.  Hence, it should
 be given in the way, most suitable to such
 circumstances.
   In many, the bowels can hardly bear
 mercury at all, and  it  should then be
 given in the mildest form possible, con-
joined with such medicines, as  will less-
 en, or correct its violent local effects, al-
 though not its specific ones on the consti-
 tution.
   When mercury can be thrown into the
 constitution with propriety by the exter-
 nal method, it. is .preferable  to  the inter-
 nal plan, because the skin is not nearly so
 essential  to  life  as  the  stomach, and,
 therefore, is capable  in itself of bearing
 much more, than the stomach.  The con-
 stitution  is   also  less  injured.   Many
 courses of mercury would kill the patient,
 if the medicine were only given intemalh,
 because, it  proves hurtful to the stonlach
 and  intestines, when  given "in  any form,
 or joined  with the  greatest correctors.
 Every one, however,  has not opportuni-
 ties ot  rubbing in mercury, and is there-
 fore obliged, if possible, to take it by the
 mouth   (Hunter, p. 338.)
   Mercury has two eff'ects, one as a sti-
 mulus  on the constitution and particular
 parts ;  the ou',er as a specific on a diseas-
 ed action of the whole body, or of parte
 The latter action can only  be  computed
 by the disease disappearing.
   In giving mercury in the venereal dis-
ease, the fii st  attention  should   be to the
quantity, and its visible effects in a given 
MERCURY.                              203 •
time, which, when brought to  a proper
pitch, are only to  be kept up, and  the
decline of the disease to be watched;  for,
by this we judge ofthe invisible, or spe-
cific effects of the medicine,  and know
what variation  in  the qifantity  may  be
necessary.  The  visible effects of mer-
cury affect, either the whole constitution,
or some parts capable  of secretion.  In
the first, it produces universal  irritabili-
ty, making it more susceptible of all im-
pressions.  It quickens the  pulse,   in-
creases its hardness, and occasions a kind
of temporary  fever.   In some constitu-
tions, it operates like a  poison.  In some
it produces a kind of hectic fever, that is,
a small quick pulse, loss of appetite, rest-
lessness, want of sleep, and a sallow com-
plexion, with  a number . of  consequent
symptoms; but,  such  effects  commonly
diminish,  on the  patient becoming a  lit-
tle accustomed to the medicine. Mercury
often produces pains like those of rheu-
matism, and nodes of a scrophulous  na-
ture.  (Hunter, p. 339, 340.)
  The quantity of mercury to be  thrown
into the constitution, for the cure of any
venereal complaint, must be proportioned
to the violence of the disease.  However,
we are to be guided by two circumstances,
namely, the time,  in  which  any given
quantity is to be thrown in,  and the ef-
fects it has on some parts of the body, as
the salivary  glands,  skin, or  intestines.
For, mercury may be  thrown into   the
same constitution in  very different quan-
tities, so as to produce the same ultimate
effect;  but,  the two very different quan-
tities must also be in different times;  for
instance,  one ounce  of mercurial  oint-
ment, used in two days, will  have more
effect upon the constitution, than  two
ounces  used in  ten.   The effects of one
ounce, used in two days, on the constitu-
tion and diseased parts, are considerable.
A small quantity, used quickly, will have
equal effects, to those of a large one em-
ployed slowly; but,  if  these effects   are
principally local, that is, upon the glands
of the  mouth, the constitution at large
not being equally stimulated, tiie effect
upon  the diseased parts must  be less,
which may be known  by the local disease
not giving way in proportion to the effects
of mercury  on some particular part.  If
it is given in  very small quantities,  and
increased gradually, so as to steal insen-
sibly on the constitution,  a vast quantity
at a time may at length be used, with-
out any visible effect  at  all.  (Hunter,
p. 341.)
  These circumstances being known, mer-
cury  becomes a much more efficacious,
manageable,  and safe 'medicine,  than it
was  formerly thought to be; but,   un-
luckily, its visible effects upon the mouth
and the intestines  are  sometimes  much
more violent, than-its general effect upon
the constitution at large.   These parts
must therefore not be stimulated so quick-
ly, as to hinder the  necessary quantity of
mercury from being used.
  The  constitution, or  parts, are  more
susceptible of mercury  at first, than  af-
terwards.   If the mouth  is  made sore,
and allowed to  recover, a much greater
quantity may be thrown in, a second ti. e,
before  the same  soreness  is  produced.
However,   anomalous  cases occur,  in
which, from unknown causes,  mercury
cannot at  one time be  made to produce
any visible effects;  but,  afterwards,  the
mouth and intestines are all at once affect-
ed.  (Hunter, p. 342.)
  Mercury occasionally attacks the bow-
els, and causes violent  purging,  even of
blood.   The effect  is remedied by inter-
mitting the use of  the medicine, and ex-
hibiting opium. At other  times, it is
suddenly  determined to the-mouth, and
produces  inflammation,  ulceration,  and
an excessive flow of saliva. To obtain
relief  in  this circumstance, purgatives,
nitre,  sulphur,  gum-arabic, limewate.r,
eiunphor,   bark, kali sulphuratum, blis-
ters, &c. have been advised.  Mr.  Pear-
son, however,  does not seem  to place
much  confidence in the efficacy of such
means, and, the mercury being discon-
tinued for a time, he recommends the pa-
tient to be freely_exposed to a dry cold
air, with the occasional use  of cathartics,
Peruvian  bark, and mineral acids,  and
the assiduous applications of astringent
gargles.  " The most material objection,
(says  Mr.  Pearson,)  which 1  foresee
against the method of  treatment  I' have
recommended, is the hazard, to which  the
patient will  be exposed, of having  the
saliva  suddenly checked, and of suffering
some other disease in consequence of it.
   " That  the hasty suppression of a ptya-
lism may  be followed by serious inconve-
niences, has been proved by  Dr. Silvester,
(Med. Obs. and Inq. Vol. 3.) who published
three cases of persons,  who  had been  un-
der his own  care;  two of whom were af-
flicted* with violent pains; and the third
scarcely retained any food in her stomach
for the space of three months.   1 have
seen not only pains, but even general con-
vulsions produced from the  same  cause.
But, this  singular kind of metastasis of
the mercurial irritation does not appear
to me to owe its appearance to simple ex-
posure to cold and dry air; because,  I
have known it occur  in different forms,
where  patients continued to breathe  a
warm  atmosphere,  but used a  bath,  the
water of which was not sufficiently heat- 
JJ-1
MERCURY.
ed.  Cold liquids, taken in a large quan-
tity into the stomach, or exposure of the
body to cold and moisture, will also prove
extremely  injurious to those,  who are
fully  uniler the influence of mercury;
whereas breathing a  cool air, while the
"body is properly covered with  apparel,
has certainly no tendency to produce any
distressing, or dangerous consequences.
   " If,  however,  a suppression of the
ptyalism should be occasioned by any act
of ■ indiscretion, the  remedy is  easy and
certain ;  it  consists  only in the  quick
introduction of mercury into the body, so
as to produce a soreness of the gums, with
the occasional use of a warm bath."  (Pear-
son on tlie Effect of Various Articles in the
Cure of Lues Venerea, Edit. 2, p. 163, 164.)
   Mercury, when it  falls on tiie mouth,
produces, in many constitutions, violent
inflammation, which  sometimes  termi-
nates in mortification.  In these  habits,
great caution is necessary.  The ordinary
operation of mercury does  not perma-
nently injure the constitution ; but, occa-
sionally, the impairment is  very mate-
rial ; mercury  may  even produce local
diseases, and retard the cure of chancres,
buboes, and certain effects of the lues ve-
nerea, after the poison  has been destroy-
ed. (Hunter, p. 342.)
   From  mercury  occasionally  acting on
the system, as a poison, quite unconnected
with its agency as a remedy,  and neither
proportionate  to the inflammation of the
mouth, nor the actual quantity of the
mineral  absorbed, Mr. Peaison noticed
that one,  or two patients in general died
suddenly every y ear in the Lock  Hospital.
The morbid state of the system, which
tends to the fatal event,  during a mercu-
rial course, is named by Mr. Pearson ere-
thismus, and is characterized by  great de-
pression of strength, a  sense of anxiety
about  the praecordia, irregular action of
the heart, frequent sighing, trembling, a
small, quick, and sometimes an  intermit-
ting pulse, occasional vomiting,  a  pale
contracted countenance,  a sense of cold-
ness ; but the  tongue is seldom  furred,
and neither the vital, nor natural func-
tions are  much disordered.  They, ^jlio
die suddenly of the mercurial eretfcisnms,
have frequently been making some little
exertion just  before.  To  prevent the
dangerous ^consequences of this state of
the system, the use of mercury must be
discontinued,  whatever may be the stage,
extent, or violence of the venereal symp-
toms.  The patient should be directed to
expose himself freely to a  dry and cool
air, in such a manner, as shall be attended
with the least fatigue, and he should have
a  generous diet.  In this manner, patients
often recover  sufficiently in ten, or four-
teen days, to resume the use of mcrcur-
with safety.   In the early stage, the mer-
curial erethismus may otten be averted by
leaving off* the  mercury, and  giving the
mistura camphorata with large  doses of
the volatile alkali.   When the stomach is
unaffected, sarsaparilla sometimes  does
good.  (Pearson, p. 154, &c)
  Occasionally, the use of mercury brings
on a peculiar eruption, which has received
the several names of hydrargyria, mercurial
rush,  eczema mercuriale,  lepra mercnriuli*,
mercurial disease, and erytliema ''mercuriale.
  " Eruptions  of various kinds  are very
common symptoms  of syphilis, but a very
unusual  effect  of  mercury.  Therefore,
until the real nature of this erythema was
lately discovered, whenever it occurred in
patients undergoing  a mercurial  course
for syphilitic complaints, it  was naturally
enough considered, as an anomalous form
of  lues venerea.  The mercury was con-
sequently pushed  to a greater extent, in
proportion to the violence of the symp-
toms,  and, from the cause of" the disease
being  thus unconsciously applied for its
removal,  it  could not fail to be aggravat-
ed, and hurried on to a fatal termination.
The observation  of  this fact, conjoined
with another, of less frequent occurrence,
namely, that a similar eruption did some-
times  appear in  patients using mercury
for other complaints, and  in whom no
suspicion of syphilis could be entertained,
at last led some judicious practitioners in
Dublin to the  important discovery, that
the eruption was entirely an effect of mer-
cury,  and not at all  connected with  the
original  disease.   This  discovery  was
not published till 1804."  (MMullin, in
Edinburgh  Medical and Surgical Journal,
No. 5.)  Mr.  Pearson  states,  however,
that he has been acquainted with the dis-
ease ever since 1781, and has always de-
scribed  its   history and treatment in his
lectures, since 1783.
   The eruption is attended  with more or
less indisposition, is not confined to either
sex, or any  particular constitution,  and
seems to be equally produced by mercury
applied externally,  and by any of its pre-
parations taken  inwardly.  Mr. Pearson
has never seen it in  subjects above 50;
and he says, its occurrence is more com-
mon about eight, or ten days after begin-
ning a mercurial  course. (P.  166.)
   Dr. M'Mullin distinguishes three  dis-
tinct stages  of the erythema mercuriale.
" The  first  stage  commences with  lan-
guor, lassitude, and cold s'hiverings; these
symptoms are succeeded by increased tem-
perature ofthe body, quick pulse, nausea,
headach, and thirst.  The patient is trou-
bled with a  dry cough,  and complains of
difficult respiration, anxiety,  and sense of 
MERCURY.                            . 206
stricture about  the praecordia.   The
tongue is usually moist,  and covered with
■j. white glutinous slime;  it  sometimes
appears clean,  and brightly  red in the
centre, whilst the margins appear foul.
 The skin  feels unusually hot and itchy,
with a  sense of pricking,  not unlike the
sensation experienced from the applica-
tion of nettles.  The belly is  generally
costive; but, a diarrhoea is often produced
by very slight causes.
  " On the first, or second day,  an  erup-
tion most commonly shews  itself, the co-
lour of which  is either dark or bright
red: the papulae are at  first distinct and
elevated, resembling very much those  in
rubeola.    Sometimes,  but  rarely, the
eruption appears like  urticaria, and  in
such instances the disease  is  observed  to
be very mild  The papulae very speedily
rim together in such a manner as to form
 a suffused redness, which disappears  on
 pressure.   In most cases it begins first on
 the scrotum, inside  of  the thighs, fore-
 arm, or where mercurial friction  had been
 applied, and the integuments ofthe parts
 affected become much swollen. There have
 also been  observed  instances, where an
eruption of a purplish colour, and  unac-
companied by papulae, has  diffused itself
suddenly  over the  entire body.   This,
however,  may  be considered  as uncom-
 mon.  In  every instance which  came un-
der my observation, it  was  confined  at
first to a few places, and from thence gra-
dually  extended, until  the different por-
tions of the eruption had united, and the
 papulae were also rough to  the feel.  But
 in those cases, which resemble urticaria,
 a number of minute vesicles, which con-
 tain a serous fluid, appear, from the com-
 mencement, interspersed among the pa-
 pulae.   Contrary to what happens in most
 diseases accompanied with cutaneous af-
 fections, the febrile symptoms are much
 aggravated, and continue to increase after
 the eruption has been  completed  The
 pulse in general beats from 120 to 130 in
 a minute, the thirst continues urgent, and
 the patient, extremely  restless, seldom
 enjoys quiet sleep.  When the eruption
 has continued  in this manner for  a cer-
 tain period, the cuticle  begins to peel off
 in  thin, whitish, scurfy exfoliations, not
 unlike  those  observed  in rubeola.  This
 desquamation has not been attended  to
 by  Dr. Moriarty or Mr.  Alley, if they
 have not, by giving the  same  name to tlie
 decrustation which occurs in the last stage,
 confounded both together.  It commences
'in those places where  the eruption first
 made  its  appearance, and  in  this  order
 spreads to other parts.   About this period
 the fauces become sore, the tongue swells,
 and the eyes appear somewhat  inflamed.
  " The duration of this Stage is very
various ; sometimes it continues fron ten
to fourteen days, and  in  other ca-es  it
terminates in half that time.  Whai the
disease has appeared in its mldestform,
the patient  recovers  immediately after
this desquamation, a new  cutcle  laving
formed  underneath; but, if sevee,  he
has only experienced the smalest fart of
his sufferings, and the skin  niw asumes
a new appearance, which I haie coisider-
ed as tiie second stage.
  " The skin at this  period aipea-s as if
studded with  innumerable  ninike vesi-
cles, which are filled with apelucidfluid.
These vesicles may be expectd, if the pa-
tient, at the close of the first tage, com-
plains of increased itching,  ad sense of
burning heat, in those  parts torn  which
the  cuticular  exfoliations  live  fellen
 They remain sometimes for a lay o' two,
but are most commonly burst, imneaiatelr
after their formation, by the ra'imt rub-
bing them, in order to relieve tie  trou
blesome itchiness with which tbse  parts
are affected.  Theyr discharge1 serous,
acrimonious fluid, which possi^es such a
very disagreeable odour as to iduce nau-
sea in tie patient himself,  ai» those who
approach near his bed-side.  The odour
is so peculiar, that it can e*ily be recog.
nised \y any person who as once expe-
rience!  it.
  " This fluid is  poured&ut mast  copi-
ously from  the scrotum&roin,  inside of
tlie thighs, or wherevy the skin forma
folds, and sebaceous gdids are most mi
morbus. Tie serous di^harge from these
minute vescles form, vth the cuticle, an
iucrustatici, which ma be  considered a *
the third <r last stage.
   " Thesecrusts are gperaHy very large,
and,  whei detached,Itain the figure of
the  parts from whichthey have fallen.
Their coloir is yellowi; but sometime*
appears dak and dirf  This period of
the  diseasi  might  b termed,  I think,
with muclnropriety, le stage of decrus-
tation, in oiier to distijuish it more fully
from  the dequamatiom\\ich has betn al-
ready noticd.  Fronue use of the  two
last terms indiscrimitely, those  who
have  descrhed  the tease, have intro-
duced into  heir desertions a degree of
confusion, vhich hasuised its ptogress
not to  be veil undewod.  Wb«n this
 stage appeirs,  the f.ips beoonu  more
affected, tte eyes intcrant of ligit,  and
 the tarsi teider, inflaid, and  sonetimes
 inverted. The crusts rmed on he face,
 as in other partsof tlbody, beore fall-
 ing off, divide asund so as :o leave
 cracks  and fissures, lich  prduce an
 hideous expression otountenaice; and
 the eyelids  are alsorom th  general 
206
MERC UK i.
swellhg of the  face, completely closed.
The btek aid hairy scalp are last affected,
and, efen it. very severe cases, these parts
are sometines observed to escape entirely.
The patienc, whilst in this state, is com-
pelledto dtsist from every kind of motion,
on acduntof the pain  which he experi-
ences in tie slightest exertion, and which
he describes as if his flesh were cracking.
The cwstsalso fall off' in such abundance,
that tie bed appears as if  strewed with
the coies d" hops.  Whilst the eruption
is only miking its appearance  in one
place, aioher  part may have arrived at
its most  aivanced form ; so that all the
different stges ofthe disease may be pre-
sent at onetime in the same  individual.
ltisattendd with'typhus through its en-
tire course but it is very curious to ob-
serve, thai the appetite for food, in most
cases,remiins unimpaired, and sometimes
is evei v»racious.   This  circumstance
was paiticilarly remarkable in a patient
who  laioured under  the disease, in  its
worst fom, for the space of three months,
in the Rival Infirmaiy of Edinburgh ;  for
double te  usual hospital  allowance  of
food  was -arcely sufficient to sitisfy his
hunger.   "\Qen the catarrhal symptoms
 have contiied during  the  progress  of
 the complain  they are, at this ad/anced
 perfod,   parVuiarly  aggravated   the
 anxiety and pn 0f the breast ar? also
 very severe, aended  with   cough, and
 bloody expectoition,  and tlie patient al-
 ways feels lanjdd  and dejected.  The
 pulse becomes fiquent, feeble,  and irre-
 gular, "he tongimack and pa-chedy and
 at length diarrho, delirium, cinvulsions,
 gangrene of theurface of thejody, and
 death, supervent  In  its  mil<  form, it
 only goes throug the first stag, and ter-
 minates, as we rve already stted, in a
 few  days, by a slht desquamiion. But,
. when severe, ity often protected more
 than two nronthsivery stage (f tlie erup-
 tion  continuingfljroportionaby longer;
  and when, in thi manner,  it has run its
  course, it repeadly breaks -ut  on the
  new surface, andisses throujh the same
  stages." (MMun in Edinb Med. and
  Surg. Journal, J\ 5.)
    Wilh respect <the remott cause, this
  is  the  employmt   of mecury.   Dr.
  M'Mulin  is inoed  to thine with Dr.
  Gregoir, that tlapplication of  cold to
  thebocy, while ider theactDn of mer-
  cury, is absolute necessary,  for its pro-
  duction)  an  onion  streng.hened  by
  there aways  ©ting catarrhal  symp-
  toms.   Mr.  Peson, Aowever,  thinks
  cold has no  coern in bringing on the
  complain.
    In the tarly sle, Mr. Pear$pn recom-
  mends snail do:  of antimonial powder,
 with saline  draughts, or the  ammonia
 acetata.   A gentle purgative  should be
 given  every  three, or  four days,  and
 opium to procure sleep.  The latter me-
 dicine sometimes  does most good, when
joined with camphor, or Hoffman's ano-
 dyne liquor.  Sarsaparilla and bark may
 be given, when the discharge is no longer
 ichorous, and the tumefaction has subsid-
 ed.  Vitriolic acid has seemed to give re-
 lief.  The diet may be  light and nutri-
 tive, without fermented liquors, however,
 till the desquamation, has somewhat ad-
 vanced.  Frequent use of the warm bath,
 and often changing  the patient's  linen
 and sheets, which soon  become stiff and
 rough with the discharge,  afford much
 benefit.  If the  warm  bath cannot be
 had, Mr. Pearson advises,  washing the
 body very  tenderly  with  warm water-
 gruel ; he  also covers parts, from which
 the cuticle is detached,  with a. mild ce-
 rate,  and renews the application twice a
 day.  (P. 178.)
  Dr.  M'Mullin advises the immediate
 discontinuance of mercury;  the  removal
 ofthe patient from wards, where this mi-
 neral is in use ; emetics and diaphoretics;
 but on account of the very irritable state
 of the bowels,  he says antimonials are
 haidly admissible, and that  when purga-
 tives are indicated, oidy  the mildest ones,
 such as ol. ricini, magnesia vitriolata, &c.
 ought to be given.  He advises mucilagi-
 nous draughts  with opium  for  relieving
 the soreness of the fauces.  In the second
 stage, the cold infusion of bark with aro-
 matics and opium,  or, what  are more
 praised,   wine,  porter,  &c. To relieve
 the  ophthalmia  tarsi,  the unguentum
 oxidi zinci, and  to appease the  painful
 sensation of the skin  cracking, the  lini-
 mentum calcis, which should be liberally
 applied  as soon as crusts  appear.  See
 more  particulars  in  Dr. M'Mullin's Es-
 say.
  Consult  Essay on a Peculiar Eruptive
 Disease, arising from the Exlubition of Mer-
cury, by  G. Alley,  Dublin,  1804.   A De-
scription  ofthe  Mercurial Lepra, by Dr.
Moriarty, Dublin, 1804. Spens and M'Mul-
 lin, in Edinburgh Med. and Surgical Jour-
nal, No.  1, and 5.   Pearson on Lues Vene-
rea, Edit. 2.

REMARKS OV  THE  PARTICULAR  MODES OF
  GIVING MEIICURY, AND  ON  ITS PREPARA-
  TIONS.

   Frictions with Mercurial  Ointment.

  No metal acts in its pure metallic state;
it  must first be more  or less  combined
witli  oxygen.  The mercury,  contained
in the unguentum hydrargyri, becomesin 
MERCURY.
207
a certain degree oxydated, when triturat-
ed for the purpose of blending it with the
fat.  The metal,  however, in  mercurial
ointment, is in the most simple, and least
combined form, of all its preparations,
and hence,  it not  only generally operates
with more  mildness on the  system,  but,
with more specific effect on  the disease.
Various salts of mercury, when given in-
ternally, operate more quickly, than mer-
curial frictions ; but, few practitioners of
the present day confide solely in any inter-
nal preparations  for curing the venereal
disease, particularly, when the virus, has
produced effects in consequence of absorp-
tion.  We shall only just mention  in this
part of  the work, that rubbing in mercu-
rial ointment is the mode of affecting the
system with mercury,  which is generally
considered to agree best with most consti-
tutions,  and to act with most certainty on
the venereal disease.

         Mercurial Fumigations.

  We have mentioned this method, as be-
ing one  of the most ancient plans of affect-
ing the  constitution with mercury, and
Lalonette and Abernethy  have stated cir-
cumstances in its  favour,  which certainly
render it sometimes a  very eligible mode.
The latter is of opinion, that if the pecu-
liar advantages of mercurial fumigations
were  generally known tof practitioners,
they would be much more frequently em-
ployed.   The  advantages of toe method
consist  in its  affecting the  constitution,
when other means have failed, and in pro-
ducing  its effects iu a1 much shorter time,
than any other mode requires.   How de-
sirable  this celerity of  operation  must
often be, when  venereal ulceration  is
making  great ravages  in  the  palate,
throat,  &c. it is needless to insist upon.
In patients, who have not strength to rub
in ointment, and  whose  bowels will not
bear the internal  exhibition of mercury,
the mode of  fumigation may prove  of
great service.
  " In the year 1776, the Chevalier La-
lonette, a physician at Paris, laid  before
the pubhc an  account of a new mode  of
mercurial fumigation, free from the  in-
conveniences of former ones, and which,
in the space ot* thirty-five years, he  had
successfully employed in  more  than four
hundred cases, that had  resisted all the
ordinary methods of cure.  His method
consisted in inclosing the patient,  previ-
ously undressed, in a kind of box resem-
bling a sedan chair, with an  opening  at
the top  to let out the head, and another
at the bottom, to which was fitted a small
grate or furnace, having in it a  heated
iron for converting the mercurial remedy
into fume.   The preparation he nude use
of was  a kind of ciuomel, which, by re-
peated  sublimation from  iron-filing, was
so far deprived of its muriatic acid} as to
be in part reduced  into running qnicksil-
ver ;  and, while it posse s'ed considerable
volatility, was perfectly irritating.  Some
of this  powder  being  strewed upon the
hot iron placed  below,  was immediately
converted into smoke,  which surrounded
the patient's body, and after  some time
settled on hi6 skin in the form of a white
and very fine calx-of quicksiher: a com-
plete dress, having its inner surface fumi-
gated with  the same powder,  wis then
put on.— The remedy being thus generally-
applied to the mouths  of the cutaneous
absorbents,  soon got admission into the
circulating  fluids,  and the constitution
became thereby  more  speedily affected,
than by any other process  known before."
(Abernethy's Surgical  and Physiological
Essays, Part 3.)
  As the fumigating powder used by M.
Lalonette  was very operose, and  conse-
quently a. very expensive preparation, and
appeared to have no advantages over one
made by abstracting the  muriatic acid
from calomel by  means of volatile  alkali,
Mr. A. has always employed the  latter,
which  is prepared at the hospital in the
following manner: Two drachms of aqua
ammon ix are added to  six ounces of  dis-
tilled water, and four ounces of calome
are thrown  into  this liquor,  and shakei
up with it;  the powder is  afterwards se-
parated by  a filter,  and dried
  The powder thus obtained is of a frey
colour, and contains a good deal of oiick-
silver in its metallic state, which ofrourse
is extremely volatile, but  becomes oxy-
dated when raised into  ftuw>  and  after-
wards   condensed   into 2/ white subtile
powder.
  Mr. A. never  knew  *le method fail in
curing the lues venerea
  In local disease of «e joints, such,  for
instance, as frequency  take place in the
knee, and  in  sarconatous  enlargements
of the breast in  women, Mr. Sharp, and
Sir C Blicke havelong been accustomed
to direct fumigat4 stockings, or under-
waistcoats  to  be worn;  by which the
complaints  have been relieved, and the
constitutions o'  the patients  affected,
without the trouble and unpleasantness
arising from the use of* the  common mer-
curial ointnlenv  (See Aberruthy's Surgi*'
col and Physiobgical Essays, Part 3 )
  Mr.  Pearsoi procured La.onette's ma-
chine,  and made a considerable number
of experiments to determine the compara-
tive advantages of this method, and mer-
curial frictions.  He found, that the gum>
became  turgid and  tender  very quickly 
208                              MERCURY.
 and  that,  the local appearances  were
 soonei removed, than by the other modes
 of introducing mercury  into the system;
 but tint it soon brought on debility, a ra-
 pid and premature salivation,  and,  of
 course, the medicine could not be steadily
 continued.   This  gentleman concludes,
 that where checking the progress of the
 disease suddenly is an object of great mo-
 ment,  where the body is covered with ve-
 nereal ulcers,  or where  the eruptions are
 large and numerous, so that there scarcely
 remains a surface large  enough to absorb
 the ointment,  the vapour of mercury will
 be  advintageous.   But,  he thinks it ex-
 tremely difficult thus to introduce a suf-
 ficient quantity of mercury into the system
 to secure the patient from a relapse, and
 therefore by no means eligible as a gene-
 ral  practice.  The vapour of mercury, he
 says, is singularly  efficacious,  when ap-
 plied to venereal  ulcers, fungi, and ex-
 crescences ; but  this  plan requires an
 equal  quantity of mercury to be given in
 other ways, as if the local application it-
 self were not a mercurial one.  (Pearson
 on Lues Venerea, p. 145, &c.)
  For  the purpose of fumigating sores,
 the hydrargyrus  sulphuratus  ruber  is
commonly used. Ulcers  and excrescences
 about the pudendum and anus  in women
 ire said to be particularly benefited in this
 ray; and in these cases the fumes are
 Host conveniently applied by placing a
 nd-hot heater at the bottom of a night-
 sf»ol pan, and after sprinkling on it a few
 grans ofthe red sulphurated quicksilver,
 placng the patient on  the stool.  On
 other occasions, a  small apparatus, sold
 at  the)hops, is used, which enables the
 surgeon xo  direct the fumes through a
 funnel *gains\the ulcer in any  situation.
   Though men-ion has just been made of
 venereal excres»ences,  I am of  opinion
 with Mr. Aberneny, that it is very ques-
 tionable,   whether any   are  ever really
 of this nature.  I .-now, that  many ex-
 crescences and verricae  about the  anus,
 and parts of  gener.tion,  diminish  and
 are cured by a course of mercury.  This
 is  the only argument in favour of their
 being venereal; for,  vhen tied, cut off,
" or made to fall off by -timulatuig  them
 with  pulv. sabinse and srugo xris, they
 are as effectually cured, is if mercury had
 been given.

 PREPARATIONS OF  MERCURY FOR  INTERNA!
               EXHIBITION.

    The acetite of mercury s supposed to
 be a mild preparation, and vas the active
 ingredient in the celebrated Seyser's pills.
 In  solution  it has also been recommended
 to  be applied externally for the removal
of some cutaneous  aHections.   It  may
be made into pills with crumb of bread.
 The dose is from one to five grains every
night.
  When you wish to excite  a salivation
quickly, when mercurial ointment  alone
will not produce this effect, or cannot be
employed,  and when * fumigating is not
convenient nor agreeable,  the  hydrargy-
rus calcinatus is  often prescribed.  The
common dose is a grain,   which may be
increased to two, a day.   It is apt, how-
ever,  to disagree with the stomachs and
bowels of many patients ;  but  some can
still continue to take it when  conjoined
with opium.
  The hydrargyrus cum creta  has occa-
sionally been prescribed.  The  dose is
ten grains;  but  it is  a preparation, at
present, not much in repute.
  The hydrargyrus  muriatus  (corrosive
sublimate) was a  medicine highly praised
for its  antisyphilitic virtues  by the cele-
brated Van  Swieten, and,  indeed,  there
is no doubt, that,  like other preparations
of mercury, it  possesses such qualities.
It retains great reputation even now, and,
probably will always  do so.  However,
like the hydrargyrus calcinatus, it some-
times deranges the stomach  and bowels,
and is never deserving of such confidence
as mercurial frictions.  Mr.  Pearson re-
marks, that " when the sublimate is given
to cure the primary symptoms of syphilis,
it will  sometimes succeed;  more  espe-
cially when it produces a considerable de-
gree of soreness of the gums, and the com-
mon specific effects of mercury in the ani-
mal system.   But it will often fail of re-
moving even a recent chancre; and where
that symptom  has vanished during the
administration of corrosive sublimate,,I
have known a three months  course of
that medicine fail of securing the patient
from a constitutional affection.  The re-
sult of my  observations is,  that simple
mercury, calomel or calcined mercury, are
preparations more to be confided in, for
the cure of primary symptoms,  than cor-
rosive sublimate.   The latter will often
check the progress of secondary symptoms
very conveniently ; and I think it is pe-
culiarly efficacious in  relieving venereal
pains, in healing ulcers of the throat, and
in promoting the desquamation of erup-
tions.  Yet,  even in these  cases, it never
confers permanent benefit;  for, new symp-
toms will appear during the use of it; and,
on many occasions, it will  fail  of afford-
ing the least advantage to  the patient,
from first to last.  I do  sometimes, in-
deed, employ this preparation in venereal
cases ; but it is either at the beginning of
a mercurial  course, to bring the constitu-
tion under the influence of  mercury at a- 
M E R                                  M E Z                209
early period, or during'a course of inunc-
tion, with tie intention of  increasing the
action of simple  mercury.  I sometimes,
also, prescribe it after tne conclusion of a
c >urse of frictions, to support the mercu-
rial influence in the h..bit,  in order  to
guard against the danger  of a relapse.
Hut, on no occasion whatever, do I think
it safe to confide  iu this preparation singly
and uncombined, for the cure of any truly
venereal symptom."  (Pearson  on Lues
Venerea )
  The dose  of hydrargyrus muriatus is a
quarter of a  grain.
  The following is a common mode of or-
dering it:  gj. Hydrargyri  Muriati gr. i.
Aquae Nucis  Moschatse 51J.  Misce. §ss.
Omni nocte sumenda.
  The hydrargyrus muriatus mitis (calo-
mel) is  not  much  used  by modern sur-
geons for the cure of the venereal disease.
Sometimes,  indeed, it is given in cases of
gonorrhoea, with a view of preventing  ve-
nereal  symptoms from  following.  But,
it is extensively  given  as  an alterative,
and for  the cure of such surgical diseases
as require the system to be  slightly under
the influence of mercury.  It generally
proves actively purgative, when more than
two or three grains are given.
  The hydrargyrus phosphorates has been
successfully  prescribed in  the  following
formula: &.  Hydrargyri  phosphorati gr.
iv. Coiticis Cinnamomi in pulverum triti
gr. xiv.  Sacchari Purif. jss.  Misce*
  The whole is  to be divided into e'n^ht
equal parts,  one of which is to be taken
eveiy morning and evening, unless sali-
vation takes place, when it ought to be dis •
continued.   Some patients,  however, will
bear from one to two  grains of the phos-
phat  of quicksilver,  .without  inconve-
nience.
  " This remedy has been  observed  to
heal inveterate venereal ulcers in a very
short  time,  nay, in the course of a few
days,  particularly those about the puden-
da.   In  venereal  inflammations  of the
eyes, chancres, rheumatisms, and chronic
eruptions, it has proved of eminent ser-
vice.  Upon the  whole, if  used with the
necessary precaution,  and in the hands of
a judicious practitioner, it is a medicine
mild and gentle  in  its operation.  The
cases, in which it deserves  the preference
over other mercurial  preparations,  are
these :  in an inveterate stage of syphilis,
particularly  in persons  of torpid insen-
sible fibres—in cases  of exostosis  as well
as obstructions in the lymphatic  system
—in chronic, complaints of  the skin, &c."
(Journ. de Gotha.)
  In the Pharmacopoeia Chirurgica  may
be seer, an account of the manner of mak-
ing the  hydrargyrus  phosphoratus, ■taken
    V«t.. H.
from the Journal of Inventions of Gotha,
Nu. 2.   As the author of the first  work
suggests, opium would certainly be most
likely  to correct the bad effects of the
preparation 011 the stomach and bowels.
  It is generally admitted by surgeons,
that the most simple preparations of mer-
cury are the most effectual in eradicating
the venereal disease. The pilulae hydrar-
gyri are the most simple of the internal
tbrmulz,  being merely  mercury-   tritu-
rated  v. ith mucilaginous and sacchariue
substances.  ftext tQ mercurial frictions,
they are, perhaps,  most  frequently em-
ployed  tor the cure of the incipient form
of the  venereal  disease, that is, while a
chancre is the only  complaint.  They are
also very commonly given in all stages  of
the disease, to  aid  mercurial frictions  in
bringing the system under the influence
of the specific  remedy.   Ten  grains  of
the mass, kept for these pills, is the  usual
dose.  When they purge, opium will some-
times prevent this effect.
  We must reserve other observations on
the use of mercury in syphilis for the arti-
cle Venereal Disease.
  Mercury is employed  both constitu-
tionally and locally  in - numerous surgical
cases;  for the removalof indolent thick-
enings  and  indurations"1 of parts; for the
relief of tinea capitis, herpetic diseases,
tetanus, hydrophobia,  hydrops  articuli,
and a multitude of other affections, which
we need not here specify.
  MEROCELE.  (from /«§»«, the  thigh,
and x-v^t), a tumour.)  A femoral or crural
liernia.  See Hernia.
  METACIXEMA.   (from  fttrx,  after,
and Ktvea, to remove.) A removal ofthe
pupil of the eye from its natural  situa-
tion.
  METASTASIS,  (from  ficSirr^t,  to
transfer.)   A transposition of a disease
from one part to another.
  MEZEREON.  (said,   by  Blanchard,
to be  derived from some barbarous dia-
lect.)  This medicine was recommended
by Dr.  A. Russell for a particular class  of
venereal symptoms,  in  the  following
terms :  " The disease, for which I prin-
cipally recommend  the decoction of the
mezereon root as a cure, is the  venereal
node that proceeds  from a thickening  of
the membrane of the bones.   In a thick-
ening  of the  periosteum,   from   other
causes,  I have   seen  very good  effects
from it: and it is frequently of service in
the  removal of  those nocturnal  pains,
with which venereal  patients  are afflict-
ed ; though, in  this last case, excepting
with rega; d to the pain that is occasioned
by the node,  I  own I have not found its
effects so certain, as  I at first thought I
     O n 
aO            MOL
SI 0 L
had reason to believe.  I do not find  it
of service in the cure of  any other symp-
tom of the venereal disease." (Med.  Obs.
Undlnq.  Vol.3, p. 194,  195.)  Mr. Pear
son, howeverj asserts, unequivocally, that
mezereon, has not the power of curing the
venereal disease in any  one stage, or un-
der any  one form, and if  the  decoction
should  ever reduce a venereal node, yet
there will be a necessity for taking  mer-
cury  in  as large quantity, and  for  as
long a time, as if no mezereon had  been
exhibited.   Cullen  found this  medicine
of use in some cutaneous affections, but,
excepting an instance or  two  of lepra,
Mr  Pearson has very  seldom  found  it
possessed of medicinal  virtue, either  in
syphilis, or the sequelae  of that disease^
scrofula. Or cutaneous affections.  (Pear-
son on Lues Venerea, p. 55—59.)
  MIASMA, (from  ptettva, to pollute.)
The matter, or effluvia producing conta-
gion.
  MODIOLUS, (dim. of modius,  a  mea-
sure.)  The crown, or  saw of a  trepan,
so called, because it was  formerly  con-
trived to enter to a certain depth.
   MOLLIT1ES  OSSIUM.   A  morbid
softness of the  bones, which become pre-
ternaturally flexible,  in  consequence  ei-
ther of the inordinate absorption  of the
phosphate of lime, from which  their na-
tural solidity  is derived, or else of this
matter not being duly secreted and depo-
sited  in  their fabric.   In rickets, the
bones only yield  and become distorted by
slow  degrees,  and retain their natural  in-
flexibility j  but,  in the  present disease,
they  may be at once bent in any direction.
The  mollities  ossium  is  rare,  and  its
cause not understood.   To give  an idea
of the disorder, I shall quote the  case of
Madame Supiot  In  the  year 1747 she
had a fall, which occasioned her to  keep
her bed for some time, and left great pain
and weakness in  her loins, and  lower ex-
tremities.   In about a year and a half  af-
terwards, she  began to  perceive her left
leg  particularly  affected.    Along  with
this weakness, she  had violent pains over
her whole body, which  inc: eased after a
miscarriage, and still more after  a  natu-
ral delivery, in the year 1751.   She was
now  seized with  startings, great  inquie-
tude, and such violent heats, that she was
almost continually in a sweat, and could
not  bear the  least covering even in the
coldest weather, and while her pains con-
tinually increased, she  took notice that
her urine precipitated  a white  sediment.
Her  pains  abated  on  the appearance of
the sediment,  but she now observed that
her limbs began  to bend, and from this
time the softness of them gradually  in-
creased  till her death.  In the  month of
April 1752, the trunk ofthe body did not
exceed 23 inches in length; the  thorax
exceedingly ill formed, and the bones of
the upper part very much distorted; those
of the lower  part were  very much bent,
and the thigh-bor.es  became so  pliable,
that her feet might easily be laid on each
side of her head.  The right side did not,
till after some time, become so deformed
as the left; but it was  surprising to ob-
serve the  alterations  which  daily  took
place, and tlie different  figures assumed
by the limbs; in consequence of the in-
creased softness of the bones;  so  that
when the  sediment in the urine was con-
siderable, the  disease of the bones seemed
to  be at a stand, increasing considerably
when it  was  suppressed.   Besides  this,
she had violent pains, startings, difficulty
of breathing,  spitting of blood) and, last-
ly, a fever, with convulsions.  She  died
in the beginning of November 1752, and,
on  dis-ecting her body,  the following ap-
pearances were observed: 1  The muscles
in general were of* a very soft and pale
consistence, the vastus externus, f'ascialis,
quadriceps, biceps, and external parts of
the gracilis,  were  much shorter than  in
their  natural state, and more firm and
tense; while  those  on the opposite side
were much elongated, thin*  and very ten-
der ; in short, the whole muscular system
had suffered more  or less, according to
the action of the muscles in her life time.
2. The bones  were entirely dissolved, the
periosteum  remaining  unhurt,  so that
they exhibited only the form of a cylinder.
3.  The  heart . and  large blood-vessels,
both veins and  arteries, contained  large
black polypi, of  a  viscid consistence,
and very unlike those  usually found in
dead bodies.
   A case of softness of the bones is re-
 lated by Mr.  Gooch, but considerably dif-
 ferent from the above, as it was attended
 with a remarkable  fragility of the  bones
 before  they became soft.  It likewise  be-
 gan -with pains through the whole  body,
 attended with  feverish sy mptoms ; but,
 after some weeks, they became confined
 chiefly to the  legs  and thighs, though
 they  were not  increased  by  pressure.
 This fragility of the bones does noj ap-
 pear to  have been the case with Madame
 Supiot   In  the month of  June, 1742,
 Mr. Gooch's patient  broke her leg, in
 walking  from  her  bed to a chair,  and
 heard the  bone snap.  No callus, how-
 ever, formed, though the fracture was in-
 stantly reduced, anil treated by one of the
 best surgeons in that part of the country;
 but, instead  of this, the bones began to
 grow flexible, and, in a few months, wert
 so from the knee to the ankle.  The  dis-
 ease still continued to increase, so that. 
MOL
M OR            2U
Ina  short time, the other leg • and thigh
were affected  in the same  manner, after
which both legs and thighs  became cede-
matous, liable to excoriations, and to dis-
charge  a  thin  yellow ichor.   Scorbutic
symptoms began to appear in the winter
after her leg  was broken, and  her gums
began to bleed.  Tonic  medicines  were
exhibited without  any success, only that
her menstruation  became more regular,
and her appetite and digestion better than
before;  but, towards tlie end of her life,
her breathing became difficult, the spine
distorted, and  a pain in  the  loins took
place upon every motion of the  vertebrae;
and, as  her  limbs was now quite useless,
she was obliged to sit upright in bed.  At
last, the end of the bones, on which she
sat, having become also very soft, spread
much,  and the ends  of her fingers and
thumbs, by  frequent endeavours to raise
herself,  became also very broad, and the
phalanges  crooked.  The  flexibility  of
the  bones  gradually  increased, and be-
came more general, attended with a wast-
ing ofthe flesh, and excessive difficulty of
breathing.  The menstrual  flux totally
ceased four months before her death; her
legs, which were very  anasarcous, and
fKcoriated almost all over, became erysi-
pelatous, but  she retained her  senses  to
the last.  She expired suddenly, having
talked in  a composed manner concerning
her miserable situation and approaching
end only a few moments before.
  On examining the body, she was found
to have lost two feet two inches of her
natural   stature.   The heart  and  lungs
appeared sound, but had been much con-
fined, principally by the liver, which was
enlarged to  an extraordinary degree;  it
was not, however,  scirrhous, nor in any
other way diseased.  The spleen was very
small, and the mesentery had one  large
scirrhous gland. All the hones, except tiie
teeth, were softened, so that scarcely any
of them could resist the knife;  but  those
of the lower extremities were  the most
dissolved, being changed into  a kind of
parenchymous substance, like  soft  dark-
coloured  liver,  without any   offensive
smell.   So completely, indeed,  were they
decomposed, that the knife met with less
resistance in cutting through them, than
in sound  muscular flesh,  though  some
bony lamellae were  here  and there to  be
met with,  but as thin  as   an  egg-shell.
The most compact bones, and those which
contained the greatest quantity of mar-
row, were the  most dissolved   and  it
Was  observable, that the dissolution be-
gan  internally, for the bony laminae re-
mained  here and  there  on the outside,
and no where else.  The periosteum was
rather   thicker, than ordinary, and the
cartilages thinner;  but, not in a stAte of
dissolution.  The  bones  were found to
contain a great quantity of oily matter
and little  earth.  No cause coultl be  as-
signed for the disease;  and in the case of
Madame  Supiot, the one  assigned, viz.
that of  her  eating too much salt,  seems
totally inadequate to explain  the  origin
ofthe disorder  All the cases ofthe mol-
lities ossium on record have proved fatal,
and no  means of cure are yet known.—
Morand in Mem,  de I'Acad, des  Sciences,
1752.   See also  Chirurgical Observations
and Cases, by  William Bromficld, Vol- 2, p.
30, &c. We meet  with cases of  this  nature
in the  Philosophical  Transactions; Act.
Hafmens; German Ephem.;  Saviard's Obs.
Cldr. ; the writings  of Forestus; Gooche's
Chirurgical  IVirks, ' Vol. 2, p.  393—399-
EtUt. 3792 ;  &c.
  MONQCULUS.   (from   fcom,  single,
and oculus, the eye.)  A bandage former-
ly applied to the fistula lachryinalis, and
diseases  of  the eye.  It   consists of a
single-headed  roller three ells long.   To
apply it to the right eye, it is  to be held
in the right hand, and its end in the left,
et vice versd. This, end isi to.be put on the
back of the neck,  and one turn of  the
roller is to be carried round, over the fore-
head, so as to meet  the extremity  of  the
bandage.  The roller is then  to descend
under the ear of the side affected,  and to
pass obliquely over  the cheek underneath
the eye, and next over the root of the nose,
and opposite the parietal bone, to the nape
of the neck.  The third turn of the roller
is to, overlap the second a little; the th'int
the fourth ;  making what the French call
doloires,- and the application of the band-
age is completed by making tuns ronnd
the head. The use of the monoculus was.
only to retain dressings.  (Eucyclopedif
Methodique;  Par tie Chirurgicale.).
   MORTIFICATION', (mortificatio, from
rjors,  death, and flo, to become.) The
death of a part ofthe body.
   Mortification is of two kinds, the  one
without inflammation,  the other preceded
by it   Inflammation is an increased ac-
tion of that power, which apart naturally
possesses ; and in healthy  inflammations,
at least,  it is probably attended with an
increase of  power.  In cases» however,
which are to  terminate in mortification,
there is no increase  of power; but, on  the
contrary,  a diminution of it. This, when
joined to an increased action, becomes a
cause of mort ification, by destroying the
balance, which ought to subsist between
the power and action of every part.  There
are, besides, cases  of mortification, pre-
ceded by inflammation, which do  not
arise wholly  from   that,  as a  cause  : of
this kind, are  the carbuncle  and  thg 
112
MORTIFICATION
 slough formed  in the small-pox pustule.
 (Hunter.)   When any  part of the body
 loses all motion,  sensibility, and  natural
 he«t,  r.nd becomes of  a brown, livid, or
 black colour, it is said to be affected with
 sphacelus,  that is, complete mortification.
 As  long as any sensibility, motion, and
 warmth, continue, the  *>tate  of  the dis-
 order is termed, gangrene.  This word is
 here made use of to signify only a degree
 of  sphacelus, or rather the process, by
 which any local  disorder falls into the
 state  of  complete  mortification.  Many
 authors use  both terms  synonymously;
 but, it is  to be observed, that gangrene
 does not invariably end in sphacelus; nor
 is the  latter always preceded by the form-
 er.  (Richler's Anfangsgr. der Wundarzney-
 kunst. Band 1. Kap. 3.)  There are some
 surgical writers, however,  who make the
 distinguishing circumstance of sphacelus to
 be the extensionof the disorder to the bones
 as well as the soft parts.  (Lassus, Patho-
 logic Chirurgicale, Tom. l,p. 30,Edit. 1809.)
   The causes of mortification are either
 internal, or external.   It  is  commonly
 taught in the medical schools on the con-
 tinent, that the internal causes probably
 operate after the manner of a deleterious
 substance, which being introduced  into
 the  circulation,  occasions  a putrefaction
 of the fluids. (Lassus, op.  et  loc.  cit)—
 This doctrine, however, is supported by
 no sort of proof,  and may  be considered
 as entirely hyppthetical, if not decidedly
 erroneous.
   There are, indeed, as  the  preceding
 author has  noticed, some  spontaneous
 mortifications,  the  primitive cause  of
 which is not always well understood : an
 inflammation, apparently slight, may be-
 come gangrenous immediately it has made
 its  appearance.   In  scorbutic,  venereal,
 and  small pox cases, we have daily in-
 stances of this fact.  Other internal causes
 sometimes cut off, without any very evi-
 dent pre-existing disease,  persons, who
 are  but little advanced in years.  (Savi-
 ard, Obs.  16.  Haller,  Disput.  Chirurg.
 Tom. 4, p. 551.)  Certain poisonous, acrid,
 caustic substances taken inwardly,  or in-
troduced under  the skin, may  have the
same effect, by  annihilating the vital ac-
tion, or destroying the  texture of parts.
 (Lassus, Pathologie Chirurgicale, Tom. l,p.
31.)   But, though these observations may
all be entirely correct,  they by no  means
justify the conclusion,  that the internal
causes of  mortification ever act like a de-
leterious matter  producing a putrefaction
of the fluids.  The mortification of  the
toes  and feet, so  well described by Mr.
Pott, proceeds from internal causes, which
have not hitherto admitted of any accurate
explanation.
   Another very remarkable  specimen of
 mortification from an internal  cause, is
 that  originating from eating bread made
 of bad black wheat, or rye.   It is curious,
 that  this case, both in  man and other
 animals, always begins upon the extre-
 mities of the limbs. (Mem. de I'Acad, des
 Sciences, ami. 1710. p. 61.)
   The  external causes  of mortification,
 which are manifest, and act mechanical-
 ly, are burns ; excessive cold;  the appli-
 cation of caustics ;  the  presence of any
 ichorous, urinary,  or fecal  matter effused
 in  the cellular substance ; violent contu-
 sions, such as are produced by gunshot
 wounds, or bad fractures;  the .strangu-
 lation of a part, as in cases of hernia, or
 when  polypi, or other tumours are tied;
 a high degree of inflammation ; and, last-
 ly, every thing,  that has the power of
 stopping the  circulation  and  nervous
 energy m parts.  (Lassus, Pathologie Chi-
 rurgicale, Tom. ),p. 34, 35.)
   Inflammation  is one of the  most fre-
 quent occasional causes  of  mortification.
 But,  as we  have   already remarked, the
 death of  a  part may  take place without
 any previous inflammatory disorder; and
 the latter, even when present, has fre-
 quently  less share in the  mischief,  than
 other incidental circumstances, and is, in
 reality, only an effect of the very  same
 cause, which  produces the  sphacelus  it-
 self.  It  is oftentimes a matter of doubt,
 whether actual inflammation precedes the
 occurrence, or not; for, a part, before it
 mortifies, is often  only affected with pain,
 and with no degree of preternatural red-
 ness.   Lastly, when  mortification is, un-
 questionably, preceded by inflammation,
 there are  so  many varieties  of the dis-
 order, depending  on  incidental causes,
 that these latter demand more  attention,
 than  the inflammation itself.  (Richter'a
 Anfangsgr. Band 1, Kap. 3.)
   Healthy phlegmonous, inflammation sel-
 dom ends in  mortification,  though it oc-
 casionally does so,  when very extensive
 and vehement.
   Of  all the inflammatory complaints,  to
 which the system is liable, erysipelas is
 observed most frequently to terminate in
 gangrene, and whenever phlegmon is,  in
 any degree, conjoined witiran erysipela-
 tous affection, which it not unfrequently
 is,  it seems thereby to acquire the same
 tendency, being more difficult to bring to
 resolution, or suppuration, than the true
 phlegmon,  and more apt to run into a
 mortified state. {B.Bell.)
  The symptoms of mortification from  in-
 flammation take place variously,  yet, ge-
nerally, as follows.  The  pain  and sym-
pathetic  fever  suddenly diminish, the
part affected becomes soft, and of a,livid 
MORTIFICATION.                           213
folour, losing, at the same time, more or
less, of its natural  warmth and sensibili-
ty.  In some places, the cuticle is detach-
ed ; while, in other  situations,  vesicles
arise, filled  with a clear, or turbid fluid.
Such is the state, to which we apply the
term, gangi'ene,  and, which stage of the
disorder too  often rapidly advances  to
sphacelus,  when  the part becomes a cold
black, fibrous, senseless substance, called
in technical language a slough.
  The causes which produce  mortifica-
tion by impeding the return of blood from
the part affected, tor the  most part ope-
rate by making pressure on the trunk, or
principal branches,, of  a vein.   In  these
instances, there  is  always an  accumula-
tion of  blood in the part,  which  first
swells, becomes of a livid colour, tense,
and very painful.  Soon afterwards,  blis-
ters arise, and the part becomes soft, oede-
matous, cold, insensible, emphysematous,
black,  and fetid.  Such are the  circum-
stances, which happen  in strangulated
herniae, in tied polypi,  and in a  limb, in
'which  the veins have been so compressed
by  any hard swelling, such as the  head
of  a dislocated bone, as to excite morti-
fication.
  Other causes operate by preventing the
entrance of  arterial blood.  The ipplica-
tion of a ligature to an  artery, as prac-
tised in  several  surgical cases,  and all
external pressure, that closes the artery,
or arteries, on which a  part entirely de-
pends  for its  supply of blood, have this
effect.  Mortification does not, however,
always take place,  when the  trunk of an
artery  is rendered impervious,  because
nature  furnishes the necessary supply of
blood, through  collateral ramifications.
But, when the disorder does happen, the
part commonly first becomes pale, flaccid,
and cold, and soon afterwards  shrinks,
loses its sensibility, grows black, and pe-
rishes
  It is usually  represented  by  writers,
that mortification  may proceed  from  a
mere lessening of the communication of
blood and nervous energy to a part.  How-
ever, it is to  be observed,  that parts, de-
prived of all connexion  with  the sensn-
rium, by the division, or  paralytic state,
of  their nerves,  do not  frequently perish
On this account.  But, as  their functions
are carried on with less vigour, and their
vitality is weakened, the same  causes,
which  sometimes produce mortification
in parts differently circumstanced, must
much  more readily occasion it in these.
Among the causes ofthe present species
of mortification, may he mentioned great
mii^sWtl  debility;  extreme  old  age;  a
thickening and  ossification of the coats
of  the  arteries, and a  consequent dimi-
nution of their capacity, and of their mus-
cular and elastic power.
  The  mortification,  arising from long
continuance  in  the  same   posture,  is
chiefly  attributable  to the  unremitted
pressure, which parts sustain, and which
obstructs the circulation.  Surgeon? have
frequent occasions to see  melancholy ex-
amples of this kind of mortification, par-
ticularly,  in cases  of fracuires, paralysis
from disease of the ve.tebrae, &c.  The
mischief most readily occurs, where the
bones have the least flesh upon them, and,
consequently, where all external pressure
has the most effect; as, for instance, about
the  os  sacrum, os ilium, spines  of  the
scapulae, &c.   The disordered part always
first  becomes soft,  livid,  red at the  cir-
cumference,  and, adematous, afierwards
losing its  sensibility, and  acquiring a
black appearance :  at length,  it is convert-
ed into a foul sloughing ulcer.
   Though long continuance  in the same
posture is the grand  cause of this kind
of  mortification; yet, incidental  circum-
stances are frequently combined with it,
and have  great influence over the disor-
der.  These are, great debility, the same
state ofthe system, as exists in typhusje-
ver, impure air, unclean bedding,  &c. -
  There are some causes,  which produce
death in a part at once, by the violence
of  their operation.   A blow,  struck very
forcibly, on  any portion  of  the  body,
may destroy the vitality of the fibres and
vessels  in this sudden manner.  When a
ball enters  the substance of  parts with
great force and  rapidity, it always kills
at once many of the fibres, which are in
the  way of its track,  and these  must be
thrown off in the form of  sloughs, before
the wound can granulate and  heal.
  Cold is often another cause of  mortifi-
cation, and, when parts, which have been
frozen, or frostbitten, aresuddei.lv warm
ed, they are particularly apt to slough.
  1  find  in M. Larrey's  late  valuable
publication,  some  interesting  observa-
tions on  the  gangrene from cold,  lie
acquaints, that after the battle of .Eylau,
one  of the  most  grievous  events, to
which the French soldiers were exposed,
was the freezing of their feet, toes, noses,
and ears:  few of the vangtia. d  escaped
the  affliction.   In  some,  the mortifica-
tion was confined to the surface of the in.
teguments ofthe toes, or heels ;  in some,
the skin mortified more deeply,  and to a
greater or lesser extent; while, in others,
the whole  of the toes, or foot, was de-
stroyed.
  " All the  writers  on  this species of
mortification (says M. Larrey)  have con-
sidered cold as  the determining  cause ;
but, if we attend to the period when  the 
214
I MORTIFICATION.
complaint begins its  progress,  and the
phenomena,  winch  accompany  it,  we
shall be convinced, that cold is merely
the  predisposing cause   In fact, during
the three or  four exceedingly  cold  days,
which preceded the battle of Eylau,  (the
mercury having then fallen to 10, 11. 12,
13,  14, and  15 degrees  below  zero of
Reaumur's thermometer) and until the
second day after the battle, not a soldier
had  complained of any symptom depend-
ing  upon the freezing of parts.  Never-
theless, we had passed these days,  and a
great portion ofthe nights of the 5,  6, 7,
8, and 9th, of Feb.  in the snow, and the
most severe frost.  The imperial guard
especially, had remained upon watch  in the
snow, hardly moving at all for more than
four  and twenty hours, yet,  no soldier
presented himself at  the  ambulance,*
nor did  any  one complain of having the
feet  frozen.   In the night of the 9th and
10th of  February, the temperature sud-
denly rose, the mercury ascending to 3,
4, and 5 degrees above zero.  A  great
quantity of sleet  that fell  on the  morn-
ing of the lOth,  was the  forerunner of
the thaw, which took place in the course
of that day,  and continued in the  same
degree for  several days.  From this mof
ment,  many soldiers of the guards and
the  line applied  for  succour, complain-
ing of acute pain in the feet, and of numb-
ness, heaviness, and prickings in the ex-
tremities.  The parts were scarcely  swol-
len,  and of an obscure  red  colour.  In
some cases, a slight redness  was percep-;
tible about the base of the toes, and on
the back ofthe foot.   In others, the  toes
were destitute of motion, sensibility, and
warmth, being already black, and,  as it
were, dried.  All the patients assured me,
that they had not experienced any  pain-
ful sensation  during  the severe cold, to
which they had  been  exposed on the
night watches ofthe 5, 6, 7, 8, and 9th, of
February, and that  it  was not  till the

  *  The ambulances of the  French  army
are caravans,  furnished with an  adequate
number of surgeons,  and every  requisite
for the dressing of wounds, and  the im-
mediate performance of operations,  upon
which last circumstance,  in particular,
the life of the wounded soldier often de-
pends.  These caravans  follow the  most
rapid movements  of the  army,  and are
always capable of keeping up with the
vanguard.  It is to be  regretted,  that
no surgeon-general  of our army has ©rw
ganized any thing of this sort ;  it is the
only means,  however, by which speedy
surgical assistance can be rende ed to the
thousands of  wounded in every consider-
able  action.
night of the 10th, when the temporal m*
had risen from 18 to 20 degrees, that they
felt the first effects  ot the cold."  It  is
further noticed by M. Larrey, that such
patients as  had had  opportunities  of
warming themselves  in the town, or  at
the fires of the  night watches, suffered
in the  greatest  degree.   (See Larrey's
Memoires de  Chirurgie Militaire, Tom. 3,
p. 60—62)
   Sometimes  mortification seems  to de-
pend on epidemic causes.   Instances have
been known, in which almost all the  ul-
cers and wounds in large  hospitals, have
become nearly at the same time afiectetft
with gangrenous  mischief.
   The hospital gangrene, as it is commonly
called,  is said to be produced by the pu-
trid effluvia in hospitals, gaols, and ships,
where the sick are crowded  together  in
great numbers. " It is (observes Lassus)
a true contagion, which is  communicated
to the wound, or  ulcer, by the  mere ap-
plication of linen, or lint,  that  has been
for a certain time in some place,  where
the air is impregnated with these delete-
rious  miasmata.  The impression made
on the skin, throat,  lungs,  and  intestinal
canal, by such pernicious emanations, oc-
casions gangrenous   diseases, which are
sometimes epidemic. . This affection, the
progress of which is  so rapid, especially
in cold (lamp weather,  and in debilitated
subjects, first shows  itself locally in the
form of greyish  ash coloured spots, like
the aphthae, which appear  on  the surface
of the ulcer.  Such spots afterwards turn
blackish, the vital powers  sink, and the
ulcer daily enlarges, emitting a most fetid
smell."  (Lassus,  Patliologie Chirurgicale,
Tom. l,p. 37,38.)
  Mortification is very  frequently  occa.
sioned by the injury, which parts sustain
from the application of fire, and heated
substances  to them.  When  the heat  is
very great,  the  substance  of  the body is
ever decomposed, and of course killed at
once   On other occasions, when the heat
has not been  so  violent,  nor sufficiently
long  applied,  inflammatory symptoms.
precede the sloughing.
  It is a curious  fact, that the blood co-
agulates in the large arteries, which lead
to a  mortified part.   This  occurrence
takes  plaee for some  distance from the
slough, and is the reason,  why the  sepa-
ration of a mortified limb is  seldom fol-
lowed by hemorrhage.
  When gangrene  and sphacelus  take
place, the patient is  usually troubled with
a kind of hiccough.
  The constitution also  suffers,  immedi-.
ately a considerable  dejection. * J'h^pa-
tient's countenance  suddenly -"Brumes a
wild cadaverous look ; the pulse  become*, 
MORTIFICATION.                           215
small,  rapid, and sometimes  irregular t
Cold perspirations come on, and  the pa-
tient is often affected with diarrhoea and
delirium.              ,
  The generality of writers  have distin-
guished gangrene and mortification, into
the dry and humid kinds, according as the
disordered part is found free from  much
moisture,' or not.  It does  not  appear,
however,  that  such distinctions lead  to
any useful objacts in practice.   Cases,  of
what  has  been  termed  dry  gangrene,
never occur  from  inflammation.   They
commonly happen from  the flow of blood
to  the  parts affecteU being stopped by
some kind of compression, or another,  as
by tumours, ligatures,  or other  similar
causes, obstructing the  principal arteries,
which used to supply  the  parts now in a
mortified state.  Such causes,  when the
stoppage of the circulation  is  complete,
always  occasion  a very slow  mortifica-
tion ; and, as the parts in such  instances,
are no longer supplied with fresh quanti-
ties of fluids, while a conside. able evapo-
ration must be going on, there must  be
less humidity, than in other cases of mor-
tification (B. Bell.)
  Authors have enumerated other  varie-
ties of mortification, as for instance, the
white gangrene, in which the parts, sup-
posed to be mortified, do not turn  back,
but retain  nearly their former colour,
( Quesnay.)
  All mortifications spread in one of the
following ways , either the  living circum-
ference sphacelates, without undergoing
any previous, perceptible changes,  or the
part first inflames, and then dies.   The
difference, in regard to the quickness,  or
slowness, with which sphacelus  spreads,
is exceedingly  great,  in different cases.
   In  cases of sphacelus,  the prognosis
chiefly depends on the nature ofthe cause
of  the disorder.  The more  easy the
cause is  of removal, the  less  room  is
there  for alarm.   It is an erroneous sup-
position,  that  mortification arising from
an external local  cause, is  more  easy  to
be  stopped and cured, than  that  origi-
nating  from an internal one.   The local
cause is sometimes exceedingly difficult,
or  even  incapable, of removal;  and a
sphacelus, which is at first entirely local,
may  afterwards  become a general dis-
order, by the universal debility, and de-
rangement of the system, resulting from
the absorption  of  putrid matter.   Hence,
it is obvious, that a sphacelus  may easily
extend beydnd the bounds of its outward
local cau.-.e.  On  the other hand, a mor-
(ification may be reduced to one  of a na-
ture entirely local, though it arose at first
from   constitutional  causes.   Sphacelus
from  extreme  debility,  or  from such a
state of the system, as attends  the scur-
vy, typhoid fevers, &c. is constantly peri-
lous, beciuise these causes  are very diffi-
cult  to  remove.  It is also a fact, that,
when numerous causes are combined, it
is an unfavourable occurrence, not merely
because the surgeon is apt to overlook
some of them, but, because there are in
reality more obstacles to the cure.
  There is a  species of sphacelus, which
spreads With  very  great  rapidity, and, as
the surgeon has scarcely time to employ
the necessary means, tiie case is exceed-
ingly dangerous. Sometimes, a mortifica-
tion spreads  so slowly, that it does not
occupy much extent at the  end of several
months, or even a whole year. The case,
however, is often  not the less  fatal on
this account.  The danger  is never alto-
gether over, until the dead  part has com-
pletely separated.   The  entrance of pu-
trid  matter into the circulation is so in-
jurious, that patients  sometimes perish
from this cause, long  after the mortifi-
cation has  ceased  to  spread.  (Richter'*
Anfangsgr. der Wundurzn. Band 1, Kap. 3,
p. 78, 79.)
  This  last  circumstance  is very much
insisted upon, by  all  the modern conti-
nental  surgeons; but, I cannot pretend
to determine, whether the doctrine is cor-
rect, or not.  Certain it is, that  few prac-
titioners in this country entertain much
apprehension of the bad effects of the
absorption of putrid matter in  cases of
mortification.
 . The danger of  sphacelus is  also  pro-
portioned to the size  and importance of
the part affected.   The event of the dis-
temper likewise depends very  much on
tiie patient's age and constitution.
   Parts, affected with gangrene, do not
immediately  lose the whole of their  sen-
sibility ; the  circulation is still continued
in a certain  degree; and when  the  pro-
gress of tiie  distemper does not surpass
certain  bounds, the  functions  of  such
parts may be completely  re-established.
Gangreite, strictly  speaking, is not a de
cided mortification; butj only  the fore-
runner  of*  this latter mischief, and  may
be regarded as the  intermediate  link,
between the most' violent stage of inflam-
mation  and sphacelus.   The presence of
this last implies the total  loss of life in
the part  affeeted, the destruction of its
organization, the abolition of all its func-
tions, and an absolute inability to resume
them again.  However, even when we see
a  part  manifestly  sphacelated, we  must
not always conclude, that  its entire de-
struction is  certain;  for, in many cases,
the disorder  only affects tiie skin and cel-
lular substance.   The  integuments  fre-
quently  slough  away, and we  have th- 
2! 6                             "MORTIFICATION.
 happiness  to  perceive, that the tendons,
 qu.scles, and  other organs, which they
 cover, remain perfectly sound, ai.d leave
 room to entertain hopes of a cure.
   It  is easily  comprehensible,  that it is
 only  in external affections of  the body,
 that the progress of inflammation to gan-
 grene and  sphacelus can be marked with
 i.ny  degree of  precision.   But,  as  we
 have indeed  already  observed, the  ap-
 proaches of the latter are  not  invariably
 announced  by the  distinct and manifest
 symptoms  of  gangrene, even  when  the
 disorder is quite superficial.   There  are
 cases, which justify the conclusion, that
 a small part of  the body may  be affected
 with sudden death, just in the same man-
 ner as the  whole machine.  Sphacelus is
 often seen making its appearance in a
 part, which is apparently quite healthy,
 without  being  preceded   by  any  other
 5-ymptom, than a sudden acute pain in  the
 seat of the mischief.  Sometimes, in  the
 earliest period of tlie complaint, a black
 spot, which rapidly  spreads on every side,
 may be observed.
  In order  to be able to form a just pro-
 gnosis, all  the above circumstances must
 be  taken into consideration, and, in par-
 ticular, we  must never deliver an opinion,
 without having closely examined the pro-
 gress  of the  disorder; for, should  we
 make a favourable prognosis from such  ap-
pearances, as might justify us as much as
 possible in so doing, there is always great
 risk of finding ourselves most miserably
 mistaken by the event of the case.  In
 all  cases  of considerable  mortification,
 even  when  arising  from an external
cause, the patient cannot  be deemed  ex-
 empt from danger, not only while  no  se-
paration ofthe mortified parts has begun,
 but, also, not before such parts have been
completely detached from the sound ones.
After the  progress of mortification has
ceased, patients  have  been known to  pe-
rish suddenly,  without there being a pos-
sibility of suspecting  any other causes of
this  catastrophe, than  tlie operation of
putrid matter  on  the animal economy
and nervous system after absorption.
      TIlEATMKNT OF MORTIFICATION.

  We shall arrange under two heads what
we have to say on the treatment of morti-
fication.  Under the first, we shall com-
prehend every thing, which relates to in-
ternal remedies, and such other ge: eral
means, as are indicated by the general
sfate of the system.  Under  the second,
we shall speak of topical remedies, and
of the local  treatment of  the  parts af-
fected.
            GENEBU "M 1 VNS.
 1. Evacuations and Antiphlogistic Remedies.
   When mortification seems to depend on
 the  violence  of inflammation, tiie  first
 indication is to moderate  the inordinate
 action of the sanguiferous  system, by the
 prudent employ nent of such means  as
 ;ne  proper  for  counteracting inflamma-
 tion.  The subjec* is treated of in Inflam-
 mation, and it is not necessary to enter here
 into any  repetitions.  When bleeding has
 not been sufficiently practised, during the
 state of the inflammation  antecedent to
 the  mortification, and  when  the general
 symptoms, which point out the existence
 of this state,  continue violent, and, espe-
 cially, when the pulse is still quick, hard,
 or full, it is absolutely necessary to empty
 the  vessels a little more, even though
 mortification has begun, particularly, if
 tiie  patient  be  young and  pletlioric.
 Bleeding, by diminishing the fever, and
 abating the general heat, is  frequently
 the  best means of all.  It may then be
 considered  better,  than all  antiseptics,
 for stopping the progress of the disorder.
 But, this evacuation is to  be employed
 with a great deal of circumspection ; for,
 should it be  injudiciously resorted to,
 from the true state ofthe system not being>:
 understood, the error may be followed by
 the  most fatal consequences.  It shogld
 also   be well  remembered,  that  liou
 strongly soever bleeding may be indicat-
 ed, the moment is commonly not long in
 coming, when this  evacuation is totally
 inadmissible, especially when the  morti-
 fication makes much progress.
   What  we have observed,  concerning
 bleeding, is equally applicable to other
 evacuations, particularly those which are
 obtained by -purgative  medicines;  and,
 which become dangerous when they lower
 the patient's strength to a  certain  point,
 or when they are accompanied with too
 violent  an  irritation  of  the  intestinal
 canal,  operating  sympathetically on tlie
 whofe  system.   Emetics, tiie  effects  of
 which  are always apt  to be confounded,
or compared,  with  those  t-f purgatives,
 act in a vei y different  and much more
 advantageous manner in cases of mortifi-
cation, especially that species of the di»7
temper, which arises  in  consequence  of
erysipelatous  inflammation.    Such,  for
example, is  the  inflammation, often  seen
in hospitals, in consequence of compound
fractures, or  other kinds. of wounds.
 When  this kind  of inflammation makes
its appearance, and  even after the symp-
toms of  mollification have begun to ap-
pear, an emetic,  g v-n  in small repeated
dose , so as to excite vomiting, is one \>f
 the best nieaus of resisting the ..progress. 
MORTIFICATION.
217
of the disorder.  But, if, instead of occa-
sioning  vomiting,  the  medicine  should
only produce  evacuations  per anum  as
sometimes  is the case, we must not per-
sist in exhibiting it, lest it should prove,
like every other cathartic,  pernicious to
the patient. A strict regimen, which may
have  been useful  and even  necessary,
during the inflammatory stage, may also
have a very bad effect, if continued too
long,   by   diminishing  the   patient's
strength, which, on the contrary, should
be  supported  by  the  most  nourishing
food.

    2. Tonic and Antiseptic Remedies.

   This leads us to a second very essential
and important indication to be  fulfilled,
as soon as the symptoms, announcing the
existence of the inflammatory state, ap-
pear to abate, and the patient begins to
be debilitated.   This indication is to pre-
vent excessive weakness by the  suitable
employment of cordials, and,  particular-
ly, of tonics.  These same  means also
contribute to place the system in a proper
state for freeing itself from the mortified
parts, or,  in other words,  for detaching
them. For, inflammation is the prepara-
tory step, which nature takes to accom-
plish the  separation of mortified  parts
from  the living ones, and,  such  salutary
inflammation  cannot take  place, if the
energies of life be too much depressed in
the rest of the system.
   In  order to fulfil the above indication,
it is necessary to  prescribe a nourishing
diet,  with  a certain quantity  of  good
wine,  proportioned   to   the  patients
strength, and the  symptoms of the com-
plaint.   This   diet  is  generally  pro-
ductive  of more  real  benefit, than the
whole class of cordial  and  stimulating
medicines.  However, when the patient
is  very much weakened, when the mor-
tification of the  part  affected  is  com-
plete, and the  disorder  is  spreading
to others, some of the following remedies
 may  be  ordered:  volatile alkali; aroma-
 tic confection, &c.  In general, however,
 wine is best:  because more agreeable
 than  cordials, and, for this purpose, one
 ought to prefer the most perfect wines,
 such as those of Spain and Madeira.
    Of all the medicines, hitherto recom-
 mended for  the  cure of mortification,
 there is certainly not  one, that has ac-
 quired such  a character for  efficacy, as
 the Peruvian bark.  It is said,  that this
 remedy often stops, in a very evident and
 expeditious  manner,  the  course of the
 disorder.  Being a very powerful tonic, it
 is thought to operate by strengthening the
     Vol.  U.
system, and  thus  maintaining  in  every
part the necessary tone for resisting the
progress of' mortification.   But,  what-
ever may be its mode of acting, the ad-
vocates for'this medicine contend, that it
is  now a weil-known fact, that  it ought
to  be  employed in  almost all cases ot
mortification, as soon as  the violence of
the  inflammatory  symptoms  has  been
appeased.
  It was Mr. Rushworth,  a  surgeon at
Northampton, who  made  this discovery
in the year 1715  Amyand and Douglas,
two surgeons in London, soon afterwards
confirmed the virtue of this remedy.  Mr.
Shipton, another English  surgeon, has
also spoken, in the Philosophical Trans-
actions, of  the good effects, which he
has produced by this medicine.  In the
Medical Essays^ of Edinburgh,  we  find
several cases, illustrative of the efficacy
of  bark in cases of  mortification.   We
there are informed', that when its exhibi-
tion was  interrupted, the separation of
the eschars  was retarded, and  that, on
the medicine  being  resorted to  again,
such  a separation went  on again  more
quickly.  Since this  period, all practi-
tioners, both in England, and elsewhere,
have had recourse  to this remedy, which
has every where  obtained the highest
praises.   Unfortunately,  these  praises
have induced surgeons to employ it indis-
criminately,  and with equal confidence,
in  all  cases.  Hence, the  partial want of
success, which occurred, led  some to de-
cry the Peruvian bark almost generally;
until observations, made with the greatest
ca^e  and circumspection,  re-established
its credit, by shewing the  limits, beyond
which, its efficacy is not to be depended
upon.
   We cannot  indeed doubt, that bark
has frequently had  the   most salutary
effect, in cases of mortification, though
sometimes it may probably have had  im-
puted to  it effects,  which were entirely
produced by nature.   In many cases, how-
ever, bark is evidently hurtful,  when  ex-
hibited prematurely.  There are  other
instances, in which it is impossible to em-
ploy  it in  sufficient quantity, the sto-
mach  not being able to  bear it  in  any
form.  In  general, it should never be ad-
ministered, when the pulse is  high, and
other inflammatory symptoms exist; but,
when the tension of the  part diminishes,
the pulse sinks, when symptoms of weak-
ness commence, and, particularly, when
 with these circumstances, we perceive a
 separation beginning to take  place  be-
 tween  the dead and living part, bark
 hardly ever fails to support the strength
 of the constitution, and  powerfully to
 accelerate  the separation  of the  mortl-
     Eb 
218
MODIFICATION.
fied parts.  (Eneyclop. Method. Art. Gan-
grene.)
  How ever, as we have already remarked,
it is quite wrong to prescribe  bark, in
every instance, as tlie sole remedy ;  for,
there are many cases, in which  it is  un-
necessary ; some, in  which it does harm;
and others, in which it is totally ineffica-
cious.   It is  a  medicine obviously of no
service, when the mortification arises from
an external  cause, and  is  the only com-
plaint, in a  healthy, strong constitution.
It is equally  unnecessary, when the spha-
celus is ofthe dry sort, and has ceased to
spread, at the  same tiuie,  that the living
margin appears to be in a state ot  inflam-
mation,  without any universal  debility.
But,  it  deserves particular notice,  that
the circumstances of each individual case
are liable to such considerable variation,
that though bark may be at first unneces-
sary, it may afterwards be indicated.
  In some cases of sphacelus, bark is hurt-
ful.  The disorder  is generally  attended
with fever, which may be of three kinds;
inflammatory; typhoid;  or one connected
with a disordered state of the abdominal
viscera.
  In the latter case, which is  far more
common, than  is supposed, bark is obvi-
ously pernicious. Here,' the indication is
to empty the  stomach  and bowels, as
quickly as  possible.   When this has been
done, and bark should now be  indicated
by  any  of the circumstances,  already
pointed out, it may be safely administered.
But, there is a great necessity, for pro-
curing evacuations,  as  speedily as pos-
sible, before great debility has come on.
  Sometimes, mortification is  accompa-
nied with a  low typhoid kind  of fever,
which, whether the  cause, or the conse-
quence of the local mischief, demands the
exhibition of bark.
  As we have above stated, the  common
inflammatory fever  may attend  a  morti-
fication,  and then the  living margin is
generally inflamed and painful  This is
particularly the case, when mortification
is the consequence of genuine  acute in-
flammation, or of an external injury, in a
healthy  subject. Here,  bark must  ob-
viously be injurious. Still, it  is  wrong
to regard  this  medicine,  as invariably
hurtful, whenever sphacelus is the effect
of inflammation.  It has already been  ob-
served, that the inflammation, frequently
has less share in the origin ofthe disorder,
than some incidental cause, which often-
times requires the exhibition of bark.   It
is also to be. noticed, that even when mor-
tification is the pure  effect of inflamma-
tion, great prostration of  strength may
Subsequently arise, or else  constitutional
symptoms in consequence of the absorp-
tion of putrid matter, and in both thrsc
instances, the voice of experience loudly
demands the employment  of bark, though
its exhibition might have been at first use-
less or hurtful.  While the genuine in-
flammatory  fever,  and  local  inflamma-
tion,  attend mortification, antiphlogistic
means  are undoubtedly  useful.   How-
ever, great caution is requisite in employ-
ing them, since, in  cases of humid gan-
grene, as it is termed, the inflammatory
state very soon changes into one, resem-
bling that of typhus fiver, &c.
   Sometimes, there is mere prostration of
strength, without any symptom  of disor-
der  in the  gastric system, or of inflam-
mation, or typhoid fever.   A  nervous fe-
ver is of this kind.  In this instance, bark
is evidently proper, though seldom ef-
fectual  alone.  Volatile, diaphoretic, and
nervous  medicines, are  commonly at the
same time  proper, and  opium, wine, and
the volatile alkali, are such as experience
has selected, together with the application
of blisters.
   From the preceding observations, it be-
comes evident, that though the method of
treatment  in cases of s'phacelus, depends
on the occasional cause, vet, it must also
be regulated by the kind'of fever, which,
as we have described, mav be-.either in**
flammatory, typhoid,  one  connected with
gastric   disorder, or  nervous.   Conse-
quently, there are four  plans of constitu-
tional treatment, and it is easy to deter-
mine the particular cases, in which bark
is unnecessary, hurtful, or inefficacious.
   We meet with one species of mortifi-
cation ;  in  which the patient experiences
severe pain in the part, without tiie small-
est appearance of  inflammation.   Here
bark  is never  of any use, and opium  is
probably the only medicine of any efficacy.
We shall consider this subject more fiilly
presently, when we introduce Mr. Pott's
remarks on a peculiar mortification of the
toes and fee*.
   Bark sometimes occasions purging, atod
then it also proves inefficacious, and hurt-
ful. This effect, however,  may frequently
be prevented by adding a few  drops  of
laudanum to each dose.
   Bark  may disagree with the stomach ;
but, it very seldom does so, when given in
exceedingly fine powder, which also gene-
rally proves more efficacious, than a coarse
one.  Administering it  with wine, some
aromatic water, or in the form of the cold
infusion, makes the medicine likewise less
likely to disorder the stomach.  (Richter.
Anfangsgr. der  Wundaren. Kap. 3.)
   The vitriolic acid may frequently be ad-
vantageously given at the same time with
the bark, and the best method of exhibit-
ing it is to acidulate with  it every thing. 
MORTIFICATION.,                           219
 which the  patient drinks.  Other  acids
 arc aLo sometimes used for the same pur-
 pose.
   Carbonic  acid gas is anotiier remedy of
 the highest efficacy in all cases ot mortifi-
 cation.  It  has even  been known to have
 the most beneficial effects when bark has
 failed in doing good.  Water impregnated
 with this gas should  be recommended, as
 a most beneficial kind of drink.
   Such are the remedies, which have ac-
 quired the  greatest  confidence of practi-
 tioners, when the indication is to support
 and strengthen the  constitution,  with  a
 view of resisting the  progress of mortifi-
 cation.  A  great many others have been
 recommended, but, there are none, which,
 in point of efficacy, can be compared with
 those abovementioned.
   The hospital gangrene, is  a  case, for
 which bark is universally allowed to be a
 medicine of the highest efficacy.   It is
 not only  to be given internally, but em-
 ployed as a lotion for the ulcers, with the
 addition  of camphorated spirit of wine.
' hi the hospital  gangrene,  however, one
 ofthe most essential measures is to purify
 the air, in which the patient is residing.
 As much fresh air as possible should be
 let into  the ward, or room;  fumigations
 of nitric  and oxygenated muriatic acids
 should be used, not  only for disinfecting
 the place,  but as an application 'to the
 gangrenous disease.   The nitric acid fu-
 migations are made by putting into a glass
 vessel on the  ground, half an  ounce of
 concentrated sulphuric acid, to which an
 equal quantity of nitre  is to be added
 gr\idatim.  The mixture  is to be stirred
 with  a glass tube, wlien an abundance of
 white vapour will be  produced.
   The oxygenated muriatic acid fumiga-
 tions are made,  by mixing three  ounces
 two drams of common salt with five drams
 ofthe black oxide of manganese in  pow-
 der.   These two ingredients are  to be
 triturated together;  they  are then  to
 be put into  a glass vessel; one ounce two
 drams of water are to be added, and then,
 if the ward, or chamber  be  uninhabited,
 one ounce seven  drams of sulphuric acid
 are to be poured upon the mixture rfli ut
 once; or, i^bMuully,  if the p.itients are
 there.  ThiH^uantity will be  sufficient
 for disinfecting a very large ward.   (See
 Lassus Pathologie Chirurgicale, Tom. 1. p.
•S8, 39.)

          3. Anodyne Remedies.  r

   A  third  indication, which should be
 observed together with  the  second,  or
 which, should even  precede it in many
 instances, is to lessen the irritability and
 sufferings of the patient, by the use of
 opium.  Attention to  this desideratum
 frequently ^contributes  more  than  any
 thing  else, to stop the  progress  of tlie
 disorder, and is often indispensable  in
.order  to promote the operation of other
 remedies.  In all cases of mortification,
 every  thing, which, heats, irritates,  or
 adds to the patient's sufferings, appears
 in general, to augment the disorder, and
 increase the rapidity of its progress.   On
 the  other hand, every thing which tends
 to calm, assuage, and relax, almost always
 retards the progress of mortification, if it
 produce no greater good.   The pain  also,
 which  is a  constant mark of too much  ir-
 ritation, contributes of itself to increase
 such irritation, and, in this double point
 of view, we cannot do better, in the majo-
 rity  of cases, than endeavour to appease
 it by more or less  liberal  use of opium.
 —When the inflammatory stage evidently
 prevails, this medicine may be conjoinea
 with  antiphlogistic remedies, such  as
 neutral salts, and, particularly,  nitre.  In
 other instances, attended with debility, it
 may be given with bark and cordials.
  The following observations on the effi-
 cacy of opium in  a particular, and not
 unfrequent  case, are highly entitled  to
 the attention of every surgical practition-
 er.   The disease is also described  with
 that accuracy and elegance, which always
 distinguish the writings of Mr. Pott.
  "  The powers and virtues of the Peru-
 vian bark  are known  to  almost every
 practitioner  in   physic  and   surgery.
 Among the many cases in which its merit
 is particularly and justly celebrated, are
 the distempers called gangrene and mor-
 tification ;  its general power of stopping
 the  one, and resisting the other, have
 made  no inconsiderable addition to  the
 success of the chirurgie art:  but  still
 there is a particular species even of these,
 in which this noble medicine  most fre-
 quently  fails:  I' mean  that  particular
 kind, which, beginning  at  the extremity
 of one  or more of the small toes, does, in
 more or less time, pass on to the foot and
 ankle,  and sometimes to a part of the leg,
 and, in spite of all the  aid of physic and
 surgery, most commonly destroys the pa-
 tient.
  " It  is very unlike to the mortification
 from inflammation,  to that  from external
 cold, from  ligature, or bandage, or to that
 which  proceeds from any known and  visi-
 ble cause, and this as well in its attack  as
 in its process.  In  some few instances, it
 make* its  appearance  with little  or no
 painl  but, in by much the  majority  of
 these cases, the patients feel great uneasi -
 ness through the whole foot and joint  of
 the  ankle/partiCularly in the night, even
 before  these parts shew any mark of dis 
220                              MORTIFICATION.
temper, or before there is any other, than
a small discoloured spot on the end of one
ofthe little toes.
  " It generally makes its first appearance
on the inside, or at the extremity, of one
of the smaller toes, by  a small black, or
blueish spot; from this spot the cuticle is
always found to be detached, and the skin
under it to be of a dark red colour.
  " If the patient has lately cut his nails,
or corn, it is most frequently, though very
unjustly, set to the account of such  ope-
ration.
  " Its progress in different subjects, and
under different circumstances, is differ-
ent ; in some it is slow and long in passing
from  toe  to toe, and from thence to the
foot and  ankle;  in others its  progress
is rapid,  and  horridly  painful: it gene-
rally begins on the  inside of each small
toe, before it is visible either on  its under
or upper pa?-t;  and when it makes its at-
tack on the foot, the upper part of it first
shews its distempered state, by tumefac-
tion, change of colour, and sometimes by
vesication; but wherever it is, one of the
first marks of it is a separation or detach-
ment ofthe cuticle.
  " Each  sex  is  liable to it; but for one
female  in whom 1 have met with  it, I
think I may say, that I  have seen it in at
least twenty males.   I think, also, that I
have much more often found it in the rich
and  voluptuous,  than  in  the  labouring
poor;  more often  in great eaters,  than
free drinkers.  It frequently happens to
persons  advanced  in life, but is by  no
means peculiar to  old  age.  It is not, in
general, preceded or accompanied by ap-
parent distemperature either of the part,
or of the habit.   1 do not know any parti-
cular kind of constitution which  is more
liable to  it than another; but as far as
my observation goes, I  think that 1 have
most frequently observed  it  to attack
those, who have been subject to flying un-
certain pains in their feet, which they have
called gouty, and but seldom in those who
have been accustomed  to  have the gout
regularly and fairly. It has, by some, been
supposed to arise from  an ossification of
vessels, but for this opinion I neve could
find any foundation but mere conjecture.
  "The common method of treating this
distemper is,  by spirituous fomentations,
cataplasms, actually and potentially warm,
by dressings of die digestive kind, as they
are called, animated with warm, pungent
oils  and balsams, &c. and, internally, by
the Peruvian bark.
  " I wish I could  say that this, which,
with little alteration, has been the general
practice,  had  been most frequently, or
even often successful; butl am, from'long
and repeated experience, obliged to say,
that it has not.
  " 1 am sensible, that many of my read-
ers will be surprised at my affirming, that
the Peruvian bark will not stop a mortifi-
cation, a distemper in which, for some
years, it has been  regarded as  specific;
bnt  1 must  beg not to be misunderstood:
I mean to confine my observation and my
objection to  this particular species of mor-
tification, which 1 regard as being sui ge-
neris ; and under this restriction I must
repeat, that 1 have seldom, it ever, seen
the  bark  successful: in all  other cases,
wherein it  is used or recommended, no
man  has a  higher opinion of it;  but, in
this  1 cannot give it a praise,  which it,
does not deserve.
  " I believe 1 may venture  to say, that I
have tried it as fairly, as fully, and as va-
riously as any man has or. can;  I have
given  it in  the  largest quantity, at the
shortest intervals, and for the longest pos-
sible space; that is, as long as the pa-
tient's life would permit: I have given it
by itselt in  decoction, extract,  and sub-
stance ;  1  have  combined  all these to-
gether ;  I have joined it with nitre, sal.
absynth. with snake rodt,  with  confect.
cardiac,  with  volatile salts,  and with
musk, as different circumstances seemed
to  require,  or admit; I have used it as
fomentation, as poultice, as dressing; I
have assisted it  with every thing which
has been usually  thought capable of pro-
curing  or assisting digestion;  still the
distemper has continued its course, per-
haps a little more  slowly, but still it has
ended in death.
   " 1 am sorry to rob one of our great
medicines of any part  of  its supposed
merit, but as on  the one hand, fts claim,
in  this instance, is unjust, and  as on the
other, I hope to  add as much to the cha-
racter of another, the res medica will be
no sufferer.
   " Some time  ago, I had  a patientla-
bouring under this complaint, who, from
antipathy, obstinacy, or some other cause,
could not be prevailed on to take bark in
any form whatever.  1 made use of every
argument, but to no  purpose: fomenta-
tion, poultice, and the usual  dressings
were applied in  the usual  manner: the
disease advanced some days more, some
days less, and at the end of a fortnight,
the small toes were all completely mor-
tified, the great one became blackish, the
foot  much swollen, altered  in colour, and
the disease  seeming to advance with such
hasty strides, that I supposed a very few
days would determine  the  event.  The
pain  in the foot  and ankle was  so great,
and so continual, as totally to deprive the 
MORTIFICATION.
2.3JL
patient of sleep.  On this account,  and
merely to procure some remission, 1 gave
two grains  of opium at night, which not
having the  desired effect,  I  repeated
it  in  the   morning.    Finding,  during
the  following  day, some advantage, 1
repeated  the  same   dose  night   and
morning  for three  days;  at the end of
which time the patient became quite easy,
and the appearances on the foot and ankle
were visibly more favourable.   Encou-
raged by this, I increased the quantity of
the medicine, giving one grain every three
or four hours, taking  care to watch its
narcotic  effect, and to keep the  belly
empty by glysters.  In nine days from the
first administration of the opium, all the
tumefaction of the foot and ankle totally
subsided, the skin  recovered its natural
colour, and all the mortified parts plainly
began to separate ; in another week they
were all loose, and casting off, the matter
was  good,  and the  incarnation florid.
During the whole of this time, I continued
the use of the opium, varying its quantity
as circumstances required, but never" gave
less  than three or  four grains in twenty-
four hours.
   " When  the sloughs were all  cast off,
the  bones separated, and  as  I had only a
clean sore to dress and  heal, I gradually
left off the medicine.
   " I am very willing  to acknowledge,
that however well-pleased I might be with
the event of this case, yet 1 really regard-
ed it as accidental; so much so, that hav-
ing very soon after another opportunity, I
did  not  care to trust to opium alone, but
joined the  bark with it.   The event was
equally fortunate.  But although I had
Joined the  cortex with  the extractum
thebaicum, and did therefore atttribute
the  success to their united powers, yet
the effect was so very unlike to what 1 had
ever seen from the bark  without opium,
that I could not avoid seriously, and often
reflecting on it, and determining to use it
by itself, whenever another opportunity
should offer.   1 did so, and succeeded in
the  same  happy manner, though  under
the  very disagreeable  circumstances  of
seventy years of age, a broken, distemper-
ed constitution, and the disease making a
. hasty progress.
   " To relate  cases which  are nearly, or
at least materially similar, is of no  use. I
shall therefore only say, that every oppor-
tunity, which I have had  since of making
the  experiment, has still more  and more
convinced  me of the great value  and
 utility of this  medicine, and of  its  power
of rescuing from destruction, persons un-
der this affliction.
   " I cannot say that  it has never failed
me : it certainly has; but then it has been
under such circumstances, as I think would
fairly account for the failure.
  " I  should be exceedingly sorry to be
misunderstood;  1 should be still more so
to mislead any body : and therefore I beg
it may be noticed, that I do not propose
the extractum thebaicum, in this case, as
an universal  infallible  specific;  1 know,
from experience, that it is  not;  but as I
also know, from repeated experience, that
it will, under proper management, and di-
rection, do  more  than any, or  than all
other medicines;  and  that  I have, by
means of it,  saved some lives, which I am
very sure, would, under the common, and
most approved method of treatment, with-
out it, have  been lost, 1 could not answer
to myself the  not  communicating what I
had observed.
   " If this was  an experiment, in which
the life or limb, or health of the patient,
was  in  any  degree endangered, or by
which the person, on  whom  it may be
tried, could, in  any degree, be injured, I
should have withheld what  1 now publish,
until  a  greater  length of time, and more
experience,  had rendered  it  still  more
absolutely certain;  and I should  have
thought myself strictly vindicable in so
doing:  but  as this is  a medicine whose
general effects are well known, and which
is, at the  same time, so capable of direc-
tion and management, that  it is almost im-
possible for any person who deserves to be
trusted with medicine  at  all, to do any
material harm w»th it, I thought it would
be wrong and unjust to conceal what had
occurred  to me, lest 1 might thereby de-
prive the  afflicted  of an assistance which,
I verily believe, is not to be obtained from
any other quarter.
   «J In short, from what I  have  seen and
done, I am perfectly convinced that by its
means,  and by its means  solely, 1  have
saved lives which, without it, must have
been lost.
   " If it preserves a few of those who are
so unfortunate  as  to  labour under this
nasty, painful, lingering, and destructive
disorder,  to which we  are  all liable, and
which has hitherto, most frequently, foiled
all attempts of art, I  shall  be sincerely
glad to have contributed to so good an
end: if it should prove in  other hands as
successful as it has with me, I shall be
still more so ; but, on the  other hand, if,
after several times giving me reason to be-
lieve and hope that it would prove an in-
strument for the preservation of many, it
should, upon more repeated trial, be found
to fail, 1 shall be sorry for the event, but
shall still  think,  that  I  did  right  iu
communicating what   I had seen, and
thereby  endeavouring  to  be useful to
 mankind. 
S22                           MORTIFICATION.
Hoc opus, hoc studium, parvi properemus
  et ampli,
Si patriae volumus, si nobis vivere cari.

  " If I am right in my conjecture con-
cerning this hazardous  and destructive
malady ; and if the method which I have
proposed and practised, should prove as
successful in the hands of others as it has
in mine, I cannot help thinking, that the
external or chirurgie treatment of the dis-
order might be amended; that is, might
be made to coincide more than it does at
present with such soothing kind of plan.
  " Since I have had reason to embrace
this  opinion, and  to  act in conformity to
it, I have found more advantage from fie-
quently soaking  tiie foot  and ankle in
warm  milk, than from any spirituous, or
aromatic fomentations whatever ;  that is,
1 have found the  one more capable of  al-
leviating tiie  pai:,  which  such patients
almost always feel, than  the other ; which
circumstance  1 regard as a very material
one.   Pain is  always an evil, but, in this
particular case, I look  upon it as  being
singularly so.   Whatever heats, irritates,
stimulates, or gives uneasiness, appears to
me always to increase  the disorder, and
to add to  the rapidity of its  progress;
and, on the contrary, I have always found,
that whatever tended merely to calm, to
appease,  and to relax, at least retarded
the mischief, if it did no more.
  " The whole plan of the chirurgie treat-
ment of this disease is founded on a gene-
ral idea of warming, invigorating, stimu-
lating, and resisting putrefaction ; and the
means generally  made  use  of are very
proper for such purpose: but I must own
that  I  think the purpose, or intention, to
be improper.
  " Upon this principle, the old theriaca
Londinensis, and the  present cataplasma e
Cymino, have been, and still are, so freely
used on this occasion.   A composition of
this kind, if it does any thing, must heat,
and  stimulate, and  it is by  heating and
stimulating the skin, to which it is applied,
that  it so  frequently does that mischief
which I am confident it often does, though
such mischief is set to the account of the
nature of the  disorder.  Cases  exactly
similar, in all circumstances, are not to be
met with every day,  but I am from expe-
rience  convinced, that of two, as nearly
similar as may be, in point of pain, if the
one be treated in the usual manner, with
a warm, stimulating, cataplasm, and the
other t>nly  with a poultice  made of the
fine farina seminis lini, in boiling milk or
water, mixed with ung. sambuc. or fresh
butter, that the pain, and the progress of
the distemper, will be much  greater and
quicker in the former than in the latter.
  " When the black or mortified spot hai
fairly made its appearance on one or more
of the toes, it  is the general practice to
scarify or cut into such altered part with
the point of a knife or lancet.  If this in-
cision be  made merely to learn whether
the part be mortified or not, it is altogc-
ther unnecessary,  the detachment of the
cuticle, and the colour of the skin, render
that a decided point s if it  be not made
quite through  thie eschar, it can serve no
purpose at all: if it be made quite through,
as there is no  confined fluid to give dis-
charge to, it can only serve to convey such
medicines as may be applied for the pur-
pose of procuring digestion to parts capa-
ble'ot feeling their influence, and on this
account they  are  supposed  to be  bene-
ficial, and therefore right.
  " When the  upper part of the foot be-
gins to part with its cuticle and to change
colour, it is a practice with many to sca-
rify immediately ;  here, as in the  preced-
ing instance, if the scarifications be  too
superficial, they must be useless ; if they
be so deep, as to cause a slight hemorr-
hage, and to reach the  parts which have
not yet lost their sensibility, they must do
what indeed  they are generally intended
to do, that is, give the  medicines, which
shall  be applied, an opportunity of acting
on such parts.
  " The medicines most frequently made
use of for thisipurppse are, like the theria-
ca, chosen for this supposed activity; and
consist of tlie warm, pungent oils and bal-
sams, whose action must necessarily be to
stimulate  and irritate : from  these quali-
ties  they most frequently  excite pain,
which, according  to my idea of the dis-
ease, is diametrically opposite to the pro-
per curative intention ; and this I am con-
vinced of from  repeated experience.
  '• 1'hc dressings cannot consist of ma-
terials which  are too soft and lenient; nor
are any scarification  necessary for their
application   But  1 would go farther and
say, that scarifications  are  not only use-
less,  but, in  my opinion, prejudicial,  by
exciting pain, the  great and chiefly to be
dreaded evil  in   this complaint.   The
poultice should also be soft, smooth, and
unirritating;   its  intention  should   he
merely to soften  and  relax ;  it  should
comprehend the whole  fooC ankle,  and
part of the leg ; and should always be so
moist or  greasy as not to be likely to be-
come at all  dry  or  hard,  between  one
dressing and another.
  " 1 will trouble the reader with only one
remark more.
  " When the toes are, to all appearance,
perfectly mortified, and seem so loose as
to be capable of being easily taken away,
it is. in general, thought right to remove 
MORTIFICATION..
2S3
them.  However  rotten and loose they
may seem to be, or  really are, yet while
they hold on, they hold on by something
which  is still  endued with sensation, as
may always be  known, if they be bent
back or  twisted with any degree of vio-
lence.
  " 1 will not enter  into a dispute about
the sensibility  or insensibility of liga-
ments, nor undertake to determine whe-
ther they be ligaments or any other kind
of parts which still maintain the connexion
ofthe toes with their own respective joints,
or with the metatarsal bones .  it is suffi-
cient for me to know, and to inform  the
young practitioner,  that  however loose
they may seem,  yet if they be violently
twisted off, or the parts, by which they
hang, be divided, a very considerable  de-
gree of  pain will most commonly attend
such operation, which therefore had much
better be avoided -, and that 1 have seen
this very pain, thus produced, bring on
fresh mischief, and that of the gangrenous
 kind.
   " If the  patient does well, these parts
will certainly drop off; if he does not, no
good can  arise from removing them."—
 (Pott's Works.}
   Other practitioners have confirmed, by
 their experience, the efficacy of opium, in
 cases, in which  the  disorder is attended
 with a great deal of irritation, though it
may not always have had the same success
 in their  hands, when the mortification has
appeared to depend chiefly on constitu-
 tional! debility.  Mr. Kirkland observes,
 that we must  be careful not to force the
 doses, especially at first;  and that the me-
 dicine does more harm, than  good, when
 its soporific effects go so far as to occasion
 delirium, take away the appetite, or cause
 affections  of the heart.
    Some authors have also recommended
 the use of camphor, which, by reason of
 its narcotic virtue, has  sometimes  pro-
 duced good effects.  M. Pouteau attributes
 considerable efficacy to  it, especially, in
 tlie erysipelatous gangrene arising from
 wounds.  In such cases, he recommends
, it to be given in the dose ol  five grains,
 with a double quantity of nitre, every four
 hours   (Encyclopedic Methodique; Partie
  Chirurgicale.)

              LOCAL MEANS.

     1. Suppression of Irritating Causes.

    With respect to the external, or  local
 treatment of mortification, the first  indi-
 cation consists  in removing,  if possible,
 such external causes, as  may have occa-
 sioned, or kept up the  disorder.  Such
 are all those causes, which originate  from
the compression of ligatures, tumours, &c.
Of this  kind, also, are all irritating, and
poisonous substances, which by their pre-,
sence stimulate the parts, more or less vio-
lently, according to their particular nature.

         2.  Topical Applications-

  When mortification arises from inflam-
mation, which still prevails in a consider-
able degree, it is evident, that the dead
part itself only claims secondary consider-
ation, and that the principal desideratum
is to prevent the mortification from spread-
ing to the living circumference, by lessen-
ing the inflammation present.   Hence,
under such circumstances, the application
of linen, wet with the saturnine lotion, and
the maintenance of a continued evapora-
tion, from the inflamed parts surrounding
the mortified ones, must be just as proper
as if the mortification itself did not exist,
and were quite out of all consideration.
  It has been justly remarked by a most
eminent  man, (Hunter)  that the  local
treatment of mortification, (meaning that
in consequence of inflammation)  has been
as absurd as the constitutional; scarifica-
tions have been made down to the living
parts, that stimulating and antiseptic me-
dicines might be applied to them; such
as  turpentines, the warmer balsams, and
sometimes the essential oils.  Warm fo-
mentations  have been also applied, as be-
ing congenial to life ; but, warmth always
increases action, and should, therefore, be
well adjusted to the case ; for on the other
hand, cold debilitates or  lessens  powers,
when carried too far, though  it first les-
sens  action    Stimulants are  likewise im-
proper, as the actions are already too vio-
lent. It is proper to keep the parts cool,
 and all the applications should be eold.  In
 cases of mortification from inflammation,
 good effects  have  also been seen to arise
 from the topical, as well as  internal em-
 ployment of opium.
   But it must be acknowledged, that how
 proper soever the employment of cold ap-
 plications is, in  cases of mortification,
 attended with inflammation, fomentations
 and emollient poultices are most common-
 ly preferred.
   Besides  common poultices, there are
 several others, which have acquired great
 celebrity, as topical applications in cases
 of mortification.   Of this kind  are  the
 cataplasma carbonis,* cataplasma cerevi-
  * Prepared by  mixing  about Jij.  of
finely powdered wood-charcoal with half
a pound of the  common linseed poul-
tice. 
224                          MORTIFK

siae,*  and  the  cataplasma  effervescensf
These local remedies  are,  perhaps, in
nine cases out of ten, superior to all others.
  With respect to stimulating, and spiri-
tuous applications, such as brandy,  spirit
of wine, balsams,  resins, and  aromatic
substances, which have  been recommend-
ed by a vast number of authors, they are
at present almost entirely laid  aside by
practitioners.  Though  such things are
indeed really very  uselid in  preserving
dead  animal substances from  becoming
putrid, very little knowledge of the ani-
mal economy is requisite to make us un-
derstand, that they cannot act in this man-
ner on parts still endued with vitality :
but, on the contrary, that they must  have
very prejudicial eff'ects,  in the cases under
consideration, by reason of the violent
irritation,  which they always  excite,
when applyed to the living fibres. It may
now and then, however, be justifiable to
apply spirituous applications to the dead
parts themselves  with a  view of diminish-
ing the fetid effluvia,  which by  conta-
minating the air, have some share in injur-
ing the patient's health  ; but the greatest
care is requisite to keep tiiese stimulants
from coming into contact with the living
surfaces around, and beneath the sloughs.
  When  mortification arises from  cold,
every sort of warm emollient application
must be avoided, and cold water, or  even
snow and ice, made use  of.  For this sub-
ject, however, See Chilblains.
  The local treatment of the mortification
of toes and feet,  described by  Mr. Pott,
has bexn already considered.
3. Scarifications, and Removal of the mor-
              tified Parts.
  Another grand indication is to give vent
to putrid matter,  extravasated in the cel-
lular substance, by making deep scarifica-
tions in the integuments.  The  majority
of authors  who have treated of mortifica-
tion, have very much  insisted upon  this
plan,  which they recommend in all kinds
of cases   They even advise the  incisions
to be made down to the sound parts, in
order to facilitate the application of topi-
eal stimulants, and to favour the operation
of the supposed antiseptic qualities of
such applications.  But, with the excep-
tion of cases, in  which gangrene affects *
some  apponeurotic membrane, and others
in which the  integuments, already morti-
fied, are exceedingly distended with pu-

  * Prepared by stirring into the grounds
of strong beer as  much  oatmeal, as  will
make the mass  of a suitable consistence.
  f Prepared by  stirring into an infusion
of malt as  much oatmeal, as will render
the substance of a proper thickness,  and
then adding about a spoonful of yeast.
ATION.

 trid matter collected  in tljc cellular sub-
 stance, either in consequence of foregoing
 inflammation, or any other cause, such as
 the extravasation of urine in the scrotum,
 all  scarifications, which  penetrate  as Ey-
 as the living parts,, are ofteu productive
 of most  serious mischief, instead of ad-
 vantage.   Such incisions cannot  be  prac-
 tised, without occasioning a great deal of
 pain, and producing inflammation, which
 itself often powerfully contributes to make
 the mortification  spread.  But,  as parts,
 which are in a complete state of sphacelus,
 are absolutely extraneous substances, in
 regard to those which still  retain  their
 vitality, they require no concern, and when
 their mass is considerable, it is not  only
 proper to scarify them, but, also to remove
 a portion of  them.  By lessening the size
 of the putrid mass of matter,  the fetor is
 diminished,  which, in this case is always
 considerable ; we also make way for the
 escape of a great deal of putrid discharge,
 which, being confined, might have a bad
 effect on the neighbouring living parts; and
 we enable these latter to free themselves
 more easily from the rest  of the sloughs.
   From what  has been already said, it
 must   appear,   that  scarifications are
 only to  be  employed with the  greatest
 prudence, lest they should increase the dis-
 order, which they are  intended to benefit.
  The same may be said ofthe too common
 practice of accelerating, with a cutting in-
 strument, the separation ofthe mortified
 parts, which process  nature tends to ac-
 complish. It is always dangerous to ir-
 ritate parts, which are affected with in-
 flammation,  in cases of sphacelus, before
 they are completely restored to their na-
 tural state, and in having recourse to the
 above-mentioned operation, while there is
 any adhesion  remaining, between  the
 sloughs and the living parts, it is impossi-
 ble  to avoid producing irritation in the
 latter. We have already given Mr. Pott's
 sentiments with  respect to  the  danger
 and inutility of cutting the tendons and
 ligaments, in the mortification of the toes
 and feet.
   If the surgeon prudently await the event
 of things, the separation  of the mortifi-
 ed from the living parts, will in general be
 soon effected, when an inflammation and
 suppuration  will also contribute  to the
 detachment of the slough.  The  other
 mode of practice is the above one, viz. the
 amputation of what is mortified.
   Altliough the certainty and expedition
 of the knife have the semblance of being
 infinitely  preferable to the  uncertain, and
 tedious, mode of procuring a detachment
 of a mortified part, by the occurrence of
 suppuration and the action of the absorb-
 ents, which remove the particles, connect-
 ing  the dead and living matter, together 
MORTIFICATION. '                          225
yet cutting away parts, in cases  of spha-
celus, is not,  very  frequently, proper.
The incision can only be performed  in the
living, or dead part.  In attempting the
latter, we are ignorant of the precise ex-
tent  of  tiie  disorder.  Sometimes,  the
sphacelus is more extensive towards the
surface,  than in a deeper situation.  There
is also a constant risk of injuring the liv-
ing parts, and thereby occasioning  very
unfavourable  symptoms.  If this  should
not  occur, still there will  remain,  after
tlie operation, a considerable portion  of
the mortified part,  for  the detachment
iff which as much inflammation,  suppura-
tion, and time, will be requisite, as if  no
operation had been  undertaken.  If the
operation have any use, it is that  of les-
sening the bulk ofthe slough, and thereby
diminishing the fetid effluvia.
   Amputation, performed in the  living
part, removes one danger by incurring a
still greater one.  Of this no doubt can
be entertained,  when we reflect, that this
important operation  has often a  fatal
event,,even when performed under the
 most propitious circumstances, and that,
 in the cases  now under  consideration, it-
 must commonly be  undertaken  on a sub-
ject, in a state of extreme debility.  Be-
 sides, there is never any certainty, that
 we are amputating in living parts.   Mor-
 tification rapidly ascends along  the cellu-
 lar  substance,  surrounding the  large
 blood-vessels, and  is  frequently  much
 more extensive internally,  than external
 appearances would lead one to suppose.
 The  adjacent  surface,  still apparently
 alive, is often so affected, that it must in-
 evitably slough,  though at present, it
 may not actually have sphacelated.  The
 surgeon imagines,   that amputation  is
 performed on living parts ;  but, soon  af-
 terwards discovers, that he has been  di-
 viding those, which are dead.   (Richter's
 Anfangsgr. der Wundarzneykunst, Band.
  I, Kap.3.)
   The operation can do no good,  while
 the mortification  is in  a spreading  state,
 and it may do considerable mischief. The
 disorder enlarges its limits, because its
 cause  still operates, and this  is  not  re-
 moveable by amputation.   If the opera-
 tion be now  injudiciously  undertaken,
 the sphacelus invades the wound, and is
 the more certainly  mortal, as the patient
 has now been further weakened by ampu-
 tation, and its consequences.
   Many mortifications, especially those,
 which  arise  from  external causes, very
 often spontaneously stop  and separate.
 But, the place, where  this will  happen,
*can  never be foreseen.  By amputating
 in this circumstance, wc run a risk of dis-
 '    Vot. II.
turbing nature in her salutary work,  and
rendering  the disorder  fatal: and the
operation, considered in the most favour-
able point of view, is a most useless one.
It is  rational  to   believe,  that,  when-
ever amputation  has  been  successfully
practised in the living part, while a spha-
celus was in a spreading state, the com-
plaint would have stopped of its own ac-
cord, and the patient been preserved with-
out the  operation.  Since  amputation,
also,  plainly renders the patient's condi-
tion  unfavourable,  we  may inferj  that
many  persons have died after  its  per-
formance, who might have been saved
without it.
   As soon as a sphacelus leaves off spread-
ing, and begins to separate, the greatest
danger is over. To practise amputation
now in the living part, is manifestly hur-
rying the patient unnecessarily into fresh
peril, just after  he has escaped from a
most  dangerous  situation.    However,
 should the  operation be done,  and the
 patient live, the cure  is not in the  least
 accelerated, as the healing of the wound
 will  require  as  much time, as  the de-
 tachment, and perfect cure of the morti-
 fication.
   The following are cases, in which, per-
 haps, the use of the  knife  is justifiable
 and  proper.  There  exists a  species of
 sphacelus, which rapidly occasions death,
 before it is yet of great extent.   Here in-
 deed, amputation might be really advisa-
 ble,  but, the nature of the cause is unfor-
 tunately never disclosed, before the fatal
 catastrophe.   Some external injuries are
 inevitably followed by mortification.  In
 such cases, amputation is evidently pro-
 per ; for, the simple incision is  attended
 with less danger, than the sphacelus would
 be. The surgeon, however, seldom knows
 beforehand, that mortification will inevita-
 bly ensue.
    When the  mortification  has  already
 ceased spreading, or  begun to  separate;
 or, when the  cause of the disorder is re-
 moved ;  one may, at  all events, cut off'
 some of the slough.  By this means, we
 shall succeed in diminishing the nuissance
 and  unwholesomeness arising from  the
 putrid effluvia.  It is only  necessary  to
 be careful,  hot to injure the living parts,
 so as to occasion pain and hemorrhage.
    In cases, in which  a whole  limb  has
  mortified, and the soft parts have already
  been detached,  the separation of the de-
  nuded bone is the only thing remaining
  to be done ; and this may be accomplish-
  ed in the usual way with a saw.   But, we
  are to remember, that we thus  only free
  the patient from the fetor  of the sphace-
  lated  limb, and  neither  accelerate the
      Fr 
226                           MORTIFICATION.
  cure nor obtain any other  essential  ad-
  vantage. The death of the bone generally
  extends  rather far upward, and, conse-
  quently, the saw can seldom remove  the
  whole of the dead portion, some of which
  must remain for nature to detach.  The
  same length of time will be requisite  for
  this exfoliation to be effected as if none
  of the bone had  been sawn off.   When
  the sphacelus is of the dry description,
  and produces no  inconvenience from fe-
  tor, the employment of the saw  is even
  unadvisable.
    From  what has been said,  it appears,
  that in the majority of cases, the  surgeon
  must abandon the  separation of a morti-
  tified part to  nature,  and  confine  his
  endeavours to checking the progress of
  the disorder.
    Sometimes, a sphacelus spontaneously
  ceases to  spread.  This  happens most
  frequently in cases which originate from
  an external cau ;e, such as a violent  con-
  tusion, burn, &C.  But, the occurrence is
  not restricted to this kind of case, nor is
  it  invariably  attendant  on  it.   When
  there are no other occasional  causes pre-
  sent, the mortification  does not readily go
  beyond  the limits of the  contusion, or
  violent burn; but the interference of sur-
  gery can hardly ever put a stop to its pro-
  gress, before it has spread as far as  the
  extent ofthe local injury.  (Richler's An-
 fangsgrnnde der Wundarzneykunsl, Bund.
  1, Kap. 3.)
    How different are the doctrines of M.
  Larrey upon tliis  subject from those en-
  tertained by Richter, and, indeed, the ge-
  nerality  of  eminent   modern  surgeons.
  " Writers on gangrene, or sphacelus of
  the extremities  (observes M. Larrey) in-
  discriminately recommend the amputation
  of a sphacelated limb  never to be under-
  taken before the mortification is bounded
  or limited by a reddish circle, forming a
*- true line of separation between the dead
  and living pans.   This circumstance can
  only occur  in a case of spontaneous gan-
  grene from an internal  cause ;  or it .t hap-
  pens,  as is very unusual, in a case arising
  from a wound,  its progress is different,
  and it would be exceedingly imprudent to
  wait for it.   The  gangrene from  external
  injuries almost always continues to spread;
  the i/ifection becomes general; and the pa-
  tient dies."  (Larrey in Mem. de Chirurgie
  Militaire,  Tom  3, p 142.)  On the other
  hand, this author  asserts, that, in the dry,
  or  spontaneous   gangrene,  absorption
  takes place with more difficulty,  and it is
  not uncommon to see the sphacelated parts
  separate from the living ones by the pow-
  eib of nature alone, without tlie  general
functions  being  impaired.  He argues,
that there is a manifest difference, between
what lie terms the traumatic and the spon-
taneous, gangrene, or, in other words, be-
tween the humid gangrene from an exter-
nal cause, and  the  dry gangrene,  which
ordinarily  proceeds  from  an internal
cause.   (P. 148 )
  In cases of mortification  arising from
external injuries, M.  Larrey  maintains,
that,  " notwithstanding  any thing  that
writers  and practitioners  may  allege to
the contrary, we should not hesitate about
promptly performing amputation, as soon
as the necessity for  the operation is de-
cidedly  established.  There  is  no  reason
to  apprehend,  that  the  stump  will be
seized  with gangrene, as in the sponta-
neous mortification, that  has not ceased
to  spread,  because   the  traumatic  gan-
grene,  after having  arisen  from a local
cause, is only  propagated by absorption,
and a successive  affection of the texture
of parts, by  continuity of the vessels.
Amputation, performed in  a  proper situa-
tion, stops the progress and fatal conse-
quences of the disorder.
  •* Supposing then the lower half of the
leg should be affected with  sphacelus, in
consequence of a gun-shot injury, attend-
ed  with a violent contusion of the part,
and a forcible concussion  of the vessels,
nerves,  and ligaments, if the skin is else-
where   uninjured, the operation may be
done in  the place of election, without any
fear of the stump becoming gangrenous,
notwithstanding  die cellular  membrane
of  the upper part of tlie member may be
already affected.  But, when the skin of
the whole leg is struck with  mortification,
the operation must be done on the thigh,
and no  time should  be lost.  The same
practice is applicable to the upper extre-
mities.   We must be careful not to  mis-
take a limb affected with  stupor for one
that is  actually sphacelated.  In the first
case, warmth, motion, and  sensibility are
still retained, although the skin may be
blackish and the parts may be swollen.
Besides, if there were any  doubt, it would
be  proper  to try at first  tonic repellent
applications, and cordial  medicines, &c.
(Larrey m Mem. de  Chirurgie Militaire,
 Tom. 3,p. 152, 153.)
   " When  amputation hasdieen practised,
this author recommends the exhibition of
baik, good wine, tonics,  &c.  in order to
promote the good effects of tiie operation.
(P. 154.)
   " The facts, (says M. Larrey) which I
shall relate in tlie course of this disserta-
tion, will prove,  1 think,  in an incontes-
table manner, the truth of  the principle,
which I lay down, that, when  gangrene is 
MORTIFICATION.
227
ihc result of a mechanical cause, and puts
the patiriit's  life in danger,  amputation
ought to be performed, without wai'.ing until
the disorder lias ceased to spread.
  " I have been a  witness of the death
of several individuals, from too rigorous
an adherence to the contrary precept; and
at length grievously impressed with  this
loss, I had long ago  determined to depart
from an axiom, which was always consi-
dered by me as false.   Besides, following
the maxim of Celsus, I preferred employ.
ing an  uncertain  remedy,, rather  than
abandon the patient to an inevitable death.
Satins  est enim  anceps auxilium experiri
qudm nullum.
  " I made the first attempt at Toulon,
in the year 1796, upon a soldier, who, in
consequence of a violent contusion of the
foot, was afflicted with a gangrenous ul-
cer, which soon threw the whole limb  into
a sphacelated state.   While the mortifi-
cation  was yet spreading,  I resolved to
amputate  the leg.  The success of the
operation surpassed my expectations; the
stump  healed;  and, in less than forty-five
days, the  patient got quite well. This
case served to encourage me.
  " During the siege of Alexandria, in
Egypt, in 1801, a second case, very  ana-
logous to the  preceding, occurred in my
practice ;  it happened in a  dragoon of
the 18lh regiment, whose  forearm  and
afterwardsarm   sphacelated,  in conse-
quence of a gun-shot wound in the articu-
lation of the left arm.   The  mortification
had extended nearly as high as the shoul-
der, and the patient's life was  in great
danger, when  I  determined to amputate
the limb at the shoulder-joint.  Tiie  dis-
order was manifestly  spreading, and the
patient's brain already affected, for he
had  symptoms of ataxia: the operation,
however, arrested  the progress  of  the
sloughing,  and saved  the  patient's  life,
who, at the conclusion of the  siege of
Alexandria, was quite cured.
  " After the taking of Ulm, M. Ivan,
surgeon to his Majesty the Emperor, per-
formed in my presence, and at my ambu-
lance established at Elchingen, the  am-
putation of the thigh of a soldier belong-
ing to  the 76th regiment of the line, the
leg having sphacelated in consequence of
a  gun-shot  injury.  The gangrene' was
not limited,  and evidently  continued to
extend itself:  notwithstanding  this the
effects of  the  infection were destroyed,
and the patient was quite cured on our
return to Austerlitz.
  " A  fourth  patient, an  officer in the
same regiment, shot in the ankle, at the
cap lure of the same town,  was conveyed
to my ambulance, in order to be dressed :
it was the  third day after the accident;
the foot was gangrenous, and the leg was
swelled and threatened likewise with
mortification.   Febrile symptoms  had
also come  on.   I hastened to amputate
the leg a little above the place of election.
The cellular membrane of the stump, of
a yellow blackish colour, was already in-
fected with the gangrenous principle,  (as
M. Larrey terms it.)  The operation, bow-
ever, stopped the progress  of the mis-
chief; suppuration  took  place  in  the
stump; some sloughs were detached; the
wound  assumed  a  cleaner  appearance;
and cicatrization  was completed  on  the
52nd day.  The patient could  already
walk with a wooden leg, when he  caught
the hospital fever, which was epidemic at
Ulm, where he awaited his regiment, and,
to my great regret, he was  carried off by
this disease, after having escaped the for-
mer danger.
  " After the battles of Austerlitz and
Jena, (continues M.  Larrey) several of
my colleagues, surgeons of the first class,
undertook, in consequence of my  advice,
and the examples of success, which I had
recited to them, the amputation of limbs
equally sphacelated, altliough  the morti-
fication was not limited, rather than aban-
don the patients to  a death, which  ap-
peared inevitable.  In general, these prac-
titioners  experienced  the   same  suc-
cess, as I did myself."  (Larrey, in Mem.
de Chirurgie Militaire, Tom.  3, p. 154—
157.)
   In M. Larrey's  memoir upon this sub-
ject,  there are some additional facts and
arguments in favour of what he  endea-
vours to prove, viz. that, in cases of mor-
tification from external injuries, if  the pa-
tient's life is in danger, amputation ought
to be performed, altliough the sloughing
may yet be in a spreading state.   I must
be content, however, with Iiaving stated
the particulars  already  explained; and
the reader, desirous of more,  must refer
to  M. Larrey's  own publication.  Cer-
tainly, the facts, which this  gentleman
has adduced, are highly important: they
tend to subvert a doctrine, and to prove
the error of a practice, which have been
urged in most forcible terms  by  all  the
distinguished surgeons of modern time.
The sentiments of Mr. Sharp are rendered
questionable; and the truth of the posi-
tive assertions of Mr. Pott is yet a matter
to  be examined.  The  latter, it  is well
known tells us,  that  he has" often seen
the experiment made of amputating, while
a  mortification  was spreading, but never
knew  it answer.  Are we  to conclude
that  all these cases, which  Pott  alludes
to, w^re mortifications from an internal 
228
MORTIFICATION.
cause?  Or, are we to suppose that the
operations failed from having been delay-
ed too Kong ?  Or, must we  imagine, that
the nature of the human constitution has
been changed between the aera of Mr.
Pott and  that  of M.  Larrey ? The last
gentleman's facts are too well authenti-
cated to admit of being disbelieved.

4. Application of Caustic  Substances, and
         of the Actual Cautery.

  Having explained the chief indications
in the treatment of mortification, we pro-
ceed  to  notice  some  particular  means,
which have been recommended by  prac-
titioners of eminence, as being in  certain
cases very efficacious. We allude to  some
caustic substances, and  even the actual
cautery, which have sometimes been suc-
cessfully employed in this disease.
  One of these applications is the muriatic
acid,  more or less diluted with water.   It
was Van Swieten,  who  particularly  re-
commended this remedy, he-mixed theacid
with six times its quantity of water, and
applied it as a fomentation  to the morti-
fied part, after making deep scarifications.
Li this manner  he stopped, or seemed to
stop,  a mortification, arising from a vio-
lent  inflammation  of the scrotum and
penis, and which extended all over  these
parts.  The same author strongly  re-
commends this  same topical application
to the sloughy state of the gums in  cases
of scurvy.  In this kind of case, he mix-
ed the muriatic acid with honey,  in vari-
ous proportiops; sometimes, he even em-
ployed the pure acid  itself for touching
the parts, which were likely to slough.  It
is easy to comprehend, that the muriatic
acid, as well as other mineral acids, and
vinegar, weakened with a sufficient  quan-
tity of water, may act as an  antiphlogis-
tic, and antiseptic, but, when it is con-
centrated, its  manner of acting  is then
very different,  as it is a real caustic, and
its salutary effects can only be explained
by the change,  which it produces in the
nature of the inflammation, which now
becomes  favourable to tiie formation of
healthy pus.
   It i> only in the same way, that we can
account for the good effects, attributed to
another, much more active caustic, than
the muriatic acid, namely, a  solution of
mercury in the  nitrous acid, with which
solution the  edges of the mortified part
are  reedtfimended  to  be  wet.    This,
it is said, stops the progress of mortifica-
tion.   We are not, however, possessed of
a sufficient number of facts in support of
such  practice.   An  example, however,
mentioned by a judicious author, Mr.
Kirkland, deserves attention.
  A man met with a fracture of the fore.
arm, and the ends of the bones projected
through  the integuments.  The ti dure
was very expeditiously reduced ,  but, at
the end of five, or six days, the whole arm
seemed to be completely mortified up to
the shoulder. Amputation was performed
as near  the joint  as possible, and the
stump, which had mortified as far as the
acromion, was  cauterized.  Tfce  follow-
ing day the mortification had reached the
inferior extremity of the scapula.   A lit-
tie of the solution of mercury in  nitrous
acid was now  applied,  by means of a
probe, along the edges of the parts affect-
ed, and  from' this moment the  disorder
made no further progress.  This caute-
risation was  repeated every day, for  se-
venteen,  or eighteen days.  The  sloughs,
and, especially, the scapula, were detach-
ed, and the patient got well.
  With respect to the actual cautery, Cel-
sus has recommended it to be applied to
the line,  which separates the dead parts
from  those which are  still living, when-
ever medicines, and, particularly, topical
emollient applications fail in stopping the
progress  of  the disorder.  M.  Pouteau
has  ventured  to  revive  this  practice,
which had been entirely exploded from
modern surgery, and he was of opinion,
that  the metliod  might have  the most
beneficial eff'ects, in cases of erysipelatous
gangrene, which is so often seen in hos-
pitals, in consequence of wounds.  For
this purpose, he recommends cauterising
chiefly the edges of  such  parts,  as are of
a dark red colour, and are on the  point of
perishing; and lie advises this to be done
with  a heated iron, or boiling oil, and to
repeat the cauterization ofthe dead parts,
at every  time of dressing them, until the
sensation of heat is even felt with a cer-
tain  degree of force  in the sound parts.
The whole of the affected part  is after-
wards to be covered with a large emol-
lient  poultice.
   M. Pouteau  relates a very interesting
case of an anthrax, which took  place on
a woman's cheek, and which he cured in
the above manner.  The tumour, wbicb,
on the third day, was quite black, and as
large as  a walnut, was accompanied with
an erysipelatous oedema, which extended
over the whole cheek, eyelids,  and front
of the neck.   M. Pouteau,  :fter having
opened the tumour in different directions
with a lancet, introduced the red-hot cau-
tery, and repeated the application several
times,  until the  heat was  felt  by  the
sound flesh.  The patient felt herself very
much relieved  immediately after this had
been done; an  oppressive headach, and a
very  afflicting sense  of  strangulation,
which she before experienced, were got 
MORTIFICATION.
2&
i id of,  and, in ten days more, the slough
Was detached by the occurrence of suppu-
ration. (Encyclopedic Methodique, Partie
Chirurgicale,  Art. Gangrene.)
  The foregoing  observations are intro-
duced into this work, that the reader may
not be left entirely ignorant of what vio-
lent measures the old surgeons adopted
in cases of mortification, and the account
is not  given, in order that such practice
may be again imitated.  The employment
of such terrible applications, as the actual
cautery,  and  boiling oils, is as unscienti-
 fic, and unnecessarily painful, as it is  un-
 productive oLany  essential good.  The
 grand object in almost every case of mor-
 tification, is  to diminish the irritation of
 the parts in immediate contact with those
 already dead.  This is indicated, lest  the
 parts still alive, and so situated,  should
 experience the same fate, as the contigu-
 ous ones.  Some  who  have  reprobated
 the application of spirituous, and resin-
 ous  substances to  parts affected  with
 mortification,  and  who have also con-
 demned incisions and  scarifications, give
 their approbation to the use of the cau-
 tery.  They assert, that the manner,  in
 which the latter acts, is essentially differ-
 ent from that, in  which spirituous and
 resinous applications   operate, and  that
 whde  these,  by  irritating the affected
 parts, tend to increase and propagate the
 inflammation, that leads to mortification,
 the lively action of the cautery changes
 the nature of such inflammation, and es-
 tablishes that state of the  vessels, which
 is necessary for a favourable  suppuration.
 They state, also, that the cautery gives a
  tone to the  vessels, in the  vicinity of the
  parts to which it is applied, and, in proof
  of this remark, they refer to the effects of
  the application on different ill-conditioned
  ulcers,  and  particularly, on carious bones.
  (Encyclopedic Methodique, Partie Chirur-
  gicale, Art.  Gangrene.)
     Notwithstanding  these assertions, I
  shall venture to congratulate the surgeons
  of this country in particular, on the  total
  rejection of the use ©f the" actual cautery
  and  boding oils, in  cases of mortifica-
  tion.
    [From repeated disappointments in the
  use of the  various remedies which have
  been recited, and from having observed
  the efficacy of blisters in arresting tlie
  progress of erysipelas,  Dr.  Physick was
  induced some years  ago to try the effect
  of epispastics in  the  treatment of gan-
 , grene.
    " The first  opportunity,"   says  the
  Doctor, " I had of  applying  a blister
  with this  intention, was in the case of
Captain  Stokes,  a gentleman between
forty  and fifty  years  of age, whom I
was desired to visit in consultation with
Dr. Rush, in January  1803.  After an
inflammation about the anus, which had
been  supposed for several  days  by  the
patient,  an  attack of piles, a  mortifica-
tion was observed to have commenced in
the  perinacum, and  on  the side  of the
scrotum. At my first visit I proposed
a blister, to extend from  the edge ofthe
mortification in the perinxum, backwards
over the buttocks; this being agreed to,
was immediately applied; the following
day,  when  the  blister was  dressed, we
were both well satisfied with its effect,
 as it had prevented the mortification from
 spreading backwards; but  so extensive
 was the mortification of the skin and an-
 terior part of  the scrotum,  which ap-
 peared  to extend upwards in the course
 of the  spermatic  chords  towards the
 abdomen, that his recovery was not to
 be  expected.   After a few  days  he
 died."
   Dr. Rush being struck with the good
 effect of the blister in  the preceding
 instance, has lately employed the remedy
 in a case of mortification, the history of
 which is contained in the following letter.
Dear Sir,

  I was called upon by Dr. Bleight, on
the 29th of last July, to visit with  him
Captain It. A. who in consequence of ap-
plying a handful of the polygonum persi-
caria, instead of^fcper, to a common use,
after going to  stool, was affected with an
inflammation in the extremity of the rec-
tum, which extended  around the adjoin-
ing parts, and along the perineum,  so as
to affect the integuments of the scrotum.
Bleeding and other depleting remedies
had been used to no purpose, m order to
cure it : a partial mortification had taken
place.  I concurred with Dr.  Bleight in
advising leeches to the sound  parts; and
recollecting the high terms in which you
spoke of the efficacy of blisters in prevent-
ing  the  progress of mortification in our
consultation, in the case of Captain Stokes,..
in January 1803,1 advised their  applica-
tion to all the diseased parts  which had
not put on  a  gangrenous  appearance.
They had the wished-for effect; the mor-
tified parts were afterwards cut away,  or
 gradually sloughed  off';  and,  under the
 faithful  and patient subsequent attendance
 of Dr. Bleight,  the Captain happily  reco-
 vered, and now enjoys his usual health.
   In the most dangerous state of his dis-
 ease, we gave him bark ;  but its distress-
 ing-effects  upon his system obliged us to 
230              NJEV
NjEV
lay it aside.  From, dear, sir, your sincere
friend,
                     Benjamin Rush.
Dr. P. S. Physick.
  Nov. 15th, 1804.
  The next case in which the remedy was
employed was that of a gentleman who
had been attacked with " a mortification
ofthe foot, which was advancing daily up-
wards, unchecked  by the  liberal  use of
the bark;" a blister in this case was  ap-
plied round the leg below the knee, in the
evening—next morning it  was  dressed,
and it was observed that the mortification
had not  increased:  the  application of a
second blister effected a cure.
  Since the  publication of these facts a
variety of respectable  testimonials have
been  forwarded  to  Dr.  Physick,  of  the
efficacy of blisters  in arresting  the  pro-
gress of mortification.   I have myself" ex-
perienced the  advantage of the practice
in several cases of gangrene, and have no
hesitation  in  recommending  it, in  pre-
ference to every local remedy hitherto in
use.]
  Consult  B.  Bell's  System of Surgery.
Encyclopedic Methodique, Partie Chirur-
gicale, Art. Gangrene.  Kirkland on Gan-
grene, and on the  Present State of Medical
Surgery.  Richter's Anfangsgr. der Wun-
darzneykunst, Band. 1, Kap. 3.   Various
parts of Hunter on Inflammation, &c. Sharp's
Critical Enquiry into the Present State of
Surgery^ Chap. 8. Riciierand's  Nosogra-
phie Chirurgicale, Tom. l,p. 131, Wc. Edit.
2*.  Lassus, Pathologie CJdrurgicale, Tom.
1, p. 30, &fc. Edit. 1809.Cjeveilie, Nouvelle
Doctrine Chirurgicale, Torn. 4, p. 321, He.
Paris 1812.  Larrey, Memoires tie Chiruv-
gie  Militaire,  Tom.  3,  particularly,  the
Mem. sur la  Gangrene de Congelation, p.
6U, and that sur  la  Gaiigrcne 'l'rauma-
tique, p. 141.
   MOXA  (Japanese.) A soft lanuginous
substance prepared from the young leaves
of a species of mugwort.  It is used in
the following  way :  A little cone of the
moxa  is  laid upon  the  part,  previously
moistened and set on fire at the top.  It
burns  down with a  temperate glowing
heat, and produces a dark-coloured spot,
the exulceration of which is promoted by
applying a little garlic.  The ulcer is  left
to discharge, or is healed up  according to
tiie object in view.   The moxa is famous
in the East for curing several  diseases;
and the French are in the habit of  using
it; but, whenever English surgeons wisti
to produce a slough, they have recourse
to  caustics,  in  preference  to  actual
fire.
   MUNDIFICATIVES.  (from mundiflco,
to cleanse.)   Applications, which  make
sores put on a cleaner appearance.
   MYDRIASIS,  (from peseta, to abound
 in moisture.)   A preternatural dilatation
 of the pupil;  so named, because it  was
thought to originate in  redundant mois-
ture, or too great an influx  of humours.
It is often a symptom of an amaurosis.
   MYO'PIA.  (from  fivo, to  wink,  and
 u-^t. the eye.)  That kind of short-sight-
 edness, m which the eyes are half shut,
and always winking.
N.
    NJEVUS.  A mole, or freckle on the
     skin.  Nxvi materni signify  the  lit-
tle spots, excrescences, or swellings, with
which many children  are  born.   There
are two kinds,  viz.  small red tumours,
which gradually increase to a large size ;
or brown flat marks, not rising in the least
above  the surface of the skin.  Mr. Latta
says,  he once  saw  in a child two years
old, a tumour of this kind weighing four-
teen ounces, which, at the time of birth,
wasjjnly equal  in size to a large bean,
and which for a year afterwards,  did  not
enlarge much;  but,  then  grew to  the
magnitude already specified.  The other
species of naevi materni, or such  as  rise
but little above the skin, are of various
forms, and  have  been compared with
cherries, grapes,  &c. and have  all been
supposed to arise  from some impression
made on the mind of the mother during
pregnancy, or at tiie time of conception.
The settlement of this  disputed  point, I
shall leave to speculative writers. 
NECROSIS.                              231
  Those  nxvi materni, which  are mere
spots, or marks, give no  inconvenience,
and of course do not require the inter-
ference of surgery.   But such  nsevi  ma-
terni as elevate themselves above the  sur-
face  of the body, increase in  size,  and
seem likely to become troublesome, should
be entirely removed with a  knife.   Many
of them seem to consist  of a congeries of
dilated vessels, and, after  they  have ac-
quired a certain size, are apt to  burst and
bleed profusely.   John  Bell  has  named
this kind of disease aneurism by  anastomo-
sis;  the description, and  proper  treat-
ment of which are to be found in the article
Aneurism.
   Mr. Abernethy cured an extensive nsc-
vus maternus, of a child's arm,  with a
bandage.  (See Latta's System of Surgery,
Vol. 2, Chap. 22.   John Bell on  Aneurism
by Anastomosis, in fas Principles of Surgery,
Vol. 1. Abernethy's Surg. Observations )
   NATRON  PRJEPARATUM,  in  sur-
gery, is chiefly given in cases of broncho-
cele,  and  scrophula.  The common dose
is a scruple.
   NEBULA, (from it^tXn, a little cloud.)
A cloudiness of the cornea of the eye. See
Cornea, Opacity of.   K
   NECROSIS, (from »£*£«*»,  to destroy.)
This word, the strict meaning of which  is
only mortification, is, by the general  con-
sent of surgeons, confined to this affection
ofthe bones.   The death of parts of bones
was not distinguished from caries  by the
ancients.  However,  necrosis and caries
are essentially different; for, in the first,
the affected part of the bone is deprived
of the vital principle; but this  is not the
case  when it is simply carious.  Caries is
very analogous  to ulceration,  while ne-
crosis is exactly similar to mortification, of
the soft parts.
   The subject of necrosis is  a  peculiarly
interesting one; for, it introduces us to  a
knowledge of reparations accomplished
by nature, which would excite admiration
and wonder even  in  men whose  feelings
are the most thoroughly chilled With apa-
thy.  What man, unacquainted with the
facts, which  the rich records of surgery
now present, would ever suppose, that  so
large a  bone as that ot the  thigh might
 perish, a new one be afterwards generat-
ed, and tiie old dead one in time removed
by absorption, so as to leave the functions
and power of the limb quite  unimpaired ?
 —We shall first explain the most remark-
able circumstances, relative to  the nature
of necrosis, next mention  a few important
cases, and lastly speak of the  treatment.
   It is a remarkable circumstance, in the
history of necrosis, that, in favourable in-
 stances of the disease, tiie uiflexibility and
 firmness ofthe limb are preserved, during
the whole of the process,  by which the
new bone is formed." Consequently, the
new bone must have begun to grow, and
must have  acquired  firmness before the
old bone separates, or is absorbed.  Were
this not the case, the limb,must become
flexible and useless, the moment the dead
bone is  removed.  Another consequence
of the new bone being formed, before the
removal ofthe old one, is, that the former
must surround  and. include the  latter.
For, since the  lifeless  portion of bone
completely occupies  the space between
the two living ends,  these cannot be im-
mediately connected by the new  bony
matter.  The connexion can alone be com-
pleted  by the  new bone being  deposited
on the outside of the old one,  from one
end to the other, and attaching itself to
the portions which still remain alive.  The
new bone must also be necessarily larger,
than the old one, because externally situ-
ated, and hence the affected limb, after
the cure is complete, will always continue
larger,  clumsier, and less shapely  than
the other.  The  length of it, however, re-
mains unaltered, because the old bone re-
tains its attachment,  while the rudiments
of the new bone are  lying on  its outside,
and connect the living ends ofthe old one;
by an inflexible  mass, equal in  length to
the portion, which is destroyed.
  Thus we see, that, in the process, which
nature  follows in  the formation of tiie
new osseous shell, the old bone  serves as
a mould for  the new one ; and the flrst
step of the process is to surround the old
bone with an effusion of coagulating lymph.
 (Russell on Necrosis, p. 2—7.)
   This author adduces  many arguments
to prove, that the pulpy m^s, which ex-
tends from one portion of the bone to the
other, and is itself at last converted into
bone, is formed quite independently ofthe
original bone, or the periosteum. (P. 27.)
   On  the  other hand, Mr. Crowther has
published  a  letter,  written by Mr. Ma-
cartney, in which the periosteum is de-
scribed, as being the organ producing the
new bony matter.  Mr.  Macartney re-
marks, " that the first and most important
circumstance is  the  change, which takes
place in the organization of the perioste-
 um ; this membrane acquires the highest
 degree of vascularity, becomes consider-
 ably thickened,  soft, spongy, and  loosely
 adherent to the bone.   The" cellular sub-
 stance, also,  which is  immediately con-
 nected wiili the periosteum,  suffers a  si-
 milar  alteration;  it puts on the appear-
 ance of being inflamed, its vessels enlarge,
 lymph is shed into its interstices, and  it
 becomes consolidated with the perioste-
 um.  These changes are  preparatory  to
 the absorption of the old  bone,  and tlie 
232
NECROSIS.
secretion of new osseous matter, and even
previous to the death of the bone, which
is  to be  removed.  In one  instance, I
found the periosteum vascular and pulpy,
when the only affection  was  a small ab-
scess of the  medulla, the bone still re-
taining its connexion with the neighbour-
ing parts,  as it readily received  injection.
The newly organized periosteum, &c. se-
parates  entirely  from  the   bone,  after
which it begins to remove the  latter by
absorption;"  and, while this is going on,
its inner  surface becomes covered with
little eminences, resembling granulations.
" In proportion  as the old  bone is re-
moved, new osseous  matter  is  dispersed
in  the  substance of  the granulations,
whilst they continue to grow  upon the
old bone, until the whole, or a part  of it,
is completely absorbed, according  to the
circumstances ofthe case.  What remains
of the investment, after the absorption of"
the old bone, and the formation  of the os-
seous tube, which is  to replace  it,  dege-
nerates, loses its vascularity, and appears
like  a lacerated membrane.  I have never
had  an opportunity of examining a  limb,
a sufficient time after the termination of
the disease, to ascertain, whether the in-
vestment be at last totally absorbed, but,
in some instances, I have seen very little
remaining. . During  the progress of the
disease, the thickened cellular substance,
which surrounded the  original perioste-
um, becomes gradually thinner; its ves-
sels  diminish, and it adheres strictly to
the  new-formed bone,  to which it ulti-
mately  serves  as  a  periosteum."  Mr.
Macartney states, that  the  anatomical
preparations, which authenticate the above
observations, are  preserved  at St. Bar-
tholomew's Hospital.  (See  Crowt/ier on
White Swelling, p. 183, Edit. 2.)
  With respect to the symptoms of necro-
sis, an incipient case is characterised by
a deep  seated  excruciating  pain, not at
first aggravated by pressure, and  which
is  soon followed by a rapid enlargement
ofthe parts along the course of  the  bone.
Soon, however, after the commencement
of the  attack,  an external  inflammation
succeeds, which quickly ends iu the for-
mation of matter. . The abscess, at length,
bursts by  a  small opening.  The extent
of  this  inflammation  is  not in general
great.  Most commonly several  inflamma-
tions, of a circumscribed kind, occur about
the  same  time, the  abscesses  burst  by
small openings, which do not cose, but
continue discliarging matter, as fistulous
sores. The apertures are generally situat-
ed over the  most superficial part  of the
affected  bone.  The pus  is  usually  of
good quality, and large in quantity, issu-
ing  from   extensive  cavities, into which
the  fistula lead.   Such abscesses,  being
situated within the newly formed osseous
shell, cannot  be discharged by  pressure,
nor can any fluctuation be felt.   A probe
can  seldom be introduced far into the
fistulous  openings, or discover any  looSfe
piece of  bone.  In  this stage,  the dead
bone,  technically called the  sequestrum,
can  seldom be felt,  though,  in a  few
instances, small spiculae make their way
outward, together  with  the discharge.
Fistulous openings may be regarded, as
necessarily attendant on all cases  of ne-
crosis; though so mild a case may be
conceived, that the  new  bone   may  be
generated without  any. outward  ulcera-
tions.  No such instance, however,  is on
record.  (RusseH.)
   After  the  openings have formed, the
case may take one ofthe following courses.
The ulcerations may in time heal up, the
sequestrum never be seen, and no vestige
of the disease remain, except a perma-
nent enlargement and induration  along
the course ofthe bone.  This is the most
favourable manner,  in which a necrosis
may  terminate.  In.the other  one, the
sequestrum makes its appearance exter-
nally, through  the new bone and the in-
teguments, attended with  different de-
grees of pain,  inflammation, and suppu-
ration, in different cases.  The  seques-
trum  may at first be moved by shaking
it;  but,  is too firmly wedged in the sur-
rounding parts to be completely  taken
out.   In time, however, it becomes loose
enough to be removed.
   Sometimes, tiie middle portion of the
sequestrum presents itselfexternally, while
its sides are every where wedged in the
substance of the  new bone.  The natural
end of such  a case would be very tedious
of accomplishment, and the interference
of art is essentially serviceable in accele-
rating the separation of  the dead bone,
thus circumstanced.  After the sequestrum
has been either absorbed, or thrown off,
in one of the above ways, the cavity ofthe
new bone becomes filled up with granula-
tions, which are,  at length, converted into
bony matter.  Thus tiie new bone differs
from the original one, in being solid, in-
stead of hollow.  ( Russell.)
   When the sequestrum is  thrown off
slowly, the inflammation is moderate; but,
when it separates quickly, while the new
bone is  in a soft  state, the detachment  is
always preceded by severe inflammatory
symptoms, and followed by a temporary
 loss of  the natural  firmness of the limb.
 This premature separation of the seques-
 trum often occurs in necrosis of the lower
jaw, and the chin consequently falls down
on the neck.  In certain cases, the seques-
 trum separates at each end from the living
 portions of the old  bone, before the ne* 
NECROSIS.
233
osseous shell has acqtured firmness, 90 that
the limb  feels as if it were broken in two
places.   (Russell.)
  When  the dead bone is removed by ab-
sorption, the process is tedious, and at-
tended with a profuse discharge of mat-
ter, which  gradually ceases, and at last
stops altogether.  In young subjects, this
work is more quickly perfected,  than in
old ones.  There are s6me chronic cases
of necrosis, in which the sequestrum re-
mains unabsorbed, for an indefinite length
of time,  producing no violent irritation,
yet,  always enough to teaze the patient,
and disturb his health.
  In necrosis of the long bones, there are
always round apertures in the new osseous
•hell, corresponding with the external fis-
tulous openings, as long as the sequestrum
remains enclosed in it.   (Russell.)
  The tibia,  femur,  lower jaw, clavicle,
humerus, fibula, • radius,  and ulna,   are
most frequently  affected with necrosis.
Except>ng  the  lower  jaw  and scapula,
the process of regeneration has only been
noticed,  in the cylindrical bones.  From
twelve to eighteen years  of age, is the
time of  life,  most  subject to necrosis.
The necrosis of the  lower jaw, however,
seldom occurs before the age of thirty.
In some  persons, two bones are affected
at once, owing to constitutional causes.
  The process of cure is  said  to take
place with more celerity in the lower jaw,
than any other bone, and may be  com-
pleted in three months.  Mr.  Russell has
never known a necrosis of the tibia get
well in less than a year ;  but,  in general,
nearly two years elapse first;  sometimes,
the cure is protracted to a much greater
length of time.
  When  the constitution is predisposed to
necrosis, any cause,  capable of exciting
inflammation, may occasion  an attack of
it  Often, however,  the disease is purely
sporadical and not referrible  to outward
causes. Cases, which occur from external
injury, are generally those of thelower jaw,
which  are frequently imputed to blows,
the application of  acrid substances to ca-
rious teeth, effects of mercury, &c.
  Necrosis of the lower jaw and clavicle
never proves fatal: that of the lower ex-
tremities, which is the worst case, does so
very -eldom,  and only, from the violence
ofthe first inflammatory symptoms, which
rapidly bring on  a  hectic fever, which
proves incurable,  without removing its
local cause by a timely amputation. When
the violence of the first  stage, however,
has abated, the irritation ceases, and the
hectic symptoms, if there  are any, are ge-
nerally moderate.  Nor is this state  of
tranquillity disturbed, till the sequestrum,
in making its wav outward,  again  pro-
  VOL. II.
duces irritation.   At this second period of
urgency, extensive inflammation may ori*
ginate,  ulcerations   spread  all over the
surface  of the limb, assume an unhealthy
appearance, violent fever succeed, and the
patient  either perish, or sink into a state,
in which he must consent to amputation,
as the only means of saving his life.  This
is the last crisis of eminent danger ; but,
in general  it is less perilous, than when
the  inflammation comes on in the inci*
pient stage of necrosis.  (Russell.)
   The  following  case of necrosis of the
thigh-bone is related by Dr. Mackenzie.
—William  Baxter,  a boy thirteen years
old, received a blow on his thigh at school,
of which he at first  hardly  complained ;
but, in  a few' months, he began  to have
pain in the thigh, which inflamed, swelled,
and  appeared to  have matter in it.  The
parents  being poor, no surgeon was called,
and  the boy  was allowed to linger for a
great while.  At length, the matter made
its way through the skin, by a small open*
ing, on the interior part ofthe thigh, about
three inches  above  the  knee, and a thin
sanies continued to be discharged for eigh-
teen, or twenty months.  At length, the
hole in  the skin enlarged, and the point
of a bone began to protrude, and give a
good deal of pain, when the clothes rub-
bed  against  it.  After  suffering  in  this
manner for two years and a half, the boy,
as he lay in bed one morning, felt the bone
looser, and projecting more, than  ordina-
ry.  He gave it a strong pull, and brought
the piece away entirely, which proved to
be seven inches and a half of the thigh*
bone. A good deal of bleeding followed;
but, the wound soon healed, and he has
never since found the least inconvenience
Dr. Mackenzie, hearing of this singular
case, sent for the boy, carefully examined
his thigh, and  found it as firm as the
other.   The only  difference was,  that it
was  somewhat thicker,  and a little more
curved.   The muscles retained their na-
tural softness, and looseness on the bone.
The detached piece of bone was a portion
of its whole circumference.
   In confirmation of this case, Dr. Hun-
ter mentions a tibia, which was sent to him
by a Mr. Inet, after amputation.  On ex-
amination, the case at first sight seemed to
be a swelling of the whole bone, with a
loose internal exfoliation.   However, it
proved to be a remarkable instance of the
separation  of the greatest  part  of  the
original  bone whose place was supplied by
a callus. The external surface of the in-
closed loose  piece of bone was smooth.
A small part ofthe surrounding bony sub-
stance being removed, the contained piece
was taken out, and found to be the whole
body of the tibia.  It had separated from
   <>o 
234                              NECROSIS.
the epiphysis at each extremity. The mid-
die part ofthe bone had perished, conse-
quently,  had lost its  connexion with the
periosteum, and was gradually thrown off
from the living parts of the bone at each
end.  A callus extended from end to end,
united tlie two extremities of the original
tibia, preserved the length, and gave firm-
ness and inflexibility to the part.  The ex-
foliation was so encompassed by the new
bony case, that, though quite loose, it
could not be thrown out.  (Med. Obs and
Enquiries, vol. 2)   In the 5th vol. of the
Mem. de I'Acad, de Chirurg. is the history
of a man,  the  whole of whose  clavxle
came away, without his being deprived
of any of  the motions of the arm.  The
death of  this pattern,  which happened
shortly afterwards,  afforded an opportu-
nity of examining  how  nature  had re-
paired the loss.   Another clavicle was
found regenerated, which neither differed
from tlie original one  in length, or  solidi-
ty ; but, only in *hape, being flatter, and
not so round.  It was  connected with the
acromion  and sternum, just like the pri-
mitive bone.
  Though necrosis  mostly  attacks the
cylindrical bones, the flat ones are not ex-
empt from the disease.   Pott makes men-
tion of  a  parietal  bone,  the whole of
which was detached, and of  an os frontis,
the  greatest part of  which  came  away,
In a thesis on  necrosis, in 1776, aux eco-
les de chirurgie, may be found the case of
a young man, a very large part of  whose
scapula perished  and came away.   Cho-
part, who relates the case, mentions, that
he saw the patient  quite  recovered, and
felt :< new  triangular moveable bone, firm-
ly supporting the clavicle, but, smaller
and flatter, than natural, and without any
spinous process.  The same has happened
to the lower jaw, as may be seen by refer-
ring- to the Ephemerides Germanix,  and
Mem. tie PAcad. de CIdrurgie. In the fifth
vol. of the latter work, is an account of a
woman, who applied to  be relieved of
some venereal complaints.   From the be-
ginning ofthe treatment, the bone was dis-
covered to be loose just under the  gums,
and seemed, shortly afterwards,  to move
backwards and forwards with a tooth. M.
Guernery  took hold of the tooth with a
key-instrument, and found it firmly  insert-
ed in the moveable  piece of the jaw ; he
made with caution the necessary manoeu-
vres for extracting the portion of  bone ;
but was greatly surprised on finding what
an extensive part yielded to his very  mode-
rate efforts.  It was the whole ofthe low-
er jaw, above its right angle, from  its di-
vision into the coronoid  and condyloid
processes  to the  space between the  first
and second of the front grinders ofthe left
side.  On the right, there only remained
the condyle  in tlie articular cavity of the
temporal bone.  This destruction left a
considerable  empty  space,  from which
great deformity was apprehended, in con-
sequence of the  unsupported soft parts
falling down.  The woman, however, got
well in two months, and had the most per-
fect use of a new jaw.  A similar fact is
recorded in the Journal de Medecine, 1791.
  In cases of" necrosis, the surgical indi-
cations are few and obvious, viz.  1. When
inflammation  attends  any stage of the
disease, to have recourse to common anti-
phlogistic means ;—2. To promote the
separation,  or absorption, of the dead
bone, according as it tends to make  its
way outward, or to become  completely
incased with new bony matter;  and, in
this situation, to be invisibly and gradu-
ally removed by a natural process.  3.
When the constitution  seems unable to
sustain any longer the effects of the local
disease, to amputate, if the situation ofthe
affection will permit.
  During the first inflammatory attack,
the patient's fife is often endangered from
the extent and violence of the inflamma-
tion, before  the new shell is  formed, or
the sequestra loose, and ready  to sepa-
rate.  In this state, art can do  little more,
than employ topical bleeding,  and fomen-
tations, and poultices.  If, notwithstand-
ing  such treatment,  the patient should
seem likely to perish of the hectic symp-
toms,  which  rapidly follow,  unless the
limb be immediately removed, the opera-
tion should then not be delayed.
  But, if the patient get over the first in-
flammatory  stage, the grand object is to
get rid of the  sequestra.  When  they,
however,  are undergoing a gradual  ab-
sorption, without ever making their  ap-
pearance externally, or giving any con-
siderable disturbance to the constitution;
or,  when the dead bone is  making its
way ou'ward, without occasioning urgent
inconveniences;  the surgeon  should  in-
terfere  very little with the natural pro-
gress of the case.  When the dead bone
does not tend to make its way  through
the skin, but lies quietly incased in the
new osseous shell, the occurrence of  ex-
tensive  suppurations  may be  prevented,
by  occasionally  applying leeches,  and
keeping  open a  blister  with  the savine
cerate, as recommended by Mr. Abernethy
in his lectures, and Mr. Crowther, in his
work on the White Swelling.   The blister
will, at the same time, have great effect
in promoting the absorption  of the  se-
questrum, and, of course, in accelerating
the process of cure. 
NEC
NOL
235
   When the dead bone, however, creates
 considerable irritation, when it* middle
 portion is very superficial, or quite ex-
 posed, while its ends, or edges, are over-
 lapped by the surrounding new bony mat-
 ter, consequently the piece so wedged in,
 that its separation  cannot be  expected in
 any moderate time, the operation of cut-
 ting it out, is, certainly, not only feasible,
 but highly proper and  commendable.  In
 this kind of case, Mr. Hey's saws  would
 be found  the most  convenient  instru-
 ments.
   Also, were the dead bone, though quite
 covered  and  incased in the new one, to
 be tediously long in being absorbed, pro-
 ductive  of great  irritation  and  impair-
 ment of the health, and the affected bone
 superficial, like the tibia, no candid man
 could condemn making an incision, and
 removing a part of the osseous shell, in
 order to take the chance of being able at
 once to extract the sequestrum lodged in
flits cavity.  Mr. Russell mentions  success-
 ful attempts of this kind,  which fully jus-
 tify the practice.  The state of the bone
 may be  examined, without proceeding to
 any severe operation, by laying bare small
 portions of the bone in the vicinity of the
 fistulous openings, introducing  a  probe,
 if possible; or, if that be impracticable,
 drilling  small holes with  a perforator,
 for the purpose of  exploring the state of
 the cavity. If the cavity should still seem
 extensive, and to contain a sequestrum of
 considerable size, the necessity of oper-
 ating is apparent.   On the contrary,  if
 the whole cavity be filled up with osseous
 matter, and no dead bone be found there,
 the progress of the case must, of course,
 be left to nature.   (Russell.)  When the
 surgeon knows, that this object is to make
 an opening large  enough  to allow the
 dead piece to be extracted, he scarcely
 needs directions how to set about making
 it.  The skin must  be divided with  a
 common  scalpel,  and the bone cut with
 small trephines, a gouge and mallet,  or
 what are in most cases best, Mr. Hey's
 saws.
   Consult Russel on Necrosis*, 1794. Mem.
 de ? Acad, de Chirurgie, torn. 5.  Bayer on
 the Diseases of the  Bones,  Vol. 1.   Ency-
 clopedic Methodique; Partie Chirurgicale ;
 Art. Necrosis.   Tliesis de Ossium Necrosi,
 1776  Crowther on  White Swelling, &c.
 Edit 2.   By far the most valuable work on
 necrosis is, I believe,  Weitlman de  Necrosi
 Ossium, Francofurti,  1793.  See  also M.
 David's Obs. sur une maladie connue sous le
 nom de necrose; Paris 1782.  Bonn's The-
saurus Ossium  Morbos.  Richerand's Noso-
graphie Chirurgicale, Tome 3, p. 138, Edit.
2. Leveille, in Nouvelle Doctrine Chirur
 gicale, Tom.4,p:Z21,&c. Pans, 1812. Lar-
 rey, in Mem. de Chirurgie Militaire, Tom.
 3, p. 367.
   NEPHELA. (dim. of yf<p«4,  a cloud.)
 A cloud-like spot on the cornea.
   NEPHRITIS,  (from nip^i, a kidney.)
 Inflammation ofthe kidneys.
   NEPHROTOMY, (from ietyof, a kid-
 ney; and reftvu, to cut.)   Nephrotomia.
 The operation of cutting a stone  out  of
 the kidney; a proceeding which, perhaps,
 has never been actually put into practice.
 In iheAbrege Chronologique de P Histoire de
 France par Mezerai,  and in the Philoso-
 phical  Transactions for  1696, two cases
 pf what is called  nephrotomy are men-
' tioned; but several circumstances in the
 accounts led  Haller and others  to  con-
 clude,  that the operation alluded to  in
 the first work, was nothing more than the
 high operation for  the stone.   With  re-
 spect to  the example  in  the latter work,
 the particulars are not  detailed enough
 to shew that aTi incision was really made
 into  the kidney. There  is no doubt that
 stones  have often   been  extracted from
 abscesses about the region of the kidneys,
 after their  presence has  been  detected
 with a probe.  But, wih regai-d to  cut-
 ting into the kidney,  the deep  situation
 of this viscus, and the want of sympoms,
 by which the lodgment of a stone in it can
 be certainly discovered,  will  always be
 strong objections to the practice.  When
 a stone, from its size,  cannot  jiass from
 the kidney, and excites inflammation and
 suppuration, no doubt, the surgeon may
 make an incision into the tumour,  and
 extract the calculus.  In this  sense, ne-
 phrotomy is  certainly  a practicable oper-
 ation.  Warner contends, that it can only
 be practised in such circumstances, not-
 withstanding  whatever  may have been
 said  by Marchetti, or others, upon  the
 subject.  In  such a case, the operation
 would not be  attended with any greater
 difficulty, than the opening an abscess in
 any other part of the body.  (See Warner's
 Cases in Surgery, p. 241, Edit. 4.)
  NITROUS  ACID.  See  Acidum  Ni-
 trosum.
  NODE.  Nodus.  A swelling of a bone -,
 a thickening of the periosteum, or a  fas-
 cia ; or a tumour on  a  tendon,  from  a
 venereal cause.  See Venereal Disease.
  NOLI ME  TANGERE.  By this  ex-
 pression,  surgeons  commonly imply an
 herpetic disease, affecting  the  skin and
 cartilages of the nose.  Mr. Home says,
that the ulcers, for which  he has been  led
to employ arsenic, are named, from  the
 virulence of their disposition, noli me tan-
gere, and are very nearly allied to cancer j 
236             N O L                                   N O L
differing from it in not contaminating the
neighbouring" parts  by absorption,  but,
only  spreading by  immediate  contact.
Ulcers  of this kind  differ  exceedingly
from one another in their  degree of  vim-
lence ; but, they are all so far of the same
nature, that arsenic  in  general  agrees
with them, and puts a stop to their pro-
gress,  while they are aggravated by mild-
er dressings.   (Home on ulcer, edit. 2, p.
267.)
  The disease generally commences  with
small,  superficial, spreading  ulcerations
on the alse of the nose, which  become
more or less concealed beneath the furfu-
raceous scabs.   The  whole  hose is  fre-
quently destroyed by the  progressive ra-
vages  of this  peculiar  disorder, which
sometimes  cannot be stopped or retarded
by any treatment, external or internal.
  The specific ulcerations do not gene-
rally extend to the parts far within the
nostrils ; but,  at the time that I am  writ-
ing this article, there is,  under Mr. Har-
vey,  in St. Bartholomew's  Hospital,  a
curious example,  in which  the greatest
part of the nose is destroyed, and the ul-
ceration  proceeds even through the front
part of the palate into the mouth.  The
morbid process  sometimes  stops for  a
considerable  time,  and then is renewed
with increased violence.  The following
case illustrates  the nature of noli me tan-
gore, and one mode of treatment, to which
it yielded: Jane Chatillon,  45 years  of
age,  was attacked, in  the course of Sep-
tember,  1T88,  with an inflammation  on
the  left alae of the nose. Some timeaf-
terwards the part ulcerated, "which occa.
sinned a troublesome and  sometimes  a
painful itching : different  means were un-
successfully employed, and  the  case re-
mained nearly  in the  same situation till
the month of September in the following
year.   At this  period, the ulcer spread
very fast; the septum nasi, the muscles,
and cartilages  of  both sides, were, in a
short space of  time, destroyed.   The ul-
ceration  extended on the  left side, on the
loose edge  of* the upper-lip.  This  was
the state of her case on her admission into
the Hospital of St. Louis,  in the month of
October, 1789.
  A poultice,  moistened  with aq. veg,
was  applied  twice a day  to the ulcer;  a
sudorific  ptisan' prescribed, and a pill,
composed  of one grain of calomel, and
one grain of sulpli.  aurat. aqtimonii, or-
dered  to be taken every day.  From the
fifth day, the inflammation lessened.  No
other  sensible  alteration  took place till
th". 21st.  The suppuration, that, till this
time, had been black and  putrid, now be-
came white and inodorous.
  On the 37th, the discharge was trifling,
and the ulcer,  being well deterged, was
dressed with pledgets, dipped in a solu-
tion of verdegris and corrosive sublimate,
in the proportion of six grams of each to
a pint of water.  On the 40th day, cica-
trization hegan  to take place, and was
finished by the 60th.
  Some time before it was completely ci-
catrized, an issue was made in the arm,
which was healed up,  without any incon-
venience to the patient, six months after
the cure.   (Parisian Chirurgical Journal,
Vol. 1.)
  One of the best external applications to
noli me tangere is the following lotion j
5*. Kali arsemcati,  gr. iv.  Aq.  menthae
sativae JiV.  Spintus  vini  tenuioris  ^j.
Misce et cola.  I have seen several cases
m St. Bartholomew's Hospital, very late-
ly, which were either cured  or seemed
disposed to get well with this application.
The  solution of arsenic, which Mr. Home
has always used, is mtde by boiling white
arsenic in  water tor several hours, in a
sand-heat.   When  given internally, the
dose is from three to ten drops;  when for
external application, a dram is to  be di-
luted with lb ij. of water;  and this solu-
tion  is gradually made stronger, as  the
parts become accustomed to it, till it is of
double strength.   However, this mode of
U9ing arsenic is by no  means a well regu-
lated one; and  Plunket's  caustic (see
Arsenic) for outward employment,  is  not
nearly so  neat  an  application as  the
above-mentioned  lotion.   At St, Bartho-
lomew's Hospital, arsenic is administered
internally  in the  following formula:  gr.
Kali  arsenicati gr. ij.  Aqua menthae sa-
tivje  giv. Spiritus vin. ten. ^j.   Misce et
cola.   Dosis £ij.  ter quotidie.   In this
way,  the quantity of arsenic is nicely de-
termined.  We shall only just add, with
regard to this medicine, that, both as an
external  application and  an inward  re-
medy, in cases of noli me  tangere, it per.
haps  deserves  the  highest rank.  One
soruple of the argentum nitratum, dis*
solved in half an ounce of distilled water,
makes a very  good  application,  which,
although  generally inferior, iu point of
efficacy, to arsenical ones, in the present
disease,  occasionally does  good,  when
nothing else seems to produce any benefit.
The   case  ahove, makes us  acquainted
with  another lotion,  which deserves fur-
ther  trial.  All fluid remedies must be ap-
plied to the part,  by dipping little bits of
lint  in them, placing these  on tiie ulcer-
ations,  and covering  the  whole with a
pledget.
  The ointments, which seem most like-
ly to prove useful applications to noli me
tangere, are the unguentum hydrargyri ni-
trati, the  unguentum picis, and unguen,- 
NYCTALOPIA.                          237
turn sulpliuris.  As far as my experience
extends, they are generally less effica-
cious than lotions in the  present  cases;
but,  in  particular  instances, they prove
superiorly useful, and it deserves particu-
lar notice, that surgeons can often make
no progress against this inveterate disease,
unless they apply a different sort of dres-
sing every day ; sometimes, a lotion;  at
other times, an ointment.  The little ul-
cers may occasionally be touched with the
argentum nitratum.  The small furfura-
ceous scabs, which are continually form-
ing on the part affected, should be soften-
ed with a little of  the unguentum sper-
matis ceti,  and removed with  as much
tenderness as possible.
   We have already  remarked,  that arse-
nic is a gocd medicine to be given as  an
internal medicine, and the  best mode of
exhibiting it is already explained.  Ano-
ther  medicine, which is  often  useful in
these cases, is what is known by the name
of Plummer's pill, or the compound calo-
mel pill.  &. Calomelanos, Sulpliuris Anti-
 monii prscipitati, singulorum gr.  xii. Gu-
 aiaci gummi resinse gr. xxiv.  Saponis
3uod satis sit. Misce.; fiant pilulae  duo-
  ecim.  Dosis una bis quotidie.  In other
 instances, we may try the decoctum ulmi,
 or sarsaparillse, with one of the following
 pills thrice a day;  &.  Calomelanos  gr.
vj. Succi spissati cicutae gj. Misce ;  fiant
 pilulae  duodecim.  The hydrargyrus sul-
 phuratus has occasionally  been given, as
 an alterative medicine,  for the relief of
 noli me tangere ;  with what good  effect I
 cannot pretend to say.
   NYCTALOPIA, (from v»|, night; and
 »•$,, the  eye; or ottu, to see.)  An affec-
 tion of the  sight,  in which the  patient is
 blind in the day-light, but  sees very well
 at night.
   The Greek physicians are divided in
 their opinions concerning the now uncom-
 mon disease of nyctalopia.  Hippocrates
 expressly says, " we call those nyctalopes
 who see by night."  The author of Defln.
 Medic. " that they see nothing in the day
 time, but  have their sight by night."—
 On the contrary, Paulus iEgineta,  and
 Actuarius are as explicit in asserting, that
 they have their sight perfect  in the day-
 time, but are blind by night.  Mtius is of
 the same mind, though he is thought to
 favour the contrary opinion, when he says,
 " they see better by night than  in the day,
1 and if the  moon shines they are blind."
The author of  Isagoge embraces both
opinions,  when  he  says,   ** they,  call
those nyctalopes who, in the day time,
see more obscurely, at the setting of the
sun more  clearly,  but, when it  is night,
much better; or, on the contrary, by day
they see a little, but, in tiie  evening, or
at night, they are  blind.  Galen explains
the word  by  a  night-blindness.  Pliny,
Varro, Nonius, Festus, Celsus, and other
Latin writers, give equally opposite de-
finitions of the disorder.  Dr. Pye ques-
tions, whether these two descriptions of
nyctalopia, so diametrically opposite to
each other, may not be reconciled by conr
sitlering  the disorder  as an  intermittent
one.  The difference then will only  con-
sist in the different times of the approach
of the disease ;  that of Hippocrates came
on in the morning ; that ot  iEgineta, in
the  evening;  both were  expressly  pe-
riodical, and the distance of time between
the paroxysms, in both, was respectively
the same ; a whole day, or a whole night.
The various shapes, in which  inteimit-
tents appear, very much favour,  says Dr.
Pye, such an opinion ; and the  apparent
success of bark in the case, which he has
related,  notwithstanding  the  unfavour-
able circumstances of the evacuations his
patient laboured  under, and the conse-
quent necessity of its disuse, seem to con-
firm it  in this gentleman's mind.  (Med.
 Obs. and Inq. Vol. 1.)
   If this  opinion  be true,  we need jmly
refer the  reader to Amaurosis and Heme-
raiopia, for the  best mode of treatment.
But, certainly there are instances of nyc-
talopia, every now and then  met with, in
 which the affection seems to depend on a
peculiarity  in the structure and organi-
 zation of the eye;  by reason of which,
 the quantity of light, which only suffices
 for vision in an eye of natural formation,
 proves too abundant for a nyctalops, and
absolutely  prevents him  from seeing at
all.  We know, that in the eye there is a
 black substance,  named  the pigmentum
nigrum ;  one supposed use of which is to
absorb the redundant rays of light, which
enter the pupil    A  deficiency of this,
 may certainly account for  a  nyctalops
 being blinded with  the  day-light, and
 seeing best at night.   On the whole, how-
 ever, there  can be no doubt, that amau-
 rosis is occasionally  a periodical disease,
 like  an intermittent; and a species of
 nyctalopia may also be thus induced. 
(  238  )
      DEMA. (from oihu, to  swell.)
       The  ancients understood  by this
term, ad kinds of tumours ;  but, it is now
restricted to a swelling arising from an
extravasation of an aqueous fluid in the
cellular substance of a particular part;
for, when the affection is more extensive,
and especially when it is  also accompa-
nied with a general dropsical tendency,
it then becomes a medical case, and re-
ceives the name of anasarca.  An cedema-
tous part is  usually  cold, and of a  pale
colour ; and, as  it is little,  or not at all
elastic, it pits, as surgeons express them-
selves, or, in other words, it retains for
some time, the mark of the finger, after
being handled, or pressed.  CEdematous
swellings  are often connected with  con-
stitutional causes.   In many cases, how-
ever,  they seem to be entirely local affec-
tions, arising from  such causes  as  only
act upon the pari ■>,  in which the  swelling
is situated.   Thus we observe,  that after
violent sprains of  the  wrist,  or ankle-
joint, the hands and feet  often become
sedematous; and limbs  are frequently
affected with oedema, in consequence of
the return of blood through  the  veins
being obstructed by the pressure of tu-
mours on them, or that of splints,  banda-
  Ces, &c.  Pregnant women  are known to
  e particularly subject to cedema of the
the legs, owing to  the pressure of  the
gravid uterus on the iliac veins.   Persons
who have been confined in bed, with frac-
tured thighs, or legs, generally have more
or  less oedema of their feet and  ankles,
on first getting up  again; and the affec-
 tion, in these cases,  is probably quite de-
 pendent on loss of tone in the vessels of
 the limb.
   In  the treatment of oedema,  great at-
tention  must always  be paid to  the na-
 ture of the cause,  in order to determine
 whether  the  disease originates from a
 mere local, or a general  constitutional
 affection.  When it depends on the pres-
 sure of a tumour on the veins, as we often
 see happen in cases of aneurisms, the ef-
 fect cannot be got rid of till the cause is
 removed;  and the aneurismal  swelling
  must be lessened,  before the osdematous
  one  can admit of  the  same  beneficial
  change.  When cedema is  the  effect  of
  vascular weakness in a limb, in conse-
  quence  of sprains, contusions,  &c. the
best means of relief is, to support  tlie
parts affected with a laced stocking, or a
flannel roller,  while they are also to be
rubbed with liniments, and bathed  with
cold spring water, till they have perfectly
recovered their tone.
  With regard to the  cedema attendant
on the  advanced state of pregnancy, a
complete  cure cannot be expected till
after delivery.  The affection is generally
more considerable in the afternoon, than
the morning, owing to the different effects
of an  erect and  a recumbent  position.
Some relief may be obtained  by keeping
as much as possible in a horizontal pos-
ture ;  and, when  much  inconvenience
and  pain are felt, the  parts  may be fo-
mented with any aromatic and spirituous
application.
  Q5dema is often one of  the symptoms
of suppuration; and, when the matter is
very deeply situated, sometimes leads to
its discovery.  The truth of this remark
is often seen in cases of empyema.
  There is  a species  of oedema accom-
panied with a degree  of heat, pain, &c.
in the part, and  which, in  short, seems
combined with phlegmon.   In  this case,
saturnine   lotions,  the, application  of
leeches, and the  exhibition of saline pur-
gatives, are  proper.  An   erysipelatous
oedema is  also met with,  in which  the
treatment  should very  much  resemble
what is explained in  the ^article Erisyi
pelus.
   C5SOPHAGOTOMY.   (from  xsopha.
gus, and rtfMot, to cut.)  CEsophagdtomia.
This operation consists in  making an in-
cision  into the  oesophagus, in  order  to
take out of this tube foreign bodies, which
lodge in it, and which  can  neither be ex-
 tracted through the mouth, nor pushed
 down into the stomach, and whose conti-
 nuance in the oesophagus would  occasion
 fetal symptoms.
   As  the oesophagus  is deeply situated,
 and covered by  very important  parts,
 such  as the  trachea, nerves, and  consi-
 derable blood-vessels, every  operation,
 the object of which is to make an open-
 ing into  this tube, has always  been re-
 garded as exceedingly dangerous, and
 was even,  for  a long while, quite  pro-
 scribed   However, although  every  ra-
 tional practitioner agrees, that  this pro-
 ceeding should  never  be  resorted  to, 
CESOPHAGOTOMY.                          239
without some most urgent cause, yet, if a
case were to  present itself, in  which the
oesophagus was so obstructed, by some
extraneous substance, that no food could
absolutely  pass into the stomach, or if,
in consequence of an accident ofthe same
nature,  respiration  were impeded in  a
manner  imminently dangerous  to life,
doubtless the uncertain chance  of  the
operation should be preferred to the cer-
tainty of a fatal event.   Many instances
of  the  oesophagus  being  accidentally
wounded, have been known to end well,
Mr. B. Bell saw a man,  who. in attempt-
ing to kill himself, by cutting his throat,
cut through a great part of the trachea
into the oesophagus.   Bohnius  relates
the case of a man, wounded in the same
way, whose wound in the oesophagus was
quite manifest, as every thing  which  the
patient attempted to swallow came out of
it.  Both the patients,  just mentioned,
got well, and many similar examples are
on record.
  Guattani, a surgeon at Rome, publish-
ed, in  the  third volume of the Mem. de
VAcad. de Chirurgie, a dissertation on the
present  subject.   After explaining  the
manner of performing this operation, he
relates some experiments made on dogs,
which  succeeded very well.   He prac-
tised the plan also on the dead subject, in
such a manner as to make it demonstra-
ble, that the method was practicable on
the human body.  What is still more con-
clusive, the operation was actually done
twice,  on  living  subjects, with  perfect
success.   The following is the account of
these facts, as recorded in the Mem. de
VAcad. de Chirurgie.
   "In   the  month  of  May,  1738,  M.
Goursauld, a surgeon at Coussat-Boune-
val,  in  Limousin,  was  called to a man,
who had swallowed a bone, an inch long,
and six lines broad. M. Goursauld made
various  attempts  to make  this  foreign
body pass down  into the stomach.  Not
being able to succeed, however, and the
bone being felt on the left side, he deter-
mined to cut upon it, and try to extract
it.  An  incision having  been made,  the
bone was easily extracted, no bad symp-
toms followed,  and the wound healed,
with the aid of an uniting bandage. Care
was taken to give the patient no food  for
six days, but to  nourish him with glys-
ters.  A similar operation was perform-
ed,  with equal success, by M. Holland,
surgeon-major of the regiment of Man-
ly.* (Memoires de PAcadimie de Chirurgie,
Tome 3.)
  Guattani,  in this  memoir,   observes,
with several  other anatomists, that  tiie
oesophagus is  always situated, not direct-
 ly between the trachea and vertebrae, but
 rather  more towards  the left than the
 right.  This  fact  would always lead a
 surgeon, when he deems oesophagolomy
 necessary, to undertake it on the left side
 ofthe neck.  The parts, which cover the
 oesophagus, from the middle and external
 part of the neck, to the upper part ofthe
 sternum, are the skin, fat,  cellular  sub-
 stance, muscles proceeding from the ster-
 num to the larynx, the thyroid gland, the
 thyroid arteries  and  veins, the trachea,
 the recurrent nerve, &c.   Things  thu9
 circumstanced, Guattani  recommends the
 following mode of operating.   " The pa-
 tient is to  sit on a chair, with  his head,
 inclined backward, as  far  as may be
 thought proper, and held by an assistant,
 so that it can neiiher move backward nor
 forward.   The  operator, placed  before
 the patient, after pinching up the skin on
 the right side, into a transverse fold,  with
 the fingers of his left  hand, while an as-
 sistant does the same  to that on the left,
 is to make, with a straight bistoury, a
 longitudinal incision hi the  integuments,
 from the upper part of toe sternum.  He
 is next to divide the celhlar substance,
 fat, &c. which he will find between the
 left sterno-hyoideus,  and stenjo-thyroi-
 deus muscles, and the  trachea.  By means
 of two double blunt hooks, he is to keep
 the edges of the wound asunder, and, on
 dividing the cellular substance at the side
 of the  trachea,  with his finger and a few
 strokes of the knife, he  will see the  oeso-
 phagus.  A longitudinal incision is  then
 to be made into the lowest part of it,  with
 a straight knife; and this  wound must
 afterwards be dilated upward, with curv
 ed,  blunt-pointed scissars.  if any diffi.
 culty should be experienced, the surgeon
 may  employ a director,  to  facilitate the
 last object.  Small curved forceps, simi-
 lar to those used for extracting polypi,
 are then to be introduced into  the  oeso-
 phagus, for the purpose of extracting the
 extraneous substance.  This canal having
 been opened in the place above specified,
 the foreign body may  be extracted with
 these  forceps,  whether  it be situated
 above or below the aperture made for the
 purpose.  This kind of opening will even
 be useful, when the extraneous substance
(has passed so far that it cannot be ex-
 tracted with forceps ; for, with a bougie,
 or some other instrument, it may now be
 easily pushed down into the  stomach.
   "The operation finished,  the dressing
 of the wound is  a point, which merits a
 great deal of attention, in regard to the
 method pursued to unite it.  This object
 has  always been  accomplished, in the
 animals on which my  experiments were 
240
CESOPHAGU8.
 made.  If comparative surgery have any
 weight, it is certainly in such cases, as
 the present onerin which the structure of
 the  part  seems to be almost the same.
 It is also proved by my experiments, that
 the oesophagus cicatrises very well, with-
 out  contracting any adhesion  to the ad-
 jacent parts.   It  is proper to observe,
 1. That the integuments being cut, and
 the parts  disengaged, if, by chance, the
 vein, which brings back the blood from
 the  inferior part  of the thyroid gland,
 and runs into the left subclavian,  should
 be cut, the hemorrhage may be stopped
 with a dossil of lint, which is  to be com-
 pressed by an  assistant's finger,  during
 the operation.  The vein will  afterwards
 be compressed by the uniting bandage,
 employed for  healing tlie  wound;  but,
 otherwise, a  ligature is  to  be  used.
 2. That,  on separating the lips  of the
 wound, tiie recurrent nerve may be seen,
 at a greater or lesser distance from the
 trachea.   If, then, it ihould be foreseen,
 that it would be injured in separating the
 cellular substance and making the inci-
 sion  into   the  esophagus,  it must be
 drawn out of <he way,  with  the same
 hook which b employed for pulling aside
 the left lip of  the wound.  In the same
 manner, 'the trachea  may  be carefully
 drawn to one side with the right hook, if
 it should embarrass the operator in, find-
 ing out the oesophagus; a thing which
 may  be done,  without fear of seriously
interrupting respiration.    3.  That the
 oesophagus is  to be opened, as near  as
possible to the trachea, especially at its
 upper  part, where the arterial branch,
 which  goes from  the subclavian, to  be
 distributed to  the thyroid gland, some-
 times runs.  4. That, if thought proper,
 the  thyroid gland is to  be separated
 from the  left  side of the trachea, when
 the foreign body,  lodged in the oesopha-
 gus, requires  a large incision, and, par-
 ticularly,  when this gland  is very much
 swollen, as it would prevent a free view
 of the  oesophagus.  5. That the oesopha-
 gus will be known to be opened, when
 the internal membrane, which is whitish
 has been divided.  6. That the operation
 should be done with promptitude, when
 it is thought necessary, in order to avert
 the afflicting consequences of inflamma-
 tion of the oesophagus.  7. That the ope-
 ration  being done, the  reunion  of the
 parts is to be promoted, by simple dress-
 ings, and the uniting bandage.
  " With  regard to regimen,  besides  all
 the general remedies required  in such
 cases,  and every thing which a judicious
 practice indicates, I am  of opinion, that
 it would  be proper (as far as possible)
only to give the patient, at intervals, a
little broth,  for the first three or  four
days after the operation,  so  as not to dis-
turb the healing of thi  parts   And, as
broth  might cause some little disturb-
ance of the wound, even nourishing glys-
ters, which we know, would suffice for
the  support of  the  patient  this short
time, who, in such cases, is  not much re-
duced."  ( Guattani, in Mem. de VAcad. de
Chirurgie,  Tom. 3.)
   Whenever nourishment is to be convey.
ed into the stomach, through a wounded
oesophaus, the hollow bougie should be
introduced, from one  of  the nostrils,
down ihe passage, and the liquid food in-
jected  through it, with a  svringe.
   CESOPHA.GUS,  FOREIGN  BODIES
IN.  There are few situations, in  which
foreign, bodies  lodge  more frequently,
than in  the  oesophagus. The function
of  this  tube  explains  the  reason of
this  occurrence,  and its great sensibi-
lity is  a  ground for the  apprehension of
many bad effects, which may result from
the  lodgment of extraneous substances
in it.
  Foreign  bodies, liable  to  stick in (the
oesophagus, are not only food, such as
pieces of crust, or meat imperfectly chew-
ed, but also various'substances  which are
accidentally swallowed alone, or with the
food, such as little bones,  stones, pins,
pieces  of money, &c. These latter tilings,
by lodging in the pharynx, or oesophagus,
may occasion very bad symptoms; and,
if forced down ^nto  the stomach, may
produce  still worse effects.   Hence, we
should immediately try to extract  them.
For  this, purpose, the fingers  arc  to be
used, and  if  they cannot  reach  them,
forceps must be employed.   Some have
recommended hooks, for 'the accomplish-
ment of the  object in view; others, va-
rious instruments, adapted  to  particular
circumstances.   The  excitement of vo-
miting has been tried, and, occasionally
with success;  but, it is not free from
danger, and the most distressing  symp-
toms have been brought on by it.
  [A solution of emetic  tartar is a very
useful  remedy  in cases  of foreign  bo-
dies in  the oesophagus.   The  nausea
produced  before  its emetic  operation
commences,  relaxes,  so completely all
spasm  in the part, that  the substance is
allowed to escape. A boy in attempting
to  swallow  a  peach stone  had it to
lodge  in  the oesophagus,   the probang
was  tried  without effect;  it  remained
immoveable; he  was directed to swal-
low  a  solution of emetic tartar; whe-
ther any passed  into the  stomach, or
whether uausea,  was  produced by its 
CESOPHAGUS.                            241
 iinpresaion on the parts, it is difficult to
 decide.  Nausea however  came on, and
 immediately the peach stone was liberated
 and passed into the stomach.]
   When such extraneous substances can-
 not be extracted,  they must  be pushed
 down into the  stomach, with some such
 instruments as a large bougie, or a whale-
 bone  probing,  fifteen or sixteen inches
 long; and, on the  end of which, a piece
 of fine sponge is  firmly fastened.   Small
 bits of sponge, tied on the ends of some
 string, have  also  been  used; the pa-
 tient  is to swallow them, and then drink
 something.   The sponge, expanded with
 the fluid, dilates the passage,  and facili-
 tates the descent of  the  extraneous sub-
 stances  into  the  stomach.  But, when
 such bodies are, from their sharp-pointed,
 angular shape,  or  hurtful  nature,  likely
 to occasion perilous  consequences, by be-
 ing pushed down  into the stomach, the
 plan must not be  attempted.   Hard, an-
 gular substances, and such things as pins
 and needles, which surgeons  have not
 chosen, or  not  been  able, to force* down
 into the stomach, have often, after a time,
 made their way to the surface of the body,
 where an abscess has  formed, out of which
 they have been discharged.
   When  hard bodies have been pushed,
 or have got of themselves, down into the
 alimentary canal, their ill effects  should
 be counteracted, and their passage through
 the bowels promoted by giving the pa-
 tient  frequent  draughts  containing the
 oleum amygdalarum.
   When foreign  bodies  in  the oesopha-
  fus, resist tiie different means  employed
  >r their extraction,  or  for  propelling
 them into the stomach, when such method
 has been judged to  be proper; when, at
 the same time, the pain which  they occa-
 sion, Is not considerable; when they do
 not too  seriously interrupt respiration,
 and leave sufficient room for the passage
 of aliment and drink;  it is prudent to
 abstain from  further  attempts to displace
 them.  They  should  be left to nature,
 while the  practitioner should content
 himself with  bleeding the  patient  a few
times, exhibiting draughts containing the
oleum  amygdalarum,  and  employing
 glysters.   But,  when the lodgment of
 such foreign bodies dangerously obstructs
respiration, by the pressure made on the
larynx, an opening must be quickly made
in the  trachea, in order  to serve for a
time the office of the natural passage fo*
the air.   (See Bronchotomy.)  As soon as
the swelling subsides,  another attempt
may be made  to move the extraneous sub-
stance. (See L'Encyclopetlie Method. Par-
tie Chir. Art.  Corps Etrangers.)
  There  may be  cases, in which  death
    Vol. II.
 would certainly result from  the  continu-
 ance of a foreign body in the oesophagus,
 and as it could neither be extracted nor
 removed by common means,  perhaps cut-
 ting into  the oesophagus would be pro-
 per.  (See QT.sopliagotomy.)
   When some extraneous substajices have
 been left to themselves, nature lias some-
 times succeeded in expelling them. They
 have excited a trivial suppuration, where
 they were lodged,  by which they have
 been loosened,  so as then  either to  be
 ejected by vomiting, or, after descending
 into the stomach, to be  discharged  by
 stool.   In  passing  any  instrument into
 the  oesophagus",  the great  skill lies in
 putting it at once  directly against the
 posterior  part of the pharynx, so as It)
 avoid touching the  epiglottis, and keep-
 ing  it  closely against  the  vertebrae  all
 the  way down.  The knowledge of this
 circumstance may be of infinite service in
 passing probangs, bougies, &c.  but, hol-
 low bougies arc- introduced in a different
 way, viz.  through  one of the  nostrils,
 down the pharynx. "When thus employed,
 they may sometimes be allowed to remain
 in the passage very advantageously. They
 are extremely useful for the conveyance
 of food and medicines into the stomach,
 wlien the oesophagus has  bc-eil wounded ;
 and  as the  elevation and depression of
 the larynx, in the  action of swallowing
 produces immense disturbance of wounds
 of the trachea, they promise to be of  in-
 finite service in the latter cases.
   OiSOPHAGUS,   S'IRICTURES OF.
 As the oesophagus is required to be wider
 at one time and narrower at another, in
 order to be fitted for conveying the  dif-
 ferent kinds of food  into  the stomach, it
 is nearly under the same circumstance
 with respect to the formation of stricture,
 as the urethra.   Strictures  in  the oeso-
 phagus, are,  for very obvious  reasons,
 much less  frequent than in  the urethra.
 However,  they are by no means uncom-
 mon, and  produce symptoms even much
 more distressing and dangerous, than
 those,  which ordinarily  arise from ana-
 logous obstructions in the passage for the
urine.
  This disease has been long noticed  by
 surgical authors, and Mr. Warner hi par-
 ticular has recited an instance of it, that
 proved fatal, the patient  having become
 incapable  of* taking  nourishment.  (See
 Cases in Surgery,  by J. Warner, F. R. S.
p. 130, Edit. 4.)
  Of course, the most remarkable  symp-
 torn  of a stricture in the oesophagus, is
 the difficulty of swallowing,  which must
 be greater or less, according as the ob-
 struction is more or less complete.  Some-
 times no  solid food whatever can pass
     11 H 
2-12                            OESOPHAGUS.
down into the  stomach,  and fluids can
only descend with great difficulty, and in
very small quantities.   This is, in some
instances,  attended  with  considerable
pain, Which extends along the fauces to
the basis of the skull, and through tlie
eustachian tube to the ear.   The pain
sometimes returns  at intervals, and lasts
a considerable time, even when no effort
is made  to  swallow.   If a bougie of pro-
per size be introduced down the pharynx,
it will often be stoppedby the stricture just
behind the  thyroid, or cricoid cartilage;
for, from Mr. Home's remarks, it appears
that the obstruction is generally as high
up*as this situation.  However, there are
other cases, in which the obstruction is
only of a spasmodic nature, and in such,
a bougie may be passed quite down.  It
is curious, that strictures high up in the
oesophagus, often occasion ulceration in
tins tube very low down towards the sto-
mach, just us strictures in the urethra oc-
casion ulceration in that passage towards
the bladder. This is  most apt to occur,
when strictures of the oesophagus have
been of long continuance, and  may arise
from  the efforts  in retching, which fre-
quently  comes on, and must strain the
parts already deprived of their natural ac-
tions, and ofthe benefit of the secretions,
with which they are lubricated in a healthy
state.  When such ulceration takes place,
the characters of the original disease are
lost;  and when  the  ulceration  extends
upwards, the stricture itself may be de-
stroyed.    A  bougie, introduced under
such circumstances, will, in general, have
its point entangled in the  ulcer;  and
when so skilfully directed as to go down
into the  oesophagus, it will meet with  a
difficulty while it is  passing the com-
mencement of the  ulcerated part of" the
oesophagus,  and  another  impediment
where i'  leaves the ulcer, and enters the
sound portion  of the oesophagus below.
These two  resistances may  lead to the
iupposition, that there are two strictures,
while in  fact there is not one, only ulcera-
tion as above described.
   Strictures in the  oesophagus  are some-
times so complete, that swallowing even
fluids is  utierly prevented; the patient is
obliged to have all nourishment  injected
intra anum, and in  general soon  perishes
iu a most emaciated condition.
   Though any part of the oesophagus is
liable to the kind of contractions forming
strictures, the part' immediately behind
the cricoid cartilage,  where  the  pharynx
ends, and the oesophagus begins, is the
most frequent seat of  the  obstruction.
Those which are situated further down,
do not so easily admit of being examined,
and relieved by any surgical  operation.
Strictures of tlie oesophagus occupy very
little extent ofthe  passage, consist of a
transverse told of the internal membrane,
and are attended with little thickening'of
the adjacent parts.  These latter circum-
stances are  such as  render tiie  disease
capable of receiving relief either  from
simple or armed bougies.
  There  are two other  diseases of the
oesophagus, which have symptoms similar
to those of strictures. One is a thicken-
ing of the coats of the oesophagus, which
extends  to  the surrounding parts, and
generally ends  in a  cancer, or an incura-
ble disease.   The  other  affection  is an
ulcer of the lining of the passage, com-
monly situated a little below the seat of
the stricture, on the back part of the tube.
In the early state, these diseases can only
be distinguished  from a stricture,  by an
examination  with a  bougie';  afterwards
their nature  becomes clear enough from
other symptoms which arise.  Strictures
also take place more commonly in young
subjects; the other two  diseases  in the
more advanced periods of life.
   Mr. Home has found,  that a bougie
can be more easily  introduced into the
oesophagus, when the tongue  is brought
forwards out of the mouth. This gentle-
man remarks, that when a bougie is pass-
ed, with a view of learning the nature of
the case,  and it passes down  to the dis-
tance of eight inches, measuring from the
cutting edge of the front  teeth in the up-
per jaw,  its extremity has gone beyond
the usual seat of stricture.  If it be with-
drawn without any resistance, the aper-
ture  in   the oesophagus  must then be
larger than the bougie employed.  But if
the  bougie stops at the  distance of six
inches and  a half, or even lower, it must
be retained there with a uniform pressure
for half a minute, so as to receive  on its
point  an impression of  the  surface by
which it was opposed.  If the end of the
bougie retains  its natural form,  or nearly
so, and  there is an indentation on one
side  of  it,  or all round  it, the surgeon
may  conclude there is a stricture.  On
the other hand, should the bougie descend
without   impediment,  as  far  as 'seven
inches and a half, and, when withdrawn,
the  surface of its point appear irregular
and jagged,  the disease is an ulcer on the
posterior part of the oesophagus.
   The mode of treatment adopted by  Mr.
Home, consists  either   in  occasionally
passing  a common bougie through  the
stricture, and employing one of  larger
size, in  proportion as tiie dilatation of
the obstruction will  allow; or else in in-
troducing an armed one at convenient in-
tervals.  Consult Practical Observations on
the Treatment of Strictures in  the Urethra 
OLE
OPH
243
and Esophagus, Vol. 1, Edit. 3, 1805. Vol.
2,1803. by E. Home, F. R. S.
   In spasmodic strictures of the oesopha-
gus, blisters haie been known to do good,
and I have heard a most eminent surgeon
express a strong expectation, that other
strictures of this passage would be bene-
fited, by feeding the patient through hol-
low bougies.
   OESOPHAGUS,   POLYPI OF.   (See
Polypus.)
   OLEUM CAMPHORATUM. . *. Olei
Olivae tbj. Camphone §iv.  Misce  ut sol-
vatur camphora.
   Some practitioners employ this for pro-
moting the  suppuration of indolent, par-
ticularly scrophulous swellings, which are
to be rubbed with  the  application once,
twice, or  thrice a day,  according  to cir-
cumstances.
   OLEUM  LINI.   In surgery, linseed
oil is often  used  as an application to
burns, either alone  or mixed with an
equal  quantity  of  the  aqua calcis.  It
has  also  been applied to cancerous  ul-
cers,  as  some assert, with considerable
benefit.
   OLEUM ORIGANI.  The oil of mar-
joram  is  often used by surgeons for dis-
cussing ganglions: the tumours are to be
rubbed with it two or three times a-day.
    OLEUM   PALMJE   CAMPHORA-
TUM.  jt.  Camphorae  3 ij.  Olei  palms
ibj.  The camphor is  to be reduced to
powder,  and  the palm oil, being melted,
and suffered to become almost cold, is to
be mixed with it in a mortar.   This ap-
plication is  a mild  topical stimulant:  it
has  been used for promoting  indolent
suppurations,  especially those of a scro-
phulous nature, which take place under
the jaw,  and are attended  with a good
deal of chronic induration at their cir-
cumference.
   OLEUM  RICINI.   In  such  surgical
cases as require the bowels  to be opened
with  the  slightest degree  of  irritation
possible, the oleum ricini is the best and
safest medicine that can be given.  The
usual  dose  is one large table-spoonful,
which  must  be  repealed every two or
three hours, till the desired effect is pro-
duced.
  OLEUM TEREBINTHINj£.   Oil  of
turpentine is  employed  externally as  a
stimulating  liniment, and a styptic.  In
the article  Liniment may be seen  some
formulae, in  which turpentine is the most
active ingredient.  It is sometimes exhi-
bited by surgeons internally, for the cure
of gleets.
  OLEUM TEREBINTHI.VATUM.  *
Olei  Amygdala:  5s*.  Olei  Terebmthinae
gutt. xl.  Misce.
  In deafness, occasioned by defective, or
 diseased actions of the glandulx cerurr.i-
 neae, Mr.  Maule directs a little of the
 oil to be  dropped into the patient's ear,
 or applied at the end of  a small dossil of
 cotton.
   When a thin secretion takes place, the
 cure is  also promoted by a small blister,
 which he orders to be placed  as  near the
 ear as convenient, and kept open by the
 common means.   Of course,  the savine
 cerate  would now be preferred  for this
 purpose.   The meatus auditorius exter-
 nus must also be cleansed every day with
 a lengthened bit of .soft cotton, affixed to
 a probe. This is to be introduced into
 the passage,  and twisted gently round, so
 as  to wipe  away the discharge.   (See
 Pharmacop. Chirurgica.)
   OMPHALOCE-'LE. (from a^«A*«, the
 navel, and jtsjAsj a rupture.)  A  rupture
 or hernia at the navel.  See Herrua.
   ONYCHIA, (from ovvf, the nail.)  An
 abscess  near  the nail of the finger.  See
 Whitlow.    —
   ONYX,  (from «»«!, the nail.)   A small
 collection  of matter, situated under the
 cornea,  in the anterior  chamber of" the
 aqueous humour, and so named  from its
 being shaped like  a nail.   It is of  the
 same nature as Hypopium, to which word.
 I must refer  the  reader.   Mai ire-Jean,
 Mauchart,  and  several  other  oculists,
 imply, however, by the term onyx, a small
 abscess between the layers ofthe  cornea.
   OPHTHALMY.  (from oQixXfMi, the
 eye.) Ophthalmia. Inflammation of the eye.
  Ophtliatmy is not only a consequence of
 several affections of  the eye and adjacent
 parts, on the existence of which  its con-
 tinuance entirely depends ; it is frequent-
 ly,  also, the  primary complaint,  and too
 frequently  the fore-runner, of those  irre-
 parable diseases which deprive the patient
 of vision.   Redness ofthe tunicaconjunc-
 tiva ; tumefaction  of the eye lids ; aver-
 sion to light; lancinating pain in the or-
 bit ; an itching,  conjoined with a sensa-
 tion of heat; and an uneasiness, seeming
 as if it arose from particles of sand in the
 eye;  are symptoms  forming the  general
 inconveniences  attendant on  inflamma-
 tions  of the eye.  No part of the eye-b;ill
 can be considered as exempt from the at-
 tack of  inflammation. Hence, in  oph-
thalmy,  not  only the conjunctiva,  the
 sclerotica,  and^the choroides, but tlie re-
tina itself,  may also be inflamed,  as well
as  the surrounding parts, the. palpebral,
the muscles in the orbit,  and the lacing
mat gland.
  The grand distinctions of ophthalmy
are in two  species, viz. acute and chronic ;
the one arising, as  Sc.rpa&ays, from 1111
excess of stimulus,  and  re-action of the 
244                              OPHTHALMY.
 living solid ; the other connected with de-
 bility, which is generally  limited to the
 vesselsof the parts affected, but sometimes
 extends  to the  whole system.   The Ara-
 bian  authors termed the one calido, the
 other frigida.   It should be well known,
 however,  tliat  every acute ophthalmy,
 though treated  in the best possible man-
 ner,  is never so completely resolved, but
 that beyond a certain period, at which all
 active disturbance ceases, there yet  re-
 mains in the conjunctiva, or lining of the
 eyelids,  a  degree of chronic ophthalmy,
 either from local weakness in the vessels,
 or  from a morbid irritability.continuing
 in the eye, after the cure of the acute in-
 flammatory stage.  As it occasions a dis-
 eased secretion  in the organ, and a slow
 accumulation of blood and  coagulating
 lymph in the part, the inexperienced are
 apt to suppose,  that the acute ophthalmy
 is not yet subdued, while it is completely
 so.  Immediately the critical moment ar-
 rives, when the acute ophthalmy changes
 into the chronic one, attended with local
 weakness,  it is  highly important, in the
 treatment, to substitute for topical emol-
 lient, relaxing applications, such as par-
 take of an astringent, corroborant quality.
 Those surgeons who now continue to em-
 ploy the first remedies, only protract the
 turgescence of the vessels, and the redness
 of  the conjunctiva.   Quo major autemfuit
 inflammut'oiiis vehementia (says Richter) to
 major plerumque seqititur partium affecta-
 rum atonia, eoque major opus est adstringen-
 tium, et roborunlium longo Usn, ut aufran-
 tur penitus, reliquix  morbi, &c.  Fascicul.
 l,p 109, 110.
  Mild acute ophthalmy is characterized by
 redness of the conjunctiva and  lining of
 the eydids, an unnatural sensation of heat
 in the eyes, uneasiness, itching and shoot-
 i'.ig pains, as if sand had got between the
 palpebrae  and  eye-ball.   At  the  place
 where the  pain  seems most severe, some
 blood-vessels appear more  prominent and
 turgid,  than  other  vessels of the same
 class.   The patient  of  his  own accord
 keeps the  eyelids closed ; for, he feels a
 weariness and restraint in opening them,
 and by this  means,  also,  he moderates
 the action  of the light, to which he can-
 not expose  himself, without increasing
 the binning sensation, lancinating  pain,
 and effusion of tears from the eye.   If the
 constitution  is  irritable,  the pulse will
be  a  little accelerated,  particularly to-
 wards the evening; the skin will be dry;
 slight shiverings will occur, and, in some
 instances, nausea, and inclination to vomit.
 (Scarpa.)
  This  complaint  is often the  conse-
 quence of  a cold, in which the eyes, as
 well as the pituitary cavities, fauces, and
 trachea,  are affected.  It  is not unfre*
 quently occasioned by change of Veather,
 sudden transitions from heat to cold,  the
 prevalence of easterly winds,  journeys
 through damp,  unhealthy,  sandy coun-
 tries, in the hot season of the year, expo-
 sure of the  eyes to the vivid rays of the
 sun, &c.  Hence, it does not seem extra-
 ordinary,  that  it should  often make its
 appearance  as  an epidemic,  and afflict
 persons of every age  and sex.   Besides
 the preceding remote  causes of ophthal-
 my,  authors have enumerated the sup-
 pression of some habitual evacuation, such
 as bleedings from tlie  nose, or piles, the
 menses, &c. affections  of i he primx viae,
 worms, dentition, Ike.  However, though
 persons thus circumstanced, are unques-
 tionably subject to inflammation of  the
 eyes, it may be doubted whether they are
 more so than other people, and when af-
 flicted with ophthalmy, whether the  ah
 Ieged causes have any share in the origin
 ofthe latter complaint.
   The mild acute ophthalmy is in general
 easily cured by means of low diet,  gentle
 purging, with small repeated do»es ofthe
 antimoniuin  tartarizatum,  and after mak-
 ing search for any extraneous body that
 may  have insinuated  itself beneath  the
'eyelid, repeatedly washing the eye with a
 warm decoction of nialloW leaves, and co-
 vering it with  any very soft emollient
 poultice,  included  in  appropriate little
 bags of  exceedingly  fine  muslin.  The
 fluid  remejly may be  most conveniently
 applied by means of an  eye-glass.  Scarpa
 orders the antiinpuium  tartarizatum to be
 taken as follows: &.  Antim. tart. gr. j.
 Decocti Hordei  Ibiss.  Crystall.  tart.  !Jj.
 Sacchari Purif. gvj. Misce.  To  betaken
 in  divided doses every day.  ' I have sub-
 si ituted the barley water tor the decoction
 of dog-grass, which is certainly not es-
 sential.
   With this treatment, the inflammatory
 stage of the mild acute ophthalmy, com-
 monly ceases in the course of four or five
 days.   The patient no  longer  complains
 of that oppressive sense of heat/ tension,
 throbbing, &c.  experienced  at first,  and
 he can now bear a'moderate light, with-
 out such an effusion of tears as was pre-
 v'tou  ly occasioned.   In this state, how
 red soever the tunica conjunctiva may ap-
 pear, it is no longer affected wi'h acute
 inflammation, and the  ophthalmy has re-
 lapsed, from its acute stage, into that at-
 tended with relaxation and weakness of
 the vessel of the conjunctiva, and mem-
 branous lining ofthe eyelids.  Emollients
 are  now  improper ; in lieu of them, as-
 tringent,  corroborant collyria  should be
 used, by means of which the relaxed ves-
 sels of the conjunctiva and eyelid will 
OPHTHALMY.
245
recover their original  tone, and the oph-
thalmy be totally removed.   One of the
following eye-watery   which are similar
in quality to  those  directed by Scarpa,
may be employed : *.   Zinci Vitriolati gr.
V. Aqua Rosx £iv. Misce.  Or &. Cerussx
Acetatxgr. viij.Aqux Fxniculi£vj. Spirit is
Vini Camphoratigutt x. Misce.  The mild
ophthalmy, originating from causes which
render it an epidemic, so quickly passes
over the first inflammatory stage, that  it
is scarcely observable, and is, according to
Scarpa, the only case in which cold astrin-
gent applications prove  in  the first in-
stance beneficial.
  Surgeons in this country certainly very
often employ vitriolated  collyria at first,
in almost all cases of ophthalmy, and with
great  benefit; but, it is to be  observed,
that in general  some days  have  usually
elapsed before they are consulted.  If the
continental surgeons are accurate in their
remarks, astringents must be very wrong
in  the  first  instance.- Richter says :—
Qjuntidie observo  quantum  dumni adferant
oculis inflammatis sueta ilia collyria aditrin-
gentia,  quantum emolumenti emollientia.
Fascicul. 3, p. 101.
  The  Severe Acute Ophthalmy, is attended
with the same kind of* symptoms as the
mild,  but  in  a  more aggravated form.
The sensation of heat  in the  eyes is burn-
ing; the constriction  of  the whole eye
and eye-lid  spasmodic; the  presence  of
even a faint light intolerable.  Sometimes
tlie effusion of tears is continual, very co-
pious,  and blended with mucus, which is
apt to  make the eye-lids adhere together.
Sometimes this  secretion is almost  sup-
pressed, and the eyes  become preternatu-
rally dry. The  sympathetic fever is  con-
siderable, with restlessness, and intolerable
pain at the back part of  the head.   The
pupil is contracted, the conjunctiva of an
uniformly deep red colour.  On the  ante-
rior hemisphere of the  eye, among the
most prominent fasciculi of vessels, may be
distinguished a delicate vascular  net-work,
continued from one fasciculus to another,
but, all being equally  turgid  with blood,
and coiled as  it were together, seem to
form a kind of excrescence,  which rises
above the surface of the eye, and has a
tendency to  project forwards, beyond the
eyelids.  (Scarpa)
  From the immoderate action of the. in-
flamed vessels, blood  is occasionally ex-
travasated  into  the  cellular substance,
connecting  the  tunica conjunctiva with
the sclerotica ;  in consequence  of which
the first of these coats, which is naturally
loose, becomes enormously distended, and
elevated in front ofthe eye, so as to make
the transparent  cornea seem  quite sunk,
and prevent the eye from being completely
shut.  Chemosis is the term usually applied
to this sort of case.
  The severe acute ophthulmy commonly
affects only the outer part of the eye-ball;
but, sometimes the interior of  the eye  is
alone  affected, or at all events,  more so
than  the outer parts.  There  is  little
change in the external  parts, the patient
has immense aversion, even to the faintest
light, the iris has a red appearance, the
pupil is exceedingly contracted, and the
aqueous humour is occasionally red and
turbid. From these circumstances, Scarpa
thinks it nut irrational to suspect, that, in
the highest pitch of internal ophthalmy,
there may be an extravasation  of blood
into the chambers of the eye, especially
betwixt the choroid and sclerotic coats.
Hepce may  arise the termination of the
internal ophthalmy in amaurosis, so  com-
mon,  when the case does not end in sup-
puration.
  The severe acute ophthalmy  requires
the antiphlogistic treatment, in the  most
rigorous degree.  Tardiness in procuring
evacuations, especially, of blood, too often
gives the disease time  to advance  to tiie
state  of chemosis ; or else to a condition,
in which suppuration, or an extravasation
of lymph within the eye, is threatened;
while, in other instances, the inflammation
degenerates into an obstinate chronic oph-
thalmy from the extreme  weakness pro-
duced in the vessels of the conjunctiva.
Both   general  and topical blood-letting
should, therefore, be speedily put in exe-
cution. Leeches should be applied to the
vicinity of the eyelids, especially about
the inner canthus,  on the vena angularis,
where it joins the frontal, deep orbitar,
and transverse vein ofthe face. (Scarpa.)
  Mr. Ware objects to leeches being put
on, or very near the eyelids, as they have
sometimes caused a considerable swelling
of the lids, and increased,  instead of les-
sening the irritation.  In  ordinary cases,
this gentlemanVecommendsnpplying three
in the hollow ofthe temple, about an inch
and a half from the outer part of the orbit.
There is one mode of bleeding, in cases of
ophthalmy, perfwps product.ve  of  more
benefit than any other, and this  probably
on  account of its acting at once both  as
a general and topical evacuation; I  mean
opening  the temporal  artery.   In  some
instances, it is true, I have seen  the sur-
geon  fail in procuring from this  source a
sufficient quantity  of blood; but I have
never seen a continuance of bleeding from
the wound any longer than the practitioner
himself wished.
  There is one particular mode of taking
blood from  tlie eye, which, in acute in-
flammations, has sometimes been  verv use-
ful.  The  visible  blood-vessels  on that 
246
OPHTHALMY.
 part of the conjunctiva, which covers the
 inside of the eyelids;  are much more nu-
 merous, than those which are observable
 on the  white of the eye.  Hence, in oph-
 thalmy, the  inflammation seems  greatest
 on the inside of the eyelids, where the
 blood-vessels are often not only much in-
 creased in number, but also extremely full
 and turgid.  Sometimes, also, the whole
 inside of the eyelids, particularly of the
 lower one, is so much enlarged,  as to be
 constantly turned out. In both these cases
 great benefit has been derived from  scari-
 fying the inner surface of these parts with
 a lancet, by  means of which a consider-
 able quantity of blood has been removed.
 When the  upper eyelid is very oedematous
 in ophthalmy, and  its thickness prevents
 the application of remedies to the eye,  a
 few punctures  made on tiie outside of the
 lid, near its edge, will cause the discharge
 of a bloody water, and a very quick sub-
 sidence ofthe swelling.  When the tume-
 faction- of the everted  eyelids  is  very
 considerable, great and speedy  relief has
 been  given,  by cutting off a piece  from
 the inside  of each of them with a pair of
 curved scissars.  ( Ware, p. 39, 40.)
   General  bleeding, though copious,  and
 assisted by  the topical  application of
 leeches, does not always prove adequate
 to remove the high degree of inflammation,
 attendant on  chemosis.  It is expedient to
 employ additional means, in order to give
 exit to the blood effused in  the  cellular
 substance, between  the  conjunctiva  and
 sclerotica,  by which the former is raised
 so much above the level of the cornea.
 Scarpa  recommends,  for this purpose,
 making a  circular  incision  in the con-
junctiva, near the margin  of the cornea,
 with a pair of curved scissars.  As a lancet,
 however, makes a cleaner  cut than  these
 instruments,  it is perhaps  preferable for
 the operation, and  scarifications might.
 suffice,  both  for the discharge of  the ex-
 travasated  blood, and of that distending
 the vessels of the conjunctiva itself.  In
 chemosis, Mr. Ware says, there cannot be
 an easier or a more effectual remedy than
 aether.  A  few drops are to be  poured
into the palm of the  hand, and diffused
over it, which may be immediately done
by  pressing  the other hand  against it.
The hand is then tobe applied to the eye,
and kept so close to it that the spirit, as
it evaporates, may insinuate itself  into the
part affected, and act on the extravasated
blood, so as to disperse it.  In a  few in-
stances of chemosis, in which the swelling
and inflammation have been considerable,
this gentleman has found the following
application of singular service: *e.  Inte-
riorum foliorum recentium Lactucae Sis-
silis jf iij.   Coque  cum aq. *pur  gss. in
balneo mariae pro  semihora; tunc expri-
matur succus, et applicetur paululum ad
Oculos et ad palpebras saepe in die. ( Ware,
p. 54.)
   After  general  and topical bleeding,
aperient  medicines, of the most gentle na-
ture, should be administered ; soda phos-
phorata,  pulp of tamarinds, cream of tar-
tar, and  magnesia vitriolata, are the  most
proper.  When the stomach is affected,
Scarpa also  recommends  an emetic, as
being  peculiarly  beneficial  to inflamed
eyes.
   When bleeding  and other evacuations
have been practised, the next most useful
measure is the  application of a blister to
the nape of the neck.  Scarpa observes,
that the  skin in this situation, and  that
behind the ears, sympathise more closely
with the eyes than any other part of the
integuments.   Many  practitioners, how-
ever, and among them Mr.  Ware, prefer
blistering the temples.  The latter says:
" When  the leeches have fallen off, and
the consequent hemorrhage has ceased, I
would advise a blister ofthe size  of  half-
a-crown, to be  applied on the temples, di-
rectly over the orifices made by the leeches,
and  I  have found, that the  sooner the
blister has followed the bleeding, the more
efficacious both have proved."  When the
ophthalmy has  been very violent,  and re-
sisted  the  common method, Mr. Ware
adds, that the most Beneficial effects  have
also been sometimes produced by the ap-
plication of a blister large^enough to cover
the whole head.   (P. 43, 44.)
   At first, topical emollien.  applications
to the eye are  most  beneficial; such as
mallows  boiled in new  milk; bread and
milk poultices;  or the soft pulp of a baked
apple; all  included in  fine little muslin
bags. Remedies of this description should
be renewed at least every two hours.  The
patient should be directed to observe  per-
fect quietude,- and to lie with his head in
an elevated position.  To  keep the  eye-
lids from adhering together, in the nighfc
time,. the spermaceti  cerate  is  proper.
When the ophthalmy is accompanied  with
a violent pain in the head, Mr.  Ware re-
commends a strong decoction of poppy-
heads  to  be applied as a fomentation.
(P. 51.)
  Under the preceding plan of treatment,
the acute stage of severe ophthalmy com-
monly  abates  in  about a week.   The
burning  heat and  darting pains in the
eyes, and the  febrile disturbance of the
constitution subside.  The patient is com-
paratively easy, and regains his appetite.
The eyelids lose their tension and wrinkle.
A discharge of thick  matter takes the
place of  a secretion of thin serum, or of
a preternaturally dry state of the eyes. 
OPHTHALMY.
247
 These organs can now be opened, without
 experiencing vast irritation from a mode-
 rate light.   In this state, notwithstanding
 the eyes may continue red,  and the con-
 junctiva swollen, all evacuations are to be
 left off, as well as the use of topical  emol-
 lients, for  which latter astringent, corro-
 borant collyria  are  to  be  substituted.
 Scarpa recommends the following  appli-
 cation: *.  Zinci vitriolati gr. vj.  Aquae
 distillatae 3vj. Mucil. sem.cydon. mali 3J.
 Spiritus  vini   camphor guttas  paucas.
 Misce et cola.  This  collyrium  may be
 injected, with a syringe, between  the eye
 and eyelids, once every two hours ; or
 the eye may be bathed in it, by means of
 an eye-cup.  Such persons as cannot bear
 cold applications to the eye, must have
 tlie same kind of collyrium a little warm-
 ed; but as soon as the irritability has
 lessened, they may be used cold.
  The tinctura thebaica of the old Lon-
 don Dispensatory proves a most efficacious
 remedy for the second stage of acute oph-
 thalmy, or that connected with weak vas-
 cular action in the part affected.  Two or
 three drops may be  insinuated,  between
 the eyelids and  globe  of the eye,  twice
 a-day, in common cases; but in others, at-
 tended with more sensibility, once will at
 first be sufficient. Mr. Ware, who brought
 this  application  into repute, has found,
 that introducing two or three drops of this
 medicine at the  innericanthus, and  mak-
 ing them glide gradually over the eye, by
 gently drawing  down  the  lower eyelid,
 proves equally beneficial, and less painful
 than dropping them  at  once on the eye-
 ball.   Immediately  the  application  is
 made, it commonly creates a copious flow
 of tears : a smarting pain, and a sense of
 heat  in the eyes, which inconveniences,
 however, soon cease, and the eyes become
 clearer, and feel evidently improved. But
 notwithstanding eveiy exaggerated  asser-
 tion,  unbiassed  surgeons are now  quite
 convinced, that  the  tinctura thebaica is
 only a proper application,  when tiie in-
 flammatory action has been  previously di-
 minished by blood-letting, aperient  medi-'
 cines, and blisters, and when the action of
 the vessels has been weakened by  the con-
 tinuance ofthe disease.  Mr. Ware,  in re-
 commending it, as a most effectual appli-
 cation, in every species  and stage of the
 disorder, from the most mild and recent,
 to the most obstinate and  inveterate, (p.
 51.) has certainly been rather too zealous.
 Scarpa has seen  the necessity of  limiting
 the use of* the remedy in question, and he
 has expressly pointed out, that it is only
 useful, when the violence ofthe pain, and
 the aversion to  light  have abated.  In-
deed,  Mr.  Ware  himself  has- acknow-
ledged, a little before sanctioning its un-
limited employment in all cases, that,  in
certain instances, in which the complaint
is generally recent, the eyes  appear shin-
ing and glossy, and  feel exquisite pain
from  the rays of light, no  relief at all
was obtained.  (P. 48,49.)  See Tinctura
Thebaica.
  Whenever the patient can easily bear a
moderate degree of light, all coverings
should be removed from tlie eyes, except
a shade of green or black silk. A brighter
light should be gradually admitted every
day into his chamber, so that he may be-
come habituated, as soon as possible,  to
the open day-light.  Nothing has a greater
tendency  to keep  up  and  increase the
morbid irritability of the eyes, than keep-
ing them  unnecessarily long in a dark si-
tuation, or covered with compresses and
bandages.  (Scarpa.)
  There is a particular species of severe
acute ophthalmy, which differs  from the
common,  in appearing  with vehement in-
flammation and swelling of tiie conjunctiva
and eyelids,  and  being followed by an
extraordinary  discharge of pus from the
eye.  It is very common in children at the
breast, and is described as attacking adults
on the sudden  suppression of a gonorrhoea,
or on  the  inadvertent application  of the
matter of clap to tiie eyes.   These cases
must   be  regarded as  complicated with
specific morbid action, and not in the light
of simple imflammation,  free  from any
diseased principle.
  The Purulent  Ophthalmy,  of children
produces such tumefaction of tiie eyelids,
as almost prevents them from being se-
parated.  Should the  6urgeon succeed  in
gaining a view of the membrane  lining
them,  it appears wrinkled,  and converted
into a red villous surface, somewhat like
the inner coat of  the rectum, when pro-
truded in young1 children.  (Warner on the
Human eye, page 42.)   Sometimes  in the
child's fits of"  crying, the eyelids become
everted, and continue so, until  rectified
by an attendant.  No sooner is  the  first
short  attack of  inflammation  past, than
there succeeds a discharge of thick yellow
matter,  truly  surprising  in  quantity,
partly   secreted  from  the  meibomian
glands, but chiefly from  that  villous,
fungus-like surface, into which the lining
of the palpebrae seems converted.  If the
eyelids can be  opened, tiie matter may be
seen diffused over the whole surface of the
eye,  and  its  confinement,  between the
swollen eyelids and the  eyeball, contri-
butes still more to aggravate the pain, in-
crease the inflammation,  and often to in-
duce ulcers, or specks, either over a part
or the  whole of the cornea.  If a speedy-
check be not soon put  to this distressing
malady, it renders  the cornea so opaque 
248
OPHTHALMY.
 and thickened, as often  to form what is
 termed staphyloma.  The cornea has even
 been known to burst, the humours to be
 discharged, and the eye to sink into  the
 orbit.   The febrile symptoms are at first
 severe;  the infant is continually fretful
 and restless, and a diarrhoea is  not unfre-
 quently  concomitant.  The  affection of
 the eyes is occasionally accompanied with
 eruptions on the hea^d, and with marks of
 a  scrophulous constitution.   (See Ware,
p. 138, &c.)
   The antiphlogistic treatment should be
 quickly opposed to the progress of  the
 dise :-e.  The  temporal arteries  should
 be opened, or leeches applied to the tem-
 ples, or neighbourhood of  the eyelids,
 and a blister put on the nape of the neck,
 or temples.  The child  should be kept in
 a cool room, and not  covered with much
 clothes.   If no diarrhoea should prevail, it
 is proper to purge with a little  rhubarb or
 magnesia in syrup of violets.
   A surgeon, however, is seldom called in
 before  the first short inflammatory stage
 has ceased, and an immense discharge of
 matter from the eyes has commenced. Of
 course  emollient applications must gene-
 rally not be used.  On  the contrary, as-
 tringents and corroborants  are  immedi-
 ately indicated,  in order to restore to the
 vessels of the conjunctiva and eyelids their
 original tone, to rectify the villous  and
 fungous appearance of the  lining of  the
 palpebrae,  and  thus finally to  check  the
 morbid  secretion   of matter.   For  this
 purpose Mr. Ware strongly recommends
 the aqua cumphorata of  Bates's Dispensa-
 tory : ij(.  Cupri vitriolati,  Bol. Ai men.
 a  a ""Jiv.   Camphorae 5J. M. & f. pulvis,
 de quo  projicegj in aquae bullientis ibiv.
 amove  ah igne,  et  subsidant foeces.   Mr.
 Ware,  in  his late  Remarks  on Purulent
 Ophthalmy, 1808, observes, that he usually
 directs  the aqua camphorata, as follows  :
 &. Cupri vitriolati.  Bob- Armen. a a gr.
 viij. Camphoric gr. ij. Misce,  et affunde
 aquae bullientis 3j\ij.  Cum  lotio sit fii-
 gida, eff'undatur fimpidus liquor, et saepis-
 sime injiciatur paululum  inter oculum et
 palpebras.  This remedy possesses a very
 styptic quality;  but it is much too strong
 for use before it is diluted ;  and tlie  de-
 gree of us dilution must always be deter-
 mined   by the  p oil ar  circumstance of
 each case.   Mr. Ware ventures to. recom-
 mend about one dram of it to be mixed
 with an ounce  of cold  clear water, as a
 medium or standard,  to he  strengthened
 or weakened  as occasion may require.
 (P. 143.)  The remedy must  be applied
 by means  of  a imall  ivory or  pewter
 syringe, the end of which  is  a blunt-
 pointed cone.  The extremity  of this in-
strument  is to  be placed  between  the
edges of the eyelids, in such a maimer,
that the medicated liquor may be carried
over the whole surface of the eye.   Thus
the matter will be entirely washed away,
and enough of the styptic medicine left
behind to interrupt and diminish the ex-
cessive discharge. According to tiie quan-
tity of matter, and the rapidity with which
it is secreted, the strength of the appljga-
tion, and  the frequency of repeatinglt,
must be regulated.   In mild recent cases,
the lotion may be used once Or twice a
day, and  rather weaker than the above
proportions ; but,  in  inveterate cases,  it
is  necessary to  apply it  once or twice
every hour,  and* to increase its  styptic
p6V er in proportion ;  and when the com-
plaint is somewhat relieved,  the strength
of the lotion may be lessened, and its ap-
plication be less frequent.
  " The reasons for a frequent repetition
ofthe means just mentioned, in bad cases,
are,  indeed,  of the  most urgent nature.
Until  the  conjunctiva is somewhat thin-
ned, and the quantity of the discharge di-
minished,  it is impossible to know in what
state the eye is; whether it. is more or less
injured, totally lost, or capable of any re-
lief.  The continuance,  or extinction,  of
the sight frequently depends  on the space
of a few hours: nor can  we be relieved
from the  greatest uncertainty, in  these
respects, until the cornea becomes visible.''
(Ware, p.  145.)
  This gentleman, with every appearance
of reason, condemns the use  of emollient
poultiaes,  which must have a tendency  to
increase  the swelling and relaxation  of
the conjunctiva.  If poultices are  prefer-
red, he particularly recommends such  as
possess  a  tonic  or mild astringent  pro-
perty -, as  one made of the curds of milk,
turned with  alum, and  an equal  part  of
unguentum  sanibuci, or axungia  porcini.
This is to  be put on cold, and frequently
renewed, without omitting the use of the
injection.  (Ware,p. 147.)
  When the  secreted matter is glutinous,
and makes the eyelids so adherent together
that they  cannot be  opened, after being
shut for any length of time,  the adhesive
matter must be softened with a little fresh
butter mixed with  warm  milk,  or  by
means of any other soft  oleaginous liqour,
after the poultice is taken off, and before
using the lotion.  (P. 147.)
  If the eversion of the eyelids only oc-
curs when the child cries, and then  goes
off, nothing need be done in addition  to
the above means.  When, however, the
eversion is constant, the injection must be
repeated more frequently  than  in other
cases;  the eyelids  put in  their natural
position, after its use;  and  an attendant
directed to hold on them, with his finger, 
OPHTHALMY.                             249
for some length of lime, a compress dipped
in the  diluted  aqua  camphorata.  (P.
148.)
  In some  cases, when the inside of the
eyelids has been very much inflamed, the
tinctura thebaica, insinuated between the
eye and eyelids,  has been useful.  If  after
the morbid secretion is checked,'any part
of the cornea should be opaque, the un-
guentum  hydrargyri nitrati, melted in a
spoon,  and  applied accurately on the
speck, with a tine  hair pencil; or Janin's
ophthalmic ointment, lowered and used in
the same manner;  may produce a cure, if
the  opacity be  not of too deep a  kind.
 When the local disease seems to be kept
 up by a bad habit, alteratives should, be
exhibited, such  as the aethiops mineralis,
 or small doses of calomel.
   The Purulent  Ophthalmy, arising either
 from suppression of gonorrhoea, or from
 the  inadvertent conveyance of gonorrhoeal
 matter to the eyes, is said to produce
 rather a swelling of the conjunctiva, than
 of tiie eyelids, which is followed by a dis-
 charge ofa yellow greenish matter, similar
 to that of clap.  The heat and pain  in the
 eyes  are  considerable;   an  aversion to
 light prevails, and, in  some instances, an
 appearance of hypopion is visible  in  the
 anterior chamber of the aqueous humour.
 When the complaint proceeds from  the
 second cause, it is described as being less
 severe.
   If it be actually true, that, in adults, a
 species of purulent ophthalmy does origin-
 ate from the sudden suppressionof a go-
 norrhoea, are we to consider the cbmplaint
 so produced as a metastasis ofthe disea-e
  from the urethra to the eyes ?  This oph-
  thalmy does not regularly follow  the
 suppression of  gonorrhoea ; nay, it is even
  a rare occurrence : also, when it  is de-
 cidedly known, that the purulent ophthal-
  my has arisen  from the  infection of go-
  norrhoea,  namely, in those instances, in
  which the matter has  been incautiously
  communicated to the eyes, it appears, that
  such an affection of these organs,  so pro-
  duced, is different from  the one alluded
  to, inasmuch as it  is slower in its progress,
  and less  threatening in its aspect.  Hence,
  there is  good reason  for supposing, that
  no  metastasis takes place in this speci-s
  pf  purulent ophthalmy,  supposed to be
  connected with a suppressed gonorrhoea :
  but,  we  must  be content with inferring
  that, if  it really has such a cause,  it ori-
  ginates from a sympathy, prevailing be-
  tween the urethra and eyes,  and, that the
  variation of irritability, in different peo-
  ple, is the reason, why it is not an invari-
  able consequence of the  sudden stoppage
  ofa gonorrhoea.
    The injection of warm oil, the intro-
      Voi. II.
duction of a bougie into the urethra, and
the application of cataplasms to  the peri-
naeum, with a view of renewing toe dis-
charge from the urethra, form the outline
ofthe practice of those, who place implicit
reliance in the suppression  of gonorrhoea
being the cause of the complaint.  The
rarity  of the occurrence ;  the frequency
of the sudden cessation of the  urethral
discharge ; the possibility of an ophthal-
my arising, as, well at this partif ular mo-
ment, as at any other, totally independent-
ly of the other complaint; cannot fail to
raise in  a discerning mind a degree of
doubt, concerning the veracity of the as-
signed cause.  Besides, admitting, that
there is  a sympathy between the urethra
and eyes, how are we to ascertain, whether
the suppression  of  gonorrhoea be the
cause or the effect of the ophthalmy, sup-
posing that the one ceases, and the other
commences, about the same time ?  Actu-
ated by  such reflections, I am induced to
dissuade surgeons  from  adopting any
means calculated to renew a discharge of
matter from  the urethra.  When the  pu-
rulent ophthalmy, in  adult subjects, is
 decidedly occasioned by the actual con-
tact, and infection of gonorrhoeal matter,
 applied accidentally  to the eyes, no one
 has recommended this unnecessary and
 improper practice.
   The first  indication, in the treatment
 of the disease from either cause, is to op-
 pose the violence ofthe inflammation, and
 thus resist the destruction ofthe eye and
 opacity  ofthe cornea. A copious quantity
 of blood should be taken  away both to-
 pically  and  generally;  mild  laxatives
 should be exhibited, and a blister applied
 to the nape of the neck, or temples.  The
 eyes ought to be often fomented  with a de-
 coction  of white poppy-heads,  and warm
 milk repeatedly injected beneath the eye-
 lids.  To prevent the palpebra;  from be-
 coming agglutinated  together,  during
 sleep, the spermaceti cerate should  be
 smeared on the margins of the tarsi, every
 night.
    When the heat and pain in the eyes, and
 febrile  symptoms  have subsided ; when
 an abundant discharge of pus  has com-
 menced: all topical emollients are to be
 relinquished, and a collyrium of Aq. rosae
 J$x, containing Hydrarg. mur. gr. j. usrd
 in  their place.  Scarpa  states, that  in
 the ophthalmy, originating from the inad-
 vertent communication of the matter of
 gonorrhoea  to  the eyes, applications,  in
 the form of ointment, such as  the ung.
 hydrarg. the unguentum ophthalmicum of
 Jan in, to which  might be added the ung.
 hvd.  nitrat. avail  more than fluid reme-
 dies.  (Scarpa.)
    Epidemic, Purulent, or Egyptian, Ob'ft-
      Ir 
250
OPHTHALMY
thalmy.  The latter name has been given,
in consequence of the very  close resem-
blance, which this inflammation  bears  to
that,  which destroyed the sight of a con-
siderable number of our soldiers in Egypt
in 1801.   Mr. Ware, however, objects to
the appellation,  because an ophthalmy,
precisely similar in its symptoms and pro-
gress, has appeared long ago in this and
other countries, and, in  Egypt, as well as
England,  several varieties of ophthalmy
prevail.    This  gentleman prefers  call-
ing the late epidemic affection of the eyes
a purulent  ophthalmy,  since one  of its
chief symptoms, and that  which distin-
guishes it from every other, is the profuse'
discharge of a purulent coloured fluid.—
Some valuable  practical remarks  have
been published in the Edinburgh Surgical
Journal for January  1807,  by my worthy
friend Mr. Peach, who has enjoyed great
opportunities of observation,  from his
having bt-en  surgeon to  the 2d Battalion
ofthe 52d Kegiment, in which the disease
li.is prevailed, perhaps, to an extent not
witnessed m any other corps.   The  total
strength  of this regiment was 691  men,
 and,  including relapses, Mr.  Peach  had
 733 cases, without taking into the account
 some slight returns of the disease, which
 vere  obviated   by  venesection.    Fifty
 men   had  lost tlie  sight of  both  eyes,
 though  Mr.  Peach  thought, that several
 of these would ultimately recover; for, he
 had already had some instances, in which
 the cornea  recovered  its  transparency,
 after having been opaque for six months.
 Forty men had lost  the slight ofrone  eve.
 The  perfect cures amounted to 404 ; and,
 when Mr. Peach's letter to Dr. M'Grigor
 vas written, he had 213 cases under treat-
 ment.  (Edin. Surg. Journ. for  January
 1807.)  The epidemic, now under consi-
 deration,  is very different from an oph-
 thalmy, \vh'f.Y, at v rious times,  has been
 epidemic m this,  and  other  countries,
 without any purulent discharge from the
 eyes, which is seldom dangerous to sight,
 and, in a few days, generally yields to in-
 ternal antiphlogistic means, and mildly
 astringent applications.  ( Ware on the F.pi.
 Purulent Ophthalmy, Note, p. 3 ;  1808 )
   According to Mr. Peach, the  patient
 complains, in the first stage of the disease,
 of being suddenly seized with a rolling of
 sand in his eye ; the vessels on the  albu-
 ginea become suddenly, turgid with blood,
 and  the   lower  palpebrae  very vascular.
 The cases treated in this recciit state, ge-
 nerally yield.  But, if very active  mea-
 sures do  not arrest the  progress  of the
 d sease, the second stage appears,  when
 the palpeb- ae supcrioi es become much en-
 larged; the  eyelids can only be opened
 With extreme difficulty ; and then either a
       r
scalding fluid is discharged and excoriate*
the face, or a flux of thick yellow matter
taker, place. In this state, it is frequently
in our power to stop  the progress of the
evil;  but, if the most decided and active
practice be  not  adopted,  the  disease
reaches the third stage, in which every
thing is seldom  of any avail in  relieving
the  most  distressing  symptoms..  The
cornea now too often  becomes ulcerated,
and the eye ruptured.
   On the first appearance of the disease,
Mr.  Peach  had recourse to venesection,
and the antiphlogistic treatment.  Being
unsuccessful,  he  tried  bark  and stimu-
lants ; but, being still more unsuccessful
with tliis mode of treatment, he reverted
to the antiphlogistic plan in its fullest ex-
tent, and with the greatest success, and
he found, that he did not  formerly suc-
ceed, because he did  not carry this mode
far enough.  It is in the commencement
of tiie disease, that a very large quantity
of blood should be  taken awi.y :  in that
stage, large venesection, even ad deliqui.
urn animi,  is  almost  an infallible remedy.
It is not su flicient to  take away twenty or
thirty ounces of blood.   Mr. Peach has
often taken away sixty, at the same time,
enjoini  ig perfect rest,  the avoidance of
all animal  food,  and putting in practice
every other  purt of the  antiphlogistic
treatment.  The  complaint is  naturally
disposed to relapse,  and, as often as the
disease, or even the slghtest pain, or un-
easiness in the eye,  returns, so often did
this gentleman return to thf lancet.  Such
practicfg Mr. Peach confesses is likely to
exciie astonishment; but the fullest trial
 of it has demonstrated to him its utility.
 In many of the cases, which  occurred to
 him, the progress ofthe inflammation was
 so i- pit!, that it probably would have  to-
 tally destroyed  the  eye, if only  the or-
 dinary  mode  of treating ophthalmy had
 been resorted to.  He  advises particular
 attention to be paid  to the first sensation
 of sand in the eye; he never defers  vene-
 section, when this is complained of; and
 the patient, in general, finds so much ad-
 vantage during  the  operation, that he
 says, "the sand is removed."   Mr Peach
 has occasionally  found  advantage arise
 from dropping the undiluted aqua litharg.
 acetat. into the  eye, though great  pain
 was  the  immediate  effect of its applica-
 tion.  On   the whole, however, he con-
 cludes, that dropping substances into the
 eye  is  not  serviceable, and   says, that,
 since th's prac ice was  relinquished, the
 eyelids have  not  been so often  inverted.
 The bowels must be kept  open.  Benefit
 has often  been derived from  shaving the
 head, and keeping it continually wet with
 water, or  vinegar.   Blisters  are  also 
OPHTHALMY.
251
sometimes indicated ; but, the great reli-
ance is to be put in the strictest antiphlo-
gistic regimen, and copious venesection.
(See Edin'i. .Med. and Surg. Journal, for
January, 1807.)
  With regard to the causes of the epi-
demic purulent  ophthalmy,  Mr.  Ware
seems to think, that the complaint is com-
monly  communicated by contact.  Some
of the  worst cases of the purulent oph-
thalmy  of  children  have  happened  in
those, whose mothers were subject to an
acrimonious discharge from  the vagina at
the  time of parturition.  Some  of the
worst forms of the purulent ophthalmy in
adults, have occurred in those, who, either
shortly before the attack of the  ophthal-
my, or, at that very time, laboured either
u-xler a gonorrhoea, or a gleet.  Mr. Ware
does not mean to impute every purulent
ophthalmy to such a cause; but, in the
majority of adults,  whom he has seen af-
fected, if the disorder had not been pro-
duced by tlie application of morbid mat-
ter, from a diseased eye, it could be traced
to a connexion, between  the  ophthalmy,
and disease of the urethra. Other causes,
Mr. Ware acknowledges, may contribute
to aggravate, and, perhaps, produce the
disorder, and the purulent ophthalmy in
Egypt, has been attributed to a great num-
ber.  The combined influence of heat and
light, ofa burning dust continually raised
by the wind, and ofthe heavy dews ofthe
night, may powerfully tend to excite  in-
flammations of the  eyes.  Yet som^hing
more must operate  in causing the malig-
nant ophthalmy now under consideration;
for, the same causes operate with equal
violence in some other countries,  besides
Egypt, and yet do not produce tlie same
effect ; and, in this  country, (continues
Mr. Ware) the disorder  prevailed during
the last summer, to as great a degree, and
upon as great a number of persons, within
a small district of less than a mile, as it
ever did in Egypt ;  and, yet, beyond th.s
space,  on either side,  scarcely a  person
was affected with it.  The disorder was
certainly brought into this country by the
soldiers who returned from Egypt, and
was probably communicated from them to
many others.   Now as  the action of the
atmosphere alone cannot  account  for the
spreading of the disease, &c. Mr.  Ware
is led to believe, that this particular dis-
order is only  communicable  by absolute
contact; that is, by the  application of
some part of the discharge, which issues,
cither from the conjunctiva" of an affected
eye, or from some other membrane, secret-
ing a similar poison, to the conjunctiva of
the eye of another person.   In   schools
and nurseries,  in consequence of children
using the  same basins  and*1  towels, as
others who had the complaint, the disease
has been communicated to nearly twenty
in one academy.  Hence, Mr. Ware cen-
sures the indiscriminate use of those arti-
cles in schools, nurseries, hospitals, ships,
and barracks.  (P. 14,15.)
   The principal difference, between the
purulent ophthalmy of infants, and that of
adults, consists in tlie different states of
the tunica  conjunctiva.   In the  former,
notwithstanding the quantity of matter,
confined within  the lids, is often profuse,
the inflammation of  the  conjunctiva  is
rarely considerable,  and  whenever the
cornea becomes impaired, it is rather ow-
ing to the lodgment of such matter on  ifc,
than to inflammation.  But,  in'the puru-
lent ophthalmy of adults, the discharge is
always accompanied with  a violent in-
flammation, and generally with a tume-
faction of the conjunctiva, by  which its
membranous appearance Is destroyed, and
the cornea  is made to seem  sunk in the
eye-ball.   (Ware, p. 23.)
   We have  already detailed  the success-
ful plan Of taking very large quantities of
blood from  the arm, ■ as practised by Mr.
Peach.  Mr. Ware speaks also in favour
of bleeding  ; but has rarely  carried it to
the extent, it has  been in the army.  In
weak persons, this gentleman prefers, in-
stead of repeating  venesection, topical
bleeding, either from the vein, that passes
on the side  of the nose,  or by means of
five, or six  leeches put  on .the temple.
Sometimes,  he thinks it better to scarify
the inside of the lower eyelid,  with the
point of a lancet, carried along parallel
to, and very near the margin of  this part.
Mr. Ware objects  to  pricking the eyelid
in an  infinite number of places, as  very
painful, and likely to iucrease the irrita-
tion.  The  lancet never need be applied
more, than  twice, and rarely more,  than
once ; and, perhaps, less pain will be oc-
casioned by  making the incision with the
edge, rather than the point of the lancet.
After talcing away blood,  Mr. Ware  says,
a large blister on the head, or  back,  is of-
ten useful.  Anodynes should be given,
with occasional purgatives, and an  anti-
phlogistic regimen.   (Ware on  Purulent
Ophthalmy,  1808, p. 26, &c.)
  Dr. Vetch, on the  subject of local ap-
plications in the present disease, advises
keeping the  eyes continually covered witii
linen dipt in some cooling lotion.  In the
first  stage,  he gives the preference to
dropping the  aqua sapphinna  into  the
eye ; afterwards, when tlie swelling ofthe
eyelids has  come on, he prefers  the  aqua
htharg. acet.  While  the  patient is sub-
ject to a recurrence of pain, he thinks, the
injection of  warm water the best applica-
tion.  For  the purpose of lcsscniig the 
OPHYHALMV
swelUng of the eyelids, he advises com-
presses, dipt in the aqua litharg. acet. to
be applied with a  moderately  firm  pres-
sure.   When  the swelling,  and   other
symptoms of the secohd stage have sub-
sided, Dr. Vetch recommends more astrin-
gent applications, such as  the  aqua li-
thargyri  acet. Bates's  camphorated wa-
ter, solutions of alum, and the muriate of
mercury.  (See An Account ofthe Ophthal-
mia, as it appeared in England since the re-
turn of the British Army from Egypt, by
John Vetch, M. D. 1807,p. 111.)
   Mr. Ware gives the preference  to the
aqua cam'phorata, which is to be used  ex-
actly in the same way,  as was described
above  in  speaking of the purulent oph-
thalmy of children.   I cannot help think-
ing, that, if army surgeons had been care-
ful to inject their  applications under the
eyelids, as advised by Mr.  Ware, great
benefit would have  been  produced.  In
other  ways, the effect of the remedies is
often lost.  When the inflammation has
been very great, Mr.  Ware has only put
four,  or five grains,  instead of  eight, of
the cuprum vitriolatum to eight ounces of
water;  and,  while  the inflammation is
great, he would never  advise  more than
eight grains to this quantity of water.  He
usually employs the lotion cold, especi.dly
in children; but, in some adults, in whom
the general I*e\er, and local inflammation
have been considerable, lie has been obliged
to use it warmed.  Incases of great pain
and swelling, it should be very   weak,
less often applied, and, sometimes only
warm water injected.  In such circum-
stances, Mr. Ware also sanctions foment-
ing tlie eye with a flannel, or sponge, wet
with  ahot decoction of poppy-heads, or
mere hot water.   When the cornea threa-
tens to burst, this gentleman approves of
opening  it,  in  order to   discharge  the
aqueous  humour, by making  an incision
in a place, where the scar wdl not obstruct
vi.-ion.
   Having now treated  of all  the princi-
pal species of acute ophthalmy, 1 shall
finish  this part of the subject with no-
ticing Mr. Wardrop's proposal  to punc-
ture the cornea, and  let out the aqueous
humour in particular slates of inflamma-
tion ofthe eyes. This gentleman remarks,
that  if the eye  of   a  sheep, or  ox, be
squeezed in the hand,  the whole cornea
instantly becomes cloudy, and whenever
 the pressure is  removed,  this membrane
 completely regains  its  transparency.—
 From this curious  phenomenon  in "the
 dead eye, it was evident, that, in the liv-
 ing body, the transparency of the cornea
 might vary according to the degree of its
 distention ; and that, in cases of opacity
 of the cornea, accompanied with fulness
of the eye-ball, its transparency might be
restored by the evacuation of the aqueous
humour.  The cornea  is little  sensible,
and, as every body knows, its wounds are
free from  danger.   Mr. Wardrop  soon
met with  a  case, favourable for making
the  experiment; the  cornea was milky
and opaque, and the  eye-ball distended
and prominent, attended with  acute in-
flammatory symptoms.  The aqueous hu-
motir was discharged by a small incision,
and the operation produced not only a re-
moval ofthe cloudiness ofthe cornea, but
an abatement of the pain,  and a sudden
check to all the inflammatory symptoms.
From the success of this case, Mr. War-
drop was led to perform the operation on
others,  not only with a view of diminish-
ing the  opacity of the cornea, but, ah>o,
of  alleviating the   inflammation.  Four
interesting cases  are related by  this gen-
tleman, very much  in favour of the prac-
tice, when the eye  is  severely  inflamed,
attended  with fulness of  the organ, a
cloudy  state of the cornea, and a turbid-
ness of the aqueous humour.   Mr. War-
drop also advises the operation, whenever
there is the smallest quantity of pus, in
the anterior chamber, accompanied with
violent  symptoms  of  inflammation.   He
thinks that, the great  and  immediate re-
lief which the method affords, is imputa-
ble  to the sudden removal of tension; and
he  performs the operation with a small
knife, such as is  used for  extracting the
cataract.  The instrument is to be oiled,
and introduced, so  as  to make  a wound
of  its own breadth, at the  usual place of
making the incision in the extraction of
the cataract.  By turning the blade a lit-
tleon its axis, the aqueous  humour flows
out. (See Edinb. Med. and Surg. Journ.
Jan. 1807.)
   Mr.  Ware seems to approve of Mr
 Wardrop's operation in the epidemic, puru-
 lent, or Egyptian  Ophthalmy, when, not-
 withstanding, general evacuations, topi-
 cal bleeding, mildly  astringent lotions,
 and a  strict  antiphlogistic regimen,  the
 symptoms still continue, and, especially, if
 the cornea  begin to lose its transparency,
 and a white rim appear round its circum-
 ference.  Mr. Ware does not object to
 using a small knife, of the kind, employ-
 ed in extracting the cataract; but, thinks
 a lancet  will safely answer the purpose,
 or, what  is  better,  a sharp-pointed couch-
 ing needle,  having a blade somewhat
 wider  than  usual, and a  groove  in its
 middle.  The  instrument,  he advises,
 to  be  introduced  about one-tenth of an
 inch before  the connexion of the cornea
 with  the sclerotica,  and  pushed gently
 on, parallel to the  plane of tiie  iris, until
 the aqueous  humour make  its escape. 
OPHTHALMY.                             253
(Ware on the Purulent  Ophthalmy, p. 41,
i808.)                 *      ^ *

          CHRONIC OPHTHALMT.

  Unfavourable peculiarities are met with
in practice,  which prevent the complete
cure of the second stage of acute  oph-
thalmy, or  that connected  with a weak
vascular action in the part affected; whence
the protracted  disease becomes  purely
chronic, and threatens  the  slow destruc-
tion of the eye.
  These peculiarities  may be chiefly re-
ferred to three causes :  1. To an increased
irritability continuing in the eye after the
cessation of acute  inflammation.  2. To
some other existing affection of the eye,
or neighbouring parts,of which the chronic
ophthalmy is only an effect.  3.  To consti-
tutional disease.
  1. That chronic ophthalmy may depend
upon  a morbid irritability  of the eye is
evinced, not only from its resisting  topi-
cal astringents and corroborants, to which
the disease from simple relaxation and
weakness  yields, but from its being exas-
perated by them, and even by cold water.
The patient complains of a sense of weight
in the upper eyelid, and restraint in  open-
ing it; the conjunctiva has a yellowish
cast, and when exposed to the damp cold
air, or a brilliant light, or when the pa-
tient  studies by candle-light,  its vessels
become injected and turgid  with blood.
If, in combination  with such  symptoms,
the habit of body be weak ai'itflrritable ;
subject to  spasms ; hypochondriasis, &c.
then, it is manifest, that the chronic  oph-
thalmy is  connected with a general im-
pairment of the nervous system.
  2. Besides extraneous bodies,  lodged
between the palpebrse and  eye-ball,  the
inversion of the ciliae, and hairs, growing
from  the  caruncuki lachrymalis; ulcers
of tiie cornea; prolapsus of tiie iris; her-
petic  ulcerations  of the margins of  the
eyelids; a morbid secretion from the mei-
bomian glands; a  diseased  enlargement
ofthe cornea, or of the whole globe ofthe
eye,  &c.  may   occasion  and  maintain
chronic ophthalmy.—It is  only my part
here to mention such remote causes; for,
the particular treatment of them is de-
scribed in other articles.   (See  Cornea,
Ulcers of; Iris,  Prolapsus of;  Lippitudo;
Staphyloma ; Hydrophthalmy ;  Trichiasis,
L'c)
  3. The cure  of the second stage of
actite ophthalmy may be retarded  by the
prevalence of scrophula in the system ; or
by  the  small-pox  affecting  the  eyes.
Chronic ophthalmy is also  sometimes a
consequence of lues venerea.
  When chronic ophthalmy depends upon
preternatural irritability, the  internal ex-
hibition of bark with valerian is proper;
animal food of easy digestion; gelatinous
and  farinaceous broths ; wine in modera-
tion; gentle exercise;  living in salubri-
ous and mild situations ; are all severally
productive of  benefit.  Externally,  the
applications should be ofthe sedative and
corroborant kind; such as aromatic spi-
rituous vapours  (from the spiritus ammon.
comp.) applied to the eye through  a fun-
nel,  for half an hour, three or four  times
a day ; and the eyelids "and eye-brows may
also  be  rubbed with the linimentum cam-
phorae.
  Patients, both during the treatment and
after the cure,  must  refrain from  strain-
ing the eye, and,  immediately the least
uneasiness is felt, must desist from exer-
cising it.  When they write, or read, it
should constantly be in a steady, uniform
light, and too little, as well as too  much,
aggravates the  disease.  Having once be-
gun  to use spectacles, they should  never
study, or survey minute objects, without
them.   (Scarpa.)
  1 shall conclude the  subject with a
few remarks upon the cure of ophthalmy,
when connected with constitutional dis-
ease.

        scnorncLous ophthalmy.

  No specific being known for scrophula,
the treatment, in this instance, rather con-
sists in preventing the aggravation, than
in attempting  the  radical cure of the
complaint.  Every thing  debilitating  is
hurtful, as all  evacuation;  indigestible
food;  intense study;  a sedentary life;
damp marshy habitations ; uncleanliness ;
frequent transitions  from  beat to  cold.
On the other hand, observing to regulate
the action of the bowels with the mildest
laxatives ; and the administration of bark,
either alone or conjoined with the  tinct.
guaiaci ammoniata, do good.   Alterative
medicines, and especially iEthiops mine-
rals, from gr.  ss. to  gr. xx.  in the day,
taken for  a few weeks  uninterruptedly ;
aqua calcis, in broth or gruel, at first, in
the dose of 3iij. at breakfast, and after-
wards the same quantity,  twice daily for
a few months,  uniformly adhering to a
good regimen in diet; may tend much  to
abbreviate the duration of this obstinate
species of the disease.  (Scarpa.)
  Mr. Ware has found, that the addition
of xs.. to xxx gr. of the sal polychrestus
of the Edinburgh Dispensatory, to each
dose of bark, suffice* to keep the bowels
in a regular state, when there is  a ten-
dency to costiveness.   In some cases, in
which there was little appearance of in-
flammation, this gentleman   found  tlit 
254
OPHTHALMY.
  eyelids so relaxed, and the eyes so irrita-
  ble,  that children would not  open their
  eyes, even in the darkest  room   In some
  such relaxed cases, very beneficial effects
  were produced by administering internally
  small doses of opium, night and morning,
  to abate the  irritability.   Sea-bathing is
  always serviceable in scrophulous oph-
  thalmy, and, probably the mere residence
  on the sea-coast, and the respiration of the
  sea-air,  may bring about some  of  those
  advantages, which have been exclusively
  attributed  to bathing.   Friction of  the
  body with a flesh-brush, or flannel, should
  be employed morning and evening.
    With regard  to topical  applications,
  those of a soft relaxing kind prove inju-
  rious, as also retirement  into dark situa-
  tions.  Slightly  astringent collyria;  the
  ung. tutiae, and the ung.  hyd. nitrat.  are
  proper when there are excoriations upon
  the eyelids, and when, from their"  occa-
  sional adhesion  to each other,  there is
  reason to  suspect,  that  the sebaceous
  glands secrete an acrimonious fluid.  Mr.
  Ware has also found that one drop ofthe
  thebaic tincture, dropped  into  the eye,
  once or twice in  the  course of the day,
  contributes greatly, both to abai e the irri-
  tability  and to increase  the strength of
  the relaxed vessels. ( Ore Scrophulous Oph-
  thalmy, p. 26.)  The same gentleman  has
  occasionally mixed old verjuice with cold
  spring-water, at first, in the proportion of
  one part of the former to  six of the latter,
  and  increasing the quantity  of verjuice,
  until, sometimes there has been an equal
  quantity of that and water.  All coverings
  should be removed from the eyes* except
  a shade of green silk, and patients should
  be  gradually  Habituated  to  a stronger
  light.   Good  air and  exercise always
  tend to improve scrophulous constitutions,
  and  thus,  indirectly, the disease under
  consideration.   Scrophula  often  disap-
  pears spontaneously, as children approach
  the adult state, and, if we only have it in
  our power to  check its  progress in  the
  early stage of life, it seems to wear itself
  out  afterwards, and  whatever  local  ef-
  fects, it may have produced, often disap-
  pear.
    As the small-pox inoculation has at pre-
  sent almost generally been abandoned by
1  the faculty in favour ofthe vaccine disease,
  there seems less occasion now for detail-
  ing circumstantially a very obstinate spe-
  cies of ophthalmy, induced by the f rmer
   Jiomplaint. When the small-pox eruption
   s very abundant  in the fice, it c.mses a
  considerable swelling of this part of  the
  body; the eyelids become tumefied,  the
  eyes redden, and there ensues a discharge
  of a  very  thick adhesive matter, which
  sggluiiiiHtes the  palpebrac together;  so
that,  if no  steps be taken, the eyes will
continue closed  for several days in sue
cession.  The matter, confined between
the eyelids  and globe of the eye,  being
perhaps of an irritating quality, and in-
jurious from the pressure it occasions on
the surrounding parts, seems  capable of
exciting ulceration  of the cornea, and
even  of irremediably  destroying vision.
When the pustules of the small-pox in
other parts of the body have suppurated,
they cicatrize; but, those, which happen
within the margin of the cartilage of the*
eyelids, are prevented from healing by .the
diseased secretion, which is then secreted
from the meibomian glands, and  such ul-
cers result, as will sometimes  last for se-
veral years,  and even during life, if unre-
medied by art. (St. fves sur les Mai. des
Yeux, p. 216, Edit. 12mo.)  After the em-
ployment of the antiphlogistic  treatment,
should the disease, when treated  with to-
pical  astringents  and  corroborants,  yet
baffle the efforts of the surgeon, setons in
the nape of the neck, kept open for a long
while, prove one ofthe most useful reme-
dies.   Scarpa has  experienced  much  ad-
vantage from giving, every morning and
evening, to  a child, ten years old, a pill,
containing one grain of calomel, one grain
of the sulph.  aur. antim. and four grains
of cicuta  in powder.  It is obvious, that
such a potent alterative, if ever servicea-
ble in this case,  will soon  evince its effi.
cacy,  nor would it be  justifiable  to sport
with  the  patient's constitution  by  con-
tinuing its use beyond a certain period,
unless sanctioned  by evident signs of its
salutary effects on the disease ofthe eyes.,
  When great irritability prevails, a mix-
ture, of three drams ofthe vinum antimo-
niale, and one dram of the tinctura the-
baica, given in doses of five, or six drops,
in any  convenient vehicle, and, at the
same  time,  applying  externally  the  va-
pours  of*  the  spiritus  ammon. comp. to
the eye, constitute an excellent  plan of
treatment.   In other cases, saturnine col-
lyria, with a little camphorated  spirit of
wine, or white wine, in which a little su-
gar is  dissolved; tinct. thebaica, Janin's
ointment, Sic. avail most. This treatment
is also applicable to the chronic ophthal-
my from measles.
  When inveterate ulcers remain upon
the edges of the palpebrx, the disease
may then be regarded as the psorophthal-
my, described by Mr.  Ware, and will de-
mand  the same  method of cure.  (See
Psor ophthalmy.)

    VENEREA! CHnOXIC OPUTH4LMT.

  Mr. Hunter entertained doubts, whe-
ther any inflammations of the eyes are sy- 
f                       OPHTHALMY.                             %r>$
philitic, and he  appears to build his opi-
nion upon two circumstances; one is, that
if such cases be venereal, the disease is
very different from what it is when it at-
tacks other parts, and is attended with
more pain,  than  venereal inflammation
arising from  an affection of the constitu-
tion : the  second is,  that he never saw
these cases attended with such ulceration,
as occurs when the complaint invades the
mouth, throat,  and tongue.  (Hunter  on
the  VenereiU, p. 324.) In regard to the first
circumstances,   I  can  accurately  state,
that in several cases, reputed  to have been
venereal ophthalmy, which I have seen in
St.  Bartholomew's Hospital,  the pain was
by  no means severe, or the  chief part of
tlie malady.  The disorder seemed rather
to  consist in  an  impairment of vision,
with here  and  there little distinct plex-
uses of dilated  blood-vessels. If the pain
should be actually more severe,  than that
accompanying  other  local symptoms of
lues venerea, will not the natural  sensi-
bility of the eye satisfactorily explain  this
semblance of a well-marked disease de-
viating from its determinate character ?
In support of this observation, may I not
remark, that the progress of a  venereal
bubo in the groin causes greater pain,
than the formation of a node on the ulna,
or tibia.  As to the second reason for sup-
posing no  inflammations of the eyes are
truly venereal,  it cannot be considered as
conclusive.  Syphilis does not seem inva-
riably to produce ulceration, in  every si-
tuation,  where it  invades  the  human
frame, and, in the bones, indeed, it would
rather seem, in general, to give rise  to a
process of a directly different tendency,
namely, tiie formation of nodes; nor does
it,  according to Mr. Hunter's own senti-
ments, produce ulceration upon mucous
membranes.  Scarpa says,  the  venereal
ophthalmy is peculiar in  not discovering
manifest signs  of inflammation, stealing
on  clandestinely, without much uneasiness.
It  afierwards relaxes the vessels of the
c njunctiva  and lining of the palpebrae,
and changes the secretion of Meibomius's
 glands.  In time  it causes ulceration of
 the margins of the eyelids ;  the ciliae fall
 off, and the cornea grows  opaque.   In
 the worst  stage, it excites itching in the
 eyes, which  is  exasperated at night, and
 abates  in  violence towards  morning, as
 do  almost all tlie eff'ects of syphilis.  It
 never attains  the  state  of chemosis.—
 (Scarpa.)
   In the few cases, which have fallen un-
der my own observation,  the decoofc sar-
 sap. and  hydrarg. mur.  have constantly
 improved  the  condition of the eye,  and,
 when taken, for a sufficient time, have
 cired the disease.   I  do  not mean to as-
sert, that these instances were unequivo-
cally  venereal  ophthalmies,  I can only
say,  that they were reputed  to  be such,'
and yielded to the above medicines.  In
some cases, mezereon, guaiacum, and mer^
curial frictions, might be tried  ;  and, -I *■
believe, in all cases, the use  of a  colly-
rium, containing hydrarg. muriatus, as
Scarpa recommends, would assist the ope-
ration of internal medicines,  in the cure
of the disease.  When the eyelids are ul-
cerated, the ung. hydrarg. nitrati, weak-
ened at first by the addition of twice, or
thrice  its quantity of hog's  lard, is the
best topical application.
  Some interesting observations on the
ophthalmy, supposed  to be venereal, may
be seen in Saunders' Treatise on the Dis-
eases of the Eye ; but, having noticed
these remarks  in  another  publication,  I
shall avoid repeating them  in tlie present
place.

       INTERMITTENT OPHTHALMY.

  There is a description of  ophthalmy,
the symptoms  of which intermit, or at
least remit, at stated periods.  Mr. w'are
has not found bark so useful in this, as in
scrophulous  ophthalmy ;  but,  he  has
known  tlie hydrarg, mur. produce the
most beneficial effects,  and,  sometimes,
he has conjoined with its internal  exhibi-
tion  the decoct, sars. com.   (See Ware
on Intermittent Ophtlialmy.)
   On the subject of Ophthalmy, the reader
may consult with advantage, Maitre-Jean,
and  St. Yves sur les Mai. des Yeux.  Ware
on Ophtlialmy, Psorophthalmy, and Purulent
Eyes of new-born Children :  on Scrophulous
and  Intermittent Ophthalmy;  also. Addi-
tional Remarks on Ophthalmy ; and Remarks
on the Purulent Ophtlialmy lately epidemical
in this country.  Tliere is a masterly account
of Ophthalmy in Richter's  Anfangsg. der
Wundarzn. Band. 3.  The Edinburgh Med.
and Surg. Journal for January 1807, con-
tains Mr. Peach's and Mr. Wardrop's re-
marks. See, ulso, An Account of Ophthalmy,
as it appeared in England, since the return
of the British Army from Egypt,  by John
Vetch. M. JJ. 1807. But, in particular, the
 Observations of Scarpa,  in cap. 7. of his
work Sulle Principali  Malattie degli Occhi,
 Venez,  1802, merit notice; tliey have been
ab'y translated by Mr. Briggs.   Consult
likewise  a Treatise  on  Several Practical
Points relative to the Discuses of the Eye,
bii  J.  C.  Saunders, Edited by Dr. Farre,
 1811.
    OPISTHOTONOS.    (from  oxitrht,
 backward, and rctva, to extend.)  A spas-
 modic disease, in which the trunk is drawn
 backwards,  with  the  head towards the 
O Z A.                            PAR
shoulders : it is one of the varieties of te-
tanus.
  ORCHOTOMIA. (from og%(s, a testicle,
and rtfviu,to cut.)   The operation of re-
moving a testicle.  See Castration.
  ORIS CANCRUM.  See Cancrum Oris.
  OSCHEOCELE,    (from «o-^£ev,  the
scrotum, and xsjAjj, a tumour.)  A hernia
situated in the scrotum.
   OSTEOSARCOMA,  or Osteosahco-
sis. (from o<r]e»*, a bone, and erxp%, flesh.)
This term signifies tiie change of a bone
into  a substance,  of the consistence of
flesh.  Bones  are  sometimes converted
into a soft, lardy, homogeneous substance,
resembling a cancerous gland, and it is
this  affection, which  has most claim to
the appellation.
  Authors seem to apply the term osteosar-
coma too  much at  random,  as  may be
seen by referring to Boyer on the Diseases
of tlie Bones, Vol. 1, Chap. 22.  The dis-
ease, called mollities ossium certainly ren-
ders the  bones soft and flexible, and their
heads become softened,  in cases of white
swellings.
  There  is not much propriety, and, cer-
tainly, no  necessity for  calling these dis-
eases osteosarcoma.  The bones  are also
occasionally  converted into  a complete
gelatinous  mass.  Boyer  relates  a very
remarkable example, in which the whole
humerus  was  destroyed  in' this  way,
nearly down to the elbow.  (See Vol. 1,
Chap. 22)
  OTALGIA,   (from #5, an ear,  and
«Ay«5. pain.)   The ear-ach.
  OTITIS, (from  Ui, the ear.)   Inflam-
mation of the ear.
  OZJENA. (from «£,,  a stench.)  An ul-
cer situated in  the nose, discharging a fe-
tid,  purulent matter, and sometimes  ac-
companied  with  caries  of  the  bouts.
Some authors have signified, by the term,
an  ill-conditioned ulcer in the antrtim.
The first  meaning  is  the original one.
The disease is described, as coming on
with a trifling tumefaction and redness
about  the ala  nasi, accompanied with *
discharge of mucus, with which the nos-
tril becomes obstructed.  The matter gra-
dually  assumes the appearance of pus,  is
most copious in the morning, and is some-
times attended with sneezing, and a little
bleeding.   The  ulceration  occasionally
extends round the ala nasi to the check,
but, seldom far from the nose, the ala of
which, also, it rarely destroys.  The oz<t-
na  is  often connected with scrophulous
and venereal  complaints.   In the latter
cases,  portions of the ossa spongiosa often
come away. After the complete cure of
all  venereal  complaints, an exfoliating
dead  piece of bone will often keep  up
symptoms, similar to those of the ozxna,
until it  is detached.   Mr. Pearson  re-
marks, that the ozaena frequently occurs
as a symptom of the chachexia syphyloi-
dea.  It may  perforate the septum nasi,
destroy the ossa  spongiosa, and even the
ossa nasi.  Such   mischief is  now  more
frequently the effect of the chachexia sv-
phyloidea, than  of lues venerea.  The
ozaena must not  be confounded with ab-
scesses in the upper jaw bone.  (See An-
trum.)
  The constitutional  disease, on which
the  ozaena generally depends, and which
acts as the remote cause, must be relieved,
before a cure ofthe local effect can be ex-
pected.  The  internal medicines, which
may   be  necessary, are preparations  of
mercury, and  antimony; sarsaparilla, elm
bark,  Peruvian bark,  muriated  barytes,
and muriate of  lime.   Sea-bathing may
also do good, by improving the health.
The best external applications are said to
be, preparations of copper,  zinc, arsenic,
mercury, the  pulvis sternutatorius,  and
diluted sulphuric acid.  (Pearson's Prin-
ciples  of Surgery, Chap. 12;)
-*agg>g«
    PANARIS,  (from wetptt, near, and
     ovff, the nail.)  See Whitlow.
  PANNUS.  (from  ^v*,  to  labour.)
When two, or three pterygia, of different
sizes, occurred on the same eye, with their
points directed towards the centre of the
cornea,  where they met, and covered all
the surface of this transparent membrane
with a dense pedicle, the ancients named
the disease, pannus.   (Scarpa, Chap. 14.)
  PA'PCLA. (dim. of puppa, a nipple.)
A pimple, or ulcerous tubercle.
  PARACENTESIS, (from vttfttMnttt,
to perforate.)  Surgeons, at  present, re-
strict the meaning of this  word to two
operations, viz. tapping the abdomen, and
making an  opening into the chest.   Tlie
first is called paracentesis abdominis, and is 
PARACENTESIS.
257
  often necessary in cases of dr psy.  The
  second is named paracentesis thoracis, and
  is sometimes proper in cases of emphyse-
  ma, empyema, hydrops pectoris, and ex-
  travasations of blood ui the chest.

   TAPPING, On PARACENTESIS ABDOMINIS.

    When the swelling extends equally over
  the whole abdomen, the fluid is usually
  diffused  among all the viscera,  and is
  only circumscribed by  the boundaries  of
  the peritonaeum.  The  water  is occasion-
  ally included in different cysts, which are
  generally formed in one of the ovaries;
  and, in this  case, the  tumour, wiiich is
  produced, is not so uniform, *he fluctua-
  tion is  not so distinct, as  iu Lie former
  instance: at  leas>, this is  the case while
' the disease has  not made very great pro-
  gress.   The  difference, also,  in the con-
  sistence of the fluid, may render the fluc-
  tuation more, or less difficult of detection.
  When  the water is contained in different
  cysts, it is frequently thick and  gelatin-
  ous ; but, when it is uniformly diffused
  all over the  cavity of the peritonaeum, it
  is generally  th nner, and even quite lim-
  pid. Sometimes  a considerable  numb ;r
  of hydatids are found floating in the fluid,
  disch irged in cases of ascites.
    Whatever  may be the efficacy of digi-
  talis, mercury, diuretics, and other eva-
  cuants, in ascites, they are rarely of any
  service  in cases of local and encysted
  dropsies.  When such swellings continue
  to enlarge, notwithstanding the adoption
  ofa few measures, which will presently be
  suggested, the sooner the  fluid is evacu-
  ated, the better.  It is also well known,
  that all efforts to produce  a radical cure
  even of dropsies, which are not encysted,
  too frequently fail.  I am decidedly of opi-
  nion, however,  with Dr. Fothergill, that
  physicians would meet with much more
  success,  in the treatment of ascites,  if
  they would recommend  paracentesis to be
  djiK* sooner, than they generally do. This
  opera ion is,  for the most part, much too
  long delayed; and during a long space,
  the bowels are continually suffering,  more
  and more, from the effect  of the  large
  quaitity of fluid, which oppresses them.
  What ought to render the practice of early
  tapping more entitled to approbation, is,
  that the operation, when done in the situ-
  ation, we  shall presently advise,  is per-
  fectly free from danger,  attended with
  very little pain, and need  not interrupt
  the further trial of such medicines, as the
. physician may place confidence in.   Para-
 centesis only becomes a serious measure,
 when the disease  has existed for a great
 length  of time,  and the patient has been
 much  weakened  by it.  Indeed,  there
     Vol. U.
 seems much reason to suspect, that the
 operation  should  be done, as soon as the
 tension of the abdomen, and the fluctua-
 tion, leave no doubt, concerning the na-
 ture of the malady; especially, when the
 first trials, which  have been made of in-
 ternal remedies, seem to promise no suc-
 cess  Dr. Fothergill  has demonstrated
 by facts, the advantages of this method.
 On the commencement of an ascites, this
 celebrated practitioner advised the trial
 of  diuretics  and  other evacuants.  He
 then adds, that, " if by a reasonable per-
 severance  in this course, no considerable
 benefit accrues; if the viscera do not evi-
 dently appear to be obstructed,  and unfit
 fyr the purposes of life; if the complaints
 have not  been brought on by a long habi-
 tual train of intemperance, and from which
 there seems little hope of reclaiming the
 patient ;  if the  strength and time of life
 are  not altogether against us;  I desist
 from medicine, except of the cordial kind;
 and let  the disease proceed,  till the ope-
 ration  becomes safely practicable.  When
 this is done, by the moderate use of the
 warmer diuretics, chalybeates and bitters,
 also the  preparations of squills, in doses
 beow  that point, at which the stomach
 would be affected, I endeavour to prevent
 the  abdomen from filling again."  (Med.
 Obs. and  Inq. Vol. 4, p. 112.)  The same
 author remarks, with regard to encysted
 dropsies, that tapping some imes effects a
 radical cure.
   Whenever a considerable  quantity  of
 fluid is suddenly let out of the abdomen
 by tapping, the quick removal of the pres-
 sure of the water off the large blood-ves-
 sels, and viscera, may produce swooning,
 convulsions,  and  even  sudden  death.
 These  consequences led the ancients to
 consider paracentesis, as a very dangerous
 operation,  and,  when  they ventured to
 perform  it, they only let out the water
 gradually, and at intervals.
   Dr. Mead, after considering what might
 occasion the bad symp'oms resulting from
too sudden an evacuation of a large quan-
 tity of  fluid from the abdomen, was led to
try what effect external pressure  would
have in  preventing  such consequences.
This practitioner thought, that,  in  this
way, he  might keep up the same degree
of pressure, which the fluid made on the
viscera.  The success,  attending some
 trials of this plan,  fully justified the  opi-
nion Dr. Mead had conceived; for, when"
the c impression  is carefully  made, the
whole of the water, contained in  the ab-
domen of  a dropsical  patient,  may  be
safely discharged, as quickly as  the  sur-
geon chooses.   For tliis purpose,  how-
ever, the whole abdomen must be equally
compressed,  the pressure increased in 
258                           PARACENTESIS.
 proportion as  the  evacuation takes place,
 and kept up, in the same degree, for seve-
 ral  days  aft' rwards.   In St. Bartholo-
 mew's Hospital, while the water is flowing
 out, the ntceshary degree of pressure is
 usually made  with a sneet, which is  put
 round the abdomen. Two  assistants, who
 hold the ends of the sheet,  gradually
 tighten it,  in  proportion, as the  fluid is
 discharged.  Immediately, after the ope-
 ration,  some  folded  flannel,  sprinkled
 with spirit of wine, is laid  over the whole
 anterior part  of the  belly, and covered
 with a broad linen roller, applied  with
 due tightness round the body. Dr. Monro
 invented a particular  kind of  belt, for
 the purpose ;  but, though  it may be well
 adapted to the object in view,  it is, per-
 haps,  unnecessary, as  the  above  method
 seems to answer every end.
   The  instrument  used  for tapping  the
 abdomen, is called a trocar.  (See  Tro-
 car.)
   The  most convenient  position  for  the
 operation,  is certainly when the patient
 is  sitting  in  an   arm-chair.   However,
 Weakness and other circumstances,  fre-
 quently make  it necessary to  operate on
 the patient, as he lies in bed.
   Until of late, the place,  in which sur-
 geons used to puncture the abdomen, in
 cases of ascites, was the centre of a  line,
 drawn from the navel to the anterior su-
 periour spinous process of the ilium, and,
 on the left side, which was preferred, in
 consequence of the liver  not being there.
 The place, for the puncture, was usually
 marked with ink, and was supposed to be
 always  situated just over  a part  of the
 linea semilunaris,  where there is ho fleshy
 substance, nor any large blood-vessel,  ex-
 posed  to injury.  This calculation, how-
 ever, was made, without considering, that
 jn dropsy,  the parietes of the abdomen
 do not yield  equally in  every situation.
 On the contrary,   it is known, that  the
 front part is always more distended, than
 the lateral ones, and, that the recti mus-
 cles,  in particular, are sometimes very
 much widened.  In consequence of these
 alterations,  induced by  the  disease, no
 dependence can be put on any measure-
 ment, made with  a view of ascertaining
 the precise situation of the linea semilu-
naris.  The surgeon,  who  trusts to  his
 being able to introduce the  trocar exactly
 in this place, from any calculation  of the
 above kind, will frequently wound a great
 thickness of muscle, instead  of  a part,
where  the  abdominal parietes are thin-
 nest.  But, a still stronger  objection is to
 be urg*ed against the practice of attempt-
 ing to tap in the linea semilunaris.   Men,
 well acquainted with anatomy, have fre-
 quently been deceived in their reckoning,
and, instead of hitting the intended  line
with their trocars, they have introduced
these instruments through the rectus mus.
cle, and wounded the epigastric artery.
Patients have died from this error, with
large extravasations of blood  in  the ca-
vity of the peritonaeum.  In  a dropsical
person, who has been tapped, it is 10 be
observed also, that, an effusion of blood in
the abdomen will of course more readily
take place, in consequence of the parts
not being in the  same close,  compact
state,  in  which  they are in the healthy
condition.
   Let every prudent practitioner,  there.
fore, henceforth abandon  the  plan  of
tapping in tiie  linea semilunaris, and, he
may the more easily make up his mind to
do so, as there is another place, where the
operation may be done with the utmost
facility  and safety.  The  linea alba is
now commonly preferred by the best sur-
geons ;  because,  here no muscular fibres
need be wounded, the place can be hit
with certainty, and no  large blood-vessel
can be injured. -About the middle point,
between the navel  and pubes,  is as good
a situation  for making the puncture, as
can possibly be  chosen.   The  surgeon
should introduce the  trocar in a steady,
firm manner, never in an incautious, sud-
den way, lest parts contained  in the pe-
ritonaeum  should  be  rashly  wounded.
For the  same reason,  immediately  the
point of the trocar has entered the abdo-
men, a  thing always known at once, by
the sudden cessation of resistance to its
passing inward, it  should  be introduced
no further, and its office of  making a pas-
sage for the cannula  is  already accom-
plished.  The surgeon,  consequently, is
now to take hold  of the cannula with the
thumb and index finger of his left hand,
and gently  insinuate  it  further  into  the
cavity ofthe peritonaeum, while,  with his
right hand, he is to withdraw the stilette.
The fluid now gushes out, and regularly
as it escapes, the sheet, which is round
the patient's body, is to be tightened.  All
the water having  been evacuated, a piece
of flannel  and a roller  are to be imme-
diately applied, as above explained, after
putting a piece of lint and soap-plastej;
on. the wound.
  It is not  uncommon for the water sud-
denly to stop,  long before the full quant
titv is discharged.  Sometimes, this hap-
pens frc <m apiece of intestine, or omentum,
obstructing the  cannula.  This  kind of
stoppage may be removed by just intro-
ducing a probe or director, and  holding
the portion of viscus  back.  When  the
water is very viscid, the only thing we can
do is to introduce a larger trocar, if do-
ing so should  promise  to  facilitate  the 
PARACENTESIS.
.259
 evacuation.   Also, when  hydatids  ob-
 struct  the  cannula, a  larger  instrument
 might allow them to escape.  In encysted
 dropsies, the practitioner, of course, can
 only let the fluid out of such cavities, as
 he can safely puncture.
   When a  dropsy of the ovary is very
 large, it also admits of being tapped in
 the iinea alba;  but,  in this particular
 case, it is  generally best to make the
 puncture where the swelling is most pro-
 minent.  In  this  disease,  the ovary  is,
 either  converted  into  one large cavity,
 filled with fluid, or else it contains several
 distinct cells.  The  contents are some-
 times exceedingly viscid.  In  early stages
 of* the case, the tumour is situated towards
 one side of the abdomen,  and seems to
 ascend out of the pelvis.  This kind of
 progress at once distinguishes the disease
 from a  common ascites, which is  attend-
 ed, from the first, with an equal,  gradual,
 universal swelling of the abdomen.  The
 cyst of the ovary, when it has attained a
 large size, generally adheres,  in different
 places,  to the inner surface of the peri-
 tonaeum, and, in this state, the whole ab-
 domen  often seems uniformly swollen, in
 consequence of the immense magnitude of
 the  disease.   The impairment  of the
 health, arising  from the pressure of the
 viscera, and  interruption of their  func-
 tions, and the great difficulty of breath-
 ing, produced by  the pressure  on the dia-
 phragm, make it necessary to let out the
 fluid, and paracentesis  must be done, in
 the way already related. The disease is of-
 ten attended with an almost total stoppage
 ofthe secretion of urine.  Sometimes, the
 urine is duly secreted, but a retention oc-
 curs, so that the use of the catheter be-
 comes indispensable.  Tapping, however,
 can.only be regarded as  a palliative mea-
 sure ; the water collects again, the same
  frievances recur,  and the operation must
  e repeated.  While an ovarial dropsy is
 recent,  and even after it has been tapped,
'some attempts may be made to effect a ra-
 dical cure.  Blistering the surfaced' the
 abdomen, keeping up  a discharge with
 the savine cerate, and  applying a  tight
 roller,  have been  known  to  do  good.
 in France,   the  celebrated  Le   Dran
 laid open the cysts of  ovarial dropsies.
 His patients did not die of the consequent
 inflammation, and the dropsy, indeed, was
 cured ;   but, there remained either a sar-
 comatous enlargement ofthe ovary, which
 continued to increase till death, or else in-
 curable fistulae, leading into the cyst,  were
 the consequences.  The  large size  of a
 wound,   necessary for this  purpose, the
 danger pf inducing inflammation in so ex-
 tensive  • surface,  as the  cyst  of a large
 ovarial  dropsy, and  the events  of Le
 Dran's case9,  are circumstances,  on the
 whole, quite enough  to keep the practice
 from ever being revived.
   A still more absurd plan has been  at-
 tempted, viz. to cure the disease,  by  in-
 jections, just as hydroceles.  I have seen
 two cases, in  which red wine  and  water
 have been injected : one patient died very
 soon afterwards of  the inflammation, and
 the  other"perished  more lingeringly from
 the  same cause.  Setons have been tried,
 without success.
   Sometimes,  though very seldom, the
 operation of paracentesis is necessary  for-
 giving vent to collections of air in the ab-
 domen.  Air, when confined in this man-
 ner, is generally contained in the bowels,
 which it inflates to  an enormous size.   In-
 stances, however, are related of quantities
 of air being confined between the perito-
 naeum and  intestines; but, in some  of
 these  cases, it is said, that the  air was
 known to have escaped through a small
 hole in some  part of the  intestinal  canal.
 and,  it is probable, that all the other ex-
 amples were ofthe  same kind.  This dis-
 ease  is named tympanites,  and may render
 making an opening into the abdomen ne-
 cessary.  Notwithstanding authors  gene-,
 rally recommend a small  trocar for the
 purpose, there cun  be no  doubt, that  di-
 viding the skin, and making a cautious
 puncture with a lancet through the linea
 alba, and peritonaeum,  would be a prefer-
 able mode of proceeding.   The abdomen
 must  also be  compressed with a sheet,
 while the air is escaping, and, afterwards^
 with a roller, just as  if the case were  an
 ascites.  Even when  the air is  contained
 in the bowels, if it should be enormous in
 quantity, occasion urgent  symptoms, and
 cannot  be  got rid  of in other  ways,
 authors recommend paracentesis.

      PARACENTESIS OF THE THORAX.

   The necessity for this operation is indi-
 cated, when the heart, or  lungs, are op-
 pressed  by any kiud of fluid confined  in
 the  cavity  of the  chest.  Every  body
 knows,  that the free  and uninterrupted
 performance,of the functions of these or-
 gans  is essential to the support of life.
 When the action of these viscera is dis-
 turbed by the lodgment of a collection  of
 any kind of fluid in the thorax* no internal
 medicines can be much depended upon for
 procuring relief.  The only means,  from
 which benefit  can be rationally  expected,
 is letting out  the  fluid, by making  an
 opening in the parietes ofthe chest.
  The nature  of the effused  fluid can
 make no difference,  in.regard to the pro-
priety of discharging  it in this manner;
and, though some authors have only treat* 
iCQ                 PAR                         PAR
ed of this operation, as applicable to cases
of hydrops  pectoris, and  empyema,  it
may also be of the greatest service when
air is confined  in the chest, (see Emphy-
sema,)  or blood extravasated  thtie (see
Thorax, Wounds of) so  as  to  make dan-
gerous  pressure on  the lungs and  dia«
phragm.
  In this place, I shall content mf self with
describing the best method of performing
paracentesis thoracis, referring the reader
to the articles just mentioned for inform-
ation,  concerning  the particular  symp-
toms and circumstances, which may ren-
der the operation proper, and the rest of
the surgical treatment  peculiar to each
affection.
  The safest, and most  convenient situa-
tion, for making an opening into the chest,
is between the  sixth and  seventh true
ribs, on either side, as circumstances may
render necessary.   The surgeon should
only recollect,  that the two  cavities of
the pleura are completely  distinct from
each other, and have no communication
whatsoever, so  that,  if fluid were contain-
ed on the left side of the thorax, making
an  opening into the right cavity  would
not serve for discharging die accumulated
matter.   The practitioner should also  re-
member, that,  when there is  a fluid on
both sides of the chest, paracentesis must
never be done for the relief of the  two
collections at  the same time;  because,
there is great reason to believe, that,  as
the lungs on  one  side  usually collapse,
when there  is  a free commun cation  be-
tween the  air  and inside  of the thorax,
they would  do so on both sides, we;\- an
opening made at the same time into each
bag of the pleura   It is hardly ni cessary
to remark, tnat, in this condition, the  pa-
tient could not breathe, and  would  cie
stiff >cied.  The operation consists,  in
making an incisi >n, about two inches long,
through the integuments, which cover  the
space between the sixth  unci seventh true
libs, just where the indigit.tions of  the
serratus  major anticus muscle  is ee1 those
ofthe externus obliquus.   Here it is  un-
necessary to  divide  any muscular  fibres,
except those of the intercostal muscles,
and, by  putting the patient in a proper
posture, the  opening that is to be made,
will be  depending  enough for any pur-
pose whatsoever.  The surgeon, avoiding
the lower edge of the upper rib, where the
intercostal artery lies, is then  cautiously
to  divide the  layers of the  intercostal
muscles,  till he brings the pleura into
view;  when the membrane is  to be very
carefully divided with a lancet. The in-
strument should never be introduced in
the least deeply, lest the lungs should  be
injured.  The size of the opening  in  the
pleura should never be larger than neces-
sary.  The discharge of blood and mailer
will of*  course  require a freer aperture
than that of air, or water.   If requisite,
a cannula  may be introduced  into  the
wound, tor the purpose of facilitating the
evacuation of the  ffuid, and it may even
in some cases, be proper to let this instru-
ment remain in the pari, in order  to let
the water, or  pus escape, as often as an-
other accumulation takes place.   It is ob-
vious, however, that a cannula,  for  this
object, should only be just long enough to
enter the cavity of the pleura, and should
have a broad rim to keep it from  slipping
into the chest.  A piece of sticking plaster
would easily fix the cannula, which might
be  stopped, up with a cork, or any other
convenient thing, or left open,  according,
as the circumstances of the case,  and  the
judgment ofthe surgeon, should direct
  The paracentesis of the abdomen,  and
that of  the thorax, are described  in all
treatises on the operations, and  systems
of  surgery.  The  works of Sharp,  Le
Dran, Bartrandi, and  Sabatier, are par-
ticularly deserving of attention.
  PARA'LYSIS. (from 5r«f«Atw,to weak-
en.)  A  palsy.   It is a symptom of several
surgical  disorders;  as,  for instance, of
pressure on the brain, from blood, matter,
or  a depressed portion of  bone; of in-
juries of the vertebrae and spinal marrow :
of disease of these latter bones, &c. (See
Head, Injuries of; Dislocations; Fructures;
and Vertebrte,  Disease of.)
  PARAPHIMOSIS,   or   PARAPHI-
MOSIS,  (from zraipot, back, and tpi/toa, to
bridle.)  This signifies the case  in which
the prepuce is  drawn quite behind  the
glans penis and  cannot be  brought  for-
ward again.   S -e Phymosis, with which
it will be considered.
  PARONYCHIA,  (from  zj-«£«,  near,
and »vt/|. the nail.)  An  abscess at  the
end ofthe finger, near the nail. See  Whit-
low.
  PAROTID  DUCT.   Every  one   ac-
quainted with anatomy,  is  aware, that,
behind the jaw, on each side, there is si-
tuated a large conglomerate'gland,  being
the principal one of such as are destined
to secrete the  saliva, with which the ca-
vity ofthe mouth, and the food, which we
swallow, are continually moistened.  The
parotid duct crosses the cheek,  being si-
tuated about one-third from the zygoma,
and two-thirds from the basis of tiie jaw.
After passing  over the masseter muscle,
it pierces the buccinator, and terminates
in  the mouth by a considerable orifice,
opposite the space, between the second
and third bicuspd, grinders of the upper
jaw.  As. soon as it has passed the mas- 
PAROTID DUCT.                            261
seter, it  dives deeply into  the fat of the
cheek, and, as M. Louis observes, makes
an angle before it opens into the mouth.
(Mem. de V Acad, de Cliir. torn. 3. p 457.)
  From the situation of the parotid duct,
it is liable to be wounded, and th.s has
even been done, by the surgeon's h.ncet,
through ignorance.  (See Monro's Works,
p. 520.)  In cases  of this kind, the con-
tinual escape of the  saliva  is apt to keep
the wound  from healing,  and,  what is
called a salivary fistula would be the per-
petual consequence, ii no steps were taken
to afford relief   The parotid duct has
sometimes  been  ruptured by  blows.—
((Euvres Chir de Desault, torn. 2, p. 221)
Cases also occur,  in  which the face be-
comes considerably  swollen,  in  conse-
quence,  of the saliva insinuating  itself
into the  cellular substance, just  as the
air  does  in emphysema.  On the  last cir-
cumstance, I shall only just mention, that
mischief ot this kind must  always be pre-
vented from becoming very extensive, by
making  a depending  opening  lor the
ready escape of the fluid.
  With regard to the treatment of saliva-
ry fisiulae, if the division of tlie parotid
duct  is recent,  the sides of* the  wound
should be  brought  into contact, and  a
steady pressure  maintained on that part
of tlie cheek,  by means of suitable  com-
presses,  and a  roller.  In this  manner,
a salivary fistula may often be  prevented
altogether: either the divided  ends  of
the duct reunite, and the spittle resumes
its  original curse  into tiie  mouth; or,
what is more probable,  the'wound in the
face heals at every par^ with the excep-
tion of a small fistulous  track, which
serves as a continuation of" the duct into
the inside of the mouth.  The latter kind
of  cure, however, can only take  place
when the wound extends  quite through
the cheek; but, tiie chance  of the two por-
tions of the duct  uniting, and becoming
continuous again, should always be taken
in recent cases.
  When a  salivary  fistula  is actually
formed,  a seton, introduced from the ex-
ternal fistulous orifice  into  the  mouth, is
a method which seems to have,  with jus-
tice,  the greatest share of appr6bation.
The celebrated Monro adopted this plan
with success : he kept in the seton till the
channel, which it had formed, had be-
come fistulous,  after which it  was with-
drawn, the external orifice being touched
with  the argentum nitratum, healed up,
ar.d the  saliva  in future flowed through
the  artificial fistulous  channel into the
mouth.
  Desault  used to  practise the seton as
follows :—He  introduced two  fingers  of
his  left  hand  into  the patient's  mouth,
and placing them between the teeth and
the cheek, opposite the fistula, thus kept
the  integuments tense, and  the  gums
from being injured.  He then introduced*
a small hydrocele  trocar,  with  its can-
nula, just before the opening of the pos-
terior part ofthe duct, and pushed through
the cheek, in a direction a little inci.ned
forward   An  assistant now took hold of
the cannula, while Desault withdrew  the
perforator,  and passed  through the tube
a bit of thread, into  the  cavity of  the
mouth.  The cannula was next taken out,
and a seton, which was then  fastened to
the end of the thread  in the mouth, was
drawn  from within  outward; but not so
far as to come between the edges of  the
external opening, where the thread  alme
lodged, and this was fastened  wall stick-
ing-plaster  to  the  outside  of  the cheek.
The outer  wound was dressed with  Unt
and compresses.  Desault used to change
the  seton  daily^  introducing regularly
rather  a larger one, and taking especial
care not to bring it between the edges of
the wound,  which was afterwards  cover-
ed  with sticking-plaster.  He enjoined
the puiient not to move the jaw much, and
only allowed him, for  some time, liquid
food.   In  about six weeks he  used to
leave off the seton,  leaving in the thread,
however, for a little while longer.  This
being  ti:ken away, he  used to finish  the
cure, by touching  the  little aperture re-
maining, with caustic.
  The making of an art ificial passage is
one of the most ancient plans of curing
salivary fistulae.  Every author  has had
his particular  method of  doing  it, and
numerous variations are to be met with,
either  in the  instrument  employed  for
piercing the cheek, or in  the substance
intended for  maintaining  the  opening.
For the first  step of the  operation, sur,
geons sometimes used  the actual cautery,
as  Saviard furnishes us an instance  of;
sometimes an awl, as Monro did; some-
times a common knife, or lancet; some-
times a straight needle, which  drew in
the thread after it; but, Desault's trocar
generally merits the preference, because
the cannula, by  remaining  in the  wound,
after the perforator is  withdrawn,, allows
the thread  to  be  introduced,  which in
every oilier way, is either difficult to ac-
complish, or requires  the  Use of several
instruments.
  For  the second  step of the operation,
viz. keeping the opening distended,  can-
nula were  employed by Duphenix, who
used to make a suture over them ;  a plan
objectionable,  inasmuch as it was attend,
ed with the  inconvenience of a solid body
left in  the parts, and also that of the in-
strument being apt to slip into the mouth. 
962
PEN
PEN
The seton, therefore, ought to be prefer-
red, and  there can be no doubt that De-
sault's method is better, than the one fol-
lowed by  Monro.  See  on this  subject,
Monro's Works;  Qluvres Chir. de Desault,
par Bichat, torn. 2, p. 221   Also, Mem. de
VAcad. de Chir. torn- 3.
  PARU'LIS. (from  vcc^tc  near,  and
s\01, the gum.)  An inflammation,  boil,
or abscess in the  gums.
  PEDUAJ'VHJM.  (from  pes, the  foot,
and lavo, to wash.)  A bath for the feet.
   PE'NIS,  AMPUTATION  OF.   No
part of the penis  should ever be amputat-
ed, on account of a mortification,'because
the dead portion will be naturally thrown
off', and the  ulcer heal, without the least
occasion for putting the patient to any
pain from the employment of the  knife.
Some cancerous,  and fungus diseases, are
the cases, in  which it is often really pro-
per  and necessary  to amputate more  or
less of this part of the body.
  The old surgeons,  fearful of hemor-
rhage, used sometimes to extirpate apart
of the penis, by tying  ligatures round it
with  sufficient tightness to make it mor-
tify  and  slough  off  Thus,  Ruysch re-
moved the penis  in one instance (See Ob-
serv 30.)   The plan, however, is exceed-
ingly painful, and quite unnecessary, not-
withstanding what Heister  states in its fa-
vour.
  The  amputation may be done in the
following manner:—A  circular  incision
is to be made through the skin, about a
finger-breadth from, the c.ncerous  part.
The  integuments are  then to be drawn
back, so  as  to expose the corpora caver-
nosa, which  are  to be divided  with one
stroke of the knife, on a  level with the
cut edge  of the  skin, in such  a  manner,
that the cxtrem.ty both of the  skin and
corpora cavernosa,  is to form one wound,
or  surface.  The bleeding arteries,  are
now to be immediately  tied :  the  chief
are, one on the dorsum of  the penis, and
one in each corpus cavernosum.  When a
general oozing from the wound still con-
tinues, some recommend (White, Hey,&c.)
applying  sponge  to its surface; others
(Lattu) finery scraped agaric, with a small
proportion of pounded white  sugar,  or
gum  arable  Perhaps,  however,  finely
scraped lint, supported with compresses,
would be quite as effcc'ual as any  styp-
tics, and,  certainly, the latter applications
should  be avoided, if possible,  because
stimulating,  and productive  of p*in and
inflammation.   A  surer  and preferable
method of stopping the oozing of blood,
and  at  the  same time  of  healing the
wound, might be to bring the skin for-
ward, over the  end of the stump, with
two strips of sticking-plaster,  after intro-
ducing a flexible gum  catheter into the
continuation of the urethra, so as to keep
its  orifice  unobstructed,  and the urins
from coming into contact with the wound,
whenever the evacuation is made.  There
can be little doubt, that the gum catheter
would be  better than a  silver one,  or any
metallic cannula, commonly advised for
the above purposes, because it lies in the
passage with less irritation.  In one case,
in which Mr. Hey  operated, he made a
longitudinal division of the integuments,
at the inferior part of the penis, so as to
make them cover its extremity, Without
puckering, or  laying over the orifice of
the  urethra.   The  corpora cavernosa,,
however, do not readily granulate  and
unite to the skin  by the first intention.
(Hey, p. 452 )  After the first dressings
are removed, the part  should be dressed
with the unguentum spermatis-ceti, or any
mild unirritating salve.
  In consequence of the introduction ofa
cannula being  neglected, Le  Dran men-
tions his having seen the orifice of the
urethra become closed a few hours after
the operation,  so that the patient could
not make water.  The orifice of* the  pas-
sage  could  not be  discovered without
great difficulty.  A  lancet being intro-
duced at  the  point, against Which the
urine seemed to be forced, a  quantity of
it gushed out,  and,  as  a cannula was not
at hand, a sound was introduced, till one
could be procured.   (Traite  des Oper. de
Chirurgie.)
  Pearson, in his Practical Observations on
Cancerous  Complaints, has treated of this
operation:  he particularly  advises  the
skin not to be drawn back, because, when
saved in this manner, it impedes the free
exit of the  urine.    He  likewise disap-
proves of  introducing  cannulae, as crea-
tive of pain, and  spasms of the urethra,
and being moreover unnecessary, since
the stream Of urine  will always preserve
the urethra in a permeable state. (P. 103.)
   Sharp, Le Dran,  Betrandi, and Saba-
tier's books on the operations, may be consult'
ed. Also, V Ency elope die  Methodique ;  Par-
tie  Chir. Art. Verge.   Hey's Practical Ob-
servations in  Surgery, p. 445.   Pearson on
 Cancerous  Complaints, p. 103, &c.  War-
ner's Cases in Surgery, p. 278, Edit. 4.
  PENIS,  CANCER  OF.  'A  wart, or
a tubercle, on the  prepuce,  the fraenitm,
or  the glans penis,  is  generally the first
symptom,  Mid it often  remains in a quiet
state for   many years.  When irritated,
however, it becomes painful, and enlarges,
sometimes enormously, in a very short
time.  At  the same time, ulceration, and
a discharge of sanious fetid matter,  take
place.  The  disease sometimes also oc- 
PES
PHA
263
 easions in the urethra fistulous openings,
 out of which the urine escapes, and the
 lymphatic glands  in the groin may be-
 come  affected  as the  disease advances.
 Mr. Pearson says, that  " cancerous  ex-
 crescences have a broad base, often more
 extensive, than  their superficies;  they
 seem to germinate deeply from within, or
 rather to be a continuation "of the sub-
 stance of the part; and,  in their pro-
 gressive state, the contiguous surface has
 a morbid appearance."   What Mr.  P.
 considers as a venereal wart, has a basis
 smaller than its  surface; its roots have
 rather a  superficial attachment,  and the
 contiguous parts have a natural appear-
 ance, p.   97.  Such are  this gentleman's
 marks of  discrimination.    We  might
 question, however, whether Mr. Pearson,
 notwithstanding his great  opportunities,
 ever saw a real venereal wart.  For many
, years past I have never seen any excre-
 scences  of  this  kind,  in  St. Bartholo-
 mew's  hospital,  which truly  required
 mercury  for their cure, or  which, when
 cured without it, were followed by any
 inconvenience.  If my memory does  not
 fail me, Mr. Abernethy also  disbelieves in
 the doctrine of venereal warts.
   Foul, spreading, sloughy ulcers of the
 penis, should be discriminated from can-
 cer.  It is worthy of attention, that almost
 all the cases of cancer of  the penis re-
 corded by Mr Hey, were attended wi'h
 a  congenital phymosis.   (See Pearson on
 Cancerous Complaints, and Hey's Practical
 Observations in Surgery.)
   PERlNiE'UM,  FISTULA  OF.   See
 Fistula in Perinxo.
   PERITONITIS.   An   inflammation
 of the peritonaeum.  Surgeons have chief-
 ly to combat this dangerous affection, in
 cases of hernia, lithotomy, wounds of the
 abdomen, fractures of the pelvis, &c. but
 as the necessary  treatment is detailed in
 the particular articles of this dictionary,
 we need   not here enlarge  upon the sub-
ject
   PE'RNIO. (from ■srt^ot. or ttt^vx, tlie
 heel.)  A chilblain, especially one on the
 heel.   See C/ulblain.
   PESSARY, (from zrte-ru, to soften.)
The intention of pessaries, among the old
practitioners, was to hold such medicinal
substances,  as they wished to apply with-
in the pudenda.   Est autum pessulus (says
Paulus) lana pectita,  et quodcunque aliud
teres digiti hurnani speciem prxferens in quo
medicartlenta sustinentur. The ancients not
only used wool for making pessaries, they
employed also silk, lint, and linen, rolled
up, and   tied  round with  a thread, by
means  of which  these substances were
withdrawn.   Instead of these  materials,
gums,  resins, and wax, were afterwards
 employed, 'and,   being softened,  were
 moulded into the most convenient shape.
   Pessaries are now never made use  of
 except for  preventing a prolapsus of the
 uterus,  or  vagina,  or  for keeping up a
 very uncommon kind of rupture, explain-
 ed in  the article  Hernia.  The moderns
 also make their pessaries of much firmer
 materials, than those employed by their
 predecessors.  Metals,  wood,  box-wood,
 sponge,  elastic gum, and  cork, covered
 with a layer of wax, have  been used  by
 different practitioners.
   Linen  pessaries,  covered  with  wax,
 are, perhaps, as  unobjectionable as any.
 Being softer, than metallic one.', they are
 not so likely to injure the parts, on which
 they press.  They are not liable to rust, nor
 can they, like ivory ones,  lose their pro-
 per shape.  When properlv covered with
 wax, they do not absorb, like those made
 of sponge,  nor can they occasion any in-
 convenience by remaining  long applied.
 For a particular  detail of the  manner of
 making  them,  see Journal de Medecine,
 Tom. 34.         •
   Dr.  Denman's  pessaries are globular,
 formed  of  sound,  well-seasoned,  box-
 wood, perfectly  spherical without, and
 excavated wiihin,  by which they acquire
 great  lightness.   They  have four  small
 holes,  which, admitting the air, diminish
 the chance of their cracking. Dr. Clarke's
 pessary  is an oval flat one, made of box-
 wood, about a quarter of an  inch thick,
 at its external surface, but  thinner to-
 wards its centre,  where there is a  small
 hole.  (See  Savigny's Engravings of In-
 struments.)
   PETE'CHIA. (from petechio, a flea-bite.
 Ital.)  A spot on the skin, which does not
 raise the surface, and which resembles a
 flea-bite.
   PHAGEDENA, (from <pxyu, to eat.)
 An ulcer, which spreads, and as it were
 eats away the flesh.  Hence, the epithet,
phagedemc,  so common among surgeons.
   PHALANGO'SIS. (&pm p«A«yf, a row
 of soldiers.) A disease, in which there
 are two  rows of hairs on the eyelids, or
 in which the eye-lashes turn inward.   See
 Trichiasis.
   PHARYNGOTOMY.   (from <pa%vy%
the pharynx, and rt^tt, to cut.) See  (En-
phagotomy.
   PHARINGO'TOMUS. (from <px£vy%,
the throat,  and rofMt, an incision.)  An
instrument  for  scarifying  the  tonsils,
 when inflamed, or for opening abscesses
 about the fauces.  It was invented by M.
 Petit,  and is nothing more, than a sort  of
 lancet, which \- inclosed in a theath.  Bv
 means of a  sprim- the point is  capable  of
 darting out  to a determinate extent,  so as 
264             PHY

to make  the  necessary wound, without
risk of injuring other parts.
  PHLEBOI OMY.  (from ^Aed^. a vein,
and  TtfMtt, to  cut.)  The operation of
opening a vein, for the purpose of taking
away blood. (See Bleeding.)
  PHLF/GMON, PHLEGMONE.  (from
$\tyo>, to burn.)  Healthy inflammation.
(See Inflammation.)
  PHLOGOSIS.  (from  QXoyoo,  to  in-
flame.)   An inflammation   A flushing.
  PHLYCT.ENA..  (from <p\vfy,  to  be
hoi.)  A small vesicle, containing a limpid
fluid.
  PHRENITIS.   (from tyem, the dia-
phragm, supposed by  the ancients to  be
the seat of the mind.)  An inflammation
of the brain.   Phrenzy.
  Inflammation of the brain is a frequent
consequence  of  injuries  of the  head.
There  is  an  increased and disordered
state of the sensibility of  the whole ner-
vous system ; the retina cannot bear the
usual  stimulus of light;, the pupils are
contracted; the  pulse is  frequent and
small; the eyes  are red and turgid, per-
haps in consequence of the ophthalmic
artery arising  from  the internal carotid;
the countenance is  flushed, and the pa-
tient  is  restless,  mutters incoherently,
and grows wild and delirious.
  Phrenitis is  treated on the antiphlogis-
tic plan.  Copious  bleedings,  and  other
evacuations, are  highly proper.    (The
blood should be taken from the temporal
arteries.   The   skin ought to  be   kept
moist  with antimonials, and  a counter-
irritation should be excited On the  scalp
by blisters.
  PHY'MA. (from Qua, to grow.)  A tu-
mour.)  According to Pott, this term was
formerly applied to  an inflammation near
the anus.  (See Anus, Abscesses of.)
  PHYMO'SIS,  or  rather  PHIMOSIS.
(from tptfMct, to bind  up.)  A disease of
the pei.is, in  which the prepuce cannot
be  drawn back, so  as to uncover the
glans.   Boih  the  phymosis,  and  para-
phymosis, according to Mr. Hunter, arise
from  a thickening of the  cellular  mem-
brane of the prepuce,  in consequence of
an irritation, capable  of producing con-
siderable  and  diffused inflammation.  A
chancre is the  most frequent cause;  but a
mere  inflammation  and discharge  from
the glans and prepuce, and  also  a go-
norrhoea, may  bring on tense  affections.
The  inflammation often runs  high, and
is frequently of  the  erisypelatous  kind.
Tht cellular membrane being  loose, the
tumefaction becomes  considerable, and
the end of the prepuce being a depending
part,  the  serum often  lodges  in it, and
                PHY

makes it  cedematous.   A natural con-
traction of die aperture of the prepuce is
very common,  and persons  so affected,
have  a natural  and constant phymosis/
Such a state of parts (says  Mr. Hunter)'
is often  attended  with chancres,  and it
produces  very  great inconveniences du-
ring the treatment. When there is consi.
derable diffused inflammation, a diseased
phymosis,  similar  to  the  natural one,
unavoidably follows;   and whether dis-
eased or natural, it may produce the pa-
raphymosis, s.mply by the prepuce being
brought back up m the  penis.  This tight
pa-t, then acting as a ligature round the
body  of  the,penis, behind the glans, re-
tards the circulation beyond the constric-
tion, so as to produce an cedematous in-
flammation on  the inverted  part of  the
prepuce.
  The natural phymosis is  so consider-
able,  in  some  children, that the urine
cannot pass with ease;  but,  the aperture
of the  prepuce  generally becomes larger
and larger as they grow older, and the
bad  consequences, which the phymosis
might have occasioned  in  disease,  are
thus avoided.
  In some persons,  especially old men,
the* prepuce sometimes contracts without
any visible cause whatever,  and becomes
so narrow as to hinder the  water from
getting out, even  after it has  got free of
the urethra,«nd, consequently, the whole
cavity of the prepuce becomes filled with
urine, attended with great pain.
  In the   phymosis,  when the  prepuce
swells  and thickens, more and  more of
the skin of the  penis is drawn forwards
over the  glans, and the latter  part be*
pomes  at the same' time pushed backward
by the swelling against its end.  Mr. Hun-
ter says,  he has seen the prepuce project-
ing, from such  a cause, more than three
inches  beyond the glans, and its aperture
much diminished.
  Mr. Hunter also notices, that the pre-
puce often becomes, in  some degree, in-
verted, by the  inner skin yielding more,
than the outer, and the part seems to have
a kind of neck, where the outer skin na-
turally terminates.   From the tightness
and distention of the parts,  the prepuce
now cannot be drawn more back, so as to
expose any sores,  which may be situated
under  it.  This state  is frequently pro-
ductive of bad consequences, especially,
when there are chancres behind the glans j
for, the glans being between the orifice
of the prepuce and the sores,  the matter
sometimes cannot get a passage forward,
between  the glans and prepuce, and, con-
sequently, it accumulates behind ihe co-
rona glandis, so as to  form a kind of ab-
scess,  which produces ulceration  on the 
PHYMOSIS.                              265
inside of  the  prepuce.   This  abscess
burets externally, and, the  glans  often
protruding  through  the  opening,  the
whole prepuce  becomes thrown towards
the opposite side, and the penis seems to
have  two  terminations.   On the  other
hand  (says Mr. Hunter) if the prepuce is
loose  and wide, and is either accustomed
to be kept back in  its sound state, or is
pulled back  to admit of the chancres
being dressed,  and is allowed to remain
in this situation,  till the above tumefac-
tion takes place, the case is then named a
paraphymosis.  Also, when  the prepuce is'
pulled forcibly back, after it is  swelled,
it is then brought from the state of a phy-
mosis to  that  of a paraphymosis.   The
latter case is often attended with worse
symptoms,  than  the former,  especially,
when it has first been a phymosis   The
reason of this is, (continues Mr Hunter)
that  the aperture of the prepuce  is natu-
 rally  less ela tic, than any other part of
 it: therefore, when the prepuce is pulled
 back upon the body of the penis, that part
 gra«ps  it more tightly, than any  other
 portion ofthe skin ofthe penis, and mere
 so. according to the inflammation  Hence,
 there are two  swellings of the prepuce,
 one close to the glans ;  the other behind
 the stricture.  The Constriction is often
 so great, as to intenupt the circulation
 beyond it.  This increases the swi-lling,
 adds to the stricture, and often produces
 a mortification of the prepuce itself, by
* which  means  the  whole  diseased part,
 together with the stricture, is, sometimes
 removed,  forming, as  Hunter  ably ex-
 presses himself, a natural cure.  In many
 cases, the skin and prepuce are not the
 only  parts  affected,  adhesions, and even
 mortification may also take  place in the
 glan>, corpora  cavernosa,  &c.  (See Hun-
 ter on the Venereal, 221, &o.)

         TREATMENT OF PHIMOSIS.

   A  phymosis should be prevented if pos-
 sible ; therefore, says Mr. Hunter, upon
 the least signs of a thickening  of the
 prepuce, which is known by its being re-
 tracted with difficulty and pain,  the pa-
 tient should be kept quiet; if in  bed, so
 much the better, as in an horizontal posi-
 tion the end ofthe penis will not be so de-
 pending.   If confinement  in bed  cannot
 be complied with,  the end of the penis
 should be kept up, though this can hard-
 ly be done,  when  the  patient is walking
 about. The object of this is to keep the
 extravasated fluids  from gravitating, to
 the prepuce, which  they would hinder
 from being drawn back even more, than
 the inflammation it-elf.
   As when there are sores, they cannot be
      Vol. IT.
dressed in the  common way, injections
must  frequently  be thrown under  the
prepuce, or the operation  for phymosis
performed.  Mr.  Hunter advises mercu-
rial injections;  either crude mercury rub-
bed down with  a thick solution of gum-
arabic ; or calomel with  the same,  and
a proportion of  opium; or else a solu-
tion of one grain of the hydrarg. mur. in
one ounce of water.  Mr.  Hunter also
recommends the application of emollient
poultices, with laudanum in them, and,
before putting them on the part, to let it
hang over the steam of hot water, with a
little vinegar and spirits of wine in  it.
  When, with a phymosis chancres  bleed,
Mr Hunter says, the oil of  turpentine is
the btst stimulus for making the vessels
contract;  but, when the hemorrhage pro-
ceeds from irritation, he  recommends se-
datives.   Whatever is  used, must  be  in-
jected under the prepuce.  When the in-
flammation  has abated, he advises mov-
ing the prepuce  occasionally to;/ prevent
its becomings adherent to the glans.   He
says, he has seen  the opening of the pre-
puce, so  much  contracted  from the  in-
ternal  ulcers healing  and uniting, that
there w;;s lurdly any passage for the wa-
ter.  If the passage in the prepuce, so
contracted,  be  in a direct line with  the
orifice of the urethra,  a bougie must be
used.  If otherwise, the or/eration of slit-
ting up, or removing part of the prepuce,
becomes necessary.
  When matter  is  confined  under  the
prepuce, in tiie manner above described,
Mr. Hunter recommends laying the  pre-
puce  open,  from the  external orifice to
the bottom, where the  matter lies,  as in a
sinus,  or fistula.  However,  Mr. Hunter
thinks laying open the prepuce for  the
mere purpose of applying  dressings  un-
necessary, as the  sores may be washed
with injections by means of a syringe.
  The common operation for the phymo-
sis consists in sli'ting  open  the prepuce,
nearly its whole  length  in the direction
of the  penis.   This plan is  certainly the
most elgible, when  the   matter of a
chancre  cannot  escape from under  the
prepuce; because  c rcumcisinn,   which
many surgeons,  since'Mr. Hunter's time,
have preferred, would  not suffice for giv-
ing vent to the accumulated pus. In many
cases of  phymosis, says Mr. Hunter, an
operation is improper; for, while  the in-
flammation  is very considerable,  such a
measure  might  bring on  mortification.
He  acknowledges,  however, there  are
cases,  in which a freedom  given  to  the
parts would prevent  the   hitter  event.
When matter is confined under the pre*-
puce, an opering is indispensable,  and, if
the patient should object to the, common
     L i. 
266             PHY
PIL
operation,  an  opening should be made
with a lancet  directly through the pre-
puce, or  else with caustic.  (See Hunter
on the Venereal Disease, p. 232. et seq.)
  When the prepuce is to be slit open, a
director is first to be introduced under it,
and the division  is then  to be made with
a curved  pointed  bistoury,  from within
upward.
  Many surgeons  object to this opera-
tion, because the  prepuce  continues af-
terwards  in a very deformed state; and
they perform circumcision, or amputation
of.the prepuce,  in the following manner.
The prepuce is first taken hold of with a,
pair of forceps, as much of the part being
left out,  as is judged necessary to be re-
moved.  The removal is then accomplish-
ed by one sweep of the knife, which, di-
rected by the blades ofthe forceps, is sure
of making the incision  in a straight and
regular manner.  A fine  suture  is next
passed through the edges ofthe inner and
outer portions of the skin of the prepuce,
so as to keep them together.  The only
necessary dressings are lint, and, over it,
an emollient poultice.

      TREATMENT OF PARAPHYMOSIS.

  The removal  of the  stricture in this
case should always be effected, because
its continuation is apt to produce a mor-
tification in the parts, between the  stric-
ture and  the glans.  It  may be done in
two ways ; either by compressing with
the fingers all the blood out ofthe swollen
glans so as to render this part sufficiently
small to allow the  constricting prepuce to
be brought forward over it, with the aid
of the other fingers; or by dividing the
stricture  with a knife.   From  the great
success, which I have seen attend the first
mode, I  should not conceive the latter
one so frequently necessary, as Mr. Hun-
ter  seems to  lay down.   This  operation
is always troublesome to accomplish, be-
cause  the swelling, on each side of the
stricture, covers or closes, the tight part,
so as to make it difficult to get at it.   Mr.
Hunter says, the  best way  is to separate
the two  swellings, as much as possible,
where you mean to  cut, so as to expose
the constricted part; then take a crooked
pointed  bistoury,  pass it under the con-
striction,  and  divide it   None  of the
swollen skin, on each side, should be  cut.
 The prepuce may now  be  brought  for-
 ward, unless it should be thought more
 convenient, for  the purpose of dressing
 the chancri&s, to let it remain in its  pre-
 sent situation.  (See Hunter on the Vene-
 real Disease, p. 238, 239.)
   The original disease, producing phy-
 mosis and paraphymcsis, must always be
attended to, and the employment of mer-
cury must be necessary, or unnecessary,
according to the nature of the affection,
of which these are only effects.
   FILES.  (See Hemorrlioitls.)
   P1LUL £.  A M MONIAR ETI  CUPRI.
&.  Cupri Ammoniaci gr.  xvj.   Mici
Panis ^iv. Aqua: Ammon. q.  s.  M. fiant
pilulae xxxii.  (Edinb. Disp.)  This is said
to  be the best form of exhibiting copper
internally, which  mineral  some  think
worthy of trial in cases of gleets.
   P1LULJE  ARGENTI N1TRATI.  ».
Argenti Nitrati gr. lij. Aquae Distillatae
gutt. aliquol. M.cae Panis q. s. ut fiant
pil. xx.  The author of the Pharmaco-
poeia Chirurgica suggests the trial of these
pills in obstinate  leprous, and other cu-
taneous affections, and phagedenic, ano-
malous ulcers, connected with  constitu-
I tional  causes.  Two, or three may  be
given twice  a day.  Dr. Powell gave the
argentum  nitratum internally, in  a case
of hydrophobia, but, without any sensible
effect.   These pills are  among the for-
mulx selectx of Dr. Saunders.
   PILULiE  CALOMELANOS.   *. Cal-
omelanos gr. xij.  Conservae'Cynosbati
quod satissit. M fiant pil. xii. These are
the calomel  pills  in common use. Sur-
geons give one, or two of them daily, as
alteratives, in numerous cases.  At Guy's
Hospital, they add three grains  of the
pulvis  opiatus to each pill, using syrup,
instead of the conserve.
   PILUL/E CALOMELANOS CUM CI-
CUTA.  5<.  Calomelanos gr. vj.  Succi
spissati Cicutae ^j. M. fiant, pil. xii. One
may be given thrice a day, in scirrhous,
 cancerous, scrophulous, and some anoma-
 lous diseases, resembling venereal ones.
   P1LULJE CALOMELANOS CUM AN-
 TIMONIO TARTAR1SATO.  *. Calo-
 melanos 3j.  Antimon. Tart. gr. xv. Opii
 Pur. ^ss.   Syrupi simpl.  q.  s.  fiant pil.
 lx.  One of these is given twice a day,
 in St. Thomas's Hospital, in cases of dis-
 eased j oints.  As the author of the Phurm.
 Chirurg. adds, they are also of use in her-
 petic   affections,   and obstinate  ulcers.
 The union of antimony with quicksilver,
 according to Dr. G. Fordyce,  quickens
 the specific operation of the latter.
    PILUL.dE   CALOMELANOS   CUM
 OPIO.   * Calomelanos  3j.  Opii Purif.
 gr  xii.  Consei v. Cynosb.  q. s. M. fiant
 pil. xii.  When  the object is to exhibit
 strong doses of calomel, one of these pills
 may be administered every night.
    PILULjE CALOMELANOS  COMPO-
 SITjE.  fy.  Calomelanos.  Sulph.  Antim.
 Praeeip.~-sing. gr.  xii.  Guaiaci  Gum-
 mi Resina: gr. xxiv. Saponis q. s. M. fiant
 pil. xii.  Similar  to Plummer's pills.
 These are most excellent  alteratives,  in 
                 PIL

the dose of one  twice  a day.   In tinea
capitis,  herpetic  aff'ections,  and  many
anomalous diseases, they are exceedingly
useful.  Some diseased enlargements of
the breast, and testicle, seem also to be
benefited bv them.
  PILUL.E CICUT.E.   *. Succi Cicu-
tae 3ss. Ptilv. Herb.  Cicutae q. s.  fiant
pil. lx.  These are  the  hemlock pills in
use at Guy's  Hospital.  Cicuta is occa-
sionally given in scrophulous, cancerous,
and venereal cases.   The surgeon should
begin with small doses, and increase them
gradually, till nausea and headach arise.
From one, to a great number of these pills
may be given, in this manner, every day.
  PILULi CEKUSS£  ACET AT JE. *•
Cerussx Acetatae gr. xii.  Opii  Purif.  gr.
vj. Conserv. Cynosbati q. s. M. fiant pil.
xii.  One may  be  given thrice a day.
Gleets  are, perhaps, the ^nly cases, in
 which surgeons can employ these pills.
   PILULAE  COLOCYN THIDIS  CUM
CALOMELANE.  fy.  Extracti Colocynth.
comp. i)ij. Calom. gr.  xii. Saponis  9j.
 Two of these operate  as  a  purgative.
 They are the pills most frequently em-
 ployed in the practice of surgery,  for
the purpose just specified.
  PILULE CUPRI  VITRIOLATI.  *.
Cupri Vitriolati gr xv.  Olibani Extracti
CinchonsC, sing. gij.  Syrup, simpl. q. s.
.fiaht pil  lx.   From one to four of these
pills  may be given in a day, for gleets.
 (Pharm. Chirurg.)
   PILULjE HYDRARGYRI.   Of these,
I need only observe here, that the usual
dose is ten grains.  (See Mercury.)
   PILULJE  HYDRARGYRI CALCINA-
 TI.   One grain of this preparation is the
 dose, which  is  commnrity taken at  bed-
 time.   (See'Mercury.)
   PILULiE  HYDRARGYRI  CUM  CI-
CUT A.  9e. Hydrargyri  purificati drach.
j. Arabici gummi  pulverisati  drach.  ij.
 Succi cicutae spissati drach.  j. Herbae
Cicutae foliorum,  in  pulverem tritorum,
 q.s.
   The quicksilver is to be first reduced
 by triture with  the  gum-arabic,  moist-
 ened with a little  rain-water.   The in-
 spissated juice of hemlock is afterwards
 to  be added, and lastly  the  powdered
 leaves  in sufficient quantity to make  a
suitable mass for pills.
   These, with a slight variation  in  the
 proportion of  the hemlock, are the piluLt
mercuriales of Plenck, who directs three or
 four  pills, each  of three  grains, to be
riven every night and morning.
  There are,  no doubt,  many  cases to
 which this formula must be very suitable ;
 such, for instance, as the. enlarged pros-
tate gland, &c.
                POL             267

  Dr. Saunders  in  his  Fvinulx  Selectx
directs equal parts  of pil  hydrarg.  and
succ. cicut. spissat. for tliese, or such
like, purposes   (Pharm. Chir.)
  PILULJE NATRI  CUM  SAPONE.
91. Natri &j. Saponis  9j.  M.  fiant  pil.
xii.  Four may be given  hrice a day, in
cases ot  broiichocele, and indurations of
the absorbent glands from scrophula.
  PILULiE OPII.   These  need only be
mentioned among such as are of eminent
utility in surgery.
  P1LUL.E OPII COMPOSITE.  *. Opii
Purif. Camphors, sing.  5ji.  Antim. Tart.
gr. xv.  Syrup. Simpl.  q. s. fiant  pil. lx.
Used for alleviating pain, and keeping up
a  gentle perspiration ;  are particularly
useful  in preventing painful erections, in
cases of gonorrhoea, chordee, &c.  (See
Pharm. Chir.)
   PILULE ZINCI VITRIOLATI.   *.
Zinci Vitriol, jj. Terebinthinae  q. s. fiant
pil.  lx.  One, or  two, are occasionally
given,  in cases of gleets, thnce a day.
   PLANTARIS MUSCLE.  This  long
slender muscle  of the leg  is said to be
sometimes ruptured, particularly in danc-
ing.  The surgeon  can do little more,
than advise rest, and the same posture of
the  limb, as in the rupture of the tendo
Achillis.  (See Achilles, Tendon of.)
   PLEURITIS.  (from vrtevpx,  the mem-
brane  lining the chest.)  A pleurisy, or
inflammation ofthe pleura.
   PLEUROSTHOTONOS.  (from srAft/-
eov, the side,  and reivu to stretch ) A
spasmodic disease,  in which the  body is
drawn to one side;  a species of tetanus.
(See 'Tetanus.)
   PLICA  POLONICA.  (from plico, to
entangle.)   A peculiar disease, to which
the inhabitants of Poland and  Lithuania
are  subject: in this singular  affection,
the  hairs  of the head  become adherent
together,  probably, in  consequence of
some morbid  secretion  from the scalp.
It may  be  cured  by  the same means,
which  ewe the scaldhead.  (See Tinea
Capitis )
   PNEUMATOCELE,   (from  srnevfMt,
wind,  and *«**» a  tumour.)  The wind-
rupture;  a case, which only existed in
tne imaginations of  the old surgeons.
   POLYPUS, (from woAt/«,many,andw*«i
a foot.)  A kind of  tumour, winch is  ge-
nerally narrow where  it originates,  and
then becomes wider,  somewhat like a
pear;  which most commonly is met with
in the  nose, uterus, vagina, and antrum  j
and which received its name from an er-
roneous  idea,  that  it usually had several
roots, or feet, like polypi, or zoophites. 
268
POLYPUS.
        I'OLtn S  OK  THE HOSE.

  Polypi mofe frequently  grow in the
cavitv of the nose, from the Schneiderean
membrane,  than   any  other  situation.
Nasal  polypi are visibly  of   different
kinds; some h'ing reel, so!'., and sensi-
ble ; but, free from pain, and exactly like
a p.ece of healthy flesh.  Tins, which has
been termed the fleshy polypus, is the most
common, and fortunately the most easy
of cure.   Other pojypi are c.tlled- malig-
nant,  being  hard, scirrhous, add painful :
some are said to  be  even capable of con-
version  into  carcinoma.    Richter de-
scribes another  kind  of nasal  polypus,
which is pale, very tough, and secretes a
vi-cid discharge ; which undergoes an al-
teratiorir of  its size wuh every change of
the weather; and which is rather a re-
laxation, or elongation, of a part  of the
Schneiderean membrane, than a  polypous
excrescence.  The  whole  membranous
lining of the nostrils is  sometimes relax-
ed, and thickened in this manner, so as
nearly to fill up the whole cavity of the
nose.   (Ansfangr. der Wundarzn.  Band.
1. Cap  21 )
  Mr Pott has taken great pains to shew,
that thefe is one kind of polypus,  origi-
nally benign  ,- another originally malignant.
He states, that those, which begin with,
Or are preceded by considerable, or fre-
quent  pain  in the forehead and  upper
part of the nose,  and which, as soon as
they can be  seen, are either highly red, or
of a dark purple colour ;  those which,
from the time of  their being first noticed,
have never been observed to be sometimes
bigger,  sometimes less,  but have  con-
stantly rather increased ; those, in which
coughing, sneezing,  or blowing the nose,
gives pain, or produces a wry disagreea-
•ble sensat ion in the  nostril, or forehead ;
those which,  when  within  reach, are
painful  to   the touch,  or  which,  upon
being slightly touched, are apt to bleed ;
those whxh seem to be fixed, and not
moveable  by the action or  blowing the
nose, or of driving  the air through the
affected nostril only  (when the polypus is
only on tine side ; those which are in-
compressibly hard,  and  which,  when
pressed, occasim pain  in  the  corner  of
the eye, and forehead, and which,  if they
shed any thing, shed blood ; those which,
by adhesion, occupy a  very considerable
space, and seem  to consist of a thicken-
ing, or of an enlargement of all  the mem-
brane covering the septum narium ; those
which sometimes shed an ichorous, of-
fensive, discoloured discharge: and those,
round whose lower part, with'm the nose,
a probe cannot easily and freely be pass-
ed, and that, to some height, ought not to
be attempted,  at least by the forceps, n<tr
indeed l<v any other means ;  and this for
reasons obviously deducible  from the na-
ture and circumstances  of  the  polypus
On the one  hand, the very large extent
and quantity of r.dhesion will render ex-
tirpation  impracticable, even  if tlie dis-
ease could be  comprehended within the
forceps,  whkh it very frequently cannot;
and on the other, the  malign nature of
the distemper  may render all partial re-
moval, all unsuccessful attacks on it, and
indeed any  degree of irritation, produc-
tive of  the  most  disagreeable conse-
quences.
   But, the polypi, which are of a palish
or  greyish light-brown  colour, or look
like a membrane just going to be sloughy •;
which are seldom or never painful, nor
become  so upon  being pressed ; which
have appeared to be at one time larger,
at another less, as the air has happened
to be  moist or dry; which ascend and
descend  freely by the  action of respira-
tion through the nose ;  which the patient
can make to descend by stopping tlie nos-
tril which is free, or even most free, and
then driving the  air through that which
the polypus possesses; which when press-
ed give no pain, easily yield  to such pres-
sure, become  flat thereby, and distil  a
clear lymph ; and round whose lower and
visible part  a probe can easily, and that
to some  height, be passed, are fair and fit
for extraction  ; the polypus, in these cir-
cumstances, frequently coming away in-
tire ; or if it does not, yet  it  is removable
without  pun,  hemorrhare, or hazard,  of
any kind ; the  second of which  circum-
stances  Mr. Pott can  with  strict  truth
affirm, he never yet met with when the dis.
ease was at all  fit for the operation.
   Of the benign kind of polypus, fit for
extraction,  there are   (says  Mr.  Pott)
two  sorts,  whose  principal  difference
from each other consists in their different
origin or  attachment.  That which  is
most freely moveable within the nostril,
upon  forcible respiration ;  which has
been found to  he most liable to change of
size, at  different  times  and  seasons;
which has increased the most in the same
space of time ; which seems most limpid,
and mo it freely yields  lymph upon pres-
sure, has its origin most commonly by a
stalk, or kind of peduncle,  which is very
small, compared with the size of the po-
lypus.  The other which, although plain-
ly moveable,  is much  less  so,  than  the
one just mentioned, which  has been less
liable to alteration from air  and seasons;
and which has been  Tather slow  in arriv-
ing at a  very  troublesome  size,  is most
frequently  an  elongation of  the  mem-
brane covering one of the ossa  spongiosa. 
POLYPUS.
269
These  latter may  be extracted with no
kind of hazard, and, with very little pain,
and hemorrhage :  but the former requiie
the least force, and mostly come  away
entire;  while  the others  often  break,
come away piecemeal, and stand  in need
of the repeated use of the forceps.  (Pott
on the Polypus of the Nose.)
  Mr. John Hell criticises the distinctions
drawn by  the preceding writer, and he
says, that  a polypus is never  mild, nor
ever  malignant;  tune,  and  the natural
growth of the tumour, and the pressure it
occasions within the soft and bony ceils of
the nostrils and j;»ws, must bring  every
polypus to one invariable form,  in its last
and fatal stage.  Polypus, says Mr. John
Bell, is indeed a dreadful disease ; but, it
becomes so by a slow progression, and ad-
vances by gradations easily characterized.
Every polypus in its early stage is, accord-
ing to this writer, a small moveable tu-
mour, attended with a sneezing and  wa-
tering of  the  eyes; swelling in  moist
weather; detruding with  the  breath;
but, easily suppressed  with  the  point of
the finger*  It is void of pain,  and not at
all alarming; it may also  be  easily  ex-
tracted,  so as to clear for a time the pas-
sage for the breath. Yet this little tumour,
simple as it may appear, is the germ of a
very fatal and loathsome disease, and this
easy extraction often the very cause of its
appearing  in its,  most  malignant  form.
The more  easily it is extracted (says Mr.
J. Bell) the more  easily does  it return ;
and whether carelessly extracted, or alto-
gether neglected, it soon returns.  But,
when  it does return, it has   not  really
changed its nature ; it has not ceased to
be in itself mild,  it is then to be feared,
not from its malignity,  but from its pres-
sure, among the delicate cells  and mem-
branes of the nose.   It soon fills the nos-
 trils, obstructs the  breathing,  and causes
 indescribable anxieties. The tears are ob-
 structed,  and  the  eyes  become watery
,'jrom the  pressure on the lachrymal sac ;
'the hearing is in like manner  injured, by
 the pressure of the tumour against tiie
 mouth of  the eustachian tube;  the voice
 is  changed, and  its resonance and tone
 entirely lost, by  the sound  no longer
 passing through the cells of  the nose and
 face.  Tlie swallowing is in some degree
 affected by the soft palate being depress-
 ed  by the tumour.  The  pains, arising
 from such slow and irresistible pressure,
 are unceasing.  From the same pressure,
 the bones become carious, and the cells of
 the face  and nose  are destroyed by its
 slow growth.  It  is not long, before the
 tumour  begins   to project  from  the
 nostril in front, and over  the arch  of the
 palate behind.    One  nostril  becomes
 widened   and thickened;  the  nose  is
turned towards the opposite side of the
face, and  tlie  whole countenance seems
distorted.   Tlie root of the nose swells,
and  becomes  puff'v, the features tumid
and flabby, the free yellow, and the parts
round the eye livid.  T,he  patient is  af-
fected  with head-achs,  «vh:ch  seem  to
rend the  bones asunder, and with per-
petual  stupor, and  dozing.  The bones
are  now absorbed, and the  membrane*
ulcerate;  a foul and fetid matter, black-
ened with blood, is discharged from the
nostrils, and  excoriates them. The blood
vessels next  give  way,  and  .sudden im-
petuous hemorrhages weaken the patient:
the teeth   fall from  the  sockets, and,
through  the  empty sockets, a foul and
fetid matter issues from the antrum.
   Now the disease verges  to its  conclu-
sion.   The patient has  terrible  nights,
and  experiences a sense  of suffocation.
The repeated  loss  of blood renders him
so weak, that.he cannot quit his bed, for
several days together;  and when he does
get up, he" is (to use Mr. J. Bell's words)
pale as a spectre, his lips colourless, and
his face like wax,  yellow and transparent.
He  now  suffers intolerable pain,  while
his  saliva is  continually dribbling from
his mouth, and the fetid discharge from
his  nose.  In.this state,   he survives  a
few  weeks: during  the  last days of his
illness, lying  in a  state of perpetual stu-
por, and' dying lethargic.  Mr.  J.  Bell
afterwards," observes,  that  " if horrid
symptoms could establish the fact of ma-
lignity* there is not to be found  in all
nosology a more malignant disease, than
this; but, aneurism, though it destroys
the  thigh-bone, the sternum, or  the cra-
nium,  is  not  accounted malignant ; nei-
ther is polypus malignant, though  it de-
stroys the "cells of the face, and penetrates
even through the ethmoid  b^ne to  the
brain.   These consequences resu t mere-
ly from pressure."   (John Bell's  Prin-
ciples of Surgery,   Vol  3. part 1. p. 90—
92.)
   The celebrated professor  Richter  has
also denied the validity of the objections,
urged by  Pott against attempting to re-
lieve the  patient;  neither  the  malignant
nature  of a   polypus, its  adhesions,  im-
moveableness, ulcerations, nor  disposi-
tion to hemorrhage, 8tc- are according to
Richter, any  apology for leaving the dis-
ease to itself.  (Sec'Anfangsgr. der Jl'un-
 darzn. Band.  1. Cap 21 )
   Mr. J.  Bell refuies  the common  no-
 tions,  that polypi  may be caused by pick-
 ing  the  nose, blowing it  too  forcibly,
 colds, and local   injuries.  He  asserts,
 that a polypus is  not in general a local,
 solitary tumour :  he has only found it so
 in three or four instances.  Both nostrils
 are  usually affected.  He states, that no 
270                               POLYPUS.
  finger  can reach that part of the nostril,
  where the root of the swelling is situated,
  as it is deep and high in the  nostrils,  to-
  wards  the throat, and  near the opening
  of the eustachian tube.   The finger can-
  not be introduced further,  than the car-
  tilaginous wing»of the nose extends, and
  can hardly touch the anterior point of the
  lower  spongy  bone.   The  anterior and
  posterior chambers of the nostril are  se-
  parated from each other by a narrow slit,
  which  the finger can  never pass, and
  .which  is divided, in  consequence of the
,jr projection of the lower spongy bone, into
  two openings, one above,  the other  be-
  low.  Through  these  the heads of the
  polypus project.   These tangible parts of
  the tumour,  however,  are very  distant
  from  its  root,  which is in the highest
  and narrowest part of the nostril.  (See
  p. 103, 104.)  Mr J. Bell also says, that
  three,  or four nolypi are often crowded
  together  in one nostril, while more  are
  formed, or forming, in the other.
     He dwells upon the difficulty, and im-
  practicableness  of  tying the  root of a
  polypus;  and  explains, that in all  at-
  tempts to extirpa.e  such tumours,  the
  surgeon's aim should be to reach a  point,
  nearly under the socket of  the eye,  in the
  deepest and highest part ofthe nostrils,
  and that  instruments can  only do  good
  when introduced beyond the narrow cleft,
  formed by the projection of the spongy
  bone.  (P. 108)
     Though  Mr.  John  Bell  is probably
  right  in his opinion, that polypi do  not
  proceed from several circumstances,  which
  we have  above  noticed, yet they are, in
  most  instances, diseases  of an entirely
  local nature.  Certainly, in general, it is
  very difficult to  decide what is the  cause
  of the polypus nasi.   Frequently the  pa-
  tient  is, in other respects, perfectly well;
  and, after the removal of the tumour, no
  new one  makes  its  appearance.  In this
  circumstance, it must originate from a
  local cause, though it is  generally difficult
  to define what the nature of this is.  Some-
  times several catarrhal symptoms precede
  the polypus, and, perhaps, constitute its
  cause   It is possible, they may only be
  an effect  of the same cause  which  gives
  birth to the tumour;  but, no doubt, they
  are sometimes  the effect of the polypus
  itself.   It is often certain, that a  faulty
  state ofthe constitution contributes  to the
  disease; for, several polypi frequently grow
  in both nostrils, and even in other  situa-
  tions  at the same time; are reproduced
  immediately after their removal;  and the
  patient often  has an  unhealthy appear-
  ance.  Notwithstanding it has been as-
  serted, that a solution  of  sal ammoniac,
  frequently injected  into the nose,  some-
times disperses polypi, the efficacy of the
remedy remains unestablished by expe-
rience ; as, indeed, the very nature of the
disease might lead one to  anticipate
Some kind of operation  affords the only
rational chance ofa cure.
  There are four modes  of extirpating a
nasal polypus:  viz. extracting  it with
forceps ; tying it with a ligature; cutting
it out; and destroying it with caustic.

              EXTRACTION.

  I suspect there must  be some innectt.
racy  in Mr.  John Bell's account of the
little space there is in  the nostril, for the
introduction  of instruments;  for, were
his description correct,  how could such
large forceps  be introduced  deeply  into
the nostrils, as we see  done every day ?
This gentleman seems to have forgotten,
for a moment, how  much the parts are
expanded, and widened by the tumour.
  Extraction  is the most  common and
proper method.  It is performed with the
ordinary  polypus  forceps, the blades  of
which have holes in  them, and  are inter-
nally rather  rough, in  order that they
may take hold of the tumour more firmly,
and not easily slip off it.  The front edge
of each  blade must not be too thin and
sharp,  lest,  with  its  fellow,  it should
pinch off a portion of  the polypus.  The
forceps must necessarily have a certain
breadth:  for, when they are too small,
they cannot properly  take hold  of and
twist the tumour.   When the handles are
rather long, the instrument may  be more
firmly  closed,  and  more   conveniently
twisted.
   However,  the forceps are not applica-
ble  to all  cases.  The anterior part of
the polypus, lying in  the  nostril, dis-
tending,  and,  totally  obstructing it, is
sometimes quite  hard;  and,  when  the
forceps are  introduced,  it  presses their
blades in  such  a  manner, from each
other, as it  lies between them,  that the
instrument cannot be   introduced suffl.
ciently far, to take hold of the tumour at
a proper depth.  If introduced to a pro-
per distance, it cannot be closed.   In such
a case, says Richter, one  might,  perhaps,
advantageously make use ofa pair of for-
ceps which  may  be separated,  and  put
together again at tiie joint, and the blades
of which diverge from each other behind
the joint, and touch again at their extre-
mities.  After separating the two pieces,
their blades  are  to be separately intro-
 duced, and then joined together again
 at   the  joint.  The anterior  indurated
 portion of the polypus  lies  in  the inter-
 space, and does not prevent the closure
 of the instrument. 
POLYPUS.                              271
  It is generally deemed of importance to
take hold of the polypus with the forceps
close to its root;  and,  indeed, when this
rule is  observed, the whole of the poly-
pus, together with its  root, is commonly
extracted, and there is less reason to ap-.
prehend hemorrhage, which  is naturally
more profuse when the polypus is broken
at the thick, middle portion of its body.
It is also a rule, frequently easy of ob-
servance, especially when the polypus  is
not too  large.  But, in many instances,
the tumour is so large, and the nostril so
completely occupied by it, that it  is im-
practicable to get hold of its root.  In
this circumstance, it is often altogether
impossible  to  discover even  where the
root lies.   Here we must be  content to
take hold of the polypus as high as pos-
sible.  The consequences are of two kinds.
The tumour sometimes gives  way at its
root, though it be only taken hold  of at
its  anterior part; and, in other  cases,
breaks where it is grasped, a portion be-
ing left behind, and a profuse hemorrhage
ensuing. This is, however, void of danger,
if the surgeon loses no time in endeavour-
ing to suppress the effusion of blood; but
immediately introduces the forceps again,
grasps the remnant piece, and extracts it.
The most, infallible method of diminish-
ing the  bleeding,  is to extract what re-
mains behind at its root.  In this way, a
large  polypus  is  frequently  extracted,
piecemeal, without any particular loss of
blood.
  After the polypus has been propelled as
far forward, into the nostril, as it can be
by  blowing strongly through the nose, its
anterior part is to be taken hold of by a
small pair of common forceps, held in the
left hand; and is to be drawn gradually
and slowly out, to make room for the in-
troduction of the  polypus forceps into the
nostril.  The more slowly we proceed in
this manoeuvre, the more the  polypus  is
elongated, the narrower it  becomes, the
greater  is the space in the nostril for the
introduction of the polypus forceps, and
the higher can this instrument grasp the
tumour.  After it  has taken hold of the
polypus as  high  as possible,  it is  to be
twisted  slowly round,  and, at the  same
time,  pulled outward, till the  tumour
breaks.  It  is a very important maxim,
rather to twist the instrument than to pull
it, and thus, rather to writhe the polypus
off, than to drag it out. The longer and
more  slowly  the polypus  forceps are
twisted, the more the part where the ex-
crescence separates, is  bruised, the less is
the danger of hemorrhage, and the  more
certainly does the  tumour break  at  its
thinnest part, or root.  When the extrac-
tion is done with violence, and celerity,
only a piece is usually brought away,  and
we  run  hazard of occasioning a copious
bleeding.
  As  soon as the polypus has given way,
the surgeon is  to  examine  whether any
part remains  behind.  When the polypus
is very narrow at the place  where it has
been broken,  and the patient can breathe
through the nose freely, there is reason to
presume, that the polypus has given  way
at its root, and  that  none continues be-
hind.  The finger, if it can be introduced,
procures  the most certain  information;
or the probe,  when this, for want of room,
cannot be employed.  The ancients  pro-
posed several means for the extirpation of
the remaining piece of polypus :  but they
are, for the most part, objectionable.  It
is best to introduce the forceps again, un-
der the guidanct- of, the finger, or  probe,
and thus pinch and twist off,  the part con-
tinuing behind.
..  Hemorrhage  invariably succeeds  the
operation; and  it has, by many,  been re-
presented as   exceedingly  perilous  and
alarming.   But,  it is  not constantly so,
and, in many  cases, is quite  insignificant.
Frequently, however, it is really  serious;
and, as the surgeon can never know be-
forehand to what extent it  will happen,
he is always to furnish himself, before the
operation, with the most effectual  means
for  its suppression.   The danger  of he-
morrhage may always  be lessened, as was
before mentioned, by slowly  twisting the
polypus at its root, in  preference to pull-
ing it directly vout.  When only a portion
of the tumour has been extracted, the
surest mode  of  stopping the effusion of
blood, is  to  extract the remaining part
without  delay.  When  the  polypus has
given way at  its root, if there should be
profuse bleeding, we may first try, ice-cold
water, and strong brandy,  which may
either be sucked or injected into the nose.
This single remedy proves effectual in nu-
merous  instances.  If the  hemorrhage
should still  prevail,  it may always be
checked with certainty, how copious so-
ever it may be, in the following  manner.,
Roll a considerable piece of lint, as fast as
possible, round the extremity ofa probe;
wet it completely through, with  a strong
solution of zincum vitriolatum ; introduce
it into the nostril, and press  it as strongly
as  possible against the part whence the
blood issues.  When  the nostril is very
much dilated, the fingers may be used, for
this purpose,  with more  advantage than
the probe.  The point, from which  the
blood is effused, may easily be ascertained,
by asking the patient at what part of the
nostril he experienced the most pain in
the operation;  anfl  then  pressing the
finger on various points in this situation. 
272
POLYPUS.
As soon as the blood ceases  to flow, we
may conclude, that the finger is on the si-
tuation ofthe hemorrhage.  This method
is so efficacious,  that there is seldom oc-
casion for any other.   When the bleeding
point lies deeply in the nostril, it might
be difficult to reach it with  the finger. At
all events, we may then employ the plan,
which some so strongly praise "in urgent
cases.
  A piece of cat-gut may be introduced
into the nostril, and, by means of a pair
of forceps, be brought out of the mouth. A
roll of l.nt is then to be attached to it, and
drawn through the  mouth  into  the nose ;
thus the posterior aperture of the nostril
may be  stopped up.   Then the nostril in
front, is to be filled with a sufficient quan-
tity  of lint, moistened  in the solution of
zincuin  vitriolatum.
  The objections to extracting some poly-
pi, says  Richter, have been  much exagge-
rated When the polypus is so large,  that
its  root cannot be got at, its anterior part
is to be  taken hold of, and the tumour ex-
tracted  piecemeal.   It has already been
noticed,  that  this  practice is free from
danger.   Experience does not prove, that
the polypus., which often bleeds profusely,
is apt to occasion a violent  hemorrhage
in the operation ; and, even  if it should do
so, powerful measures may be adopted for
the stoppage ofthe bleeding.  The  malig-
nity, and ulcerations, attending a polypus,
are no objections to the operatii in; but, are
rather motives for its being promptly per-
formed, as delay must occasion more ma-
nifest and urgent danger.  If  the polypus
should be here and  there adherent  to the
membrane  investing  the  nostrils, it is
proper to separate it, before the operation.
This  object cannot  be accomplished by
straight  inflexible instruments,  such as
have  been invented  by various  surgeons.
It may  be ven conveniently done,  ac-
cording  to  Richter,  with thin,  long,  flat
pieces of  tortoise-shell, introduced  as
deeply as possible into  the  nostril, on
every side of the  polypus.  As it can sel-
dom be  known wiih certainty, d  priori,
that adhesions are nj t present, it is proper,
whenever the tumour is large, to introduce
these instruments before the operation.
  Sometimes, the greatest part ofthe poly-
pus extends backward, hanging down be-
huid the palatum molle, towards the pha-
rynx. If there bhould be but little of the
polypus  visible in the nostril, its extrac-
tion must be performed backward,  in  the
throat.   This is usually done with a pair
of curved polypus forceps, which are to be
introduced  through  the mouth, in order,
to seize and tear off the tumour as high as
possible above the soft palate.  Care must
be taken not to irritate the  root  of  the
tongue, or else a vomiting  is produced,
which disturbs the operation.  When the
polypus cannot be properly taken hold of,
we may, according to the advice of some
surgeons, divide the soft palate.  But this
is  very  rarely necessary.   As,  by  this
mode,  the polypus is  not twisted,  but
pulled away, the hemorrhage is, in gene-
ral, rather copious.  If a fragment of the
tumour  should  remain  behind,  it  may
commonly be extracted through  the nose.
   Some recommend,  for the extraction of
polypi  in the throat,  a ring, consisting of
two semicircular portions, with a kind of
groove externally, which are  capable of
being opened and shut,  by being fixed on
the ends of an instrument constructed like
forceps.  A ligature is to be pi ced round
the ring, and its end is to be  brought to
the handle of the instrument, and held
with it in  the hand.  The instrument is
to be  introduced into the mouth, under
the polypus, and expanded as  much as
the size of the tumour requires.   Its ring
is  then to be carried  upward,  over the
polypus, so as to embrace it; and after-
wards  is to be shut,  whereby the noose
after being carried upward, is disengaged
from the ring.  The noose is to be pushed
as high as possible over the tumour, by
means of forceps, and the extremity ofthe
packthread is then to be drawn,  so as to
apply the noose tightly round the polypus.
When  this is done, the ring of the instru-
ment is to be turned round, firmly closed,
and placed in front of the polypus, on the
noose,  in such a way, that the packthread
is  to lie between two little pegs, made for
the purpose, at the 'ends of the ring  On
drawing the packthread firmly, and press-
ing tiie  instrument,  at the same time,
downward,  so  as  to  make  it act  like a
lever,  the  polypus,  in general,  easily
breaks.  Another peg projects in the di-
rt ction of the ring, so as to  prevent the
ligature from insinuating itself within the
circle.  (See Theden's Bemerk. Part 2. and
Plate 6.fig. 1. in Richter's Anfangsgr.)
   The  employment of  this instrument,
however,  is attended, says Richter, with
many difficulties, and  little  advantage.
Polypi in the throat are most conveniently
extracted by the ordinary straight polypus
forceps, with which  they may be siezed,
and gradually drawn  out   through  the
mouth.  The tumour generally allows it-
self to be drawn out without trouble, and
the inclination  lo vomit, which at  this
moment occurs, also contributes to propel
it  outward.   When it  is so stretched, that
it  cannot  be drawn out further, without
considerable  force, a spatula is  to be in-
troduced into the mouth, and tube carried
as high as possible behind the polypus, in
order to press it downward, toward the 
POLYPUS.                               273
 root of the tongue.  When the tumour is,
 at the same time, forcibly pulled outward
 by the forceps, it usually gives way.
   When tiie polypus is situated partly in
 the throat and partly in the nostril, though
 it admits of being extracted,  in the same
 way, through the mouth, yet its anterior
 part often continues attached, and  must
 afterwards be separately removed through
 the nostril.  It is  also  frequently advis-
 able to twist off" the anterior portion of the
 polypus first, by which, the mass in the
 throat is often rendered so loose, that it
 can be easily extracted.  Whenever it is
 conjectured, that the  polypus will  come
 away in  two pieces, it is always preferable
 first, to extract the part in the nostril, and
 afterwards that  in the  throat:  because,
 the separation of the  last is  constantly
 productive of more bleeding, than the re-
 moval of the first. Sometimes, the follow-
 ing plan succeeds in detaching the whole
 polypus  at once.  Both the part in the
 nostril, and that in the  throat, are to be
 firmly taken hold of with tlie forceps, and
 drawn at first gently,  and then more for-
 cibly,  backward and forward.   By  such
 repeated movements, the root  is not un-
 frequently broken, and the whole polypus
••brought  away from the mouth.
   Frequently  the polypus  grows again.
 Policy requires that the patient should be
 apprised of this before-hand.  Some ofthe
 root remaining  behind,  may often  be a
 cause of the relapse.  Hence, tiie surgeon
 should examine carefully, after tiie opera-
 tion, the part at which the root of the po-
 lypus  was situated,  and  separate,  and
 twist pff, most diligently, with the forceps,
 any fragments that may still continue at-
 tached.  The recurrence of the  disease,
 however, may arise  from  other  causes.
 The tumour is  occasionally reproduced,
 after it has been extracted in the  most
Complete manner;  and, doubtless,  this
circumstance is  sometimes  owing to the
 continued agency of constitutional causes,
 which  so often remain undiscovered  and
unremoved. Sometimes, also,  the recur-
rence of the disease is  owing to a local
morbid affection of the Sclmederian mem-
brane,  or of  the bones situated beneath
the root  of the polypus.  Richter, in this
case, approves of the cautery;  hut few
English surgeons will coincide with him.
The polypus, occasionally observed  sub-
sequently to the operation,  is frequently
not,  in fact, a new substance,  but only a
part ofthe original tumour, not previously
noticed by the surgeon.  Sometimes it oc-
curs, that a smaller and  a larger polypus
are found in the nose at the same time.
The larger one  is extracted, while the
other remains undiscovered ; and, when it
has increased in magnitude, it is apt to be
    Vol. H.
 mistaken  for a reproduction of the one
 previously extirpated.   (See  Richter's
 Anfangsgr. der Wundarzn. Band. 1. Cap.
 21.)
                UGATURE.

   As the extraction of the polypus is in-
 variably attended with hemorrhage, which,
 is sometimes profuse, another more mo-
 dern  method  of  cure has,  with  some,
 gained the preference, as being far more
 convenient and secure.  This is, tying
 the root ofthe tumour wfth a ligature, by
 which the polypus is thrown into the state
 of  inflammation,  suppuration,  and spha-
 celus ; and, at length,  becomes detached.
 Many instruments have been invented for
 applying tlie ligature.; but Levret's double
 cannula seems to  be the  best.  Through
 this, a silver wire is to be introduced, so
 as to form a noose at tlie upper end ofthe
 instrument,  proportioned tin size to the
 anterior part  of the tumour, situated in
 the  nostril. The two ends ofthe wire are
 to hang out ofthe two lower apertures of
 the  double cannula; and  one of them is
 to be fastened to a small ring on its own
 side of the instrument.   The other is to
 remain loose.   The wire must be made of
 the  purest silver, and ought  to be  as
 flexible as  possible, that it may nof readily
 break. It must, also, not be too thin,  lest
 it should cut through the root of the poly-
 pus.  The cannula is to be somewhat less
 than five inches long.  By the assistance
 of this cannula, the noose is to be intro-
 duced into the  nose,  and put round the
 polypus.  But, as  the cannula, which is
 usually constructed of silver, is straight
 and  inflexible, while the inner surface of
 the  nostril is preternaturally arched, es-
 pecially  when  much  distended  by  the
 polypus, it is easy to discern that its in-
 troduction must be attended with  con-
 siderable difficulty. In fact, it can seldom
 be inteoduced as deep as  the root of the
 polypus.   There are two ways of avoiding
 this  obstacle.   The cannula  may either
 be passed under the polypus, over the ossa
 palati,  which present a tolerably straight
 surface,  or it  must be curved a  little.
 Perhaps, a tortoise-shell  cannula,  says
 Richter,  might be convenient.
  The noose is to be applied in the follow-
 ing manner.  The  polypus is ^o be taken
 hold of with tlie forceps, and drawn a little
 out of the nose.  The noose is then to be
 carried over the forceps and polypus, into
the nostril.  In order to carry it as high
 as possible, it is necessary not to push the
 cannula straight forwards  into the  nose,
 but to  move it from one side of the  poly-
pus  to the other.  The more deeply the
instrument has entered the nose, the more
of the loose end of the wire must be drawn
     Mm 
•27A;                             POLYPUS
out of the lower aperture of the cannula,
so as to contract the noose, which  other-
wise, might stop in the nostril, and not be
carried sufficiently high.  The elasticity
ofthe silver wire tends to assist in raising
it over the polypus, and, hence, it is more
easy of application than a more  flaccid
kind of ligature.  When there is cause to
conclude, that the polypus is complicated
with adhesions, they must  be previously
broken, in the way already  mentioned.
   As soon as the noose has been intro-
duced as deeply as possible, the loose ex-
tremity of the wire is to be drawn out of
the lower aperture  of the cannula, and
rolled round  the ring on that side  of the
instrument. Thus the root ofthe polypus
suffers constriction.  The wire must not
be pulled too forcibly, nor yet too  feebly.
In the first circumstance, it readily cuts
through the  root of the polypus; in the
second, great tumefaction of the excres-
cence,  and  many inconveniences  arise,
which a tenser state of the wire prevents.
As the  noose gradually makes a furrow,
where it surrounds the polypus, it grows
slack, after  a  short time, and no longer
constricts the  tumour.  One  end of the
wire, therefore, is to be daily unfastened,
and drawn more tightly. The more tense
it is kept, the sooner the separation ofthe
polypus is brought about.   Hence, when
it is  particularly indicated to produce a
speedy  detachment of the polypus, the
wire should  be tightened,  at  least,  once
a day.
   In this manner the cannula is to remain
in the nose,  until the  noose is detached,
together with the polypus. There is an-
other method of tying the tumour, without
leaving the Cannula in the nose. After the
 noose has been  introduced as far as pos-
 sible into the nostril, the two ends of the
 wire are to be twisted round the two rings,
 and the cannula  is to  be turned round  a
 couple of times.  The wire is then  to be
 unfastened from the rings, and the can-
 nula withdrawn.   In this way, the noose
 is made to  embrace the polypus, round
 which it remains lastly applied.   When-
 ever it is wished to produce a greater con-
 striction, the cannula  may be again intro-
 duced into the nose, the ends of the wire
 fastened to the rings, and  the instrument
 turned round again : after which,  it is to
 be taken away, as before. As the cannula,
 when it continues  long in the nose, may
 occasion pain, and  other inconveniences,
 the last method seems preferable to the
 former. However, introducing and  with-
 drawing the c.innula every day, as Richter
 adds, may,  perhaps, be equally  trouble-
 some and painful.   The cannula,  for this
 purpose, being necessarily straight,  is by
 no means handy. One might, at all events,
make use of a single cannula, tlie upper
opening of  which is divided by a bridge;
this  could  be much more conveniently
twisted than a double one.
  Although the ligature  has been very
much praised by some of the  moderns, it
is attended with so many difficulties, that
the forceps are infinitely preferable in the
majority of cases. Hemorrhage is the only
inconvenience,  for which  extraction  is
abandoned for the employment ofthe liga-
ture.  But this, as was before stated, is
far less  dangerous, than  is represented.
The inconveniences ofthe ligature are far
more serious, and numerous.  The cure
by  the ligature is always accomplished
with much less expedition than by extrac-
tion.  When the polypus is of such a size
as to occupy the whole ofthe nostril, it is
generally impractic; ble to introduce the
noose to a sufficient depth.   The figure
of the polypus renders it almost impossi-
ble to tie its root; for, commonly, the  tu-
mour expands very much  before and  be-
hind, and the wire must be brought over
the  posterior  part of the  polypus, ere it
can  be applied to its root.  In general,
also, th'e noose only includes the front part
of the polypus, while the root,  and back
portion remain untied, and, consequently,
do not become detached.—It is, indeed,
asserted, that the ligature, when only  ap-
plied to the front part of  the polypus, is
capable  of bringing about inflanuuelion,
suppuration, and a detachment of  the
whole of the tumour.  This may some-
times be the case; but, analogous instances
prove, that it  is undoubtedly not con-
stantly so.  The ligature  seldom accom-
plishes an entire  destruction of the dis-
ease ; and  there is usually reason to  ap-
prehend its recurrence. It"the polypus be
very large, and the'whole nostril occupied,
it is frequently utterly impossible to in-
troduce the wire; and, when this is done,
the  front ofthe tumour alone can be tied.
   The polypus  nasi  is commonly very
sensible, and, consequently, tying it proves
very painful.   As  soon  as  the noose is
drawn tight, not only the polypus inflames,
but, the whole extent of the Schneiderian
 membrane.  The  pain, and inflammation,
 often  extend even to parts  at  some  dis-
tance, such as the throat,  eyes, &c. occa-
 sioning  acute  fever, which  requires the
 strict observance of low diet, the exhibi-
 tion of cooling physic, and the evacuation
 of blood.  Hence, it is advisable in many
 cases, to prepare patients for this treat-
 ment, by diet and medicines.
   When the polypus is tied, it swells very
 much, and all the complaints  it previously
 caused are exasperated.   But, in particu-
 lar, the part situated in the throat, some-
 times obstructs deglutition, and respira- 
POLYPUS.
275
tion, in such a degree, that prompt relief
becomes necessary.  The patient soon de-
rives comfiirt, when  a few punctures are
made into the tumour.   These excite a
bleeding, that very speedily  lessens  the
swelling, but is, sometimes,  difficult to
check.  Hemorrhage from a  part of the
polypus that is tied, is most effectually
stopped, by twisting the wire so tight, that
it closes the arteries distributed to it.
  The wire sometimes breaks off close to
the lower aperture ofthe cannula, in con-
sequence of being twisted so much, and
thus the progress ofthe cure is  interrupted.
A new wire may be introduced; but it is
difficult to apply it  exactly in the situa-
tion of the other.  A fresh place is com-
monly tied, which  is almost the same
thing as commencing the cure anew.  It
is better to prevent  this interruption of
the treatment, by employing very flexible
wire, made of the purest silver; and by
not twisting and untwisting regularly the
same extremity of it, but sometimes one
and sometimes the other. A strong piece
of cat-gut might be a very good substitute
for  silver wire.
  Immediately the polypus  is  tied, it
swells, inflames, and becomes painful; in
a few days, it becomes shrunk, free from
pain,  and sphacelated.   The fetid dis-
charge now occasions considerable incon-
venience to the patient, and ought to  be
washed away by repeated injections. To-
wards the termination of the case, the
surgeon ought to take hold ofthe polypus
with the forceps, to try whether any of it
is loose.  When the polypus is extracted,
one may  inject a solution  of alum, for
a day or two  afterwards, in order to di-
mimsh the effectof the irritating discharge
on  the Schneiderian  membrane, and the
suppuration in the situation of the liga-
ture,  i.s it is sometimes profuse, and of
long duration.
  Though one might also tie  polypus tu-
mours in the throat;  and, indeed, the in-
troduction  of the  cannula  through the
mouth, and the application of the noose,
would be attended with no great difficulty;
and, though the treatment might be ren-
dered more  tolerable to the  patient, by
withdrawing the cannula after twisting the
wire . yet, the swelling of the tied portion
of tlie tumour, would, probably, create im-
mense inconvenience. In this  case, there-
fore, extraction usually merits the prefer-
ence,  and the ligature is only fit to be
practised in the throat when the polypus
is very small, or there is some especial
cause forbidding extraction.   When de-
glutition  and respiration are impeded by
the  swelling ofthe tied portion ofthe po-
lypus in the throat, the swollen part must
be scarified by means of the pharyngoto-
 mus, so  as  to  excite  a bleeding, and,
 thereby,  produce a  diminution  of the
 swelling.  The  noose is to be frequently
 and strongly tightened, in order to accele-
 rate the detachment  of the polypus, and
 shorten  the  inconveniences.  When the
 excrescence  has  not  only descended  to-
 wards the pharynx, but  also into the nOs-
 tril, its front portion is to  be tie I first.
 The result of this may be, such an inflam-
 mation and suppuration  of the whole po-
 lypus, that, after the  separation o;  i.s  an-
 terior portion, the posterior one n-uy also
 become detached, or  at least, easy of  re-
 moval.

               CAUSTICS.

   The cautery, form?rly recommended for
 the cure ofthe polypus nasi, is now almost
 entirely  rejected, and,  indeed,  in the
 manner it was customary to use it,  little
 good could be done.   It was applied to
 the anterior surface of the tumour in the
 nostril, and its employment was repeated
 every time the slough separated. P.  ope-
 ration could naturally be but of small ex-
 tent, as  it only  came into contact w'.th a
 trivial portion of polypus.   Its irritation
 augmented the determination of blood to
 the  excrescence, and  accelerated  its
 growth;  while as much of the tumour
 was reproduced, ere the  slough separated,
 as was thus destroyed; and the design
 of completely extirpating the disease,  in
 this way, seldom or never proved success-
 ful.  However, says Richter, there is one
 particular example, where the cautery is
 the only  means from which relief can  be
 derived;  and, used  in a certain way, it
 always speedily  produces the desired ef-
 fect.
  There  are polypi of  the nose, which
 readily bleed profusely.   Touching them
 in the gentlest manner,  and every trivial
 concussion of the body,  give rise to he-
 morrhage.  The  patient is  exceedingly
 debilitated by repeated loss of blood ; his
 countenance  is pallid; his feet swollen;
 he  is affected  with  hectic fever; and
 faints whenever there  is  any considerable
 bleeding. Doubtless, extraction, in this
 case, is a very precarious method, as the
patient is so circumstanced,  that any co-
 pious effusion of blood must be highly pe-
 rilous. Sometimes the poWpus is, at the
 same time,  so large,  and the nostril  so
 completely occupied and distended, that
 it is impossible to apply a ligature.  Such
 is  the case, to which alone the cautery
 promises  assistance.  (Richter.)
  In employing the cautery, (says the lat-
 ter author,) the object is not to effect,  by
 its direct agency, a gradual d«. struction of
 the polypus; but to excite such an inflam* 
276
POLYPUS
mation, and suppuration, of the whole of
it, as shall lead to this event.  To fulfil
this  purpose,  a  common  trocar,  three
inches long, may be  used.   The cannula
ought to be two inches shorter than the
trocar,  whereby the  latter  may protrude
from  it so far; and it should be con-
structed with  a  handle.   The cannula
should  be  made wider  than it  is in
common,  to  allow  the  trocar  to  be
introduced, and withdrawn with  facility.
It, is  to be wrapt round with a piece of
wet  linen, and applied to  the  polypus.
The red-hot  trocar  is then to be pushed
into  the tumour, as far as the cannula
mcill  allow it, which is, of course, two
inches.
   According to Richter, this method of
treatment  is far less painful than  it has
the semblance of being.  It is only neces-
sary to  dry the front part of the nostril,
and fill it with lint all round the cannula,
in order that any moisture, heated dur-
ing the operation, may not touch, and in-
jure the inner surface ofthe nose,  ff care
be taken to introduce  the trocar in a pro-
per direction, there  is no  reason to fear
damaging the septum  nasi, especially as
it is prelernaturally distended by the po-
lypus.  The  immediate effect of the ope-
ration is to bring on  an inflammation and
swelling of the whole polypus, frequently
accompanied with 'headach, sore throat,
fever, and other complaints, which require
the antiphlogistic treatment; but, on the
whole, are not dangerous.
   When the  patient  entertains a dread of
the actual cautery, one might, at all events,
employ the potential  one, in various forms.
One might introduce into the puncture of
the unhealed trocar, a tent of the emplas-
trum cantharidum, or a tent smeared with
butter of antimony, which may be allowed
to continue in for some time.  But, these
applications operate slowly, and are hardly
•apable of exciting  inflammation of  the
whole polypus.
   As soon as suppuration has taken place,
emollient and detergent lotions should be
injected into the  nose; cleanliness, and
thexpromotion of the suppurative process,
demand them.  It  is  only requisite to
maintain suppuration, until the polypus is
so small, that it can be conveniently ex-
tracted, or tied.   To  effect its entire de-
struction  by suppuration, is a tedious un-
dertaking.  (Bidder's Anfangsgr.)

               EXCISION.

   In the treatment  of the polypus,  the
use  of cutting instruments has always
been reprobated, because they usually oc-
casion  a  profuse  hemorrhage, t and  can
hardly ever be passed, without 'mischief,
to a sufficient depth into the nose to di-
vide the root of the tumour.  Yet, there
are instances, in which their use might be
productive of 'advantage.  The anterior
part of the polypus, situated in the  nos-
tril, is sometimes so thick and hard, that
it is  utterly impracticable to  introduce
the forceps for the performance of extrac-
tion,  or the cannula for the application of
tiie ligature.  In  such a case, it might be
a judicious step to_cut off the front ofthe
polypus, by a sharp instrument, of a suit-
able shape, in order to make room for the
use of the  ligature, or forceps.   The  po-
lypus is sometimes of a ligamentous struc-
ture, and  neither admits of being  tied
nor extracted.  There is no means of re-
moving such a polypus, except the knife,
by which it is to be cut away piecemeal.
   Mr. Whately after failing in several at-
tempts to extract, and tie, a considerable
polypus of the nose, succeeded  in cutting
it out.  He used " a narrow, straight bis-
toury, with a probe-joint, having a sheath
fixed upon its edge, by a screw put into a
hole in the handle.  An eye was made at
its point, to receive one end of a thread
intended to be passed routid the polypus,
for the purpose of directing the knife to
the extremity of  the tumour.  There was
also a contrivance by which  the knife
could be unsheathed at its extremity, the
length of three quarters of an inch.  This
was done by means of the screw, which
might be fixed in  another hole, by drawing
back the sheath. v By exposing such a
length of  edge only,  the interior parts
ofthe nose were;defended from the  dan-»
ger of being wounded." Whoever wishes
a particular account  of  the manner of
using the instrument, must consult Mr.
Whately's  Cases of  two  extraordinary
Polypi, &c. 1805.
   In the polypus, which arises from a re-
laxation of the Sclineiderian membrane,
external astringent applications may be
first tried;  such  as ice-cold water, solu-
tions of acetite of lead, alum, muriate of
ammonia,  &c.   These remedies (says
Richter)  commonly  lessen it,  and  fre-
quently, when it is not very large, accom-.
plish its entire removal.  If this should
not happen, there is no  reason against
putting a ligature round it. Here,  also,
we may venture  to employ a cutting in-
strument, if it be in our power to do so.
At all events, an effort may be made to
bring on suppuration of the tumour, by
the cautery.  But, the practice of extrac-
tion is here prohibited.
   When  the Sclineiderian membrane i.^
preternaturally swollen all over  the nos-
tril, which  is quite obstructed, the pervi-
ous state of the cavity is to be restored by
the introduction of cat-gut, or bougies- A 
POLYPUS.
277
  thin piece is  first passed into the nose,
  and afterwards a larger, and larger one
  gradually, until the passage for the air is
  perfectly  re-established.   But,  usually,
  this relief is only of short duration, as the
  nostril  very soon closes  again.   Hence,
  such patients are advised to make constant
  use or flexible tubes passed into the nose;
  or, when  this is  too troublesome, to fill
  the nose regularly at bed-time, with cat-
  gut, and take it out again in the morning.
  ■{Sec Richter's Anfangsgr. Band. 1.)

            POLin OF THE UTERES.

     The polypus of the uterus is of three
  kinds, in  respect to situation. It either
  grows from the fundus; the inside of the
  cervix; or, from the lower edge of the os
  uteri. The first case is the most frequent,
  the last the most uncommon.  Polypi of
  the uterus are always shaped like a pear,
  and have a thin pedicle. They are almost
  invariably of that species, which  is deno-
  minated fleshy, hardly ever  being  scir-
  rhous, cancerous, or ulcerated.
     The polypus of the first kind, growing
  from the fundus uteri, is very difficult to
  detect in  its incipient state.  While it is
  small, it  produces not  the  smallest per-
  ceptible change in the organs of genera-
  tion.    As  it enlarges,  it  distends the
  uterus, and often excites a suspicion of
  pregnancy, which a more attentive exam-
  ination, however,  soon disperses.  The
  swelling of the abdomen does not take
  place  in  the  degree and space  of time,
# which it does in pregnancy; the menstrual
  discharge continues to flow; the  breasts
  do not become full; and, in the progress
  of the case, no motion is to be felt While
  the polypus lies in the uterus, its growth
  is slow.  It frequently,  at tlus early pe-
  riod, occasions profuse bleeding.  Women
  afflicted with  the disease,  are   seldom
  pregnant,  and when they are so,  parturi-
  tion  commonly  happens   prematurely.
  However, it occasionally occurs, that they
  hold  out  till  the  end of the  regular
  time,  and  experience  an  easy and safe
  delivery.
     As the  polypus encreases, it expands
  the  os  uteri,  and,  at length, protrudes
  into the vagina.  This either  takes place
  suddenly  from an accidental concussion
  of the  body; or  slowly and  gradually.
  In the latter circumstance,  pains similar
  to those of labour occur, and  cause the
  tumour to  be expelled into the  vagina.
  As soon as it has arrived in  this situation,
  and is no  longer confined and compressed
  by tlie uterus, it begins to grow more ra-
  pidly, and gives rise  to far more trouble-
  some complaints.  It presses the bladder
  and rectum, and thus, more or less, dis-
turbs the  evacuation  of the urine and
feces.  But,  in  particular, it causes re-
peated and profuse  hemorrhages, which
weaken the patient exceedingly, and often
bring her to the brink of the grave.  The
root of the polypus is situated in the os
uteri, and is there so compressed, that the
blood in the polypus is prevented from re-
turningthrough the veins; consequently,
all  the vesseb become  turgid,  and the
above effusions of blood  are  the result.
Though they generally cease spontaneous-
ly,  the least circumstances cause their re-
currence i-  such  as slight concussions of
the body in riding, walking,  &c.  In the
mean while,  a quantity of mucous and
aqueous fluid is  voided, by which the pa-
tient's strength  is more reduced.  The
polypus, thefsource of this blood and mu-
cus, is frequently misunderstood, and the
patient is  in  a  perilous state.   So ne-
cessary is it in cases of preternatural dis-
charge from the uterus, always to examine
with the finger, per vaginam.
  When  the polypus has been for soma
time in the vagina, it at length protrudes
from it externally.   This happens gradu-
ally or suddenly, on the occurrence of any
concussions of the body.  Hence, it again
excites additional grievances.  As it cannot
descend so low, without dragging the fun-
dus of the  uterus downward with it, and
occasioning its prolapsus, the patient, on
walking, or standing, commonly experienc-
es a very  painful sense  of dragging, or
stretching, in the pelvis.   As the bladder
and ureters are also forced into a derang-
ed position, the evacuation of urine is, more
or less, disturbed, or rendered  difficult.
The flow of the urine over the  polypus,
as well as the irritation of outward friction
on it, frequently causes it to inflame, be-
come painful, and ulcerated.
  The polypus situated in the vagina, or
protruding from it externally, may easily
be  mistaken  for  a prolapsus uteri: an
error that  may have very perilous conse-
quences ; but, by a careful  examination,
is generally not difficult to avoid.  The
polypus is  softer and less sensible,  than
tlie uterus in the state  of" a prolapsus.
The imperfect prolapsus  uteri, in which
this viscus  is not turned inside out, is be-
trayed by the os tincx, at the lower part
of  which it  is plainly  perceptible.   In
this situation, the polypus may occasion-
ally  have  a  depression,  resembling tlie
mouth ofthe womb, but easy of discrimi-
nation from it.  A probe can be passed
deeply into the os uteri;  .but, not so into
this other opening.  The polypus resem-
bles an inverted pear, that is, it is thickest
below, and becomes gradually thinner up-
ward.  The above species of the prolap-
sus uteri, is thinnest below, and gradual I > 
278
POLYPUS.
increases  in  width upward.  The fallen
uterus may easily be pressed back, and
when it is so, the patient experiences re-
lief.  The polypus does  not admit of be-
ing pressed back, and during an attempt
to do this, the patient is put to much in-
convenience.   A probe may be introduced
by  the side of the polypus deeply to the
fundus uteri.  When passed by the side of
the fallen uterus,  it is very soon stopped
at the upper part of the vagina, which has
sunk  down with  the cervix of this organ.
  It is  much more easy to distinguish a
polypus protruded externally  from  the
vagina,  from  a  perfect  prolapsus uteri,
without inversion.  The os uteri at once
characterises the uterus, as it can here
not only be felt,  but seen.  A  probe may
be  passed deeply  into the vagina, along
the side of the polypus ;  but, not so by
the side of the uterus, for reasons easy of
comprehension.  Moreover, the figure of
the tumour, and the state of the patient,
on an effort being made to reduce the pro-
truded part, betray its real nature.
  The inversio uteri, is commonly the con-
sequence of a difficult labour, and hence
is easily discriminated  from a  polypus,/
by  its occasional cause.  While the in-
verted uterus lies in the vagina, its shape
is broad above, and narrow below; where-
as the polypus is  thin above, and broad
below.  Hence, in  cases of very large po-
lypi in  the vagina, the os uteri is but
little  dilated ; while it is extremely dis-
tended by the incomplete descent of tlie
inverted uterus  itself.   Here,  likewise,
the reduction ofthe part is attended with
relief; while every effort to push back a
polypus causes an aggravation of all the
complaints.
  When the inverted uterus hangs out of
the vagina, its figure, like that of the po-
lypus, is  thin upward, and broad down-
ward ;  and,  like the latter tumour, has
no  aperture at  its lowest part.  Here,
an  erroneous opinion  is very liable to be
formed.   An attentive  observer,  how-
ever, will easily avoid it. The inverted
uterus includes  a  circular fold at its up-
per part,  next to the orifice  of the va-
gina.   This fold is nothing less than  the
os uteri itself, through which the body of
this viscus has descended. There is no-
thing of this kind to be felt in cases of
polypi.  By  the side of a polypus  the
finger or probe may be passed deeply into
the vagina ; but  not so by the side of the
uterus.   The  root of the polypus is firm
and hard  to the touch;  the upper  thin
part ofthe uterus, which is hollow,  has a
soft flabby feel   Useful light is also ge-
nerally thrown on the case, by the above-
mentioned occasional cause of the  pro-
lapsus uteri with inversion.
  In  the  two last descriptions of uterine
polypi,  which are situated  either on the
inside of the cervix,  or  at the margin of
the os  uteri, the disease is, as it were',
from  its commencement  in  the vagina,
and the tumour, when large, produces all
the complaints  attending polypi of the
first kind,  except frequent profuse bleed-
ings.   These seldom occur,  and  when
they  do,  are slight,  because the root  of
the polypus suffers no constriction m the
os uteri.  As it descends out of the vagi-
na, it occasions a prolapsus uteri without
inversion, in addition to the other incon-
veniences.

 TnEATMEST OF POLYPI OF THE  UTERUS.

  Experience evinces,  that  uterine po-
lypi,  when once extirpated, have not that
propensity to be re-produced, which those
of the nose  have.  Extraction  is not fit
to be practised here for obvious reasons'.
Sometimes, however, uterine polypi are
met with,  which have such a  thin and
soft pedicle, that although they ought not
to be  pulled out,  yet they admit of being
twisted off with facility and safety.   Also,
numerous complaints of a serious nature,
are occasionally the result of tying a po-
lypus of the uterus. In this circumstance,
after  the  ligature has been applyed some
days,  we  may  attempt to shorten such
complaints,  by twisting off the tumour
altogether.  This  object  is most  conve-
niently performed with a pair of forceps,
made" something like  Smellie's midwifery
forceps.  As the part of the polypus in
the ligature  is constricted,  thin, and al-
ready partly detached, the tumour, with
a little caution,  may frequently be easily
twisted off, and that without any material
bleeding.  The actual and potential cau-
tery,  are here unnecessary, as there is al-
ways  room to employ the instruments for
applying the  ligature.
  The ligature is the most proper means
of extirpating uterine polypi, and is here
much more  easy of application, than  in
the nose.  HoW large soever the polypus
may  be, there is always abundance of
room  for the introduction of the necessa-
ry instruments.  The  polypus of the ute-
rus has,  commonly,  a thinner pedicle,
than  that of the  nose;  and, hence, its
cure  by the ligature is more expeditious,
than that of  the  latter case.  The swell-
ing of the tumour, after  the ligature  is
applied, occasions here  far less inconve-
nience,  than in  the nose, on account  of
the greater room, and more yielding na-
ture  of the  parts. The  inconveniences
that do arise, are easy of removal; for
instance, the retention of urine may be
relieved by the catheter : costiveness by 
POLYPUS.
279
glysters, &.c.   Uterine  polypi  are also
less  sensible,  than  nasal  ones;   and,
hence, less pain and fever follow the ap-
plication of a ligature  to them.   The
fetid matter, that forms as soon as the
polypus sphacelates, has a free vent out,
and may easily be washed  away by in-
jections.
  That the polypus cannot be tied,  while
it lies in tlie uterus, is easily comprehen-
sible.   But, immediately it  has descend-
ed into the  vagina, the operation may be
undertaken, and  may be performed  with
the same kind of double cannula, as was
employed in the nose.  However, here it
is extremely  requisite, that the cannula
should be rather longer, than that already
described, and somewhat curved.   But,
as the silver wire sometimes breaks, two
other  very  convenient instruments  have
been invented.
  The  first is  M. Levret's instrument.
It consists of two silver cannula:, which
are curved in such a manner, and so united
by  a joint,  that they  are shaped like a
pair of forceps.  After introducing a  li-
gature through the two tubes, so that its
ends hang  out of their lower apertures,
the instrument is to be shut, and passed
upwaru into the vagina, over the polypus,
on whichever side seems most convenient.
Then it is to be opened, and the polypus
is to be pushed through the two  branches
ofthe instrument, which is to be brought
over tlie opposite  side  of  the  tumour.
In  doing this, the ligature becomes ap-
pbed round the root of the  polypus, and
'forms a noose.   The  extremities of tlie
ligature  are next to  be drawn as tightly
as possible  out of the lower openings  of
the cannula,  and tied first  in a surgical
knot,  and  then in a slip-knot.  When
this is done, the instrument is shut, and
the ligature constricts  the root of the po-
lypus.  Afterwards it  is to be tightened
daily, until the tumour separates.
  It  is plain, that this instrument has
some defects,  which are, however,  easily
amended.  It is very inconvenient, that
it should be necessary for the surgeon to
have several such instruments, of varioHS
sizes, and curvatures,  to be able to  select
that, Avhich  seems most calculated for the
magnitude  and  .shape of  the  polypus.
Moreover,  as  the size and  figure of the
polypus  cannot  always be ascertained be-
forehand, it is often indispensable  to try
several instruments, ere the  most suitable
one  is found out, and such fruitless at-
tempts must be very irksome and painful
to tlie patient.  The worst is, that though
the upper ends of the instrument were to
touch,  when the lower are tied  together,
yet there  would always be a space be-
•weeu the two apertures, where no liga-
ture would be applied to tiie root of the
polypus, and where, consequently, its se-
paration would not easily be accomplish-
ed.  The tubes may, also, bend with the
force used in applying them,  and the
pain caused by the expansion of the in-
strument, would then be very considerably
increased.
  All these defects are done away in the
instrument described by Nissen, de poly pis
uteri, (See Richter's Chir. Bibl.  9. B. S.
613.)   It consists of two silver tubes,
twelve inches  in  length, and as thick as
an ordinary writing pen.  Both are curv-
ed about as much as the os sacrum ;   but,
as they are made of pure silver, tiie curva-
ture may easily be increased or diminish-
ed, according to circumstances. Through
each of the cannulas a strong ligature is
to be passed, so that its ends hang out of
the lower apertures, while its middle por-
tion forms  a  noose between the upper
apertures of the cannulz.
  The tubes are to be kept together, un-
til they have been introduced into the va-
gina, as far as the root of  the  polypus.
One is then to be held fast, while the other
is to be carried round the tumour, to the
opposite side of the cannula that remains
stationary.  Thus the ligature  becomes
applied  round the root of  the  polypus.
After introducing the finger into the va-
gina, to ascertain that the ligature lies in
its  proper situation,  its ends are to be
drawn through a small double  cannula,
which is  only one third of an inch  long,
but so wide that it can be pushed over
both the lubes a certain way with the fin-
ger, and  the upper end of the long can-
nulas with the aid of a sort of long probe,
with a forked extremity.  Then a  third
double  cannula, through which  the ends
ofthe ligatures have likewise been passed,
and the width of  which is sufficient, is to
be pushed over the lower ends of the long
cannulz,  so as to unite them.  The liga-
tures are next to be  drawn tight in the
ordinary way, and fastened  to the rings.
The  management of this instrument  is
so easy, as to need no further  explana-
tion.
  This  instrument is  certainly far supe-
rior to any one  commonly  used in this
country.  It  is   difficult  to  pronounce,
whether its simplicity; aptness for the
object intended;  or, the facility  of using
it; lays the greatest claim  to bur  com-
mendations.  'Ihe  same reasons, which
recommend its employment  in polypi of
the uterus,  equally point out  the 'advan-
tage of having an instrument, construct-
ed on the same principle, for tying nasal
ones.
   Besides the above  instruments, there
are numerous other ones, that have been 
280                               FOLYPUS
  devised, and recommended for tying po-
  lypi of the uterus.  That, invented by
  Desault, claims the attention of such sur-
  geons, as wish to be informed of others.
    Acute symptoms frequently follow the
  application of the ligature, and are either
  of an  inflammatory, or spasmodic kind.
  The former require antiphlogistic treat-
  ment.  Sometimes a fever arises, and the
  polypus becomes exceedingly painful: in
  this case, venesection is often  necessary.
  Tlie spasmodic symptoms require the ex-
  hibition of opium.  When this is ineffec-
* tual, and the symptoms are severe, it may
  be proper to slacken the ligature a little.
  As the polypus at first always swells, it
  produces great pressure on the adjacent
  parts.  For this reason, it is generally ne-
  cessary, for the firat few.days, to draw off
  the urine with the catheter, and to open
 ■ the bowels with glysters.   Sometimes he-
  morrhage takes place.   This is generally
  suppressed by astringents ;   but, when
  they prove ineffectual,  tying the ligature
  more tightly answers the purpose.  The
  rest of the treatment  resembles that of
  nasal polypi.
    WThen the polypus is large, forceps are,
  in the end, often necessary for its extrac-
  tion.   The  inflammation,  or  ulceration,
  that  may  possibly be occasioned  in the
  vagina by  the  fetid  matter, is easily re-
  moved by injectidns after the detachment
  of the polypus. As the ligature is always
  applied round the pedicle, closely to the
  os uteri,  consequently  seldom  to  the
  root of the polypus,  whieh is  usually at
  the fundus uteri, there is almost always a
  portion of the  root remaining  behind, af-
  ter the tumour has separated. Though
  it is said, that  this afterwards diminishes,
  and falls off;  yet, it is quite a matter of
  uncertainty. But, it is an undoubted fact,
  that the polypus uteri is exceedingly sel-
  dom reproduced.  {Richter.)
    This author observes, that cutting in-
  struments are, in general, improper to be
  Used for polypi of the uterus, as their em-
  ployment would injure the vagina, and,
  for the most part, occasion a  dangerous
  hemorrhage.   There  is,  however,  one
  case, where the knife is indispensable.
  The polypus has occasionally a ligament-
  ous pedicle, and consequently can  neither
  be tied, nor extracted. This circumstance
  is usually undiscovered till after a ligature
  has been applied, which here  commonly
  produces extraordinary pain, and,  though
  it be applied  ever so long, and forcibly
  occasions no detachment of the polypus.
  In this instance, the surgeon  has the
  choice of two plans.  He may either cut
  off the polypus closely to its root in the
  vagina ;  or he may first draw it gradually
  downward out of this situation. The first
object might, perhaps, be perflated with
a  sharp  hook, somewhat curved at its
side, and similar to what is used for tear-
ing the foetus piecemeal in  the uterus;
or, with what seems better, a pair of long,
curved, blunt-pointed scissars.  The last
object may be accomplished  with  forceps
resembling   Smellie's   midwifery   ones.
They are to be introduced into the vagina
in the ordinary way.   The polypus  is
then to be taken hold  of, and  gradually
drawn so far  out of the vagina, that its
pedicle may be divided with  a knife. This
is, indeed, not done without pain, and a
forcible inversion of the uterus ; but, it
is always free   from  dangerous conse-
quences.   When a  polypus, the root of
which is attached to  the fundus uteri,
lies in the vagina, the uterus is always, in
some degree, inverted  beforehand; and
this  state is, therefore, only  increased
by the foregoing plan, which never creates
danger, when done slowly, and cautious-
ly.   How often has the  uterus  been sud-
denly inverted, and forced outward, with-
out;  fatal  consequences!  Besides,  the
above plan  has already  been successfully
practised.  (See Herbiniaux Parallele des
differens  Instrumens pour la  Ligature des
Polypes.)
  When  a  polypus,  that has its  pedicle
attached  to the fundus uteri, suddenly
falls  downward, it  occasions  a  sudden
inversion of this viscus. In order to re-
lieve, as  speedily as possible,  the great
pain, and danger of this case, the surgeon
must, tie the root  of the   polypus, as
soon, and as firmly as he can, and pass the
ligature,  by means of  a needle, through
the pedicle, before the  place where  it is
tied, allowing the ends afterwards to hang
down for some  length.  Then  tiie  poly-
pus is to be amputated below the ligature,
and  the uterus immediately reduced.—
This is another example, where a cutting
instrument may be used with advantage.
The ordinary method  of  tying such  tu-
mours, so situated,  accomplishes only a
slow detachment of them, and is not suf-
ficiently expeditious in  procuring relief. '
  Fleshy excrescences  also  occasionally
form in the vagina, some of  which have a
broad basis, and others  a  thin pedicle.
The last merit the  appellation of polypi.
Their existence  is  easily  ascertained by
the touch.   By  making pressure on  tlie
bladder,  and rectum, they occasion seve-
ral impediments to  the evacuation of the
urine, and feces.  They may  be most con-
veniently tied, by means  of the  double
cannula.  Should the polypus be situated
at the lower part of the vagina, the can-
nula'would not  be  required.  The liga-
ture might be applied with the hand, and
the tumour cut off below it. 
POLYPUS.                             281
  There is  still  another kind of tumour
 ki the vagina, to be classed in the rank of
 polypi.   It  resembles,  in  many points,
 the polypus of the mucous membrane of
 the  nostril, consisting  altogether  of the
 membranous lining of the vagina, which,
 at the part affected, becomes  relaxed,
 thickened, and  elongated;  hence,  tiie
 tumour might more properly be termed a
 prolapsus of tlie membrane lining the vagina,
 than a polypus. When it resists theefficacy
 of astringent and corroborant injections, it
 may be tied,  or, what  is better, cut off.
   A polypus  in  the oesophagus renders
 deglutition difficult; and,  when of large
 size, puts an entire stop to it.   When an
 inclination to vomit is excited by irritat-
 ing the  throat  with the finger, or a fea-
 ther, the polypus, if situated towards the
 upper part of  ,the tube,  ascends into  the
 mouth,  so as to become visible.  But, as
 it impedes respiration during its residence
 in the mouth,  the patient is soon necessi-
 tated, as  it were, to swallow it  again.
 When the polypus is situated at the lower
 part of the oesophagus, of course, it can-
 not be  brought  into the mouth, and  is
 very difficult  to  detect.  The difficulty
 of swallowing, its only symptom, may re-
 sult from other causes.  In this case, it is
 also incurable;  for,  it  is  impossible to
 take hold of  it   with  instruments.   An
 operation can only be practised, when the
 polypus is situated at the upper part of
 the oesophagus.   The tumour obviously
 cannot be extracted ; it can only be tied,
 and this is  difficult.  In order to apply
 the ligature, the excrescence must be first
 brought into the mouth by exciting an
 effort to vomit.  As this impedes respira-
 tion, the operation must be done with the
 utmost celerity, and the ends of the liga-
 ture cut off short, that  the patient may
 immediately swallow  the tumour  again.
 It is easy to discern, that in this way,  the
 ligature is never applied sufficiently close
 to the root of the polypus,  nor tightly
 enough:  consequently, the separation of
 the tied portion either does not take place
 at all, or very slowly ; and a  large part
 commonly remains behind, which  soon
 attains   its former bulk, and  causes  its
 preceding inconveniences.   Perhaps,  the
 operation might  be performed with more
 exactness and success, if an opening were
 previously made into the trachea by bron-
 cliotomy.  Then the patient might breathe
 through the aperture, the polypus  might
continue in the mouth  during the whole
cure, until detached ; and perhaps, might
 be tied close to  its root, by means of a
curbed tube.  Experience, (adds Richter)
must decide, whether this plan is advan-
tageous, and practicable.
  Polypi in the rectum maybe felt by the
    Vot. II.
 fingers.  The first suspicion of them arises
 from the impediment to the evacuation of
 the excrement.  They are to be tied with
 the  aid of the cannulz.   Excrescences
 in the meatus  auditorius  eiternus,  re-
 sembling polypi,  have been successfully
 extirpated by  extraction; or  rather by
 twisting them off.
   For  many of the foregoing  remarks, I
 am indebted to  Richter,  who has very
 ably  treated of polypi  in  his Anfangs,
 der  Wundarzn. Band. 1, Kap. 21.   Sec
 also Pott's Remarks on the Polypus of the
 Nose.   Whately's 'Two Cases of Extraor-
 dinary Polypi.  John BelVs Principles  of
 Surgery,  Vol. 3,  Part.  1.   Encyclopedic
 Methodique; Art  Polype.
   PROCIDE'NTIA.   (from procido,  to
fall down.)  A prolapsus, or falling down
of any part.  (See Anus, Prolapsus of;
 Uterus, Prolapsus of,  &c.
   PROGNO'SIS. (from «"£o, before, and
ytvtto-KU, to know.) A knowledge of the
signs, by which we foretel what will hap-
pen to tlie patient.
   PROLAPSUS,  (from  prolabor,  to slip
 down.) A falling down of any part. Same
as Procidentia.
   PROSTATE  GLAND, DISEASE OF.
According to  Mr.   Homej  the  pros-
tate  gland is not a very sensible part.  Dr.
Baillie has seen a common abscess situat-
ed in it, and he says, that it is also sub-
ject  to scrophulous disease, as, on cutting
into it, he has met wiih the same white
curdy matter, which is formed in  a scro-
phulous absorbent gland.  He has  like-
wise forced out of its  ducts scrophulous
pus.
  The most frequent disease of this part
is a scirrhous  enlargement of it,  when,
from its natural size of  a chesnut,  it be-
comes  as  large as the  fist.  When cut
into, it  exhibits a very  firm whitish, or
brown substance, containing membranous
septa.   Sometimes its external surface is
ulcerated,  though this  is  not often the
case ; and  fistulous communications are
occasionally formed with the rectum.   A
considerable enlargement of tiie prostate
gland is attended with great difficulty of
voiding the urine, and the  muscular coat
of the bladder  becomes, in consequence
of the efforts it has to make, very much
thickened.  This  disease of the prostate
gland seldom occurs, except in old men,
and  is not so common as  many suppose.
Mr. Home observes, that  the morbid en-
largement of the gland docs not diminish
the size of the passage  into the bladder,
but rather increases it.   The lateral por-
tions of the gland as  they swell, widen
the passage between them, rendering it of
an oval form; it is therefore the project-
     N s 
^                 PRO

ing portion, from the lower part,  which
prevents the urine from flowing, and ob-
structs an instrument in  its passage into
tlie bladder.  The  obstruction,  in some
instances, arises from the two sides ofthe
gland enlatging  unequally;  the  larger
portion   pressing  against  the  smaller,
which is made hollow to receive it, so that
the passage winds  round the  projecting
part, and this  winding cannot be  followed
by an instrument.
  Mr. Home remarks, that  a  stricture
may be distinguished from an enlargement
of the prostate gland, by the following
circumstances: the distance of  the ob-
struction from the external orifice is to be
determined by passing a soft bougie, which
is to be left in the canal  for a minute, so
as to receive an  impression  from the ob-
struction.  If  the bougie does  not pass
further than seven inches, anil the  end is
marked by an orifice of  a circular form,
(it is immaterial as to the size of the ori-
fice,) the disease is  certainly a stricture ;
but, if it passes further on, and the end is
blunted, a  disease  in the prostate gland
is to be suspected.   This in general can
be ascertained by a flexible gum catheter
with a stilet,  very much curved, passing
into the bladder, which it will do, in most
cases of enlargement ofthe gland.
  Among the symptoms of a diseased pro-
state, we have  also to mention, a difficulty
of voiding  the feces ;  an occasional  dis-
charge of  a kind of mucus;  an uneasy
sensation about the rectum, after going
to stool, as if more of the feces remained
undischarged.  The difference  between
the symptoms of a  stone in the  bladder,
and  those  arising from  disease of the
prostate, is explained in the article Litho-
tomy.
  Tlie occasional retentions of urine, to
which patients with disease of the prostate
are subject, to require the introduction of
the catheter, and the surgeon will succeed
in passing this instrument better, when he
remembers, that the urethra, in  conse-
quence-bf the  disease,  makes a very sud-
den turn upward, just before it terminates
in the bladder.
  The enlargement of the prostate gland
may often be  felt by passing a finger into
the rectum.   Surgeons are unacquainted
with any certain mode of diminishing the
scirrhous  enlargement of the  prostate
gland.   The pilula hydrargyri  cum c/cutu
have  been recommended.  (See Pilulx.)
Mr. Home mentions a case, in which sup-
positories of opium and hemlock,  passed
up the  fundament,  and  allowed  to dis-
solve there, gave more  relief,  than any
other plan; they not only lessened the ir-
ritation, but produced a diminution of the
projection of the gland.
               P SO

  Some abscesses,  and ulcerations of the
prostate,  in  consequence  of strictures,
may be cured, by removing the latter dis-
ease.
  The prostate gland  has  occasionally
small calculi in the ducts : but, the disease
is  so  uncommon, that authors have not
ascertained the particular symptoms, &c.
I shall conclude with  referring to Baffle's
Morbid Anatomy ;  Home on  Strictures. Vol.
1,  and on Diseases of tlie Prostate  Gland.
   PRURITUS, (from prurio, to itch.)  A
violent itching.
   PSEUDOSYPHIL1S.  (from  fyvhf,
false, and Syphylis, a shepherd, who fed
the  flocks of  King Alcinous, and who,
proud of their number  and beauty,  in-
suited  the  Sun;  as a  punishment  for
which, the venereal disease  was sent on
earth ; or from e-i^Aoj, filthy.)   Disease,
resembling the venereal, but not really of
this nature.  The spurious venereal dis-
ease.   (See Venereal Disease.)
   PSOAS ABSCESS.  See  Lumbar Ab-
scess.
   PSORA,  (from -^cti^u, to rub.)  The
itch,  which  is  attended with a perpetual
inclination to rub,  or scratch the parts.
   PSOROPHTHALMY.    (from  t},^*,
the itch, and  epixk/uct, an inflammation
ofthe eye.)   An inflammation of the eye-
lids,  attended  with' ulcerations, which
itch very much.  By psorophthalmy Mr.
Ware means a case,  in which the inflam-
mation qf the eyelids is attended with an
ulceration of their edges,  upon  which a
glutinous matter, lodges, incrusts, and be-
comes hard, so that, in sleep, when they
have been long in contact, they become so
adherent, that they cannot be separated
without pain.
   Mr. Ware  remarks, that " the ulcera-
tion in the psorophthalmy is usually con-
fined to the edges of the  eyelids; but,
sometimes, it is seen  to extend over their
whole external surface, and even to exco-
riate  the  greater part of the cheek.   In
cases of the latter kind, the  inflammation
which accompanies, has often much the
appearance of an  erisypelas,  and will re-
ceive most relief from cooling applications.
The use  of  the, citrine ointment,  which
will hereafter  be recommended, must, in
such  instances, be deferred until the irri-
tability of the  skin is in  a good degree
abated.
   " This  disorder is also,  sometimes, at-
tended with a contraction of the skin of
the  lower  eyelid;  in  consequence  of
which, that lid is  drawn  down, and  the
inner part turned outward,. so as to form
a  red, fleshy,  and most disagreeable ap-
pearance, called ectropium.  Whenever
this happens, it proves the complaint  to 
               PTE

be of the most obstinate nature; though
it is generally removed by the cure ofthe
psorophthalmy,  which is the occasion of
it."  (Remarks on Ophtlialmy, &c. p. 112.)
Mr. Ware recommends, for the cure of
this disease,  the unguentum hydrargyri
nitrati.   This-is to be melted into an oil,
and rubbed with the end of the forefinger,
or the point of a small pencil-brush, into
the edges  of the affected  eyelids,  once
every night, on going to bed. A plaster
of ceratum album  is then put  over  the
eyelids to  keep them  from  adhering to-
gether.   If they should still adhere in the
morning, he advises cleaning them with
milk and butter, well mixed together.  In
a few cases, it is necessary to  touch the ul-
cers, forrried on the edge of the eyelid, after
the small-pox, with the argentum  nitra-
tum.  When the globe of the eye  is iir-
fiamed,  use  the thebaic tincture, as di-
rected in the article Ophthalmy.  In scro-
phulous  subjects,  alterative medicines ;
an issue, or perpetual blister; and atten-
tion to diet, &c. are proper.   (See  Ware
on Ophthalmy, &c,)
  PTERYGIUM,  (dim. of a-Teft/f, a
wing.)  Scarpa accurately  remarks, that
surgeons apply the  term "pterygium" to
that preternatural,  reddish, ash-coloured,
triangular  little membrane,  which  most
frequently grows from the  internal  angle
of tlie eye,  near the caruncula lachrymalis,
and gradually extends over the cornea, so
as to cause  considerable  impediment to
vision.
  Though  the pterygium most commonly
proceeds from the internal angle, it is ob-
served to arise sometimes from  the  ex-
ternal one, and, in some instances, from
the superior,  or inferiour hemisphere of
the eye-ball.  But, whatever be its origin,
its  figure is  invariably that of a triangle,
with its base on the white ofthe eye, and
its apex more or less advanced  over  the
cornea, towards its centre, and that ofthe
pupil.  Indeed, there are a few  cases, in
which two,  or three pterygia of  different
sizes occur on the  same eye, and are ar-
ranged round its  circumference  at  inter-
spaces of various breadths.   Their points
are directed towards the centre ofthe cor-
nea, and if they should unfortunately con-
join there,  the whole of that transparenl
membrane becomes covered With an opaque
veil, and a total loss of sight is the con-
sequence.  It seems to Scarpa,  that  the
term  "  pannus"  was  applied   by  the
ancients  to exactly this sort of  compli-
cation.
  Strictly  speaking,   chronic   varicous
ophthalmy, with relaxation, and thicken-
ing of the  conjunctiva;  opacity of  the
cornea ; and the pterygium ; only  differ
in the degree of tfie disease.  In reality,
                PTE               233

all the three complaints consist ofa more,
or less extensive varicous state of the ves-
sels  of the conjunctiva, combined with a
degree  of preternatural relaxation, and
thickening, of that membrane.
   In chronic varicous ophthalmy, the ex-
traordinary amplitude,  and knottiness of
the vessels ; the flaccidity, and thickening
of the  conjunctiva;  t"e limited to  the
white of the eye.  In opacity of the cor-
nea, certain  veins  even dilate, and  be-
come knotty, for some way, over  that
delicate layer of the conjunctiva, which is
continued over the surface of the cornea.
In the pterygiu.V, an extraordinary swell-
ing of this subtile membranous expansion
is added to the varicous state of its veins.
Hence,  the pterygium seems  at first like
a netv membrane formed on the cornea,
while it is really nothing more,  than the
delicate continuation of the conjunctiva
just mentioned, deprived of  its  transpar-
ency, and degenerated,  in consequence of
chronic ophthalmy, into a  'thick, opaque
membrane, on which there is a plexus of
varicous  blood-veswels.    Consequently,
in the case of  pterygium, there is no new
production on  the eye, but only an altera-
tion of one of the thin,  transparent mem-
branes,  which naturally cover  it.  The
following circumstance, as will be more
fully explained presently, illustrates, says
Scarpa,  the  veracity of  the preceding
statement.  The incipient pterygium may
be cured in the  same manner as opacity
of the cornea, viz. by merely cutting off
that portion of it, which is situated at the
junction ofthe cornea with the sclerotica,
without detaching the  whole of it from
the surface ofthe former membrane ; just
as is  practised in opacity  of the cornea,
in order to destroy the communication of
l'«* varicous veins ofthe conjunctiva with
their  trunks, the ramifications of which
produce, and maintain the disease.
  Scarpa  observes,  that the  pterygium
would be as  common a complaint as tiie
varicous chrome ophthalmy, so often oc-
cupying the white of tlie eye, if  the deli-
cate continuation of tlie conjunctiva, over
the surface of  the cornea, were not natu-
rally of a denser,  and more compact tex-
ture, than the rest ofthe membrane, from
which  it is produced, and if its vessels
were not very minute, and delicate, and
not so dilatable as those of the other part
of tlje  conjunctiva.  This  is  the  reason
why the pterygiun>is comparatively a rare
case, in respect to the great frequency of
varicous, chronic ophthalmies. But, should
the vessels ofthe transparent layer ofthe
conjunctiva once yield to the impulse of
the fluid propelled  into them ;   should
they once become varicous; the cellular
texture, in  which  they niv  enveloped, 
284
PTERYGIUM.
 never fails to swell gradually, and, thus,
 the  delicate,   diaphanous membrane in
 question, changes into a pulpy, reddish
 tunic, precisely similar to the pterygium.
   That the pterygium is truly nothing else
 but the natural, delicate, transparent ex-
 pansion of the  conjunctiva, on the cornea,
 converted,  for a  certain extent, into a
Lpulpy, flaccid varicous membrane, may be
 inferred  (continues  Scarpa)  from  the
 folds,  which the  pterygium and conjunc-
 tiva form at the same time, when the mor-
 bid  eye  is turned towards the  origin of
 the disease. The same inference is equally
 deducible from tlie tensi f.\ occasioned in
 both these parts,  whenever the eye is
 moved in the opposite direction.  We be-
 come still more convinced of the fact on
 observing, that in  the first position of the
 eye, both the  pterygium, and the  corre-
 sponding portion of the conjunctiva (which
 is equally relaxed, varicous, and reddish,)
 may be easily taken hold of with a smalt
 pair of forceps, and raised together in the
 form ofa fold.
   When the pterygium is met with in the
 dead subject, on carefully cutting off", and
 detaching,  that  flaccid,  and thickened
 portion of the conjunctiva, in the  white
 of the  eye,  which corresponded to the
 part of the cornea in the  state of opacity
 from the pterygium, Scarpa has constant-
 ly found, that the pterygium might be se-
 parated,  with  equal facility,  both on the
 white  of the eye,  and the cornea.   The
 latter  membrane  was  evidently  denuded
 at the seat of the  disease, being no longer
 covered with the transparenl continuation
 of the conjunctiva. But, Scarpa has never
 been able to deprive the cornea of  its na-
 tural covering, beyond the limits of the
 pterygium.   Also, when several pterygia
 occur on the same eye, with interspi^.-s
 between them, as many flaccid, varicous,
 pulpy places appear in the conjunctiva on
 the bulb, and constitute the basis of the
 pterygia; while the rest of this membrane,
 covering the white of the eye, continues
 smoothly spread over the ball, and no va-
 ricous blood-vessel is perceptible on the
 anteriour hemisphere  fcf the eye, except
 where the relaxation  of  the conjunctiva,
 and the  knottiness of the vessels,   have
 implanted,  as  it were, the  distant roots,
 and rudiments of the pterygium.
   The pterygium, whether large, or small,
 and whatever  its  situation  may be at the
 circumference of the eye-ball, constantly
 retains its triangular shape,  with its  base
 on the white of the eye, and its apex on
 the cornea.   The constancy of this fact
 seems to Scarpa  attributable  to the in-
 creasing degree of firmness, with which
 the subtile,  transparent layer of the con-
 junctiva adheres to the surface of the cor-
nea, as it proceeds from the circumference
to tiie centre of that membrane.  Tlie fol-
lowing consequences must necessarily re-
sult from this  sort of structure, and the
different degree of cohesion, actually ex.
isting in healthy eyes.  1. The progress
of the pterygium must be slower in every
instance on the cornea, than on the white
of the eye.  2. As the pterygium  always
meets with augmented resistance,  in pro-
portion  as it endeavours to approach the-
centre ofthe cornea, it must, from mecha-
nical  necessity assume the form of a tri-
angle, with its base  on tiie white of the
eye, and its apex directed towards  the
centre of the  cornea.  Forestus  (Oper.
Med.) has accurately noticed the circum-
stances  of this appearance, and, he con.
tinues :  non cooperit oculum nisi in forma
s.agittx.    _  .'
  From this  invariable appearance, and
figure of the pterygium, one of its princi-
pal diagnostic characters results, by which
the  true disease may be discriminated
from false instances, and from every other
soft, fungous,  reddish  excrescence, that
obscures  the  cornea.  For, on this mem-
brane,  excrescences  sometimes   form,
which,  from having the colour and con-
sistence of a  soft membrane, bear a very
great  resemblance  to  the  pterygium,
though they are really widely  different,
and strictly speaking, consist of the tex-
ture ofthe cornea itself, degenerated into
a soft, fungous substance.  Such pellicles,
however, not  only almost always create a
greater  prominence on the  cornea, than
what accompanies  the pterygium, but
they  are  constantly of  an irregular tu-
berous  form,  and never  represent a tri-
angle,  with the apex pointing towards
the centre of the cornea, like the genuine
pterygium.
  Another distinguishing character ofthe
pterygium (continues Scarpa) consists  in
tlie facility, with which  the whole of it
may be taken hold of with a pair of for-
ceps, and raised into a fold on the cornea.
Every other kind of excrescence, attached
to this  membrane,  continues firmly ad-
herent  to  it,  and cannot be  folded, and
raised from the surface of the cornea,  in
any manner  whatever.   This  particu-
 larity is of the highest importance in the
 treatment of the disease; for, the genuine
 pterygium may be cured by simple means,
 while fungous excrescences ofthe cornea,
 can only be radically removed, and per-
 fectly cicatrized witii the utmost difficul-
 ty.  Plenck  very  properly  observes, on
 this head : Pterygia, qua filamentis solum-
 modd adhxrent, facile abscinduntur, difficil-
 lime qux ubique accreta sunt cornets, ac in
 plicum elevari non possunt.  If this excres-
 cence  should adhere  firmly to the cor- 
PTERYGIUM.
285
nea, be ofa deep red colour, easily bleed
on being  touched, and, cause  shooting
pains  in  the whole eye, and  temple,
though  it be of a triangular figure, and
constitute the  true pterygium, it  now
threatens to assume a malignant' cancer-
ous nature, or has done so already. Hence,
in the treatment, it is necessary only  to
adopt a  palliative plan, or else extirpate
the whole eye-ball.
  The  true, benign   pterygium,  says
Scarpa,  which has a triangular figure, is
ash-coloured, or pale-red,  is  free  from
pain,  and admits of being raised in the
form of a fold on the surface of the cor-
nea, may be cured by cutting the opaque
triangular  little membrane  accurately
from the surface of the  cornea,  which is
in part covered by it.  But, as it appears,
from what has been said, that the ptery-
gium  is nothing, but  a portion  of the
delicate, transparent  layer of  the  con-
junctiva, converted by chronic  varicous
ophthalmy into a thick, opaque  tunic,  it
follows, that the pterygium cannot be re-
moved in any way, without the spot, which
it occupies on the cornea, being  bereft of
its natural  external covering.   Also,  as
this  denudation  of the cornea renders
a cicatrix  unavoidable at the  place, it
equally  follows, that the knife cannot be
employed in the cure of the disease, with-
out the  cornea  being rendered more  or
less opaque at the part, where the ptery-
gium was before situated.   Hence, Scarpa
cautions young surgeons  not  to allow
themselves to be deceived by ihe specious
accounts of authors, who assert, that they
have removed pterygia with the scalpel,
and entirely restored  to the cornea its
former  natural transparency.  It is  true
(says he) that, after the  removal, and
cure, of the pterygium, the cornea at the
part affected becomes less opaque than it
was before ;  but, the place always  con-
tinues dim, and clouded with  an indeli-
ble,  though  a superficial cicatrix.  The
amendment,  derived from the operation,
cannot but be considerable; by means  of
the incision, and firm  cicatrix,  a stop is
put to the progress of the complaint,  or
rather to the increase of the varicous af-
fection, and swelling, of the thin, trans-
parent layer, of the conjunctiva,  situated
on the cornea;  the local cause  of irrita-
tion,  and inflammation of the eye, is en-
tirely obviated;  and, thus, complete opa-
city  of the  cornea is  prevented.  But,
should  it ever  have  happened  after the
recision of a large pterygium, that the
patient  regained his sight,  we are to un-
derstand a  certain degree of virion ; in
that proportion (Scarpa wishes  to signi-
fy) which exists between a dense mem-
brane, which entirely obstructs  tfte pas-
sage of the light, and a slight, superficial
cicatrix ofthe cornea, which does not in-
tercept it altogether.
  Scarpa's  experience  enables  him to
state, however, that the  superficial, inde-
lible speck, remaining on the cornea, af-
ter the recision of* tiie pterygium,  is al-
ways less extensive, than the  space pre-
viously occupied by  the  disease.  This
fact, says he, is a constant one, and, in the
vast number of pterygia, for which he has
operated, some had advanced over the
cornea two lines, others two  and a half,
towards its centre^.  In all, the scar, and
opacity, of  the cornea, diminished after
the cure was perfected, and never exceed-
ed a line and a half, or a little  more, in
cases, in which the pterygia had been two
lines in length.
  The recision of the pterygium  is a very
easy operation.  For this  purpose,  there
is no occasion for a needle threaded with
silk, which most surgeons  recommend to
be passed through the little membrane, in
order to make a noose for raising the pel-
licle, which  must be divided  at  its base.
The plan is disadvantageous, as it pro-
longs  the  operation considerably, and,
particularly, as  the  bleeding from the
punctures prevents the operator from dis-
tinguishing, with the necessary clearness,
the margin of  the parts designed for re-
moval. A pair of dissecting forceps, and a
parr of sharp  scissars,  suffice  for this
operation.
  It is customary (continues  Scarpa) to
remove the  pterygium by making the in-
cision on the cornea, and extending it over
the white of the eye, as far as the base of
tiie disease  reaches on  the conjunctiva;
so that when the pterygium grows from
the internal  angle of the eye, most sur-
geons continue the  section as far as the
caruncule.   This practice  is disadvanta-
geous, first,  because it denudes too much
ofthe white of the eye ; secondly, because,
in consequence ofthe large portion ofthe
conjunctiva  removed at the base  of the
pterygium,  and,  in consequence  of the
direction of the wound, the cicatrix  in the
white of the eye, forma an elevated frz-
num, which, like a little cord, keeps the
eye-ball  approximated to the caruncula
lachrymalis, and destroys the freedom of
its motions,  particularly, towards the ex-
ternal angle.
   To  avoid this inconvenience, Scarpa
says, he has found it useful, in the  treat-
ment of pterygia with bases extending
far in the white ofthe eye, to detach them
at their apex,  as far as the  junction of
the cornea with the sclerotica,  and then
to separate them at their base by a semi-
circular incision, comprehending one fine
in breadth ofthe substance ofthe com une- 
286
PTERYGIUM.
 tiva, and made in a direction concentrical
 with the edge of the cornea.  Scarpa has
 observed, that, in this mode of operating,
 the subsequent cure takes  place  sooner,
 than when the common method is adopt-
 ed ;  the cicatrix occasions no sort of frz-
 num, and  the  conjunctiva,  circularly
 stretched  by the cicatrix,  lies  smoothly
 over the white of the eye, and loses  that
 relaxation, and varicous state, which are
 the groundwork of the pterygium.   Such
 attention,  however, is not requisite,  when
 the pterygium is  small, and its base does
 not extend far in the white of the eye.
   Scarpa describes the operation, as fol-
 lows :   The  patient being seated, an as-
 sistant behind him is to elevate the upper
, eyelid with the index and  middle fingers
 of one hand, while he depresses the lower
 eyelid with the corresponding ones of the
 other.   Supposing it tiie right eye, the
 operator is to stand, or sit down, just as
 he  prefers,  in front of the patient; and
 the former, after directing the latter to
 move his eyeball towards  the part cor-
 responding to the base of the pterygium,
 is to seize the morbid  membrane with a
 pair of forceps held in his left hand, and
 pinch it into a fold, at about one line from
 its apex.  The duplicature is now to be
 raised, and  drawn out gently until a sen-
 sation of  something giving way  is  felt,
 which  indicates  the detachment of the
 pterygium from the delicate cellular tex-
 ture, by which it is connected with the
 subjacent  cornea.  Next, by means of a
 pair of scissars in the right hand, the sur-
 geon must dissect this fold, as closely as
 possible,  from  the  cornea, proceeding
 from the apex towards the base of the
 pterygium.  The section being completed
 to where the cornea and sclerotica  meet,
 the fold is to be again elevated still more,
 and, with  one stroke of tiie scissars, the
 pterygium, and the relaxed portion of the
 conjunctiva,  forming its base, are to be
 detached, as concentrically,  and  closely
 to the cornea, as possible.   This  second
 incision will  have  a  semilunar shape,
 the  horns of which ought to extend two
 lines beyond  the relaxed part of the con-
 junctiva in following the curvature of the
 eye-ball.
   When the operation is finished, the sur-
 geon must promote  the hemorrhage ; by
 washing the  part with warm water, and
 then cover the eye, tbat has been operated
 on, with  a pledget of dry lint, or lint
 moistened  in tiie aqua vegeto-mineralis,
 supported by a bandage,  that does not
 make too much pressure on the part.
   If no particular symptoms arise,  (con-
 tinues  Scarpa) such as pain, tension  of
 the eye, considerable tumefaction of the
 eyelids, it  is sufficient to  wash the eye,
and inside of the eyelids, three  or fouf
times a day with a  warm lotion  of mal-
lows, and carefully keep these parts from
being exposed  to the air, without com-
pressing them.  If the symptoms just men-
tioned should afterwards occur,  the anti-
phlogistic treatment must be adopted in
its full extent, &c.
  On the fifth or sixth day, at latest, after
the operation, all the surface, from which
the pterygium was cut, appears yellowish,
and covered  with a  fluid,  like  mucus.
This is a mode  of suppuration (says Scar-
pa) peculiar  to  membranes in  general,
and particularly, to those of the eye. The
edges of the wound, and the adjoining
part ofthe conjunctiva, assume a reddish
colour. Afterwards,  the surface  of tlie
wound contracts more and more daily, so
that, at length, it completely closes, and
tlie cicatrix forms.
  During the  whole treatment,  subse-
quent to the operation, there is no occa-
sion to employ  any other topical applica-
tions,  but the  warm lotion of mallows,
three or  four  times a day. Numerous
cases have convinced Scarpa, that  astrin-
gent collyria, and the boasted powders of
the florentine iris, and alum,  cause great
irritation to* the eye  operated on, and give
rise to tumefaction, and  a  fungous-like
state of the conjunctiva, which are impe-
diments to the cure.  What  is still more
incommodious, is, that such means pro-
duce fungous excrescences on the middle
ofthe wound itself, which only admit of
being repressed and cicatrized with diffi-
culty.  Scarpa  has  seen all these incon-
veniences arise  from one single unneces-
sary application ofthe argentum nitratum.
On  the other hand, when a  mere lotion
of mallows is the only remedy employed
in the treatment, the cure proceeds regu-
larly ;  the yellowish surface of the inci-
sion diminishes daily, and in three, or, at
most,  four weeks, the wound is  quietly
healed. Thevitrioliccollyrium, containing
afew drops of camphorated spirit of wine,
can only be prudently instilled,  three or
four times a day, into the eye, for the pur-
pose of strengthening the conjunctiva and
its vessels, after the wound is  perfectly
cicatrized.
  We have already repeated Scarpa's sen-
timent, that   the  incipient pterygium,
strictly speaking, is nothing more, than
an opacity ofthe cornea, in which the ve-
nous  vessels of the conjunctiva covering
that part ofthe cornea, which is the seat
of the disease, are somewhat more dilated,
than in the case, to which the term, " opa-
city," is usually assigned ; and,  also that
the density, and opacity, of the delicate
layer of the conjunctiva  are  much more
considerable, at the part affected, in the
» 
PUP
PUP             287
instance of pterygium, than in that of sim-
ple opacity of the cornea.
  The incipient pterygium (adds this au-
thor)  is not a dense, opaque membrane,
but a pellicle as fine as a cobweb, inter-
woven in  different  places  with varicous
blood-vessels, the iris continuing tolerably
visible behind it.  In this early state of the
pterygium, it is unnecessary to deprive the
cornea of  its natural covering; it is quite
enough to cut off a portion of it, in order
to intercept all  communication between
the dilated venous ramifications of  the
pterygium, and the varicous trunks in the
white of the eye.
   The recision, says Scarpa,  is accom-
plished by cutting out, with a pair of for-
ceps and scissars, a semilunar piece of the
conjunctiva, at the point where.the cornea
and sclerotica conjoin,  and exactly at the
base ofthe incipient pterygium, just as is
practised  for opacity of the cornea.   The
recent pterygium is observed to disappear
gradually  after the operation, or to change
into  a slight dimness of the cornea,  ex-
tending over a part of the space previ-
ously occupied  by  the  disease.   This
opacity is commonly much more trivial,
than  what follows   a  cicatrix.   Acrell,
ip his  Surgical  Observations,  mentions
having successfully  treated an  incipient
pterygium in  this  manner.  Scarpa  has
also  tried the plan  several times with
success. Scarpa sulle Malattie degli Occhi,
cap. 11.)
   PTOSIS,  (from w««rr*, to fall down )
An inability of raising the upper eyelid.
The affection  may be owing to several
causes, the chief of which are a redund-
ance  of skin on  the eyelid; a paralytic
state  of" the  levator muscle, a spasm of
the orbicularis.  Ptosis  from  the  first
cause  may be cured by cutting away the
superfluous quantity of skin.  When  the
case depends  on paralysis, the surgeon
may try bathing the eye and surrounding
parts with cold  spring water, and  rub-
bing the eyelid and  eyebrow with any lini-
ment containing  a  little of the tincture
of cantharides.   The linimentum cam-
phorz; the   shower  bath;  and  bark ;
may also  be  occasionally tried.   The
spasmodic ptosis requires antispasmodic
medicines ; the  application of a  blister
to the temple ; and fomenting and bath-
ing the eye and  eyelids with a decoction
of cicuta, or poppv-heads.
   PTYALISMUS.   (from  vrvttXi^st, to
spit.)  A copious discharge of saliva.
   PUNCTURED WOUNDS. See Wounds.
   PUPIL, CLOSURE  OF.   An incon-
venience,  not frequent indeed, but which
however  sometimes  follows  the  opera-
tions  of depression, and extraction,  is  a
closure of the pupil in such  a  degree,
that it becomes almost, or quite shut,  at-
tended at first with a  diminution, and
afterwards with an entire loss, of sight.
  This unpleasant occurrence, says Scar-
pa,  is most frequently the consequence of
a vehement  inflammation of the internal
membranes ofthe eye, especially, the iris,
occasioned by the extraction,  or depres-
sion, of the  cataract.  In some particular
instances, this inconvenience follows one
of these  operations, but without the in-
flammation  of the internal parts  of the
eye, and especially of the iris  having any
share in its  origin, at least, as far as we
can judge  from  appearances.   In such
circumstances, after an indeterminate time
from  the operation of depression, or ex-
traction, tlie pupil is perceived to dimi-
nish in di tmeter daily, without any evi-
dent cause,  so that at last it becomes, as
it  were,  entirely obliterated, and that
without  the patient  complaining  of any
uneasiacss in the eye, if we except, in a
few  individuals,  a  greater  sensibility,
than is natural, in the  immediate organ
of  vision, even to a very moderate  degree
of  light.  In both cases, the pupil ordi-
narily closes so much, that it can  hardly
admit a small pin's head, and continues
motionless; while  within  the  situation
of the pupil itself, the iris assumes a stel-
late,  rugose appearance, with a little ir-
regular aperture  in  the  centre, behind
which, when the  cataract has been  ex-
tracted,  or depressed, the deeper part of
the eye seems  black; or, if a portion of
the anterior convexity of the  opaque
crystalline capsule, should chance to re-
main  behind after one of these operations,
and has  subsequently come into contact
with, and adhered to, the posteriour sur-
face of the iris, a small whitish speck, or
veil, may be seen there.
  Theory has induced some to  suppose,
that,  when  this  morbid closure  of the
pupil originates from an excessive dis-
tention of the vessels <of the iris,  in con-
sequence of severe inflammation affecting
that membrane, it may be cured by means
of local and general bleeding, purgatives,
blisters,  and a  seton in the nape  of the
neck.  On the other" hand,  they have
deemed  emollients, and internal and ex-
ternal antispasmodics, serviceable, in the
instance of constriction  of the pupil aris-
ing from spasm of the iris, and increased
morbid sensibility ofthe immediate organ
of  sight, in  consequence of the sympathy
of  the latter with the iris.  But, how
plausible soever these curative indications
may  seem to be  for  the closure  of the
pupil, practice  has  not admitted their
efficacy.   On the  contrary, says  Scarpa,
it has Clearly evinced,  that this  disease
cannot be remedied, except by making an 
$88
PUPIL.
 artificial opening in the iris, as  a substi-
 tute  for the natural pupil, now wholly,
 or partly obliterated, and as an  aperture,
 which is to do the functions of the origi-
 nal one.
   To the  best of  Scarpa's knowledge,
 Cheselden  was the first, who ventured to
 devise, and execute a section of the iris,
 for the purpose of forming an artificial
 pupil.  He introduced a couching needle,
 having a sharp edge only on  one  side,
 through the sclerotica, at the distance of
 a line  and a  half from the cornea, into
 the interior of the eye.   After perforat-
 ing the iris towards the external angle,
 and flien pushing the ps'int of the needle
 through tlie  anteriour chamber  of the
 aqueous humour, as far as that side of
 the  iris, which is nearest the  nose,  he
 turned the edge of the instrument back-
 ward, and withdrew it, so as to make a
 transverse division of the iris.
   It  is related, that this operation was
 attended with the greatest success. How-
 ever, Janin (Mem. sur VCEil) assures us,
 that, having performed it on two subjects
 with  the utmost care possible, he did not
 find the smallest benefit follow it; for, in
 these two patients, as soon as the symp-
 toms, produced  by the operation,  sub-
 sided,  he  found the transverse section,
 made in the iris  by the edge ofthe needle,
 re-united,  and consolidated.  Sharp had
 experienced the same thing, before Janin.
 ( On Operations, chap. 29.)
   An accident occurred to Janin, in the
 act of extracting a  cataract; viz. he in-
 cluded the iris together with the cornea,
 in Daviel's scissars,  and cut it perpen-
 dicularly. This circumstance taught him,
 as he expresses himself, that a perpendi-
 cular section,  made in this membrane, on
 one side of the pupil, was the only truly
 efficacious method of preventing the edges
 of the  wound of the iris from  growing
 together again, so as to form a durable
 artificial pupil.  This is exactly  what led
 this  Oculist to make it an operative me-
 thod, and to propose it, as the besfexpe-
 dient fiir making an  artificial pupil.  His
 plan consisted in opening the cornea, as
 is practised for the extraction of the ca-
 taract,  and in  dividing the iris perpendi-
 cularly with  scissars, near that part of
 the pupil,  which is next to the nose, and
 he affirms,  that he  has seen strabismus
 result from making  the section towards
 the external side, on account of the too
 great divarication ofthe optical axes.
  In the small number of cases of closure
 of the pupil, which  Scarpa  has seen and
 treated, as consequences of the operation
of the cataract by extraction, or depres-
sion, he has never been  able to make up
his mind to open tlie cornea, in order to
accomplish  with scissars  the perpendi-
cular section of the iris, as proposed  by
Janin, or with the  knife, as recommend-
ed by  any  other person.   He  has felt
conscious of tlie frequent severe  symp-
toms, which arise  from making  an open-
ing  into the cornea, when the eyes have
already been affected, after the first opera-
tion, with  violent  internal   ophthalmy,
spasm, and morbid increase of sensibility
in the  immediate  organ  of  sight.  He
says, he will never cut the cornea again
after the extraction of the cataract, lest
an irregular cicatrix should be the con-
sequence.   He is the less inclined to do
so, as he is convinced, that  it is not so
easy, as some may conceive, to divide the
iris, with scissars,  when  it has  become
flaccid in consequence of the escape ofthe
aqueous humour.   Scarpa had had occa-
sion to see more frequently,  than once,
the edge ofthe iris detached, by blows on
the  eye-ball,  from the ciliary ligament,
to the extent of two  lines, and  without
any  laceration  of the body of this  mem-
brane.  At  the place where the  iris had
been separated from the ciliary ligament,
he says, he had seen an oval fissure re-
main during the rest of the patient's life,
and  it might have answered  every pur-
pose of an  artificial pupil, had  not the
immediate organ of vision, and the crys-
talline, in the  instances alluded  to, suf-
fered too severely from the violence ofthe
blow.  In a case of prolapsus  of  the iris,
through a  small  ulcer of  the  cornea,
where the  former  part was  very  much
dragged, in consequence of the large por-
tion  of it protruded,  and the adhesion,
which it had contracted with the edges of
the  ulcer of the cornea, Scarpa  had re-
membered,  that this same part,  the iris,
instead of being lacerated at its middle,
had  rather been detached, for a certain
extent of its circumference, from the ci-
liary ligament, so  as to  produce  there
an artificial pupil,  which  was very ser-
viceable to  the patient after the cure  of
the  prolapsus  of the  iris.   Scarpa like-
wise called  to mind, that in depressing a
cataract, he had seen a similar  separa-
tion  of the margin of the iris from the ci-
liary ligament  take place, in consequence
of having merely pushed the opaque crys-
talline inadvertently against the  internal
edge of this membrane, at the moment,
when the lens continually rolled round
the spear of the straight needle,  without
his being able to seize it, so as to immerse
and  depress it deeply  in the vitreous hu-
mour.   Besides these circumstances, it
had often occurred  to  him  to  observe  in
frequent dissections of the eye,  that on
taking hold of the iris with forceps, and
pulling it, not  only at a  little distance 
PUP
PUS               289
(rom its greatest disk, but also at the very,
edge of the pupil, this delicate membrane
m«)ie  readily became  detached from  its
junction  with the ciliary ligament, than
lacerated at its middle, although it is cer-
tainly of a very soft  nature.   Lastly, it
cannot be doubted, that the iris is a mem-
brane  perfectly distinct from the cho-
roides, and has a proper, though feeble,
connexion with the ciliary ligament,  in-
dependently of the union ofthe choroides
with tlie same ligament.
  All these considerations taken together,
especially that of the  feeble union of  the
iris with the ciliary ligament, and, conse-
quently, of the greater facility of detach-
ing the edge of the iris from the ligament,
with  which it  is connected, than of la-
cerating the body of this membrane, have
induced  Scarpa to try a new  method of
forming an artificial pupil, when the  na-
tural one has become  too much contract-
ed, or quite obliterated, after the extrac-
tion, or depression of the cataract.  This
method of operating, consists  in detach-
ing, by means of a couching  needle, a
certain extent of the circumference ofthe
iris from the ciliary ligament, without ever
preceding this operation by a section of
the  cornea.  The attempt met with suc-
cess.
  The patient being seated, and support-
ed, as if he were about to have the oper-
ation for the cataract performed, a straight
couching needle,  not so large  as that
which most  surgeons use,  but  slender,
like that which Scarpa prefers, (see Cata-
ract,) is then to be introduced through the
sclerotica, at the extemal angle of  the
eye, about two lines from the union of this
membrane with the cornea;  and its point
is to be pushed as far as the upper and
inner edge of the iris ; in other words, as
far as that side of the iris  which is near-
est the nose.  The needle advances near-
lyto the ciliary ligament,  and the sur-
geon perforates the internal edge of  tiie
iris, at its upper part,  so  that the  point of
the  instrument  scarcely appears in  the
anteriour chamber of the aqueous  hu-
mour, because, that part ofthe anteriour
chamber being very narrow, the  point of
the instrument, how little soever it might
advance beyond the iris, would enter  the
substance ofthe cornea. The moment  the
needle appears in the anteriour chamber,
the instrument must be pressed on  the
iris from above downward, and from  the
internal towards the external angle, so as
to bring it in a parallel line to the ante-
riour surface of the iris, for the purpose
of detaching a portion of the edge of this
membrane from the ciliary  ligament.
    Vol. IT.
This separation being effected, the oper-
ator (continues Scarpa)  must depress the
point of the needle, in order to apply it to
the inferiour angle of the slit, that he has
begun to make.  Then the aperture may
be enlarged at pleasure, by pushing the
iris towards the temple, and withdrawing
the needle from before backward, parallel
to the  anteriour surface of the iris, and
the greatest  axis  of the  eye.  If,  when.
this detachment has been accomplished,
no opaque body should  appear at the
bottom of the eye, the needle is to be with-
drawn altogether. If any portion of opaque
capsule,  left  behind after the depression
or extraction of the cataract, should af-
terwards advance,  ancr present itself in
the vicinity of the, new pupil, the littfe
opaque membrane must be reduced to
fragments, and pushed through the arti-
ficial opening into the anteriour chamber,
where, as  we have shewn in the article
Cataract, such membranous portions, or
flakes  of' the capsule, are,  in  time, dis-
solved and absorbed with the aqueous
humour, which is continually undergoing
a renovation.
   This separation of the iris from the ci-
liary  ligament,  invariably occasions an
extravasation  of  blood,  which al'-ays
renders the aqueous humour more or less
turbid; but the turbidness is afterwards
absorbed, and  the eye recovers its  origi-
nal transparency.
   The patient, says Scarpa,  complains,
during the operation, of a vast  deal more
suffering, than at the time when he under-
goes tiie extraction or depression ofa ca-
taract.  It cannot  be  otherwise; for, in
detaching a part of the edge of the irisi
from the ciliary ligament, some filaments
ofthe ciliary nerves, which proceed to be
distributed in the  iris,  must at least be
dragged, or lacerated.  Hawever, on the
whole, the symptoms consequent to this
operation,  have neither  been obstinate
nor fatal in the two cases which Scarpa
has seen.  From some experiments made
on the dead subject,  Scarpa thinks the
curved needle, which he uses for the de-
pression of the cataract, would.also be
better than the straight one for making
an artificial pupil; a thing which he in-
tends to ascertain the first favourable op-
portunity.   (Scarpa suae Malattie  degli
Occhi, Capo  16.)  Consult also  Gibson on
tlie Artificial Pupil.  Richter Vonder Vers-
chlossnen Pupille, in Anfangsgr.  der  Wun-
darzn. Band 3, Kap. 9, Gottingen, 1795.
   PUS.  (from vvov, matter.)  The fluid
formed by the process of  suppuration.
(See Suppuration.)
    Oo 
(  290  )
    RACHITIS, (from ^u%i<, the spine of
     the back, because the disease was
once supposed to depend on disease of the
spinal marrow.)  The rickets.  (See this
word.)
  RANULA. (dim. of rana, a frog.)  A
whimsical  name applied  to a tumour  un-
der the toftgue, arising from an accumu-
lation of the  saliva in the ducts  of  the
sublingual  gland.   The term has  either
been derived from an imaginary resem-
blance ofthe swelling to a frog; or, from
the  disease  making the patient,   as  it
were, croak when  he attempts' to articu-
late.  The writers, who  have treated of
this  disease,  before it was known, that
the parts affected by it were destined  for
the secretion of the saliva, have had no
accurate notions of its true nature. Cel-
sus has been  supposed to have alluded to
the  ranula, in  the fifth section of  his
seventh book, where, after treating of the
diseases of the tongue, he continues with
the following passage: sub lingua quoque
interdum aliquid abcedit, quod fere cqjisistit
in tunicd, doloresque magnos movet.  The
latter circumstance, however, renders it
probable, that  some other affection was
alluded to, as a ranula is rather attended
with a sense of restraint,  than of pain.
Various erroneous sentiments were  enter-
tained, concerning ranula,  by authors,
who treated of it subsequently to Celsus.
Pare" thought it proceeded from  an  accu-
mulation of a pituitary, cold, viscid mat-
ter, which  descended "from the brain  be-
neath the  tongue.  Fabricius ab  Aqua-
pendente consider.-, the ranula as an  en-
cysted tumour of the meliceris kind.  Di-
onis  is of  a similar  opinion.   Munick,
better  acquainted  with the modern dis-
coveries of anatomy, does not mistake  the
nature of the present disease ; and  he ex-
pressly says,  that  the affection originates
from a thick,  acrid  saliva,  which,  not
being  able to pass out of  the salivary
ducts, accumulates under the tongue, so
as to cause a swelling in that sftiiation.
Far  from adopting the opinion %f Mu-
nick, Heister fell  back to  that of Fabri-
cins, and borrows every thing from this
author.—Lastly, De la Faye, in his  notes
on Dionis, has taken  up Munick's sen-
timents; he says,  that, " there  are two
sorts of ranuls; some, which are. round,
and  situated beneath the  tongue, seem
only to be produced by a dilatation of the
excretory duct of the sublingual gland;
the  others  are  longer, than  they  are
round;  are situated at  the side of  the
tongue, and are formed by  a dilatation of
the excretory duct of the inferior maxil-
lary gland.  The fluid, which  fills such
tumours, is the saliva which lodges  and
gradually accumulates in them,  in con-
sequence of its viscidity and atony of the
duct.
  The ranula is said to be frequently met
with in persons who move their tongue
a great deal, and  in those who sing. The
fluid in the tumour is precisely like white-
of-egg;  but, it is thicker after having re-
mained a long while in the swelling; it is
occasionally .of a calcareous,  and even
stony nature.   Modern surgeons are of
opinion, that the ranula does not proceed
from  an inspissation of the saliva,  but
from an obliteration  of the duct, or ori-
fice, of this tube.  The collection of saliva
often produces a  tumour  of  very large
size; but, it generally bursts when it has
attained theMimensions of a walnut, and
then leaves an ulcer,  which cannot be
healed while the real cause ofthe disorder
remains unknown.
  Mr. B. Bell mentions his having seen
an ulcer of this kind treated with the ut-
most care for several  months;  various.
detergent and corrosive  applications had
been  employed;  and even a  mercurial
course was resorted to; but all  in vain.
At length, the true  cause  of the disease
having been ascertained, a cure was an-
complished in a few days, by removing a
piece of calcareous matter, which by ob-
structing the  ducts, had  first caused «
swelling, and  then the ulceration which
ensued.
  The edges  of  the opening very often
close again, especially when it has been
made with a lancet,  and not of sufficient
size.  In this case, the swelling makes its
appearance again, some  time afterwards.
M.  Louis observes, that the ancients have
made the same remark; and hence, Pare
preferred the actual cautery to the lancet.
Dionis  also mentions   his having  seen
ranulz, which  recurred in consequence of
a mere  opening having been made with a
lancet;  and he recommends, for the pre- 
RANULA.                            291
vention of  this, applying  a mixture of
honey of roses  and vitriolic acid to the
inside of  the cyst, so as to destroy it.
M. Louis remarks, that all authors seem
to regret, that the situation ofthe tumour
should prevent the sac from being totally
dissected  out.  The success,  which Fa-
bricius  ab  Aquapendente  experienced,
when he  merely opened  the tumour its
whole length, did  not free him from this
prejudice ;  and  Heister says, he should
prefer extirpation, if  the nature of the
adjacent parts, which  would be wounded,
were not a formidable objection.  But, if
this pretended cyst, this pouch, is nothing
else  than the gland itself, or its duct, di-
lated by  the retention of the saliva, its
inside should not be irritated.  Whenever
a sufficient  opening is made,  no relapse
takes place.  Munick  particularly advises
such an  incision, and Rossius mentions
the  smallness of the opening,  among the
defects in the treatment, and its being a
cause of  the disease returning.   How-
ever, he does also recommend destroying
the  sac ; but, specifies for  the purpose,
only astringent drying applications, which
 did not act in so powerful a manner.
  In a ranula, there is nothing like a cyst
 which ought  to  be  extirpated.  It is
enough to lay the cavity open, and occa-
 sionally to cut off the edges of the inci-
sion, when they will  not otherwise unite.
 M. Louis  always observed,  that the radi-
cal cure depended on  affstulous aperture,
through  which the  saliva  continued to
 flow; and  that, when this opening was
situated behind the lower incisor teeth, a
very annoying ejaculation of  the  saliva
took place, in certain  motions of  the
tongue.   This  inconvenience must  be
obviated,  to render  the cure complete.
 For  this purpose, such an opening for the
saliva must be made, as will  not  close.
The perforation of the tumour with the
actual cautery, was Pane's method.; and
thus a durable opening might certainly be
 obtained, for the excretion of the saliva,
 in a part of the mouth  more backwards,
so that patients would be freed from the
disagreeableness of continually slobber-
ing, or having their  spittle ejected from
their nn uths in talking.
  The ranula,  when of long standing, is
sometimes so large as absolutely to hinder
a person  from articulating.  M. Le Clerc
has  recorded a case, in which the root of
the  swelling extended under the tongue;
the  tumour filled the whole mouth ; tiie
prominence it  formed outwardly, was as
large as a duck's egg  ; and the disease, in
its  progress, had  made the teeth of both
jaws project outward.   At some parts of
its surface, a fluctuation was perceptible;
Other places were exceedingly hard. The
patient, who could hardly breathe, de-
manded assistance : and a puncture was
made in the softest part of the outside of
the swelling,,  A thick yellowish fluid is-
sued out of the cannula. The opening was
enlarged with a knife ; and about a pint
of gritty, inodorous  matter was extract-
ed.  There was no hemorrhage from the
cut;  and,  no sooner  had the contents of
the swelling been taken out, than the pa-
tient  began to articulate, which he had
not been able to do for a long while. The
sides of the tumour  having been so pro-
digiously distended, M. Le Clerc thought
it proper  to  destroy the inside of the
cavity with a tent, dipped in a mercurial
solution.   The cure  was completed in a
month, and the tongue gradually regain-
ed its original size, a part of which it had
lost.
   But, as M. Louis observes, fortunate as
the termination of this case was,  it must
not  be  indiscriminately set down,  that
destroying the cyst,  or even opening the
tumour, is always   requisite?  A  more
simple method will'sometimes succeed.
In  a  particular case, which this gentle-
man  has related, a sinuosity,  which di-
vided the  swelling into a right and left
portion,  made him  suspect that it con-
sisted of two  sacs, in contact with each
other.  On each side, in front,  and in the
same line,  there was a point, which was
the orifice  of the salivary duct, somewhat
dilated,  and  blocked up with a viscid
matter.  Having  very  easily  passed  a
small probe into  the orifices,  a matter,
similar to  wh.te of egg, made its escape.
A  small  leaden probe was passed into
each  opening, and, two days afterwards,
the  sacs  were emptied again, and two
pieces of  lead, somewhat  larger,  intro-
duced.  The man was advised to take out
the pieces  of lead every morning,  empty
the  swelling,  and then replace them. In
a fortnight,  the openings, having been
kept continually d dated, had no tendency
to close; the  saliva  had not accumulated
since, and the ranulz  had  not appeared
again.
   In  certain cases, the' above  means are
quite inadequate, and  the tumour must
be totally  extirpated.  M. Boinet has re-
lated, to the French Academy, a case in
 which  the swelling not only filled tlie
 whole mouth, but one half of the tumour
 projected  out, and a cure could only be
 accomplished in the latter manner.   The
 two  upper incisor teeth,  on the left side,
 were lodged  in a depression observable
there ; and the canine tooth, of the same
side, forced outward by the mass of dis-
ease,  had  pierced the lip near its com-
missure.   A  fluid,   resembling  mucus,
 flowed  from  a narrow  aperture,  at the
» 
292             It E C
  *
lower part of the swelling.  The tongue
could not be seen, so much was it pushed
backward;  and, for  some time,  the pa-
tient had only subsisted on liquid food,
which  he was first necessitated to convey
to the  back of the throat, with some me-
chanical contrivance.  The four incisor
teeth,  two canine, Aid. first grinders  of
the lower jaw, had  been pushed out  of
their sockets, by the  pressure of the swell-
ing.  The  patient's  aspect was alarming,
and he was threatened with suffocation.
Extirpation was  deemed necessary, and
it w^  performed, with all the  caution,
which  the situation of the tumour de-
manded. The large cavity thus occasioned,
was filled with lint.  The lower jaw being
found diseased,  M.  Boinet scraped some
of its  surface off, and covered the places
with  lint,  either dry, or  dipped in spirit
of wine.  Some exfoliations followed, and
the fungous  granulations  which  grew,
were  repressed with proper applications.
In three months, the parts were healed
in  so  regiflar a manner, that the motion
of the  tongue was not in the least ob-
structed, and no change continued, ex-
cept the alteration of the voice, occasion-
ed by ihe loss of teeth.   This case is very
interesting, and shews how much may be
 hoped for in difficult cases,  from prudent
 and judicious measures.   (Encyclopedic
 Methodique ; Art. Grenouillette.  Mem. de
 I' Acad, de Chirurgie, Tom. 3.)
   RASPATORIUM.   (from   ratio,  to
 scrape.) A kind of rasp formerly employ-
 ed by surgeons.
   RECTUM.   The last large intestine,
 terminating in  tlie anus,  is so named,
 from   an  erroneous opinion that  it was
 straight, while,  in  fact,  it is semilunar,
 being adapted  to  the concavity of  the
 sacrum.
    Piles, which are  a disease of the veins
 of this bowel, are  treated of  under  the
 term Hemorrhoides.
    The rectum is also subject to have tu-
 mours formed in it. Mr. Hey mentions a
 young man, who had had, for  two years,
  a swelling  in this bowel.  The tumour
  protruded from the  anus, whenever the pa-
  tient went to stool, and generally bled on
  the same occasion.  The disease had been,
  from the first, attended with pain in the
  loins.  On examination, Mr. Hey found
  the swelling to be ofthe size ofa nutmeg,
  adhering  to  the  intestine by a  narrow
  basis.  It was firmer in its  texture than
  piles usually are,  except  when inflamed.
  The  apprehension  of a troublesome he-
  morrhage, led  Mr. Hey to prefer tying
  the  base of the  swelling  .o cutting it
  away, and thus he successfully extirpated
  the  disease.  (Practical Observations in
  Surgery, p. 443.)
               REC

  The scirrho-contracted rectum is what
we have chiefly to consider in the present
article.  Scirrhus of  the  rectum  is not
uncommon at an advanced period  ot lite.
Sometimes it extends over a considerable
length of  the  gut,  but  generally it  is
more circumscribed.  The coats of the
bowel become much thicker  and  harder
than  in the natural state.   The muscular
is subdivided  by membranous septa, and
the  internal  coat  is sometimes formed
into hard, irregular folds.  The surface
of  the inner  membrane  is occasionally
ulcerated, so  as to form a cancerous dis-
ease.  Every vestige of the natural struc-
ture  is sometimes lost,  and  the  gut  is
changed  into a gristly substance.  The
cavity of the bowel  is always rendered
narrow  at tiie scirrhous part,  and is,
sometimes, almost obliterated. When tlie
passage   through  the gut is  very much
obstructed, the bowel is  always a good
deal enlarged just above the stoppage, or
stricture,  from the accumulation  of the
feces  there.  As  the disease advances,
adhesions form between the rectum and
adjacent  parts, and ulcerations produce
communications between them.
   The disease is usually not much no-
ticed till somewhat  advanced, not being
at  first very  painful.  The patient only
thinks,  that  he is costive,  and that he
voids his stool with a little difficulty.  In
 time, a  good deal of pain is felt in the
part  affected,  especially  at stool,  after
 which, some relief is experienced. Pus
 and blood may sometimes be noticed with
 the excrement, particularly when  the dis-
 ease has advanced to the ulcerated state
 The  patient at length becomes  sallow,
 the constitution suffers,  and dissolution
 follows.   Severe  tenesmus  attends  the
 whole course of the disease.
    Desault has often seen the disease form
 a communication between the rectum and
 vagina, and the feces have passed through
 the latter part.  In the latter stage of the
 affliction, the  rectum,  bladder,  vagina,
 uterus, and adjacent parts, are all involv-
 ed in one common ulceration.
    When  the  disease has attained the ul-
 cerated state, it is probably always incu-
 rable.  Palliatives can  now only be  re-
 sorted to, such as anodyne and emollient
 glysters,  the warm-bath, &c. with the
 exhibition of medicines like opium, cicu-
 ta, uva ursi,  &c.  Claudius  applied  his
 remedies to  the inside of the bowel,  by
  means of tents, and did  not  employ the
  latter as a mode of curing  the  disease,
  when less  advanced.  Valsalva  used to
  introduce a  cannula, pierced with  nu-
  merous  holes, when his  patient  got into
  the bath, so as to let the fluid enter the
  intestine. Numerous practitioners,.among 
                 RET

tltem  Morgagni,  made  mercurials the
base of their treatment, from a  supposi-
tion that  the complaint was  of  venereal
origin.
  When the disease is not attended with
ulceration, the contraction and thicken-
ing of the gut may be diminished, by  in-
troducing bougies, keeping them for a cer-
tain time, every day, so introduced, and
increasing their  size gradually.   The
pressure of these  instruments seems to
lessen the disease, and stop its progress ;
a proof that its  nature differs from that
of what is usually understood by scirrhus.
Desault used to employ long  tents, made
of lint, smeared with cerate, and passed
into thebowel by means of a  probe, with
a  forked  end.  This surgeon gradually
increased the  size of the  tents,  so as to
continue the compression, to which  he
conceived all the good was owing. Their
length was  also augmented,  by degrees.
 Fresh  ones were,  at  first, introduced
 twice every day.  When  any hardnesses
 were situated ou the outside of the anus,
 Desault cured them on the same principle,
 viz. by making pressure  on them, with
 compresses and a  bandage. This eminent
 suigeon effected a cure of a scirrho-con-
 tracted rectum by this method.  The wo-
 man was  taught to pass occasionally  the
 tents herself, so as to prevent a relapse.
 Tlie disease is said to afflict women more
 frequently than men : from  a  compara-
 tive table  kept at  the Hotel-Dieu, this
 has been  the case there in the proportion
 of ten to one.
   See Baillie's Morbid Anatomy.   (Euvres
 Chirurgicales de Desault par  Bichat, Tom.
 2. p. 422.
   REFRIGERANTS, (from refrigero, to
 cool.) A  term often applied  by  surgeons
 to such remedies and applications  as cool
 the whole body, or any part of it.
    REGIMEN,  (from rego,  to  govern.)
 The regulation ofthe diet.
    REPELLENTS,  (from repello, to drive
 back.)   Applications are sometimes  so
 pained which make diseases recede, as it
 were, from the surface of the body.
    RESOLVENTS.    (from  resotvo,  to
 loosen.)   Medicines which disperse swell-
 ings, inflammations, &c.  The  term  ori-
 ginated  from the idea that the  tenacious
 humours were loosened.
    RESOLUTION,  (from resolvo.)  The
 subsidence of inflammation,  without  any
 abscess,  ulceration, mortification, &c. be-
 ing  occasioned,  is so named.  The  dis-
 persion (■*'swellings, indurations, &c.
    RETENTION OF URINE.  See Urine,
 Retention of.
    RETROVERSIO UTERI.  A turning
 backward of the  womb.  See Uterus, Re-
 troversion of.
               RIC              29J

  REVULSION,  (from revello,  to draw
away.) An old term, used by the humoral
pathologists,  signifying the  drawing of
humours a contrary way.
  RHACOSIS.  (from £«»«$, a rag.)  A
ragged  excoriation of the scrotum.
  RICKETS.  (Rachitis.)  Is mosdy met
with in young children; seldom in adults.
Morand, however,  (Acad,  des  Sciences,
1753,) mentions an instance in which  an
adult became affected.  Pinel has given a
description of the skeleton of a  ncketty
foetus. (Fourcroy's Journal.)  The disease
seems to consist of a want of due firm-
ness in the bones, in consequence of a
deficiency  of the  phosphate of lime in
their structure.  The causes of the affec-
tion are involved in great  obscurity, and
authors have referred them to scrophula,
scurvy, lues venerea,  difficult dentition,
&c.;  mere conjectures, which it is not
worth while  to enquire  into.  Ricketty
subjects are often at the same time scro-
phulous ; but, this is,* probably, the only
reason for  scrophula  being accounted a
cause of the  other affection.   Ihe parti-
cular  appearances  of ricketty children,
we need not detail, as every onejtis fami-
liarly acquainted with them : s^ch  chil-
dren are usually of a bad, weak constitu-
tion, and their limbs and bones  become
bent in such directions as the actions of
the muscles,  tiie weight and pressure, Etc.
which  they  sustain, determine. When
the  affection is very general, the spine
becomes shorter, and is curved in various
directions; the breast becomes deformed,
not only in consequence of the curvature
ofthe spine, but by the depression of the
ribs, and projection of the  sternum.  The
bones of the pelvis fall inwards, and the
os pubis generally approaches the sacrum.
The latter  circumstance is one of the
causes of difficult parturition.   The cla-
 vicles become  more bent  and prominent
 forward; the os humeri is distorted out-
 ward ;  .'ie lower ends of the radius and
 ulna are twisted in the same direction •
 the thighs are  curvrd forwards, or out-
 wards ; the knees fall inwards ; the spine
 and front surface ofthe tibia become con-
 vex ; and tiie feet are thrown outwards.
   When the thoracic viscera are consi-
 derably oppressed by the  alteration  in
 the figure of thrf chest, produced by the
 rickets, the. disease  may bring on fatal
 consequences.
   Many infants, which are  very ricketty
 and  deformed, improve as they grow up,
 and  their  constitutions acquire  strength.
 The deformity ofthe bones of their limbs
 spontaneously diminishes, and these parts
 gain a due degree of firmness,  resulting
 from a proper deposition ofthe phosphate
 of lime in their texture. 
294             h A C
a ah
  The restoration of the proper figure of
the bones may sometimes be promoted by
the  constant  pressure of  bandages and
mechanical  contrivances,  sold  in  the
shops.  (See Distortion.)   Some authors,
however, contend,  that  in very  young.
children machines are useless, as the con-
finement and  inactivity of the muscles,
necessarily  occasioned  by  such contriv-
ances, must increase the general debility,
and  consequently the  disease.  But, all
writers allow, that, after a certain age,
aha when the  strength is not too much
exhausted,   mechanical aid  is   proper.
Were  I to  offer  my own  sentiments on
this subject, they would be in favour ofthe
employment of proper machines and ban-
dages, at an early age.
  No medicine is known, which possesses
any direct  efficacy  in cases of rickets.—
Tonics are  indicated, and  should be em-
ployed. More good, however, may be  ef-
fected by keeping children in healthy si-
tuations, and in a salubrious air, than by
any medicines,  whatever.   Light, whole-
some, nutritious, easily digestible food j
cold bathing ;  the use of the flesh-brush,
Sec. are also highly serviceable. The con-
stitutional  treatment of rickets  belongs
more properly to  the physician than the
surgeon ; and it is  not necessary to intro-
duce more  of the  subject in a Dictionary
expressly allotted to surgery. The reader
may consult Boyer's Lectures on the Bones,
Vol. 2,  Chap. 2, if he wishes to see the va-
rious absurd notions which  many have en-
tertained concerning rickets.
  RIGOR,   (from rigeo, to be cold.)  A
cold chill.   A shivering.
  RUBEFACIENTS,  (from rubefacio, to
make red.)  Applications which make the
skin red.
  RUBINUS.  (from ruber, red.)  A car-
buncle, named from its colour.
  RUPTURE.   A protrusion of some of
the  abdominal viscera.  A hernia.  See
Hernia.
 O ABINA.  (said to be named from the
 © Sabines,  whose  priests used it  in
 their religious ceremonies.)  Savine. The
 use of the leaves of this plant, in forming
 the active ingredient in the ointment com-
 monly preferred for keeping open blisters,
 we have explained in the  article Blisters.
 The other chief surgical use of savine, is as
 a  stimulating  application for destroying
 warts, and other excrescences.  For the
 latter purpose, it is generally  powdered,
 and  mixed with an equal proportion  of
 zrugo zris.  The same   powder  is also
 sometimes employed by surgeons for main-
 taining the hollows in which peas are in-
 serted in issues. The bent plan is, first
 to wet  the peas, then roll them  in the
 powder,  and put them, in this state, on
 the issue.  But, when the whole surface
 ofthe issue has risen high, above the level
 ofthe skin, the powder must be sprinkled
 all over the sore, so as to  produce  an ab-
 sorption  of the  high  granulations.—In-
 deed, even in this manner, a good cavity
 often cannot  be obtained ; and,  it be-
 comes necessary to  destroy the surface
 of the issue,  by rubbing it with the ka-
 li  puruni, or  kali  purum  cum  cake
 viva.
  SACCHARUM SATURNl.   Sugar of
Lead.  Cerussa Acetata. Acetite of Lead.
This is very extensively used in surgery,
chiefly as a local  application  to  inflamed
parts, and in the form  of a lotion. See
Inflammation, Collyrium, Lotio, Gonorrhxa,
 Ophthalmy, and numerous other articles of
this Dictionary, for an explanation of the
uses of acetite of lead.
    SAL-AMMONIAC.  Ammonia Muri-
ata.  Muriate of Ammonia.   Employed a
good deal by surgeons, as an ingredient
in  discutient lotions.  See Lotio Amnion,
Mur.
   SALIVARY FISTULA.   See Parotid
Duct.
   SALIVATION.  An  increased secre-
tion of the saliva, excited by mercury.
   SA'NIES.   (Latin.)  A  thin,  serous
matter,  discharged  from  fi^tulz, un-
healthy sores, &c.  It is sometimes tinged
with blood
   SAPO TEREB1N IHlNiE.  (Starkey's
Soap.)  &. Kali przpar. calidi ^j.  O.ei
Terebinth, giij.—The hot kali  praepara-
tum is to have the  oil of turpentine gra-
dually blended wiih it, in a heated mortar.
Indolent swellings were formerly rubbed
with this npplicalion, and, perhaps, some
chronic affections of the joints might still
be benefited by it.
   SARCOCE'LE. (from tr<tp\, flesh; and
r-riXt), si tumour.)  A fleshy enlargement of
the testicle.  See  Testicle, Diseases of. 
SAR
SCR       •"    295
  SARCO'MA,  Sarcdsis.  (from  o-xp£,
flesh.)   A fleshy tumour on any part of
the body.   (See Tumours, Sarcomatous.)
  SARCO'TICS, (from rxpKott, to incar-
nate.)   Sarcotica.  Medicines, which pro-
mote  the  formation of granulations in
wounds and sores.
  SARSAPARl'LLA.  The root of sar-
saparilla was brought into  Europe about
1530.  It was  at first reputed to possess
singular efficacy in venereal  cases; but,
afterwards lost all its fame.   Sarsaparilla
was again brought into notice by  Dr. \V.
Hunter, who  advised Dr.  Chapman to
make trial of it in a bad case of phagede-
nic bubo; and  the  benefit, obtained  in
this  instance,  led  Dr.  Hunter to extend
the  recommendation  of the medicine.
Sir W.  Fordyce stated, that sarsaparilla
would quickly relieve venereal head-achs,
and nocturnal pains, and if persisted in,
cure them ; that  in emaciated,  or con-
sumptive habits, from a venereal cause, it
was the  greatest restorer  of appetite,
flesh, colour,   and  strength,  which he
knew of;  that when mercurial  frictions
had been  previously employed, it would
generally  complete the cure of the disease
of the throat, nose, palate, or spongy bones ;
and that  it would  promote the cure of
blotches and ulcers.sometimes accomplish
it,even without mercury; though,  in this
 circumstance, there Was danger of a re.
 lapse.   Sir W. Fordyce said, sarsaparilla
 was of  little use in chancres ; but, when
 these or buboes, would not heal, after the
 employment of mercuiy, it would, often
 cure, and always  do good.  He  allows,
 however,  that in all venereal cases, sarsa-
parilla is not to be trusted to, unless preced-
 ed by, or combined with, the use of mercury;
 and he thought sarsaparilla  would, pro-
 bably, always cure what resisted mercury.
 (Medical  Obs. and Ir.q. Vol. 1.)
   The  celebrated Cullen considered sar-
 saparilla as possessing no virtues of any
 kind; for,  (says  he)  " tried in  every
 shape,  I have never  found it an effectual
 medicine in syphilis, or any other disease."
 (Mat. Med. Vol. 2.)
   Mr.  Bromfield declares, that  he never
 saw a single  instance in which  sarsapa-
 rilla cured the venereal disease, " ithout
 the aid of mercury,  either given before, or
 in conjunction  with it.  (Pract.  Obs  on
 the Use of Corrosive Sublimate, &c. p. 78.)
 Mr. Pearson also  contends,  that sarsapa-
 rilla has  not  tfie power of curing  any one
 form of tlie lues venerea; but, he allows
 that it may suspend, for a time, the rava-
 ges of that contagion, the disease return-
 ing, if no mercury should have  been used.
 This gentleman admits, also, that sarsapa-
 rilla will  alleviate symptoms derived from
 the venereal virus.  He  maintains,  that
the exhibition of sarsaparilla does not di-
minish the necessity for giving less mer-
cury. Nocturnal pains in the limbs, painful
enlargements ofthe elbow and knee, mem-
branous nodes, cutaneous ulcerations, and
certain other symptoms, resembling vene-
real ones, are  often experienced after a
full course of mercury. Such complaints,
Mr. Pearson allows, are greatly benefited
by sarsaparilla, and exasperated by mer-
cury  and,  he observes, that it is from
these complaints having  been  mistaken
for venereal ones, that the idea has arisen,
that sarsaparilla has cured syphilis, when
mercury has  failed.  Mercury, and the
venereal poison, may jointly produce,  in
certain constitutions, symptoms which are
not strictly  venereal, and are sometimes
more dreadful, than the simple effects of
syphilis.  Some of the worst of these ap-
pearances are capable of being cured by
sarsaparilla, while the venereal virus still
remains in the system.  When this latter
disease had been  eradicated by mercury,
sarsaparilla will also cure the sequelz of
a course of the other medicine. (Pearson
on the Effects  of various Articles  in  the
cure of Lues Venerea ; 1807.)
   SCA'BIES, (from scaber,  rough.) The
itch.
   SCA'LPEL.  (from scalpo, to  scrape.)
Scalpeilum.   Scdlprum.  Originally a ras-
patory, or instrument for   scraping dis-
eased bones,  8cc.  The term  now gene-
rally signifies, a common, straight, surgi-
cal knife.
   SCARIFICATION, (from scarifico,  to
scarify.)   Scarificatio.  The Operation of
making little cuts, or punctures, in a part,
for the purpose  of taking  away  blood,
letting out ffuid in anasarcous cases,  or
air, in instances of emphysema.
   SCIRRHUS,  SCIRRHO'MA   ^CIR-
RHOSIS, (from o-Kippuo, to harden.)The
etymological import of these terms seems
merely to.be any induration.  The first is
 now  generally restricted to the indura-
 tion, which  precedes cancer, -in the  ul-
 cerated state.
   SCLERIASIS,  SCLEROSIS,    (from
 0-kAȣ6a>, to harden.)   A hard tumour, or
 induration.
   SCLOBETOPLA'GA.  (from sclopetum,
 a gun ; and plaga, a wound.)  A gun-shot
 wound.
   SCOLl'ASIS.(from o-KoXmu,  to twist.)
 A distortion of. the spine.
   SCORBUTUS, (from schorboet,  Germ.)
 The scurvy.
   SCRO'PHUIA,  OR   SCROFULA.—
 (from scrofa, a sow.)  The king's  evil, so
 named, because swine are  said to  be sub-
 ject to it, called  also, struma.  A disease,
 the chief, or at least, the  most palpable
 symptom of which is a swelling of the ab- 
296                             SCROPHULA.
sorbent glands, in various  parts  of the
body, which glands tend very slowly to a
state  of  suppuration, that is  almost al-
ways  imperfect.   Scrophula  generally
shews itself during infancy, between the
age of three and seven ;  sometimes rather
sooner; but., frequently, as late as puberty,
and in some instances, though a very few,
not till a much more advanced period of
life.   In  the latter cases, the disease is
said to be rarely so complete, or well
marked,  as  it is in  young  subjects.
Scrophula is also as hereditary as any dis-
ease can be; that is to say, it  is  so  as
far as any  particular  kind  of  tempera-
ment, or constitution, can descend, more
or less completely, from parents to  chil-
dren. Mr. White, in his treatise on stru-
ma, has strongly censured calling the dis-
ease hereditary; but his observations only
lead to these conclusions,  that  children,
born of scrophulous parents, are  not inva-
riably affected with scrophulous  diseases ;
and that,  sometimes,  one child  has some
strumous affection, while the parents, and
all the rest of the family, have no appear-
ance of scrophulous habits.   However, I
shouldconceive, that neither Mr. White,
nor any other writer will maintain the opi-
nion,  that scrophula does not much more
frequently afflict the children of scrophu-
lous parents, than the offspring of persons,
who have always been perfectly free from
every tendency to any form of this  afflic-
tion.  Too numerous are the facts, which
occur to my own mind,  to  allow  me  to
entertain  the smallest  doubt, that  scro-
phula runs very much in certain families.
In this sense, I think  the term hereditary
perfectly  accurate and  allowable.    But,
at the same time, I beg the reader to un-
derstand, that 1 have no intention of ques-
tioning what seem to be irrefragable truths,
viz. that the children of scrophulous pa-
rents often continue, as  long  as they live,
entirely free from the  disease ; and that
one child is sometimes  afflicted, while its
fither, mother, brothers, sisters, and all
the rest of its relations, have never had
any tendency to strumous disorders.
   When scrophula does not actually take
place at  a very early period of life, it is
generally  stated by writers on the subject,
that the particular constitutions, in which
there is a disposition to the disease, are,
in a certain  degree, distinguishable.  In
the individuals, possessing the disposition
in question, a peculiar  softness  and flac-
cidity of fibre are remarkable ;  their hair
is more frequently light coloured than
dark ; and their eyes are .said to be more
often of a blue, than   any other colour.
Their skin is generally very fine, and even
handsome, both in regard to its outward
texture,  and complexion.  Subjects with
scrophulous constitutions, frequently have
a kind of thiokening of the  upper lip;
this swelling is sometimes very consider-
able,  and occasionally extends as far as
within the  nostrils.  Scrophula  is also
very often complicated  with rachitis, or
follows the latter affection ; but, there is
as little  reason for supposing  rickets to
arise from scrophula, as this  latter from
rickets.  In some instances, however, the
complexion is dark, and the skin coarse;
but, in these subjects, at least when young,
the face  is generally tumid, and the look
unhealthy.   (Burns on  Inflammation,  Vol
2, p. 232.)
  Mr. White seems, as I think, with some
appearance of truth, to deny that grey, or
blue  eyes, light hair,  and a  fair  com-
plexion, ought  to be considered as marks
of a scrophulous  predisposition ;  for, the
majority of children  in this country have
light hair,  and eyes,  while young, which
become darker as  they advance in life.
Now, as  the  majority of scrophulous pa-
tients are children, and young subjects,
and as most children in  this country have
naturally the kind of  hair and eyes above
described,  it seems  inaccurate to lay any
stress on persons affected with struma, or
predisposed to this  disease, having such
appearances.   (See White on the Struma,
or Scrofula, p. 38. Edit.  3.)
  I believe the fact is now almost  gene-
rally  admitted, that  females  are rather
more  subject, than males, to scrophulous
disease.
  Struma,  according to Mr. White,  is as
universal a complaint as it is ancient;
but it prevails more extensively in tem-
perate latitudes, than in very hot or  very
cold climates.  It is also more frequent in
some parts of  Europe than others; and,
in this country, it has  been found to be
most general in the  counties of Suffolk,
and Lancashire.  At all periods, it seems
to have been a very common complaint in
this island.   From history, we learn, that
it was denominated the king's evil in the
time  of  Edward  the Confessor,  who is
supposed to  have been  the first  that at-
tempted to cure it by  the royal touch.
From a register kept in the royal chapel,
we find that Charles  the Second touched
92,107 persons, in  a certain   number of
years ; and this eqnally bigotted and use-
less practice was not discontinued  till a
recent period, when kings were found to
be, as well as their poorest subjects, to-
tally  destitute  of all supernatural power.
   Scrophula is not communicable  from
one person to another;  neither can it he
conveyed into  the system by inoculation.
The opinion also, that scrophulous nurses
may  infect children,  seems also  to  rest
on little foundation. (See White,p  56, 57.) 
SCROPHULA.
297
   The  parts, which are most frequently
 affected by scrophula, next to the lym-
  hatic glands, are the spongy h-ads ofthe
  ones,  and the joints.  The form,  which
 the  disease assumes in  the latter  situa-
 tions,   is particularly described in the
 article  Joints.   The disorder  of  the
 spine, attended with a paralytic affection
 of the  lower  extremities,  is, no doubt,
 very  frequently  of  scrophulous  origin.
 (See Vertebrx) The abscess, which forms
 in the cellular substance, between the pe-
 ritoneum and psoas muscle, is often re-
 garded  as a strumous disease ; and when
 the contents of the abscess are found to
 contain  flakes of a curdy  matter,  some-
 what resembling white-of-egg,  a  sub-
 stance peculiar to scrophulous abscesses,
 no one  can doubt, that the complaint is
 connected  with this constitutional  affec-
 tion. (See  Lumbar Abscess.) The chronic
 enlargement of the thyroid gland,  is by
 many considered as  scrophulous ;  and,
 the opinion seems to be strengthened by
 the fact, that patients,  with this affliction,
 very ofen  have,  at the same time,  other
 Complaints, wh.ch are unequivocally stru-
 mous.    It might also be  noticed, that
 this enlargement ofthe thyroid gland most
 frequently  commences at an early period
 of life,  like other scrophulous diseases ;
 and, like them, is benefited by the mineral
 alkali.    (See   Bronchocele)  Scrophula
 also frequently makes its appearance  in
 the form of imperfect suppurations,  in
 various  parts of the body ; the  contents of
 such abscesses being a curdy kind of mat-
 ter, and the skin covering them, having
 an unhealthy red  appearance, and a thick-
 ened doughy feel. The mesenteric glands
 are  particularly  often found  universally
 diseased,  and  enlarged in scrophulous
 subjects ; and, as all nutriment has to pass
 through these parts, before it can get into
 the circulation, we cannot be surprised at
 the many ill effects  which must be pro-
 duced on the system,  when such glands
 are altered, and, no doubt,  obstructed, in
 the way in which  they frequently are.
 Scrophula also frequently makes its attack
 on the testicle.  (See Testicle, Diseases of.)
 —The fem.de breast not unfrequently be-
 comes affected with scrophulous tumours,
 and abscesses.
  The   scrophulous  inflammation  (says
 Mr Burns) is marked by a soft swelling
 of the affected part, which, very frequently
 is one  of  the  lymphatic glands.    The
 covering, or coat of the  gland, becomes
slightly  thickened, and  its substance  more
porous  and doughy.   The swelling  in-
creases,  and the  doughy feel changes by
degrees  into that of elasticity,  or fluctun-
tion, and a fi*in, circumscribed, hardened
 margin,  can be felt round the base of the
    Vol. II.
 tumour.  The skin is slightly red. If, at
 this time,  an incision,  or puncture, be
 made, either no matter, or very little, is
 evacuated,  the lips of the wound  inflame
 and  open,  displaying a sloughy-looking
 substance within ; and,  betwixt this and
 the skin, a probe can often be introduced
 for some way all round.  If, however, the
 disease should  have  advanced further,
 then  there  is very little elasticity in the
 tumour;  it is quite soft,  rather  flaccid,
 and fluctuate-, freely;  the skin becomes of
 a light purple colour,  and small veins may
 be  seen  ramifying  on  its surface.   Some
 time after these appearances, the skin be-
 comes thinner at one particular part,  and
 here it also generally becomes of a darker
 colour.  It  afterwards bursts,  and dis-
 charges a thin fluid,  like whey,  mixed
 with a curdy matter, or thick white floc-
 culi.   1'he  redness  of the  skin still con-
 tinues ; but the  aperture enlarges as the
 tumour subsides, and  thus a scrophulous
 ulcer is  produced.  The margins of this
 kind of sore are generally smooth, obtuse,
 and overlap the  ulcer ;  they are of a
 purple colour, and rather hard, and tumid.
 The surface of the sore is  of  a light red
 colour; the granulations are  flabby and
 indistinct, and the aspect is ofa peculiar
 kind, which,  says Mr. Burns, cannot be
 described. The discharge is thin, slightly
 ropy,  and copious, with curdy flakes. The
 pain is inconsiderable.  When this ulcer
 has Continued for some time, it either be-
 gins slowly  to cicatrize, or, as more fre-
 quently happens, the discharge diminishes
 and becomes  thicker.  An elevated scab
 is next formed, of a dirty  white, or yel-
 lowish colour.  This continues on the part
 a good while ; and When it falls off", leaves
 the place oovered  with a smooth  purple
 cicatrix.   Mr. Burns adds, that the pre-
 ceding description corresponds to the mild
 scrophula, or the struma mansueta,  of the
 old writers.  This gentleman next remarks,
 that, occasionally, especially if a bone be
 diseased  below the ulcer,  the sore has a
 more fiery appearance, the surface is dark-
 coloured,  the margins  soft, elevated, and
 inflamed, and sometimes retorted.  The
 discharge is watery, the pain very consi-
 derable,  and the  surrounding skin  in-
flamed.   This has been called the struma
maligna.   Such  overacting  scrophulous
 sores  are  most frequently met with over
 the  smaller  joints, particularly,  those of
the  toes.  (Burns)  Sometimes a  scro-
phulous abscess, after it has burst,  forms
 a sinus ;  the mouth  of which ulcerates,
 and assumes the  specific scrophulous ap-
 pearance, while the track ofthe sinus still
 continues to emit a discharge.  Mr.  Burns
 also remarks,  that scrophulous swellings
 are often  disposed  to subside  in winter,
    Pf 
ii98                             SCROPHULA.
   and recur  on the approach of summer ;
   but,  he adds, that tins is not an invariable
   law.   The glandular  enlargements are
   very apt to become smaller,  in a short
   time, in one place, while other glandular
   swellings originate with equal suddenness,
   somewhere in the vicinity of  the former
   ones.  Ulcers, also, very often heal, upon
   the appearance of the disease in other
   parts.  (See Dissertations on Inflammation,
   by John Burns, Vol 2, 1800 )
     With  regard to the proximate cause of
   scrophula, medical men may be said to re-
   main, even at the present day, in entire
   ignorance.  Of the exciting causes,  very
   little is also known.   Mr.  John Hunter
   remarks,  that " in this country, the ten-
   dency to scrophula arises from the climate,
   which is in many a predisposing cause,
   and only requires some derangement to
   become an immediate cau.-e, and produce
   the whole  disease."  (Treatise on the Ve-
   nereal Disease, p 26.)   In the same part of
*  the work, this celebrated writer takes no-
   tice of slight fevers, colds, smallpox,  and
   measles,  exciting scrophulous diseases.
   He  observes  also,  that,  in  particular
   countries,  and in young people, there will
   sometimes "be  a predisposition to scrophu-
   la : and that, in such subjects, buboes
   will  more  readily become scrophulous.
   (P. 27 )   In  short, it was one of  Mr.
   Hunter's opinions, and probably a most
   correct one, tha,t the  venereal disease is
,  capable of calling into action such suscep-
   tibilities as are  remaik..bly strong,  and
   peculiar  to  certain  constitutions   and
   countries ;  and that, as scrophula is pre-
   dominant in this country, some eff'ects of
   other diseases may partake of a scrophu-
   lous   nature    (P.  96.)   Mr.  Hunter,
   speaking ol  venereal  buboes,  mentions
   his having long suspected  a mixed ca.^e,
   and adds, " I am now certain that such
   exists. I have seen cases, where the vene-
   real matter, like a cold, or fever, has only
   irritated the glands tqdisease,iproducing
   in. them scrophula, to  which they were
   predisposed.  In such cases, ihe swellings
   commonly  arise slowly,  give but little
   pain,  and  seem to be rather  hastened in
   then progress, if mercury is given to de-
   stroy  the  venereal  disposition.   Some
   ccme to  suppuration  while under  this
   resolving course ; and others, which pro-
   bably had a venereal taint at first, become
   so indolent, that mercury  has  no effect
   upon them; and, in the end, they get well
   of themselves, or by other means."  (P.
   269.)  For such buboes, Mr. Hunter used
   to recommend sea-bathing ; and, in case
   of* ^ uppuration, poultices made with sea-
   water.
      It would be tedious and useless toexpa-
   liate on the many absurd notions, which
 have  been  entertained  concerning  the
 proximate cause of  stn ma.   All that we
 need add in this work, is, that certain  con-
 stitutions probably have a congenital dis-
 position to the disease; that such disposi-
 tion may probably be increased, or dimi-
 nished, by the operation of climate, mode
 of life, age.  &c; and  that irritations of a
 thousand kinds  may excite the disease
 into action, when the system is predispos-
 ed to it,  by inexplicable causes  That
 climate  has  great  influence, cannot be
 doubted, when we reflect, that the inhabit-
 ants of  certain countries,  in which the
 temperature  is  invariably warm, never
 suffer from  scrophula.  There can  also
 be no doubt that, with age, the disposition
 to scrophula diminishes ;  for,  children
 much afflicted while.young, frequently get
 quite  well  when they approach the adult
 state ; and, if a person has remained per*
 fectly free from any mark of a scrophu-
 lous constitution, till  the  age of twenty-
 five, he  may be considered as almost en-
 tirely exempt from the disease.

       Treatment of scrophula.

   " For the  cure of scrophula,  (says the
 celebrated Cullen,) we have not yet learn-
 ed any practice that is certainly, or even
 generally successful.  The remedy which
 seems to be the most successful, and which
 our practitioners especially trust to, or em-
 ploy, is the use of mineral waters." "But,
 (adds this   eminent physician,) in very
 many instances of the use of these waters,
 I  have not  been well satisfied,  that they
 had shortened the duration of the disease
 more than had often  happened when no
 such remedy had been employed.  With
 regard to the choice of the mineral waters
 most fit for the purpose, (says Cullen,)  I
 cannot, with any confidence,  give an opi-,
 nion. Almost all kinds of mineral waters,
 whether chalybeate, sulphureous, or sa-
 line,  have been employed for the cure of
 scrophula,  andf  seemingly,  with equal
 success  and  reputation ;  a circumstance,
 which leads  me to think, that, if they are
 ever successful, it is the elementary water
 that is the chief part of the remedy. Of
 late, sea-water has been especially recom-
 mended, and employed ; but, after nume-
 rous trials, I caitert yet discover its supe-
 perior efficacy." d\ Cullen next speaks of
 bark ; but seems to consider its efficacy
, in scrophula, as very dubious and trivial.
 He mentions that,  in several instances,
 the leaves of colt's-foot appeared to him to
 be successful.  He used it frequently, in a
 strong decoction, and even then with ad-
 vantage ; but he found more benefit from
 the expressed juice, when the plant could
 be had in rather  a succulent state, soon 
SCROPHULA.
299
after its first appearance  in the  spring.
Dr. Cullen observes, that he had frequent-
ly employed the hemlock,  and sometimes
found it useful in discussing obstinate
swellings;  but, that  it ateo  frequently
disappointed him, and he never remarked
that  this medicine disposed scrophulous
ulcers to heal.  The sentiments of Cullen
are decidedly against the use of antimony,
and mercury, in scrophulous cases.  (See
First Lines ofthe Practice of Physic, Vol 4 )
  Dr. Fordyce  extolled bark  for its effi-
cacy in scrophulous diseases; he endea-
vours to prove, by some cases which are
adduced, that in cases of tumefied glands,
attended with a feeble  habit, and a weak
circulation,  it is a most efficacious medi-
cine, and acts  as a resolvent and'discuti-
ent.  He also brings  forward a case, in
support of bark being a means of cure for
tlie ophthalmia strumosa.  (See Med Obs.
and Inq. Vol 1 p 184)  Dr. Fothergill,
in the same  work, p. .-03, writes in favour
ot  the good  effects of bark in similar
 ca.^es;  the latter sometimes gave, at the
same time, small doses of calom«d.
   Mr  Burns remarks, that bark has been
frequently  found  useful in the  cure of
scrophulous inflammation, but more often
of ulceration,  than tumefaction of  the
glands.   But,  adds  this gentleman, ft
does not appear to possess, by any means,
that certain power of  curing scrophulous
affections, which is attributed  to it by Dr.
Fothergill and several  other  authors.
He observes, that  we are not  to suppose,
that it will infallibly cure scrophulous in-
flammation, or ulceration of parts which,
even when affected with simple inflamma-
tion, are  very  difficult of cure.   If it be
difficult to cure a simple inflammation, or
ulceration of a tendon, cartilage,  or bone,
We  must not be disappointed if even a
specific remedy for scrophula  (were such
ever discovered)  should prove ineffectual
in  procuring  a  speedy restoration to
health.  Mr. Burns contends, that bark is
often ineffectual,  because improperlfcad-
ministered.   Given in  small  quantities,
once or twice a day, it may prove a sto-
machic, and increase, like other tonic bit-
ters, the power of the stomach, or the
functions dependent on it; but, in  order
to obtain the benefits of the specific action
of bark, he maintains, that  it should be
given   in  large  quantities,   for several
weeks, with a good diet,  air,  and proper
exercise.—(Dissertations on Inflammation,
 Vol. 2. p. 371)
   As far as I can judge, Mr. White has.
with much  reason, recommended paying
attention to such circumstances as  may
have effect in preventing the disease,  viz.
air,  cleanliness, exercise, and diet.   He
mentions cold bathing among the prevent-
ives of struma, and speaks of sea-bathing
as being the  best.  He advises attention,
also," to be paid to the manner of clothing
children, keeping them more  covered in
winter than summer..  Mr. White thought,
that  allowing children to sleep a great
deal  was prejudicial;  but, this seems  to
me only conjecture. .
  In noticing the treatment ofthe disease,
Mr. White states, that "  the general  idea
ofthe struma is, that it is a disease of de-
bility ; and therefore, the great object is,
to invigorate the habit by every possible
means ; the chief of which are tonic medi-
cines, and sea-bathing.  Some are of opi-
nion, that in  the case of young patients,
this should be continued, dur ng the sum-
mer  months, every year, to fhe age of four-
teen or sixteen.  Many recommend it, not
only in the summer, but throughout the
year : whilst others are for administering
alteratives, principally the alkaline  salt?,
with or without antimonials, and the dif-
ferent tonics, during the winter;  and the
sea-water, and sea-bathing, or  cold-bath-
ing, during the summer, for a continuance
of two or three years from tiie commence-
ment of the disease; with this  general
observation,  that they will  outgrow the
complaint."  Mr White adds, that  the
chief external means  are fomentations of
sea-water, and cataplasms, made with the
same.  With respect to regimen,  some
recommend a milk  and vegetable  diet;
others animal food, and fermented liqu .rs.
   Mr. White maintains, that the preced-
ing plans of treatment are not, in general,
efficacious, though in some instances, they
may prove  useful.   " In early affections
of the lymphatic glands, (says this gentle-
man,) and from the want of a pure air,
and  proper  exercise, where children are
delicate  arid irritable, a  change of situa-
tion  to  the  sea-side, together with bath-
ing,   when   they have  acquired '^some
strength, must be  exceedingly  proper;
and,  in  gross  plethoric  subjects,  who
have diseased lymphatics, from improper
feeding,  and want of necessary exercise, a
journey  to the sea-coast may be very use-
ful,  particularly if the salt-water is drank
often, and in  a sufficient quantity to be-
come purgative. This, with the novelty
•f their situation, which may naturally
produce an  increase of exercise, might
answer every expectation ; but, these are
the  kind of cases that,  with a very  little
attention, are easily cured."  (While on
the Struma,  Edit. 3. p. 104.)
   The conclusion to  which Mr. White's
remarks upon this part ofthe subject tend,
is, that  sea-bathing only deserves praise,
as a preventive, and in the early stages, of
the  disease.   He particularly condemns
cold-bathing,  for poor,  weakly,  dcbifi- 
300
SCROPHULA.
tated children,  whose thin  visage,  en-
larged belly, and frequent tickling cough,
sufficiently indica'e diseased viscera; such
do not recover tiVir natural warmth, after
cold-bathing, for  hours,  and their  subse-
quent head-ach, livid lips, and pale coun-
tenance, are suificient marks of its impro-
priety.  (P. 107.)
  " Cold-bathing,  especially  cold  sea-
bathing (says  Mr. Russell) is a remedy
universally employed in scrophula, and J
believe  with  great  advantage  in many
cases ; for it not only appears to improve
the p itieiu's general health and strength,
but likewise to promote the detumescence
of enlarged glands,  and the resolution of
indolent swellings in the joints, even after
they have attained a considerable size, 'and
have existed for a great length of time.
But,  in order that  cold-bathing may be
practised with safety, and advantage,  the
constitution must have vigour to sustain
the shock  of immersion  without  incon-
venience.  If the immersion be succeeded
by a general glow over the surface of the
body, and the patient feels cheerful, and
has a keen appetite, we may conclude that
he agrees with the cold bath ; but if he
shivers on coming out  of .the water,  con-
tinues chill, and becomes drowsy, we may
be assured that the practice of cold-bath-
ing does no  good,  and had  better be
omitted.                 \
  " In estimating the  comparative merit
of cold-bathing and  warm-bathing, in the
cure  of scrophulous complaints, my own
experience, together with the result of
different conversations on the subject with
some of the most judicious practitioners
of my acquaintance,  would lead me to be-
stow much more commendation on the ef-
fects of warm-bathing.   I should not even
be inclined to circumscribe the practice
to cases of emaciation and debility, since
from observation, I am fully satisfied with
regard to the beneficial effects ofthe warm
bath  to  patients of plethoric  constitu-
tions, who  were much affcted with swell-
ed scrophulous glands.  Several of those
instances occurred in young women, about
the prime of life,  who were in all respects
healthy and vigorous,  abating the swell-
ings of the glands, and those symptoms of
distress which were connected  with  ful-
ness of blood.
   " The sensation of  the warm bath is
exceedingly grateful to most patients, and
the practice is universally safe.  It may
be employed at all seasons of tiie year,
and in all weather,  without danger or in-
convenience; the risk of suffering from
exposure to cold, immediately  after im-
mersion  in the warm  bath, having been
much  magnified  by prejudice.   There is
not even any good reason to believe in the
existence of such  a risk.  The precau-
tions, however,  which  are  employed  to
avert it, are perfectly innocent; and, pro-
vided they do not impose any unnecessary
and  incommoding  restraints upon the
practice, may be encouraged, so far as-to
relieve the  patient's mind  from uneasi-
ness and groundless apprehensions.
  " It requires  many weeks, and some-
times several months, to ascertain the full
effects of warm-bathing in relieving scro-
phulous complaints; but, as the practice is
not attended with any inconvenience, nor
followed by any bad consequence,  there
can be no reason to intermit the course,
till the trial  is  completely satisfactory:
and  I am convinced, that the practice  of
warm-bathing, in cases of scrophula, will
be  more universally adopted, after the
knowledge of its beneficial effects is more
widely diffused."   (See Russell's Treatise
on Scrophula.)
  With regard to electricity, Mr. White
thinks it is useful, when from length of
time the enlarged glands have acquired a
degree of hardness and  insensibility.
  Mr. White, after enjoining attention  to
air, exercise,  and diet,  as promotive of a
recovery, as well as preventive of the dis-
ease, proceeds to explain his own practice.
The internal cases, which  properly be-
long to  the physician,  we  shall  dismiss
from consideration.  The first external
symptoms, such as swellings of the lips,
side of the face, and of glands under the
chin, and round the neck;  also,  other
symptoms, usually considered as stru-
mous, viz. roughness of  the skin,  erup-
tions on the back of the liand, and differ-
ent parts of the body, redness, and such*.
ing  of the eyelids,  and eyes;  are  ac-
companied,  according  to   Mr.  White's
conceptions, with  an inflammatory dis>
thesis, though  seldom  such a one, as to
require bleeding.   Calomel is the  medi-
cine, which this gentleman recommends
for  the  removal of  the  foregoing com-
plaints.  It is not  to be given  in such
quantities, as to   render  it  a  powerful
evacuant, either by the intestines, or any
other way: but, in small doses, at bed-
time.  Thus,  says  Mr. White,  "it re-
mains longer in  the intestinal; canal, Ta
greater quantity is taken into the  habit,
and the patient is less susceptible of cold,
than when taken in  the day-tim,e.   The
first, and,  perhaps, the second dose may
prove purgatiye,  which  is,  in  general,
a salutary effect;  but, afterwards,  the
same quantity will  seldom do more, than
is sufficient to keep the body open ; and
should it fail of answering that purpose*
I have usually recommended some gentle
purgative, every third or  fourth morning,
according  to   circumstances.   If  there
\ 
SCROPHULA.
301
should  be a  prevailing acidity,  a  few
grains of the sal sodac,  magnesia, or some
testaceous powder, may be added to  the
medicine   By  this simple  method (con-
tinues  Mr. White) most of  the symptoms
before-mentioned, will, in a short time,
disappear; but if the tumours  should
continue  hard,  and retain their  figure,
wtthout dividing into  smaller ones,  we
may derive some benefit from external ap-
plications, particularly the steam of warm
water. I have used a variety of medicinal
herbs  with success; but, am inclined 10
believe, that the advantage was principally
derived from  the  warm water, &e.  At
other times, I  have stimulated  the part
affected by  electricity, insulating  the pa-
tient,  and drawing sparks from the tu-
 mour, until a slight degree of inflammation
 was excited.   After  the  application of
 the steam, or the use of the electrical ma-
 chine, I have sometimes rubbed a little of
 the unguentum mercuriale into the tu-
 mour, and neighbouring parts, or applied
 the emplastrum saponaceum,  or mercuri-
 ale cum ammoni:ico, over the swelling, or
 a liniment with camphor, ol. olivarum, and
 sp. terebinth."  Mr. White adds,  that in
 such cases, if the tumours should suppu-
 rate, and burst, the parts will, in most in-
 stances, heal without  much trouble.  For
 eruptions on the head, he recommends ap-
 plying the ung. saturn. album camphora-
 tum,  or the cerat. alb. cum hydrarg. prac-
 cip. alb.  For the roughness  of the skin,
 which is  generally followed  by eruptions,
 he also advises  the aqua-vegeto-mineralis,
 aqua  calcis, solutions of sal. tartar, or of
 the hydrarg. mur. as outward applications.
 " This last (says Mr.  White) will seldom
 fail to check the progress  of the com-
 plaint, and dry  the  sores; and  in the
 quantity  of ten or twelve  grains,  to a
 quart of warm water,  the use of it will not
 be productive of any pain.  If the eruption
 should ulcerate, and require any unctuous
 application, to prevent the adhesion  of
 the linen,  the ointment beforementioned
 may be applied ; the  best remedy will be
 warm-bathing,  and when practicable, the
 sea-water claims a preference." {P. 114.)
 The author next mentions his having occa-
 sionally recommended the vinum antimo-
 niale, tartarum emeticum, decoctum Lusi-
 tanicum, decoctum lignorum, or sarsapa-
 rilla:; and that he sometimes found advan-
 tage derived from artificial drains. We need
 not detail this gentleman's mode of treat-
 ing affections of the  eyelid, as the reader
 may  find  all  the  necessary instruction,
 concerning scrophulous diseases of the eye
 and eyelids, by referring to  Ophthalmy and
 Psorophthalmy.
    For  the cure  of  indurations  in  the
 breast,  remaining after mammary ab-
scesses, Mr. White speaks very highly of
the eff'ects of the steam  of warm water;
and cautions us against  indiscriminately
employing calomel, which will often af-
fect the mother little, but the child vio-
lently.  Mr. White mentions his employ-
ing a  small tin machine, large  enoilgh to
hold  a pint and a half,  or two pints of
boiling water.   From the top  proceeded
a  harrow tube, ten,  or twelve  inches
long,   through which  the steam passed.
Near  its end,   which was moveable and
curved, was a joint, for the greater  con-
venience of directing the steam  to the
diseased  parts.  The water  was easily
kept   boiling,   by  means  of  a  lamp
under the machine.   Mr.  White says,
that the steam should be employed twice,
or thrice a day,  and a piece of flannel, or
skin,   afterwards  applied.    The  body
should also be kept  open.  In obstinate,
neglected cases, mercurial preparations,
according to Mr. White,  must  likewise be
given, and, if they affect the child much,
suckling should be suspended.  (P. 117,
118)
   Mr. White  treats largely of the treat-
ment of cases, in which the  mesenteric
glands are diseased; but,  this subject
strictly belongs to the physician.  When,
 in these instances, the glands of the neck,
or other parts ofthe body, tend to a state
 of suppuration, it is very slowly, the skin
 appearing uniformly thin, and of a  deep
 red colour, and the tumour seeming flac-
 cid.  In  such  cases,  Mr. White  recom-
 mends the use ot" the lancet  or caustic ;
 for,  if no artificial opening is  made,  it
 will  be a long time, before the skin gives
 way; and, when  it does,  the aperture
 will  not  only  be  very small,  but  often
 unfavourable in its situation.  Mr. White
 adds, that the  contents will  often  be
 more like mucus,  than pus, or Uke a mix-
 ture  of both ,  and the discharge will con-
 tinue for a great length of time, if no re-
'medy is  applied.  This gentleman  men-
 tions his having found a solution of gum
 myrrhx  in aqua  calcis, used as a lotion,
 and  the  ceratum  saponaceum,  or  some
 similar outward application, the best me-
 thod of treating this symptom.
   We need not describe Mr. White's prac-
 tice  in the treatment of scrophulous joints,
 as the subject is fully  considered in the
 article Joints.   It appears,  however, that
 he confirms the efficacy of stimulating ap-
 plications, and  pressure with  bandages,
 when the fingers  and  toes  are  affected
 with strumous disease.  (P  143 )
    Dr.  C awford, M. Pinel,  and others,
 have tried the mtft-iated barytes,  as a re-
 medy, in >crophulous c:>ses. (Med. Commrp
 nications, F»Z.  2.   Nosographie  PhiloSo-
 phique,  Vol. 2. JV238.)  Mr. Burns says. 
JOJ
SCROPHULA.
that the muriate of barytes has no effect
on diseased glands ; but, that  it is occa-
sionally serviceable in scrophulous ulcera-
tion, though,  he adds, that it deserves
tittle dependence.   (Dissert, on Inflamm.
Vol 2. p. 372.)  This gentleman recom-
mends the following formula:  iy. Terrx
Ponder. Salit Chryst. gr. x. Aq. Font. Aq.
Cassix, utrituque,£u]. Syrup. Aurent. ^ij.
Half an ounce of" this may be given  at
first, twice or-three times a  day,  and
gradually increased to  such quantity,  as
the stomach can bear without Sickness.
   Fourcroy purposed trying the muriate
of lime ; but, its efficacy is very doubtful,
and inconsiderable.  " Professor Thom-
son (says Mr. Russell) has favoured me
with the f blowing observations  on the
effects  of   muriate  of lime.   He  em-
ployed muriate of lime in various cases  of
scrophula, without having derived benefit
from it in  a' single  instance.   Some pa-
tients,  indeed, he admits, got well, while
under  a course of muriate of lime ; but
then he had no  reason to ascribe the
cure to the effect of the medicine. In other
eases,  on the contrary, the muriate  of
lime produced  severe  sickness and op-
pression at the stomach, and the patients
got  daily worse, till  the muriate  of lime
was intermitted, and other medicines em-
ployed  The relief, experienced from the
intermission of the muriate of  lime, left,
no doubt, with regard to the injurious ef-
fects, which the use of it had produced ;
and from expensive experience and accu-
r* e observation on the  subject, Professor
Thomson is  satisfied,  that  muriate  of
lime is attended with prejudicial effects in
many cases of scronhula."  (See Russell's
Treatise on Scrophula ) The same may be
said of  iron given either alone,  or joined-
wih the fixed, or volatile  alkali. /Burnt
sponge,  millipedes,  ,nd k li vitnolatum,
have all been extensively tried:  the first
of these is, in my opinion,  sometimes use-
ful in  diminishing enlarged scrophulous
glands  .- that it  has  this effect on bron-
choceles, is indisputable.
  The  M.irischal de  Rougeres employed
a remedy, composed of iron filings, mu-
riate of ammonia, kali praepuatum, &c.
(Jourri. de Med torn. 40. p. 219.)
  Fothergill praised cicuta, and, perhaps,
it is as good an  internal  medicine as can
be tried; but, it is far from  being gene-
rally efficacious.  It is highly deserving
of recommendation for irritable scrophu-
lous ulc.rs.
  With regard to mercury,  we have al-
ready noticed, that calomel was much em-
ployed  by Mr.  White.  Some  have ex-
hibited  the sublimate; others the acetite
of mercury.   All these preparations have
been at times conjoined with cicuta, anti-
mony, &*.  Calomel, is, perhaps, the best
mercurial  preparation   in   scrophulous
cases;  but,  mercury,   given  internally
with  any view of exciting a  salivation,
is justly deemed hurtful by all the best
practitioners.  As an alterative, and an oc-
casional purgative, it is undoubtedly, a
good medicine for strumous patients.
   Mr. Burns thinks the  nitrous acid  has
some effect in promoting the suppuration
of scrophulous glands, and tumours, and
disposing ulcers  to  heal.  He says,  two,
or three drams may be given every  day,
for a fortnight;  but, if  in this time, it
should do no good, its employment ought
to be discontinued.
   The  pills containing  natron praeparj.
turn (see Pilulx,) and  the different soda
waters, sold at the shops, have repute, for
their good effects on scrophulous constitu-
tions, and diseases.
   Eight,  or ten  drops of the hepatized
ammonia, given thrice a day,  are useful,
according to Mr. Burns, in irritable stru-
mous ulcers.  The breathing of oxygen
gas has been proposed; but, of jMV plan i
can say nothing myself.                 '
   Dr. Cullen mentions, that  cold bathing
seemed to produce more benefit, than any
other remedy, which  he had occasion to
see employed.  (First Lines of the Practice
of Physic, Vol. 4.)
   The local treatment, preferred by Mr.
-White, has been already described. 1 have
only a few words  to add,  concerning this
part of the subject;   Dr. Cullen  states,
that, in  his practice, he had very little
success in discussing incipient scrophu-
lous tumours by topical applications; and
that a solution of the saccharam satunii,
though sometimes useful, more frequently
failed.  Dr Cullen  found the  aqua am-
moniac :icet. not more successful.  " Fo-
mentations of every kind (savs he) have
been  frequently found to do harm; and
poultices seem only to hurry on a suppura-
tion.  I am doubtful, if  this last be ever
practised with advantage;  for scrophu-
lous tumours sometimes - spontaneously
disappear,  but never after any degree of
inflammation has come upon them; and,
therefore, poultices, which commonly in-
duce inflammation, prevent that discussion
of tumours, which might otherwise have
happened."  Even when  scrophulous tu-
mours have advanced towards suppura'
tion, Dr Cullen thought, that hastening
the spontaneous opening, or making one
with a lancet,  was hurtful.
   With respect to ulcers, Dr. Cullen re-
marks,  that escharotic  preparations, of
either  mercury,  or  copper,  have been
sometimes useful  in bringing on a proper
suppuration, and  thereby disposing  the
ulcers to heal;  but,  they  have seldom 
SCROPHULA.
303
succeeded, and more commonly, they have
caused the ulcer to spread more.   The
escharotic, from which Cullen saw most
benefit result,  u> burnt alum, mixed with
some mild ointment.  But, this celebrat-
ed writer  gives the preference  to keeping
the sores  continually  covered  with linen
wet with cold water in the day-time, and
some   ointment,  or  plaster  at   night.
Cullen says, that he  usually  found sea-
water too  irritating, and no mineral water
better, than common water. (First Lines
ofthe Pract. of Physic, Vol. 4.)
  Formerly tne extirpation ot scrophulous
tumours was advised; but, this method is
now  considered  as,  being for the most
part, injudicious, and unnecessary, with
the exception of diseased joints, and a
few other parts, which frequently  require
being amputated,  for  the sake of saving
the patient's life   Certainly, no particu-
lar danger (generally speaking) would at-
tend cutting out scrophulous glands, and
tumours;  the  objections to the plan are
founded on the pain of the operation ; on
the number of such glands frequently dis-
eased;  on their  often subsiding either
spontaneously, or by surgical treatment;
on the operation doing no good to the ge-
neral affection of the system, &c  When,
however, a scrophulous testicle, breast, or
joint, seriously impairs the health,  and en-
dangers life, the very existence of the pa-
tient demands the immediate removal of
the diseased part.  Wiseman relates, that
he was in the habit of cutting out scro-
phulous glands, and tumours, with great
success; but, for reasons, already alleg-
ed, most of the moderns think such opera-
tions in general at least unnecessary.
  Caustics have been employed  for the
same purpose, instead of the knife ; but,
as they effect tile object in view less cer-
tainly,  more painfully and tediously, and
cause extensive ulcers, they are disused
by all  the best surgeons of the present
day.
  Some authors have advised making is-
sues, and keeping them, open, in order to
prevent any ill effects from healing scro-
phulous ulcers. Issues are certainly quite
unnecessary for*ny purpose of this kind;
but they are eminently useful as a part of
the local treatment of scrophulous joints
and abscesses, fas we  have more particu-
larly explained in the articles Joints, Lum-
bar Abscess, and Vertebrx.)
  Mr.  Burns notices,  that issues  have
hitherto been  chiefly used in  diseases of
the bones and joints ;  but,  he  adds, that
it is  reasonable  to  suppose,  that they
ought likewise to be useful in the  cure of
enlargements of the  glands,  and other
scrophulous  tumours, if inserted in the
immediate vicinity of the part.   The only
objection to their use is the-scar, which
they leave,  and which, in certain situa-
tions,  one  would  particularly wish to
avoid.   When the tumour is thickly co-
vered  with the  integuments,  the  issue
may be made directly over it,  and kept
open with tiie savine ointment.   In other
cases, a small pea issue, or seton, may be
inserted by the side ofthe tumour.  This
method  would   be  objectionable,   for
scrophulous glands in the neck, in conse-
quence of tlie scar; but, it might be em-
ployed, when the  mamma is  diseased.
(Dissertations on Inflammation, Vol.'II.)
   Preparations of lead: cloths dipped in
cold water,  sea-water, or weak vegetable
acids ; aether ; sea-salt mixed with  bile ;
the linimentum camphors ; a mixture of
aether and the linimentum  opiatum ; and
hemlock poultices; form a long list of ap-
plications, which have been employed-for
scrophulous tumours.
   According to Mr. Burns, moderate pres-
sure,  by means of adhesive plaster,  con-
joined with the applications of cold water,
is one of the best plans of treating mild
scrophulous ulcers, when  their situation
admits  of it.  In other cases, he recom-
mends applying a powder, five parts of
which consist  of cerussa acetata, and the
sixth of burnt alum. A piece of dry lint is
next to be applied, and a compress, with
such pressure as can  be  used.  Benefit
occasionally results from dipping the com-
press in cold water.
   The ceratum e" lapid. calamin. is a good
common dressing, when it is wished not to
interfere much with the progress of the
ulcer.   The ung.  hydrarg. nitrat. rub.
and the ung. hydrarg. nitrat. are the best
stimulating ointments.  Poultices of bread
and sea-water;  solutions  of alum,  cu-
prum vitriolatum, and the hydrarg. mur.;
solutions  of the nitrates of copper, bis-
muth, and silver; the recent leaves ofthe
wood-sorrel bruised ; lipt dipped in lemon
juice, or  vinegar and water; are among
the applications to common scrophulous
ulcers.
   For  irritable ones,  diluted, hepatized
ammonia ; ointments  containing  opium  :
carrot and hemlock poultices; a solution
of opium ; and  carbonic  acid  gas; are
commonly recommended.
   The following are  Mr. Russell's senti-
ments  respecting the treatment  of scro-
phulous ulcers: "Scrophulous complaints
in  general   do  not   agree Well  with
stimulant applications.  In the treatment
of scrophulous ulcers, under the ordinary
circumstances of complaint, the simplest
and mildest dressings answer best. When
the patients are using a course of sea-
bathing, it is usual to wash the sores with
sea water, over and above the momentary 
304                            SCROPHULA.
 application of the  sea water during the
 immersion of  the  whole  body.  Cold
 spring water is likewise a favourite appli-
 cation with  many  practitioners ;  and,
 from  much observation, it appears  that
 the operation  of cold is well suited to
 counteract' the  state of  inflammation,
 which accompanies  scrophulous sores.
 Preparations of lead are, upon the whole,
 very convenient and  useful applications,
 provirled the  solutions be used in a state
 of sufficient dilution to prevent irritation.
 Liquid applications are applied by means
 of wet lmen, which is renewed whenever
 it dries,  so that the surface of the  sore
 may be kept constantly moist, when under
 this  course of management.  Upon  the
 same  principle,  simple  ointment  and
 Goulard's cerate, furnish the best dress-
 ing in ordinary cases.
   " Scrophulous congestions, ofa solid na-
 ture,  in the more external parts  of the
 body, are little adapted to  tiie practice of
 local  bleeding, unless they be  attended
 with symptoms  of inflammation,  but  as
 some degree of inflammation is, in gene-
 ral, present during the incipient stage, it
 may be prudent to employ local  bleeding
 in  moderation  at the commencement  of
 the attack, although there may be no indi-
1 cation to persist  in the practice,  after the
 complaint has advanced farther in its  pro-
 gress.  If, however, these congestions are
 more of an indolent nature, unaccompanied
 with heat or pain, there is no benefit to be
 expected  from  the  local  detraction  of
 blood; warm fomentations, together with
 the use of stimulants, and a repetition  of
 blisters, are the most  serviceable class  of
 remedies: such  cases, too, are  the best
 adapted to the  use of friction as a discu-
 tient.   Friction, indeed, has long been
 employed  for this purpose; but, of late
 yex.rs, it has been introduced to an extent,
 and with an effect,  far beyond the expe-
 rience of all former pract ice.   As yet,  it
 has been circumscribed to the practice  of
 a very few individuals, with whom it  is
 said to have performed very great cures ;
 and if, upon the test of more extensive ex-
 perience,  it is found to answer its present
 high character, I shall consider the use  of
 repeated frictions to be one ofthe most va-
 luable improvements which has been in-
 teoduced into practice in modem times.
 The safety and simplicity of the  practice
 recommend it  very strongly to  favour,
 though I am afraid they are the very cir-
 cumstances which  retard  its  adoption
 by the public in general.   I only  regret
 that I do not feel myself entitled to give a
 decided opinion upon the subject from my
 own  experience, though I have known
 some instances of successful cures;  but
 the  reports of success are so numerous
 and so well supported, that I am inclined
 to think very favourably of the practice.
  "There is no substance interposed be«
 tween the surface of the swelling and the
 hand of the person who administers the
 friction, excepting a little  flour, to pre-
 vent  the  abrasion  of  the skin.   The
 friction is  applied regularly two or three
 hours every day, with great celerity, the
 hand being made to move to and fro one
 hundred and  twenty times  in  a minute,
 and the course may require to be continu-
 ed without interruption, for sqme months."
 (See  Russell on Scrophula)
  I shall not enlarge upon this endless
 subject, which still stands in need of elu-
 cidation, as much as any disease, that can
 be instanced.  The scrophulous affections
 ofthe joints are explained in Joints. Bron-
 chocele ; Lumbar Abscess ; and  Vertebrx,
 are other articles, containing matter  con-
 nected with the preceding  observations.
  With regard to sources of information,
 Concerning, scrophula,  I profess myself
 totally unacquainted  with any, which are
 even moderately respectable. The reader
 may consult Wiseman's  CfururgicaT Trea-
 tises.  Heister's  Surgery.  Cullen's  First
 Lines of the Practice  of Physic, Vol. 4.
 Ferne on the King's Evil.   Cheyne on the
 King's Evil. B. Bell's Surgery, Vol 5. B.
 Bell on Ulcers.   Kirkland's Medical  Sur-
gery  Vol. 2. White on the Struma, Edit. 3,
 1794. A. G. Kortum's  Comment, de  Vitio
 Scrophuloso, in 2 Vol. 4to. Lemgovix, 1789,
 London Med. Obs and Inq.  Vol.  1.   En-
 cyclopedie Methodique, Art. EcroueHes.  Dis-
 sertations on Inflamnmtion, by John Burnt,
 Vol. 2.  Crowther's  Obs. on the Disease of
 the Joints, commonly called ll'lute Swelling;
 with remarks on Caries, Necrosis, and Scro-
phulous  Abscesses, &c. Edit.  2, 1808.  A
 Treatise on Scrofula,  by James  Russell,
 Edinburgh, 1808. Of the preceding works,
 Cullen's  First  Lines,  White's  Treatise,
 Mr  Burn's Dissertation in   Vol. 2,  -»nd
 Mr.  Russell's Treatise,  have been  most
 u eful to me, in the compilation of the
 present  article.
  SCROTOCE'LE. (from scrofwm.and *v*h
 a tumour.)  A rupture, or  hernia in the
 scrotum.
  SCROTUM, CANCER  OF.   (Chim-
 ney-Sweeper's Cancer. Tlie soot-wart.)  Mr.
 Pott  gives the following account of this
peculiar disorder.
  " It is a disease, which always makes
 its first attack on, and its first a; pearance
 in, the inferior pail ofthe scrotum; where
 it produces a superficial, painful, ragged,
 ill-looking sore, with  hard  and rising
 edges :  the trade call it the soot-wart.  I
 never saw it under  the age of puberty,
 which i^,  I suppose, one reason why  it is
 generally taken, both by patient and sur- 
SCR                                   SET              305
geon, for venereal, and being treated with
mercurials, is thereby soon and much ex-
asperated :  in no great length of time,  it
pervades the skin, dartos, and membranes
of the  scrotum, and  seizes the testicle,
which  it enlarges, hardens, and renders
truly and thoroughly distempered ; from
whence it makes its way up the spermatic
process into the abdomen, most frequently
indurating  and spoiling  the   inguinal
glands :  when arrived within  the  abdo-
men, it affects some of the viscera, and
then very soon becomes painfully destruc-
tive.
   " The  fate of these people  seems sin-
gularly hard :  in their early infancy, they
are most fn quently treated with  great
brutality, and almost starved  with cold
and hunger;  they are thrust up narrow,
and sometimes hot chimneys, where they
are bruised, burned, and almost suffocat-
ed; and when they get to puberty, become
peculiarly liable to a most noisome, pain-
ful, and fatal disease.
   " Of this last circumstance there is not
the least doubt, though perhaps it may
not have been sufficiently attended to,  to
make  it  generally known.  Other people
have cancers of the same parts; and  so
have others beside lead-workers, the Poic-
tou colic, and the  consequent paralysis:
but it  is nevertheless a disease to which
they are peculiarly  liable ; and so are
chimney-sweepers  to the cancer of the
scrotum and testicles.
   " If there be any chance of putting a
stop to, or preventing  this mischief,  it
must be by the immediate removal of the
part affected ;  I  mean  that part  of the
scrotum where the  sore is ; for, if at  be
suffered to remain  until  the  virus has
seized the testicle, it is generally too late
even for castration.  I  have  many times
made  the experiment;  but though the
sores,  after such operation, have, in some
instances, healed kindly, and the patients
have gone from the hospital seemingly
well, yet, in the space ofa few months,
it has generally happened, that they have
returned either with the same disease  in
the other testicle, on in  the glands of the
groin,  or with such wan complexions,
such pale  leaden  countenances, such a
total loss of strength, and such  frequent
and  acute  internal pains, as have  suffi-
ciently proved a diseased state of some of
the viscera,  and which have soon been
followed by a painful death.
   " If extirpation ever  bids fair for the
cure of  a cancer, it  seems to be  in this
case;  but then the operation should  be
immediate,  and before  the habit is taint-
ed.  The disease, in these people, seems
to derive its  origin from a lodgment  of
soot in the rugx of the scrotum, and  at
     Vol. II.
first not to be a ihseasc  of the habit.  In
other cases of  a cancerous nature, in
which  the  habit is  too frequently con-
cerned,  we have not often so fair a pro-
spect of success by the removal of the dis-
tempered part; and are obliged to be con-
tent with means, which I wish  I could
say were truly palliative : but  here the
subjects are young, in general  in good
health,  at  least  at  first;  the  disease
brought on them by their occupation, and
in all probability local; which  last cir-
cumstance  may, I think, be fairly pre-
sumed from its  always  seizing the same
part: all this  makes  it (at first) a very
different case  from a cancer, which ap-
pears in an  elderly man, whose fluids are
become acrimonious from time, as well as
other causes; or from the sanf€ kind of
complaint in womeYi Who have ceased to
menstruate.  But be  all this as  it may,
the scrotum is no vital organ, nor can the
loss of a part of it ever  be attended with
any, the smallest degree of  inconveni-
ence; and if a life can  be preserved by
the removal of all that portion that is dis-
tempered, it will be a very good and easy
composition;  for when  the disease has
got head, it is rapid in its progress, pain-
ful in all its attacks, and most certainly
destructive in its event."  (Pott's Works,
vol. 3.)
  SEARCHING.   The  operation of in-
troducing a metallic  instrument, through
the urethra into the bladder, for  the pur-
pose of  ascertaining  whether the patient
has a stone, or not.  See Sounding.
  SE'DATlVES. (from sedo, to appease.)
Sedantia.   Sedativu.   Medicines,  which
diminish irritability.
   SEMICU'PIUM.   Strictly a  bath for
about one half of the body : medical men,
however,  now frequently  mean by the
term only  a warm bath, especially, the
slipper-bath.
   SERPI'GO.  (from serpo, to creep, be-
cause it gradually creeps over the surface
of tlie skin.)  A ring-worm, or tetter. See
Herpes.
   SETON;  (from seta, a bristle, because
hbrse-hairs were formerly used for keep-
ing open the wound.) Setaceum.   A kind
of issue.  It is usually made by means of
a particular needle, which is of various
breadths, from half an inch to a full inch.
The needle is commonly a little  curved ;
but, if  straight, it would be better calcu-
lated for the purpose.  From the point,
to its broadest part, it  is double-edged,
and, behind,  it  has a transverse  eye,
through which a skein of thread, or silk,
of exactly the same breadth as the needle,
is placed.
   A fold of skin is to  be pinched up, at
        ft 
306                                SIGHT
the part where the seton is designed to be
made,  and the needle  is to be pushed
through  it, together  with the skein, of
thread, which is to be dipped in sweet-oil.
The instrument is not to be introduced
too low into the base of the fold, nor too
high,  near its edge.  In the  first  case,
the muscles, and  parts,  which ought to
be avoided, might''be wounded; in tiie
second, the interspace, between the two
wounds,  would be  very narrow, and the
seton soon make its  way through it.
  When  no seton-needte is at hand, the
fold of the skin may be punctured with a
lancet, and the skein of thread introduced
by means of an eye-probe.  A seton may
be applied almost to any part of the sur-
face of the body,  when circumstances re-
quire it -, but, one of its openings should
always be made  lower, than the  other,
that the  matter  may  readily flow out.
The skein of thread is to remain untouch-
ed, for a  few days after the operation, un-
til  the  suppuration  loosens  it.   After-
wards the part of the thread nearest the
wound, is to be smeared with oil,  white
cerate, or  any digestive ointment, and
drawn under the fleshy interspace between
the two  wounds,  and what was there be-
fore is to be cut off.   Tlie seton is to be
drawn in  this  manner once, or twice,  a
day, according as the quantity of  matter
may require.  A new  skein of silk, or
thread, is to be attached to the preceding
one, as often as necessary.  Care is to be
taken to keep the thread on the outside of
the wound  well covered, awl free  from
the discharge, which would make  it stiff
and hard, and apt.to occasion pain and
bleeding on being drawn into the  wound.
If the discharge should be deficient in
quantity, powdered cantharides may be
mixed with the digestive ointment.
   SIGHT,  DEFECTS OF.   There  are
persons, who, from their infancy,  are in-
capable of distinguishing one colour from
another.  A man, who was  affected with
tlus infirmity, could not distinguish green
at all.  Green  and red  appeared  to him
the same.  Yellow and blue he could dis-
cern very well.  With regard to dark-red
and dark-blue, he  frequently made mis-
takes.  In other  respects, his vision w:s
sound and acute. ^The father of this pa-
tient was afflicted with the same infirmity.
The mother and one sister was free from
 it. Another sister  and two of her chil-
 dren  had it.  The patient himself had
 two children, who did not labour  under
 the disorder.  (See Phil. Trans.  Vol. 68,
 Part 2.)  Another subject, whoseeyes were
 in other respects healthy, and  whose eye-
 sight  was sharp,  could not  distinguish a
 dark-green from a dark-red.
   Sometimes,  objects appear to the eye
to be of a different colour from what they
really are.   This is occasionally  owing
not to the eye,  but to the unclear and
coloured light, by which the object is illu-
minated.  Thus, for instance, a bad tal-
low candle, which  emits a yellow  flame,
makes every thing appear yellow.  When
brandy is burning all objects appear blue.
In short, it is only by the light of the sun,
til at any object can be seen in  its clear
natural  hue.  In certain cases, the infir-
mity is  owing to  the  transparent  parts
and  humours of the  eye,  which  do not
happen to be of a proper  colour.  Thus,
persons having the jaundice in a high de-
gree, see all things yellow, because the
transparent  parts of the eye are of that
colour.   When, in consequence of exter-
nal  violence applied to the eye, blood  is
effused, and the aqueous humour rendered
red  by this fluid, all objects seem to the
patient to be red ;  and, white, when the
aqueous humour has been made of this co-
lour by the couching of a milky  cataract.
Sometimes this defect  in vision is ascrib-
able  to  the" duration of  an impression.
When one has surveyed a bright  coloured
object  a lon# while,  as  for  example a
bright red or yellow  wall, on which the
sun  shines,  that colour will often remain
a good  while before the  eyes,  although
one  may not be looking any more at an
object of this hue.  There are some eyes,
which seem  much disposed to retain the
impression of objects, which are not very
bright coloured;  but, such a disposition
always  betrays  great weakness  and irri-
tability of those organs.  The  most fre-
quent cause of this defect in vision, is  an
irritation operating upon the optic nerves,
so as to produce  the irritability in them,
which alone makes objects appear of one
colour.  The seat  of such irritation, ac-
cording to Richter, is also most commonly
 in the abdominal viscera, and the case  de-
mands  evacuations, tonics, and anodyne
 medicines.   But,  the  disorder  may also
originate from other causes.  The  opera-
 tion of bright-coloured or shining objects
 upon the eye, sometimes  has this conse-
 quence, that, for a certain time afterwards,
 objects of diverse colours appear to  be
 moving before the eyes.   In extreme ter-
 ror, or fright, things may also  seem to
 have a  different colour  from their real
 one. The  same often happens in fevers
 attended with delirium.   A sudden expo-
 sure of the head to cold, at a period, when
 it was perspiring much, in one instance,
 caused many coloured appearances before
 the eyes; but, the disorder subsided in a
 couple of days.  Richter*s Anfangsgr.  der
  Wundarzneykunst, Band. 3, p. 523.)
   Also a healthy eye sees a distant object
 with uncertainty, and  error, in a room, or 
SIGHT.
207
apace, the extent, length,  and breadth,
of which are  unknown, when the  size of
the  object  itself is unascertained, and
when there are few or no other objects in-
tervening  at a smaller distance between
the eye and the thing looked  at.  The
more numerous the objects are between
the eye and the principal thing looked at,
the more distant it is made to appear; the
fewer they are, the nearer it seems to be.
In a country covered with snow, and upon
the sea, very distant objects appear to be
close.  The  smaller an object  is to the"*
eye, in relation to its known magnitude,
the  further off it seems.  The  errors,
which the eye makes, in regard  to the
distance of objects, also tend to deceive.
But, there  are certain cases, in which the
eye is almost entirely incapable ofjudging
of the distance of objects.  The first is,
when the object,  of which we wish to as-
certain the distance, is   looked at  with
only one  eye.  Hence all one eyed per-
sons, ^ind persons affected with strabis-
mus, are unable to judge well of the real
distance  of objects.  However  they are
only so for a certain time ; and,  by prac-
tice, they gradually acquire the faculty.
Even when two eyes are employed, it re-
qiiiressome exercise, in order to  enable
them to j udge of the right distance  of ob-
jects.  Persons, born blind, but who have
their sight restored in  both eyes  by the
operation  for the  cataract, are a  long
while incapable  of judging of distances,
and only obtain  this power very gradual-
ly.  Lastly, this  infirmity  is sometimes
owing to an irritation affecting the optic
nerves, whereby their sensibility is so al-
tered, that distant objects make the im-
pression upon them of near ones.  In this
circumstance, all  objects  appear to  the
patient closer than they really are.   This
is the only case,  which admits  of being
treated as a disease.  The irritation, pro-
ducing the disorder, is mostly s -. ted in
theabdommal viscera, and  requires eva-
cuations and such medicines as invigorate
the nerves.  A suppression  of the perspi-
ration is alleged to be sometimes a cause.
(Richter's  Anfangsgr.  der  Wundarzn.
Band! 3, p. 525.)
  A sound eye likewise does not  always
judge with accuracy and uniformity of the
magnitude of objects.   This may arise
from  three causes.  In order to  judge
rightly ofthe size of any thing, its precise
distance must be known;  for, the more
remote it is, the smaller will it  seem to
the eye.  Hence, any conjecture, respect-
ing the magnitude of an object, is con-
stantly erroneous, unless the distance  be
ascertained.  Size is invariably something
relative.  A single large object, surround-
ed by many small  ones,  always appears
 to be larger, than it really is;  et vice
 versa.  An object, whose magnitude  is
 known, seems smaller, than it actually is,
 when one has been a little previously
 looking at another that  is still  larger.
 Lastly, the refraction of the rays of light
 in the eye,  by which operation an object
 is made to appear large or small, is not
 always accomplished in the same degree,
 as the eye is not at all times equally full
 and distended with its humours.   Hence,
 at one time, the same object  will  appear
 to the same eye, and at the same distance,
 larger ; at another time, smaller.  Some-
 times, however, the eye judges so errone-
 ously  of the magnitude of objects, that
 there is reason for regarding the  case  as
 an infirmity, or disease.  It  is  for the
 most part owing to a defective sensibility
 in the nerves, caused by some species  of
 irritation  acting upon the  eye, and gene-
 rally seated in the gastric  organs.   A
 man, to whom every thing  seemed one half
 smaller and nearer, than  it  really was,
 was cured by means of an emetic bark,
 an issue,  and  valerian.   (Leutin, obs.
fascic.)
   Sometimes to the eye,  under circum-
 stances of disease, straight lines  appear
 serpentine; perpendicular objects,sloping,
 things standing upright, to be inverted,
 &c. All these cases are set down by Rich-
 ter as depending upon a wrong sensibility
 of the nerves, occasioned by the effect of
 some  irritation.  The  irritation, he says,
 may be of many  kinds; but,  experience
 proves that it is mostly seated in the gas-
 tric organs.  These defects of sight may
 generally be cured by first  exhibiting
 emetics and  purgatives,  and afterwards
 having recourse to remedies for strength-
 ening the nerves, bark, oieum animate, va-
 lerian, issues, &c.  One mark of a very
 weak  and irritable eye, is when objects,
 after being looked at  a good while, and
 presenting  a right appearance,  begin to
 move, swim about, mix together,  and,  at
 length, become  quite  indistinguishable.
 This principally happens when the objects
 regarded  are small and strongly illuminat-
 ed.  Here such remedies, both  general
 and topical, as have the effect of invigor-
 ating the nerves,  are   indicated.   How- •
 ever, sometimes, the  infirmity is partly
 owing to the operation of  some species of
 irritation, which will require removal, ere
 the tonic  medicines and applications can
 avail.  Indeed, in  particular  cases, the
 dispersion of" such irritation is alone suf-
 ficient to accomplish the cure.
   Sometimes, all  objects  appear  to the
 eye, as it they were in a more or less dense
 mist.  This' defect in vision  is   always
 owing either to some slight opacity of one
 of the humours ofthe eye, or to excessive 
308             SOU
SPI
debility of the optic nerves.   (See Rich-
ter's Anfungsgr. der Wundarzn. Band. 3,
p. 521, &c^>
  SINGULTUS,  (d  sono vocis,  from its
peculiar noise.)  The hiccough.
  SINUS,  (a gulph, from *£va?,  void.)
This term  in surgery means a long, nar-
row, hollow track, leading from some ab-
scess, diseased bone,  &c.
  S1PH1LIS.  (from c<pA«s, filthy.) The
venereal disease.  (S e Venereal Disease.)
  SOLUTIO  ARUENTI  N1TRAT1.—
St. Argenti Nitrati^j. Aq. Distillat. 3SS.
M.  This is a very  good  application for
sores, which are frequently met with round
the roots of the nails, both of  the fingers
and toes.   It is also useful in herpetic  af-
fections,  noli-me-tangere, and   several
kinds of ulcers.  The proportion of the
argentum  nitratum may be lessened, or
increased, as  occauon requires. A strong
solution of this  substance is a good appli-
cation for  destroying warts, to which it
must be applied by means of a hair pen-
cil.  When used for sores, it is  best to
dip little bits of soft  lint in  it, lay them
on the part affected, and cover them with
a common pledget.
  SOLUTIO  FERRI   VITRTOLATL—
gt. Ferri Vitriolati ad albidinem  calcinati
5j. Aq. Distillat. $\i\\.  Misc.  Has been
recommended as an  application for sores
on the nipple, and other ulcers.
  SOLUTIO    HYDRARGYRI    CUM
PLUM BO  fy Hydrarg. ,§ij. Plumbgi jiss.
Acidi Nitrosi Jj.  The two- metals are to
be dissolved in  the acid, in a glass vessel,
placed in a sand heat.   Plenck employs
this caustic solution for destroying warts,
and excrescences.
  SORDI'TIES. (from  eordea, to be fiT-
thy.)   Putrid pus of  bad quality ; any fe-
tid discharge.
  SOUND. An  instrument, which sur-
geons introduce through the urethra into
the bladder, in  order to discover, whether
there is a  stone in this viscus, or not.
The sound is usually made of very highly
polished steel,  that it may be well calcu-
lated for conveying  to the surgeon's fin-
gers the sensation of any thing, against
which its end may strike.  It is also«ge-
nerally rather less curved, than a cathe-
ter,  so  that  its extremity may be more
easily inclined  to the lower part of the
bladder, where  the stone is most frequent-
ly situated.
  SOUNDING.  The  operation  of  in-
troducing the foregoing instrument.
  Sounds are generally  introduced much
in the same way as catheters, either with
the concavity towards the abdomen, or
the convexity, in which  last method,  it is
necessary, as soon as the beak ofthe sound
has arrived in the perineum, to bring the
handle of the instrument downward by a
semicircular movement on the right, while
the other end is  kept as  much fixed as
possible.  This is what the  French term
the coup, or tour de  maitre ; a plan, that
is  often  followed  at the  present  day,
though, except in very corpulent subjects,
it has no particular recommendation.
  When a patient is to be sounded, he is
usually put into a posture very similar to
that adopted in the  lateral  operation for
the stone, with the  exception that he is
not bound  in this position,  as  there  Is
sometimes  an advantage  in being  able
suddenly to alter it, in order that the stone
may thereby be made to come into contact
with the end of the  sound.  The instru-
ment having been introduced, its extre-
mity is to be turned, and moved in every
direction within  the bladder, when, if
there be a calculus, its presence will usu-
ally be indicated  by the collision against
the beak of the sound.
  SPARGANO'SIS.  (from c-?r*?y«#, t0
swell.)  An enlargement  of the breast
from a redundancy of milk: the mamma-
ry abscess.
  SPA'TULA. (dim. of spatho,  a broad
instrument.)   An instrument for spread-
ing salve.
  SPEC1LLUM.  (from  specio. to  ex-
amine.)  A probe.
  SPE'CULUM.    An   instrument  in-
tended for facilitating the  examination of
parts,  and also operations  on them : thus
we  have specula ani, specula oculi, auris,
&c
  SPERMATOCELE,  (from  ««fl*<
and xtiXtj,  a tumour.)  The old writers
seem  to signify, by  this term, a swelling
caused by a stagnation of the  semen.  I
am acquainted with no real disease, which
answers to any meaning of this kind.
  SPHACELl'SMUS. (from <r$a,M\itf>,
to mortify.)  A mortification.
  SPHA'CELUS. (from o-$*£«,  to  de-
stroy.)   Surgeons imply,  by this  word,
complete mortification,  which is mostly
preceded by  a  stage of the disorder,
termed gangrene.  (See Mortification.)
  SPICA. (from «"?r«;6««,anearof corn.)
A name, given to  a kind of bandage, in
consequence of its turns being thought to
resemble the rows of an ear of corn.  Of
spica  bandages there are  several kinds:
but, we shall here only mention a few.
  In order to apply the  spica bandage,
employed in dislocations of  the shoulder,
we are to  take a common single-headed
roller, and place the end of it under the
opposite arm-pit.    After  conveying the
bandage backward,  obliquely over the 
S P1                                    S P1             309
shoulders, we are then to bring it forward
over the head of  the   dislocated bone.
The roller is next to descend  under the
arm-pit,  then  be  carried upward again,
and made to cross on the deltoid muscle.
The roller is now to  be carried obliquely
downward  over the front of the chest,
and  under the  opposite arm-pit,  where
the end of it is to be pinned, or stitched.
The bandage is next to pass across the
back, over the part of the roller previous-
ly applied in this situation, and is to be
conveyed rouncl the head of the os  bra-
chii, so as to  form a  turn, or doloire, with
the first circle ofthe roller. Three, or four
doloires,  or turns, each of which  covers
about one-third of the preceding one, are
to be made, and then the upper part ofthe
arm is to be once surrounded with  a plain
circle of the bandage.   This last circular
application  leaves between  it, and the
cross previously made, a triangular, equi-
lateral space, technically named by wri-
ters geranis.  The roller is now to be car-
ried upward in a spiral  manner; its head
is to be brought  to  the opposite arm-pit,
and the application  of the  whole  con-
cludes with a few turns round the body.
The bandage is to be  fastened with pins
at the*place, where it commenced.
   Before putting on the spica, the injured
part, and margin  ofthe axillae, must be
guarded from the effects of the pressure
by compresses.
   The spica bandage for the broken clavi-
cle is applied in the same manner,  with
the exception, that the crossings are made
over this bone.  It is proper to state,  in
 this  place, that the spica is a very in-
effectual bandage for this kind of case.
 (See Fractures of the Clavicle.)
   In  oider to apply, what is named, the
 spica ingmnis, tiie end of the roller is to be
 placed on the spine of the os ilium, ofthe
 affected side.   The  bandage is then to  be
 carried obliquely  over  the groin, and un-
 der the perinauim.  Then it is to  pass
 over the back of the thigh, and next for-
 ward, so as to cross the  part previously
 applied on the  front of the groin.  The
 application is  continued by carrying the
 roller over the pubes,  over the opposite
os ilium, and next round the body above
the buttocks.  The bandage thus returns to
 the place, where it began.   Its applica-
 tion  is completed by making  a few do-
 loires, and turns,  like  the  preceding
ones, and  lastly, a  few turns  round the
 body.
   The spica for  the  thigh is applied in
the same way ;  only the crossings are  to
be made on the upper  and outer  part of
the limb.  (See Encyclopedic Methodique,
Part. Chirurgicale, Art. Spica.
   SPINA  BIFIDA,    (i.  e.  the  Cloven
Spine.)   Hydro-Rachitis.  A disease,  at-
tended with an incomplete state of some
of the vertebra:,  and a fluid swelling,
which is most commonly situated over the
lower lumbar  vertebra,  sometimes over
the dorsal and cervical ones, and, in some
instances, over the os sacrum.   The same
name has also been given  to  an  analo-
gous  tumour,  which  sometimes occurs
on  children's  heads,  attended with  an
imperfect ossification of some part of the
cranium.
  The Arabians, who first treated of this
disease,  erroneously imputed the defi-
ciency of one, or more of the spinous pro-
cesses to the tumour, while it  is now well
known,  that the  incomplete state of the
affected vertebrae is a congenital malform-
ation, and that the swelling  is only an
effect.  In fact, the tumour generally bi*
come3 larger  and larger,  the longer it
continues.   The spina bifida  may be re-
garded  as an  affliction only met with in
children : few, very few, live to the adult
age  with this incurable  affection.   War-
ner, however, has related a case, in which
the patient lived  till he was twenty.—
(Cases in Surgery, p. 134, Edit. 4.)
  As I have  remarked, the  swelling is
most frequently situated towards the lower
part of  the spinal canal, particularly at
the place, where the lumbar vertebrae join
the sacrum.  The fluid, which it contains,
resembles serum,  being  somewhat more
liquid, than the white-of-egg,  and, like
the latter, frequently coagulable.  It is in
general limpid and Colourless ;  but, occa-
sionally,  it is  turbid, and  tinged  with
blood.  On  pressing tiie tumour,  a fluc-
tuation  is very perceptible, and a preter-
natural space may also  be felt existing
between some of the  spinous  processes.
The fluid is contained in a  kind of cyst,
which is composed of the continuation of
the dura mater, investing the spinal'canal,
and is usually closely adherent to the in-
teguments.
  Spina bifida is sometimes attended with
hydrocephalus.  It has even been record-
ed,  that the enlargement of the head has
undergone  a  considerable   diminution,
when the tumour  of the  spine casually-
burst, and  discharged the fluid, which it
contained;  a  proof  of some communica-
tion between the two parts.  (Ephem. Cur.
Nat. Decad. 3,  Ar. 1, Decad. 2, Art. 2.)
The fluid, which was lodged in the lateral
ventricles,  and third  ventricle,  passed
into the fourth, through the  aquaductus
Sylvii, ruptured  the calamus scriptorius,
and thus got into the spinal canal.
  Spinae bifida; usually occur on the lower
part of the spine; but, they occasionally
take place  on the cervical vertebrae, in
which hitter situation, the tumours have 
310
SPINA  BIFIDA.
 the same characteristic marks, as those
 which form near the sacrum.  Many facts,
 recorded by Ruysch,  in his  Anatomical
 Observations, confirm the preceding  ac-
 count.
   The present affliction is one of a most
 incurable nature: at least, (with the  ex-
 ception of two or three recently published
 by Mr.  Astley  Cooper,) there  is  not, I
 believe,  in all the records of medicine, or
 surgery, any case, which either got well of
 itself or was benefited by any mode of
 treatment.  Opening the tumour,  either
 with caustics,  or cutting  instruments,
 has hitherto only tended to hasten the
 fatal event of the disease.   Death soon
 follows an operation of this kind, and, it
 js said,  that  the  child sometimes dies
 immediately.  Tulpius  observes on  this
 subject: quam  calamitatem si qxddem re-
formides, chirurge, cave sis improvitleaperias
 quod tarn facile  occidit hominem.   Observ.
 Med.
   But, whether  the tumour be opened, or
 not, still the  disease  is one of  tiie most
 fatal, to which children are  exposed.
 When afflicted  with it, they very seldom
 live till  three years of  age: but, after
 lingering several months from their birth,
 suddenly  die.  It  has  been said, that
 children, with spina bifida, always have
 their legs in a paralytic state.  This, how-
 ever, is  not true; for, the largest spina
 bifida I  ever saw,  was  under my friend
 Mr. Maul, now resident  at Southampton,
 and was unattended with any weakness
 of the legs.  Indeed,  the  child was, to
 all appearances, as  stout, healthy, and
 full  of  play,  as  possible.  The fatal
 event, however,  took place after a time,
 as  usual;  and,  if my  memory does  not
 fail me,  Mr. Maul noticed, that a little
 before  death,  a  remarkable subsidence of
 the  swelling occurred,  though it  never
 burst externally.  It  is  a fact,  notwith-
 standing, that many infants,  with  spina
 bifida,  have paralytic   legs ;  and  can
 neither retain  their feces, nor urine.    «
   If we draw  our  inferences from  the
 cases,  and  remarks,  offered by almost
 every writer on  spina  bifida,  we must re-
 gard all attempts to cure the disorder,  by
 making any kind of opening,  as exceed-
 ingly perilous, if not positively fatal.  It
 is to be  observed,  at the same time, that
 some very eminent surgical authors have
 not altogether abandoned the idea of  de-
 vising a  mode of accomplishing a  cure,
 at least,  in a few instances.  Mr. B. Bell
 says, that  if the tumour proceeded from
 disease of the spinal marrow, or its mem-
 branes, no means of cure will probably
 ever be discovered. But,  if the deficiency
 in the spinous  processes of the vertebrae,
 with wliich the  disease is always accom-
 panied, is not an effect of the  complaint,
 as  was commonly imagined, and  if the
 collection of fluid takes  place from the
 want of resistance in the dura mater, in
 consequence of the imperfection ofthe
 bones,  Mr. B. Bell questions,  whether
 it would not be proper to tie the base of
 the tumour  with a ligature, not merely
 with a view of removing the swelling, but
 in order to resist the propulsion of the cyst
 further outward.  Mr. Bell acknowledges,
 that the event of  this practice must be
 considered  as very dubious;  but,  ex-
 presses his wish to devise any plan, that
 would afford even the least chance of suc-
 cess,  in a case which must terminate in
 an  unfavourable manner.  Mr. Bell  men-
 tioned his  design  of putting the method
 to  a trial,  on the  first opportunity, and
 after  the detachment of the swelling on
 the outside ofthe ligature, he intended to
 keep a soft compress on the part with a
 proper bandage.  I do  not know whether
 this gentleman ever put the above scheme
 in practice;  but, suppose not.   It is pro-
 perly objected to  by  the author of  the
 article  Spina Bifida, in the Encyclopedic
 Methodique, Part. Chir. because the disease
 is often attended with other mischief of
 the spinal marrow and brain, and the base
 of the swelling is almost always too large
 to admit of being tied at all,  or not with-
 out hazard of dangerous consequences.
  Richter has proposed the trial of two
 caustic issues at a little distance from the
 swelling ;  but,  I am not acquainted with
 any facts in favour of this practice.
  Mr. Abernethy first suggested trying a
 gentle degree of pressure on the tumour
 from its commencement, with  a view of
producing absorption ofthe fluid, and pre-
 venting the distention of the unsupported
 dura mater.   Were the  fluid to continue
 to increase, notwithstanding such  pres-
 sure, Mr. Abernethy thinks, that as death
 would be inevitable on  the tumour burst-
 ing, it might be vindicable to let out the
 fluid, by means ofa puncture, made with
 a finely-cutting instrument.   The wound
 is to be immediately afterwards closed
 with  slicking plaster,   and,  if possible,
healed.  Another  accumulation is  then
to  be  prevented,  if  practicable,  with
bandages  and topical  applications.   Mr.
 Abernethy actually made the experiment
of trying a puncture in one  hopeless in-
 stance,  in which  indeed,  the  swelling
 had previously just begun to burst.   The
puncture was repeated,  eyery fourth day,
for six weeks, during which  time the
child's health continued unaffected.   The
 wounds were regularly healed  ; but the
plaster having been rubbed off one of the
punctures, the  part ulcerated,  the  open-
 ing could not be healed, the discharge, 
8PTNA BIFIDA.
3U
from having been of an  aqueous quality,
became purulent, and death ensued. This
case was unfavourable for the trial of the
method, as the integuments covering the
tumour were diseased, and had no disposi-
tion to contract.
  The annexed case,  published by Mr.
Astley Cooper, will  serve to shew  the
benefit, Which may be derived from pres-
sure.
  " James  Applebee,  Baldwin  Street,
Old Street, was born on the 19th of May,
1807,  and his mother, immediately after
his birth,  observed a round and  transpa-
rent tumour on the loins, of the size of a
large  walnut.
  " Mr. Deering, who was her accouch-
eur, requested  Dr.  Petch  to see  the
child with him, who informed the  mother
of the dangerous nature of the complaint,
and of the probability of its fatal termina-
tion.
   " On the 22d of June, 1807, the child
was brought to my house, and I found,
that  although it had spina bifida,  the
head  was  not unusually large; that  the
motions of its legs were perfect; and its
stools and urine were discharged natu-
rally. -
   " I< applied a roller around the child's
waist, so as to compress the tumour, be-
ing induced to do so  from considering it
as  a species of hernia, and that the defi-
ciency of the spine might be compensated
for by external pressure.
   " The  pressure,  made  by the roller,
had no unpleasant influence on its volun-
tary  powers; its stools and urine con-
tinued to be properly discharged,  but the
mother thought, that the child was occa-
sionally convulsed.
   " At the end of a week, a piece of plas-
 ter of Paris, somewhat hollowed, and that
 hollow partly filled with a piece  of lint,
 was placed upon the surface of the  tu-
mour: a strap of adhesive  plaster  was
 applied to prevent its changing its situa-
tion,  and a roller was carried around the
 waist, to bind the plaster of Paris firmly
upon  the back, and to compress the tu-
 mour as much as the child could bear.
   " This  treatment was continued until
 the month of October, during which time,
the tumour was examined  about three
times a week, and the mother reported,
that the child was occasionally convuls-
 ed.
   " When the child was five months old,
a truss was applied, similar in form  to
that, which I sometimes use for umbilical
hernia in  children, and this has been con-
tinued ever since.
   " At the age of fifteen months, it  be-
gan to make use of its limbs; it could
crawl along a passage, and up two pair of
stairs.
  " At eighteen months,  by some acci-
dent, the truss slipped from the tumour,
which had  become of the size of a small
orange, and the mother observed,  when
it was reduced, that the child  appeared
in some degree dull; and this was always
the case, if the truss was left off for a few
minutes, and then reapplied.
  " At fifteen  months, he began to talk;
and at two years of age, he could walk
alone.
  " He now goes  to school, runs, jumps,
and plays about,  as other children. His
powers of mind do not appear to differ
from  those of other children.  His me-
mory is retentive, and he learns with  fa-
cility.  He had the measles  and small-
pox  in the first year,  and the hooping-
cough at three years.  His head,  previ-
ously and subsequently to the bones clos-
ing, has preserved a proper proportion  to
the other parts of the body.
  " The tumour  is kept by the truss en-
tirely within the channel of the spine ;
but, when  the truss is removed, it soon
becomes ofthe size of half a small orange.
It is therefore  necessary,  that the  use of
the truss should be  continued.  When the
truss is removed, the finger can be readily
pressed through the tumour into the chan-
nel of the  spine."   (Medico-Cliirurgical
Transactions, Vol. 2. p. 323, &c.)
  The next case, also published by Mr.
Astley Cooper, will  prove, that spinx bifi-
da may sometimes  be treated on another
plan, so as to accomplish a permanent cure.
  " January 21st,  1809,  Mrs.  Little, of
No. 27,  Lime-house Causeway,  brought
to my house her son, aged ten weeks, who
was the subject of spina bifida.
  " The tumour  was  situated on  the
loins; it was  soft,  elastic, and transpar-
ent ;  and its size  about as large as a bil-
liard-ball when cut in half; his legs were
perfectly sensible, and his urine and feces
were under the power of the will, &c
   " Having endeavoured to push the wa-
ter, contained  in  the tumour,  into the
channel of the spine,  and finding that if
the  whole was  returned,  the   pressure
would be  too great  upon the brain;  I
thought  it a  fair opportunity  of  trying
what would be the effect of evacuating
the  swelling  by means of  a  very fine
pointed  instrument,  and by subsequent
pressure to bring it into the state  of tiie
spina bifida in Applebee's child.
   " 1 therefore  immediately punctured
the tumour with  a needle, and drew  off
about two  ounces of water.
   " On the 25th of January, finding the
 tumour  as  large as  before it had been 
312              SPI                                      SPI
 punctured, I  opened it again,  and in the
 same manner, and discharged  about four
 ounces of fluid.  The child cried when
 the fluid was evacuated, but not whilst it
 was passing off.
   "On  January 28th, the  tumour  was
 as large as  at first,  I opened it  again,
 and discharged the fluid.  A  roller was
 applied  over the tumour, and around the
 abdomen.
   " February 1st,  it was  again pricked,
 and two ounces of fluid discharged.
   " On the 4tb, three ounces of ffuid were
 discharged.
   " On February 9th,  the  same quantity
 of fluid  was evacuated as on the 4th; but,
 instead of* its  being perfectly clear, as at
 first, it  was now sanious, and it had been
 gradually becoming so in tlie three former
 operations.
   "On  the, 13th,  the same quantity of
 fluid was taken away;  a flannel  roller
 was applied over the tumour and around
 the  abdomen ; a piece of pasteboard was
 placed upon  the flannel roller over  the
 tumour,  and another roller over the paste-
 board to confine it.
   " On the 17th, three ounces of fluid, of
 a more limpid kind, were discharged ; the
 pasteboard was again applied.
   " On the 27th, the surface of the tumour
 inflamed ; the ffuid, not more  than half
 its former quantity,  was mixed with  co-
 agulable lymph, and the child, suffering
 considerable constitutional  irritation, was
 ordered  calomel and scammony, and the
 rollers were discontinued.
   "  February  26th, the tumour was not
 more than a quarter of its former size; it
 felt  solid; the  integuments were thick-
 ened, and it  had  all the appearance  of
 having undergone the adhesive  inflamma-
 tion.
   "  On the 28th, it was still more reduced
 in size, and felt solid.
   "  On  March 4lh,  it was in  the  same
 state as on the 28th of  February.
   "  March  8th, the swelling  was very
 much lessened; the skin over it thickened
 and  wrinkled;  a  roller was again had
 recourse  to ;  a card was put over the tu-
 mour ; and a second roller was applied.
  "March 11th, the tumour was  much
reduced ; the  skin covering it was a little
ulcerated.  On the 15th, it was flat, but
still  a little ulcerated.
  " On the 27th, the effused coagulable
lymph was considerably reduced in quan-
tity, and  of a very firm  consistence.
  "On  the 2d of  May, nothing  more,
than a loose pendulous  bag of skin re-
mained,  and the child, appearing  to  be
perfectly well, the bandage was  soon left
off.
  " On December  18tb, it  was  attacked
 with the small-pox, and went well through
 the disease.
   " The  skin now hangs  flaccid from
 the basis  of  the  sacrum;  its centre  is
 drawn to the spine, to which it is united,
 and thus the appearance of a navel is pro-
 duced in the tumour by retraction of the
 skin.
   " The pricks  of the needles are very
 obvious on each of the punctured parts of
 the tumour, forming slight indentations."
 (See Medico-C/ururgical Transactions, Vol.
 2, p. 326—329.)
   At the time when Mr. A. Cooper trans-
 mitted this case to the Medico-Chirurgi-
 cal  Society, it had been under his obser-
 vation two years  and a half.
   The first of  the preceding observations
 exemplifies  the   palliative   treatment,
 adopted by the latter gentleman, and con-
 sisting of  the  application of pressure, in
 the  manner of a  truss for hernia;  the se-
 cond shews the radical mode of cure by
 puncturing the swelling from time to time
 with a needle,  and exciting the adhesive
 inflammation, which, with the  assistance
 of pressure, stops the disease altogether,
 that is to say,  in such examples as admit
 of cure.
   Consult  Ruyschii  Observ.  Anat.   War-
 ner's Cases in Surgery.   B.  BelPs  System
 of Surgery, vol 5.  Abernethy's Surgical
 and Physiological Essays, Part 1 and 3. En-
 cyclopedic Methodique;  Part. Cliir. Art.
 Spina  Bifida..  Richter's Ansfangsgr. der
 Wundarzneykunst.  A.  Cooper in Medico-
 Chirurgical Transactions, Vol 2. p. 322, &c.
   SPINA  VENTOSA.   The Arabian
 writers first employed this  term  to ex-
 press a disease,  in which matter formed
 m  the  interior  of a  bone,  and  after-
 wards  made its way outward beneath the
 skin.  Until the matter had escaped from
 within the bone,  these  authors describe,
 that the pain was  incessant and intoler-
 able; but that after the pus had made its
 way outward by  fistulous openings, the
 pain underwent a considerable diminu-
 tion. The matter sometimes insinuated
 itself, from the interior of the bone, into
 the  cavities of  the  cellular substance, so
 as to render them soft and flabby,  unat-
 tended occasionally  with any change of
 colour  in the  skin.   The swelling being
 partly a serous and  partly an inflamma-
 tory one, had some of the appearance of
emphysema.  To  express this state, the
 Arabians added the term ventosa to that
of spina, wliich  was employed, before
them, to describe the nature of the pain
attendant on the disease. (See an account
of this subject in the Encyclopedic Metho-
dique, Part. Chir.  Art. Spina  Ventosa.)
  The  term spina ventosa has,  since the
time of the Arabian writers, been used by 
SPINA  VENTOSA.
31:
  many to signify tlie disease named to/ute-
  swelling, and the former might also mean
  by it a similar affection, though we should
  infer the contrary from their account of
  the matter passing from the interior of the
  bone to  get under  the  integuments, a
  thing which I believe never yet happened
  in any case of white-swelling.  Another,
  and, perhaps, a decisive argument, against
  the  original signification  of the word
  being the same as that of white-swelling,
  is, that it was not restricted to diseases of
  the  joints and heads  of the  bones;  but
  was also applied to abscesses, which com-
  menced in the cavities of the middle por-
  tions of the long bones, on which parts,
  I need hardly observe, white-swellings
  never make their attack.
    For  these reasons, many   respectable
  authors have implied by the term spina
  ventosa, an abscess in tiie  interior  of a
  bone. See, on this subject, Laud's System
  of Surgery, vol. 1, p.  165.  Cases of this
  hitter kind, I know,  are infinitely rare,
  compared with that common disorder, in
  this country,  the white-swelling ; and, I
  am  also  certain,  from the  descriptions
  given by some  authors, that they  have
  mistaken instances of necrosis  for cases
* of spina ventosa.   But, that abscesses  do
  occur,  and begin  in  the interior of the
  bones,  more particularly of those of young
  persons,  I  have no  doubt myself,  both
  from two or three cases, which I remem-
  ber having seen  in   St. Bartholomew's
  Hospital, and from some cases recorded by
  the most authentic writers. J. L.  Petit re-
  lates, that a man,  with a tumour on the
  middle ofthe tibia, who had been treated
  by  him as a venereal patient,  found, a
  fortnight  afterwards, that  the  pains,
  which had  never ceased,  now  began to
  grow more violent.  The  patient  was fe-
  verish, his leg became7 red, and even pain-
  ful, externally.  An incision was made in
  the situation of tlie tumour with a view of
  lettingout the matter which was suspected
  to be the occasion of the bad symptoms,
  and to have  insinuated itself under the
  periosteum.  The incision was of no  ser-
  vice, and, two days afterwands, the trepan
  was  applied,  by which means,  a large
    Quantity of matter was let out.  The me-
    ullary part of the  bone seemed quite
  annihilated, and the cavity almost empty.
  Petit made three other perforations  with
  tlie  trepan, and cut away the intervening
  pieces  of  bone.   The  actual  cautery
  was also used several times to  destroy
  the  caries, and  the patient at length got
  well. (Traite des Maladies des Os,de J. L.
  Petit.)  If any one doubt, that abscesses
  now and  then form in the  middle of tiie
  bng bones, I must request him to consult
  Mr.  Hey's Practical Observations in Sur.
         Vol. II.
gery, p. 22, where he may peruse two very
interesting cases illustrative  of what Mr.
Hey calls Abscess in the Tibia with Curies.
One of these I shall take the  liberty of
quoting.
  " Towards the conclusion of the year
1786, a young lady from Richmond, in
Yorkshire, consulted me on  account of a
small tumour in the anterior and middle
part of the tibia.  It had exactly  the ap-
pearance  of a common node; and had
such a degree of softness  in its centre,
that I apprehend a small quantity of fluid
was contained  in it; though  that could
not, from the thickness of the periosteum,
be  distinctly  felt.   The  account which
she gave me of her disorder was as fol-
lows:
  " In the preceding May she had a fever,
which continued about four weeks; at
the expiration cf which, a violent pain
began to  affect her leg.  The pain con-
tinued, without intermission, during six
weeks, and then abated upon the  appear-
ance of a small tumour on the shin.  She
could then Walk about with little or no
\measiness: but  sneezing  or  coughing
caused a painful sensation in the tumour.
She  was, in  other respects,  in perfect
health.
   " I  recommended the trial of  some
means to effect the dispersion of the tu-
mour; and, with  this view, I directed
Plummer's pill, with the decoction of me-
zereon,  and applied mercurial ointment
to  the part, covering the tumour, in the
intervals  of  this application, with cera-
tum saponis.  By the use of these means
the tumour became less, and the uneasi-
ness was diminished; so that the young
lady thought  herself nearly well.  But
before the expiration  of winter, the tu-
mour began again  to  increase in bulk;
and in the summer 1787, she returned to
Leeds to put herself entirely under my
care.
   "The  tumour  was then larger and
softer, and there remained  not the least
hope of curing my patient without dis-
charging the matter, and afterwards treat-
ing the case as the state of the periosteum
and tibia might require.
   " Upon laying  open  the tumour,  T
found the periosteum diseased and thick-
ened; separated from  tiie  tibia, and in-
cluding a small quantity of purulent mat-
ter.  The surface of the tibia was rough,
as  far as the matter had covered  it; and
in the centre ofthe rough part there was
a hole equal in bore to a goose's quill,
which penetrated the bone in a direct line
about a quarter of an inch.
   " As the bone was firm on the rough
part, and resisted the pressure ofa probe,
I thought it right to try whether the sur-
     Rr 
314                           SPINA VENTOSA.
  face, upon exposure to the air, would not
  produce good granulations; and, there-
  fore, after removing so much of the peri-
  osteum  as  I found in a morbid state, I
  dressed the wound simply.
    " Upon continuing this treatment about
  a fortnight, I became sensible, that more
  matter issued from the  wound  than  the
  surface  of it ought  to  have produced.
  Suspecting, that the hole  above  mention-
  ed might lead to some cavity, in the bone,
  1 plugged it up with lint, and found, on
  removing the  plug the  next  day,  that
  more purulent matter flowed out than  the
  perpendicular cavity  of the bone could
  contain.   I made an examination with a
  bent probe,  and discovered  a horizontal
  cavity connected with the perpendicular
  one, and running both upwards and down-
  wards in the longitudinal direction of  the
  bone.  It was now clear, that the bone
  was affected with an  internal caries ; but
  it was impossible to ascertain the extent
 of the caries by such an examination.
   " Nothing now  remained  to be done,
 which could afford a rational hope of cur-
 ing this disease, except amputation of the
 limb,  or a bold attempt  to explore fully
 the extent of the  internal caries, and  to
 remove the diseased part of the bone.   I
 explained the case fully to  my  patient,
 who submitted entirely to my judgment
 the means to be used for her recovery.
 She had, apparently, a good constitution ;
 and, excepting tl-ys  caries ofthe bone, was
 in  perfect health.  I  determined, there-
 fore, to avoid, if it were  possible, disfi-
 guring this young lady by an  amputation.
 I was satisfied, that  she  would not re-
 proach me on account of my ineffectual
 endeavours to preserve her limb, if my
 attempt to remove the diseased  part  of
 the bone should prove unsuccessful.
   " I  began  the operation by dissecting
 off the granulations of flesh, which had
 arisen from the bone, and then sawed out,
 by means of a circular  headed saw, a
 wedge of the tibia two inches in  length,
 which I had  previously marked at each
 extremity  of  the longitudinal  cavity  in
 the  bone. This wedge was half an inch
 in breadth, and a quarter of an  inch  in
 thickness, and consisted entirely  of the
 laminated  part of the  bone.  The re-
 moval of tins portion of the tibia brought
 to view a caries of  the cancelli almost  as
 extensive as the length ofthe piece which
 I  had  sawn  out.  With   different  tre-
 phines, suited to the breadth of  the ca-
 ries, I  removed the diseased cancelli  of
the bone quite through to the opposite
lamejla, as this part of" the bone was ca-
rious throughout its whole thickness.
  '* As the caries extended  itself in vari-
ous directions, it was  not possible to re-
  move the whole of it  with a trephine,
  without removing  also  a large portion of
  the sound part  of  the bone.  But this I
  wished to avoid as much as possible.  By
  the  assistance, therefore,  of  a  strong
  sharp pointed knife, I pursued the caries in
  every direction, until I had removed every
  part wliich had  an  unsound appearance.
    " This  operation took  up  more than
  two  hours ; yet the young lady bore it
  with the utmost patience and fortitude.
  I dressed the cavity in the bone, and the
  rest of the wound, with dry lint, iu the
  most  simple manner.   The  whole sur.
  face  was speedily filled with good granu.
  lations, and a complete cure  was obtained
  without any exfoliation.
    " The limb which was diseased, has
  now as much strength as the other; and
  no uneasiness is produced even by vio-
  lent exercise." (Practical Observations in
  Surgery, p. 22, &c.)
    In the First Lines ofthe Practice of Sur.
  gery I described, ut der the name of spina
  ventosa, a disease in which matter formed
  in the interior of a bone, attended with
  expansion  of the p irt affected.  In giv-
  ing this  meaning to the  word spina ven-
  tosa, the reader is  already aware, that I
  have only imitated many of my predeces-
  sors, and that, perhaps,  the  original im-
  port ofthe term  would vindicate me in so
  doing.  Mr.  Crowther,  in  his book on
  the white-swelling,  observes, " it is sin-
  gular, that Mr. Cooper  should allow to
 the spina ventosa that expansion which
 he his denied to  the white-swelling.   Did
  this gentleman (he  continues) not know,
 that the  spina ventosa of die joints has
 been considered as a scrophulous caries of
 •tlie ends  of the  bones ?" To  this  pas-
 sage,  my preceding statement answers
 every  purpose of a reply, and I am only
 left a little surprised, that this gentlermn
 should have been disposed to make an at.
 tack on me, without first ascertaining, by
 a careful perusal of proper works,  whe»
 ther I had any authority- for my remarks,
 With regard to the swelling of" the bone,
 in the  spina ventosa, or  case of abscess
 in the interior ofthe part, 1 cannot decide
 from my own observation, if it be a fact
 or  not; and,  as Mr. Crowther had no
 idea that the term spina ventosa was ever
 used to signify the kind of disease already
 described, I Conclude, that he is equally
 uninformed concerning the other  point.
 As a systematic writer, I  was, of course,
 obliged to take from other authors some
 descriptions which were, of necessity, not
 founded on my  own observation.  But,
 without pretending to decide the question
 myself, I  may safely say, that the ac-
 count,  given by authors,  of the bo;ie be-
coming swollen,  when affected  with ab- 
STA
STA             315
jcess  within  it,  has nothing to do with
what is the case in white-swellings, and
that, because the heads of the  bones are
not expanded in the latter disease, we are
not to infer, that bones may not sometimes
swell in a totally different disorder.
  For an account of spina ventosa, in the
sense of white-swelling, refer to Joints.
   SPIRITUS   AMMONIJE   COMPO-
SITUS.  Besides the well known  uses
of this medicine, internally exhibited,  its
vapours are an exceedingly  proper appli-
cation to the eye in some  cases of chronic
ophthalmy.  Scarpa recommends a reme-
dy of a similar nature.
  SPLINTS.   Long pieces of wood, tin,
or strong pasteboard, employed for pre-
venting the ends  of broken bones  from
moving so as to interrupt the process  by
which fractures  unite.  These  instru-
ments are sometimes used in other cases,
for the purpose of keeping  limbs  from
moving,  particularly  in  some  kinds of
dislocations,  wounds,  &c.  For  an ac-
count of  the principles on which splints
ought to be  employed,  see tiie article
Fractures.
   SPONGIA  PR>EPARATA.  (Prepared
 Sponge;  Sponge-tent.)  This  is  formed
by dipping pieces of sponge in  hot  melt-
ed emplastrum  cerae  compositum,  and
pressing  them between two iron plates.
As soon as cold,  the substance  thus form-
ed, may  be cut into pieces of any shape.
It was formerly much used for dilating
small  openings,  for which  it  was well
adapted, as when  the wax melted, the
 elasticity of the sponge  made  it expand
and distend the opening,  in which it had
 been  put.  The  best  modern surgeons
 seldom employ it.
   SPONGIA  USTA.   (Burnt Sponge.)—
This is often given in the form of lozenges,
 in cases of bronchocele, in which particu-
lar instances much efficacy is imputed to
allowing the lozenges to  dissolve gradu-
ally in the mouth,  after putting them un-
der the  tongue.   Burnt  sponge  is also
exhibited in  many scrofulous diseases.
Its good effects are supposed  to  depend
on the quantity of soda which it contains.
 The dose is from a scruple to a dram.
   STAPHYLOMA,  (from fttQvXn,  a
 grape.)  A disease of the eye, so named
 from  its being  thought to resemble a
 grape.   Staphyloma is that disease of the
 eyeball,  in which the cornea loses its  na-
 tural transparency, rises above the level
 ofthe eye, and successively even projects
 beyond  the  eyelids,  in  the form  of an
 elongated, whitish, or pearl-coloured tu-
 mour, which is sometimes smooth,  some-
times uneven, and is attended  with total
 loss of sight.
   Scarpa observes, that  infants are often
attacked by this disease soon after their
birth, and mostly in consequence of the
purulent ophthalmy.  It is also  produced
by  the  small-pox,  jiet  never during its
eruption, which  is  singular;  nor during
the stage of suppuration ; but, when the
pustules dry, and even after the detach-
ment ofthe variolous scabs.
  In  a  great  number  of subjects, sayi
Scarpa, when the staphyloma has attain-
ed a certain elevation above the cornea, it
becomes stationary,  or only increases  in
due proportion to tlie rest of the eye. '  In
other instances,  the small tumour of the
cornea successively enlarges in all its di-
mensions, and in such a disproportion  to
the rest of the eye,  that it at  length pro-
trudes considerably between the eyelids,
to the great molestation and deformity  of
the patient.
  Scarpa notices,  that- this disease  is
justly considered as one of the most seri-
ous, to which the eyeball is subject; for,
to the total and irremediable loss of sight
that it occasions, are added all the evils
which necessarily   result from  the bulk
and protuberance ofthe staphyloma, after
the swelling of the  cornea has acquired
such a size, that it  can no longer be co-
vered  by the  eyelids.  In such circum-
stances, the continual exposure of the
eyeball to the contact ofthe air, and par-
ticles of matter  suspended in it; the fric-
tion of the eyelashes against it; the in-
cessant flux of tears down  the  subjacent
cheek;  are enough to render the eye
painful  and inflamed;  the sound  one is
affected^, by sympathy, and the diseased
one at  length ulcerates,  together ^ with
the lower eyelid and cheek,  on which it
presses.
  Scarpa next  remarks,  that  surgeon*
have long thought,  that, in this disease,
the cornea yields  to the  distention pro-
duced by the turgescence of the humours;
of the eye, nearly in the same manner  a9
the peritoneum  yields  to the pressure  of
the  abdominal viscera, when  an intestinal
hernia takes place.  Richter  (Obs. Chir.
Fasc. 2.) has opposed this theory, observ-
ing, that the  staphyloma, for  the most
part, forms, without the swelling of the
cornea having been preceded by any  of
those morbific dispositions, which are ge-
nerally considered  capable of weakening
the texture and elasticity of  the cornea j
that this membrane, when affected with
staphyloma,  acquires  a much  greater
thickness than what it  has in its natural
state, and, consequently, that the staphy-
loma, far  from  being  concave  within, Is
every where compact and  solid; though
 it ought to be quite the contrary, if the
 tumour had been  occasoned by  an  \m-    ^
 moderate  distention,  operating  on the 
316                            STAPHYLOMA.
cornea from within outward, with an at-  eyelids ;  a  thing,  says  Scarpa, tha  is
tenuation of its natural texture.           not  observable,  under  similar  circum-
  In regard to  this circumstance,  says  stances, in the eyes of adults.
Scarpa,  though I  would  wish to  give    To such  qualities of the cornea, in
Richter all the praise, to which he is en-  children of tender years, and to the na-
titled for his  conspicuous merit in every  tural narrowness of the anterior chamber
branch  of  the healing art, I cannot re-  of the aqueous humour, Scarpa imputes
frain from  noticing, that this celebrated  the  cause, why ophthalmies in infants to
author, in  pointing out a matter of fact,  often produce opacity and  thickening of
as he has done, respecting the origin and  this membrane.  The cornea swells, be-
nature of the staphyloma, has generalized  comes preternaturally thickened, and is
his doctrine too much, by not drawing any  very soon converted into a  pointed, whit-
line of distinction  between the staphy- ish, or pearl coloured  tumour, without
loma of" recent occurrence in infants, and  any cavity internally, and either  in  per-
that of adult subjects,  in whom the dis- feet contact with, or adherent to, the iris.
ease has acquired so large a volume, as to In the course of years,  however, Scarpa
protrude  considerably  beyond the'eye- remarks, that this disease undergoes new
lids.   I fully agree with Richter, (for  it modifications.  For,  as the whole eye en-
is a certain and demonstrable  fact,) that  larges with age, the iris, and crystalline,
the recent staphyloma in  infants is quite  from causes not sufficiently  understood,
compact and solid, on account of the aug-  abandon their natural situation, and are
mented thickness of  the cornea in this  incessantly urged forward.  This effect is
disease; but it is equally certain,  as I  increased, by the  very  limpid  and copi-
have been convinced by  repeated observa-  ous state of the vitreous humour, always
 tion, that, in this very  same staphyloma,  existing, when the disease under consi-
 originally  quite solid and compact, the  deration is  inveterate.   In this  circum-
 comea, strictly speaking, becomes thin-  stance,  whenever  the cornea is  not com-
 ner, or, at all events, is  not thicker, than  pletely  indurated,  and  inflexible, the
 in  its natural state, after the disease has  crystalline  and iris are insensibly  pro-
 existed a -eries of years  in adult subjects,  pelted,  from within outward, nearer and
 and in  whom the swelling of the  cornea  nearer to the cornea, which  they in time
 has attained  such a size, as to protrude  distend in all its  dimensions,  so  as to
 between the  eyelids.   1 Wish  to  imply,  make it project beyond the eyelids, at the
 that the tumour  is not  solid throughout,  same time attenuating it, in a ratio to the
 except in  regard to its containing, in its  bulk, and magnitude, which it assumes.
 amplified  state, the iris, the  crystalline,  Scarpa  has  never met with a voluminous
 and very often, also,  a  portion of the vi-  staphyloma,  projecting beyond the eye-
 treous  humour.   These parts,,  having  lids in  adult persons, which had not ori-
 quitted  their natural position, are pro-  ginally made its  first  appearance in in-
 pelled forward, so as to fill  the  cavity,  fancy;  and he has invariably found, that
 which gradually forms in the cornea, and  the thickness, and density  of the cornea,-
 grows larger.                           both in  the  living,  and dead bodies of
    As  Scarpa continues, the cornea of in-  those, who have  been  affected with this
 fants,  in  its  natural  state,  is, at least,  disease, were  in-an inverse ratio to the
 twice as thick and pulpy as that of adults,  eye.  In inveterate cases  of staphyloma,
 and, consequently, the anterior chamber  forming a large protuberance beyond the
 of the aqi eous humour, in the former, is  eyelids,  the  iris may here and there be
 comparatively so contracted, to what it is  clearly discerned through the diseased
 in the latter, that, in infants at the breast,  cornea, and, if it be not equally manifest
 the cornea may be considered  as  in con- at all points  of the tumour,  it is because
 tact with the iris.  In the latter subjects, the conjunctiva  externally  spread over
 the  softness, flexibility,  and succulency the cornea forms, in conjunction with  its
 of the cornea are naturally  such, that, various vessels, on the  surface  of the tu-
 when this membrane is  separated from  mour,  a stratum  of matter,  not every
  the  rest  of the  eye in the dead subject, where equally dense, and  opaque.  This
 and compressed between the fingers, it dense stratum of  the conjunctiva, spread
 loses, at least, one half of its volume, and over the cornea, easily causes deception,
  thickness, which  does  not   happen  in  in the staphyloma that has attained  a
  adults.  The cornea of young children is  considerable bulk.   The  more the tu-
  so supple, and  distensible, that,  in mi-  mour increases, the more the substance of
  nute injections of the head, when the in-  the cornea seems to become  dense and
 greeted matter is copiously  extravasated  thickened;  while, in reality, the contrarv
  in the eye-ball, the cornea distended from  happens ;  for  the augmentation in the
  behind forward, elevates  itself  in the  density of the layer of the conjunctiva,
  dead  subject  considerably towards the  covering the cornea, only partly supplies 
STAPHYLOMA.                            317
the diminution in the thickness of the
texture  of this last membrane.  Scarpa
thinks it very improbable, that the accu-
rate observers of all ages would have ne-
glected  to notice, that the cornea, in this
advanced stage of the disease, instead of
being attenuated, according to the com-
mon opinion, is even quite a compact and
solid body.  Scarpa  says, the  contrary
is recorded in their  works,  where they
■peak of the extirpation of thick staphy-
lomas by means  of a ligature, and they
caution  Us to tie^the thread very gently,
lest the cornea,  which, in these cases, is
very thin,  should easily be torn.   Gunz
relates,  that he  was an  eye-witness  of
such an accident, which  happened  to  a
patient, in whom a staphyloma had been
 tied by means of a needle,  and thread.
 (De Staphylom. Dissect, vid. Disput. Chir.
 Halleri.)
   Scarpa allows, that Richter's doctrine
 is then a matter  of fact, as it relates to the
 recent  staphyloma of infants; but, as far
 as his own experience goes,  it admits of
 exceptions,  in regard'to the thickness of
 the cornea, in the staphyloma of old date,
 considerable bulk, protruding beyond the
  eyelids.
   Some pretend, says Scarpa, that the
  sclerotica is also subject to staphyloma,
  that is, to a partial  distention,  and pro-
  minence of its anterior hemisphere in the
  white  of  the eye.   Others question the
  existence of such  a disease.  Scarpa ac-
  knowledges, indeed, that he has never yet
  met with any tumour, or prominence on
 •the front  surface of the sclerotica, corre-
  sponding to the white of the eye. On the
  contrary, what  will seem extraordinary
  and singular, this  celebrated surgeon has
  twice  seen, in the dead subject, a staphy-
  loma,  in the posterior hemisphere of the
  sclerotica,  a situation,  in which it  has
  neither been seen, nor described, by any
  one, as far as  Scarpa knows."  The first
  instance was in an eye, removed for quite
  another motive, from the body ofa woman,
  forty  years of age.   This eye was of an
  oval shape, and altogether  larger  than
  the other, which was healthy. On its pos-
  terior hemisphere, on the outside of the
  optic nerve, or the part nearest the temple
  of the same side, the sclerotica was ele-
  vated, in the form of an  oblong tumour,
  resembling a small nut.  As the cornea
   was  healthv and pellucid,  and the hu-
   mours still'retained their natural trans-
   parency, on looking into the pupil of the
   eye in question,  an unusual  brilliancy
   could be seen at the bottom, formed there
   by the light passing through that part of
   the cornea, affected with  staphyloma,
   which had become attenuated, and dia-
  phanous.  On opening  this eye, Scarpa
found the whole of the vitreous humour
deranged  in  its  organization, and con-
verted into a limpid, aqueous fluid, and
the crystalline  somewhat yellowish, but
not opaque.  The posterior hemisphere of
the eye being immersed in spirit of wine,
to which a few drops of nitrous acid had
been added, in order to give to the retina
consistence,  and opacity,  Scarpa could
distinctly  discern, that the cavity of the
staphyloma, in the sclerotica,  was not in-
vested with the nervous expansion of the
retina; that the choroides, in this place,
was very subtile, discoloured, and desti-
tute of its usual reticulated  vascularity;
and that,  in  particular the sclerotica was
so attenuated,  in the situation of the sta-
phyloma,  that  it was hardly aS thick as a
sheet of writing-paper.  Scarpa learnt,
that the woman, from whose body this eye
was taken, had some years previously lost
the power of seeing with this organ, dur-
ing the prevalence of an obstinate oph-
thalmy, attended with habitual and excru-
ciating head-achs.
   Scarpa had an opportunity of observing
 a similar  disease  of an eye, accidentally
 taken from the body of a woman, thirty-
 five years of age.  It was sent to him from
 Milan, by Doctor Monteggia.  It was of
 an oval shape,  and larger, than its fellow.
 The staphyloma of the sclerotica was si-
 tuated on its posterior hemisphere, on the
 outside of the entrance of the optic nerve,
 in other words, towards the temple.  The
 vitreous humour was converted into water,
 the capsule of tlie crystalline was very tur-
 gid, with a limpid, whitish fluid; the lens
 was yellowish, and smaller, than natural j
 in the interior of the staphyloma of the
 sclerotica, the retina was wanting; the
 sclerotica itself,  and the choroides  were
 elevated in the form of a tumour, and at-
 tenuated in such a manner, that the light
 passed through them. Scarpa  could not
 learn any  thing  concerning  the  state of
 this woman's sight;  but, in regard to the
  disease he much doubts, whether art will
  ever succeed in administering efficacious
  means for the stoppage of its progress,
  much less for its cure.
    But, to return to the staphyloma ofthe
  transparent cornea,  this part of the eye-
  ball being, in this circumstance, affected
  with an  irremediable opacity.  Scarpa re-
  marks, that tiie surgeon can have no other
  aim in the treatment of this disease, when
  it is recent in children of ten years, but to
  hinder the increase of the swelling ofthe
  cornea,  the organization of which mem-
   brane is already destroyed.   The tumour
  must be levelled, and flattened as much as
  possible;  and when  the swelling of the
  cornea is inveterate,  very large, and pro-
   minent beyond the eyelids,  it is to be di- 
218
STAPHYLOMA.
minished by surgical means, so as to re-
turn within the orbit, sufficiently to per-
mit the deformity ofthe face to be amend-
ed by the application of an artificial eye.
  Richter proposes, in ca>es of recent sta-
phyloma, to make  at the bottom of the
rumour of the cornea an artificial ulcer,
by  repeatedly  applying the argentum
nitratum, or the oxygenated muriate  of
antimony (butter of antimony,)  and  to
keep it open by the continued use of the
same caustic, with a view of affecting by
means  of this little issue, the dispersion of
the gross tenacious humour,  which is the
immediate cause of the preternatural opa-
city, and swelling of the cornea.  The au-
thor assures us, says Scarpa, that, in this
way, he  has many times effected a dimi-
nution of the staphyloma,  and,  in one
particular case, even restored the trans-
parency  of  the  cornea.  This  cure has
always seemed to  Scarpa, the most rare,
and surprising, of all, that are recorded on
the subject of diseases of the eyes; the
more so, as  this success was obtained in
the space of fourteen days.   Ter repetitd
operatione, quarto scilicet, septimo et decimo
die, ne vestigium quidem morbi die decimo-
quarto supererat.  Obs. Chir. Fascicidus 2.
  Scarpa declares, that though he has fre-
quently attempted to cure the recent sta-
phyloma, in infants, by the above method
of making  an issue, and this  with the
greatest confidence of success, and in the
persuasion,  that this plan of cure  was
founded on certain,  and obvious premises,
respecting the nature of the disease, when
it  is recent, and in' children of  tender
years; though, in doing so,  he  had for
imitation a master in surgery of" the high-
est authority; he has  never yet met
with such success, as  can be at  all com-
pared  with  Richter's,  either in restoring
the transparency of the cornea, or accom-
plishing a diminution of the volume ofthe
staphyloma.  Having formed with the ar-
gentum  nitratum a small ulcer, at the
bottom of the cornea,  and kept the sore
open thirty  days and more, he failed in
obtaining any benefit, in respect to the di-
minution, much less  the opacity of the
cornea, in three infants, one a year and a
half old, and  the  two others somewhat
more  than  three, all which subjects had
been recently attacked with staphyloma in
one eye, in consequence of the small-pox.
A violent chemosis, in  a very short time,
produced a staphyloma in the eye of a
child,  five  years old.   Scarpa  made an
ulcer  at  the bottom of the cornea, in the
unorganized, swollen substance of which
he introduced, for a little depth, the flat
part of a lancet.  Scarpa kept the  sore
open,  for five weeks, with a solution  of
the argentum nitratum, and he remarked,
that the  staphyloma became somewhat
flatter, so as to lose the acute prominence,
which it had at its centre; but the cornea
continued as before, every where opaque,
Though Scarpa  employed  the same me-
thod in two other subjects, of about the
same age, and in the same circumstances ;
though he kept the ulcer open fifty days,
he was never able to effect any depression
or diminution of the staphyloma; and,
consequently, the pointed, pearl-coloured,
projecting  part of the tumour continued
in the same state as it was before.  Scarpa
states, that the conical shape, which the
cornea  assumes  in  this  disease, is a
characteristic symptom, by which a sta-
phyloma may be distinguished  from the
leucoma,   wkji   total  opacity   of the
cornea.
  If, also, in  the course of further trials,
partial benefit be found to accrue from
this plan,  adopted not for the purpose of
re-establishing the transparency  of the
cornea,  but for that of merely checking,
and diminishing the recent staphyloma in
infants,  still Scarpa is of opinion, that no
one will be  easily persuaded,  that the
same treatment can ever prove ofthe least
service,  in diminishing the size of the
large, inveterate, staphyloma in adults;
in other words,  of that, which projects
beyond  tlie  eyelids,  and  rests  on the
cheek.  What advantage can be expected
from  an  artificial  ulcer, formed in the
substance of the cornea, no longer soft
and  pulpy, nor  merely thickened by a
viscid matter, effused in the interstices of
its texture, but become dry and coriaceous
from time, protruding in consequence of
the excessive distention from within out.
ward, and  covered with a cullous crust,
consisting ofthe  layer of the conjunctiva,
and its  varicous  vessels ?  Certain it is,
says Scarpa,  that as often as it has hap-
pened,  that  the inveterate staphyloma,
protruding out ofthe eyelids has accident-
ally ulcerated from the irritation  of any
extraneous body,  the tears, or long pres-
sure of the parts, on which it rests, the
ulcer has never been seen to effect a dimi-
nution ofthe  disease ; we even read, that
the ancient staphyloma, under such cir-
cumstances, has often degenerated into a
malignant fungus.
  Hence,  Scarpa observes,  that  in the
highest  stage of the disease, when tiie
staphyloma projects beyond the  eyelids,
art  has, at  present,  no more  effectual
means for restraining the progress of the
complaint,  and removing the  deformity,
than cutting away  the staphyloma, and
when the place is healed, applying an  ar-
tificial eye.
  Celsus thus expresses himself on the
subject of this operation: Curatio duplex 
STAPHYLOMA.
319
 tit.  Altera  ad ipsas radices per medium
 transuere acu, duo Una ducente, deinde al-
 terius hni duo capita ex super tore parte, al-
 terius ex inferiors adstringere inter se qux
 paulatim seoando id excidant.  Altera in
 summd parte ejus ad lenticules magnitutUnem
 excindere; deinde  spodium, aut cadmium
 infneare.  Utrolibet autem facto, album ovi
 lana excipiendum, et impenendum ; postxque
 vapore aqux calidm fovendus oculus, et leni-
 bus medicamentis ungendus est.  De Medi-
 cina, lib. 7. cap 7.
   Though, says  Scarpa, the first plan or
 that of  the ligature, is  at present aban-
 doned,  as  being generally thought the
 least appropriate;  the majority  of  sur-
 geons still persevere in  passing a needle
 and ligature, through the lower part of
 the staphyloma,  not for the  purpose of
 tying, or constricting the tumour, it is
 true,  but of  making  a noose,  in order to
 fix the eye conveniently,  when the staphy-
 loma is  to be cut  off" in a  circular  manner.
 But Scarpa proves, that  the same advan-
 tage may be obtained by  a very simple
 method, which is more  expeditious,  and
 less incommodious to the patient, and, he
 is therefore, persuaded, that the apparatus
 of the needle and ligature will very so.n
 be disused, both as a  means of cure,  and
 an auxiliary in the operation.
   With regard to  the second method of
 removing the staphyloma,, or that of exci-
 sion, Scarpa  thinks, that sufficient atten-
 tion has not  hitherto been paid to what
 Celsus  has  written on this subject.  In
 fact, Celsus does not  forbid cutting away
 the staphyloma, by a circular incsion at
 its base, as is practised at th present day,
 but says, that this operation is to  be done
 in the centre, or conical point of the tu-
 mour, and that as much of this part of the
 staphyloma  is  to be cut  away,  as will
 equal a lentil in size :   In summd parte
 ejus ad  lenticulx  mugnitudniem excindere.
 Scarpa  remarks,  that the  great  import-
 ance of this precept of Celsus in regard
 to the successful treatment ofthe  staphy-
 loma,  can  only be duly appreciated by
 such as  have often had occasion to com-
 pare the advantages of Celsus's doctrine,
 with the serious inconveniences,  which
 resultfrom the common practice of cutting
 away  the  staphyloma circularly at its
 base;  and with tiie evils produced  by a
 semicircular section,  comprehending  the
 sclerotica, in Woolhouse's manner, alway s
 followed by acute inflammation ofthe eye-
 ball and eyelids, violent pains in the head,
 restlessness, spasms,  copious and some-
 times  gangrenous  suppurations  of  the
 eye and eyelids.  To Scarpa it is a mat-
 ter of fact, proved  by a  numerous series
of observations,  that, the more the semi-
circular   recision  of  the  staphyloma is
 distant from the centre or apex of the
 tumour, approximating its base, and ad-
 vancing towards the sclerotica, the more
 aggravated are the symptoms consequent
 to this operation ; & vice versd.
   The following  is  Scarpa's  method of
 effecting the destruction of the inveterate
 staphyloma, protruding out ofthe eyelids.
 The patient being seated, Scarpa directs
 an assistant to support his head properly;
 then  taking in his hand a knife, similar
 to what is used in the extraction of the
 cataract, he passes the instrument com-
 pletely across  the staphyloma, at the dis-
 tance  of one line and a half,  or two lines,
 from the centre or apex of the tumour,
 from  the  external  towards the internal
 angle ofthe eye, and, by passing the knife
 forward in the same direction, just as is
 done in the extraction of the cataract, he
 makes a semicircular incision downwards,
 in the  most prominent part ofthe tumour.
 Having done this,  he takes  hold of the
 segment of the staphyloma with the for-
 ceps, and  turning the  edge  of the  knife
 upward, he completes the circular reci-
 sion of the apex of the tumour, in such a
 way,  that  the  detached  portion is one,
 two, three, or four lines in diameter, ac-
 cording  to the size of the staphyloma.
 As a portion of the iris, adhering to the
 cornea, from the very  commencement of
 the disease, is  commonly included in this
 secuon ot the pointed part ofthe iumour,
 bo sooner  is the circular division of* the
 apex of the staphyloma  made, than the
 cryslallii.e, or its nucleus, issues from the
 eye,  followed  by a portion  of  the dis-
 solved, vitreous humour.  In consequence
 of this evacuation,  continues Scarpa, the
 eye-ball  often  diminishes in  s* ch  a de-
 gree, that it can be covered by the eyelids,
 to  which  Scarpa immediately applies a
 pledget of dry lint, supported by a reten-
 tive bandage.
  The pain, .produced by this section, is
 of the smallest consequence,  and it  is
common  to see patients  perfectly  tran-
 quil, the three, or four first days after the
operation.   The eye  and eyelids  most
frequently  begin to be painful, inflame,
and swell,   on  tiie fourth day.  On  the
appearance of  these symptoms, which or-
dinarily are very mild, the eye,  on which
the operation  has been done,  is  to be
covered with a  bread  and milk poultice,
in order to promote and accelerate the sup-
puration ofthe internal membranes of the
eye.  When things proceed  in a regular
manner,  the tumefaction  of  the  eyelids
subsides about the seventh, or ninth  day,
and purulent matter is seen on the poul-
tice,  blended with the dissolved vitreous
humour,  which slowly  issues from i the
bottom of the eye.  The matter afterwards 
320
STE
SUP
becomes thick, and whitish,  with relief
to the patient, and manifest diminution
of the whole  eye-ball,  which  not only
shrinks within the eyelids, but even sinks
into the orbit.
  At  this  period,  observes  Scarpa,  on
gent.y separating the eyelids, the conjunc-
tiva is found  swollen, and reddish, and
the margin of the wound of the  staphy-
loma  seems like a whitish circle.   When
the detachment  of this gelatinous circle
takes  place,   which  usually is  on the
twelfth or fourteenth  day after the opera-
tion,  the edge of the surface, from which
the staphyloma  was  cut,  becomes  red,
contracts, and daily diminishes, so that,
at last, the  wound  is  entirely  closed.
There only remains in the centre of the
cornea, for a few days, a small fleshy pro-
minence resembling a little  reddish pa-
pilla,  which,  after being touched a few
times with the argentum nitratum, con-
tracts, and becomes completely healed.
  So  far, says Scarpa, are alarming symp-
toms  from  following this operation,  that
in a great number of cases, the surgeon is
even obliged,  several days afterwards, to
stimulate the  eye, on  which it has been
performed, in order to make it inflame,
partly by  leaving it  a  long while un-
covered, and  exposed to the air, partly
by enlarging the circular recision made
in  the  centre  of  the staphyloma, of
wliich  another  circular portion,  half a
line broad, is  removed, in order to facili-
tate ihe more  abundant discharge of the
humours, and the ingress of air into the
cavities of the eye, which are  so backward
to inflame.   As soon as inflammation has
invaded the interiour of the eye, and sup-
puration has  taken place, the rest of the
cure  regul-rly follows under the use  of
topical emollients, and is soon completed
with  all possible mildness.  As by putting
into execution the above method of de-
stroying the  staphyloma, the cot-sequent
shrinking  of the  eye-ball  takes  place
equally around the great axis, of this or-
gan,  the stump, which follows, has also a
regular circumference,  and  presents an
easy, and commodious place for the appli-
cation of an  artificial  eye.  (Scarpa sulle
Maluttie degli Occhi.)
   Wcnzel  and numerous  other  writers,
imply by staphyloma, a protrusion of a
piece of the iris, through a wound or ul-
cer of t'e eye.  See Iris, Prolapsus of.
   SliEATOMA. (from <r}ex£, fat.) A wen,
or encysted tumour,  containing fat.  See
Tumours, Encysted.
   STELLA,   or   STELLATED  BAN-
DAGE.  A bandage so named becauseit
makes a cross, or star on the  b^ck. It is a
roller, applied in the manner of the figure
8, so as to keep back the shoulders.  It is
often employed in cases of fractures, and
dislocations ofthe clavicle.
  STERNUTATORIES,   (from sternuto,
to  sneeze.)   Sternutatoria.   Medicines,
which provoke sneezing.  In surgery, they
are sometimes recommended  in cases  of
gutta serena.  See Amaurosis.
  STERTOR.  (from sterto, to snore.)  A
snoring noise, or rattling, in the throat;
a symptom of several surgical, as well  as
medical affections.
  STRABISMUS,  (from  trlpxGifr,  to
squint.)  Squinting.
  STRANGURY, (from cfy»y|, a drop,
and upov, the urine.)  Stranguria. A diffi-
culty ot voiding the urine, which comes
away by drops, and with pain.
  STRICTURE,  (from stringo,  to bind.)
A diminution, or contracted state of some
tube, or duct in  the body.  See Urethra.
Strictures of; Oesophagus, SJc. Rectum, &c.
Stricture  also  means, in cases  of  stran-
gulated hernia, the narrowest part of the
opening, or passage,  through which the
bowels  protrude, which narrowest part
makes on the viscera the pressure causing
all  the bad symptoms.  See Hernia.
  STRUMA,   (from struo, to heap up,)
Scrofula, or Scrophula.   The King's Evil'.
See Scrophula.
  STYE.   A-little inflammatory tumour
on the eyelid.   See Hordeolum.
  STYPTICS, (from trivia, to  bind.)"
Styptica.   Medicines and applications for
stopping hemorrhage. See Hemorrhage.
  SUBSULTUS.  (from subsilio, to leap a
little.)  An involuntary spasmodic twitch-
ing of the muscles and tendons.
  SUDORIFICS.  (from sudor, sweat, and
facio,  to  make.)   Medicines  which pro-
duce perspiration.
  SUFFUSION.  (Suffusio, from suffundo,
to  pour down.). The   cataract was  so
named by Celsus, from an idea, that the
opacity arose from the pouring down of a
thick humour from the crystalline lens.
  SUGILLATIO.  (from sugillo, to make
black  and blue with beating.)  The dis-
colouration, following a bruise, and caused
by  an  extravasation of blood; an  ecchy-
mosis.
  SUPPOSITORY, (from suppono, to lay
under.) Suppositorium. A globular, medi-
cated substance, intended to be introduced
into the rectum.
  SUPPRESSION   OF   URINE.  See
Urine, Retention of.    '
  SUPPURATION.  (Suppuratio,   from
suppuro, to suppurate.)  This signifies a
process, by which a peculiar fluid, termed
pus, is  formed in the substance, or from
the surface, of parts of the  body, when
such parts are particularly circumstanced. 
SUPPURATION.
321
  The article, inflammation made us  un-
derstand, that phlegmonous inflammation,
when it exceeds a certain pitch, sometimes
terminates in suppuration,  and  conse-
quently, it follows, that parts, in a certain
state of inflammation, are in one of those
circumstances, which qualify them for the
production of pus.         '

       SYMPTOMS OF SUPPURATION.

  When matter is fully formed in a tu-
mour, there is a remission of all the symp-
toms.  The throbbing  pain, which was.
before frequent, now goes off, and the pa-
tient complains of a more dull,  constant,
heavy pain.  A conical eminence, or point-
ing, as it is termed,  takes place at some
particular part of the tumour, generally
near  its  middle.   In  this  situation,  a
whitish, or yellowish appearance is gene-
rally  observable, instead of  a  deep red,
which  was  previously  apparent,  and  a
fluctuation of a  fluid underneath may be
discovered, on a careful examination with
the fingers.   Sometimes, indeed, when an
abscess is thickly  covered with muscles
and other parts,  the fluctuation cannot be
easily distinguished,  though, from other
concurring circumstances, there can hard-
ly be the least doubt of there being even a
very considerable collection of matter. An
cedematous swelling over the situation of
deeply situated  abscesses is a symptom,
which often occurs,  and is  well worthy
the attention of every practical surgeon.
  The discovery of the existence of deep
abscesses is a circumstance ofthe highest
importance in practice,  and one which
greatly involves  the practitioner's reputa-
tion.  In no part of the surgeon's employ-
ment is experience, in former similar cases,
of* greater use to him, than in the present;
and however  simple it may appear, yet
nothing, it is certain, more readily distin-
guishes a man of observation and exten-
sive practice, than his being able easily
to  detect collections of deep-seated mat-
ter.  On the contrary,  nothing so  mate-
rially injures  the  character and profes-
sional  credit of a  surgeon, as his having
in such cases, given an inaccurate or un-
i'ust prognosis; for,  in disorders  of  this
 hid, the nature and event of the case are
generally at last clearly demonstrated to
all concerned.
  Together with the several local symp-
toms of the presence of pus, already enu-
merated, may be mentioned the frequent
shiverings, to which patients are liable on
its first formation.   However, these rigors
seldom Occur so as to be distinctly observ-
ed, unless the collection of matter is con-
siderable, or situated internally in some
of the viscera.
     Vol. II.
  The pain, attending what  Mr. Hunter
termed  the suppurative inflammation,  is
increased at the time when the arteries are
dilated, and this gives the sensation called
throbbing, in which every one can count
his own pulse, by merely paying attention
to the inflamed part.  Perhaps,  this last
symptom is one of the best characteristics
of" this species of inflammation. When the
inflammation is moving from the adhesive
state to the suppurative, the pain is con-
siderably increased; but, when suppura-
tion has taken place, the pain in some de-
gree subsides.  (Hunter.)
  The redness that took place in the ad-
hesive stage, is now increased, and is of a
pale scarlet colour.   The part, which was
firm,  hard, and swelled, in the previous
si age of the inflammation,  now becomes
still more swelled, in consequence of the
greater dilatation of the vessels,  and the
greater quantity  of coagulating  lymph
thrown out.  (Hunter.)

        THEORY OF SOPPUBATIOX.

  The dissolution of the living solids  of
an animal body into pus, and the power
of this fluid to continue the dissolution,
are old opinions, which, however, are still
entertained by  many, tor their language
is,pus corrodes, it is acrid, &c.  If these no-
tions were true, no sore, which discharges
matter, could be exempted from a conti-
nual  dissolution.   Such ideas probably
arose from the circumstance of an abscess
being a hollow cavity in the  solids, and
from tlie supposition, that the whole  of
the original substance of this cavity was
now  the matter,  which was  found in  it.
This was a very natural way of account-
ing for the formation of pus by one entirely
ignorant of the moving juices, the powers
of tiie arteries, and what takes place in  an
abscess after it is opened. The knowledge
of these three  subjects, abstracted  from
the  knowledge of the abscess before  its
being opened, should have led surgeons tu
account for the formation of pus from the
blood by the powers ofthe arteries alone.
According to the above erroneous princi-
ple, abscesses would continue to  increase
after being  opened, as  fast as before.
Upon the  principle of  the solids  being
dissolved into pus,  the practice of bring-
ing all  indurated parts to suppuration, if
possible, and not making an early  opening,
was founded.  This was done for the pur-
pose of giving time  for the solids to melt
down into pus ; but,  it was apparently
forgotten,  that abscesses  formed matter
after they were opened, and, therefore, the
parts stood the same chance of dissolution
into  pus  as before.  Blinded with the
idea, that tlie solids entered into the com
      S s 

SUPPURATION.
jiosition of pus, the partisans of this doc-
trine could never  see pus  flowing from
any inteinal canal,  as from the urethra, in
cases  of gonorrhoea, without supposing
the existence, of" an ulcer in the passage.
Such sentiments might be forgiven, before
it was known,  that such surfaces could,
and generally did, form  pus, wi'hout  a
breach ofthe solids ; but the continuance
of this way of thinking now is not mere
ignorance, but stupidity.  The formation
of pints of matter in the cavities of the
chest, and abdomen, without  any  breach
in the solids, could not  have been over-
looked by the most zealous  advocates for
the doctrine of dissolution.   (Hunter.)
  The moderns have been still more ridi-
culous ; for, knowing, that it  was denied,
that the solids were ever dissolved into
pus, and that there was not a  single proof
of it, tLey have been busy in producing
what to them seemed a proof. They have
been putting dead animal matter into ab-
scesses, and, finding, that  it was either
Wholly, or in part  dissolved, they, there-
fore, attributed the loss to its beingformed
into  pus.  This,  however, was putting
l.ving and dead animal  matter upon the
same footing, which if a  contradiction in
itself; for, if the result of this experiment
were really what they supposed it to be,
the idea of* living parts  being  dissolved
into  pus  must  be abandoned,  because
living and dead animal matter can never
be considered in the same light.  (Hunter.)
  It might have been remarked, that even
extraneous animal matter  would lie  in
abscesses  for a considerable time, without
being dissolved, and, that  in  abscesses
arising, either from violence, or from a
species of  erysipelatous  inflammation,
there wjre often sloughs of the celluhr
membrane, which  sloughs would come
away, like wet tow, and  tlierefore,  were
not dissolved into pus.   (Hunter.)
  It might also have been noticed, that in
abscesses  in tendinous parts, as about the
aiikle, a  tendon  often mortified,  and
sloughed away, and that the  sores would
not heal till such sloughs were detached ;
but though this sep ration Vas sometimes
not completed, before  tlie expiration of
months, yet the sloughs  at  last  were
thrown off, and consequently could not
be comerted  into pus.  Pieces of dead
bone often lie  soaking in matter for many
months,  and yet without  being changed
into pus, and although bones, so circum-
stanced, mny lose a considerable  deal of
their si b^tance, a loss which some might
impute to the  dissolution of the bone into
pus, yet that waste can  be  accounted for
and proved on the principle of absorption.
The loss is always  upon that  surface, up-
on which the continuity is broken off, and
it is a part of the process by which t"Mr
exfoliation of a dead piece of bone is ac-
complished.  The formation  of pus has
been attributed to a kind of fermentation,
in which both the solids and  fluids  were
concerned.  This doctrine is  easily re-
futed by staling what happens in internal
canals  wliich  naturally  secrete  mucus,
but frequently form pus, without any loss
of substance, or any previous fermenting
process.  Were we to suppose a fermenta-
tion ofthe solids and fluids the immediate
cause of the production of pus, whence
could the sol ids  come, which enter  into
the composition  of discharges from the
urethra ?  for the whole penis could not
afford matter enough  to  form  the  pus,
which is discharged in  a common gonorr-
hoea.  How also should tlie fermentation
of  the solids ever cease ? for, there is the
same surface secreting its mucus, when-
ever the formation of pus is discontinued.
li may be asked, likewise by wiiat power
the first particle of pus in an abscess, or
on  a sore, is formed, before there is any
particle existing, which is capable ot dis-
solving the solids ?  An  abscess may be
stationary for months, and at last be ab-
sorbed ; what becomes of tlie fermentation
all  the while the collection of matter con-
tinues stationary ?
  Extravasated blood has been supposed
to be capable of being converted into pus.
We find, however, that blood, when ex-
travasated, either from violence, or a nip-
ture of a vessel, as in an aneurism, never
of  itself becomes pus ; nor was pus ever
formed in these cases,  without being pre-
ceded by inflammation.   Both the blood
and matter are also found together in the
same cavity, under  such circumstances.
If the blood had coagulated, which it sel-
dom does in cases of violence, it would be
found still coagulated ; and if it had not
coagulated, the  pus would  be bloody.—
(Hunter.)
  The modern theory  of suppuration w,
that the  matter  is  separated from tlie
blood by the secretory power of ihe ves-
sels of the inflamed part, which now ac-
quire a  new mode of action.
  The opinion, that suppuration is a pro-
cess, analogous   to  glandular  secretion,
has been hastily  rejected by many,  who
are swayed by  the fact, that  there is no
pus ever found blended with tiie blood in
the circulating system.  By this mode of
reasoning, however, such thinkers  must
be  lid  to deny  the universally received
and undoubted doctrine, that the bile is  a
secretion; and,  yet, it is  well  known,
that notiiing like this fluid can be detect-
ed in an analysis of the blood, and, in-
d ed, a very small quantity would be suf-
ficient to tinge the whole mass  of circu- 
SUPPURATION.
323
 lating blood  with a yellow colour, the
 same as we see in cases of jaundice.  No
 one would wish to defend tiie idea of tin re
 being either pus, or bile, actually in the
 circulation ; but, only the matter, or mo-
 difications of the matter, which, by the
 combinations, or whatever changes, we
 may choose to term them, taking place in
 the secreting vessels, and by their opera-
 tions are converted  into one of the parti-
 cular fluids in question.
   No suppuration ever takes place with-
 out being preceded  by inflammation ;  no
 pus is ever formed but in consequence of
 ^t.  In abscesses, a  suppuration is an im-
 mediate effect of inflammation;  and when
 internal cavities  remain exposed, no sup-
 puration comes on,  till inflammation has
 formed the disposition and action.
   Violence done to parts is one of the
 great causes of suppuration; but, simply,
 violence does not always occasion it.  The
 violence must be followed by a prevention
 of a cure in a more simple way, viz. by a
 restoration ofthe structure, so as to carry
 on the animal functions of the part.  The
 parts must be kept  long  enough in  that
 state, into which they were put by the
 violence.  Or, what is somewhat similar
 to this,  the  violence must be  attended
 with death in  a part, as, in many bruises,
 all mortifications and all sloughs, in  con-
 sequence of the application of caustic,
 which, when the dead parts separate, leaves
 internal surfaces exposed.   (Hunter.)
   As  every violence,  committed  from
 without, under the above circumstances,
 is more or less exposed to  the surrounding
 air, its  application  to  internal surfaces
 has been assigned as a cause  of suppura-
 tion ;  but,  certainly,  the  air  has  not
 the leasl effect on parts, circumstanced as
 above, f »r a stimulus would arise from a
 wound, were it even contained  in a  va-
 cuum.  In  circumscribed abscesses, the
 air cannot possibly get to  the parts, so as
 to have any share in  making them suppu-
 rate.
   In cases of emphysema,  when the air is
 diffused over the whole body, no suppu-
 ration.is the consequence,  unless an expo-
 sure, or  imperfection  of  some  internal
 surface should be made, for the purpose
 of allowing the air to escape  A stronger
 proof, that it is not the admission of air,
 which makes parts inflame, is, that  the
 cells in the soft parts of birds, and many
 of the cells and  canals of their bones,
 communicating with the lungs,  and  al-
 ways containing air,  never inflame ;  but
 if these cells are exposed in an unnatural
 w;«v, then the stimulus of imperfection
 is  given,>these cavities then inflame,  and
 their surfaces either form adhesions toge-
ther, or produce pus.  (Hunter.)
            ftOAIITIES of res.

    True pus has certain properties, wliich
  when taken singly,  mny belong to other
  secretions,  but  which, conjointly, form
  ths peculiar  character of this  fluid, viz.
  globules,  swimming in a fluid, which  is
  coagula:>le by a  solution  of sal  ammo-
  niac,  which no other animal secretion is,
  and, at the same time, a consequence of
  inflammation.
    The colour and the consistence of pus
  are the  two qualities which  first  attract
  the notice of  every, the most superficial
  observer.,  The  colour  arises  from the
  largest portion of this fluid being com-
  posed of very small round bodies, very
  much  like those little globules,  which,
  swimming in  a fluid, make cream.  The
  fluid, in which the globules of pus swim,
 we might at first suppose to be the serum
 of the blood,  for it coagulates with heat,
 tike the latter fluid.   Pus is also probably
 mixed  with a small quantity of coagulat-
 ing lymph ; as it partly coagulates, after
 it is secreted.
   The fluid  part of pus, however, is
 known to  have properties, which  serum
 has not.  There  being a  similarity he-
 tween pus and  milk, experiments have
 been made to  ascertain whether the fluid
 of pus could  be coagulated with the gas-
 tric juice of animals;  but, no coagula-
 tion coujd be effecied in this  manner ;  a
 solution of sal ammoniac made  the fluid
 part of pus coagulate ; but, not any other
 secretion, or  natural  fluid; and  hence,
 it was concluded, tiiat whenever globules
 were found swimming in a fluid,  coagu-
 lable by s 1 ammoni ic, thWnatter  was to
 be considered as pus. (Hunter )
   The proportion, which the  white glo-
 bules bear to the other pirts  of pus,  de-
 pends  on the health of the  parts pro-
 ducing the discharge.  When  the  glo-
 bules are very abundant,  the  matter is
 thicker and whiter, and U called healthy
 pus; the meaning of which is,  that the
 solids  which  produced  it, are in good
 health; for,  these  appearances in  the
 matter are   no more, than  the  result of
 certain salutary  processes  going on in
 the solids, the effect  of which processes
 is to produce the disposition, on  which
 both suppuration and granulation depend.
 ( Hunter )
   Pus is  specifically  heavier than water,
 and is probably about as heavy as blood.
   Besides the above properties, pus has
 a sweeiish  mawkish taste,  very different
 from that of most other secretions, and
the same taste takes  place,  whether it is
pus from a sore, or an irritated inflamed
 surface.
  Pus has a smell, in some degree  pectt* 
:;:♦                            suppuration.
                                                                             i
liar to itself; but  this differs in different  pable of stimufating any other part of the
cases.  Some diseases, it is said, may be  body.  (Hunter.)
known bv the smell, as for instance,  a go-     Whenever a real disease attacks, either
norrhcc;.                                 the suppurating surface, or the constitu-
   Pus sinks in water : mucus floats.  Pus  tion,  the production of true pus  ceases,
communicates to water an uniformly trou-  and  the fluid becomes changed in some
bled  while  colour ; mucus gives the ap-  measure,  in proportion to these morbid
pearance of stringy portions floating in it,  alterations.  In general it becomes thinner
Mucus is said to be more readily dissolv-  and   more  transparent,  and it partakes
ed by sulphuric acid,  than pus is.  It has  more of the nature of  the Wood, as is the
also been asserted, that if water be added  case  in most other secretions under simt-
to such solutions, the pus is precipitated  lar circumstances.    Sanies  is  the term
to the bottom of the vessel;  while the  usually applied by surgeons, to pus,  in
mucus, instead of being completely preci-  this  degenerated state.  This unhealthy
pitated, forms swimming flakes.   A  solu-  sort of matter has more of the serum, anil,
tion of caustic alkali dissolves  both pus  frequently,  more of the coagulating lymph
and mucus; but,  when  water is added,  in it, and less of the combination, which
ihe  pus  is said to become separated, but  renders it coagulable by a solution of sal
not the mucus.                          ammoniac.  It  has  also  a  greater pro*
   Though solutions in chemical menstrua  portion of  the  extraneous parts of  the
and  precipitations,  have  been thought  blood, which are  soluble in  water, such
a  test of the distinction, between  these  as salts;  and it has a greater tendency,
two  fluids ; yet,  the method  has  been  than  true pus,  to become putrid.  Such
thought  absurd and unphilosophical.  It  unhealthy matter  may even bo  irritating
has  been conceived,  that all animal sub-  to the surface, which produces "it.
stances whatever, when in solution, either     The discharge, when of  an  irritating
in acids or alkalies, would be in  the same  s»rt, is more stimulating to the  adjoining
state,  and  therefore,  that the precipiia-  parts,  with which  it comes in contact,
tion would be the same in all.  Calcareous  than to it.« own secreting surface.  In this
earth, when dissolved in muriatic  acid,  manner, it  frequently produces excoria-
is in  that acid in the same state, whether  tion of the  skin, and ulceration.   Thus
it has been dissolved  from  chalk,  lime-  the tears excoriate  the skin of the cheek,
stone, marble, or  calcareous  sp.tr,  and  in consequence of the quantity of salts,
precipitations from all  are  the same,  which  they contain.   From this effect,
J fence, experiments  were  made on or-  matter has  been called corrosive, a quali-
ganic, animal  matter,  such  as muscle,  ty, which it has not; the  only property
tendon,  cartilage, liver, and brain; and  which it possesses, being that of irritating
on inorganic, such as pus and the white  the parts, wh.ch it touches, so as to cause
of an egg. ^11  these  substances were  their absorption. (Hunter.)
dissolved in sulphuric acid, and precipi-     When the vessels thus lose the power
tated  with  the vegetable alkali.  Each  of producing good pus, they also lose more
precipitation  was   examined  with  such  or less the power of forming granulations.
magnifiers,  as plainly shewed  the forms  This may depend on some deviation from
of the precipitates,  all which  appeared  the due structure, and action, which such
to be flaky substances.  The precipitate  vessels  should  possess,  in  order to be
by  the  volatile  alkali  had exactly the  qualified for tiie performance of these two
same appearance.  The same appearances  operations.
were seen, when the above kinds of animal     Pus, from several circumstances, would
matter were dissolved in the vegetable  appear in general to have a  greater ten-
caustic alkali, and precipitated with the  dency to putrefaction, than the  natural
muriatic acid.  A flaky substance,  void  juices  have;  but,  perhaps, this-is not
of any regular form, composed each pre-  the case with pure pus, which, when first
cipitate.  (Hunter.)                     discharged  from an abscess,  is commonly
   Pus does not irritate the particular sur-  perfectly sweet.  There are,-  however,
face, which secretes it, though it may be  some exceptions to this,  but these de-
 very irritating to any other.  Hence, no  pend on circumstances entirely foreign to
suppurating surface of any specific  kind,  the  nature  of  pus itself.  Thus,  if  the
 can be kept up  by its own matter.  If abscess  had any communication with the
 this  had not been the case, no sore of a air,  while tiie  matter was confined in it;
 specific  quality, or producing matter of or if the collection has been so near the
 an irritating kind, could ever have been colon, or rectum, as to have been infected
 healed.  This is similar to every other se- by the feces, then we cannot wonder, that
 cretion of stimulating fluids,  as the bile, the matter  should become putrid.  When
 tears, &c.  which fluids do not stimulate blood is blended with pus; when sloughs
 their own glands, or ducts, but are ca-  are mixed  with it;  when the parts form- 
aUPPURATION.
325
ing the seat of tlie abscess, are in a gan-
grenous state from an erysipelatous affec-
tion ; the matter has a greater tendency
to putrefy, than the pure pus,  discharged
from  sound abscesses, or  healing sores.
Pure  matter, though easily rendered sus-
ceptible  of change,  by extraneous addi-
tions,  is in  its  own  nature  tolerably
uniform  and immutable.  It appears so
unchangeable,  that we find it retained in
an abscess for weeks, without having un-
dergone  any alteration.  These qualities,
however, only  belong to perfect pus.  if
a healthy sore inflames,  the matter, now
produced from it, though  unmixed  with
extravasated blood, or  dead solids, be-
 comes  much  sooner putrid,  and much
 more irritating, than the  discharge, form-
ed  before  this alteration of the ulcer.
 (Hunter.)
   In the preceding paragraph, it is stated,
 that matter remains very  often unchanged
 in abscesses for weeks.  This expression
 of  Hunter's  is not strictly correct;  for,
 it is well known, that  tlie surfaces of the
 cavities of abscesses are always absorbing,
 as  well as secreting ones ;  consequently,
 there must be a .continual mutation going
 on in the contained matter.
   When there are diseased bones, or other
 extraneous  bodies,  exciting  irritation,
 sometimes even to so great a degree as to
 make the vessels bleed, and often wound-
 iug*the vessels of  the part, the  matter is
 always found to be very offensive.  This
 state' of the discharge is one mark of a
 diseased bone.
   The discharge of  an unhealthy sore
 blackens silver'probes,  and preparations
 of lead.  This effect  is imputed by Dr.
 Crawfoid  to  the sulphurated  hydrogen
 gas, generated in the matter. (Phil. Trans.
 vol.60.  Year 1790, p. 385.)

               USE OF PUS.

   By some it is supposed to carry off
 humours from  the constitution.  Suppura-
 tion  is sometimes regarded as a constitu-
 tional disease, changed  into  a  local one,
 which constitutional malady  is discharg-
 ed, or thrown out of the body, either  in
 tlie form of pus, or together with this fluid.
 Critical abscesses  have  been thought to
 be cuses of this  sort  Suppuration has
 also  been imagined to carry off'local com-
 plaints from other parts of the body, on
 the old principle of derivation,  or revul-
 sion.  For this reason, sores,  or issues
 are made in sound parts before allowing
 other sores to  be dried up.  Suppuration
 is sometimes excited with a view of  mak-
 ing  parts, such  as indurated  swellings,
 dissolved  into pus; but, we have endea-
 voured  to shew,  that  no dissolution of
the solids is concerned in the production
of pus.
  A secretion of pus is looked upon as a
general prevention of many, or of all, the
causes of  disease.  Hence, issues are
made to keep off both  universal as well
as local diseases.  However, the  use of
pus is perhaps unknown ;  for,  it is form-
ed most perfectly from healthy sores, and
in healthy constitutions ; and large dis-
charges from parts not very essential to
life, produce veiy little change in the con-
stitution, and as little upon being  healed
up, whatever some may suppose  to the
contrary.  (Hunter.)
  This is certainly the case with many old
ulcers, tiie suppuration from which seems
to have little, or no effect, in impairing
the health. Nor is there any real reason to
be afraid of healing such ulcers, when pos-
sible, lest  a worse disease should follow
from  the  stoppage of the discharge, to
which the system is supposed to be habitu-
ated  so much,  that the  continuance of
such discharge is essential to health.
  Every  one knows,  that  when there is
no  interference of art, that is, when the
surface of a sore is left uncovered, the
thin part  of the  matter evaporates, and
the  thick  part  dries and  forms a scab.
Nature, therefore, seems to have designed,
that one use of pus should be to make a
cover, or protection, for ulcerated  surfa-
ces.  But I cannot agree  with what has
been  asserted (Hunter,) that the natural
healing ofa sore under a scab takes place
more quickly, than  when  surgical dres-
sings are employed.
  Among  the  secondary  uses of  sup-
puration, may be mentioned,  opening a
communication between a disease and the
external surface of the body ; forming a
passage  for the   exit  of  extraneous
bodies, &c.

  TREATMENT WHEN  SUPPURATION  MUST
              TAKK  PLACE.

  In cases of inflammation, arising from
accident, but so  circumstanced, that we
know  suppuration  cannot be prevented,
the indication is to moderate the infiam-
mation, which, if the powers are great,
and the  injury done considerable,  will
probably  be  very  violent.  If the con-
stitution  should also be  much affected,
certain general means are proper, such
as  bleeding,  purging,  and  nauseating
medicines.  While the  constitution con-
tinues to  be disturbed, suppuration can-
not take  place  in the most favourable
manner.   In these cases, also, such medi-
cines  as  produce  a gentle perspiration
greatly relieve the patient, for instance, 
^  326                            SUPPl

  the pulv. ipecac, conip.; antimonials;  aq.
  ammon. acet.; saline draughts, &c.  Opi-
  ates may produce a temporary diminution
  of  action ;  but,  this is  not always  the
  consequence of this medicine, as there
  are constitutions, which  it renders more
  irritable, and of course it aggravates  the
  inflammatory action.
     The  applications  to   inflammations,
  which are to suppurate and  form an  ab-
  scess, commonly used,  are poultices  and
  .fomentations.  These, however, appear to
  be applied without much critical exactness,
  or discrimination ; for, they are applied
  before  suppuration  has taken place,  and
  when this event is not desired; and they
  are also  applied after suppuration  has
  taken  place.  With respect  to  suppura-
  tion itself, abstracted from all  other con-
  siderations,  the indication cannot be the
  same in every state ; but,  if poultices and
  fomentations are  found  to be of real ser-
  vice in the two stages ofthe disease, there
  must be something common to both,  for
  which they are of service, independently
  of simple  suppuration.   Poultices  are
  useful, when  the inflammation attacks
  the skin, either in  the first instance  or
  after an abscess has approached so near
  the skin  that  this becomes secondarily
  affected.  This benefit  appears to arise
  from the  skin being kept  soft and moist*
  Such is the use of a poultice in inflamma-
  tion, either before or after suppuration,
  until the abscess is  opened.   But,  when
  poultices and fomentations are applied  to
  inflamed parts, in which we wish to  avoid
  suppuration, reason  and  principle will
  not justify the  practice, though  such ap-
  plications may be  proclaimed by experi-
  ence to be very proper.  (Hunter.)

  TREATMENT AFTER SUPPURATION HAS TAKEN
                  PLACE.

    When suppuration  cannot  be stopped,
  or resolved,  it is  in  general to be pro-
  moted.
    How far suppuration can be  increased
  by medicines, or applications,  is doubt-
  ful; but  attempts are  generally made,
  and, for this purpose, suppurating  cata-
  plasms  and  plasters, composed  of the
  warm gums, seeds,  &c.  have been re-
  commended.   Mr. Hunter doubted,  whe-
  ther such applications had any consider-
  able effect in the  way intended; for,  if
  they were  put  on  a sore, they would
  hardly  increase the discharge  from  it,
  and, perhaps, even  diminish it.  However,
  in many cases,  in which the parts are in-
  dolent,  and hardly admit  of true inflam-
  mation, in consequence of which a perfect
 suppuration cannot take place, stimulating
 the skin brings on a more salutary inflam-
i RATION

  mation, and of course a quicker inflamma-
  tion,         s
    These  applications  have been  found,
  how ever, to bring the matter more quickly
  to the skin, tven in the most rapid suppu-
  rations. This effect has been mistaken for
  an increased formation of pus ; but, this
  consequence can only follow in  cases, in
  which  the  inner surface of tiie abscess
  is within the influence of the  skin.  The
  accelerated progress of the matter to the
  surface of the body arises from another
  cause,  viz.  the  promotion of ulceration
  in the  parts, between the collection  of
  matter, and the cuticle.
    Emollient  poultices are commonly ap-
  plied to inflamed  parts,  when  suppura-
  tion  is known to have taken place.  These
  can have no effect upon suppuration, ex-
  cept  that of lessening the inflammation,
  or  rather making  the skin  more easy.
  The inflammation must have reached the
  skin  before poultices can have much tffect,
  for they can only, affect  that  part.  The
  ease  of the  patient, however,  should  be
  considered,  and we find, that fomenta-
  tions and poultices are often beneficial in
  this way.  By  keeping the cuticle moist
  and warm, the sensitive'operations of the
  nerves of  the parts are soothed.  On the
  contrary,  if* the inflamed skin is allowed
 to dry,  the inflammation is  increased,
 and as suppuration is probably  not check-
 ed by the above treatment, it ought to  be
 put into practice.  As warmth  excites ac-
 tion, the fomentation should be as warm
 as the patient can bear, without inconveni-
 ence. (Hunter.)

  OF TUE TIME WHEN ABSCESSES SHOULD HE
                 OP£NED.

   As abscesses,  wherever formed, must
 increase that part of their cavity, which
 is next  to the skin,  more quickly than
 the bottom, they must become,  in some
 degree,  tapering towards  the latter part,
 with  their greatest  breadth immediately
under the skin.  This shape of an abscess,
 when allowed to take place, is  favourable
to  its healing,  for  it puts  the  bottom,
which is the seat of the disease,  more
upon  a  footing with tiie mouth of the
abscess,  than it otherwise  could  be.  As
the bottom,  or  part, where the abscess
began, is more or less iu a diseased state ;
and as the parts between the seat of the
abscess  and  the external surface are
sound p«trts, having only  allowed a pas-
sage  for the pus, they,  of course, have a
stronger disposition to heal, than the bot-
tom lias.
  To keep the mouth of an abscess from
healing before its bottom,  tlie  collection
of matter should be  allowed to break of 
SUPPURATION.                            327
itself; for, altliough abscesses in general
only open by a small orifice, more espe-
cially when sound,  yet,  in  such cases,
the skin over the general cavity of the
matter  is  so thinned,  that it has very-
little tendency to heal, and often ulcerates
and makes a free  opening.  If the latter
event should not  spontaneouslv occur, it
may now be more easily obtained  by the
interference of the surgeon.
  Abscesses, which are the most disposed
to heal favourably, are  the  quickest  in
their progress to the skin, and the matter
comes to the surface almost at a  point;
the swelling is not so conical as in other
cases, and when it bursts, the orifice is ex-
ceedingly small.  On tiie other hand, when
there is an indolence in the progress  of
the abscess, the collection spreads more,
or distends the  surrounding  parts in a
greater degree, in consequence of their
not being so firmly united by inflamma-
tion, in the oue as they are in the other
instance; nor will ulceration  so  readily
take the lead,  and the  matter will come
to the skin by a broad surface, so as  to
thin a large portion ofthe cutis. (Hunter.)
  It may certainly be set down as a gene-
ral axiom, that all phlegmonous abscesses
should  be allowed to break,  and  not  be
opened by the surgeon.  When punctured
unnecessarily, or prematurely, they never
heal so favourably as when left to  them-
selves.
  Particular cases, however,  should  be
opened, as soOn as the existence of matter
is ascertained.  Abscesses should only be
allowed to burst of themselves, when the
confinement of the matter can do no m is-
chief.   Abscesses in  the abdomen, or
thorax, under the cranium,  in the eye,
and joints,  should  be mostly opened very
soon.    When  suppuration  takes  place
beneath ligamentous expansions, or apo-
neuroses, which invariably retard the pro-
gress of the matter to the surface  of the
body, an early opening  should be  made.
If this be not done, the matter spreads
to a great extent, separating  such liga-
mentous expansions from the muscles,
and t!ie muscles from  each  other, and,
as the  pus cannot get  to the surface  of
the body, the length of the disorder is  of
course  increased.   When matter is  so
situated, as to be liable to insinuate itself
into  the chest, or abdomen, or into the
capsular ligaments of the joints,  it  is
highly  proper to prevent this extension  of
mischief, by making a timely opening into
the abscess.

Or THE PLACE  WHERE THE OrENINO SHOULD
   ,           BE MADE.

  If a  free opening is  not required, or
 making  one is not  practicable, it is  at
 least proper to make whatever opening
 can be made in  a  depending situation.
 By this  means,  the matter will  more
 readily escape, and all  pressure arising
 from the confinement or lodgment of pus,
 will be prevented.  A very small degree
 of  pressure on that side of the abscess
 which is next to  the skin, may produce
 ulceration   there;  and  although  such
 pressure might not,  in many cases, be so
 great  as to produce  ulceration at the bot-
 tom of the  abscess; yet it may be suf-
 ficiently great to -prevent granulations
 from forming on  that side, and thereby
 retard the cure,  as no  union  can take
 place, but by means  of granulations.  The
 pressure is always most, and retards the
 formation of granulations in the greatest
 degree, at the most depending part of the
 abscess.  Hence, if no opening be  made
 in  this situation, the upper part  of the
 abscess readily heals to  a small  point,
 which becomes a  fistula.
  When circumstances forbid making  an
 opening at the most depending part of  an
 abscess,  perhaps,  nothing  more can be
 done, than to evacuate the matter as often
 as necessary, and gently to compress the
 sides of the  abscess together,  when the
 situation of tlie case admits of the prac-
 tice,
  But abscesses  are not  always  to be
 opened at the most depending part.  The
 distance between the matter and the skin
 at this part is the common reason against
 the  method.   If  an  abscess  is  rather
 deeply  situated,  and  points in a  place
 which is higher than  where the collection
 lies, it is  proper  to make the opening
 where the  conical eminence, or, as it is
 termed,/the pointing, appears.  Thus, if
 an  abscess should form in the centre  of
 the  breast, and point  at tiie uppermost
 part, which is often the case, it would be
 improper to cut through the lower half of
 the mamma, in order to  make a passage
 for  the matter in  that direction.   If an
 abscess should form on the upper part of
 the  foot, it would be wrong to make an
 opening through  the sole of the foot  to
 get  at the most  depending part of the
 abscess ; for, besides  cutting such a depth
 of sound parts, a  great many useful ones
 would be destroyed.
  When the abscess do?s  not point in a
 depending  situation, as  in the instances
just cited, since  the  place where the
 matter  threatens to open a passage,  is
 likely to be the future opening,  and this
 situation ^is disadvantageous to the heal-
 ing of the deep part of the abscess, it is
 generally best to let the collection of mat-
 ter  first burst  of ilseif,  and then dilate
 the opening as freely as necessary. By 
328                            SUPPURATION.
allowing abscesses to burst spontaneously,
the opening is not so apt to heal as if made
by art, and,  therefore, is better in such
situations.  (Hunter.)
  In some cases,  it is more advantageous
even to cut through a certain thickness of
parts, for the sake of obtaining a depend-
ing opening, than to make  an  opening,
where the pointing appears,  as  the parts
are most  attenuated, and  the  matter
nearest the surface.  This  remark  is
highly worthy  of  remembrance, when
there is no doubt ofthe existence of mat-
ter at the depending place, and when the
parts to be divided are not important ones.
Collections of  matter beneath the  fasciae
of the fore-arm  and thigh, particularly
demand  attention to  this direction, as
they commonly point where those liga-
mentous expansions are most attenuated,
not  where the matter can most readily
escape.
  Abscesses in  the  sheath of the rectus
abdominis should also be opened in a low
situation.

     DIFFERENT METHODS OF OPENING
               ABSCESSES.

   All  abscesses will  burst of themselves,
unless the matter should  be   absorbed,
and, in general, they ought to be allowed
to take this course.  There are, however,
as we have already explained, particular
circumstances  which require  an  early
opening;  but, when the skin  over  the
abscess is very thin,  it is not of so much
consequence,  whether the case be  per-
mitted to burst of itself, or it be opened
by the surgeon.
   When abscesses are large, it is generally
necessary to open them by art, whether
they have burst of themselves or not; for,
the  natural opening  will seldom be suf-
ficient for the completion of a cure ;  and,
although  it may  be sufficient for the free
dischargeof thematter, yet these abscesses
will heal much more readily when a free
opening is made ; for, the thin skin over
the  cavity  granulates but indifferently,
and therefore  unites but slowly with the
parts underneath. (Hunter.)
   Abscesses may be opened either by an
incision, or by making an eschar with
caustic. To the latter plan, however, many
urge strong objections: the use of caus-
tic is not usually attended with any ad-
vantage which may  not be obtained by a
simple incision; upon a tender inflamed
part is gives much more pain ;  it is more
slow in its effects ;  and the surgeon  can
never direct the operation of the  caustic
so  accurately as to  destroy exactly tiie
parts which be wishes, and  no more,   if
the eschar be  not made  deeply enough,
the  lancet  must,  after  all, be  used.
Caustic also leaves after its application,
a disagreeable  scar, a  consideration of
some  importance in opening  abscesses
about the female neck or face.   To these
numerous objections  we  have  to  add,
that the eschar is, very frequently, ten
or twelve tedious days  in becoming de-
tached.
  When there  is  a  redundance of skin,
or when there is a good deal of it thinned,
however,  an opening made with caustic
will answer, perhaps, as well as an in-
cision.  The application of a caustic may
also sometimes  be advantageously re-
sorted to  when there is a good deal of
indolent  hardness  around  a small ab-
scess.
  The calx viva  cum  kali  puro, or the
kali purum  alone, is the best caustic for
opening  abscesses.  The  part  is first to
be covered with a piece of adhesive plas-
ter, which has a portion cut out exactly
ofthe same figure and size as the opening
intended to be made in the  abscess.  The
best way of making the eschar, is to dip
the end  of  the caustic  in water, and to
rub it  on  the part till the skin becomes
brown.  The active substance is then to
be immediately washed  off with some wet
tow, the plaster is to be removed, and an
emollient poultice applied.
  In almost all cases, it is better to use
the lancet,  or  double-edged  bistoury.
Either of these  instruments  opens the
abscess at once, and with  less pain, than
results from the use of caustic ; it  occa-
sions no  loss of  substance, consequently
a smaller cicatrix; and, by using it, the
opening  may  be  made in  the  most ad-
vantageous  direction, and of the exact
size required.

   DRESSINGS AFTER OPENING ABSCESSES.

   When  an abscess has burst  of  rtself,
and it  is  unnecessary  to enlarge the
opening,  all that is requisite is to keep
the surrounding parts  clean.   The con-
tinuation of the  same  kind of poultice,
which was  before used,  is, perhaps, as
good  an application  as any; and when
the tenderness, arising from the inflamma-
tion, is over,  lint and a pledget may be
made use of, instead of the poultice.
   But, an abscess, opened by  a cutting
instrument, is  both a wound and a  sore,
and partakes  more of the nature of a
fresh  wound  in  proportion to  the  thick-
ness of the parts  cut.  Hence, it is neces-
sary that something should be put into
the opening to keep it from healing by the
first intention.  If it is  lint, it should be
dipped in some salve, which will answer
 better than lint alone, as it will  allow  cf 
SUP
SUR          329
being taken out sooner.  This  is advan-
tageous, because such sores should be
dressed tiie next day, or, at latest, on
the second day, in order  that the pus
may  be discharged  again.  When the
cut edges ofthe opening have suppurated,
which will  be in a few days, the future
dressings may be as,  simple as possible,
for nature will, in general, complete the
cure.
   If  the abscess  has  been opened by
caustic, and the slough has  either been
cut out or  separated of itself, the case is
to be regarded as an entire  suppurating
sore, and dressed accordingly.
   Perhaps, dry lint is as good a dressing
as any,  till the nature of"  the sore is
known.  If it should be of a good kind,
the same dressing may be continued; but,
if not,  then it  must be dressed accord-
 ingly.  Par*", which at first  appear to
 be sound, sometimes assume every species
 of disease, whether from indolence, from
 irritability, from scrophulous,  and other
 dispositions.  This tendency to disease
 arises, in some cases, from the  nature of
 the parts affected, as, for instance, bone,
 ligament, &c.  (Hunter.)
   It is impossible to refer the  reader, in
 a satisfactory manner, to  any  particular
 works  for information concerning ab-
 scesses  and  suppuration, because  some-
 thing is to be met with on the subject in
 almost  every  surgical book, ancient as
 well as modern. The author ofthe article
 Abscess in Rees's Cyclopxdia, makes par-
 ticular mention of the following writers :
 Severinus, Hildanus,  Wiseman,  Heister,
 Van Swieten, Sharp, Pott,  B. Bell, and
 Kirkland.   Same  curious  cases  are said
 also to be related, or referred to,  ill the
 Bibliotheque Choisiede Metlecine, the Com-
 pilations  of  Mangetus,  Bernstein, and
 James; tlie memoirs  and  transactions  of
 different learned societies (the Mem.  de
 VAcad. tie Chir. might be especially men-
 tioned;) and  in the  works of Bonetus,
 Forestus,  Lusitanus, Tulpius,  Morgagni,
 Horstius, Stalpart, Vander Wiel, &c.
    I am rather surprised,  that  the  author
 of the article above alluded to, should have
 neglected to notice John Hunter's Treatise
 on tlie Blood, Inflammation, &c. a work, in
 which,  perhaps, more interesting know-
 ledge, respecting  abscesses  and  suppura-
 tion, is  contained, than in any other one
 ever published.  The Traite de la Suppu-
 ration  de  F.  Quesnau,  1749,  is also en.
 titled to some attention ; so are the Dis-
 sertations  on Inflammation  by  J.  Burns.
 Richter has  written a tolerable  chapter
 on the subject,  in  his Anfangsgr.  tier
 JVundarzn. Bund. 1.  Consult also Home
 on Pus, and VEncyclopedic Methotlique.
    SURGERY.  (Chirurger ,  from %ttc.
        Vol.  II.
the hand, and ega»v,  labour.)  A branch
of the science of melicine, having for  its
principal object the cure  of external dis-
eases.  The etymological meaning of the
word surgery reduces this part of the me-
dical profession to a  very degraded con-
dition, and, by  no  means  conveys  an
adequate idea of what it  really is ait the
present day.  They who consider surgery
merely as the mechanical part of medicine,
or  as  that  branch of it wliich consists
entirely  in  the performance of manual
operations, must either be very ignorant,
or  very  prejudiced  and illiberal.   In
order to remove these foolish notions, it
is only necessary to ask, by what dex-
terity of the hand could  the surgeon  ac-
complish the cure ofthe various forms of
the  venereal  disease, and of numerous
scrophulous affections.'   Yet these, and
many  other disorders, equally incurable
by the hand alone, fall to  the province of
the surgeon, and by him are oftentimes
successfully treated.
   A modern author observes, that" many
people have imagined, that when a man
has learnt the art of dressing sores, of ap-
plying bandages, and performing opera-
tions with a little dexterity, that he must
necessarily be an accomplished surgeon.
If a conclusion  so  gross and fallacious
had been  confined  to  the vulgar  and
illiterate, the progress of scientific  sur-
gery would have suffered little interrup-
tion ;  but if young minds are directed to
 these objects, as the only important mat-
 ters upon which their faculties are to be
 exercised;  if the gross  informations of
 sense constitute the sum of their  know-
 ledge, little more can be expected from
 such a mode of  study, than servile  imitaa
 tion,  or  daring  empiricism.   Indeed,
 some people have  affected to  oppose
 surgery as an art to medicine as a science ;
 and if their pretensions were justly found-
 ed, the former would  jcertainly be  de-
 graded to a mere mechanical occupation.
 But, it  is not very easy to comprehend
 the grounds  of  such  a  distinction.   The
 internal and external parts of the body
 are governed by the same  general  laws
 during  a sta{e  of health;  and, if an in-
 ternal part be  attacked with  inflamma-
 tion,  the   appearances  and  effects.will
 bear  a  great similarity  to the same dis-
 ease  situated   externally;  nor are  the
 indications of cure, in general, materially
 different. " If by science,  therefore, be
 meant " a knowledge of the laws  of na-
 ture," he  who knows what is  known of
 the order and method of nature, in  the
 production, progress, and termination of
 jurgical diseases, merits  as  justiy  tha
 title of a scientifical practitioner,  as tire
  well educated physician. The  practical
      Tt 
330
SURGERY
  parts of  physic  and surgery  are  very
  frequently disunited; but,  their  theory
  and principles are indivisible, since they
  truly constitute one and the same science."
  (Pearson's Principles of Surgery, Preface.)
    We shall m xt introduce a short account
  of the  rise and progress of surgery, as
  given by Mr. Gooch, in  the first volume
  of his Chirurgical Works.
    Writers have  divided surgery  into
  these  six  branches : Synthesis; Diaere-
  sis ; Exxresis ;  Aphseresis ;  Prosthesis;
  and Diortiirosis:  the  first signifies unit-
  ing parts divided; tiie  second, dividing
  parts united; the third, removing, or ex-
  tracting, extraneous,  or other noxious
  substances, lodged in any  part  of  the
  body; the fourth, .taking away what is
  superfluous ;  the fifth, supplying deficien-
  cy ,- the sixth, restoring parts to their pro-
  per places.
    The daily instances ofthe relief, which
  surgery  brings  the  afflicted, under  the
  various circumstances of distress, even
  delivering them from  the jaws of  death,
  sufficiently proclaim  its  excellence ; and
 it appears to be of much earlier date, than
 the other parts of the medical  art.
   We see, by the antediluvian history,
 that soon after the creation of the world,
 feuds and animosities, envy  and malice,
 possessed the  minds of  men,  and were
 productive of rapine and war, which inev-
 itably extended the contending parties to
 wounds,  and other  external injuries.
 Reason, implanted  in man  for his preser-
 vation, as the first principle in nature, di-
 rected him, on various occasions, to seek
 a remedy; and this necessity gave  rise to
 surgery, which, at first, was rude and im-
 perfect, growing, in successive ages, like
 other  ingenious arts  and sciences, to a
 state of perf- ciion.
  The inhabitants  of  the earth,  in  the
 primitive ages of the world,  lived fru-
 gally, upon  plain simple  food, according
 to the dictates  of nature  and right rea-
 son ; and enjoying a pure  serene air and
 temperate climate, their lives were pro-
 tracted to a great length, without  being
 so subject as we are  to diseases,  which
 have been much increased since that time
 by  luxury and intemperance.  They were
 peculiarly happy in  the enjoyment of ro-
 bust and vigorous  constitutions, raised
from good original  stamina ;  and,   when
attacked with diseases, nature wanted  lit-
 tle or no  assistance from  art, to restore
their health; consequently, surgery was
then looked upon, as almost tiie only ne-
cessary branch of medicine.*
    Ancient history  informs  us,  though
 there may be something fabulous and al-
 legorical in it, that Apollo communicated
 his skill in this science to lu.-. son Escu-
 lapius, who then profited under the tui-
 tion of Chiron the  Centaur ; and for his
 great improvement and knowledge of sur-
 gery in particular, he was deified, and had
 temples dedicated to him in several parts
 of the world. Many countries contended
 for the  honor of his birth, and, according
 to tiie  learned, his name signifies a man
 of the knife,  in the Phenician language;
 whence some writers, conclude he was a
 native of Phenicia;  but this  controverted
 point, whether he was  by birth a Pheni-
 cian, an Egyptian, or  a Grecian, is not
 material to our purpose.  In  those early
 days, there were no regular professors of
 the mediqal art, the knowledge  of which
 was then conveyed by oral tradition, or re-
 corded  upon pillars in the most public
 places, or on the walls  of temples, dedi-
 cated to the  god of Health; and after-
 wards  registers  of cures Were  kept in
 those consecrated places for  the general
 good of mankind.
   Machaon and  Podalirius,   the sons of
 iEsculapius, were both medical and milita- '
 ry men,  and  being particularly  skilful
 in surgery, they proved very useful to the
 soldiers in curing their wounds,  in  the
 Trojan  war;  on  which account, when
 Machaon himself*was dangerously wound-
 ed with a dart,  greater  lamentation was
 made for him  than for any other hero.
   From the destruction  of Troy, to the
 Peloponnessian war, which was  an inter-
 val of more than seven hundred years, the
 Aselepiadse, descendants of  jEsculapius,
 and their disciples  "ere  the  only noted
 professors of the healing art.
   About the conclusion  of this period of
 time, the immortal Hippocrates began to
 be famous in the  world,  who  was also of
 the JEsculapian family, and lived between
 four and  five  hundred  years  before our
 Saviour.    He  was  endowed  with ' the
 greatest  sagacity, excelled all his prede-
 cessors and contemporaries, and reduced
 this science into  better  order, compiling,
 and laying down   for   posterity,  rules
 founded  upon  his own observations,  con-
 firmed by experience, and was deservedly
 called the father of physic. In his writings
 he also treats of wounds, ulcers,fractures,
 &c. interspersing observations  and  re-
 marks through the whole, to direct the
judgment  and practice  of  succeeding
  • Vid. Dissertat.  physico-med. Fred.
HofFmanni de Methodo acquirendi Vitam
Longam.  The great luxury of the Ro-
mans in Seneca's  time made  him  say,
Non ad rationem, ted ad similitudinem vi-
vimus. 
SURGERY.                               331
ages   He was the ablest surgeon, as well
as physician, of his time.
  The other  Greek  physicians, whose
writings have been transmitted to us in a
more  universal language,  treating  also
professedly of surgery,  are  Oribasius,
Alexander, Trallianus, JEtius, and  1'au-
lus  JEgineta.  and the great Galen, who
flourished more than a century before Ori-
basius.*
  Among the Romans, Celsus, a man of a
sublime and  penetrating genius, is the
only author we have in his time, though
he  mentions  several; but,  there is no
other record, or monument of them  left.
Both  he and  Galen,  who  was a practi-
tioner of great repute at Rome, though a
native of Pergamus, in Asia Minor, speak
of some ancient surgeons, as well in Egypt
as  in other parts of the  world, whose
works have perished.
  When tiie knowledge of arts and scien-
ces was transferred from Egypt to Greece,
it  received great  improvements,   and
Athens was looked upon as the seat of all
kinds of learning, till the  death  of Alex-
ander the  Great ; after which  xra, the
Ptolemies ruled in Egypt, and Alexandria,
became the most renowned school in the
world, for physic, surgery, and  anatomy,
which flourished near a thousand years ;
and in those days, physicians boasted of
receiving their education in that universi-
ty.  Then the  different branches of me-
dicine were practised together, and not
separated till the  time  of  Herophilus
and Erasistratus,  who were educated  at
Alexandria, and lived in the reign of Se-
leucus Nicanor, king  of Syria, as appears
by a memorable incident, in respect to the
latter of those illustrious men, who shew-
ed his great  penetration in  discovering
 Antiochus's distemper, when fallen despe-
 rately in love with his mother-in-law, the
young and beautiful Stratonice, Seleucus's
 second wife,  whom he had married in his
 old age.*
   In the year 640 of the Christian sera,
 the caliph of the Saracens, professed ene-
 mies to literature, as  well as to the Chris-
 tians, took Alexandria, destroyed the uni-
 versity, and burnt  the  library of Pto-
 leroy Philadelphus, which was tiie great-
  • Oribasius was a practitioner of great
note at Sardis, in Cent. IV. M. C.   What
he has said, de Laqueis et Manchiamen-
tis, in  his voluminous works, is  chiefly
taken from Heliodorus.  It appears, that
Paulus was a more considerable surgeon,
having improved upon his predecessors.
  + Seleucus began  his reign Ao. Mdi.
3684.   Erasistratus resided at lus court,
and was archiater.
est magazine of learning in the world, said
to contain  700,000  volumes;* however,
some books might be  saved out of that
lamentable  conflagration.
   In the same century, that this dreadful
catastrophe happened at  Alexandria, Eu-
rope was over-run with  Goths and Van-
dals, by which calamitous event, the libe-
ral arts and sciences  also suffered very
much; and undoubtedly medicine shared
the same fate.
   After the fall of Alexandria, and the ir-
ruptions of the above  barbarous people,
the Arabians Iiaving collected libraries, and
probably possessed themselves of some
books, that were saved out of the flames,
Alexandria  became  more  conspicuous
and considerable in this science, than any
other nation; of which, the most eminent,
who blended surgery with  their other
medical writings, were Rhazes, Avicenna,
Avenzoar, Averrhoes, and Albucasis.
   Rhazes probably Was born  in  the pro-
vince of Cherasan in Persia:  he was  su-
perintendant of  an hospital  there, and
died advanced in years, A. C. 932.
   Avicenna was the next writer of note
among the  Arabians ; he was born at Bo-
chara in Chorasan, towards the end of the
9th century.  He resided and  practised
at Ispahan.  He  was  a  man  of extraor-
dinary talents ; but,  shortened his days
by intemperance and  indulgence in plea-
sures ; he was buried at  Hamadan.
   Avenzoar succeeded Avicenna : if not
born, he resided much at Seville, the ca-
pital of the Province of Andalusia  in
Spain, then the seat  of  the  Mahometan
caliph.  He lived and enjoyed good health
to 135 years.
   Averrhoes followed Avenzoar;  he was
a native of Corduba in Spain, and died at
 Morocco.
   Of" Albucasis the place and time of na-
 tivity  do  not  certainly  appear ; but  he
 comes after Averrhoes, and was the best
 acquainted with surgery of  any  of  the
 Arabians.   There is  reason  to  suppose
 that he lived in the 11th or 12th century
 of the Christian aera.
   These Arabians were  favourers of Ga-
 len's  doctrine, and their authority pre-
 vailed unrivalled for  many ages.
   Afterwards the  chemists opposed the
 Galenists, each of which had zealous par-
 tizans, who were bigoted to the  opinion
 of their chiefs, and combated each other's
 notions with great .vehemence,  whence a
  • Great part of the  Ptolemean  library
having been burnt in tiie wars between
Caesar  and Pompey, the  loss was sup-
plied, as far as possible, by  Cleopatra,
queen of Egypt, and her successors, at an
immense expence. 
332
SURGERY.
kind of schism arose in the  provmcf of
physic ; but the wiser moderns huve freed
themselves from implicit faith, and the
embarrassments of hypothesis, and fine
speculative systems, more curious  than
useful, regarding  only  what is founded
upon rational experience, to which theory
must be subordinate.
  In tlje  13th century, learning emerged
from the dark clouds of ignorance, under
which it had long been veiled; and about
this period of time,  the reformation of
surgery was begun in England by Arden.*
originally a practitioner of great fame at
Newark, and afterwards  in London : and
it was begun  rather earlier in France, by
Pitard and Lanfranc.f By a succession of
men of genius, learning and application
here, such as Gale, Clowes, Woodall, Ba-
nister, Wiseman, and many others; and
there, by Vavusseur,  Mondeville, Gudo
de Cauliaco,  Par6, Guillemeau, &c. sur-
gery  was  gradually advanced,  in  both
countries, to its present  state of perfec-
tion.  Pitard  was a  Parisian by birth;
but Lanfranc  was a native of  Milan, edu-
cated at  Salernum, the most  famous uni-
versity for physic and surgery in those
days, as its motto, Civitas Hippocratica,
emphatically  expresses.  He  was driven
from Italy, with many other learned men,
by the dreadful factions of the Guelphs
and Gibelines, at the conclusion of the
12th  century,  and found  an asylum at
Paris, where  he met with a very honour-
able reception.  His  acquaintance  with
Pitard was soon improved into a strict
friendship, which was inviolably preserv-
ed, for the public good, between  these
eminent   men,  who  co-operating,  sup-
ported with great credit and dignity, the
college ot St. Come, founded by  Lewis
the Ninth, who was sainted for engaging
in the crusades; and public lectures were
appointed to be read, and demonstrations
made, in anatomy and surgery,  by the
royal  founder.    Pitard having  given
early proofs  of his extraordinary talents
and abilities  in his profession, was ho-
noured, before he was thirty years of age,
with  the appointment of first surgeon to
the  king, and  standing in  the  highest
esteem,  attended him in his expedition
to the Holy  Land,  where he  gathered
laurels, and  returned  loaded with  hon-
ours.
   Our neighbours having had for some
ages, better opportunities, from royal pa-
tronage, of acquiring knowledge in their
profession, than other countries and be-
  • Vid. Opera I. Friend, M. D. de Histo-
ria Medicinac.
  f See Histoire de l'Origme & des Pro-
grea de la Chirurgie en France.
ing regular in giving lectures, and mak-
ing demonstrations in anatomy and sur-
gery, they distinguished themselves,  and
were deservedly  extolled throughout Eu-
rope; and from every part of it, surgeons
used to resort to Paris, to complete their
education ; which city now can no longer
claim tiie superiority to London.
   In the foreign universities, the profess-
sors of physic generally adopted surgery;
and  now  at  the  famous  university of
Edinburgh,  and  others,  there are pro-
fessorships appropriated  to" surgery  and
anatomy conjointly.  Marianus Sanctus,
a celebrated  lithotomist, was a doctor of
Padua.   Marcus Aurelius Severinus, Vi-
go, Fabricius ab Aquapendente, Cxsar
Magatus, Marchetti,  and  many other
practical surgeons,  that might be enume-
rated, were doctors oitphysic.  Mons. Le
Cat, at  Rouen,  and Mons. Poutean, at
Lyons,  chief surgeons to the great hospi-
tals in those  cities, are styled doctors of
physic and surgery.  The late illustrious
M. De  La Peyronie, who  was first  sur-
geon to the king, and to whom the whole
faculty is greatly indebted, was bred, and
took a doctor's degree in the university of
Montpelier.  Some of the physicians to
the kings of France were  originally sur-
geons, in which country  singular marks
of royal favour have, for many ages, been
conferred upon  surgeons, as we have ob-
served; and  by  a late edict, upon the es-
tablishment  of  the Royal Academy of
Surgery at  Paris, no surgeon is  allowed
to practise, and  be master of his company,
without having taken a master  of arts'.
degree in some university  of that king-
dom.*—The  great  Fabricius  Hildanus,
who flourished  in the 15th century at
Bern,  in Switzerland, was physician and
surgeon in ordinary to that illustrious re-
public,  and   to the marquis of  Baden.
He stands at the head of the first class of
observators,  and should be in the hands
of every practitioner. ( Chirurgical Works
ofB. Gooch,  Vol. I.)
   Perhaps, nothing contributed so mate-
rially  to the improvement of  surgical
knowledge, as the establishment of the
Royal Academy of Surgery in France;  a
noble institution, which, for a long while,
gave the French infinite  advantage  over
us,  in the cultivation of this most useful
profession.   Indeed, every one, truly in-
terested in the improvement of surgery,
cannot fail to regret the discontinuance of
a society, in which emulation and talents
  • See Histoire de l'Origine & de Pro-
gr£s de la Chirurgie en France; where
great encouragement for the improvement
of surgery appears to have been given by
royal edicts, in different ages. 
                SUR

were so long united for  the benefit of
mankind.   The  various   dissertations,
published  by the  illustrious members of
the academy, will serve as a perpetual
memorial  of the spirit, ability, and suc-
cess, with wliich tiie objects of the insti-
tution were pursued; and, centuries hence,
practitioners shall reap from the pages of
its memoirs tlie most valuable kind of sur-
gical information.   Unfortunately,  this
celebrated establishment, which was over-
thrown by the agitation ofthe French re-
volution, has had only a very inferior sub-
stitute in the Ecole de Sante.
  Were I  to name any one  tiling, which,
in my opinion, would have the  greatest
influence in giving life  to  the study and
cultivation Of surgery in this country, I
should certainly assign  such importance
to tlie establishment* of an  institution in
this metropolis, on the  same grand, and
encouraged plan, as tlie late Royal Acade-
my of Surgery in*France.
   Within tlie last twenty, or thirty years,
most important improvements  have cer-
tainly been made in almost every branch
of surgery; and,  it  must gratify every
Rngiishman to find,  that his own coun-
trymen have acted a very leading pari in
effecting an object, in which tiie interests
of mankind in general are so deeply, con-
cerned.
   External aneurisms,  which  formerly
used to prove nearly as fatal as internal
ones, are now treated with immense suc-
cess, by operating upon  the plan first
suggested by Mr. Hunter, and of late very
materially improved  by Mr. Abernethy.
The doctrines of this  disease have also
been recently elucidated, with great abili-
ty, by Professor Scarpa, of Padua.
  The diseases ofthe eyes, to which affec-
tions English  surgeons seemed  to pay
much less attention, than was  bestowed
by foreign practitioners, seem now to ob-
tain due attention in this  country.   Al-
though we have generally  had some dis-
tinguished oculists, our surgeons at large
have been wonderfully ignorant of this
part of their profession, and, uninformed
in the subject, they have given up to pro-
fessed oculists, and  quacks, one of the
most lucrative and agreeable branches of
practice.  However,  the able writings of
Wenzel and Ware begin now to be fami-
liarly known  among practitioners : and
the observations of Scarpa, Richter,-War-
drop, Saunders,  &c.  will soon  have  im-
mense effect in diffusing in the profession a
due knowledge ofthe numerous diseases,
to which the organs of vision are liable.
  Before Mr. Hunter,  our ideas of the
venereal .disease  were surrounded- with
absurdities;  and  it is to  this luminary
that we  are in an eminent degree indebt-
                S U S             333

ed for the  increased discrimination, and
reason, which now prevail, both  in the
doctrines and treatment ofthe malady.
  Strictures  in the urethra,  an equally
common and  distressing complaint, were
not well treated of, before Mr. Hunter
published on the venereal disease; and
the infinite advantage of anned bougies,
in the treatment, has been subsequently
described by Mr. Home.
  I must not omit to  mention, among the
most  modern improvements  in surgical
science and practice, the discoveries  of
Dr. Jones, relative to the subject  of he-
morrhage.  Very important practical in-
ferences are to be drawn from his  experi-
ments.
  Ruptures, those common afflictions, in
every country, have in modern times re-
ceived highly interesting elucidations from
the labours of Camper, A. Cooper, Hey,
Gimbernat, Scarpa, &c.
  The treatment of injuries of the head
has been materially improved by Quesnay,
Le Dran, Pott, Abernethy, &c.
  The disease of the vertebrae, which oc-
casions paralysis of-  the limbs, formerly
always baffled the practitioner; but, the
method proposed by Mr. Pott, is now fre-
quently found productive of considerable
relief, and sometimes ofa perfect cure.
   The mode  of treating  lumbar  ab-
scesses has been rendered much more suc-
cessful, than formerly,   and, for  this
change, the world is greatly indebted  to
Mr. Abernethy.
  The almost infallible plan of curing
hydroceles, by an injection,  in the way
described by Sir James Earle, may also
be enumerated among the recent improve-
ments.
  I shall conclude this article with notic-
ing the increasing aversion to the employ-
ment  of the gorget in lithotomy, and the
many distinguished advocates for the use
of a common scalpel in  this operation.
These latter circumstances I hail  as pro-
pitious omens of very beneficial changes
in this part of surgery.
  SUPPURATIVES.  (from  suppuro,  to
suppurate.) Suppurantia.  Medicines,  or
rather applications, wliich promote the
formation of good pus.
  SUSPENSORY,  (from  susperuleo,  to
suspend.)  Suspensor. A bandage for con-
taining, and supporting the scrotum ;  a
bag-truss.   Bandages of  this  kind  are
now usually sold at the shops, and  seldom
made  by surgeons themselves; therefore,
a particular description of them is not es-
sential in this work.   In cases  of hernia
humoralis, varicocele, cirsoeele, some par-
ticular ruptures, and several other affec-
tions ofthe testicle, and spermatic chord,
a suspensory bandage is of infinite service 
334
SUTURES.
  SUTURES, (from sua, to sew.)  A su-
ture in surgery, means a mode of uniting
the edges of a wound, by keeping them in
contact with stitches.
  Mr. Sharp  remarks,  that,  " when  a
wound is recent, and the parts of it are
divided by a sharp  instrument, without
any  further violence, and,  in  such man-
ner, that they may be made to approach
each  other, by being returned with the
hands, they will, if  held in close contact
for  some time,  reunite by inosculation,
and cement, like one  branch of a tree in-
grafted on another.   To maintain  them
in this situation, several sorts of sutures
have been  invented,  and formerly  prac-
tised, but the number of them has, of late,
been very much  reduced.   Those now
chiefly described are the interrupted, the
glovers,  the quilled,  the twisted, and the
dry, sutures; but,  the interrupted and
twisted are almost the only useful ones,
for the quilled suture is never preferable
to the interrupted ;  the dry suture is ri-
diculous in terms, since it is only a piece
of plaster, applied in many different ways,
to reunite  the lips of a wound ; and the
glover's, or uninterrupted  stitch,  which
is recommended in superficial wounds, to
prevent the deformity of a scar, does ra-
the/, by tiie frequency of the stitches, oc-
casion it, and is therefore to be rejected,
in favour of a compress  and sticking plas-
ter."  (Oper. of Surgery.)   The twisted
suture is described in speaking ofthe hare-
lip ; and gastroraphe, which also properly
belongs to the present subject, forms  a
distinct article in this Dictionary.

         INTERR' PTEP SUTURE.

   The wound being cleansed from all
clots of blood, and its lips being brought
evenly into contact,  the needle,  armed
with a ligature,  is to be carefully carried
from without, inwards to the bottom, and
so  on  from within outwards.  Care must
he taken to make the puncture far enough
from the edge of tiie wound, lest the liga-
ture should  tear quite through the skin
and flesh.   This distance, according to
Mr. Sharp, may be three, or four-tenths of
an  inch.  The other stitches required are
only repetitions ofthe same process. The
threads having  been all passed,  you are
in general to begin tying them in the mid-
dle of the wound ; though, if the lips be
held carefully together, (says  Mr. Sharp,)
it will not be of great consequence, which
stitch is  tied first.  (See Operations  of
 Surgery, Chap. 1.)
   Surgical writers in general state, that
the number of stitches must, in a great
measure, depend upon the extent of the
wound.  The common  rule is, that one
suture is sufficient for every inch of the
wound; but, that, in  some instances, a
stitch must be more frequently made, par-
ticularly when a wound gapes very much,
in consequenCe of a transverse division of
muscles.  As we have already explained,
it is necessary to pierce the skin, at a suf-
ficient  distance from the  sides of the
wound, lest the thread should cut through
the flesh in a short time : but, though Mr.
Sharp lays  down the necessary distance,
in general,  as three, or four-tenths of an
inch, and others advise  the needle to be
always carried through  the deepest part
of the wound, we  must receive these  di-
rections, particularly the last,  as subject
to numerous exceptions.   When a wound
is very deep, it would be conspicuously
absurd, and even, in many instances, dan-
gerous, to  drive  tlie needle through  a
vast  thickness of parts.   Other wounds,
of  considerable length, might not be, in
some places, four-tenths of an inch deep ;
though it  is true,  sutures could never be
requisite at such points.
  The needles for  making the interrupted
suture will pass, with the greatest facility,
when their shape corresponds exactly with
the segment of a circle,  and they should
always form a track, of sufficient size, to
allow tiie ligatures, which they draw after
them, to  pass through the  flesh with the
utmost ease.
  The interrupted suture  obviously re.
ceives its name from the interspaces be-
tween the stitches  ; and it is the one most
frequently employed.  Its action is always
to be assisted, and supported, either with
the  uniting bandage,  (see  Bandage,) or
with  strips of adhesive  plaster, com-
presses, &c. *

            UUILLED SUTURE.

   As Mr. John Bell has observed: " when
the  wound  was deep among the muscular
flesh,  the old surgeons imagined,  that so
large  a wound  could  not be commanded
by the common interrupted suture, how-
ever deep the stilches might be driven
among the flesh ; they were, besides, fear-
ful of using the continued  (gtover's) su-
ture in deep gashes, lest the wound should
be made  to adhere superficially, while  it
was still  open within, forming perhaps a
suppuration, or deep collection of  matter.
They believed,  that a deep muscular
wound could not be safely healed, without
a degree of suppuration ; while they wish-
 ed to bring it together at the bottom, they
 were afraid to close it very  exactly at the
mouth, lest the matter should be collected
 in the deeper parts of the wound;  it was
 for this purpose   (says  Mr. John Bell)
 that they used, what they called the torn- 
SUTURES.                               335
 pound, or quilled suture.   It is merely the
 interrupted suture, with this difference,
 that the ligatures are not tied over the
 face ofthe wound, but over two quills, or
 rolls of plaster, or bougies, which are laid
 along  the sides of the wound.   In per-
 forming  this suture,  we  make first two,
 three, or four stitches, of the interrupted
 suture very deep, and then, all the liga-
 tures being put in,  we  lay  two bougies
 along  the  sides of the wound, then slip
 one bougie into the loop of the ligatures
 on  one  side,  drawing  all the ligatures
 from the other side,  (Mr. Bell should ra-
 ther have said towards the other side,) till
, that bougie is firmly braced down.  Next
 we Lay the other bougie, and make the
 knots of each ligature over  it, and draw
 it also pretty firm ; and thus the ligatures
 in form of an archj^go deep into the bot-
 tom of the wound, and hold it close, while
 the bougies, or quills, keep the middle of
 the wound, and lips of it pressed together,
 with moderate closeness, and prevent any
 strain upon the threads, or any  coarse
 and painful tying across the face  of the
 wound."  In  a  note Mr.  J.  Bell says,
 that Dionis violently reprobates the quill-
 ed suture ; but, that De la Faye (the an-
 notator  on Dionis)  says, it is good for
 deep muscular wounds.   The quilled su-
 ture is now scarcely ever employed ; nor
 has it any advantages,  except, perhaps,
 in some wounds of the belly. (See Prin-
 ciples of Surgery, Vol 1, p. 50.)
    I think the reader will more easily com-
 prehend the manner of making the quilled
 suture,  by directing it  to be done as fol-
 lows ; Take as many needles,  as stitches
 intended to  be made; arm them  with a
 double  ligature, or one capable of being
 readily  split into two;  introduce  the li-
 gatures  through the wound ; cut  off' the
 needles  ; lay a piece of  bougie along one
 side of the wound, and tie the ends of the
 ligatures over  it.  Next draw the other
 extremities ofthe ligatures, so as to bring
 the first piece of bougie  into close contact
 with the flesh  ; lay  the second piece of
 bougie  along  the  opposite side  of the
 wound,  and tie the otiier ends of the liga-
 tures over it, with sufficient tightness.

            glover's suture.

    This had also the name ofthe continued
 suture.  It was executed by introducing
 the needle first into one  lip of the wound,
 from within outwards, then into the other
 in the same way ; and, in this manner the
 whole track of  the wound was sewed up.
   The glover's suture  has long been re-
 jected by all good surgeons, as improper
 to  be   employed  in cases of  common
 wounds.  It was  not, however,  till very
lately, that this suture was totally aban-
doned ; for, Mr. Sharp,  and several emi-
nent writers, since his time, have advised
its adoption in wounds of the stomach
and intestines.  From what we have said
in the articles Abdomen, and Hernia, the
reader will  perceive, that even in such
particular instances, the glover's suture
would not be advisable ;  so that it may,
in every point of view, be now considered
as totally disused in every case of surgery,
which can possibly present itself.   When
we remember, in making this suture, how
many stitches are unavoidable ; how un-
evenly, and in what a puckered state, the
suture drags the edges of the skin to-
gether ; and what irritation it must pro-
duce  -, we can no longer be surprised, at
its  now being  never practised on the liv-
ing subject.  It is commonly employed
for  sewing  up dead bodies;  a purpose
for  which it is well fitted ; but,  for the
honouri of surgery, and the sake of man-
kind,  it  is to be hoped, that it will never
again be adopted in practice.

         FALSE OR DRT SUTURE.

  This term signifies the retaining of the
edges of  wounds in contact,  by means
of sticking plaster,  in various manners,
and  the  expression,  as  Mr. Sharp has
justly remarked, is highly ridiculous, as
no  kind of sewing is concerned with the
method.  The proper  plan of dressing
wounds with adhesive plaster, is detailed
in  describing  the treatment  of  incised
wounds.   (See Wounds.)  Besides the
common way  of using  strips  of sticking
plaster, some surgeons havebeen partial
to  little particularities.   M.  Petit used
adhesive  plasters,  which had  in the
middle, one, or two holes, or even more,
according to the extent  of the  wound.
Such  openings enabled the surgeon not
only  to see, whether the edges of the
wound were in accurate contact, but also
in  what state they were; and the aper-.
tures afforded an opportunity for applying
to  the wound such remedies, as were*
deemed  expedient.  However,  as when'
common  strips of adhesive  plaster  are
properly applied, there should generally
be  left a certain uncovered interspace, be-
tween every  two.  Petit's plan had no
particular advantage in this respect.
   Another method was to take two pieces
of  adhesive plaster,  of  a breadth and
length proportioned  to  the  extent and
depth of the wound.  Three, or four liga-
tures, or tapes, were then  fastened to one
ofthe edges of each piece of plaster. Both
 pieces were then warmed, and put on the
 skin, along the sides ofthe wound.  Then
 the edges ofthe cut were evenly  brought 
336
SUTURES.
into contact, and held so by an assistant,
until the surgeons confined them perma-
nently in this position, by tying each two
corresponding  ligatures,  or  tapes.  A
pledget was next applied over the wound,
and a longitudinal  compress over each
plaster.  Over these, a large square com-
press was put, and the whole ofthe dress-
ings were covered,  and supported with a
bandage.  The  following  day,  it  was
usual to inspect the wound, and if the li-
gatures seemed lax, they were tightened;
but, if in a proper condition, they were
not  meddled with.   Sometimes,  when
much inflammation and swelling had come
on,  the ligatures were  loosened; and,
when these symptoms had abated, the liga-
tures were tightened again, if necessary.

     RE-MARKS OS THE EMr-LOVMEXT OT
                SUTURES.

   Sutures, by which I mean such as were
made  with a  needle and ligature, were
much  more frequently employed by  the
old surgeons, than they are by the mo-
derns.  All the best practiticfriers of  the
present day, never resort to this method
of holding the sides of a wound in Con-
tact,  except in cases, in which there is a
real necessity for it,  and other modes will
not suffice.
   There were, indeed, certain instances,
in wliich the employment of sutures was
long ago forbidden.  Of this  kind were
envenomed wounds, in which- accidents,
the destruction of the poison always form-
ed a  principal indication in  the treat-
ment.—Wounds,  accompanied with con-
siderable inflammation, were not deemed
proper for the  use of sutures,  as  the
stitches  had a tendency  to increase  the
inflammatory  symptoms.  Also, as con-
tused wounds necessarily suppurated, and,
consequently,  could  not be  united,  su-
tures were not recommended for them;
nor  were  they  judged  expedient  for
wounds, attended with such a loss of sub-
stance, as prevented their lips from being
placed in apposition.  Wounds, penetrat-
ing the chest, were not united by sutures;
nor  were those,  in which large blood-
vessels were  injured;  at least,  until all
danger of hemorrhage was removed  by
such vessels being tied.
   Dionis believed, with several other au-
thors,  that wounds  should not be united, -
when bones  were exposed,  on account of
the exfoliations, which might be  expect-
ed.  This  precept  is  no longer  valid;
for, when bones are neither altered, nor
diseased,  and are only simply  denuded,
or divided with a cutting instrument,  no
exfoliations will commonly follow, if the
surgeon take care to replace the fresh cut
soft parts, so as to cover the exnosed por-
tion of tlie bone.  Tlie practicableness of
uniting  wounds, attended with the divi-
sion of a bone, is confirmed, by numerous
facts. M. de la Peyronie communicated to
the Academy of Surgery, in France, a
case,  which is  very  conclusive  on this
point.  A man was wounded with a cut-
ting instrument, in  an oblique direction,
on the external and middle part of  the
arm.  The  bone  was  completely   cut
through, together with the  integuments
and muscles; in such a manner,  that  the
arm only hung by an undivided portion ot
the skin, about an inch wide, under wliich
were  the large vessels. M. de la  Peyronie
tried to unite the parts, being convinced,
that it would be time enough to amputate
afterwards, if the case should require it.
He placed the  two  extremities of  the
divided bone in  their natural situation;
made several sutures for promoting  the
union of  the soft parts; and applied a
bandage to the fracture.  In this  bandage,
there were slits, or apertures,  over  the
wound, to allow the dressings to be  ap-
plied.  Spirit of wine, containing a  little
sal ammoniac, was used as a topical appli-
cation, and the fore arm, and hand, which
were cold, livid, and insensible, were also
fomented with the same. By these means,
the natural warmth was restored, and  the
wound  was dressed.  In a  week,  the
dressings  were  removed, through   the
opening  in the bandage; in a fortnight,
they were changed, a second time, and  the
wound seemed disposed to heal.  On  the
eighteenth day,  the  healing had made
progress;  the part had a  natural appear-
ance ; and  the beating of the pulse was
very perceptible. M. de la Peyronie now
substituted a common roller, for the pre-
ceding kind of bandage.   Care was taken
to change  the dressings,  every ten  days.
In  about seven  weeks,  all  applications
were  left  off, and, at the  end of *twu
months, the  patient was  quite well, with
the exception of a little numbness in  the
part.  This case is one of the most  im-
portant in all the records of surgery; Fov
it displays, in a most striking manner,
what  very  bad wounds it is the duty of
the surgeon to  attempt to  unite;  and,
above all,  it shews  the  propriety of at-
tempting to save many  compound frac-
tures, which, judged of only from first ap-
pearances,  would lead almost any one to
resort to amputation.  When the' divided
parts, in such cases,  have been  put into
contact,  the  appearances are quite  al-
tered.
   From what has been already stated, it
appears,  that surgeons,   a  considerable
time back, did not at once sew up every
sort of wound.  The best modern practi- 
SUTURES.
337
      »
tivneis employ sutures much  less  fre-
quently,  than - their  predecessors.   M.
Pibrac's dissertation on  the abitse of su-
tures, inserted in the third volume of the
Memoirs of the Academy of Surgery, has
bad considerable effect in producing this
change, and I may safely add, this  im-
provement  in practice.  This judicious, -
and enlightened practitioner opposed the
method of uniting wounds  by means of
sutures, which he contended, ought never
to be" adopted in practice, except in  cer-
tain cases,  in which it was absolutely im-
possible to keep the sides of the wound in
contact, by the adoption of a proper  pos-
 ture,  and the aid  of  a methodical band-
age.  Such  circumstances  M. Pibrac re-
presents, as exceedingly rare, if they can
occur at all.  He  speaks  of sutures, as
 very seldom fulfilling the intention of the
 surgeon, who, in tlie majority of cases, in
which he employs  them, finds himself ne-
 cessitated  to remove them, before  they
 have  accomplished the wished-for  end.
 M. Pibrac believes, that sutures are gene-
 rally more hurtful to, than promotive of,
 the  union  of wounds; and, that when
 they  succeed, they do not effect  a  cure
 more speedily, than  a  proper  bandage.
 He cites numerous cases of very extensive
 wounds of the abdomen, neck, &c. for the
 cure of which a bandage proved effectual,
 and this even in many instances, in wbich
 sutures  had previously failed, and cut
 their way through the flesh.  M. Louis
 adopted the opinions of  M. Pibrac, and
 published, in the  fourth volume of Mem.
 de VAcad.de Chirurgie, a dissertation, in
 which he  endeavours to shew, that the
 hare-lip can be better united, by means of
 the uniting bandage, than when sutures are
 used for the purpose.
   As far as I can judge, the fair statement
 ofthe matter is,  that sutures  are, by no
 means,  requisite  in  the  generality of
 wounds;  but, that  there are particular
 cases, iu which, either their greater con-
 venience, or superior efficacy, still makes
 them approved, and employed, by all the
 most eminent practitioners of the  present
 day.   Since sutures cannot  be practised,
 without making  additional  wounds, and
 occasioning pain,  aiid since  the ligatures
 always  act  as extraneous bodies in the
 parts, in wbich they are introduced, ex-
 citing  more  or   less inflammation, and
 suppuration round them ; there can  be no
 doubt, that their employment is  invaria-
 bly wrong, whenever the sides  of a wound
 can be  maintained  in  contact by means
 less  irritating.  For, what is  it which
 generally  counteracts the wishes of the
 surgeon in  such  cases,  and  makes  his
 attempts,  to make  the opposite surface
 of wounds  grow together,  prove una-
      Yoi. U-
vailing? Is not the general cause too high
a degree of inflammation,  which necessa-
rily ends in suppuration ?  Are not sutures
means  exceedingly likely to augment in-
flammation,   both  by  the   additional
wounds of the needles, and the still more
pernicious irritation of* the threads, which
always act as foreign bodies, sometimes
producing not merely an  increase of in-
flammation,  and  suppuration in  their
track ;  but,  frequently,  such ulceration
as enables them to cut their  way out, or
else sloughing of the  parts ; or, in  parti-
cular constitutions, a very extensive erysi-
pelatous redness round the wound.
   By the ulcerative  process, just mention-
ed, sutures very often cease to have the
power of any longer keeping the edges of
wounds in contact; as the observations
of M. Pibrac,  and, indeed, what every.
man may daily remark  in  practice, fully
testify. The violent  inflammatory symp-
toms, which they excite, frequently obliges
the surgeon  to  cut them, and withdraw
them altogether.
   But, even  admitting,  that, in the gene-
ral adoption of sutures,  some  wounds
would be united, which would not be so,
were  this means  of accomplishing an
union  (generally  speaking)  abandoned,
still it must be allowed,  on the other
hand,  that the cause of some wounds not
Hinting, is entirely  ascribable to  the irri-
tation, occasioned  by the sutures them-
 selves.  Hence, if  it be  only computed,
 that as many wounds are  prevented from
 uniting by  the  irritation of sutures, as
 other  wounds, wliich are united  by their
 means, and  could  be united by no other
 methods, we must perceive, that mankind
 would be no sufferers, and surgery under-
 go no deterioration, were sutures alto-
 gether rejected from practice. I believe,
 however,  that  every man, who  has had
 opportunities   of  observation,  and  has
 made use of them, with an unprejudiced
 mind, will  feel  persuaded, that more
 wounds are hindered from uniting by su-
 tures, than  such as  are healed  by them,
 and, could not be'united by other means.
   But, prudent practitioners are not obli-
 ged, either to condemn or prase,  the use
 of  sutures, »in every instance,  without
 exception.   Men of independent  princi-
 ples will always adopt the line of conduct,
 which truth points out to them as tln.t
 which is  right ; nor  will  they obstinately
 side with M. P.brac and M. Louis, in con-
 tending that sutures  are  always improper
 and disadvantageous, nor, with other bi-
 goted persons,  who may use sutures  in
 every kind  of wound whatever.
    Sutures  are, perhaps,  still rather too
 much employed,  and  in  all probability,
 will long be so.  It will  be difficult en-
     U 0 
.'08            S U T

tirelv to eradicate the prejudices, on which
their too frequent use is founded ; as long
as we see, what may be called, the Mnitres
de I'Art, holding up the practice for  imi-
tation, in every principal hospital in the
kingdom. Such surgeons, however, as are
ready to imbibe fair and candid sentiments
on the subject, and to qualifythemselves
for practising this  part  of surgery, with
judgment, should by no means, neglect to
read, both what M. Pibrac and M. Louis,
have  written  on  the  subject.   I know,
that the latter authors  are a little too
sanguine, in  their representations;  but,
as I have already  remarked, sutures are
still rather too much used, and something
is yet necessary to do  away  a certain un-
warranted  habit of having recourse to
them in several particular cases.  Nothing
will tend to produce this desirable change
so  much, as  the perusal of every argu-
ment  against  the employment  of su-
tures.
  I am decidedly of opinion, not from
what I  have  read, but  what I have ac-
tually seen, that the  sides  of the gene-
rality of  wounds  are  capable  of being
effectually kept in contact, by means of a
proper position  of the part, the  aid of
strips of  adhesive plaster,  and  that of
compresses,  and  bandages. I  believe,
that such success  can  be obtained, with
every advantage, which can be urged in
favour of" sutures,  and  without their dis-
advantages; such as greater pain, inflam-
mation, &c I even think, with M. Louis,
that the hare-lip could in general be unit-
ed  very well, by • means of a bandage;
but, still, I am of opinion, that the twist-
ed suture is attended with  least trouble,
is most suited for universal  practice, 'and,
that,  unless such  pains  were taken, as
many practitioners would not, and others
could never take, the method by bandage
would frequently fail.
  I find  it exceedingly difficult to lay
down any fixed principles for the guidance
ofthe surgeon, in respect to when he ought,
and when he ought not, to use sutures.
  Perhaps, sutures, should be made use
of,  for all cuts and wounds,  which occur
in parts, which are subject to an unusual
degree of motion,  such  as would be apt
to  derange  the operation  of bandages,
sticking plaster and compresses.   Hence,
the propriety of using the twisted suture
for the hare-lip.
  Sutures are probably, for the  most
part, advantageous, in  all wounds of the
abdomen, of a  certain  length, and at-
tended with hazard ofthe viscera making
a protrusion.   In this situation, the con-
tinual motion and action ofthe abdominal
muscles, in carrying on  respiration, be-
sides the tendency of the viscera to pro-
                S V A"

trude, may  be a reason in favour of the
use of sutures.
  When two fresh-cut surfaces positively
cannot be brought into  contact, by stick-
ing plaster, bandages, the observance ofa
proper posture, &c. there can be no doubt
of the advantage of using sutures, if they
will answer  the purpose.  Some  wounds
of the trachea ; some  wounds  made for
the cure of certain fistulous  communica-
tions  between the  vagina and bladder;
or others for the cure of" similar affections
in the  perinaura;  afford instances of
cases, to which 1 allude.
  I observe, that many of the best opera-
tors in this metropolis, use  sutures  for
bringing the sides of the wound together
after several operations; such as  that of
removing a diseased  breast; castration
and  operations for  strangulated hernia.
The reason for using  Mittires  in the scro-
tum, I suppose, arises from the difficulty
of keeping the edges ofthe wound in con-
tact, owing  to tha great quantity,  and.
looseness of the part.  I cannot pretend
to determine, whether, in  this case, su-
tures  are really  necessary, or not: but,
after the amputation of" the breast, I have
no hesitation,  in pronouncing their  em-
ployment wrong and injudicious.
  I shall conclude  with referring to what
M. P.brac and M.  Louis have written on
the above subjects, in  Mem. de VAcad. tk
Chir ton\. 3 & 4.   Sharp, Dionis,   Gooc/i,
Le  Dran, Bertrandi, Sabatier, B. Bell,
and J. Bell, have all treated of sutures.
  SYCOMA. (from o-vkj,, a fig.) A wart,
orexcresence, resembling a fig.
  SYCOSIS.  The  same.
  SYMPATHETIC BUBO. (See  Bubo.)
  SYNCHYSIS, (from trvyyjtox, to con-
found.)    Saint-Yves,  and  Maitre-Jan,
signify by this  term a conversion  of the
vitreous and crystalline humours  of the
eye into a viscid, purulent matter, which,
in the course of time,  assumes the ap-
pearance of a yellowish serum.  Since the
time of the preceding  oculists, the term
synchysis has been used to denote the con-
fusion of the humours of the eye, occa-
sioned  by blows,  and  attended  with a
rupture of the internal membranes, and
capsules.  (See Encyclopedie Methodique;
Part. Chir. Art. Synchyse.)
  SYttCOPE.   (from o-vynoirru, to cut
down.)   A sudden prostration of the vital
powers ; a fainting fit.
  SYNOVIA. (A term of no radical mean-
ing, and invented by Paracelsus.)  The
fluid, secreted in joints, for the purpose of
lubricating the articular surfaces.
  SYNTASIS. (from rvvrtna, to extend.)
A distention of parts by swelling.
  SYNTHESIS,  (from «•*», together, and 
TAB                                  TER             S3$
Stc-Jti  position, situation.)  A  generic
term, formerly much used in the schools
of surgery, and comprehending every ope-
ration, by which parts, which had been
divided, were reunited.
  SYXTHET1SMUS.  (from  o-v*6e»,  to
concur.)   The reduction of a fracture.
  SYNULOTICA.  (from trvmXoa, to ci-
catrise.) Medicines or applications which
promote the cicatrization of wounds.
  SYPHILIS,  (is  fabulously said to be
derived from  the  name of a shepherd,
who fed the flocks of King Alcinous,  and
who from pride insulted the Sun, whence
the disease was sent on earth as a punish-
ment.)   I.ties  Venerea.  The venereal
disease; others write Siphilis, and derive
the term from ci^tef, filthy.  (See Vene-
real Disease.)
  SYRINGOTOMUM.  (from <rv^y%, a
fistula, and  Ttfwu, to  cut.  A  kind of
concealed knife,  for dividing fistulae, and
sinuses.  Figures of it may be  seen in
Scultetus, and Fabricius  ab  Aquapen-
dente.  . It was  constructed  in  various
Ways ;  but, as it is not  at  present em-
ployed by surgeons, it would be  a  waste
of time to introduce a  description of its
different forms.
  SYSTOLE  (from o-voQiXXu,  to con-
tract.)  The  contractile  motion of the
heart and arteries.
T.
T BANDAGE.  A Uandage so named
    from its figure.  It is principally used
for supporting the  dressings  after the
operation for the fistula in ano, in diseases
of the perinaum, and those of the groins,
anus, &c.  It is composed of two  longi-
tudinal pieces of  cloth, of greater or les-
ser breadth,  according  as  occasion  re-
quires.  The  transverse piece of  cloth
serves to go round  the body above the
hips ; the perpendicular piece is sewed, at
one of its ends, to the middle of the lat-
ter; and, in general, its other extremity is
slit into two portions, or tails, about six or
eight  inches  long.   The  perpendicular
piece of the T bandage applies itself be-
tween the glutaei muscles, and to the peri-
naeum; while its two ends, just described,
are to be carried  between the thighs, and
the pudenda, to the right and left, and fas-
tened to the transverse piece, surrounding
the body.  Besides the common T ban-
dage,  there is another one named double,
which has two perpendicular pieces, sew-
ed to the transverse one, about four inches
apart.  The double T bandage is said to
be more particularly applicable  after  li-
thotomy, and for the diseases of the peri-
naeum ;  because,  one may make  the two
perpendicular pieces  crqss each other  on
the part affected, and leave the anus un-
covered : an advantage, which the simple
T bandage  certainly has  not   The 1
bandage may be used in some other ways,
as we have noticed, in making mention of
it in the article Bandage.
  TABES, (from tabeo, to consume.)  A
wasting of the  body, attended with ex-
treme debility and hectic fever.
  TALPA. (a mole.)   A tumour, which
creeps under the skin, as a mole under the
surface of the ground.   Such is the ety-
mology.  It is often applied to an encyst-
ed tumour,which forms on the head, and
contains a paplike matter.  (See Atheroma
and Tumours, Encysted.)
  TALPARIA.  The same.
  TAPPING.  See Paracentesis.
  TARAXIS. (from Tu^ao-ru,to disturb.)
A slight  ophthalmy, or inflammation of
the eye.
  TAXIS, (from rao-tru, to put in order.)
The operation of, reducing a hernia with
the hand.   (See Hernia.)
  TELEPHIUM.  In surgery means  a
malignant,  dangerous  ulcer, difficult of
cure. The  word is derived from Tele-
phus, who received a mortal wound from/
Achilles, which injury, it is said, became,
before death, a disease of the above de-
scription.
  TENDO ACHILLIS-     See Achilles,
Tendor\of.
  TENESMUS, (from «i»*,to stretch.)
A painful, ineffectual, and repeated effort
to go to stool.                 .  ,
  TKNT.  A roll of lint for dilating open-
ings, sinuses, &c.(See Spongia Prtparato.)
  TEREBEI.LA. (dim. of terebra, a per-
forating instrument.)   A' irepan, or in-
strument for sawing out circular portions
of the skull.  A trephine.
  TEREBRA.  (from rtptet, to bore.)  A 
$40                              TESTICLE.
 trepan, or trephine.  Also an instrument
 called a perforator, such as is contained,
 in the  generality of cases of trephining
 instruments, and is used for making a hole,
 in which the centre pin of the trephine is
 to work.
  TERETRUM.  The same.
  TERMINTHUS.  (from  Tept*,iv6ot, a
 pine-nut.)  A large. tumour,  or painful
 pustule on the  skin,  resembling a pines
 nut.
  TESTICLE, DISEASES OF.   For an
 account of many  of" these aff'ections, I
 must refer the reader to distinct articles
 in this Dictionary; for instance,  Cirsoeele,
 Hernia Humoralis, Hxmatocele, Hydrocele,
 &.c.  I shall next insert Mr. Pott's  ac-
 count of Sarcoeele; but, before I  do so, it
seems proper to observe, that, when this
 author uses the epithet  scirrhous, he fre-
 quently seems to attach no other  significa-
 tion  to it, than  indurated.   Indeed, any
 one,  in the least acquainted with the sub-
ject, would readily discern, that Mr. Pott
 could not always mean the malignant  tu-
 mour, or hardness, which is often  named
 the occult cancer.

              SAI1COCELE.

  " This (says Pott,) is a disease of  tlie
 body of tlie testicle ; and, as the  term  im-
 plies, consists, in general, in such an al-
 teration, made in the structure  of it, as
 produces a resemblance to a hard fleshy
 substance, instead of that fine, soft, vas-
 cular texture, of whichvit is, in  a natural
 and healthy state, composed.
  " The ancient writers have made a great
 number of distinctions of the  different
 kinds of  this disease, according  to its
 different appearances, and  according to
 themildness or malignity of the symptoms,
 with which it  may chance to be attended.
 Thus, the sarcoeele, the hydro-sarcocele,
 the scirrhus, the cancer, the caro adnata ad
 teslem, and the caro adnata ad vasa, which
 are really "little more than descriptions of
 different states and circumstances of  the
 same disease,  are reckoned as so many  dif-
 ferent complaints, requiring a variety of
 treatment, and deriving their origin from
 a variety of different humours.
  " Every species of sarcoeele  consists
 primarily in an enlargement, induration
 and  obstrhction of the vascular part of
 the  testicle ;  but,  this  alteration is, in
 different people, attended with such a va-
 riety of ciicumstaiices, as to  produce se-
 veral different appearances ; and to occa-
 sion the  many distinctions  which have
 been made.  .
  "  If the body of the testicle, though,
 enlarged and  indurated to some dr glee,
 be perfcctlj equal in  its surface,  void of
 pain, has  no appearance of  fluicl in tt»
 tunica vaginalis, and produces very  little
 uneasiness, except what is occasioned by
 its mere weight,  it is  usually called a
 simple sarcoeele or an indolent scirrhus.. If,
 at  the  same time that the testis is enlarg-
 ed and  hardened, there be a  palpable ac-
 cumulation of fluid in the vaginal  coat,
 the disease has by nvany  been  named a
 hi/tlro-sdrcocele.  If the lower  part of the
 spermatic vessels and the epididymis were
 enlarged, hard, and knotty, they supposed
 it to be a fungous or  morbid accretion,
 and called it the  caro adnata ad vasa: if
 the testicle itself  was unequal in its sur-
 face, but at the  same time not painful,
 they distinguished it by the title of car
 adnata ad testem ; if it was tolerably equal,
 not very painful, nor frequently so, but at
 the same time hard, and large, they gave
 it the  appellation of an occult or benign
 cancer : if it*was ulcerated, subject to fre-
 quent acute pain,  to  hemorrhage, &c. it
 was known by that of a malignant or eon-
firmed  cancer. These  different  appear-
 ances, though distinguished  by  different
 titles, are really  no  more than so many
 stages  (as  it were) of the same kind of
 disease  : and depend  a  great deal on se-
 veral accidental  circumstances; such as
 age, habit,  manner of living, 8tc.  It is
 true, that many people pass several years
 with this disease, under its most favour-
 able appearances, and without encounter-
 ing any  of  its worst:  but on the other
 hand, there are many, who, in a very short
 space of time, run through all its stages.
 They who are most conversant with it,
 know liow  very  convertible  its mildest
 symptoms are into its most dreadful ones;
 and how very short a space of time often
 intervenes between the one and the other.
   "There is hardly  any disease, affect-
 ing the  human body,  which is subject to
 more variety than this is, both with regard
 to  its first  manner of appearance, and tlie
 changes which it may undergo.
   " Sometimes the first appearance is a
 mere simple enlargement and induration
 of the body of the testicle; void of pain,
 without inequality  of  surface,  and pro-
 ducing  no  uneasiness, nor inconvenience,
 except  what is occasioned by  its mere
 weight. And some few people  are so
 fortunate, as to have it remain in  this state
 for  a veiy  considerable length of time,
 without visible  or  material alteration.
 On the  o her hand, it sometimes happens, ,
 that, very soon  after  its  appearance in
 this mild  manner, it suddenly  becomes
 unequal, and knotty, and is attended with
 very acute pains, darting up  to  the  loins
 and back; but still remaining entire, that
 is, not bursting through tiie integuments.
 Sometimes the fury of the disease brooks 
TESTICLE.                              341
»o restraint; but making ts way through
all  tiie  membranes which envelope the
testicle, it either produces a large, foul,
stinking,  phagedenic  ulcer with  hard
edges ; or it thrusts forth a painful gleet-
ing fungus, subject  to  frequent hemor-
rhage.
  "  Sometimes  (as  I  have already ob-
served) an accumulation ofwater is made
in tlie  tunica vaginalis,  producing that
mixed appearance, called the hydro-sar-
cocele.
  " Sometimes there is no fluid at all  in
the  cavity of the tunica vaginalis ;  but
tlie  body  of the testicle  itself is formed
into cells, containing either  a turbid kind
of water, a bloody sanies, or a purulent,
fetid matter.
  " Sometimes the disorder seems to be
merely  local, that  is, confined to the tes-
ticle, not proceeding from a tainted habit,
nor accompanied with diseased viscera ;
the patient having all the general appear-
ances and  circumstances  of health, and
 deriving his local mischief from an exter-
nal  injury. At  other times,  a pallid,
leaden countenance, indigestion, frequent
 nausea, colic pain, sudden purgings, &c.
 sufficiently  indicate  a  vitiated  habit,
 and  diseased viscera;   which  diseased
 visceramay also sometimes be discovered
 and felt.
   " The progress also which  it makes
 from the testis upward, toward the pro-
 cess, is very uncertain ; the  disease occu-
 pying the testicle only, without affecting
 the spermatic process, in some subjects,
 for  a great  length of time ;  while  in
others, it totally spoils the testicle very
 soon; and almost as soon seizes on  the
 spermatic  cord.*
   " These, and some other circumstances
 to be mentioned hereafter, are  materially
 necessary to be observed ; as they charac-
 terise the disease, point out its particu-
 lar  nature and disposition, aud_ serve as
 marks  whereon  to found our  judgment
 and prognostic ofthe most probable event,
  * This is  the common  language,  and
therefore l,use it;  but I  would  not be
understood to mean, that the progress of
the disease is always  and  invariably up-
ward, from the testis into the process.  I
have seen the  spermatic  process truly
eancerous, when the testicle has been free
from disease ; and am well satisfied from
experience, that a diseased state of the
vessels  within  the' abdomen, or of the
parts in  connexion with those vessels, may
produce a morbid state of the process, pro-
ceeding downwards from thence : but the
other is  by  much  the  most frequent.—
(Pott.)
as well as the most proper method e€
treatment.  Various have been the causes,
to which the theoretic and  whimsical
people have assigned this disease; but" as
a recital of conjectures can  convey no in-
struction, or  useful  information, I  shall
pass  them over; and only take notice,
that among the great number which have
been  mentioned,  there are two which,
though equally groundless with the rest,
have  yet obtained a degree  of credit, that
may  mislead; these two are  the hernia
humoralis, and the hydrocele of the vaginal
tunic.
  "  The  hernia  humoralis   (continue=
Pott) is a defluxion  of the inflammatory
kind, proceeding most frequently from an
irritation in  that part of the  urethra,
where the vasa  deferentia, or vesiculse
seminales  terminate.*  It   is  attended
with pain and heat, and  most frequently
fever:. during the first, or  inflamed state
ofthe disease, the whole compages of the
testicle is enlarged;  but when by  rest,
evacuation, and proper applications,  that
inflammation is calmed, there seldom or
never remains, either  fulness,  hardness,
or any other mark of disease in the glan-
dular part of the testis.  The  epididymis  '
indeed seldom escapes so well; that often
continues enlarged and  indurated  for a
considerable  space  of time,.but without
producing either  pain or inconvenience ;
and without  occasioning  any alteration
in the figure or structure of what is call-
ed the body  of the testicle ; whereas the
true  sarcoeele, or hernia carnosa,  most
commonlyj- begins by an indolent indura-
tion of that part of the testis, ahd  affecte-
the epididymis secondarily; or after it has
already spoiled the vascular part of the
gland.
   " I would not be understood to mean,
 (says Pott) that a sarcoeele never follows
a liernia  humoralis; there is no reason
in nature  why it should  not;  a hernia
humoralis does not, nor can prevent the
 testicle, in any future time, from becom*
 ing scirrhous -. I only say, that  it  does
 not,  at any time, necessarily cause or pro-
 duce it.  So also with regard to the epidi-
 dymis, I do not mean to say, that it never
 is the primary and original seat of a scir-
 rhus :  1 know that it is,  and shall pro-
 duce some  instances  of it; neither do I
 intend to say that a scirrhus  never at-
 tacks an epididymis, which has  been pre-
 viously hardened by a hertiia humoralis ;
 there can be no reason why it should not:
 1 only mean to signify, that it is my opi-
  * This may be doubted.—S. C.
  +1  say most  commonly, because it is
neither necessarily, ^pr always. 
342
TESVICLE.
 nion, that  the induration caused by a
 venereal hernia humoralis docs not, at
 any time, necessarily produce a scirrhus.
 A scirrhus  indeed may fall on that part,
 after it has  been so  diseased; but it
 would  as certainly have  attacked it,  if
 there had been no preceding affection of
 it.
   '« There  is also a venereal affection of
 the testicle, independent of a gonorrhoea,
 or of any disease of the urethra.
   " This  is seldom an early symptom;
 and  I do not  remember (observes Pott)
 ever  to have seen an instance, in which it
 was  not either immediately preceded, or
 accompanied,  by some other appearance,
 plainly venereal.   It has neither tiie ine-
 quality, nor darting pains of the scirrhus,
 and  always  gives way to a mercurial pro-
 cess  properly conducted.
   " A quantity of water is frequently col-
 lected in the vaginal coat  of a truly scir-
 rhous testis.   This has  given rise to the
 supposition,  that  the testicle  often be-
 comes diseased,  from its being surround-
 ed by, or swimming in the same fluid : a
 supposition entirely groundless.
   " That scirrhous and cancerous testes
 very  frequently are found to have a quan-
 tity of fluid accumulated in the tunica va-
 ginalis of them, is l>eyond all doubt;  but
 that  such testicles become  diseased, in
 consequence of being surrounded by such
 fluid, or, in  other  words,  that a simple
 hydrocele may  produce a scirrhous testi-
 cle, is by no means  true.
   " The simple hydrocele is a collection
 of water  in the tunica vaginalis.-  this
 fluid,  in a natural and healthy state of
 the parts, is small in quantity, and, by
 being constantly absorbed, does not dis-
 tend  the cavity  of the tunic,  but only
 serves to keep that membrane from con-
 tracting  any unnatural cohesion with  the
 tunica albuginea.  The. regular absorp-
 tion of  this  fluid being  by some means
 prevented, the quantity soon becomes con-
 siderable, and  distending  its containing
 bag, constitutes the disease called a  hy-
 drocele ; ,but makes no morbid alteration
 in the structure of the testicle.*  (See
Hydrocele.)
  " When the  testicle becomes enlarged
in size, hardened in texture, craggy and
unequal  in its  surface,  painful upon or
after having been handled,  attended with
 irregular pains  shooting up the  groin to-
  * That is,  no such alteration as ren-
ders it painful, or incapable of executing
its office ;  and consequently, no such al-
teration  as can ever require extirpation
or any other chirurgical operation on the
testicle itself.
 ward tlie back, and this without any  pre-
 vious  inflammation,  disease,  or  injury
 from external violence, it is said to be
 affected with a scirrhus.  This, as I have
 already  remarked, is of  different kinds
 and degrees, and appeal's under different
 forms;  but,  although the  appearances,
 which the disease makes, are various, ac-
 cording to the alteration produced by it
 in  the testicle;  yet, every  such  morbid
 alteration may obstruct or prevent the re-
 gular  absorption of the fluid deposited in
 the vaginal tunic, and occasion a species
 of hydrocele;  that  is,  a   tumour from
 water.
   " This is  that kind  of disease,  which
 by Fabricius ab Aqiiapendente, is called
 hydro-sarcocele ;  but  which is so very
 unlike to a  simple hydrocele, that who-
 ever mistakes the one for the other,  will
 commit an error, which  may prove very
 mischievous  to his patient,  and very de-
 trimental to himself.
   " In the true,  simple  hydrocele,  the
 testis, though somewhat  loosened  in  its
 texture,  and a little enlarged, yet pre-
 serves very nearly its natural form ; the
 collection  is  made without pain or un-
 easiness, and very soon becomes sufficient
 to hide, or conceal, the testicle; nor is the
 examination  of such  tumour  attended
 with  any pain: but  the  increased sizej
 and hardened state, of the  scirrhous testis,
 renders  it discoverable, through a much
 larger  quantity of fluid than will totally
 conceal the former.  When felt, it will be
 found to be hard, and generally somewhat
 unequal, and' not unfrequently  attended
 with irregular shooting pains,  especially
 after having been examined.
  " In the simple  hydrocele,  the .fluid
 distends the  tunica vaginalis so equally,
 that, although it does not surround  the
 testicle,  (nor indeed can) yet it seems
 so to do : whereas in the hydro-sarcocele,
though the anterior part  of  the tumour
 may, in some measure,  bear the appear-
 ance of a simple hydrocele;  yet,  an  ex-
amination of  its posterior part will always
discover the  true nature  of the case : to
which may be added, that, under the same
apparent  magnitude, the latter will  al-
ways be found to be considerably heavier
than the former.
  " In  short, the name of this species of
disease (hvdro-sarcocele)  is  undoub'edly
a very proper one, and capable of con-
veyinga very just idea of  its  true nature,
viz.  an  accumulation  or collection  of
water in the vaginal  coat of a scirrhous
or diseased testicle; but the  majority of
writers have, by supposing the water to
be the cause,  instead of the consequence
of the  diseased state of the  testis, com-
mitted  a very material  blunder,  and 
TESTICLE.
J<k
endeavoured  to establish  and authorise
» very prejudicial  and  destructive me-
thod of practice.   For, by conceiving,
that the noxious quality of the fluid pro-
duces a fungous or fleshy excrescence on
the surface of the testicle, they have sup-
posed, that, after having discharged the
said  fluid from its  containing  bag,  they
could, either by establishing a  suppura-
tion,  or  by  using escharotic medicines,
waste or destroy the said excrescence, and
obtain a radical cure ofthe  whole disease.
Now the scirrhosity of the testicle being
the original disease, and the extravasa-
tion a mere accident, such  treatment can
never do  any material good,  and  may
often be the cause of very essential evil.
  " Fabricius  ab   Aquapendente  has
given  a  particular description  of  this
method, which he recommends from hav-
ing practised it with'success : his words
are; " Modus singularis est q'uandohernia
aquosa cum carnosd mista est ,-  tunc enim
primum incide, etfine foramen in parte scroti
qxtX  non sit declivis, neque in fundo scroti,
sed circa medium ; necfac admodurn latum :
et extractd aqnt), turundam impone qutirn
loitgissimam, metlicamento, pus moventi in-
fectam, ut resina terebinthinx, cum thure,
ovi vitello, et butyro ; empiustrum emotliens,
et pus movens applica, ut diachylon cum gum-
nut, et axungr-d porci: genitum autem pus,
non evacuetur per foramen,  sed data operd
intus servetur, utcontactu suo, carnemsensim
pufrefaciat. Neque innovantla medicamenta,
nisi tola carofuerit in pus conversa ; id quod
hrtgoflt tempore."*
  " N"vv>  to  pass over the absurdity  of
the doctrine of removing or dissolving a
fungous excrescence,  by means of the
putrefying quality of matter : as well as
the great disturbance,  which must be the
consequence  of confining  it within the
tunica vaginalis ; it is very clear from
these, and from every other circumstance
attending the disease in question, that the
cases, which Fabricius had  successfully
made his experiment  upon, must have
been mere simple hydroceles,  attended
with  a small  degree  of  enlargement j
but without  any diseased  state  of the
testicle.
  "This  is one method of  procuring a
radical cure of the said disease; a me-
  • " Si  carnosa,  et  aquosa  sit hernia,
ego talem adhibeo curam :  Seco cntem,
et incisionem  facio exiguam,  et  in loco,
potiiis  altiore, quam in fundo :  hide  tu-
runda  imposita  cum  digestivo et pus
movente  medicamento  diutius  procedo,
neque unquam pus extraho,  sed perpetud
bonam   partem intus  relinquo  ;  quod
sensim carnem corrodit, et Ua.sanat."
thod in use, before Fabricius practised it;
and  still in some measure  employed : a
method,  which,  in  some instances, has
always been successful; and which may,
in general, be  tried on any simple hydro-
cele,  in a  young  and healthy  subject.
The cure  (when  it affects one) is not
brought  about by  the destruction of an
excrescence from the testicle, or the dis-
solution of its supposed induration ; but
merely  by  exciting  such an  inflamma-
tion,  as  shall occasion  an adhesion  of
the tunica vaginalis to the tunica albu-
ginea ;  by  which means the  cavity  of
the former is obliterated ;  the  testicle
remaining,  as to size  and consistence,
just as  it was before such operation was
performed.   But this,  though  practica-
ble,  and  sometimes successful in the
hydrocele, is  not to be thought of "m the
diseased or scirrhous testicle.  The opera-
tion, as described by Aquapendente, con-'
sists of two points ; first to let  out the
water,  and then to cause a plentiful sup-
puration.   When the testicle is really ami
primarily diseased,  and the  extravasation
is a consequence of  such disease, the
discharge of the  water from the cavity of
the tunica  vaginalis,  whether> by punc-
ture, or by incision, can contribute nothing
material  toward  a  cure of  the  principal
complaint, and is therefore useless ; but
it may, in  many  cases, do harm, by cre-
ating a disturbance in parts, whose state
requires  the most  perfect quietude; and
is therefore wrong.  When the disease
is a mere simple-hydrocele, the palliative
cure, as it is called,  by puncture, is right
and  necessary; it renders the life of the
patient easy; rids  him, every  now and
then, of a  very troublesome  burden; is
perfectly  safe ;  may be  performed and
repeated occasionally, at any time of the
patient's life, or in almost any state of the
disease:  but the introduction of tents  or
setons, or the endeavour by any means  to
excite  inflammation, or  to establish sup-
puration  within the tunica  vaginalis, re-
quires  (even in the simple  hydrocele,
where the testicle is unaffected) some lit-
tle consideration, and  ought not  to be
hastily or unadvisedly put in practice.
   " In some  ages,  habits, &.c.  tlie symp-
toms will rise very high, and occasion both
trouble and hazard ; and if this  be the
case, when thV testis is not at all diseased,
and when theoe is no malignity, either in
the local complaint, or in the habit of the
patient;  what have we not to fear where
there is both ? where the parts are already
spoiled by  disease, and where irritation
and inflammation may (and do) excite the
most fatiguing symptoms,  and the most
direful consequences ?
   " Beside the hydro-sarcocele, or limpid 
CM                               TEST

extravasation of fluid in the cavity of the
vaginal coat (and  which must therefore
always be external to the testicle) scir-
rhous and cancerous testes are liable to
collections of fluid, within the substance
of them,  under  the  tunica  albuginea.
These are sometimes  large, and in one
cavity ; sometimes small, and in several
distinct  ones.  They are alsq very dif-
ferent in nature, in different cases ; some-
times serous, sometimes  sftnious; some-
times purulent,'sometimes bloody. These
are very apt to impose on the inadvertent
and  injudicious;  (especially if they  be
attended with some degree of inflamma-
tion   in  the   skin;) and  to  induce  an
opinion of an abscess, or impostliumation,
wliich may be'relieved or cured by  an
opening;—but caveat operator.   These
collections will be  found  to  bear a much
smaller proportion to the  general size of
the tumour,  than they  who are not con-
versant with them  are inclined  to appre-
hend ; the subsidence, after the  opening
has been made, will also be much smaller
than  was  expected;  and  instead of
relief and ease, all the symptoms of pain,
swelling, inflammation, &c.  will be in-
creased and aggravated ; and if the open-
ing  be  considerable, it not  unfrequently
happens,  that  an  ill-natured  fungus is
thrust forth ; which, by bleeding, gleet-
ing, and  being horribly  painful, disap-
points the surgeon, and renders the state
of the patient much more deplorable than
it was before: neither is  this  sensation,
wliich is thought,  like the fluctuation of
a fluid within  the testicle,  to be at all
times depended upon as implying that
there is any fluid at all there. The touch,
in this case, is subject to great deception;
and  1 have seen  a  loosened  texture of
the whole vascular structure, or  body of
the testicle, produce a sensation  so like
to the fluctuation  of a»fluid lying deep,
as has imposed on persons of good judg-
ment, and great caution.
  " Many ofthe most esteemed writers on
this part of surgery,  either  not  being
practitioners,  or being afraid  to  differ
from those who have written before them,
have lazily  and   servilely  copied each
other, and have   thereby fallen  into an
obscure jargon  concerning  this  disease,
which neither themselves nor their rea-
ders have understood.  They have talked
of the scirrhous testicle, the caro adnata
ad testem, and the  caroadnataad spermati-
ca vasa,  as so many different diseases, re-
quiring different methods of treatment.
   " Tiie melancholia, the atra bilis,  and
a certain inexplicable adust state of hu-
mours, are said to be the causes of these
different appearances;  and  the  fleshy
substance arising  from,  or  adhering to,
the spermatic  vessels,  is  said to  be
more benign, than  either tlie fungus aria-
ing from the testicle, or the true scirrhus.
For the first,  they  have  described  an
operation, which is coarse, cruel, painful,
and (notwithstanding all that they have
said about it)  unsuccessful; all  which
they must have known, if they had prac-
tised it.  I therefore am  much inclined to
believe, that this is one of the many parts
of ancient  surgery,  which having been
devised by some one bold, hardy operator,
and by him described as  practicable, has
been related by many of his successors, as
practised.  The second, the caro adnata
ad testem, they allow to be attended with
more  difficulty, as well as hazard, and
seldom to be attended with success.
  " They,  who are  under the necessity
of forming their opinions principally from
books, and who have not frequent oppor-
tunities of  knowing from experience how
very little they are (in many cases) to be
depended upon, may be  inclined  to think
that all these  distinctions really  exist;
and that  these  operations  by  fire and
sword, by  knives  and cauteries, so   ex-
actly described, must be sometimes  ne-
cessary ; but having never seen the parti-
cular cases requiring such treatment, have
a very imperfect idea, either of  them, or
of thcoperations ; and  are,  to  the  last
degree, alarmed and intimidated, when
any thing, which  they think is like to it,
occurs to them in practice.  To such, it
may not be amiss to explain  this matter
in as few words as I can;  begging pardon
of the more  intelligent  reader for  the
digression.
   " In the short anatomical account which
I have given of these parts, I have taken
no notice, that the spermatic vessels ter-
minate in the testicle : and that, after the
semen has been secreted from the blood,
it passes from that gland  into  a body,
which  seems  superadded, to,  although
it be  really  continuous  with  it.  This
body is, therefore, called the epididymis,
and is so placed, with regard to the testis,
that a heedless or uninformed  observer,
may suppose, that the  spermatic vessels
terminate in it:   especially  if it be en-
larged by disease.   It takes .its  rise from
the testicle, by a number of vessels, call-
ed, from  their  office,  vasa eff'erentia:
these  soon become one tube, which, being
convoluted and contorted in a most won-
derful manner, forms the  greater part of
the said body : and at last, ceasing to be
so convoluted, it ends in one firm canal,
called the vas deferens ;  by  which, tiie
 secreted af-men is conveyed from the tes-
 ticle to the vesiculx seminales.
   " Whoever will attentively consider the
 epididymis in its natural position, with 
TESTICLE.                               345
  regard to the testicle,  and the  spermatic
  vessels, will see, that if it be enlarged be-
  yond its  proper size, it will extend itself
  upward, in such a manner  as to seem to
 ' be closely connected with  them,  and to
  bear the  resemblance of a diseased body,
  springing from them.
    " This is the case called the caro  ad-
  nata ad vasa* spermatica; and is reallyand
  truly nothing more, than an enlargement
  of the epididymis ; a circumstance which
  occurs not unfrequently,  but does not im-
  ply any malignity, either in the part, or
  in the patient s habit; and can  never  re-
  quire such a horrid operation as our fore-
  fathers have directed us to perform upon
  it; nor indeed any at all.
    " The  epididymis  is  frequently  en-
  larged, in venereal cases, either separate.
  ly, as in the rcmiinsof a hernia humoralis,
  or together with the testicle, in that affec-
  tion of it, which  I have  called the vene-
  real sarcoeele  ; and sometimes from mere
  relaxation of its natural texture, without
jMhy disease at all.  But in none of these
^can it require, or even  admit any  manual
  operation of any kind.   Indeed, whoever
  will consider  the epididymis as it really
  is, as the medium by and through  which
  the semen is conveyed from the testicle to
  the vas deferens,  must  immediately be
  sensible of the glaring absurdity of re-
  moving any part of it.
    " The scirrhus  and cancer do not very
  often begin in this part; tliey most fre-
  quently make the first attack on the body
  of the testis :  and, though the epididymis
  is often cancerous, yet  it most frequently
  becomes  so secondarily, or  after the tes-
  ticle is  spoiled ; so that the removal of it,
  if practicable, could serve no good pur-
  pose : it would not remove  the disease ;
  for that has, before-hand,  most commonly
  taken possession of the testicle  ; and the
  cutting off any part of a scirrhous or can-
  cerous  tumour of any  kind, is what no
  man, who has the least knowledge of what
  he is about, will ever think of.
    " In short, these two cases, which  by
  the inattention  and misrepresentation of
  our ancestors, have  created such per-
  plexity in the minds of  their readers, are
  either a simple enlargement of the epi-
  didymis,  without any morbid alteration
  in its structure ; or a diseased (that is, a
  scirrhous) state ofthe same part; or else,
  a scirrhous or cancerous testicle, with  in-
  equality of surface.  The first of these
  requires no manual operation of any kind ;
  and the two last will  admit of none : the
  first is no  disease at all; and the two last
  are such-diseases, that every attempt made
  on them  by knife, or caustic (unless for
  total extirpation, must render them worse,
  and mwee intractable.
      Vor  II
   " The manner of treating a sarcoeele,
 or hernia carnosa, depends entirely on tiie
 particular nature and state of each indi-
 vidual  case.  In some, it will admit of
 palliation  only;  in  others,  the  disease
 may be eradicated by the extirpation of
 the part: so that, under the article of me-
 thod of cure, we have only to consider,
 and point out, as clearly a* the nature of
 the disease  will permit, what states  and
 circumstances, both of it, and of the pa-
 tient labouring under it, forbid the opera-
 tion, and what render it advisable.
   " On this head, a great variety of opi-
 nions  will be found  among writers; so
 great,  that a man, who is under a  necessi-
 sity of  forming his judgment from  them
 will find himself under some difficulty how
 to act; and so great, that I cannot help
 thinking it to be clear, that the majority
 have not written from practice, but from
 mere conjecture, or from  the  works of
 those,  who have gone before them.
   " Some have given it  as their opinion
 that while the testicle is perfectly indolent,
 (let the alteration  in its structure,  form,
 or consistence, be what it may,) it is bet-
 ter to suffer it to remain,  than to remove
 it.   In  support of this opinion, they say,
 that although the disease has plainly tak-
 en possession of the part, yet, while it
 causes no pain, the constitution receives
 no damage from it';1 nor is the health of the
 patient impaired by it; whereas, by remov-
 ing the testicle, the same virus may seize
 on some part of more consequence to life.
 This method of reasoning takes for grant-
 ed two things, which do not appear to be
 strictly or constantly  true, viz. that this
 disease  is never perfectly local; and that
 a scirrhous testicle, though free from pain,
 will  not in  time  produce any evil to  the
 general habit of tiie patient.   Others ad-
 vise us to stay until the tumour becomes
 painful, and manifestly increases in size,
 or acquires a sensible inequality  of sur-
 face ; that is (in other words) until it be-
 gins to alter from a quiet state, to a ma-
 lign one ; which advice,  as  well as  the
 preceding,  supposes, that tlie  hazard of
 the.mere operation  of castration is  too
 great to render it an advisable thing,  un-
til the  patient is  pressed by bad symp-
toms ; and that a scirrhous testicle, which
has been quiet and free from pain for some
time, may be as successfully extirpated
after it  has become painful,  and  has ac-
 quired a malignant  and threatening state,
 as at any time before  such  alteration.
 The latter of these will hardly b<* admit-
 ted (Ibelieve) by  those who form their
opinions from  experience :  and with  re-
gard to the  former, I can, with great
truth, affirm, that  I never saw the mere
 oneration of castration, when  performed
     \ x 
346                              TESTICLE.
in time, and on a proper subject, prove
fatal.
  ■" Many people have I known, who have
lived several years, their whole lives per-
fectly free from disease, after the removal
of quiet, indolent, scirrhous testicles; and
several have I known, who, having defer-
red the operation until they were urged
by pain, increase of size, and  inequality
of the tumour, have, from the sore becom-
ing cancerous, not  been able to obtain a
cure.   That I have seen the same thing
happen, after  the removal of a testicle,
circumstanced in the best manner, is be-
yond all doubt; but not near so frequent-
ly, as in those cases, in which  the opera-
tion has been deferred, until  the symp-
toms  became  alarming, and the disease
had changed its  appearance, from a be-
nign quiet one, to one that was malign
and painful.   Indeed, were  we  capable
  ^knowing with certainty which those
scirrhi were, that would remain quiet and
inoffensive  through life, or for a great
length of time, and which would not, we
should then be enabled to advise  or dis-
suade  the  operation upon much better
(that  is, much surer) grounds,  than  at
present we are able to do.  We have no
such degree of knowledge; all our judg-
ment is formed  upon the  mere recollec-
tion of what  has happened to others in
nearly  similar  circumstances;  and expe-
rience, though the best general guide, is,
in these cases,  more fallacious than in
many others.
  " A  few people  there  certainly  have
been,  who  have  been so fortunate as to
carry  a scirrhous testicle  through many
years,  with little or no pain or trouble:
but the number  of those,  in whom  time
(and  that frequently  a  short space,)
change of constitution, external acciden-
tal injury, &c. do not make such an alte-
ration  in this disease,  a»  to  render the
operation less likely to be successful, than
it would have been at first, and under
more   favourable circumstances,  is  so
small,  that I think early castration  (that
is, as soon as the disease is fairly formed
and characterized) may be recommended
and practised by every  honest and ju-
dicious surgeon.
  " Indeed, the circumstances of frequent
pain,   and  manifest tendency to an in-
crease of" size, are by some people looked
on as such marks of a malignant disposi-
tion, that they have been by them  reck-
oned as dissuasives from the operation.
   " But  these   gentlemen  carry  their
fears and apprehensions much too far the
other way.  Pain and a quick  increase  of
size are  certainly  no favourable symp-
toms ;  they shew  a disposition to mis-
chief i  but, they are  not such positive
proofs of a cancerous  habit, as to render
all nope of a cure, from tiie removal of
the diseased part, vain: there are many
instances to the contrary: and though no
honest or judicious man will venture to
promise success, even in the most favour-
able of these cases, yet it is well known,
that they which have had very unpromis-
ing appearances, not only from the state
ofthe testicle, but from that of the sper-
matic chord, have succeeded often enough,
to make the chance of'a.cure, by the ope-
ration, by no means a desperate one. The
state of a man left to his fate in these cir-
cumstances, that is, to the fury and pro-
gress.of the disease, is so truly miserable,
that nothing should be left unattempted,
which carries with  it any  probability of
being serviceable : and a practitioner is
vindicable, in pressing what he has known
to be successful;  though,  at the same
time, he ought to make a guarded kind of
prognostic.
  " Upon the whole, I think it may justly
be said, that the man who has the mis-
fortune to  be afflicted with a truly scir-
rhous testicle, has very little chance (not-
withstanding all that  has  been said and
written about specifics) to get rid of it by
any  means, but by extirpation : and all
the time the operation is deferred, he car-
ries  about him a  part not only useless
and  burthensome, but which is every day
liable, from many circumstances (both ex-
ternal and internal) to become worse, and
more unfit  for such operation.
  •'  While  the testicle is  small, and free
from acute or  frequent pain,  the vessels
from which it is dependent, are most fre.
quendy  soft,  and free  from  disease  ;
whereas, when the testis has been suffered
to attain a considerable size, the case is
frequently  otherwise; the  spermatic ves-
sels are often large and varicose ; and the
cellular membrane investing them some-
times becomes  thick, and contracts such
connexions and adhesions, which, though
theymay not amount to an absolute pro-
hibition of the operation,  do yet render
it tedious, troublesome, and more hazard-
ous than  it  would be in  other Circum-
stances.  Every addition  to the original
complaint  in the  body of the  gland is
against the patient; and  if any of these
are  the  consequence  of  not having re-
moved it in time, it will follow, that  the
sooner it is removed, the  better,   If" we
wait for what some call indications of  the
necessity of operating, we shall often stay
until it will do no good.  Maiiy a one
have 1 seen lose a very probable chance
of a cure by delay : but 1 do not remem-
ber ever to have seen a testicle removed,
by a man ofjudgment, which testicle did
not, upon  examination, fully vindicate 
TESTICLE.                              347
    the  extirpation.  If we were possessed
    of any medicines, either external or inter-
    nal, which had been known now and then
    to have dissolved scirrhi, it would always
    be right to recommend the trial of them
    previous to an operation; and  it would
    always  be  right to defer operating  until
    such trial had been made.  But  the truth
    is, we know no such medicine.  The cre-
    dulous on the one hand, and the designing
    on the other, have  told us many strange
    stories of cures effected by such applica-
    tions and  remedies; and [ do  most sin-
    cerely wish, that what each of them  have
    said was true :  but repeated, faithful ex-
    perience has proved, that  it is  n<.; and
    that they  who have  placed their" confi-
    dence in them, or laid out their money on
    them, have been disappointed and cheated.
      " Some  circumstances there  are  now
    and then attending this disease, which are
    out  of our sight and  out  of our know-
    ledge, and which will render all  our pains
    abortive : such  are tubercles, indurations,
    and other diseased  appearances,  in the
IP cellular membrane enveloping the sperma-
    tic vessels  within the abdomen ; scirrhous
    viscera, &c. If any of these can be known,
    they constitute a good reason for not at-
    tempting tiie cure by the operation ; but
    the mere possibility that such may exist,
    is certainly no reason for abstaining from
    it: the apparent evil, that is, the diseased
    testis, is certain; the  other may or  may
    not  be the case :  the one, if left to itself,
    is most  likely to destroy the patient  in a
    most miserable and tedious manner ; and
    the  other,  the suspected  mischief,  may
    possibly not exist.
      " But though the timely and proper re-
    moval ofa scirrhous or cancerous testicle
    does frequently secure to the patient life,
    health,  and ease, which, in such circum-
    stances,  are not attainable by any other
    means;  yet it must be  remarked, that the
    improper  and  untimely performance of
    the  operation is  not only  not  attended
    with such  happy and salutary event, but
    generally brings on high symptoms, and
    quick destruction.  It  therefore behoves
    every practitioner to be perfectly well ac-
    quainted, not only witiisuch  circumstances
    as render castration practicable and ad-
    visable,  but  with those which  prohibit
    such attempt.
      " These  are  of two kinds,  and relate
    either to the general habit of the patient,
    and  the  disorders and indispositions of
    some of the viscera,  or to the state ofthe
    testicle, and spermatic chord.
      " A pale, sallow complexion,  in those
    who used to look otherwise ;  a wan coun-
    tenance, and loss of appetite and flesh,
    without any acute disorder; a fever of the
    hectic kind ; and frequent pain  in the
 back and bowels, are, in those who are
 afflicted with a scirrhous  testicle, such
 circumstances as would  induce a suspi-
 cion of some latent mischief, and incline
 one to suppose that the same kind of vi-
 rus, which had  apparently spoiled the
 testis, may also  have exerted its malign
 influence on some of the viscera; in which
 case, success from the mere removal ofthe
 testicle is not to be expected. They, whose
 constitutions are spoiled by debauchery
 and intemperance, previous to their being
 attacked  with this  disease ;  who have
 hard livers, and anasarcous limbs, are not
 proper  subjects for such  an  operation.
 Hard tumours within the abdomen in the
 regions of the liver, spleen, kidneys, or
 mesentery, implying a diseased state of
 the said viscera,  are very material objec-
 tions to the removal of the  local evil in
 the  scrotum.  In short,  whenever there
 are manifest appearances, or symptoms of
 a truly diseased state of any ofthe princi-
 pal viscera, the success of the  operation
 becomes very doubtful; more especially,
 if such symptoms and appearances, upon
 being properly treated, resist in such man-
 ner, as  to make it most probable, that a
 cancerous virus is the real cause of them.
 When none of these require our attention,
 the object of consideration  is the testicle
 and  its spermatic vessels.   The state of
 the mere testis can hardly ever be any ob-
 jection  to the operation; the sole consi-
 deration is the spermatic chord:  if this
 be in a  natural state, and free  from dis-
 ease, the operation not only  may, but
 ought to be performed, let the condition
 of" the  testicle be what  it  may;  if the
 spermatic chord  be really diseased, the
 operation  ought  not  to  be attempted.
 For although, on the one  hand, a  pro-
 bability of success  will vindicate  an at-
 tempt, even though it should fail; yet, on
 the other, where there is no such proba-
 bility,  an  operation, though performed
 in the most dexterous manner, will prove
 only a more ingenious method of torment-
 ing.
  *' This,   therefore,  (the  state of the
 spermatic chord) is a matter, which may-
 require our most serious  consideration
 since, on this it is (when the disease ap-
 pears to be local) that we must  found our
judgment; and by this must form our re-
 soluiion, either to  leave a nun to the
 truly miserable  fate  of being slowly,
 though certain!-, destroyed, by a cruelly
 painful, and frequently very offensive dis-
 ease ; or endeavour to save, and preserve
 him  in  health and ease, by means, which
 have so often proved successful,  as truly
 to deserve the appellation of probable.
  " All writers on this subject,  agree in
 saying, that if the spermatic process has 
343
TESTICLE.
 partaken of the diseased state of the tes-
 ticle,  that is,  has become enlarged  and
 hardened, and such enlargement and in-
 duration  extends itself quite  up to the
 abdominal muscle, that the operation of
 castration ought not to be performed, be-
 cause it will not only prove successless,
 but will hasten the death of the patient.
 And this is, in some degree, most certainly
 true; but not  without some  limitation.
 A truly and absolutely  diseased state of
 the  spermatic chord, in any part of it, is
 certainly a very material objection to the
 operation,  as it most  commonly proves a
 bar  to the success of  it: and  a morbid
 state of the same chord quite  as high as
 the abdominal muscle, that is,  of all  that
 part of* it,  which is external to the cavity
 of the belly, is a just and full prohibition
 against such attempt.   But, on the other
 hand, it must be observed,  that every ; p-
 parently morbid  alteration of  the sper-
 matic chord is not really such ;  and, there-
 fore, that every enlargement, induration,
 fulness, &c. which seems to niter the sper-
 matic vessels from  that state,  which is
 called a healthy and natural one, is not to
 be regarded as a disease ; at least, not as
 such a disease  as is  sufficient to prohibit
 the  attempt to  obtain a cure by extirpa-
 tion.
  "  The difference  between these,  it is
 the duty of every practitioner to become
 perfectly  aquainted with, as it is from a
 consideration of these, that he ought to
 determine,  whether lie  may,  with   that
 firmness and assurance,  which the   pro-
 bable  expectation of  success will  give
 him,  propose  and advise  castration; or
 find himself obliged in conscience to  dis-
 suade, or refuse, the performance of it.
  "  When the spermatic vessels are not
 only turgid and full, but firm  and hard;
 when  the membrane,  which invests  and
 connects them, has  lost its natural soft-
 ness  and  cellular texture,  and has con-
 tracted 'Such a state, and such adhesions,
 as not only greatly to  exceed its  natural
 size, but to become unequal, knotty,  and
 painful,  upon  being handled,  and  this
 state has  possessed  all that part of the
 chord, which is between the opening in
 the  oblique muscle and the testicle, no
 prudent, judicious, or humane  man,  will
 attempt the  operation;  because he will,
 most certainly, not only do no good to his
 patient, but will bring on such symptoms
 as will most rapidly,  as  veil  as painful-
 ly, destroy him.  Of  this, there are so
 many proofs, that the  truth of it is incon-
 testible.
   " In some modern  French books,  we
 have  indeed, miraculous accounts of ope-
rations of this kind, performed by divid-
ing the tendon of the oblique muscle, by
tracing  the  diseased  spermatic vessels
within the cavity of the belly, and  thare
making the ligature and excision -. but
these are operations, which make a figure
in books only, and are performed only by
visionary writers; or,  if ever they  have
been practised, serve to shew the rashness
and insensibility of the  operators,  much
more than  their judgment, or humanity.
Whoever  (notwithstanding these  tales)
performs  the operation  in the circum-
stances above-mentioned,  will prove him-
self much  more hardy  than judicious;
and will destroy his patient, without hav-
ing  -.e satisfaction  of thinking that his
attempt, though successless, was yet vin-
dicable ;—the  only circumstance  which
can, in such events, give  comfort to a man
who thinks rightly.
   " On the other hand, as I have already
said,  every enlargement of the  spermatic
chord is not of  thi9  kind, nor by any
means sufficient to prohibit or prevent the
operation.
   " Tliese  alterations, or enlargements,
arise from^two causes, viz. a varicose di-
latation of  the  spermatic vein, and  a col-
lection, or collections, of fluid in the mem-
brane investing and enveloping  the said
vessels.  In the first place, as there is no
reason in nature  why a  testicle, whose
vess-els have  previously  (for some  time
perhaps) been  in a varicose state, should
not become scirrhous ; so  it is also cleai,
that the scirrhosity seizing such testicle
will by no means remove, or even  lessen
such  varicose  dilatation of the  vessels
from  wliich it is dependent; on the con-
trary, will,  most probably, and  indeed
does  most  frequently, increase such dis-
tention :  but such mere  varicose enlarge.
ment of  the vessels, whether it be previ-
ous or consequential to the morbid state
of the testis, does not, nor ought to pre-
vent the removal  of  it,  if otherwise  fit
and right.   It is, indeed, an objection to
the doctrine of Mr. Le Dran, and  a few
other writers,  who make no ligature  on
the chord,  and trust to a slight contusion
of it between the finger and thumb for a
suppression of  the  hemorrhage;  but  is
none to the rest of tlie operation, as 1 can,
from experience, testify.
   " In the  next place, the diseased state
of a  truly scirrhous testicle, its weight,
and the  alteration that must be made in
the due and proper  circulation  of the
blood,  through  both it and the vessels
from which  it is  dependent, may and do
concur in inducing a varicose dilatation of
the spermatic  vein,  without  producing
that  knotty, morbid alteration and hard-
ness, which forbid our  attempts.  Be- 
\
TESTICLE.
349
tween these, a judicious and experienced
examiner will generally be able to dis-
tinguish.
  " In the  former  (the  truly diseased
state,) the chord is not  only enlarged,
but feels Unequally hard and knotty ; the
parts  of which  it  is composed  are un-
distinguishably blended together;  it  is
either  immediately painful to  the touch,
or becomes so, soon after being  examin-
ed ; the patient  complains  of"  frequent
pains  shooting up through his groin into
his back ; and from  the diseased state of
the membrane composing the tunica com-
munis,  such adhesions and  connexions
are sometimes contracted,  as either fix
the process in the  groin,  or  render  it
difficult to get the finger and thumb quite
round it.
  " In tlie other  (the mere varicose dis-
tention,)  the vessels,  though consider-
ably enlarged and dilated, are neverthe-
less smooth, soft, and compressible; the
whole process is  loose and free, and will
easily permit the fingers of an examiner
to go quite round  it, and to  distinguish
the parts of* which it is composed;  it is
not painful to the touch ; nor does  the
examination of it produce, or  occasion,
those darting pains,  which almost always
attend  handling  a  process  malignantly-
indurated.
   " I do not say that the distinction be-
tween these two states  is  always and
invariably to be made;  but  that it often'
mCy,  I know from  repeated experience:
and  that  the  operation  may safely  be
attempted, and successfully be performed,
I  know from  the same experience.  The
state  of a man,  lef'tr-to the mercy of a
malignant scirrhus, is so truly deplorable,
that we cannot  be  too attentive in ex-
amining the precise nature  of  each  in-
dividual case,  and  in  embracing  every
opportunity of  giving  him  that  relief,
which it may at one  time be in our power
to give, and which, the lucky  opportunity
missed,  it may never  be in  his power
again to receive.
   " The  other  circumstance,  which I
have  mentioned  as  capable of deceiving
an operator, and  inducing him to believe,
that the spermatic  chord is  much more
diseased than it really is,  and thereby de-
terring him from the performance of an
operation,  which might prove successful,
is  the  extravasation,  or  collection  of
fluid  in the cellular  membrane enveloping
the spermatic vessels, between the abdo-
minal opening and the testis.
   " In the cellular  membrane, leading to
a  diseased testicle, it is  no very uncom-
mon  thing to find collections of extrava-
sated  fluid.  These, as  they  add con-
siderably to the  bulk,  and  apparent size
of the process, make the complaint ap-
pear more  terrible; and, as  I have just
said, less likely to admit rehef.
  " When  the extravasation  is  general,
through all the cells ofthe investing mem-
brane, and the  spermatic vessels them-
selves are hardened, knotty^ and diseased,
the case is without remedy; for, although
a puncture, or an  incision, will undoubt-
edly give discharge to some,  or even the
greatest  part of the fluid; yet this ex-
travasation is so small, and so insignificant
a circumstance  of the  disease, that the
parts, in this state,  are so little capable of
bearing irritation, that an attempt of this
kind must be ineffectual, and may prove
mischievous.
  " But, on the  other  hand, collections
of water are sometimes made in the same
membrane,  from  an obstruction  to the
proper circulation  through the numerous
lymphatics   in  the  spermatic  process,
while the  vessels themselves are really
not  diseased, and therefore  very capable
of permitting the operation.  In this case,
the fluid is generally in  the cyst, or bag,*
like to  an  encysted hydrocele,   and  tlie
spermatic chord, cyst and all, are easily
moveable from side to side; contrary to
the preceding state, in which the general
load  in  the membrane  fixes the whole
process,  and  renders it almost immove-
able.
  " A discharge of the fluid  will, in this
case, enable the operator to  examine the
true state of the process, and, as I haw
twice or  thrice  seen,  put  it  into  his
power to free his patient from one of the
most terrible calamities which can bef.d
a man.
  " There is one more  circumstance re-
lative to the  scirrhous  testicle, which
appears  to me to be worth attending to,
as  I cannot  help  thinking  that it  ha>
misled many, who have not had sufficient
opportunity  of comparing  theory  with
practice.
  " It  has   been  confidently  asserted,
and is generally believed, that a scirrhous
testicle never begins in the epididymis of
the  said  testicle.  The consequence of
this doctrine is, that  when a  disease,
which  affects a  testicle; by enlarging
and hardening it, makes its first attack
on  the epididymis  only, such disease is
not allowed to be a scirrhus, nor permitted
to be treated as such.
   " That  inflammatory kind  of  tumour,
which in the virulent  gonorrhea, siezes
the testicle, and is called the hernia hu-
moralis,  affects  the epididymis;  ahd,
even under  the  best  care, sometimes
leaves it too large, and too hard. This
is  said  never to  end in, or produce a
 scirrhus;  and, I do rpt recollect, that I 
:"oO
TESTICLE.
   have ever known it to do so.  The dis-
   ease,  which  consists  in  an induration
   and enlargement of the whole testicle, in
   the more confirmed lues, affects the epi-
   didymis also, as well as  the  glandular
   part of the testicle; and 1  do not remem-
   ber to have seen it, either become can-
   cerous, or not yield to mercury, properly
   administered.  But that a  true scirrhus,
   or cancer, sometimes makes its first attack
   on  the  epididymis,  which it alters and
   spoils, before it at all affects the testicle,
   is a truth, of which I have not the least
   doubt  Among  others, I  for_merly  be-
   lieved the contrary doctrine; and,  in  the
   first edition of this book, have given it as
   my opinion : but  I  am, from experience,
   so  perfectly  convinced of  the truth  of
   what  I have now asserted, that I think
   my»elf obliged to declare  it.  TJie mis-
   take, I suppose to have been made by the
   first propagators of  this  opinion,  thus:
   The hernia humoralis, and the venereal
   sarcoeele, always enlarge the epididymis,
   and generally leave it somewhat too hard:
   both these  have,  by adventurous and
   unknowing  people,  been  mistaken  for
x  scirrhi; but it being found, by experience,
   that these alterations in the epididymis,
   were either totally removed by medicine,
   or, if  any part  remained,  it continued
   harmless through  life; an inference was
   drawn, that as true scirrhi are not often
   either removed by medicine, or continue
   harmless,  therefore an original affection
   of the  epididymis could never be a true
   scirrhus:  a deduction,  which the pre-
   mises do  not by any means authorise;
   and which I am satisfied,  is not true."
   (Extract from Pott's Treatise on the Hydro-
   cele, &c.)
    In the  preceding remarks,  we find,
   that Fot.t considered sarcoeele and cancer
   of the  testicle, only as different stages of
   the same disease ; but, I am of opinion,
   that the  only reason  for  this doctrine
   must have  been built on the fact now  so
   well established,  that  every  kind   of
   swelling is  liable to  oe eventually con-
  verted  into cancer.   The observations of
   Mr. Home, particularly  illustrate  tiie
  truth of the latter remark.

    SCIRRHUS  AJSI) CANCER OP THE TESTirLE.

    Dr. Baillie  has  noticed,  that the  testi-
  cle is often found much enlarged in its
  size, and changed into a hard mass,  of
  a brownish colour, which  is  generally
  more or less intersected by membrane.  In
  this disease,  there  is  no  vestige of the
  natural  structure;  but,  cells are  fre-
  quently observable  in  it,  containing a
  sanious  fluid; and sometimes, there is
  a mixture of cartilage.  Dr. Baillie con-
siders this state  as  tlie true scirrhous
testicle ; and, according to the progress
of the disease, the epididymis, and sper-
matic chord, are more or less, or not at
all  affected.   A  foul deep  ulcer  is, at
length, frequently formed, or else a fungus
is thrown out, when it is called, the true
cancer of the testicle.  This  affection is
characterized,  in the living subject, by
its great hardness; tiie frequent pain in
the part  darting  from it  along the sper-
matic chord to tiie loins.  The  chord it-
self, at last, becomes diseased, and  the
health impaired.   The ulcer and fungus
form  additional symptoms.  (See Baillie"s
Morbid Anatomy.)

      SOFT CANCER OP  THE TESTICLE.

  This part is very subject to a disease,
which, though of a  very malignant and
incurable nature,  is  very different from
the true cancer,  already described.   It
has  been  particularly noticed by Mr.
Abernethy,  under the name of Medullary
Sarcoma.  In most of the instances, which
this gentleman  has  seen, the  tumour,
when examined after removal,  has  ap-
peared to be of a whitish colour, resem-
bling, on a  general and distant inspection,
the appearance of the brain,  and having
a pulpy consistence.  Mr. Abernethy has
also often seen it  of  a brownish red  ap-
pearance.   The following  case is  re-
lated, to illustrate the  nature and progress
of the disease.
  " A tall,  thin,  heal thy-looking  man,
of about forty years of  age,  had, about
fifteen years before,  a swelled testicle
from  a gonorrhoea;  the epididymis  re-
mained indurated.  Six years afterwards
it became  enlarged,  and a hydrocele at
the same time formed.   Half a pint of
water was discharged by a puncture, but
inflammation - succeeded  the operation,
and this testis became  very  large.  An
abscess formed,  and burst in the front of
the scrotum, and the testis  subsided in
some  degree.  Mercury  was employed
to reduce  it, but without effect.  The
part,  however,  was  indolent, and  gave
the patient no trouble  but from its bulk.
  " About  a year afterwards,  a gland
enlarged in  the left groin (the same side
as the testis :) another then became swoln
in the right  groin, and,  in the course of
two years, several  glands in each  groin
had obtained a very  considerable  mag-
nitude.   At  this  period,  he was  ad-
mitted into  St. Bartholomew's Hospital,
under the care of Mr. Long.  The  testis
was, at this time,  between four  or five
inches in  length,  and  about  three in
breadth; it  resembled its natural  form,
and was indolent in its disposition.  The 
TESTICLE.                               351
spermatic  chord was thickened, but not
much indurated.   Four or  five glands
were enlarged in the groin on both sides;
each of wliich was of the size of a very
large orange; and when observed toge-
ther, they formed a tumour of very, un-
common shape and magnitude.
  " They  gradually increased in size for
several months, till at  last the skin ap-
peared as  if unable  to contain  them any
longer.    It  became thin,  inflamed, and
ulcerated, first in the left groin, and thus
exposed one  of  the  most  prominent
tumours-  The exposed tumour inflamed
and sloughed  progressively,  till  it en-
tirely came away.  As the sloughing ex-
posed its  vessels, which were large, they
bled profusely,  insomuch  that the  stu-
dents endeavoured,  but in vain, to secure
them by  ligatures: for the substance  of
tlie tumour was  cut through, and  torn
away in the attempt.   Pressure by the
finger, continued for some time, was the
only effectual  mode of restraining this
hemorrhage.
   " The loss of one  gland relieved the
 distended skin, which had only ulcerated
 on the most prominent part of the tu-
 mour, and had not become diseased.  It
 now lost  its  inflamed  aspect.- granula-
 tions formed, and a cicatrix took place.
 In the opposite groin a similar occurrence
 happened.   One gland, exposed  by the
 ulceration of  the  skin,  sloughed  out,
 being attended by the  circumstances just
 recited'?  However, before  the skin was
 cicatrized,  ulceration  had  again taken
 place in the right groin, in consequence
 of tlie great distention of the  skin from
 the growth of the tumour; and sloughing
 had begun  in  the tumour, when the pa-
 tient, whose vital  powers  had long been
 greatly exhausted,  died."   (See Surgical
 Observations, &c. 1804. by J.  Abernethy,
 F.R.S.,&c.)

       SCROPEULA. OP TUE TESTICLE.

   This part is sometimes  converted into
 a truly scrophulous mass.  It  is  usually
 enlarged, and when cut into, a white, or
 yellowish-white, curdly substance  is seen,
 which is  sometimes, more or less, mixed
 with pus.  This  affection may be dis
 tinguished from a scirrhous testicle by its
 greater softness, by the little pain felt  in
 it, and by its  not  affecting the health so
 much.  (See Baillie's Morbid Anatomy.)
   Mr.  Pott has regarded every kind  of
 sarcoeele as demanding an early perform-
 ance of  castration ; and the observations
 which I  have  had  opportunities of mak-
 ing, lead  me to agree with this celebrated
 writer, in the general truth ofthe remark.
 But (setting out  of consideration  the
swelling  and hardness arising  from the
common hernia humoralis) there are a few
diseased  enlargements of  the  testicle,
which  certainly do  frequently diminish
and remain  in  a state which does not at
all impair the health, after taking cicuta,
and other alterative medicines, wearing
a  suspensory,  and  rubbing  mercurial
ointment on the scrotum.   Many of such
cases  I have suspected to be scrophulous
diseases.
  Dr.  Baillie  has  noticed some  other
affections of the  testicles, in which it
becomes  bony, cartilaginous, &c.;  but,
on  these it  is not  necessary  for us to
dwell in this dictionary.  The preceding
observations  may be considered as relat-
ing expressly to  the diseases  for which
castration is generally performed.  (See
Castration.)

        FJJNGUS OF THE TESTICLE.

  In a former work,  I described " a par-
ticular affection of the testicle, in which
a fungus grows from the glandular sub-
stance of  this  body, and, in some in-
stances,  from the surface  of the tunica
albuginea.  This excrescence  is usually
preceded by an enlargement of the testicle,
in consequence ofa bruise, or some species
of external violence.   A  small abscess
takes  place,  and bursts,  and from  the
ulcerated opening the  fungus gradually
protrudes."  I then proceeded to repre-
sent  how unnecessary and  improper  it
was to extirpate  the testicle, on account
of this affection, if,  after the subsidence
of the inflammation, the part should not
seem  much enlarged and indurated.   I
recommended the fungus to be cut off, or
else destroyed with caustics; and I founded
my advice on a successful attempt of the
first  kind,  which was  made in St. Bar-
 tholomew's Hospital, by Sir James Earle,
 a little  while before my book was pub-
 lished.  (See First Lines ofthe Practice of
 Surgery, p. 399.)
   Since this  period, an interesting little
 paper has been written on the subject, by
 my friend Mr. Lawrence, who has favour
 ed the public with  a more particular ac
 count, and nine cases illustrative of the
 causes,  symptoms,  and progress of the
 disorder.   According to  Mr. Lawrence,
 the patient generally assigns  some blow,
 or other injury, as  the causes  of the com-
 plaint ;  in otiier  instances,  it originates
 in consequence  of the  hernia humoralis
 from  gonorrhoea, and sometimes  appears
 spontaneously. A painful  swelling of the
 gland,  particularly characterized by  its
 hardness, is the first appearance of the
 disease.   After a certain  length of time,
 the  scrotum, growing gradually thinner, 
352               T E S                                T E T
 ulcerates;  but, the  opening,  which is
 thus formed, instead of discharging mat-
 ter,  gives issue to a firm, and generally
 insensible fungus.  The surrounding in-
 teguments  and cellular  substance, aie
 thickened and indurated by the complaint,
 so that there appears  to be  altogether a
 considerable mass  of disease.   The pain
 abates,  and the swelling subsides con-
 siderably, when the scrotum  has given
 way.  In this state, the disorder appears
 very indolent;  but if  the  fungus be de-
 stroy ed  by any  means,  the integuments
 come together, and  a  cicatrix ensues,
 which is  inseparably connected  with the
 testicle.  Mr. Lawrence next informs us,
 that  if the part be examined  while the
 fungus still remains, the excrescence is
 found to have its origin in the glandular
 substance of tiie testicle itself; that the
 coats of the part are destroyed to a cer-
 tain extent; and that a protrusion of the
 tubuli seminiferi, takes place through the
 aperture  thus  formed.   Mr.  Lawrence
 says, htf  has  often ascertained the con-
 tinuity of the excrescences with the pulpy
 substance of the testicle, of which more
 or  less remains,  according to the differ-
 ence in the period  of the disorder.  The
 same gentleman thinks, that the glandular
 part ofthe testicle  experiences an inflam-
 matory affection in the first instance, in
 consequence of  the violence inflicted on
 it;  and  that  the  confinement of the
 swollen substance, by the dense and un-
 yielding  tunica  albuginea,  sufficiently
 explains  the peculiar hardness of  the
 tumour,  and the pain which  is always
 attendant on  this stage of the  disorder.
 The absorption of the coats of the testis,
 and of the scrotum, obviates the tension
 of the parts, and, thereby, restores ease
 to the patient, at the same  time  that the
 fungus makes its appearance externally'.
  With  regard  to the  treatment, Mr.
 Lawrence is of opinion, that, if the com-
 plaint were  entirely  left to itself, the
 swelling would  probably  subside,  the
 fungus shrink, and a complete cure ensue,
 without any professional assistance; but,
 he adds, that the disorder is so indolent
 in  this stage, that a  spontaneous  cure
 would not  be  accomplished' till  after
 much time.  He says, that the excrescence
 may be  removed with  a knife, or, if the
 nature of its attachment permit, with a
 ligature, or  that it. may  be destroyed
with escharotic  applications. Mr. Law-
rence very judiciously gives the preference
to  removing the tumour to a level  with
the-scrotum, by means of the  knife, as
the most expeditious and effectual  mode
of treatment.  lie can  discern no ground
whatever for proposing castration in this
malady, since", in no part of its progress,
 nor in any  of its possible consequences
 and effects, Can it expose the patient to
 the slightest risk.
   Mr. Lawrence also mentions the pos-
 sibility  of  there being other  kinds of
 funguses, which may be  met with,  grow-
 ing from  the  testicle, and quotes an
 iystance, in  which Mr.  Macartney  found
 a fungus, of a firm and  dense structure,
 growing from the tunica albuginea,  while
 all the substance of the  testicle itself was
 sound.   .Mr. Macartney was so kind as
 to shew  me the  preparation, affording a
 clear specimen of the  second kind of
 fungus.  The cases drawn  up  by Mr.
 Lawrence  are,   in my  opinion, highly
 interesting,   and may  be  read in  the
 Edinb. Med. and Surgical Journal for July,
 1808.
   TETANUS,  (from rsivta, to stretch.)
 Tetanus  is defined by all authors to be a
 more or  less violent, and more or less  ex-
 tensive,  contraction  of  the muscles, at-
 tended  with tension and rigidity of the
 parts affected.
   It presents itself in four different states.
   When its  effects  are confined to  the
 muscles  of the jaw and throat, it is called
 trismus or locked-jaw ; when all the  body
 is  affected and becomes rigid, but retains
 its ordinary  straightness,  the  case  is
 named tetanus.  When  the  body is bent
 forwards, the disease is termed empros-
 thotonos; and opisthotonos,  when the cur-
 vature is backward.
  To these four forms, some writers have
 added a  fifth, which  they  denominate
pleurosthotonos, and wliich is characterized
 by the body being drawn to one side. It is
 the tetanus lateralis of Sauvages.
   Each of these  states  is strikingly  dif-
 ferent :  the two first  often prevail at the
 same  time, forming what may be termed
 complete tetanus.
   As M. Larrey also observes, tetanus
 may likewise  be divided into the  acute
 and chronic, according  to its greater, or
 lesser intensity.
   The first is exceedingly dangerous,  and
 usually fatal.
   Chronic tetanus  is less  intense, and,
 on account of the more gradual  progress
 of the symptoms, affords more oppo|tunity
 of being successfully treated. (Larrey, in
 Mem. de Chirurgie Militaire, Tom. 1. p.
 235,236.)
   Tetanus  may also  be   distinguished
 into the traumatic, or  that arising from
 wounds, being the case  with which sur-
 geons have  principally to deal;  and into
 tiie idiopathic, or that proceeding from a
 variety of other causes.
   This  disorder, which may be excited
 by different causes,  is much more com-
 mon in  warm climates than  our own 
TETANUS.                      *        353
However, it sometimes occurs among us,
especially in consequence of wounds, and,
more particularly, after such injuries of
tendinous and ligamentous parts.  It is
one .of the most fatal symptoms,  which
can possibly arise in cases of wounds, and,
therefore, demands tiie  most assiduous
attention of the surgeon.
   M.  Larrey   observed,  that  gunshot
wounds in the course of the nerves, and
such injuries of the joints, often  produce
tetanus in the climate  of Egypt, par-
ticularly when  the  weather, or tempera-
ture,  passed  from one extreme  to the
 other, in damp situations, and  in those
 which were adjacent to the Nile,  or the
 sea.  What he terms dry and  irritable
 temperaments, were the most subject to
 the disorder,  the  event of  which  was
 found to be almost always fatal.  (Larrey,
 Op. et. Loc. cit.)
   Dr. Cullen remarks, that " tetanic com-
 plaints may, from  certain causes, occur
 in every climate that we are acquainted
 with; but they occur most frequently  in
 the warmest  climates, and, most com-
 monly in the warmest seasons of such
 climates.  These  complaints affect  all
 ages, sexes, temperaments, and complex-
 ions.  The causes from whence they com-
 monly proceed, are cold and  moisture
 applied  to the body while it is very warm,
 and especially the  sudden vicissitudes  of
 heat and cold. Or, the disease  is pro-
 duced by punctures, lacerations, or other
 lesions of nerves in any  part of  the body.
 There are, probably, some other causes 0/
 this disease ; but, they are neither dis-
 tinctly  known  nor  well   ascertained.
 Though the  causes  mentioned do, upon
 occasion, affect all sorts  of persons, they
 seem however, to attack persons  of mid-
 dle age, more frequently than  the older
 or younger, the male sex more frequently
 than the female,  and  the  robust  and
 vigorous  more   frequently  than  the
 weaker.                             .
    " If the disease proceed from  cold, it
■ commonly comes on in a few days after
  the application of such  cold ;  but, if it
 arise from a puncture, or other lesion  of
  a nerve, the  disease does not commonly
 come on for jnany days  after the lesion
  has happened, very often when  there is
 neither  pain  nor uneasiness,  remaining
  in the wounded, or  hurt part,  and, very
  frequently,  when  the  wound  has been
  entirely healed up.
    " The disease  sometimes comes  on
  suddenly to  a violent degree;  but, more
  generally, it approaches by slow  degrees
  to its violent state.  In this case, it comes
  on with a seuse of stiffness  in the back
  part of the  neck,  which,  gradually in-
  creasing, renders the motion of the head
         Vol. II-.
difficult and painful.  As the rigidity of
the neck comes  on, and increases, there
is commonly, at the same time, a sense of
uneasiness  felt about the  root  of  the
tongue;  which,  by degrees, becomes a
difficulty of swallowing,  and, at length,
an entire interruption of it.  While  the
rigidity of the neck goes on increasing,
there arises a pain, often  violent, at  the
lower  end   of the sternum,  and from
thence shooting  into  the back.  When'
this  pain arises, all the muscles  of  the
neck, and particularly those of the back
part of it,  are immediately affected with
spasm, pulling the head strongly back-
wards.  At the  same time, the muscles
that pull up the lower jaw,  which, upon
the first approaches of the disease, were
affected with some spastic rigidity,  are,
now generally affected with more violent
spasm, and set the teeth so closely toge-
ther, that   they do  not  admit  of  tiie
 smallest opening.
   " This is what has been  named the
locked jaw(Trismus,) and is often the prin*
cipal  part  of the disease.   When  the
 disease has advanced thus far, the pain at
 the  bottom of the sternum  returns  very
 frequently, and  with it,  the spasms of
 the  hind-neck and lower jaw, are  renew-
 ed,  with violence  and much pain.   As
 the  disease thus proceeds, a greater num-
 ber of muscles  come to  be affected  with
 ■spasms.  After  those of tlie neck, those
 along the  whole  of the  spine  become
 affected, bending the trunk of the  body
 strongly backwards ; and this is what has
 been named the Opisthotonos.
   " In the lower  extremities, both the
 flexor and extensor muscles are  com-
 monly a*,  the  same time  affected, and
 keep  the limbs  rigidly extended.  Though
 the extensors of the head  and  back are
 usually the most strongly affected, yet
 tiie flexors, or those  muscles of the  neck
 that pull the head forward, and the  mus-
 cles that should pull down the lower jaw,
 are often at the same time strongly affect-
 ed  with spasm.   During the whole ofthe
 disease, the  abdominal* muscles  are vio-
 lently affected  with spasm, so that the
 belly is strongly  retracted, and feels as
 hard  as a piece  of board.
   " At length, the  flexors of the  head
 and trunk become so strongly affected as
 to  balance the extensors,  and to  keep
 the head and trunk straight, and rigidly
 extended,  incapable of being moved in
 any way;  and, it  is to  this  state the
 term  of Tetanus has  been strictly applied.
 At thevsame time, the arms little affected
 before, are  now rigidly  extended; the
 whole of  the muscles belonging to  them
 being affected  with spasms, except  those
 that move the fingers, which often to the
      Yx 
354
TETANUS.
last  retain some mobility.  The tongue
also  long retains its  mobility;  but,  at
length, it also  becomes  affected  with
spasms, which, attacking  certain  of its
muscles only, often thrust it violently out
between the teeth.
  " At the height of the disease, every
organ of voluntary motion seems to be
affected, and, amongst the rest, the mus-
cles  of the face.  The forehead is drawn
up  into  furrows; the  eyes,  sometimes
distorted, are commonly rigid  and im-
moveable in  then; sockets; the  nose is
drawn up, and the cheeks are drawn back-
wards towards the ears, so that the whole
countenance  expresses  the most violent
grinning.   Under these  universal spasms,
a violent convulsion comes on, ahd puts
an end to life.
  "  The spasms are every where attend-
ed   with  most  violent  pains.  The  ut-
most violence of spasm is, however,  not
constant; but after subsisting for a  mi-
nute or two, the muscles  admit of some
remission of  their contraction, although
Of no such  relaxation,  as can allow  the
action of fheir antagonists.  This remis-
sion  of contraction  gives  also some re-
mission of pain ; but neither is  of long
duration.  From time to  time, the vio-
lent contractions and pains are renewed,
sometimes every ten, or fifteen minutes,
and that often without any evident ex-
citing cause.  But, such exciting causes
frequently occur ;  for almost every at-
tempt at motion, as attempting a change
of posture, endeavouring to swallow, and
 even to  speak, sometimes gives occasion
 to a renewal of the spasms over the whole
 body.
   " The attacks of this disease are seldom
 attended with any fever. When the spasms
 are  general   and violent, the  pulse  is
 contracted, hurried,  and irregular;  and
 the respiration is affected in like manner ;
 but, during  the  remission,  both  the
 pulse and respiration  usually return to
 their natural  state.  The heat of the
 body is  commonly  not  increased; fre-
 quently the face is pale, with a cold sweat
 upon it; and, very often, the extremities
 are  cold, with a  cold sweat  over the
 Whole body.   When, however, the spasms
 are frequent and violent, the  pulse  is
 sometimes more full and frequent,  than
 natural ; the face is flushed, and a warm
 sweat   is forced  out  over  the  whole
 body."
   " Although fever be not a constant at-
 tendant of  this disease, especially when
 arising from a lesion of nerves ; yet, in
 those  cases,  proceeding  from  cold, a
 fever  sometime- has supervened, and is
 said to have been attended  with inflam-
 matory symptoms.  Blood has often been
drawn in this disease ,  but, it never ex-
hibits any  inflammatory  crust; and  all
accounts seem  to agree, that the blood
drawn seems to be of a looser texture,
than ordinary, and that it does not coa-
gulate in the usual manner.
  " In this  disease,  the head is  seldom
affected with delirium, or even  confusion
of thought, till  the last stage of it; when,
by the repeated shocks of a violent dis-
temper, every  function* of the  system is
greatly disordered.
  " It is  no less extraordinary, that, in
this  violent disease, the natural functions
are not either  immediately, or consider-
ably affected.  Vomitings sometimes  ap-
pear early in the disease; but commonly
they are not continued; and it is usual
enough for the  appetite  of  hunger to
remain through the  whole  course of the
disease; and what  food  happens to  be
taken  down,   seems  to   be  regularly
enough  digested.  The excretions  are
sometimes affected, but not always.  The
urine  is  sometimes  suppressed, or is
voided with difficulty and pain.  The belly
is costive; but, as we have hardly  any
accounts,  excepting of those  cases, in
 which opiates   have  been  largely  em-
ployed,  it  is  uncertain,  whether  the
costiveness has been the  effect of the
opiates  or of*  the disease.  In several
 instances of this disease, a miliary erup-
 tion has appealed upon the  skin,but whe-
 ther this be a symptom of the disease, or
 the  effect of a certain treatment of it, is
 undetermined.  In the mean while, it has
 not been observed to denote either safety
 or  danger, or to  have  any   effect in
 changing  the  course  of the distemper."
 —(First  Lines of the Practice  of J'hysic,.
 vol. 2.)
   According  to M.  Larrey,  tlie  opis-
 thotonos, is more seldom observed, than
 the emprosthotonos, and the  experience
 of this gentleman taught, that the former
 was the most  rapidly fatal.  It appears,
 says he, that  the violent extension of the
 vertebrae  of the neck, and the manner^
 in which the head  is  thrown back, cause
 strong compression ofthe spinal marrow,
 and a permanent contraction ofthe larynx
 and pharynx.—(Larrey, in  Mem. de Chi-
 rurgie Militaire, Tom. 1. p.  240.)
   This experienced  writer notices  how
 much  the nerves of the  neck and throat
 seem generally to  be affected on the in-
 vasion of this  disease, and tlie  consequent
 contraction ofthe muscles  of  these parts,
 which is  soon attended with difficulty of
 deglutition and respiration.  The pat ents
 then experience, if"not a dread of liquids,
 at  least a great aversion to them, which
 often   prevents   the administration  of
 internal remedies;  and   if  tlie wound 
TETANUS.
355
is out of reach of the interference of art,
tlie patient  is doomed to  undergo the
train of suffering attendant on this cruel
and terrible disorder.  Nothing can sur-
mount the obstacles, which present them-
selves in the oesophagus.   The introduc-
tion of an elastic gum catheter into this
canal,  through  the nostrils, is followed
by convulsions and suffocation.  " 1 have
tried  this means  (says Larrey)  on the
person of M.  Navailh, a surgeon of the
second class, who died of a locked jaw,
brought on  by a wound of the f.ice, ac-
companied with a comminuted fracture
of the bones of the nose, and part of the
 fell orbit.
   " In the examination of the bodies  of
persons dead of  tetanus, I have found the
pharynx and oesophagus much contracted,
 and  their internal membrane red, inflam-
 ed, and covered with a  viscid reddish
 mucus.
   " Hydrophobia,  hysteria,  and several
 other nervous diseases, likewise produce
 their chief effects upon these organs, and
 the  result appears to be the same.  So, I
 have just remarked,  when tetanus is ar-
 rived  at its worst degree,  the patients
 have a great  aversion to liquids,  and, if
 they are forced to swallow them, immedi-
 ate convulsions are excited. This circum-
 stance  was particularly observed in M.
 Navailh."—(Mem. de Chirurgie Militaire,
 Tom. 1. p. 247,  248)
   Hippocrates has taken notice' of  tetanic
 affections, in  several parts of his  works,
 and he seems to regard the disorder only
 as a consequence of other diseases,  or  of
 wounds or ulcers of the nervous or tend'r-
 nous parts, of  which symptomatic kind
 of opisthotonos he  gives  three remark-
 able cases in lib.  5.  § 7. de Morb. Vnlg.
 and repeats them in another place; but
 some of the symptoms, which he relates,
 are said not to be  now observed.  Galen,
 Coelius  Aureliinus,  Aretauis, ike.  seem
 only to have copied Hippocrates,  with
 tlie addition of some suppositious symp-
 toms, which  really do not appear.  The
 account given by Bontiiis is also deemed
 very defective.  Dr.  Lionel Chalmers, of
 Charles  Town, South Carolina,  states,
 that when the disease forms very quickly,
 and invades  the unfortunate person with
 the whole  train of its mischievous symp-
 toms, in a few hours, the danger is pro-
 portioned to the rapidity of tlie attack,
 and that patients thus seized, generally
 die in  24, 36, or 48 hours, and very rarely
 survive the  third day.   But, when  the
 disease is  less acute, few  are lost after
 the  ninth,  or  eleventh.   However, per-
 haps,  this  gentleman's  descriptions ot
 the  dise.se  in South Carolina may not
 be   altogether applicable  to  it  in our
climate.   (See Med. Obs. and Inq. vol. 1.
p. 92, 93.)
  Tetanus was generally considered by
the  ancients as a mortal disease ;  but,
we are now aware, that,  until  of  late
years, medical  practitioners had  no  just
notions concerning the proper treatment,
and  that since more judicious methods
have been practised, many persons, afflict-
ed  with  tctinus, have recovered.   Al-
though the treatment, which has succeed?
ed in some instances,  has not  been found
successful in others,  yet,  the degree of
success proves, that the affection is not
invariably incurable, and more modern ex-
perience has pointed out additional plans,
the  efficacy of which  entitles them  to
trial.             ',
   When tetanus is evidently dependent
on the particular state of a wound, prac-
titioners in general agree, that the wound-
ed part should be completely removed,
whenever  such au operation is  practic-
able ; or  that, at least,  all communica-
tion  between  the injured plaCe  and the
brain, should  be done away either .by
making a complete division of the nerves
of the part, or  destroying them with caus-
tics.   Some writers, however, remonstrate
against this practice,  and adduce reasons
of the following kind.  One of tlie  prin-
cipal grounds of objection is, that greater
 success  does not attend the treatment of
 tetanus, when the wounded  part is am-
 putated or destroyed, than when no ope-
 ration of this  kind is performed.   Any
 man who will take the trouble to consult
 the  cases of tetanus  on record,  will find
 this  to be a matter of fact;  and, though
 hypothesis may sanction the trial of the
 plan, experience is not at all in favour of
 it, When it is judged of, as  it ought to
 be, by the results of numerous cases com-
 pared together.   No  practitioner could
 justifiably   amputate,   or  destroy  the
 wounded  part, no one would ever  think
 of such a thing, before the symptoms had,
 at least, decidedly evinced the nature of-
 the  disorder.  Could it be known before-
 hand, that tetanus, which in this country
 is not a frequent affection, would certainly
 follow any particular appearances  of a
 wound, then the amputation, or destruc?
 tion of it, with caustic, would  undoubt-
  edly be  proper,  and promise  to be an
  effectual  preventive.   But,  experience
  has  now fully proved, that such  an opera-
  tion, after tetanus has commenced,  does
  no good whatever, since at least as many
  have died, when so treated, as others,
  who have not submitted to the method.
  If the operation  do  no good, it must be
  hurtful,  and  increase  the  number  of
  deaths ;  because limbs must frequently
  be removed,  and a certain proportion of 
256
TETANUS
persons,  on  whom  amputation  is per-
forrffed, on any account, always  perish.
However, the wounds, which most com-
monly occasion tetanus, are those of the
fingers  and  toes, and  the  removal  and
loss of one of these parts is a  matter of
less importance.
  The valuable observations of M. Lar-
rey,  in  favour of  amputation, will be
found towards the conclusion of the pres-
ent article, as well as his other interesting
remarks upon the various modes of treat-
ing tetanus.
  Experience has shewn, that opium has
sometimes been a very efficacious remedy,^
in cases  of tetanus; but, from  the same
source of knowledge, we also learn,  that
it can only become a means of cure, when
exhibited in very powerful  doses, such,
indeed,  as would be exceedingly danger-
ous in any  other instances.  The com-
mon  plan has been to give the  medicine,
at  first, in moderate doses, and repeat
them, every two, or three  hours, or, at
longer  intervals,  according to  circum-
stances.  In this manner, twenty, thirty,
forty grains, and even  more,  have fre-
quently  been administered in the space of
four and twenty hours, without any other
effect, than that of diminishing a little the
 spasms and pain ; the patient having nei-
 ther  sleep, nor drowsiness, nor  any of the
other effects, usually resulting from this
medicine, even when exhibited in much
 smaller quantities.  It is, for such reasons,
 that the doses may be boldly augmented,
 in  proportion as the violence of the symp-
 toms seem to demand.  Opium, however,
 does not fail to have sometimes inconven-
 iences, which prevent its being exhibited
 as  freely  as one  might  wish, under
 other circumstances.   The functions of
 the  stomach  and  bowels have  been
 known to be so seriously impaired, in con-
 sequence of the medicine, that its exhibi-
 tion could be no longer continued, but was
 left  off, before any  salutary effects had
 been produced.  ^
    Another circumstance, which  deserves
 particular  atention, is,  that altliough
 the  first doses  of opium  may produce
 some  abatement of the symptoms, the
 benefit  is not of  long continuance, and
 fresh doses of the medicine must be ad-
 ministered,  some time before the opera-
 tion of the previous one ceases. This plan
 must  be persevered in, as long as  the
 symptoms have any tendency to reappear;
 and it  is not, till some time after they
 have seemed to  be  subdued, and to have
 left the p.tient in a long and uninterrupt-
 ed interv.il of ease, that one should ven-
 ture to diminish either the quantity, or
 number of the doses ofthe  medicine.
    Opium is  sometimes prevented from
being taken,  in an effectual manner, by
the difficulty of swallowing, which is  *
common symptom of this  disease, and
occurs particularly often, when  tiie dis-
order  is in an advanced stage.   I once
conceived, that medicines  might, under
such circumstances,  be  introduced into
the stomach, by means of a hollow bougie,
passed, from one of the nostrils, down
the  oesophagus.  I have lately  been in-
formed, liowever, that using a bougie in
this way brings on very insupportable fits
of spasm ; and the truth  of this objection
is fully confirmed by  M.  Larrey.  The
occurrence of a difficulty  of swallowing
medicines,  when the disease has made
some  progress,  is,  at  all events,  an
urgent reason, for having recourse, with-
out delay, to such remedies, as  have ob-
tained repute,  and of these, opium >s un-
doubtedly one of the principal.  Should
it be found to be impracticable to convey
opium  into  the  stomach,  after the dif-
ficulty of swallowing comes on, authors
 advise  the medicine to be exhibited  in
glysters, in such doses as the violence
ot the disorder demands. Thecostiveness,
which opium usually brings on, may com-
 monly  be obviated by emollient glysters,
 and laxative medicines, as occasion  re-
 quires.
   Analogous  reasoning has  led to the
 supposition,  that the efficacy of opium
 might be increased, by  employing some
 other  medicines  of the  antispasmodic
 class,  and,  with  this  view, musk and
 camphor have been given,  as being justly
 regarded  as among the  most  powerful
 remedies of  this kind.  But,  although
 some practitioners  have  thought,  that  v
 they have seen good  effects result from
 musk, yet the majority of practitioners,
 who  have made trial of  both  this and
 camphor,  in cases of tetanus, have found
 no reason to recommend these medicines.
 Possibly,  this may be owing, in some in-
 stances,  to sufficient  doses not having
 been exhibited, or to the musk  not being
 of a  good  quality.   One hundred  and
 fifty grains of musk, however,  hive been
 given in the space of twelve hours,  to a
 young girl, thirteen years old, affected
 with  an incipient tetanus ; but, no salu-
 tary effect on the disorder was produced.
    Analogy  has also  led  to the employ-
 ment of the warm bath, as a plan, which
  seemed to promise great benefit, by pro-
  ducing a  relaxation of  the contracted
  muscles.  But, notwithstanding this means
  has appeared, in a few instances, to oc-
  casion  some  little relief, particularly,
  when  the practitioner  has been content
  with mere fomentations, it generally fails,
  and, often, hm even done  mischief.  This
  may perhaps be,  in some measure, ascrib- 
TETANUS:                               25?
 able to the disturbance and motion, which
 the patient must necessarily undergo, in
 erder to get into the bath; for, it is  very
 well  known,  that every exertion, on the
 part of the patient, is very apt to excite
 most violent paroxysms of spasm.  The
 author of the article Tetanus, in the En-
 cyclopedie  Methodique,  mentions  his
 Iiaving seen the warm bath do  harm, in
 two or three cases, in which it  was ex-
 pected  to do good.   Though numerous
 writers have  recommended the  trial of
 the plan, it would be difficult to  trace, in
 their accounts, any facts, which decidedly
 shew, that its  adoption has ever  been
 followed  by unequivocal  benefit.    Dr.
 Hillary,  who  practised, a long while, in
 the warm climate of America, where teta-
 nus is very common, disapproves of this
 method of treatment.   He observes, that
 although the  use of the warm bath  may
 appear to be  very rational, and  promise
 to be useful, he has always found it much
 less serviceable, than emollient and anti-
 spasmodic fomentations; and, he also  men-
 tions, that he has sometimes seen  patients
 die, the very moment, when they came out
 ofthe bath, notwithstanding they had not
 been  in it more  than twenty minutes, the
 temperature of the water being likewise
 not higher  than  29 or 30 of Reaumur's
 thermometer.   (See Hillary on the Air and
 Diseases of Barbadoes.)
   De Haen  also relates  a similar fact of
 a patient dying, the instant he was taken
 out of the warm  bath.
   It was, in all probability, the bad effects
 of  the warm bath, which induced practi-
 tioners to try what might be effected by
 the cold one.  Of all the remedies, which
 have  been employed in cases of tetanus,
 the cold bath seems to  be that, which -has
 been attended with the greatest success.
 Dr. Wright has published, in the MetUcal
 Observations and Enquiries,  Vol.   6, a
 paper, in which may be found a narrative
 of* the first trials of this method, which
 were  all  successful.  The plan is  said to
 be at  present preferred throughout all the
 West Indies.  The way adopted consists
 in plunging the  patient in  cold  water,
 and in that of the sea,  when at hand, in
 preference to any other;  or else in throw-
 ing from a certain height, several pailfuls
ef cold water over his body.  After this
has been done, he is to be very carefully
dried with a towel, and put to bed, where
he should only  be lightly covered  with
clothes, and take twenty or thirty drops
of laudanum. The symptoms usually seem
to give way, in a certain degree, but, the
relief*, which the patient  experiences, is
not of long duration, and it is necessary
to repeat  the same measures, at  the end
of three, or four hours.  They are to be
 repeated in this manner; that is to say,
 at such intervals,  until those of freedom
 from the attacks of the disorder  increase
 in length.  This desirable-event generally
 soon follows,  and ends in a perfect cure.
 Wine and bark were sometimes conjoined
 with the foregoing means, and seemed to
 co-operate in the production pf the good
 effects.   Dr.  Wright concludes  the ac-
 count with the following remark, sent to
 him with a case,  by Mr. Drummond, of
 Jamaica.—" I am of opinion, that opiates
 and the  cold  bath will answer every in-
 tention in the tetanus and such like dis-
 eases; for, whilst the opium  diminishes
 the irritability, and gives a truce from the
 violent symptoms, the cold bath produces
 that wonderful tonic effect, so observable
 in this, and some other cases.  Perhaps,
 the bark, joined with these, would render
 the cure more  certain.  May we. not then
 have faded in many cases, by using opiates
 alone in  large  doses, or what probably is
 worse, with the warm bath, instead of the
 cold bath? And have we not reason to
 suspect that the increased doses of opium,
 that seemed requisite, when the warm bath
 was used, may have proved pernicious V*
 (Vol. 6, p. 161.)
  Another remedy, which is said to have
 frequently effected a  cure  in  tetanus, is
 mercury.  It has.been employed in France
 with the greatest success, as may  be seen
 by referring to the forty-fifth  volume of
 the Journal de  Medecine. •  This  remedy,
 however,  should  be  resorted to, in an
 early period of the disorder.  Mercurial
 frictions are preferred, and these are to be
 put  in practice so as to bring on  a quick
 affection of the mouth; taking care, how-
 ever, not to render the soreness and sali-
 vation too violent.  Some contend, that it
 matters not, whether mercury be rubbed
 into the body,  or  given internally.  It is
 generally allowed, that opium may be ad-
 vantageously exhibited at the  same time.
  Dr. Cullen mentions  his* having been
 informed, that  the Barbadoes  tar (Pis-
 selxum Barbadense) had cured tetanus in
 all its different  degrees.
  It  was an opinion, entertained by this
celebrated physician, that the cold bathing
 had neither been so frequently employed,
 nor found so commonly successful, in cases
 of tetanus from wounds, as in those from
 the application  of cold.
  Unctuous, balsamic, and spirituous em-
 brocations; bleedings; and the  applica-
 tion  of blisters; which many practitioners
 have recommended, are  not only  useless
 remedies in the majority of cases, but even
 hurtful   Hence, none of the best physi-
 cians or surgeons, of the present day, ever
advise toem to be adopted.
  The trial of strong shocks of electricity, 
358                             TETANUS.
  in cases of tetanus, has been suggested.
  We hare no fact, however, on record, of
^ the metliod having done good in this dis-
  order.  (Latta's System of Surgery, Vol. 3.
  P- 61.)
    It has also been proposed to exhibit, in
  cases of tetanus, some other very strong
  stimulants,  besides  opium,  musk, and
  camphor; for instance, the fixed and vola-
  tile alkalies,  ardent spirits, spices, &c.
    Mr. Latta's sentiments are against the
  employment of opiates and the warm bath,
  and tiie great object,  which he seems to
  be desirous of bringing about, are,  a cer-
  tain degree of inflammation and suppura-
  tion in the wounded  part, and a general
  inflammatory diathesis.   The  measures,
  which he advises, with these views, will
  be fully understood by the following ex-
  tract.
    " Some cases  (says this author) have
  been related, where a cure was evidently
  effected by opium; yet, from the numbers,
  who  have suffered,  under this manage-
  ment, we may freely say,  that  the  cures
  are only in the proportion of one to eight,
  or nine.   There  are some  cases, related
  by authors,  where the patients have  in-
  deed recovered from the tetanus, but have
  soon after been attacked by complaints in
  their stomach, which quickly put an  end
  to their  life.  Upon opening their bodies,
  the stomach  was always found  in a high
  state of inflammation, and sometimes ac*-
  tuallyr mortified.  Notwithstanding,  there-,
  fore, it appears that the disease has, some-
  times been cured by opiates, I am clearly
  of opinion, that, in cases of tetanus, they
  ought almost to be entirely given up. The
  warm  bath, 1  am  likewise  of opinion,
  ought not to be  used; and indeed, I must
  recommend a course  almost directly op-
  posite to that hitherto recommended and
  practised.  Instead of putting the patient
  into a warm bath, I  would plunge him
  into a tub of cold water, rendered still
  colder by the addition of  vinegar.  This
  ought to be  repeated  as often as the pa-
  tient could bear it; and, in the mean time
  he ought to take the bark in  very large
  doses, not less than two ounces in twenty-
  four hours, washing down every dose with
  a gill of port wine.   Thus, a degree of
  inflammatory diathesis might be produced
  in the system, without the danger  of ex-
  citing a local inflammation and mortifica^
  tion  in  the  stomach, which arises from
  immense doses of opium.   I am not, how-
  ever,  for rejecting opiates entirely.  A
  large dose may be given at first, and still
  farther  augmented, if the first has no ef-
  fect to mitigate the  symptoms, until we
  have an opportunity of pushing the bark
  to i s full extent,  llesides this, we ought
  to endeavour to excite a  local inflamma-
tion  in the wounded  part  itself, and td
raise this inflammation as high as is con.
sistent with a resolution afterwards.   We
certainly know, that nothing promotes a
general  phlogistic  diathesis through the
system, more than a wound attended with
an high  degree of inflammation.  In all
relaxed habits we find, that, even in  this
climate,  wounds are attended with  less
topical inflammation in  summer than in
winter;   and, from  perusing the best au-
thors that have lately written upon  this
subject, I find that, in wounds productive
of tetanus, there is an absolute want of
this  inflammation,  so  necessary to  the
cure and well-being of the patient.  Nay,
I myself know,  from gentlemen of un-
doubted  abilities in their profession, both
in America and  the East Indies,  that, if
inflammation and suppuration takes place
even in these climates, immediately after
an injury that might be suspected of in-
ducing a tetanus, such as,  slight wounds
or scratches on the fingers, or a splinter
driven in below the nail, nothing of the
kind takes place.   Hence, it is evident,
or,  at least, very  probable,  that if in a
wound threatening to produce a tetanus,
we  could induce  this inflammation, the
disease   would  certainly  be prevented.
Our  first care,  therefore,  should be, in
warm climates, or in cases where we have
reason to fear a  tetanus, to dress tho
wound in such a manner as to bring on
the requisite inflammation; and nothing
can do this more effectually, than  to  en-
large it considerably, and apply a pledget
dipped in warm oil of turpentine.
  " It must be observed,  however,  that
though dressings of this kind applied to
the wound before a tetanus has come on,
may very probably prevent it, yet we have
no reason to believe, that they will remove
it after it has come on.  It is even doubt-
ful, whether, after this dreadful disease
has  appeared,  any  application  to  the
wounded part would raise  the desired in-
flammation.  In this case, we must do the
best we can, instantly  to  remove, or at
least palliate, the violence of the spasms;
and, while we do  so, an  incision  made
above the original  wound,  and dressing
this incision with warm oil of turpentine,
might possibly be of service.  The  mis-
fortune  is, that now we have not time to
wait for the effect of any  ordinary medi-
cine.  Tlie disease makes such rapid pro-
gress, that  we  are under a necessity of
using violent remedies,  even though we
thereby  run the risk of destroying our pa-
tients afterwards,  as  has been  remarked
 of opiates.   Mercury has been much re-
 commended in the tetanus, as well as the
 hydrophobia, but has not often  been at-
 tended with success in either.  It isevi- 
TETANU9.                              359
dcntly too  slow in its operation; but in-
deed, if we can g,ve it in such  quantities
as to produce symptoms of salivation in a
day or two at most, it has a chance of be-
ing useful; for, while it is producing a
salivation quickly, it  brings on a diathesis
phlogistica; but 1 believe  that, when it
acts slowly, or after a salivation  is tho-
roughly produced, it rather has a contrary
effect, viz.  that of relaxing the body, and
thus tending to bring on the disease, if
the wound be not healed before this hap-
jen.  To avoid this,  we ought  to  begin
tlie unction with mercury as soon as the
disease begins to shew itself; to rub in a
very considerable quantity at once, and to
stop as soon as the breath begins to turn
fetid, or tiie gums to swell, lest a saliva-
tion should be excited, which would be
contrary to the intention with which the
medicine was  exhibited."   (Latta, Vol. 3,
p. 70, &c.)
   This gentleman is an advocate for cold
bathing, which, he observes, should, like
other remedies in tetanus, be pushed to
its utmost extent.  He recommends plac-
ing the patient in a tub,  about two feet
 and a half high, and three  feet in  diame-
ter, and pouring repeatedly over his head
 and shoulders, buckets of  water, as cold
as can  be  procured.   This plan is to  be
 " repeated, according to  the urgency of
 the symptoms; but,  not less,  than four
times, in four and twenty hours.  During
this time,   the patient should be made to
drink half a gill of the best brandy every
hour, with two scruples of the powder of
bark put into it;  and, if" his stomach can
 bear it, from two to three ounces of bark,
 with a bottle and  an  half of port-wine in
 twenty-four hours.  If, by these  means,
 the strength of the system increases, every
 symptom of the disease will decrease.  I
 have already  given my opinion with re-
gard to opiates.   The smallest dose that
can be  given, provided it  will have any
effect in relieving the spasms, ought to be
adhered to ; and, if they can be kept under
without opium, so much the better ; but,
if not,  no  doubt we must give it in large
quantities.  The dose, indeed, cannot be
ascertained; but, we must always remem-
 ber,  that,  after the stimulant  power of
opium  is  gone,'it has a very remarkable
sedative effect, which, in persons not ac-
customed to it, Is productive of something
similar to downright intoxication, and a
very great degree of debility consequent
thereto.  We must, therefore,  be as care-
ful as  possible not to give immoderate
doses of opium after the spasms  are re-
moved  ; or, at any time more than is ab-
solutely necessary to keep  them under.
The strength of  the system cannot be ul-
timately restored by medicines, which act
only for a short time, and then lose their
effect.  It is  evident that these are to be
used  only'with a view  to  others, which
act more permanently, though slowly.   '
   " The sedative qualities of one dose of
opium may indeed be prevented, by giving
another before they have time to manifest
themselves;  but this  would require an
endless succession of doses.  By far the
best method seems  to  be  to counteract
them,  by giving  large  quantities of the
most nutritious food, as soon as the spasms
are mitigated to such a degree as to allow
the patient to swallow.   This is conform-
able to the doctrines delivered by the late
Dr. Brown, who, after a dose of opium or
laudanum,  always ordered  his patients to
be supplied with some strong and solid
food, to prevent the debility, which would
otherwise  take  place."  (Latta,  Fo/. 3.
p. 75.)
   Dr. Rush, professor of medicine in Phi-
ladelphia,  has lately published,  in the
Transactions of  the American Philoso-
phical Society, Vol. 2.  a paper, intitled,
"  Observations on the Cause  arid Cure of
Tetanus."  Dr. Rush,  considers tetanus,
as a disease  occasioned by a relaxation,
and,  consequently,  recommends  for its
cure, such  medicines, as arc calculated to
remove  this  relaxation, and to restore
tone to the system.  Hence, he advises tlie
liberal use of wine,  and Peruvian bark ;
and states, that he  has put this plan in
practice with  success. When the disorder
is the consequence of a wound, Dr. Rush
recommends stimulants to the part affect-
ed : the  wound is to  be dilated, and filled
with oil  of turpentine, t
   In  Spain,   however,   a  very opposite
mode  is said to  be adopted  with great
success; practitioners  there advise the
use of mild emollient applications to the
wounded part, and, they,  in  particular
recommend it to be immersed, for an hour
in tepid oil, and to repeat this plan, at
short  intervals.  In this manner,  many
cases are s^fl to have been relieved,  after
very  alarnung  appearances had  taken
place.
   I shall now insert the truly valuable
observations of the experienced M. Larrey
upon the treatment of this disorder.
   " Experience has proved (says this au-
thor)  that when tetanus is  altogether
abandoned to the resources of nature, the
individuals quickly  perish.  The  practi-
tioner, therefore, should hasten to fulfil,
as much  as  possible,  the indications,
which this disease presents;  the principal
are,  to  remove the causes of irritation,
and re-establish the suppressed excretions.
   " The first is fulfilled by suitable inci-
sions made in  the wound before the symp-
toms of  inflammation have  come on ; for, 
360                              TETANUS.
if this has made progress, tlie incisions
would be useless  and even  dangerous.
They should comprehend, as much  as
possible, all the nervous  filaments, and
membranous parts, which  have  suffered
injury;  but,  incisions  in  the  joints are
pernicious, and appear, in all cases, to
accelerate the symptoms of tetanus, as I
have seen instances of.
  " The application of caustics to  the
wound  may be practised  with advantage,
on the first attack of the  symptoms, the
same precept being observed as in making
incisions,  these operations may be  fol-
lowed by bleeding, if necessary, and the
use  of  topical emollients  and anodynes,
though their  effect  is  generally  very
feeble.
  " Internal remedies, whatever may  be
their properties, are almost always use-
less, because the patient,  soon after the
invasion of tetanus, falls into a state of
strangulation;  but,  if such   state  only
comes on towards  the latter  stage, and
gradually, such remedies as have obtained
the  greatest confidence of practitioners
may be employed, as, for instance, opium,
camphor, musk, castoreum, and other an-
tispasmodics, in strong doses, which are
to be gradually increased.  These means
were used with some  advantage for the
patients, who were the subject of the an-
nexed observations.
  " A mameluke of Mourad-bey, named
Mustapha, 27 years of age, and of a dry
bilious constitution, received, the 19th of
April, 1800, a gunshot injury, by which
the first phalanges of the fingers of his
right hand, and the corresponding meta-
carpal bones,  were broken in pieces, and
the thumb shot away at  the  articulation
with the  trapezium: many tendon's and
ligaments were also torn and lacerated.
  " Mourad-bey had every possible care
taken of him ; but, as the remedies  were
administered,  without the cause of the
disease being understood, they could not
fulfil the indication, which presented it-
self.  It may therefore be said,  that this
individual continued without assistance,
till the 18th  of  May, at which period
Mourad-bey, seeing the bad state of the
patient, sent him to the French surgeons,
with a  recommendation to General Don-
zeloL M. Celliere, surgeon, of the second
class at the hospital of Syout,was directed
by the general to take care of this mame-
luke.
  " All the symptoms of tetanus had pre-
vailed for three days;  the suppuration of
the wound was serous and in  small quan-
tity ; its edges were red  and puffed up;
the muscles of the arm already contracted
and  in a state of convulsion; the jaws
closed;  deglutition attended with diffi-
culty ;  and the  patient constipated  and
restless.
  " The first attention  of M.  Celliere
was to dilate  the wound,  and carefully
extract  the loose splinters of bone:  he
applied emollient dressings, and gave the
patient six grains of opium, joined with
four of camphor. A few hours afterwards
some relief was experienced,  and the fol-
lowing night was less severe.   The sleep,
however, was  interrupted by spasms m
the wounded member, and the acute pains,
which accompanied them; a  perspiration
took place in the upper half of the body ;
and  the lower extremities continued in
their  ordinary state.   This  melioration
induced the surgeon to go on with the
same  remedies,  the  doses of which were
gradually increased.  The symptoms by
degrees diminished until the 24th of May,
at which period the  patient was moved
from Syout to Minyet: the obstacles to
deglutition were removed, and the excre-
tions partly re-established. The burning
heat of  the day, and the journey had fa-
tigued him; and this circumstance,  per-
haps, together with the coolness of the
night, to which he  exposed himself in
lying upon the  terrace of the hospital,
contributed to the reproduction of the
symptoms of  tetanus.   The same means
were continued, without keeping the dis-
order from  advancing with its usual ra-
pidity.   Warm  bathing was tried: the
second  bath produced a general amend-
ment, which enabled the patient to swal-
low the half  of a potion, composed of
eight grains of camphor,  as much musk,
and twenty grains of opium,  dissolved in
an emulsion :  the other half was taken in
the course of the  day.  Very soon after-
wards,  the pain diminished, the jaws be-
came relaxed, and the sleep was tranquil.
On the  morning of the 19th of May, there
was great improvement; the suppuration
of the wound was re-established -,  the or-
gans by  degrees resumed their functions,
and a few  days sufficed  to  bring this
mameluke into  the  way of getting well,
and the cure  was completed by the most
assiduous attention,  and the varied use of
remedies specified.  Lastly,  on the  29th
of June, he was restored in perfect health
to the General Mourad-bey.
   " At the battle of Aboukir, the general
of division, Lannes, received a ball, which
passed through  the lower half of the leg,
between the two bones.   During the five
first days, he  was treated in his tent; but
he was  afterwards  conveyed to Alexan-
dria.   Although  he  was  carried  in  a
covered carriage on springs,  the journey
was uneasy and extremely painful.
   " On  his arrival, he sent  for me.  I
fotmd him restless, and agitated, express- 
TETANUS.                                 361
ing the greatest apprehension of the con-
sequences of his  wound   The leg was
swelled, and the wound dry and pamful;
he had spasms, the whole limb was affect-
ed with  violent  starting,  and tiie foot
was  numbed.  The  voice  was  hoarse;
the jaws much closed; the eyes haggard;
and a good deal of fever prevailed.
  "At his request, 1 left him alone, for
some time, in  order that he might sleep;
but,  he was soon  roused by pain and ge-
neral indisposition.  I applied emollient
dre-sings, and ordered cooling beverages,
strict quietude, and a low diet.
  " On my second visit, three  hours af-
terwards,  I  found  all the symptoms
worse.   I immediately had him bled in
the arm, and prescribed for him emul-
sions, to which were added  the nitrate of
purified potassa,  alcoholized sulphuric
aether,  some  sirop  of  diacodium,  and
orange flower water, in suitable propor-
tions, a glassful to be taken every quar-
ter of an hour.   The topical emollients
were continued.                       ,
  " The patient passed  a bad night, and
the next day he  was in the same state,
with the leg highly inflamed ; he swal-
lowed with difficulty, and the jaws were
constantly closed.  The bleeding was re-
peated,  and I continued the same medi-
cines, with  the addition of  antispasmo-
dics.
  " The  following night was easy ; the
fever abated; and all the other symptoms
diminished : the wound  and the leg were
relieved by an oozing of bloody matter ;
the spasms totally ceased;  a healthy and
copious suppuration  took place; the ex-
cretions resumed  their course, and, at the
period,  when  I set off for Cairo, the pa-
tient was in a convalescent state.  Soon
afterwards, he was well enough to return
to France with the general  in chief Buo-
naparte.
   "  In consequence of such a wound, M.
Croisier, aid-de-camp to the commander
in chief, had perished of tetanus, in the
deserts of .Qatyqh, on  our  return from
Syria.
   " M.  Estcve, director-general of the
public revenue in Egypt, was seized with
a slight inflammatory quinsy, occasioned
by the presence  of  a piece of fish-bone,
which had lodged in one ofthe sinuses of
the  fauces : its  smallness concealed  it,
notwithstanding every examination.
   "On the 13th day after the accident,
and the 3d from the time, when inflam-
matiou  began, the symptoms of tetanus
came on, such as a contraction of the jaws,
convulsive motions ofthe muscles of the
face, accompanied with violent pain, and
rigidity of all the muscles  of the throat;
tie  pulse was nervous  and  accelerated;
     Vo*.  II
frequent catchings occurred in the upper
extremities; the stools were suppressed;
and there was  considerable difficulty of
speech and deglutition.
  " The rapid progress of the symptoms
made me tremble for the life of my friend ;
his death would have  deprived us of an
officer, whose talents and qualities all the
army appreciated, and whom it regarded
as a man of the highest integrity.
  " I immediately prescribed for the pa-
tient a  sweetened emulsion, to which I
added  the extract of opium, castoreum,
camphor,  the nitrate of purified potassa,
and alcoholized sulphuric  sether, in  very
strong but graduated  doses, which were
taken by  glassfuls  every  quarter of  an
hour.   The weak state of the  pulse did
not allow me to employ bleeding.  I ap-
plied  resolvent pouitices to the forepart
of the neck;  I ordered  the feet to  be
bathed  in  warm water;  emollient clys-
ters ; the  throat to be exposed to the va-
pour of a strong decoction of hyoscyamus,
poppies, and marshmallows; dry frictions
over the whole body ; and I recommended
the avoidance of every thing, which could
tend to disturb the patient's rest.  I ob-
served regularly all the successive pheno-
mena of the disease. The following night
wes  attended with great  agitation ; the
pain was violent; deglutition interrupt-
ed ;  the saliva  flowed out of the mouth;
and the jaw strongly closed. The patient
suffered painful and incessant agitation;
he fell for a  short time into a comatose
state, attended with slight attacks of de-
lirium ; in short, every thing portended
the most imminent danger.  About four
in the morning, however,  a copious per-
spiration  over  the chest  and  abdomen,
succeeded this violent paroxysm; the pa-
tient became easy, and was able to swal-
low some of the above emulsion.  The
second dose increased the perspiration,
and relaxation  of parts, and I was there-
fore led to think favourably ofthe effects
ofthe medicine; for, when the perspira-
tion is symptomatic,  it begins upon the
head and extremities; while,  when it is
critical, it occurs over the chest and  ab-
domen.   The  next day,  the jaws  were
quite  relaxed, the deglutition was  easy,
 and the contraction of the muscles mate-
 rially  diminished.  I  substituted for  the
 resolvent cataplasms, volatile liniments,
 and for the  emulsion,  a bitter laxative
 mixture, in order to unload the bowels,
 and re-establish the tone of the stomach.
 A  few days  afterwards, M. Esteve was
 quite cured.
   " The  fish-bone seemed to have been
 moved away by  a  slight suppuration,
 that took place in the fauces.
   " I have remarked, that patients have
     Z z 
■Jtv-
TETANUS.
less  aversion to  swallowing  emulsions,
than any other liquid.  They are smoother
and more agreeable, and facilitate the ef-
fect ofthe remedies, with which they are
combined.
  Frictions  with oily liniments,  as re-
commended by some authors, were tried
at the hospital,  No.  2, in  Cairo;  but,
they produced no change in the state ofthe
disease.
  " Mercurial frictions have appeared to
me to aggravate the symptoms in the pa-
tients, upon whom  they were tried.  In
Egypt,  the employment of this  means,
even  for venereal  complaints, requires
the utmost precaution; for, when admi-
nistered in this climate, as in Europe, it
has occasioned the  most afflicting conse-
quences, idiot ism, hepatic  diseases, &c.
  " Poultices, made of the leaves of to-
bacco, and applied to  the wounds  of per-
sons labouring  under  tetanus, have  been
followed by no advantageous effect.  The
alkalies have also been tried  in  several
tetanic cases, without  success.
  " The application  of blisters  to  the
throat, in cases of trismus, and especially
in th.t  of M. Navailh, have failed in ar-
resting the symptoms.
  " The moxa and actual cautery, recom-
mended, by the Father of Medicine,  have
been  equally unavailing.  The moxa was
employed at Jaffa upon three wounded
men ;  the disease  notwithstanding  fol-
lowed its  usual  course, and terminated
fatally.
  " I have cited a striking instance of
the inefficicy of the second method, in a
Case of opisthotonos.             ,*
   " Although large wounds,  like those
which are produced by the amputation of
a limb,  or wounds with loss of substance,
may  be sometimes followed by tetanus,
this does  not prove,  that amputation,
which I propose for the relief of this dis-
ease, is dangerous, nor that it cannot have
beneficial effects; especially, as it is easy
for  an  attentive  surgeon to prevent the
cold  damp air from  coming into contact
with the wound, as well  as prevent the
irritation arising from the presence of fo-
reign bodies,  and the suppression of the
purulent discbarge, which are (says M.
Larrey) the common causes of tetanus,
particularly i;i warm climates.
   " This  end  may be accomplished by
keeping the patient, as much as possible,
in a  very warm and  equal temperature;
by taking ere to extract without  delay
all foreign  substances, dress  the wound
tenderly,  cover it  immediately with fine
linen, having slits cut in it, and not dress
recent wounds until  suppuration is  well
established.   Lastly,  a  regimen,  and
quietude are to be enjoined.
  " When tetanus is caused by the sup-
pression ofthe dischsr^e, blisters, applied
as near as  possible to  the  wound, or to
the wound  itself, re-excite suppuration,
and put an end to the effects ot this acci-
dent.   1 proceed to detail some instances
of such success.
   " Pierre  Bonnet,  of tiie 85th  demi-
brigade, aged 20 years, of a bilious and
irritable constitution, lingered in the hos-
pitals at Cairo, ever since  the  campaign
in Syria, with a fistulous ulcer, attended
with caries of the bones, wliich constitute
the right ankle joint.  In  a clinical con-
sultation, it was determined, in consider-
ation ofthe diseased state of the foot, and
the marasmus to which the patient was
reduced, that amputation  was the only
means of saving his life.  It was done' on
the 2lst of September, by M. Valet,  sur-
geon of the first class,  who had the parti-
cular care of this patient.
   " The success of the operation was in-
terrupted by no  accident.  Suppuration
occurred  at the  usual period,  and the
wound looked well. Ten days afterwards,
the cicatrix began to form at the circum-
ference, and gradually extend  towards
the centre.
   " When  the patient was just on the
point of being well, (it was the 24th day
from  the  operation)  he  was suddenly
seized with  symptoms of tetanus, wliicn
no doubt were excited by the suppression
ofthe discharge.
   " Perspiration  was also obstructed, in
consequence of the patient's imprudence
in walking  in the night-time.  Diapho-
retics, strong doses of opium, and dry
frictions over the  whole body, were em-
ployrd, by  my  advice.  Ihe  symptoms,
however, advanced with their wonted ra-
pidity.
   " The patient experienced strange pains
in the epigastrium, and intolerable/dragA
ging  sensations  in the amputated mem-
ber.  Respiration was  laborious;  deglu-
tition difficult; the jaws were closed ; the
head bent  upon  the  chest;  the trunk
curved ;  and emprosdiotonos prevailed
in the highest degree.
   " Opiates not passing any longer, ano-
dyne and antispasmodic emulsions were
given, through a vacuity, left, by the loss
of two of the incisor teeth :  and these
medicines at first relieved the pain about
the stomach.  A large blister, applied to
the whole circumference ofthe stump, re-
 produced  suppuration in 24  hours,  and
occasioned a miliary eruption  on the face
and chest.   From this moment, the pa-
 tient  was  a great deal better ; all the
 symptoms of tetanus gradually diminish-
 ed;  the functions were  re-established,
 and,  on the 50th day  from the operation, 
TETANUS.                              363
this soldier was discharged from the hos-
pital perfectly cured.."
  Monsieur Larrey next details  a case,
which is  materially the same as the pre-
ceding, and I snail therefore omit itjn
this work.
  " The equally unexpected and entire
success (continues  M. Larrey,)  obtained,
by tiie amputation of the injured  limb, m
the person  of an  officer, attacked with
chronic  tetanus, leads me t > propose the
question, whether,  in  this disorder, occa-
sioned by a wound of some part  of the ex-
tremities, it would not be better to amputute
the injured limb immediately tlie symptoms of
tetanus commence, rather than expect from
the resources of nature, and from very un-
certain remedies, a cure, which so seldom
happens ?
   "If tetanus is chronic, as is sometimes
observed, amputation  may be done  at
every period of the disorder, provided a
choice be made of the time, when there
is an intermission of the symptoms. The
operation would not  answer  so well  in
acute tetanus, if the disease   were   ad-
vanced, and the muscles  to be divided
were strongly contracted and rigid, as I
have observed at the  siege of  Acre  in a
soldier, who was seized with tetanus,  in
consequence of a gun-shot wound of the
left  elbow.
   " When I saw the patient, who makes
the  subject of this last observation, the
symptoms Were already advanced. How-
ever, I madii the experiment of amputat-
ing  the arm.  The operation was followed
by considerable ease,  so that I had some
hope of its success ; but,  not  being  able
to shelter the patient from the coolness of
 the  nights, andjjhe tetanus having made
too  much progress, and being exceedingly
acute, the  symptoms recurred in a few
hours afterwards,  and  the patient fell a
victim on the third day from the operation.
   " Without presuming to settle the im-
portant question, which has been propos-
ed,  I shall endeavour to offer  some rea-
sons, which appear to be in favour of am-
putation.
   " When it is  clear, that tetanus arises
from the wound, we  should not hesitate
to amputate on the first access ofthe symp-
toms.  We may certify   ourselves, that
the  case is traumatic, by the nature of the
wound,  the progress of the early symp*
toms, and  the period  of their attack,
which, at latest, is between the fifth  and
fifteenth day.  When suppuration is esta-
blished, the  stupor  quickly diminishes,
the  vessels unload themselves, the sloughs
are  detached, and the nerves enter into a
state of perfect liberty.   Then their  sen-
sibility is extreme, and from the slightest
impressions, tbeyare susceptible of a most
violent irritation, which  is  rapidly pro-
pagated throughout the  whole  nervous
system.  If, in  this  circumstance,  tiie
wound is affected by a cold damp air, or
if there should be present any foreign bo-
dies, pricking  the nervous parts now se-
parated from  the sloughs, tetanus is in-
evitable, especially,  in   warm  climates.
We must then expect to  see the disorder
make rapid  advances, so that  in  a  very
short time, every part of the member is
affected, and all the nerves suffering irri-
tation.  The effects  of  this first cause,
may also be complicated with a bad ha-
bit, or with worms  in the  bowels,  as I
have  seen an  example of at Nice ;  but,
by pay ing careful attention to  the pheno-
mena of tetanus, we may readily distin-
guish the symptoms, which characterize
these  slight complications, and  combat
them with the proper remedies.
  " The section of the member, perform-
ed on the first access of the  symptoms,
interrupts  all  communication  between
the source of  the disorder and the rest of
the body.  This division unloads the ves-
sels,  relieves  the tension of the nerves,
and puts an end to the convulsive motion
ofthe muscles.   These  first  effects are
followed by a general relaxation, which
promotes the excretions, and sleep, and re,
establishes the equilibrium  in every part
of the body.
  " The  aggregate  of  the  temporary
pains, caused  by the operation, cannot
increase the existing irritation:  besides,
the sufferings of tetanus render those of
the operation  more supportable, and les-
sen  their intensity,  especially, when the
principal nerves of the limb are strongly
colffpressed.
   " M. Bonichon,  lieutenant  in the 1st
battalion ofthe 21st demi-brigade of light
infantry, was admitted  into tiie hospital,
 No. 1, October  7, 1798, for a gun-shot
wound of the left foot, that he met with
at the battle of Sedment.
   " The  direction  of  the wound  was
obliquely from behind forwards, crossing
tiie tarsus,  several  bones of which  were
broken ; and the short extensor muscle of
 the toes, and the corresponding articular
 ligaments,  lacerated. On  his arrival at
 the hospital,  however, the case did not
 have  any unfavourable  appearance; the
 first dressings were methodically appliedj
 the wound was dilated, and  some  splin-
 ters extracted.
   " Tlie same  evening, the patient be-
 came uneasy ; his  sleep was  painful; he
 experienced  in  the  wound acute  p..ins,
 which continued to  increase until he was
 visited in the morning ;  the edges of the
 wound appeared puffed  up, and surround-
 ed with a reddish   circle;  the discharge 
364                              TETANUS.
was suppressed ; and  the  application of
the dressings, though executed with  ten-
derness, was exceedingly painful.  The
patient, in short, was affected with gene-
ral indisposition.
  " Cooling anodyne beverages, and the
application of emollients to the wound,
had no effect.  '
  " On  the 19th of October, the closure
of the jaws  began, and, by the  29th, all
tlie symptoms of tetanus were  manifest.
The muscles of the injured limb were in
a state of convulsive contraction ;  the ab-
dominal parietes were drawn in;  the de-
glutition  obstructed; and  the  patient
constipated.
  ""' These symptoms continued regularly
to increase, but, in a slow  and gradual
manner, as the tetanus became chronic.
A dilatation  of the  wound  was made,
without delay, for the purpose of extract-
ing some moveable splinters, which  had
escaped the first examinations.  Opium
was prescribed in  suitable  dotes.  This
means appeared at  first  to lessen the
symptoms, which subsided  and recurred
alternately;  but these alterations were of
short  duration; and  on  November 2,
1798,  the disease  was  at   its highest
pitch.
  " All the  muscles were in a state of
convulsive contraction ;  the legs were
stiff, and strongly  befit upon the thighs;
and these  upon the pelvis.   The parietes
of the abdomen were drawn close against
the vertebral column; the head bent upon
the chest; the arm and forearm  in a state
of flexion  ; the ji.ws closed ;  andO&eglu-
tition  attended with difficulty.  The pulse
was small and nervous ; the patil^towas
reduced to a degree  of extreme emacia-
tion ;  his  body was  constantly  covered
with perspiration ;  and he suffered inces-
santly such violent pain, that he prayed
for death as a desirable thing.
  " After having  in vain tried all  the
means, which  the  healing  art offers in
this sort of case, such as opiates in every
form,  even  united  with  camphor  and
bark; lotions  of cold  water;  solutions
of opium to  the wound, emollient cata-
plasms, and afterwards those of tobacco ;
after having, I say, tried all these reme-
dies, 1 thought of amputating  the limb.
The despair  of  this unfortunate man,  and
the certain death, that awaited him, in-
duced me, contrary to the advice of seve-
ral military surgeons, who were  consult-
ed,  to employ immediately this  last re-
source.  Advantage  was taken of an in-
terval of ease, which  occurred  the same
day.   The  operation was   dexterously
performed in my presence, and  before all
the surgeons consulted, by M. Asalini,
surgeon of the-  first  class.   The  patient
 who was desirous of having  it done, be-
 haved courageously, and  without betray-
 ing signs of great  suffering.  A  slight
 syncope, which happened very soon  after
 the operation, was the forerunner of the
 cessation of the  symptoms.   In  short,, a
 general melioration occurred, which  al-
 lowed  the  patient to  swallow  some  li-
 quids.  The following night was  easy,
 and the patient had three hours  of sound
 sleep.  The next day, I  found  his pulse
 stronger, the limbs less  rigid,  the jaws
 relaxed ; and  some stools  had already
 come away, with the aid of clysters. At
 tiie  ordinary  period,  suppuration took
 place,  and all  the symptoms gradually
 subsided.   The stump, however,  was at*.
 fected, for several days,  with  violent
 spasms, which were  increased  by  the
 slighest touch of any thing externally,
 and, particularly, on applying the dress-
 ings,  notwithstanding every care taken
 not to irritate the parts.   I succeeded in
 assuaging  these spasms  by  making an
 exact compression along the course ofthe
 sciatic  nerve.
   " The strength returned very quickly;
 but, the digestive organs were a long time
 affected with  atony, (as M. Larrey thinks)
 by reason ofthe  pressure, which the pa-
 rietes of the  abdomen had made upon
 them.
   " Towards   the  end of the following
 December,  however, this  officer  left the
 hospital quite well,  beginning  to walk
 about on his   wooden leg.  Soon after-
 wards,  he returned to  France, with some
 discharged blind soldiers, and  he must
 be at the Hotel des Invalides at Paris.
   " The battle  of the 2lst of March,
 1801, gave me  occasion^to amputate a
 soldier's leg, for  an injurftimilar to that
 of M  Bomchon.  Although tetanus had
 begun, and was  of the  acute kind, the
 operation stopped all the  symptoms as it
 were, by enchantment; and doubtless, if
 it had not  been for  the dampness of the
 ward, where the patient lay, and the want
 of proper means for keeping him from the
 coolness of the  nights,  this  operation
 would have been equally successful.  He
 passed about twelve hours in perfect ease;
 but, the coldness of the following night,
 (which was greater than usual) reproduc-
 ed the symptoms.  These resisted all the
 proper remedies, and the patient died on
' the third day from the operation.
   " The  general  of  division, Destaing,
 received in the same battle a ball, which
 went  through tlie middle  internal and
 back part of his right arm.  A  portion of
 the biceps, coraco-brachialis. and the radial
 and internal cutaneous nerves, were divid-
 ed.  Between the two openings, there was
 an intervening mass of soft parts, consist) 
TETANUS.                              365
   ing of integuments, cellular substance, and
   some muscular fibres.  The first effects of
   this injury were, the fall ofthe sabre from
   the general's hand,  paralysis of the arm,
   and  a  painful  trembling,  which imme-
   diately affected the whole  limb, attended
*   with anguish,  general debility, and op-
   pression of the organs of respiration.
     " It  was with difficulty,  that the gene-
   ral was  conveyed to  Alexandria, where
   he first received the succour of one of my
   colleagues.   1  was not consulted till the
   8th day, at which  time his pains were be-
   ginning to be extremely acute.  Although
   suppuration had taken place, the patient's
   appetite was disordered, his sleep broken,
   and in  the evening febrile symptoms came
   on.  I immediately  saw the necessity of
   dividing the parts between the two  ori-
   fices where there were some filaments of
   the internal cutaneous nerve ;  but, as the
   patient would  not consent to this slight
   operation,  I  was  obliged  to be content
   with applying emollients, and prescribing
   proper internal remedies.   I dressed the
   wound daily, and continued to do so till
   the  cure was  finished  The next day,
   the  local pains were more acute.  There
   were convulsive motions in the hand and
   forearm, heat  all  over the body, and  a
   closure  of  the jaws.   The patient  was
   very restless and in continual agitation.
   The rapid progress of the  symptoms led
   me  to divide the parts between the two
   orifices, and to make  an incision through
   tlie  bottom  of the  wound, where some
   nervous and aponeurotic fibres lay.
     "  This  operation was  painful;  but,
   two hours  afterwards, the patient felt
   much  relieved.  With the assistance of
   anodyne emulsions,  emollient  clysters,
   rest, and diet,  all  the symptoms subsided
   in the  course of two days.   The suppura-
   tion became healthy, the wound put on a
   clean  appearance, the swelling of  the
   edges  disappeared, and, at the conclusion
   of the siege of Alexandria, the cicatriza-
   tion was completed.
     "This wound  left the forearm  and
   hand affected with paralysis: the two last
   fingers also continued senseless for a long
   while.
     "  Although  (says M. Larrey)  I have to
   regret not having more examples of cures
   effected by amputation, I have a sufficien-
   cy to  conclude:
     " 1. That of all the remedies, advised
   by skilful practitioners,  experience has
   convinced  me,   that the  extract  of
   opium,  combined  with   camphor,  and
   the nitrate of purified potassa, dissolved
   in a small quantity  of emulsion, made
   with  sweet   almonds,  and  given  in
   doses  more or less strong, acts  the  most
   favourably, since patients, who have an
aversion to other fluids, take with plea-
sure  this mixture, the effects of which
must be promoted by bleeding,  if indi-
cated,  and blisters  under the  circum-
stances, which have been specified.
   " 2. That amputation,  done at a pro-
per time, is the most certain means of ar-
resting and destroying the effects of te-
tanus, when  it  depends  upon a wound
situated in the  extremities." (See Lar-
rey's Memoires deChirurgieMilitaire, Tom.
1, sur le tetanus traumatique, p. 235, &c.)
   Having now touched upon all the differ-
ent modes of treating tetanus, it only re-
mains for me to remark, that, among such
diversity of practice, it is difficult to pro-
nounce, in positive terms, wliich  method
claims  the   preference.   Comparative
trials, faithfully and  impartially made,
can alone enable us to form  an  accurate
judgment.  As the disease is not common
in this country,  the experience of" indivi-
duals, concerning it, cannot be extensive
enough for this  purpose.  Medical prac-
titioners, in our  settlements abroad, have
the best opportunities of undertaking the
investigation.   From  all, that  I have
read, I conceive, that facts prevail in fa-
vour of the following plans, in the order
set down.   1. Removal of the wounded
part and exhibition of opium, camphor,
musk, castoreum, and other  antispasmo-
dics in large doses.   2. Cold  bathing
and opium.   3.  Cold bathing, and strong
stimulants, such as  vol:.tile alkali, brandy,
wine, and spices, with bark.   4.  Mercu-
rial frictions, practised so as  quickly to
induce-a salivation.
   The reader may find some cases,  or in-
teresting matter, in Hippocrates de Morb.
Popnlaribus,  lib. 5 et 7.>  Aretxi et Galeni
Opera.  Cxlius Aurelianus de Morbis Acu-
tis.  Med.  Obs. and Inq.  Vol  1, p. Land
87; Vol. 6, p. 143; and in Hillary on the
Air and Diseases of Barbadoes. Edinburgh
Physical and Literary Essays,  Vol. 3.  In
this last work,  Dr. D. Monro describes
the mode of cure  by salivation,  as suc-
cessfully practised by a gentleman in Ja-
maica.  In Medical Transactions, Dr. Car-
ter relates a case, which yielded to a blis-
ter, applied  between  the shoulders the
whole length of the spine,  rubbing the
jaw with the oleum lateritiurn, and repeat-
ing the following  purge,  at  intervals of
three, or tour days: %. Tinct. Sacrx 3"j.
Tinct. Jalap, ^j Syr. i spina Cerv.  ^ss. M.
fiat haust.  purg.   On the intermediate
days, the oleum succini, the fetid gum, and
ol.amygdal. were exhibited.   Ofthe first,
the patient took thirty drops; ofthe ^um
twenty grains ;  and of the ol. amygdal
four ounces ; in twenty-four  houra.  Dr.
Cochrane first represented the advantages
Qf the cold bath  in the Edinburgh Medical 
366                                THORAX.
 Commentaries; a  plan, which was after-
 wards more fully explained by Dr. Wright,
 in the .Medical Observations .md Inquiries,
 Vol.  6.  Dr.  Currie, of Liverpool,  used
 tlie cold bath with success, and his name
 should not be omitted,  in favour of what
 seems one ofthe most efficacious measures
 in tetanus.
   The reader should also consult Cullen's
 First Lines of tlie Practice of Physic, Vol. 3.
 Rush's Observations on theCause andCure of
 Tetanus, in the second volume of tlie Trans-
 actions of the American Philosophical  So-
 ciety. Latta's System of Surgery, Vol. 3.
 Larrey, in Me moires de Chirurgie  Mili-
 taire, Tom. 1, p.  235, &c. and Tom. 3,p.
 286, &c.
   THERIOMA.  (from B-^iow, to rage,
 like a wiid beast.)  A  malignant ulcer.
   THERMAE, (from -re§fco«, warm.)  Mi-
 neral warm baths.
   THORAX. (The Chest.)   The term,
 thorax, is  said to be  derived from  the
 Greek verb,  B-ot^eu, to leap, because  tiie
 heart leaps, or pulsates in it.
    In .the language ot anatomy, the thorax
 implies the upper part ot the trunk, or
 that portion of the body,  which is sur-
 rounded by the sternum, the ribs, and  the
 dorsal vertebrae.
    The chest is subject to different kinds
 of injuries, produced by external causes,
 and the important nature of the organs,
 which it contains, renders the considera-
 tion of such cases of  the high, st conse-
 quence to the practitioner.   In speaking
 of Fractures ofthe Ribs,Emphysema,Para-
 centesis of the Thorax,  £Jc. an account  has
s already been offered, of some affections of
 the thorax, which are very essential to be
 known by every surgeon.   In the present
 article, we intend to treat of the subject
 of wounds,  interesting this  part of  the
 body;  but,  before beginning what  we
 have to say, concerning  these  cases, it
 seems proper to remind the reader of some
 anatomical circumstances, relative to  the
 thoracic viscera.
    The thorax is a very large cavity, of an
 irregularly oval figure, bounded in front
 by tlie sternum, laterally by the ribs, pos-
 teriorly by the vertebrae ofthe back, above
 by the clavicles, and  below by the  dia-
 phragm, a very powerful muscle, which
 forms a kind of partition between the ca-
 vity of the thorax, and that of the abdo-
 men.
    The diaphragm is not stretched across,
 in a straight direction, from one side of
 the  chest to the other.; but, on the con-
 trary, descends  much further in some
 places, than in others.  If the cavity of
 tlie thorax be opened,  by  a transverse
 section, about the middle ofthe sternum,
 the diaphragm appears, on  examination,
to be very prominent and convex towards
its centre, while it sinks downward at its
edges, towards all  the  points, to which
the muscle is attached.   At its  anterior,
and  most elevated part, it is fixed to the
ensiform cartilage, whence, descending
obliquely to ihe  right  and left,  it is in-
serted, on  both sides,  into the  seventh
rib,  to all the lower ribs, and, lastly, to
the lower dorsal vertebrae. According to
this  description,  it is  obvious,  that the
cavity of the thorax has  much greater
depth  and capacity behind,  than  before;
a circumstance, which surgeons ought to
be well aware of, or e se they will be very
apt to give most erroneous opinions, con-
cerning  such wounds  as happen to the
chest.  For instance, a practitioner, defi.
cient  in anatomical  knowledge, might
imagine, that a weapon  struck from above
downward,  into the  front of the chest,
could  never reach the lungs, after having
penetrated the cavity ofthe abdomen.  It
is a fact, however, that no  instrument
could  be pushed in this  direction, even
some inches below the highest part of the
abdomen, without entering into the cavity
of the chest.
.   The whole cavity of the thorax is lined
by a membrane, named  the pleura, which
is every where adherent  to the bones, which
form the parietes of this cavity, and to the
diaphragm.   Each side of the thorax has
a  d stinct pleura.  The two membranes
meet in the middle of the chest,  and ex-
tend from the sternum to the vertebra.
In this manner, two cavities are  formed,
which  have no  sort  of communication
"With each other.  The  way, in which the
two pleurae touch,  and lie against each
other, forms a middle partition,  which is
called the mediastinum. These two mem-
branes are  intimately  adherent  to each
other, in front, the whole  length of the
sternum; but,  behind, where   they ap-
proach the vertebrae, they separate from
each other, so as to leave  room for the
passage of the aorta, oesophagus, &c. The
heart, enclosed in  its pericardium, occu-
pies a considerable space on the left ofthe
mediastinum, all the rest of the  cavity of
the  chest being filled with the lungs, ex-
cept behind, where the large blood-ves-
 sels, nerves, thoracic duct, and  oesopha-
gus, are situated. In the perfectly healthy
stale, the lungs do not adhere to the pleu-
 ra ;  hut, in this climate, at least, the ma-
jority of subjects, which are examined af-
 ter death, are found to have such adhe-
 sions in different places.  The disease may
 probably be occasioned by a very slight
 inflammation in  the  chest ; and, as the
 surface of the lungs is  naturally dest ined
 to be always in  close  contact with the
 pleura,  and patients are  frt-quently not
 suspected to have any thing wrong in the 
THORAX.
367
thorax,  this morbid change being  often
accidentally discovered  after death,  in
looking  for something else; we may con-
elude, that it does  not occasion any in-
conveniences.
1  The thorax is subject to  all  kinds  of
wounds  ;  but,  the  importance of  these
injuries  most particularly depends on the
depth, to whichthey extend.   Such as do
not reach beyond the integuments, do not
differ from common wounds,  and,  when
properly treated, are seldom followed  by
any bad consequences.   On the  contrary,
those which penetrate the cavity of the
pleura, even by the slightest opening, are
apt  to occasion, in  some circumstances,
the  most  alarming symptoms.  Lastly,
such wounds, as injure any ofthe thoracic
viscera, are always to  be considered,  as
placing the patient in a state of consider-
able danger.
   From wha,t has been said,  it appears,
that wounds of the thorax are very pro-
perly divisible  into  three kinds: viz.  1.
 such as only affect the skin, and muscles ;
 2. such as enter the cavity of the  chest,
 but injure none  of the viscera ;  3. others,
 which injure the lungs,-or   some  other
 viscus.

   SUPERFICIAL WOUNDS OF THE THORAX.

   Immediately a surgeon  is  called to a
 recent wound ofthe chest, his  first care
 should  be  to  endeavour  to ascertain,
 whether the weapon has penetrated the
 chest, or not.  An opinion may be formed
 on this subject,  by attending  to several.
 circumstances.   1.  Surgical  writers  re-
 commend, for  this  purpose,  placing the
 wounded person in  the same  posture,  in
 which  he  was, when he  received tiie
 wound,  and  then  carefully   examining
 with a finger, or probe, the direction, and
 depth of the wound.  2. We  are also  ad-
 vised, if possible, to get the weapon, with
 which  the injury  was inflicted, and,  by
 the bloody part, judge  how  far  it has
 penetrated.  3. ""I've are advised to inject
 some liquid into the orifice ofthe wound,
 and to observe,  whether it regurgitates im-
 mediately, or lodges in the part.  4. The
 colour and quantity of the blood, emitted
 from the wound, are  to be noticed, and
 whether any is  coughed  up.   5. We  are
 to examine, whether the circumference of
 the wound becomes  emphysematous, or
 any air escapes from its orifice in respira-
 tion.   6.  Lastly, the state of  the pulse
 and breathing is to  be attended to.
    It is a general precept, that, in order to
 examine a wound in the best  manner,  the
 patient should  be put, as nearly as possi-
 ble, in the 6ame posture, as he was in at
 the moment of meeting with the accident;
but, it is very  essential, that this pre-
caution should not be neglected,  in ex-
amining a wound ofthe chest.  The great
number of muscles, which surround this
part, and the continual motion of the ribs,
may make  a wound appear, in one posi-
tion of the body, quite superficial,  while,
in another posture, it  shall  be  found to
extend  to  a great depth.  For, should
any part of a rib, or even  any of the cel-
lular substance, in consequence ofthe pa-
tient's  posture, become situated  in the
track of the wound,  neither the  finger,
the probe, nor an injection, will pass with
sufficient ease to make a proper  examina-
tion.
   Sometimes, the orifice of the wound is
so large, that one can easily distinguish
with  the eye,  whether the injury pene-
trates into  the cavity of" the thorax, or
not; or, one can introduce a finger, which,
when this can be used, without  bruising,
or tearing the parts, is always preferable
to any probe.  But, when the smallness
of the opening prohibits the  employment
of the finger, we are necessitated to make
use of a probe ; and the best instrument,
of this kind, is in this case a bougie, which
is not so apt  as a silver probe,  to pierce
parts,  which have not  been  wounded.
However,  a prudent,  and experienced,
practitioner  will seldom do any mischief
of this sort, whether he uses one  instru-
ment, or the other.
   In treating of wounds of the abdomen,
 I have cautioned  surgeons against being
 too officious in  probing  such injuries,
 merely, for the sake  of  gratifying their
 own curiosity.  The same advice  is  equally
 applicable to the present cases.  Surgical
 authors have, perhaps, dwelt too much on
 the subject of probing wounds of  the ab-
 domen, and thorax, and their readers im-
 bibe  an opinion, that, until they have
 traced the wound, with their  finger, or
 probe, to its very bottom, and termination,
 they are not qualified to  put in practice
 any kind of measures.  The only  advant-
 age of knowing,  that a wound penetrates
 the chest, is that the practitioner imme-
 diately  feels himself justified  in  having
 recourse to bleeding and other antiphlo-
 gistic means,  and thus averts  inflamma-
 tion of the pleura, and lungs,  which af-
 fection, when it has made progress,  often
 proves fatal.   However, there can be  lit-
  tle doubt, that if the nature and depth of
 the  wound cannot  be readily detected,
  with the eye, the finger, or a probe, it is
  much safer to bleed the patient,  than  to
  put  him  to  useless pain, irritate the in-
 jury with the introduction of instruments,
  and waste opportunities of  doing good,
  which  can  often never  be recalled.   In
  short, it is  belter, and more advantage- 
368
THORAX.
ous, for  all patients, that some of them
should lose blood, perhaps, unnecessarily,
than that any of them should die, in con-
sequence of t he evacuation being omitted,
or delayed.
  Almost all the writers, who have taken
pains in  directing, how wounds of tlie
thorax should be probed, conclude with
remark ng, that, however advantageous a
knowL-dge of the direction and depth of
the wound may  be, much harm has fre-
quently been  done by  pushing the  at-
tempts to gain such information too far.
It is,  perhaps, of greater importance to
ascertain, by some  kind of examination,
the extent  of a  wound,  which does not
reach beyond the integuments, or inj,er-
costals, than to know, whether the wound
extends into the cavity of the chest.  For,
even when  the pleura is found  to be  di-
vided, if the wound is attended with no
urgent symptoms,  the  information  is of
no practical use, if  we make it a rule to
adopt, without the least  delay, a strict an-
tiphlogistic plan of treatment, in all cases,
in which there is any doubt, or chance of
the parts, within the chest,.being wound-
ed, and likely to  inflame.  Besides, very
frequently, the symptoms are more urgent
and alarming,  than they could be, were
only parts on tiie outside of the thorax
injured; and, in these instances, it  is ob-
vious, that the employment of a probe can-
not be necessary for discovering, that the
wound extends into the  chest.
  We h.^ve above adverted to  inspecting
the weapon, with which the wound  was
inflicted, as a mode of  gaining some in-
formation, concerning the probable  depth
of  the   wound.  Enquiry may also be
made, in what  direction it  was pushed:
and, sometimes, the  blood on the instru-
ment will denote how deeply it penetrat-
ed.  It  is  clear, however,  that though
information of" this kind  may be obtained,
in a few instances,  in general, it is other-
wise.
  When, by any ofthe  above  means, it
'cannot be learn , whether the wound pene-
trates the chest, or not, various authors
recommend the injection of hike-warm
water.  If the water regurgitates at once,
they conclude, that th«-  injury  is only  su-
perficial; but, when the fluid,  either
wholly, or in part, continues in the wound,
without producing any external swelling,
they infer with certainty, that an opening
has been, made in the pleura.  This plan
of examining the state of parts, however,
is much more objectionable, than the em-
ployment of a probe ; for, if the liquid be
propelled, with a certain degree of force,
for tiie purpose of driving it to the bottom
of the wound, parts, which  were not  be-
fore hurt, will in this manner become in-
jured.   The  fluid may also be injected
into the cavities of the cellular substance,
and may seem to be passing through the
track of the wound into the chest, while,
in reality, not a  drop does so.   Besides,
is it a  warrantable  proceeding  to try to
insinuate any quantity, or kind, of liquid,
whatever, between the pleura and lungs,
into a situation, in which  it must neces-
sarily obstruct the important function of
respiration, and  cause serious inconvem-
ence ?
   When air issues from the wound in ex-
piration, there is ground  for suspecting,
that the lungs are wounded. But, authors
have erred in  setting down this circum-
stance, as an infallible criterion  of the
nature  of the accident;  for, the  same
symptom may happen, when there is only
an opening made into i he chest, without
any injury of the lungs whatever.  The
air, which is  expelled in  expiration, has
previously got into  the  bag of the pleura
through the  wound,  in  inspiration.  In
such cases, the external air insinuates it-
self, through  the opening into the chest,
between the pleura and lungs, and, it will
be seen to escape, during expiration, al-
though tiie lungs may not be at all wound-
ed.  In order to  remove  all doubt upon
this subject, the patientshould be request-
ed to expire, as strongly as  he  can, so as
to force out whatever air  may have accu-
mulated in the chest.  At the end of each
expiration of this kind, care must be taken
to bring the  skin closely over the orifice
ofthe  wound, and to keep it thus applied,
during each following inspiration, for the
purpose of  preventing  the external  air
from  entering.  In this way, if there be
no wound of the lung,  all the air will
soon be expelled; but, when some still
continues to  come out  in expiration,  we
may conclude,  with certainty,  that the
lungs are  wounded.
   Sometimes, an emphysematous swelling
takes  place round wounds of the thorax,
in consequence of a quantity of air diffus-
ing itself in the cellular substance.  This
symptom is very uncommon in wounds,
wliich are straight, and ample; but, it is
by no  means,  unfrequent, in  wounds
caused by narrow stabs, more  especially
oblique ones, and by the points of broken
ribs   (See Emphysema.)  When a consi-
derable quantity of  blood flows from  a
wound of the chest, there is great cause
for  conjecturing, not  only, that it has
penetrated the cavity of the thorax, but,
also, that some of the thoracic viscera are
injured.  Excepting the intercostal arte-
ries, which run  along the lower edges of
the ribs, and the trunk of  the thoracic ar-
teries, all the other  vessels, on the  out-
side of the chest, a very  inconsiderable 
THORAX.
369
K  proper compression will soon shew,
whether the blood escapes from an artery
on the outside ofthe c.ivity ofthe pleura.
The  situation, and  direction of wounds
very  frequently denote at once, that the
hemorrhage  cannot  proceed from any of
the trunks of tlie  thoracic arteries.
  Even, the  appearance of the  blood,
which comes from  the wound,  may lead
to some conjectures, concerning the depth
of the injury  The blood, which flows
from wounds of the  lungs, is ofa brighter
scarlet colour, and more frothy, than that
which is emitted from any other part.
  There can be no doubt of the lungs be-
ing wounded, when the patient is observ-
ed to spit up blood ; but, the absence of
this symptom is,  by  no means,  to be re-
garded as a proof of the contrary.
  The state of the pulse, and that of re-
spiration, ought to be particularly attend-
ed to by the practitioner.   Neither one,
nor the  other, seems altered, at  least at
first,  when  wounds do  not reach more
deeply, than the integuments ; but, those,
which penetrate the cavity of the thorax,
and,  especially, such as injure any of the
viscera,  may frequently be distinguished,
from the very first moment of their occur-
rence, by their effects on the sanguiferous
system,  and the  function of respiration.
When the lungs  happen to be wounded,
at a  place where they have  contracted an
adhesion to  the pleura, the  wound may
extend to a great depth, and yet no air
may be diffused in the cavity ofthe thorax,
nor the functions of" these  organs be at
all disturbed.  But, when  either air,  or
blood, has insinuated  itself between the
lungs and the pleura, the  lungs become
immediately oppressed, the breathing  is
attended with difficulty, the pulse is weak,
contracted,  and  intermittent;  and  rio
doubt can be entertained, concerning the
nature ofthe injury.
  Having said  enough,  relative to the
diagnosis of wounds of  the thorax, we
shall next consider their treatment.
  Wounds of the thorax, which only  in-
jure  the  integuments, are  not  generally
attended with any danger; they heal with
the same readiness, and by the same means,
as common, superficial,  wounds in any
other part ofthe body.
 ' But, when the surgeon  has to treat a
punctured, or a gun-shot wound,  it is too
frequently  directed,  by writers  on sur-
gery, to lay open  the track of the injury,
from one end to the other with a knife, if
its  course should not be  too extensive,
and then to dress the cavity down to the
bottom.  Such authors  also add, that
when the track of tiie wound is so exten-
sive,  as not to "admit of this plan, ft is
better to introduce a seton through  it.
     Vol. II.
Their object, in employing these methods,
is to prevent the outer part of the wound
from healing too soon, and thus give time
for the whole of  it to heal in an equal de-
gree.  Afterwards, they advise the silk of
the seton to be gradually diminished, and
when, at length, the whole 01 it is remov-
ed, a slight degree of compression,  kept
up,for a few days, is deemed  sufficient
for the completion of the cure.
  The French surgeons  have the discre-
dit of bringing setons into  fashion in this
branch of surgery, and  I am particularly
glad, that an able modern  writer has ex-
posed the absurdity of the practice. " We
find  (says  Mr. John Bell) the  history of
it, to  be plainly this :   that as Guy de
Chauliac,  Pare", and  all the older sur-
geons, did not know  how  to dilate gun-
shot wounds,  they found these same se-
tons useful  in bringing the eschar sooner
away, and in preserving  an open wound ;
and, as they believed the wounds to be
poisoned,  they  took  the opportunity of
conducting, by  these setons,   whatever
acrid medicines  might,  according to the
prevailing  doctrines  of   that time,  have
any chance of correcting  the poison." Mr.
J. Bell notices, how surprising it is to see
the cruelty, and perseverance, with which
some modern  practitioners, particularly,
French, draw these cords through wound-
ed limbs ; and  when the roughness of
such a cord, or the acrimony of the drugs
conveyed  by it,  produces a copious sup-
puration,  these men are delighted  with
such proofs of their success.  The setons
have been introduced by the French sur-
geons, across  the  thickest  parts of the
limbs, along the whole length of the fore-
arm, and, at the same  time, frequently
through the wrist-joint.   The setons have
also  been covered with stimulating appli-
cations. Profuse suppurations, and dread-
ful swellings of  course  ensued; still, as
Mr. J. Bell has remarked, these cruelties
were continued,  till the  wound healed al-
most in spite ofthe pain; or till-the com-
ing on of very dreadful pain, great suppu-
rations, convulsions, &c. made the sur-
geon discontinue the method, or even am-
putate the  limb.  The  French have be-
come so familiarized to setons, that they
do not restrict their use to flesh wounds,
they pass them  quite across the thorax,
across the  abdomen,  and  even through
wounds of the knee-joint.
  When we wish to excite inflammation,
in the cavity of the tunica vaginalis, for
the purpose of radically curing a hydro-
cele, we either pass a seton through the
part; lay it open with an extensive inci-
sion ; cram a tent into it; or inject some
irrigating fluid into it.  While the animal
machine  continues the  same,  says Mr.
     3A 
$70
THORAX.
 John Bell, the same stimuli will produce
 tlie  same effects, and a seton, injection,
 or long tent, if they produce pain and in-
 flammation  in the scrotum,  will not he
 easy in the chest; and, unless we can use
 them in the chest, with the same  inten-
 tions, with which we use them in the hy-
 drocele,  (in other words)  unless we are
 justified in inflaming the chest, and caus-
 ing an adhesion of all the parts, we can-
 not  use  them, with any consistency, or
 good sense.
   With  regard to the cases, which  the
 French  adduce  in confirmation of  the
 good effects of their plans, I am entirely
 of. opinion with Mr. J. Bell, that the facts
 only prove, that  ihe patients recovered in
 spite of the setons.  " It is like  (adds  this
 author) what happened to a surgeon, who
 was  dabbling in  the  thorax with a piece
 of caustic, which  fell directly into the ca-
 vity  of the chest, where it caused very
 large suppurations,  anil • yet the patient
 was  saved-  The patient  recovered, in
 spite of  the caustic, just as M. Guerin's
 patient,  and many other  poor unhappy
 souls, who lived  in  spite of the setons.
 One  would think,  that people took a plea-
 sure in passing setons across the eye-ball,
 the chest, the knee-joint, &c. merely to
 make-fools stare, when the business might
 be as effectually dwne  with an abscess lan-
 cet."
   Mr. John Bell,  in his usual lively  style,
 makes the employment of tents, in wounds
 of the chest, seem equally ridiculous and
 improper  Indeed, he says,  he knows of
 no occasion in all surgery, in which tents  can
 be useful, except in the single one of a nar-
 row opening, which we desire to dilate, in or-
 der to get at tlie bottom of the wound ; and
 where either, on account of some great arte-
 ry, or the fearful temper of our patient  we
 dare  not  use the  knife.   (See  J. Bell on
 Wounds.  Discourse 2,  Vol. 2.)           ,
   Having hitherto been engaged, rather
 in pointing out, what ought not to be done,
 than  what ought,  I shall next make some
 remarks  on  the line of conduct,  which
 should be adopted, in cases of wounds of
 the parietes of the chest.
   When the wound is a common cut,  the
 sides of  the division  are to be brought
 into contact, and  maintained in this posi-
tion,  by the aid of strips of adhesive plas-
 ter,  compresses,  and a bandage,  until
 they  have  grown together.  There will
 very  seldom be any occasion  to employ
 sutures in these instances, if the surgeon
 only  observe  to  relax such  muscles as
 happen to be cut,  or to be situated imme-
 diately under  the wound of  the integu-
 ments.
   As cut wounds seldom, or never pene-
 trate the chestt and there is generally no
reason, why they should not unite by the
first intention, without being followed by
extensive  inflammation   and  abscesses,
only a moderate  use of antiphlogistic
means will usually be necessary.  Bleed-
ing will not often be requisite. The grand
objects are, to keep the patient in a quiet
state,  on  rather low diet, and to hinder
him from taking wine, porter, spirits, or
any stimulating beverages.
  If the  wound, instead  of healing  fa-
vourably, should inflame, the  treatment
should be regulated by the principles laid
down  in  the  article  Inflammation.  If it
should suppurate  over its whole surface,
still the  sides should generally be kept
approximated by one, or two  strips of
sticking  plaster ; for, in  this way,ihe ca-
vity, which must now be filled up by gra-
nulations, will be rendered much smaller,
than it otherwise would be.  The softest
particles of lint may be laid in the  cavity
of the wound, which thp sticking plaster
does  not  entirely remove, and over the
whole a pledget of some mild,  unirritat-
ing ointment.  No pressure is now pro-
per, until tlie  inflammation diminishes;
and if the matter should be very copious,
attended  with much  surrounding inflam-
mation, the best application would then
be  an emollient  poultice. The patient
should also be bled, and leeches should be
applied,  as often as necessary,  round the
wounded  part.
  When the case is a stab, or punctured
wound, the fibres of the divided parts are
not simply cut, they are also considerably
stretched, bruised, and otherwise injured.
Hence, they cannot, in general, be expect-
ed  to admit so readily of being united, as
the sides of a clean incision, made with a
sharp  instrument.  However, the  possi-
bility of  uniting the  opposite  sides  of
punctured wounds must depend very much
on the shape of the weapon, and the sud-
denness,   roughness, and violence,  with
which it  was driven  into the  part.  A
prick with a needle is a punctured wound;
so is that so of en made by surgeons with
their lancets ; yet, these injuries do pot
so frequently bring on violent inflamma-
tion, and  abscesses, as those wounds of-
ten do, which are inflicted with bayonet?,
and pikes.
  Let  us  suppose a man has received a
thrust of  a bayonet, which has  run into
the skin  and muscles, covering one side
of the thorax ; what plan can the surgeon
follow, with the greatest advantage to his
patient }
  Instead of laying open the whole track
of such a wound with a knife,  as is bar-
barously  recommended in many of the
principal  works  on surgery;  instead of
drawing a seton through its whole course", 
THORAX.
371
 tfr of cramming into the part,  a hard, ir-
 ritating  tent;  the  practitioner  should
 take whatever chance there is  of uniting
 the  wound  without  suppuration.  For
 this purpose, he should recollect, that the
 great degree of violence, done to the parts
 in punctured wounds, is the reason,  why
 they are so apt to  inflame and suppurate.
 Hence,  the expected inflammation is (to
 use a vulgar expression) to be knocked on
 the head, if possible, on the very first  in-
 stance ; and  immediately  the  wound is
 dressed, the patient should be freely bled,
 and take some saline purgative medicines.
 With regard to the dressings,  the orifice
 of the wound may be closed with sticking
 plaster, if the circumstance is practicable :
 if not, it may be covered with any mild
 superficial  applications.   Over the track
 of" the stab, a compress should  be placed,,
 and  over this a common roller  applied
 with  some degree of tightness.  Thus,
 the sides of the wound will be kept,  as
 much as possible, in universal contact;
 the  chance  of union by  the first inten-
 tion  taken ; and all  painful  operations
 avoided.
  If strict antiphlogistic means, and pres-
 sure, are thus put in practice, many stabs
 unite without abscesses, when surgeons
 entertain little hope of such success.
  But supposing,  that  suppuration  fol-
 lows, and a  collection of matter takes
 place, will tlie patient suffer more, or  be
 put into greater danger, by having a pro-
 per depending opening,  of just sufficient
 size, now made  into the abscess at a pro-
  Eer place, than  if he had submitted  to
  ive the formidable  operation  of laying
 open the whole extent of a stab, perform-
 ed in the first  instance.  In short,  will
 he suffer half so much,  be half so long in
 getting well, or have to encounter half the
 danger ? With all this  advantage,  he
 will have taken  a  certain chance, which
 attends all these cases, of the wound  be-
 coming united by, what 'r. called, the first
 intention, that is to say, without any sup-
 puration.  I need not enlarge upon  this
 subject,  but refer the reader to Punctured
 TToundr, "hi the article Wounds, and to the
 treatment  of  abscesses,  in  the  article
 Suppuration.    Gun-shot  Wounds,  only
 injuring  the parietes of the chest,  are
 to be  treated,  according to the princi-
 ples explained in  the   article  Gunshot
 Wounds.

 •F WOUNDS rEXETBATINO THE CAVITX  OF
             THE THORAX.

  Wounds, which penetrate the chest, are
always dangerous, and consequently, claim
the utmost  attention of the  practitioner,
We shall first treat  of such wounds, as
 enter the cavity of the thorax, but with'
 out injuring any of the viscera.
   In the healthy state, the lungs so com-
 pletely fill the cavity of the thorax, that
 both  in  inspiration and expiration, they
 are always in close contact with the pleu-
 ra ;  and,  whenever  air,  blood,  or any
 other  matter,  insinuates  itself, between
 the outer surface of the lungs, and the
 inner one of the pleura, more or less op-
 pression, and difficulty, of breathing im-
 mediately take place.  In all wounds, at-
 tended with a division of the pleura, oc-
 curring  in  a situation, where there hap*
 pens to be no adhesion between  i his mem«
 brane and the lungs, some of the external
 air, or a small quant.ty of blood, or bothj
 can hardly fail to get into the cavity ofthe
 thorax.  If one of the intercostal  arteries
 should  be  wounded,  and  the   external
 wound be, at the same time, very narrow,
 the blood furnished by this vessel, is Very
 apt to insinuate itself inwardly into the
 chest, and  immediately occasion an im-
 mense oppression of the breathing, ahd
 other symptoms of pressure on the lungs.
 Of what is to be done in this case, we shall
 presently speak.
  When a  wound is known  to have en«
 tered the pleura, and there is no symptom
 leading to  a suspicion, that the lungs, or
 any large vessel, is wounded, the injury is
 to be dressed according to common prin-
 ciples, and the more superficially the bet*
 ter.  Authors also usually direct us, just
 before we close the opening, to tell the pa«
 tient  to make  a deep inspiration, for
 the purpose of expelling as much of the
 air as possible, which may have got  into
 the cavity of the pleura.  At the  end of
 such inspiration, the edges, of the wound
 in the skin are to be brought together, and
 kept so, with sticking plaster compresses,
 and a roller, applied round the bodyi The
 other grand indications, in the treatment^
 are to  avert inflammation of the pleura
 and lungs,  by a rigorous adoption of the
antiphlogistic  plan, copious bleeding, in
 particular,  not being forgotten.
  Let  us now  consider  such wounds aj
penetrate the chest, and are complicated
with some ofthe followingcircumstances:
 l._With  the presence of foreign  bodies
 2. W ith injury of one of" the intercostal~
arteries.  3 With a protrusion of a pot*
tion of the lungs.  4.  With a considerable
emphysema.  5. With an extravasation of
blood in the thorax.
  1. Almost all wounds, Which penetrate
the chest, occasion pain and difficulty of
breathing. M.<ny of them are also follow*
ed by an emphysematous swelling rourid
the wound;  the patient is frequently at*
tacked by a  Spitting of bloOd i and after
having had, fof soma timei ft small totr* 
37*
THORAX.
tractcd,  irregular  pulse, with  a pallid
countenance, and cold extremities, he is
too often  seized  with  febrile  symptoms.
These should be counteracted by bleed-
ing, diluent beverages,  a proper regimen,
quietude, and  extern.il  applications of
the resolvent kind.  If such  symptoms
should continue  longer, than the  first
few days, without any diminution,  wri-
ters inform us, that there is  ground for
suspecting, that they  depend upon the
presepce of some foreign body. However,
it  may be  doubted, whether Sabatier's
advice, immediately to make search after
the extraneous substance, is proper, under
thi se circumstances.  For my own part,
I cannot think the symptoms, above re-
lated, by  any  means unequivocal, and
even  were they  so, the practice would
still  be questionable.    (See  Medecine
Operatoire, torn. 2, p. 244.)
  M. Sabatier has quoted the two follow-
ing cases, for the purpose of shewing what
may be attempted in  these  cases.—" A
man,   twenty-seven  years  of age,  was
struck very violently with a knife, on the
outer part of the fourth true rib.  Simple
dressings  were applied for the  first few
days ; but, a considerable coughing, and
spitting of blood ensuing, M.  Gerard was
consulted.  This gentleman  found, that
the symptoms depended,  on the presence
of a piece ofthe blade ofthe knife, which
pierced the  rib, and projected,  to  the
extent of about  six lines, into the cavity
of the thorax.  So  little of the foreign
body  was on  the outside of the  rib. and
it was so fixed in the bone, that it could
neither be extracted with any kind of
forceps, nor even moved in the least with
a le.iden mallet,  8cc.  Although, in these
urgent  circumstances, there  seemed to
be no  other resource, except that of saw-
ing, or cutting out the  portion of the rib,
M. Gerard, however, thought, that an at-
tempt might first be made to  extract the
foreign body, by  pushing it from within
outward.  For this  purpose, having put
a steel thimble on  his index finger, he
introduced it into the cavity ofthe thorax,
and thus  succeeded in pushing out the
piece  of the knife.
  The foreign body  being  taken out, M.
Gerard next introduced his finger, with-
out the  needle,  for the purpose of ex-
amining, whether the inner surface of the
rib  was not splintered.  A spicula of the
bone  was  in fact   detected, capable of
pricking the parts within the  chest;  but,
it was too firmly connected with the rest
of the rib to admit of being  completely
taken out.  Hence,  M. Gerard adopted
the plan of making tin. splintered piece of
bone  continue in  close contact with the
njain  portion, by immediately surround-
ing the whole rib, at the splintered  part,
with  a  ligature.  This  was  passed by
means of a  curved  needle, and firmly
tied  over a thick compress.   To   these
ingenious proceedings,  as  tiie French
term  them; was  imputed, not only the
cessation of all the  bad symptoms,  but a
speedy recovery.  (See M.  de  la Faye's
Notes to the  Traite ties Operations de
Dionis.)
   M. Sabatier quotes another case, which
we next insert in this Dictionary, for the
information of the reader.
   An officer was  shot in  the left side of
the chest.  The ball entered about where.
the bone, and  cartilage  of the seventh
true rib unite, and came out in  the situa-
tion of" the angle  of the same bone, which
was  broken in  two places.  The neigh-
bouring part ofthe first false rib was also
broken  behind.  Incisions were made,
which enabled the surgeon to take  away
several splinters of  bone, and facilitated,
(that absurd  French practice) the  intro-
duction of a  seton.   Soft  mild dressings
were  put on the wounds. In consequence
of the dangerous  nature of the accident,
the patient was  bled twenty-six times,
with a view of relieving the fever, difficul-
ty of breathing,  and spitting  of blood.
On the fifth day,  suppuration  had begun
to take place, and the seton could be ea-
sily drawn.  In about a fortnight, the pa-
tient  experienced a considerable abate-
ment  of" his  sufferings, and passed  some
of the ensuing days  in a tolerably easy
state.  Circumstances having made  it ne-
cessary to move him to another place, on
the twenty-fourth day, he had  an uneasy
night :  febrile  symptoms  took place,
ajnd the discharge  was  not of its  usual
consistence.  Two more bleedings  were
practised, and  the  critical state of the
patient led the surgeon to  examine the
wounds again.  On passing a finger into
the wound, which was situated behind, a
foreign body was felt, and easily extract-
ed.  It proved  to be a  piece  of the pa-
tient's coat.   A spicula of bone  was also
felt more deeply lodged, which required
the posterior wound to  be dilated for its
extraction.  Some amendment  followed
the  removal of  these  extraneous  sub-
stances.
   On the thirtieth  day  from the receipt
of the wound, the  bad symptoms having
come on  again,  two more  bleedings were
practised, and, as fear was entertained,that
the seton did harm, it was suppressed. The
patient now first made complaint of feel-
ing something, which pricked him, in a
deep  situation, between the two openings
of tiie wound.  It  was found impracticable
to ascertain  the cause of  this sensation,
without dividing  all that intervened,  be- 
THORAX.
j7o
tween the two wounds, and which formed
a space of seven or eight finger-breadths.
This serious operation  was resolved on
in a  consultation,  and M. Guerin  set
about it  by cutting from within outward,
tiie parts between the two ribs, with the
aid of a finger introduced into  the  pos-
terior wound.   Care was  taken not to
cut near the lower edge of the upper rib."
In this way, the whole track of the ball
was  laid open, and, in the middle of it,
a very sharp splinter was found, sticking
in the substance of the lungs.  This was
removed,  and the  wound dressed with
simple applications.  From this  day all
the bad  symptoms  ceased, and  the  cure
was  completed at the end of four months.
 (Obs. de  Guerin in  Mem. de  VAcad. de
 Chirurgie, torn. 2; 4to.)
   Mr. John Bell has  taken notice of the
 preceding case :  he observes, that some of
 M. Guerin's steps were bold and good, as
 well as successful; but, that the employ-
 ment of the seton  was wrong.  The ex-
 ample teaches us several  important cir-
 cumstances :  1.  The propriety of making
 very free dilatations for the extraction of
 splintered pieces of bone.  2.  The utility
 of repeated copious bleedings, which, in
 the  above case, indeed, had the greatest
 effect both in preventing such hemorrhage
 in the chest, as  would probably have pro-
 duced suffocation,  and also in averting a
 degree  of inflammation in the thorax,
 which would have proved fatal.
   Mr.  John  Bell  very judiciously con-
 demns the seton,  used by M. Guerin :
 " Had  M. Guerin (says he)  been asked
 what good it was to do, it would have
  been difficult for  him  to  have invented
 even a plausible apology for the practice,
  which, if it was not doing good, could not
  fail to do harm. Was this seton necessary
 for  keeping the wound open ? No, surely;
 for  tlie wound  could  not have closed,
  while it was irritated, and kept in suppu-
  ration  by splinters of bone, and a piece of
  cloth within  the breast.  Was it to draw
  the piece of cloth out?  Surely,  in the
  course  of twenty  days, a piece of cloth
  would have had some chance, at least,  of
  being floated towards the wound, either
  by  the  natural  flux pf the matter, or by
  the help of a mild injection.  Was it use-
  ful  in  supporting the  discharge?  This
  would have been  a  sore question for M.
  Guerin; for it supported the  suppuration
  only by inflaming the chest; and where
  inflammation of the chest, or high cough,
  or  bloody expectoration, or a profuse dis-
  charge, were the  chief dangers, a great
  seton could hardly be a comfortable  in-
  mate in the breast.  I think one might
  verv boldly promise toproduce bloody ex-
  pectoration  and  terrible cough, profuse
suppurations, and  oppression, to any de-
gree,  by drawing  such a cord across  a
sound thorax."
  Mr. John  Bell next censures M. Goerin
for  not  having  discovered the  pricking
piece of bone before the thirty-eighth day;
and imputes his,  in some degree, to the
seton, the pain of drawing which across
the chest deadened every lesser pain, and,
consequently, the  patient could not feel
the trifling  pricking of the bone, till his
greater  sufferings from the seton were al-
layed.   " In short, (says  Mr. John  Bell)
M. Guerin passes a great strap of coarse
linen across  the cavity of the chest, and
when it causes inflammation, he thinks  to
subdue  it by bleeding;  when M. Guerin
continued for thirty days drawing a coarse
seton through the breast every morning,
and bleeding  for the cough  every night,
what did  he do,  but raise inflammation
with  his left hand,  to shew how well  he
could cure it with his right ?"  (See John
 Bell on  Wounds, Vol. 2, p 36—38.)
  2. When  one of the intercostal arteries
is wounded in the  track of  a narrow
oblique wound, the nature of the accident t
cannot  at first  be known.   The blood,
which the vessel  pours  out, commonly
makes its way into tiie cavity  of the chest,
where it causes an extravasation, which is
more, or less considerable.  But when the
 wound  is ample,  and penetrates in a  di-
 rect manner, the effused blood, whfeh has
 all the  characters of arterial  blood, leaves
 no doubt, concerning the injury of an in-
 tercostal artery.  However,  should there
 still be the  least uncertainty,  it may easily
 be dispelled, by introducing  the end of a
 finger  into  the wound,  and making pres-
 sure with it on the lower edge of the rib,
 which corresponds to the vessel suspected
 to be injured.   Some have recommended
 introducing, under the  rib,  a  hollow  cy-
 lindrical piece  of pasteboard; and they
 infer, that  when the blood flows through
 its cavity,  it comes from the  intercostal
 artery; but, that if it passes out under-
 neath the pasteboard, it issues from  the
 cavity  of the  thorax.  However, besides
 several objections, which might be  urged
 against this method, its adoption  cannot
 be made, unless  there  be a large, open
 wound, in  which case,  the  plan may be
 dispensed with, because the  pl.ice whence
 the blood flows, is now visible.
    Surgeons, long ago, began to exercise
 their industry, in devising  some  means
 for suppressing hemorrhage from the in-
 tercostal arteries,  in wounds ofthe chest.
 Gerard first proposed  to stop such  he-
 morrhage,  by means of a ligature.   His
 plan was to enlarge the external wound,
 as far as the upper edge of the rib, corre-
 sponding to the  intercostal  artery, which 
374
THORAX.
 is wounded, and then to introduce into
 the chest a common curved needle, armed
 with a ligature,  to which is attached  a
 dossil of lint.  The needle is to be passed
 liehind the rib, rather higher than the su-
 perior edge of the bone.  The point ofthe
 instrument is  then to be pushed, from
 within outward, and brought out through
 the  external  wound, together  with  the
 ligature,  which follows  it.    When  the
 dossil has come into contact with the ar-
 tery, the two ends of the ligature are to
 be tied over a thick compress,  placed on
 the  outside of the rib.   In  this manner,
 the bone is surrounded with the ligature,
 and the artery compressed.
   Goulard, a surgeon of  Montpelier, hav-
 ing found difficulty in passing a common
 needle, whose  shape  little corresponded
 to the track,  through  which  it had to
 pass, being  curved towards  its point,
 and  straight towards the eye, had a par-
 ticular one constructed for this operation.
 He also feared, that the former instru-
 ment,  wliich  has  a sharp  point,  and
 edges,  might  wound the  lungs.   The
•one,  which  Goulard  invented,  formed
 three-fourths of a circle, and  was  fixed
 on a long handle,  which facilitated its
 being introduced.  The eye,  in which
 the ligature is to be put, is situated near
 the point, which  is a little blunted, and
 the ligature lies also in  a groove, con-
 structed along the convexity of the in-
 strument.  When this needle had passed
 through the  intercostal muscles, and its
 point had  made its appearance over the
 rib,   which was  above  the  artery, the
 ligature used  to  be united, and  held,
 while the needle was withdrawn at the
 place, where it had entered.  The liga-
 ture was then tied, just in the same man-
 ner, as in Gerard's method.
  Since the use of the  ligature, it has
 been  thought,  that compression might
 answer better.  Lottery, professor of ana-
 tomy in the  university   of  Turin,  had
 constructed, for this purpose, a steel plate,
 which he submitted to the /inspection of
 the Academy of Surgery, and is both de-
 scribed,  and  engraved  in  the  second
 volume, 4to.  of the Memoirs of this So-
 ciety.  This plate,, as  we have said, is
 made of steel, and  is of  a  long shape;
 narrow at one end; broad at the other;
 curved in two directions at its narrow
 part; and pierced at this  place with some
 lioles, by means of which  a compress, cal-
 culated for  compressing the artery, is
 fastened  on the instrument,  an opening
 having been first made in the situation of
 the wound of the vessel,  for the purpose
 of giving vent to blood, already extrava-
 sated in the chest.   The other end of the
 steel  plate has two long parallel  slits,
through which  a  ribband  is passed, in
order to fasten the instrument.
   This steel contrivance  is used  in the
following  manner:  when   the  wound,
corresponding to  the  intercostal artery,
is sufficiently extensive in the transverse
direction, the narrow,  bent end of the
instrument is to be introduced, in such a
way,  that the lower edge of the rib above
may lie in the concavity of the curvature,
and the compress press on the edge of
the bone, and, of  course, on the artery.
The rest of the  instrument  applies itself
to the side-of the  thorax, in which situa-
tion  it is to be  fastened.    When the
wound is not ample  enough, a sufficient
dilatation of it must be made for the in-
troduction of the instrument.
   M  Quesnay  made use iff a piece of
ivory, which he covered  with lint,  Sec.
and  then introduced within  the  chest. ~
The instrument was thendrawnfrom with-
in outward, by means of a ribband, which
was fastened to it,  and thus the necessary
compression  was produced.
   Quesnay's  pLm  is  somewhat like that
invented by L6ttery.  But^to have intro-
duced the  compress  entirely into  the
thorax, together with  the  ivory,  whicn,
was the basis  of it, and  then  to  have
drawn the'contrivance  from within out-
ward,  as was probably  intended, a very
large  wound would have been  indis-
pensable.  This  is also one of the  objec-
tions  to  L6ttery's  instrument, which, in
fact, could only be employed, when there
was a free and ample opening.  However,
there are other objections to this instru-
ment :  it obstructs the motion of  the
thorax;  it prevents  blood,  extravasated
in the chest, from readily making its
escape,  notwithstanding   the   opening"
made in the curved part of the instru-
ment ; and, lastly,  it does not effectually
stop the bleeding, because it does  not
hinder the rib from rising, against  which
the pressure  should  be made, and, con-
sequently, tlie hemorrhage may then lake
place.
  Belloque, seeing the  inefficacy  of all
the compressing means, used before his
time,  and their inconveniencies, invented
an instrument,   which,  he  says, is  cal-
culated from making proper pressure, and,
following, the motion of the ribs, with-
out hindering the escape of extravasated
blood.  The  machine is engraved,  and
described, in 2 lorn.  4fo. of  the Memoirs
of the Royal Academy of  Surgery in
France.  It  is composed of two  plates,
which are wadded, and  capable of being
approximated, by means  ofa screw. This
instrument, as M. Sabatier observes, does
indeed promise to be completely effectual
in its action; but,  it is complicated, and 
THORAX.
375
awkward, and its utility is  founded on
the supposition of the wound being larger,
than wounds are, which are  made with
common weapons.
  As the object is to make pressure on
the artery, it is quite unnecessary to have,
for "this rare  accident, numerous instru-
ments, which could seldom be at hand,
and which are also liable to all  the above
objections.   A common dossil oflint (says
Sabatier,) fastened to a  strong ligature,
and introduced  between the  two  ribs,
or even  quite  into the  chest, and then
drawn, from  within outward, like  Ques-
nay's compress, would fulfil every desira-
ble purpose.    This  being  done,  the
external wound  should be  covered with
simple dressings, and a  bandage applied
roum. the body.   The patient should be
freely, and repeatedly bled, and treated
on the most  rigorous antiphlogistic plan;
•very method being adopted, which seems
proper, in cases of wounds  penetrating
the chest, which  are almost always attend-
ed with symptoms of^high inflammation
and  irritation.   The* dressings  should
not be removed, tdl the wound has sup-
purated,  and then the rest of the treat-
ment  resembles  that,  wliich  becomes
necessary in  wounds with  extravasation,
of which we shall presently speak.
  3. The protrusion of a portion of the
lungs, in consequence of wounds pene-
trating the chest, is a very unusual case;
but, there are some instances  recorded
by  writers.   Schenckius  relates  an ex-
ample, taken  from Rolanyus,  one of the
commentators on Albucasis.   Rolan'dus
hav.ng been  called to  a man,  who  had
been  wounded  in the  thorax,  six days
before, found a portion of the iungs pro-
truded, and  in  a state of  mortification,
in consequence of the compression, which
it had sustained. This surgeon extirpat-
ed the part, and  applied  astringent pow-
ders to the wound : the patient recovered
in a very little  time, without any indis-
position whatever remaining.
  Tulpius has recorded a similar fact. A
man received an extensive wound, just
below his left nipple.  His naturally gay
disposition, however, led him to neglect
the injury;   and, on  the  third day, a
piece of the lung>,  three finger-breadths
long,  protruded at the wound.   The
patient went to  Amsterdam, whence he
Was  distant two days' journey, for the
purpose of receiving succour in one of
the hospitals of that city.   The protruded
piece of lung, which was already mortify.
ing,  was tied, and cut' off  with scissars.
It weighed  three ounces.  The  wound
pealed in a  fortnight, and  the patient
experienced no  complaint afterwards, ex-
cept a  slight cough, which troubled him
from  time to time.  The man survived
the accident six years, leading a wander-
ing, drunken life.  After death, nothing
particular  was observed in the thorax,
except  that the lungs  had become ad-
herent to the pleura, in the situation of
the wound.   Fabricius  Hildanus also re-
lates  a  case, which was communicated
to him  by  Abel Roscius.   A man  was
wounded with a knife, between the fifth
and  sixth ribs, near  the  sternum.  A
piece of  lung protruded  through  the
opening, and it was wished to reduce the
part; but, as it  seemed  to assume  a
livid colour, it was extirpated  with the
actual  cautery.    Having  dilated  the
wound,  and kept tiie ribs apart,  with a
wedge, made of wood, the portion of lung,
which had been girt by the opening, was
returned.  The patient  after taking, what
were called, pectoral and vulnerary medi-
cines, soon got well, and felt no complaints
in his chest afterwards.
  A fourth example of a piece of lung,
making  a protrusion through a wound in
the tlmrax, is among  the cases, recorded
by the celebrated Ruysch.  The servant
of a sea-faring nun was wounded  in  the
anterior and inferior part of tiie  chest,
and was immediately attended by  a sur-
geon, who mistook the protruded piece
of lung, for a portion  of omentum,  and
applied a light ligature round it.  Ruysch,
who was called in to the case,  soon  de-
tected the  error, which  had been com-
mitted ; but, he had no apprehensions, as
he was convinced, that  the wound would
heal very well, as soon as the tied piece of
lung was detached.  The even, justified
his prognosis, and  the patient recovered,
in the same manner as the above-mentioned
ones.
  When the piece of protruded lung is
sound, and its small size would admit of
its being reduced, the attempt ought to
be  made, without  the least  delay.  It
should be done on tiie same  principles
as those, on which  we return into  the
abdomen a piece of  protruded intestine,
or omentum. (See Abdomen)   A recur-
rence of the accident is to  be  prevented
by  closing  the  wound,  and  placing  a
compress over it.  But, when  the 'liece
of lung  is  already in a mortified state, in
consequence  of  the  constriction,  which
it ha3 suffered, or when its large size pre-
vents reduction, Sabatier is of opinion,
that the only resource is to extirpate the
part, after applying a ligature round its
base.  If the latter step were not taken,
a dangerous hemorrhage might  follow,
or else an extravasation of blood  in  the
thorax.   (Medecine  Operatoire, torn.  2.
p 224.)  However, the practice just now
recommended seems  very questionable i 
376                               THORAX.
 in the instance  of mortification, extirpa-
 tion is clearly unnecessary, as the dead
 part  will  naturally be thrown  off by a
 spontaneous process;  and,  when  the
 wound is too small to allow the part to be
 returned,  ought it not to be  diluted,
 rather than cut off a considerable portion,
 or even any, of the lung ?
  4.  Emphysema  is another symptom,
 with which wounds penetrating the chest
 are  frequently  complicated,  especially,
 when  they are  small,  and  do not enter
 the thorax in a direct manner.  When
 such  wounds are small, and not straight
 in  their  course;  when their  track  is
 rendered  impervious   either  by  some
 change in  the situation of  the  muscles,
 by  the swelling, by clots of  blood, or by
 any extraneous  substances; air may in-
 sinuate itself into the cellular substance,
 so as to cause a great deal of tumour and
 distention.   The emphysema  is  easily
 distinguishable by the tumefaction of  the
 part affected, without any pain, or change
 of colour in the skin, and by the crepita-
 tion,  which is perceptible, on  making
 the air quit the  situation which it occu-
 pies, and pass into the  adjoining cavities
 of the cellular substance.  The emphyse-
 ma may take place, in cases in which  the
 lungs are   not  wounded,   and  also in
 others, in which they are so.  In  the first
 instance, the emphysematous swelling is
 caused  by   the  external air,  which in-
 sinn tes  itself into the cavity of  the tho-
 rax through the  wound, during the first
 inspirations, which follow the occurrence
 of the accident, and the same air is  ex-
 pelled  ii the subsequent acts of expira-
 tion.  In the second case, the emphysema
 arises from the escape  of  air from  the
 lungs,  during inspiration,  first  into  the
 cavity ofthe thorax, and thence, through
 the inner opening of the external wound,
 into the cellular substance.
  I should not have deemed it necessary
 to have said any  thing in this part of the
 work, on the present subject, but should
 have contented myself" with referring the
 reader to the article Emphysema, were not
 the cause  of this symptom  rather per-
 plexing,  and, did 1 not hope,  that the
 following extract from Dr. Halliday's late
 publication will tend to facilitate the com-
 prehension  of these cases.   This gentle-
 man mentions the following circumstances,
 under which air may escape  from  the
 lungs, or emphysema arise.
  1st.  " An injury  or disease  of the
pleura  pulmonalis, causing  a wound or
ulceration  of that  membrane, and thus
 allow ing the air to escape from the lungs,
 as in oblique external wounds,  where the
 outer opening, and that  of the pleura cos-
 talis have  healed, or closed up, and in
 ulcers ofthe surface ofthe lungs.
   2dly.  *' The pleura  pulmonalis, and
 pleura costalis, may be wounded or ulce-
 rated, when there  is no external opening,
 as when the  ends of fractured ribs  pene-
 trate through both into  the substance of
 the lungs, and it is from this accident, ike.
 that emphysema most commonly  takes
 place.
  3dly. " The  common  integuments of
 the  parietes of the chest, the intercostal
 muscles and the pleura costalis,  may be
 wounded, while the  pleura pulmonalis
 and the lungs remain uninjured, so that
 the air  admitted from without, and col-
 lected in the cavity ofthe thorax, may be
 pressed into the cellular membrane,  so as
 to occasion emphysema."
   Dr.  Halliday shortly  afterwards  re-
 marks : " that the  lungs in the thorax,
 have often, and not  unaptly, been  com-
 pared to a  bladder in a close pair of bel-
 lows :  but  if we suppose the bellows to
 be  divided into two compartments, and
 each of these to contain a bladder, wliich
 mutually  communicate with each other,
 and with the external air, by means of a
 tube, which is  exactly  adapted to the
 nozzle of the bellows,  and which admits
 tlie air only into the cavity  of  the  blad-
 ders, and not into the space, betwixt the
 bladders and bellows, we shall  then have
 a perfect representation of the mechanical
 structure  of the  thorax.  The  bellows
 will  represent  the  thorax,  divided in
 the middle by the mediastinum ; the blad-
 ders will represent the lungs of tlie right
 and left sides; and the tube, which  com-
 municates  with  the bladders  and  with
 the external air, will  represent the tra-
 chea.  The only thing, which is wanting
 to render this mechanical representation
 perfect, is, that tlie  bladders should ex-
 actly fill the bellows, so as to leave no air
 betwixt them and the bellows."
  Dr. Halliday  notices,  than when  we
 iiit up  tiie  handle  of the  bellows, the
 bladders become filled by  the  external
 air,  which  rushes in through  the  tube,
 which communicates with both of them.
 When the handle is depressed, the  air is
expelled again.   In  the like  manner,
the lungs are filled with air, and emptied
again when the capacity of  the chest is
enlarged by the inspiratory muscles, and
then diminished by the  expiratory ones.
  When emphysema arises from a wound,
or ulceration ofthe pleura pulmonalis, on
one side of the thorax, the case is nearly
the same as if an opening were made in
one ofthe bladders, which opening would
form a  communication,  as Dr.  Halliday
observes, with the bellows and bladder 
THORAX.                               377
on  one  side.   If  this  should  happen,
while the handle of the bellows is de-
pressed,  no sooner is tiie handle raised,
than air  rushes into the space,  betwixt
the bladder and bellows, and, on  keeping
up  the handle a little while, the bladder
wdl become  quite  collapsed,  and the
place which it occupied, while distended,
will now be occupied by the air.  If now,
says Dr. Halliday,  " we attempt to force
out  the  air, by depressing  the handle-of
the bellows, we shall find that this cannot
be done ; for, there is no direct communi-
cation, between  the  bellows and the ex-
ternal air; and, as the effused air presses
equally on all parts of the collapsed blad-
der, it cannot escape through it."
  When  the thorax is expanded  in inspi-
ration, the pressure  is taken off  tlie sur-
face of the wounded lung,  and  the  air,
which now enters this  organ,  instead of
distending its  cells, passes through its
wound into the space between the pleura
pulmonalis, and  pleura costalis.   The
lung will, indeed, be partially expanded,
as long as inspiration on that side goes on;
the  more so,  the smaller  its wound is.
At every expiration, however, when the
thorax is diminished, the effused air will
be compressed against the wounded lung ;
but none of the air,  which  has escaped,
can  re-enter the lung  again;  " because
(as  Dr. Halliday accurately  remarks) the
whole of the air contained  in the  lung
must be forced out, and then the pressure
(of the air) against  every part ofthe col-
lapsed lung being equal, will prevent its
separating any part,  so as to make a pas-
sage for itself into  the trachea."  Tfius
fresh air accumulates at every inspiration
in the space,  between  the  plurx, while
none can escape from the same situation
during expiration, and the quantity accu-
mulated will,  at last, equal that  which is
received, into  tlie other lung, during the
most powerful  inspiration.   Dr.  Halliday
notices, that some authors  have termed
this case thoracic emphysemu ; it is clearly
attended with no diffusion of  air in the
cellular substance,  a circumstance, gene-
rally implied,  when  we speak of emphy-
sema.
   When both the pleura pulmonalis, and
pleura costalis are wounded,  the  same
effusion  of air  between these  two mem-
branes continues to  take place,  from the
above-mentioned causes, till the lung is
collapsed. When an attempt is now made
to  expire, the injured side  of  the thorax
must continue distended, notwithstanding
every effort of tlie patient.   However,
whin, in  this expiratory act, the capacity
of the thorax  is diminished, and the air
compressed,  a part of it  finds its way,
 through tiie wouud in the pleura costalis,
     Vol.  IL
Into the common celtular substance of the
parietes of the chest.
  The passage of air  into the cavity  of
the thorax during inspiration is, as Dr.
Halliday observes, now more easy, than
the return of that, wliich is already effus-
ed  in  the cellular  membrane, and con-
sequently, the subcutaneous emphysemu con-
tinues  to  increase  with  the rapidity,
which  is remarkable, as long as  the pa-
tient lives.
  To explain the origin of emphysema,
in cases of wounds, which only enter the
chest,  and  do not injure the lungs at all,
Dr. Halliday has recourse to the simile
of the  bellows, and bladders.  Were an
opening made into the bellows, without
injuring the contained bladders,  if the
access  of air by  this opening be  more
free, than that by the  nozzle, communi-
cating  with  the cavity of the bladder,
more air will enter by  the opening, than
by the  pipe, on the handle being raised,
so that the  bladder will not  rise as be-
fore, when no opening in the side of the
bellows existed.  If the latter opening
be smaller,  than that of the pipe, the
bladder will only be partially filled, and,
on depressing the handle of the bellows,
the air,  contained  in  the  bladder,  and
that between the bladder and  the bellows,
will  be expelled, in the same proportion
to each other, as that, in wliich they were
formerly filled.   This process would con-
tinue to  go on in tiie  same way,  did not
the bladder naturally  collapse more and
more  from  its gravitation.  Let  us now
stop the mouth of the pipe, while the
handle of the bellows  is raised, and the
bladder partially filled.  On  trying next
to depress the handle,  it results, that,  as
no air  can escape from the pipe, that air,
which  is contained  between the bladder
and the bellows,  must be first evacuated,
while  that,  contained  in  the bladder  of
tiie sound side, will be forced into the
bladder on  the injured side,  and either
distend it, so as  to rupture  it, or cause
it to protrude.
  Hence, in the case of a wound, penetrat-
ing the chest, without  injuring tiie lungs,
if the  air can  enter more freely by the
wound, than by the trachea,  more of it
will enter, in the act of inspiration, into
the cavity of the thorax,  than into tlie
lungs.   On the contrary,  when the open-
ing ofthe wound is not so large as that of
tlie trachea, less air will enter the thorax,
than the lungs.
   Iu expiration, the air will be expelled
from  tiie two different situations, in pro-
portion to the quantity, which enters each
of  them in inspirit ion, and,  no air at all
would accumulate  in the thorax, did not
the  lungs  alwu\» tend to  collapse from
     j B 
378
THORAX.
their gravitation.  Should, however, the
patient,  in  making an effort to expire,
contract the glottis, the air, contained in
the lungs of tiie sound side, may be pro-
pelled into  the bronchia and  air-cells of
the lungs, on the same side as the wound,
so as to distend them,  and even  make
them protrude at the wound.
  Dr. Halliday remarks,  that such a pro-
trusion often happens, when wounds are
made in dogs, and  has been erroneously
adduced as an argument against the col-
lapse of the lungs, when  an  opening is
made into the thorax of the human subject.
See  Observations on Emphysema, by A. Hal-
liday, M. D. 1807.   This work is highly
deserving of perusal.
  For information, concerning the  treat-
ment of the affection, the  reader is  re-
ferred to the article Emphysema, in this
Dictionary.
  5.  We  have already  noticed,  that
wounds of tiie thorax may injure one  of
the  intercostal arteries,  and  when the
blood  cannot find  free vent outward,  it
may become extravasated in the cavity of
the  chest.   The same consequence may
follow wounds of the pulmonary vessels,
those of the heart,  or of the heart itself.
When the hemorrhage,  however,  takes
place from vessels above a certain size, the
wounded person dies almost instar.tane-
ously ; but, when  they are  not  so large,
he  may live for a greater or less  time,
and receive the succour of surgery.
  The following are the symptoms, which
denote an extravasation of blood in the
thorax.  The  patient feels  great oppres-
sion,  and such uneasiness as will not let
him  long continue  in one  position.  He
experiences  much  difficulty in  standing
up,  or sitting up  in his bed, unless  he
bends  his  body very much forward,   in
which position, the diaphragm  is relaxed,
and  not so much dragged by tlie weight
of the extravasated  fluid.   When the
thighs are  bent, the patient can lie with
tolerable ease on his back;  he  is also not
averse to lying on the side,  on which the
wound is situated ; but, he cannot place
himself on the opposite one, without feel-
ing very acute pain in the situation of the
mediastinum.
  His respiration is short,  frequent, and
interrupted  by sighs; his  veins become
empty; a  mortal paleness spreads over
his  countenance ; his extremities become
cold;  a viscid perspiration  covers his
neck and temples ; his teeth chatter ; his
pulse  becomes  weak,  and if,  as  most
frequently happens, the lungs are wound-
ed,   he spits  up frothy blood, and air
issues from the wound.
  Though one might suppose thejibove
class of symptoms were always attendant
on a considerable effusion of blood in the
thorax, yet  they are not so.  Wounded
persons have been known to die of such
an  extravasation, whose respiration  was
tolerably free,  and who did not complain
of  suffering more inconvenience  in one
posture  than  another.   Sabatier  says,
that several facts of thi6 kind have fallen
under his own observation.  Other wound-
ed  persons, also, who have suffered most
of the complaints ascribable to extravasa-
lions of blood  in the thorax, have been
cured  by  ordinary means.   M. Mery
gives an account of a young man, wound-
ed  in  the  anterior and superior part of
the oliest, about two o'clock in ihe morn-
ing, who had .such difficulty  of breath-
ing, and so much fever, five hours after-
wards,  that M. Mery was of  opinion,
that an extravasation had happened, and
he  was thinking of making an opening
for the evacuation ofthe blood. A tumutir,
which  originated near the  great pectoral
muscle, and presented, neither  the  feel
of fluctuation,   nor that of emphysema,
made  him  suspend his decision.  Some
bleedings, and the application to the tu-
mour of compresses, dipt in a mixture of
spirit of wine  and  water,  dispersed tiie
symptoms.  This  recital shews,  as M.
Mery has remarked,  how  equivocal the
symptoms of an extravasation in the chest
are; how difficult it is to form an opinion;
and how liable to failure any operation is.
  However, even the assemblage  of the
above symptoms, did not lead M. J. L.
Petit into  a mistake.  Having been re-
quested to assist at an operation, which
was about to be done on a wounded' man,
about  whose armpit,   pectoralis  major,
and latissimus dorsi muscles, a prodigious
emphysematous swelling bad taken place;
whose  respiration  was painful and diffi-
cult ; and who spit up frothy blood from
his mouth;  M. Petit  gave  it  as  his
opinion, that it was unnecessary to make
an opening  into the chest.  He thought,
that it would be sufficient to enlarge the
wound, which  was at a little  distance
from the armpit,  near the edge of the
latissimus dorsi, so as to give vent to the
effused air.  This  advice  having been
followed,  tlie emphysema in a little while
disappeared, and  the  patient  soon re-
covered.
  The equivocal nature of tlie symptoms
of extravasations of  blood  in the thorax,
has induced practitioners to pay tiie most
scrupulous  attention  to  every circum-
stance  attendant on  these cases.   Valen-
tine remarked,  in several instances,  that
a few days after the wound,  an  ecchy-
mosis occurred, at the angle of the false
ribs, and spread towards the loins.   The
ecchymosis is described as being of  a 
THORAX.                              S79
dear purple colour, like the spots,  which
sometimes form on the abdomen, a little
while after death.  Such is the difference,
between this ecchymosis' and  that,  which
consists of an extravasation  of blood in
the cellular substance, from the  rupture
of blood-vessels, which makes its appear-
ance shortly after  the accident, begins
close to the injury itself, and is of a deep
colour, commonly spotted with some red
points.    Valentine advised  a  counter-
opening to  be made, in a case, in  which
most of  the symptoms  of extravasation
were combined with the  above sort of
ecchymosis.   The advice was overruled,
and tiie patient  soon  afterwards  died.
More than six pints of blood, were found
extravasated in the thorax.
  Sabatier remarks, that we cannot too
highly  applaud the zeal of  those prac-
titioners, who  endeavour  to dispel the
doubts, which still prevail in some parts
of surgery.  At the same time, he thinks,
that all, who take interest in the improve-
ment of this  science, should endeavour to
ascertain the truth  of any  new observa-
tion's,   which are  offered.    Hence,  he
deems  it proper to relate a case,  which
was communicated to him  by M. Sauce-
rotte (the father)  an  eminent  military
surgeon, and   which  shews, that the
ecchymosis,  observed by   Valentine, is,
at least,  not  invariably   attendant  on
extravasations of blood  in the chest.  A
carabinier, who had received a thrust with
a sabre in the right side of  the thorax,
above the tendon of the pectoralis major,
appeared to be going on very well for the
first four days  following  the accident.
On the  fifth, he complained of difficulty of
breathing, uneasiness, and an  inability of
lying on the leftside, without  aggravating
his complaints.  He complained of a great
deal of pain in  the region  of the liver,
and at the top of the shoulder.  His pulse
was small  and  contracted,  and  rather
hard, than weak.  The  right  side of the
chest seemed larger, than  the left.  On
the eighth and ninth day, the symptoms
became more urgent,  and  the  patient
found no ease, except in leaning on his
right side, and supporting  himself on a
chair, placed across his  bed. This as-
semblage of symptoms  indicated  an ex-
travasation of blood in the right cavity of
the thorax; but,  as   tiie ecchymosis,
which  M.  Valentine  has described, was
not  apparent,  M.  Saucerotte  thought
that they might be deceitful.  Their long
continuance, however,  had made  him re-
solve to make a counter-opening, but, in
the  mean while, the patient died, in the
night between the ninth and tenth day.
When   the  operation  was  done on the
dead body, a pint of putrid blood flowed
out.
  When the surgeon feels assured, that
an  extravasation  of blood  in  the thorax
has really  occurred, the only indication
is to  make an opening for its escape.
However, before  undertaking this  opera-
tion,  the revived state of the pulse, the
return of warmth in the extremities, and
the  cessation  of convulsions  ought to
denote that the  hemorrhage  no  longer
continues from. the wounded vessels.  If
this were not  the- case, a fresh  quantity
of blood would soon be extravasated, and
the patient die exhausted.  Besides, by
delaying to make an opening for the dis-
charge of the blood, we give nature time
to employ her own resources.  Observers
have  recorded instances, in which extra-
vasations of blood( in the thorax have got
well,   without any operation.   Fabricius
ab Aquapendente relates an example of a
man receiving so narrow  a  wound  in the
chest, that it was impossible to make out,
whether it had penetrated the pleura, or
not.  The  spitting of blood,  weight on
the  diaphragm,  fever, and oppression,
with which the patient was soon seized,
removed all uncertainty.  It  was  deter-
mined to make an opening into the chest,
when a large glassful of blood came away
with the urine ; the pain now  subsided,
the fever and  other complaints abated £
and a speedy recovery followed.
  Though Fabricius sets this case down
as one of extravasation, and that it wast
cured, in consequence  of the  evacuation
of  blood with the urine, both inferences
may,  at all events, be  rationally ques-
tioned.
  Authors make mention of five methods
of discharging collections of blood in the
thorax;  viz. 1st.  By placing the patient
in a posture, which favours the escape of
the blood ; 2clly.  By introducing a syringe
for the purpose of sucking it out, or a
mere cannula, through which it is to flow ;
3dly.  By enlarging the wound; 4thly. By
employing injections; 5thly.  By making
an opening into the thorax in a depending
situation.
  1. Success cannot be  expected from
merely placing the patient  in  a posture,
which is favourable to the escape of the
extravasated blood, except  when  the
wound is situated at the  inferior part of
the chest, and is large and direct  in its
course.  Pare"  successfully  adopted this
method in the  case of a soldier, who was
stabbed in three places  with  a sword,
one of the  wounds, which entered the
chest, being situated under the right nip-
ple.  The man was first dressed by a sur-
geon,  who made  several sutures.  The 
vSo
THORAX.
patient was soon afterwards attacked with
considerable difficulty of breathing, fever,
coughing, spitting of blood, and  acute
pain in the side. Pare, who was consulted
the next day, suspected, that an extrava-
sation  had happened; consequently, he
cut out the sutures, and placed the patient
in a position, in which his feet were much
more raised,  than the head.  Par*  also
recommended him to hold his breath, and
then introduced his finger into the wound,
in order to take away some clots of blood,
which  appeared at its orifice.  By these
steps,  the discharge of seven,  or eight
ounces, of fetid, coagulated blood,  was
effected.  Injections  of barley-water,  in
which  were mixed a little honey of roses
and sugar-candy, gave tiie patient  ease,
and finiihed the cure.
  2.  The idea  of  sucking out of the
cavity   of the thorax,  by means of a
syringe, blood extravasated in this situ-
ation,   was conceived a long while  ago.
The pipes of all syringes,  for this  pur-
pose, should  have blunt ends, lest they
should injure the  lungs.  Mere  tubes,
containing a  stilet, have also frequently
been employed.   In the cases, related by
Sculi etus, there is an example, in which
an  instrument of the latter sort was  suc-
cessfully made use of.  No syringe, nor
any suction with the mouth, was requi-
site,  it was  only found necessary to in-
troduce the tube, and then "withdraw the
stilet.
  Lamotte only used  a simple cannula,
which  he introduced into the  centre  of
the extravasation.  Then having  placed
the patient in what he conceived to be the
most favourable posture, and  requested
him to hold  his breath, he drew off' the
collection of fluid.  The cases,  numbered
216, 217, 218, shew the  success, wliich
attended tins method.  Although it might
also have answered very well in case  219,
Lamotte  saw, that the exceedingly  high
situation" of the wound  would  not  have
allowed all the  blood to be discharged,
and, therefore,  he matte a  counter-open-
ings  Thus the thorax  was completely
emptied, and  a recovery the consequence.
When  a  cannula is employed, authors
recommend it  to be introduced  every
d:.y, till the bad symptoms cease, and  no
more fluid escapes through the cavity of
tlie instrument.   After having given vent
to  blood, it allows a bloody serous  fluid
to escape, and at a later period pus, which
becomes of a thicker and thicker consist-
 ence,  the nearer the patient is to a reco-
very.
   3. The cases, in which  an enlargement
of a wound, complicated with an extrava-
sation  in the chest, should be practised,
are those, in which there  is reaton for
thinking, that the situation is favourable
for the escape of the blood.   The 'opera-
tion is performed by introducing a groov-
ed director, alongwhich the knife is to be
guided.  The integuments, and external
muscles, are to be divided in  a perpendi-
cular direction, and the intercostal mus-
cles  in a Une parallel  to the ribs.  Care
is to be taken not  to cut  too near the
lower edge of the upper rib,  lest the in-
tercostal artery should be wounded.   Dio-
nis relates, that he  practised such an
operation on a soldier, who was wounded
at BfcTort in 1703, by the  thrust of a
sword below the right nipple, which made
a direct opening into the thorax.  As the
patient was half a league from the town,
his chest had become full of" blood, before
he could be assisted.   When the extrava-
sated fluid had been  let out,  Dionis made
the patient lie on the wounded  side,  dur-
ing the mght, and  in  proportion as the
blood continued to be thus evacuated, the
breathing became free from oppression.
The next day, the thorax was quite emp-
tied, and the cure was so speedy, that the
patient was in a state to join the army, a
month afterwards.
   4.  The methods, which have just  been
explained, may be of use, when the blood
retains its natural state of fluidity ;  but,
when it has coagulated, as often happens,
they can be of no avail.  In  this circum-
stance, the best plan, which  dan be adopt-
ed, is to inject warm water into the chest,
which injection is the  best calculated for
loosening, and dissolving the coagula, and
washing them out ofthe wound. A proper
opening must, of course, be  previously
made.  The French  writers,  even the
modern ones (Sabatier') most absurdly re-
commend tiie injection of various deter-
gent vulnerary decoctions,   and  of solu-
tions  of honey of roses, soap, salt, &c.
What idea these authors can entertain  of
the  great sensibility and tendency to in-
flammation of the lungs and  pleura,  or
what good they can  expect  from  such
applications, is difficult of conception.   I
am  firmly convinced, that  the  meanest
scribbler on  surgery, in  this  country,
would be ashamed of  being  an authority
for such advice.
   5. When the  wound is   narrow, and
situated at  the upper part  of the chest,
we cannot expect to be able  to give vent
to the  extravasated blood, without  mak-
ing  a counter-opening at the lower part
of this cavity.   The best place for  mak-
ing  the opening, and the  proper  man-
ner of executing the  operation, are ex-
plained in the  article, Paracentesis of the
 Thorax.
   When the opening has been  made, the
 blood makes its escape.  Its exit is to be 
THORAX.                               381
promoted by placing the patient in a pos-
ture, which makes the opening as depend-
ing as possible, and by desiring him to
hold his breath.
  After as much blood,  as can be obtain-
ed, has been taken out, the common plan
has been  to maintain  the opening, and
not let it heal, till after a certain  time.
  For  this  purpose, the old  surgeons
used to employ tents, made of lint, which
were proportioned to the size of the open-
ing,  being  short,  soft,  and flattened.
They bad a sort of head, and a double
ligature attached to them, and were often
dipped  in some  kind  of  application.
Tents  have  now  been quite  abandoned,
as they  are apt to bring on an inflamma-
tion of the  lungs,  hinder the  escape of
whatever fluid is .contained in the chest,
and  cause great irritation in the parts,
through  wliich  it   passes,  occasioning
pain, inflammation, and even exfoliations
from the ribs.
   Others have recommended introducing
the end of a kind of wick, which, they
contend, keeps open the wound, without
hindering  the escape  of fluids.   Such
advice, however, is not free from objec-
tions, nor is the  latter reason altogether
true.
   Le Dran preferred tents to wicks: he
states, that the hemorrhage  can only be
stopped by the  coagulum,  which forms
over the mouth of the wounded  vessel.—
The clot is elongated, and even continued
into tlie  vessel itself, and  while  it re-
mains  there, 'no  more  blood is effused.
In the mean while, it flows into the colla-
teral vessels ;  and the mouth ofthe vessel
closes, and  includes within its  parietes,
the portion  of the  coagulum, wliich has
formed  in it.  Thus  the clot becomes
gradually separated into  two   portions,
one of which  remains in the  vessels, and
acts as a sort of plug, while the other is
detached with the  suppuration.   Hence,
continues Le Dran, when a tent is intro-
duced into the opening, which  has been
made,  it must confine a part of the blood,
which has been extravasated in the chest,
and without  which portion being retain-
ed, the clot would not be supported, but
fall  off,  before the  mouth of the vessel
had closed, and the hemorrhage constant-
ly continue.   Without entering into an
examination of Le Dran's theories of the
stoppage of bleeding,  a subject, which is
fully explained in the article Hemorrhage,
we may  onlv remark, that  this author's
predilection for the use of tents is founded
on a supposition, that the counter-opening
has  been made  for  the   hemorrhage
from the vessels has ceased.  Kvery one,
however, agrees, that no steps should be
taken for the discharge of the blood, con-
tained in the thorax, before being assured,
that the hemorrhage has ceased.   Hence,
the tent can only be regarded as  hurtful.
But, dismissing from consideration wicks
and tents, the best means of maintaining
an opening (were such thing  necessary,
which  cannot  frequently be  the case,)
would be, a short cannula, with a rim to
keep it  from slipping into the thorax, and
two little rings for confining it in its situa-
tion with a  ribband.   This should only
just enter deeply enough to have its inner
orifice on a level, or very little  further
inward, than  the pleura  costalis,  and
consequently it could not injure,  nor irri-
tate the lungs.   A plug should be kept in
its outer opening, and withdrawn, as often
as occasion requires, that is, as  often as
any material  quantity  of fluid  collects,
and requires to be discharged.
  When the patient has been dressed, he
is to be kept in bed,  with his head and
chest somewhat elevated, and his thighs
bent, hi which position, the breathing
will be  found to be least oppressed.  It is
usual also  to recommend him to lie, as
much as possible, on the side on which
the operation has  been done.   He is to
keep himself in as still, and quiet, a  con-
dition  as he can.  He is to  be put on
very low diet, and, if his strength allows,
hei  is to  be  bled, and this  evacuation
repeated, with other antiphlogistic means.,
as often as the  urgency of the fever and
inflammatory symptoms indicates, and the
strength of  the  constitution  allows.—
Bleeding from the arm, besides counter-
acting inflammation in the chest, which is
a principal source of danger,  does good
by  lessening the force of the  circulation
in  the  wounded vessels, and  thus it di-
minishes the tendency  to internal hemor-
rhage.
  In keeping open wounds  of tiie chest,
the surgeon  must  be  careful,  that no
tents, nor any of the  dressings, glide
into the cavity of the pleura.  Numerous
cases on record shew  the  necessity  of
using great caution, that no accident  of
tins kind occur.  Tulpius makes mention
of  a Danish  gentleman, who had been
under a careless surgeon, on account ofa
wound  in the thorax, and  who  coughed
up, six months afterwards, a large tent.
A  similar fact is  recorded, among the
cases collected and published by Fabricius
 Hildanus.  A  man was  stabbed' with  a
 sword in the right side of the chest, near
 the axilla, between tiie second and third
 ribs. A great  deal of blood was discharg-
 ed, during the first fortnight, both from
 tlie wound,  and  by  the  mouth.  The
 wound was successfully healed;  but, the
 patient continued to  suffer considerable
 difficulty of  breathing,  and an incessant 
332
THORAX.
cough, and he used to spit up a greenish,
fetid matter.   Three months afterwards,
he  coughed  up  two  tents, which had
slipped  into the  cavity  of the  thorax,
from  beneath the dressings, with which
the wound had been covered. t
  In whatever condition the patient may
be, any change in the antiphlogistic regi-
men,  must be made with  very great cir-
cumspi ction.  Too much  nonrishment,
talking too frequently,  and  any exertion,
are circumstances, which may  induce a
renewal of the hemorrhage, and extrava-
sation, even  after  a considerable time.
Vesalius saw an accident of this nature
happen,  a fortnight after the wound, and
eleven days after the operation for empy-
ema.  A Biscayan soldier,  who had been
stabbed in two places with a sword above
the right nipple,  was attacked by fever,
difficulty of breathing, restlessness, and
acute pain at the bottom  of the  chest.
These symptoms indicated to Vesalius,
that  an  extravasation had taken place;
but, he was afraid of making an opening
into the  chest, for fear the  hemorrhage
should still continue from the wounded
vessels.  However, as the patient remain-
ed in  the same state, the fourth day after
the receipt ofthe wounds, and his strength
still lasted, Vesalius undertook the opera-'
tion, by which a considerable quantity of
extravasated blood was discharged.  The
patient  felt great relief at the instant.
The oozing of blood continued for a few
days, after which a favourable  suppura-
tion took place in all the  three  wounds,
and the case was, therefore, expected to
end well. But, the patient having regain-
ed his strength, and taken too much food,
the recurrence of hemorrhage caused his
death, at the very time when he seemed
to be getting well.   M.  Lombard, well
known for some excellent productions on
surgery, saw a soldier die instantaneously
of internal hemorrhage, from throwing a
bowl at some nine-pins, two months after
he had been cured ofa wound ofthe chest
and lungs.
   Authors in general advise us, before we
 close the wound, for the purpose of heal-
 ing it, to make the patient expel, the air
from the chest.  For  this object, they
advise the patient to be requested to make
 a strong inspiration, with the  Wound
 closed, and then a long  slow expiration
 with it open, and so on,  till as much of
 the  air as  possible  is  discharged,  and
 then the wound is to be accurately closed
 with sticking plaster.  From  what we
 have said, however, in tiie article Emphy-
 sema, it will  appear, that when there is  a
 direct  opening into the  thorax, so as to
 admit the external air,  the lungs on one
 side  collapse, and  remain so  till  the
wound is healed, and the air absorbed.
When one of these organs is wounded, a
collapsed state is, indeed, the best condi-
tion, in which it can possibly be  for a
certain time, that is, till the breach of
continuity in it  has  healed.  All efforts
to make  the lung expand, by exhaus»ing
the air  from, th^ cavity  of the  pleura,
seem  unavailing; but, there is certainly
no objection to  not  closing the  wound,
before as much air  has been expelled in
the above way, as can be thus got rid of.
   Fistula? sometinjes continue for a long
while after wounds of the thorax.  Felix
Platner mentions an  instance, in which a
man had in his  chest a fistulous opening,
out of which the air rushed with such
force as  to blow out  a candle.  He lived a
long while with  this  disease,  without suf-
fering any particular inconvenience.
   Another  occasional   consequence of
openings made  in the chest, is a hernia
of the lungs, an affection, of which,  Sa-
batier says, he is not aware,  that any one
has  spoken.  This gentleman, however,
has seen such a case.  A  soldier, thirty
years of age, who had been  wounded at
Rostock, with a bayonet, in the  right
side of the  chest, between the  middle
part of the fifth and  sixth true ribs, had
several bad symptoms  which he surviv-
ed.  The wound was successfully healed;
but, as the intercostal muscles had been
divided  to  a great extent, and could not
be approximated  with precision, there
remained an empty space under the inte-
guments, which allowed a piece of the
lungs, as large as  a walnut, to protrude
between the ribs.  The swelling enlarged
at the  time of inspiration, and  grew
smaller  when expiration  took  place.  It
only  occasioned a  slight  pain, without
any oppression in the chest.
   The making  of an opening  into  the
chest, as already spoken  of,  is recom-
mended, as Sabatier,  remarks, by all
 authors, who 'have  treated of wounds of
the chest.  However, it does not appear,
 that the operation has  been often done*
 Few instances are to be met with on re-
 cord.   J. L. Petit  does  not make men-
 tion of even one.  Lamotte, who  had the
 care  of an infinite  number of patients,
 never practised the  operation,  except
 twice, and, in one  of these instances,  it
 was done to let  out a collection of matter
 in the thorax, which had occurred after a
 wound,  which injured the lungs.  Sabatier
 notices, that the seven  volumes of the
 Journal de Medecine Militaire, which con-
 tain a collection of  the  most interesting
 ca-es, which have presented themselves
 in the military hospitals, record no exam-
 ple, in which it was necessary  to resort
 to the  operation  in  question.  No in- 
THROAT.                              38*
6tances are related in the Mem.de VAcad.
de  Chirurgie.  Sabatier si^ys, he has en-
quired  of  many army-surgeons;  but,
none of them have either seen the  ope-
ration  done by others, or performed it
themselves.    M. Saucerotte, observes
Sabatier, is the only one,  who  did  it
with  success  in  a  case, in which the
exigency for the operation  would not be
expected.  It was in  an  instance  of a
gun-shot wound.  The  necessary dilata-
tions, and  the  extraction of extraneous
substances, had diminished the inflamma-
tory symptoms.  These were subsiding
entirely, when, on the third day, a violent
hemorrhage took place from one  of tlie
branches of tlie internal mammary artery.
This loss of blood, together with repeat-
ed venesections, did  not hinder  a consi-
derable extravasation  of  blood in the
chest from happening on  the fifth  day.
The patient was threatened with suffoca-
tion.  He was made  to  bend forward, in
order to  promote the escape of the fluid,
of  which  about a pint,  in  colour  like
wine-lees,  and  having  a  disagreeable
smell,  was discharged.  A  considerable
quantity was in this way evacuated, every
morning  and evening.   The posture, in
which  the patient was necessarily  put,
and the efforts he was obliged to make to
promote  the evacuation,  fatiguing  him
exceedingly, he consented to have a coun-
ter-opening made, at the lower part of
the chest, on tlie  eighteenth day.  ■The
operation  gave vent  to  a pint of blood,
of  the same kind  as  that which  had
issued  from the wound.  The quantity
emitted became daily less and less, and,
in three  months,  the patient got quite
well.  Sabatier questions,  from what has
been stated,  whether we may not  con-
clude, that such extravasations of blood
in the  thorax, as admit of  surgical  aid,
are exceedingly unfrequent  cases,   and
that the  symptoms,  indicative of these
instances,  are not sufficiently clear, so
that most of the patients,  with such ex-
travasations die,  without it  being in  the
power of surgeons to make any attempt
to save them.
  Every systematic writer on surgery has
treated of  wounds of  the thorax: John
Bell's Discourses on Wounds, and Sabatier's
Medecine  Operatoire, from which latter I
have extracted  a great deal of the  pre-
ceding account, seem to me to merit at-
tentive perusal.
  THROAT, WOUNDS  OF.   Injuries
of this kind are often attended with con-
siderable  danger, on  account  of  the
great  number of important  parts,  which
are  interested; but, mere  cuts  of  the
integuments of the throat and neck are
not (generally speaking) dangerous cases,
and do not materially differ from common
incised  woynds of the skin, in any otiier
part of the body.  They are not liable to
be  followed   by  any  particular   conse-
quences,  and require  the same kind of
treatment, as cuts in general do.  (See
Wounds—Incised Wounds.)
  In  wounds of the  throat and neck,
however, the  larynx and trachea, pharynx
and oesophagus, the trunk of tlie carotid
artery, and all the principal branches of
the external  carotid,  the large  jugular
vein, the  eighth pair of nerves, and the
recurrent nerve, are all exposed to injury  j
some  much more so,  than others; but,
all  of  them  occasionally not  escaping
the edge of  the knife, or razor, or tlie
point  of the sword, or other instruments.
  It would   certainly amount to  absur-
dity,  to offer an account of what is to be
done,  in cases attended with some part of
the mischief  above pointed out;  for,  no
patient, thus wounded, would  ever be
found alive.   Wounds of the  eighth pair
of nerves are universally considered  by
all  surgeons  as  certainly  fatal.   These
nerves,  we   know, proceed  down  the
neck,  in  the same sheath   of  cellular
substance, which  includes  the  carotid
artery,  and   lie on the outside  of this
vessel, between it and the internal jugular
vein.
  AVounds, either  of the carotid  artery,
or internal jugular vein, must for  tiie
most  part 'prove  immediately fatal,  in
consequence of the great and sudden loss
of blood, which would inevitably arise
from  an open, cut wound,  interesting
these  vessels.  However, were any sur-
geon on the spot at the moment, he should
immediately  tie  the end of  the   vessel,
from  which  the blood  gushes  with tlie
greatest force, which end, we know, would
be the lower one of the carotid, and upper
one of  the jugular vein. One  caution,
however, is highly necessary in tying the
carotid, viz.  always to  be sure,  that the
par vagum is excluded from  the liga-
ture ;  for were this  nerve to be tied, this
erroneous proceeding  alone  would  re-
move  every  possibility of the patient's
recovery.
  If the mouth of the vessel could not be
got at, pressure must be instantly resort-
ed to, for the purpose of producing a
temporary suppression ofthe hemorrhage.
The  surgeon should  then either make
the necessary enlargement of the wound
in the integuments, with a due and con-
stant recollection of the important parts
near the place, or else, in the case of the
carotid   being injured, he   should  cut
down  to this  vessel on the side towards 
J84
THROAT.
 the trachea,  where no parts of  great
 consequence are situated.
   In lacerated wounds, the carotid artery
 may be injured, and yet the patient  not
 immediately bleed to death ; for, it is  the
 nature of all wounds, attended with much
 laceration and contusion, not to bleed  so
 freely as clean cuts. Mr. Abernethy  has
 related a case, in which  the carotid, and
 all the chief branches of it, were wounded
 in a man who was gored in the neck with
 a cow's horn; yet, death did not immedi-
 ately follow, and there was  time to have
 recourse to the ligature.
   Punctured wounds might obviously in-
jure,  either the carotid, or the internal
jugalar vein, without the patient  expir-
 ing of hemorrhage at once ;  because,  the
 smallness of  the  wound  in  the  skin,
 would often hinder  the  fatal  effusion of
 blood.
   However, when these vessels are wound-
 ed, the par vagum is generally wounded
 also, and the case is  inevitably mortal,
 either immediately, from the direct effects
 both of the injury of the nerve, and sud-
 den loss of blood, or very soon afterwards,
the bleeding being of a slower, and more
interrupted  kind, which must  depend on
 the lacerated nature of" the wound, the
 small  size of the opening in the vessel,
or of that in the skin, &c.
   Persons  who  attempt  to  commit sui-
cide, by cutting their throats, do not often
divide  the carotid  artery, on account of
their  incision  being made too  high up.
Where the carotid arteries  emerge  from
the chest, they are situated by the side of
the trachea, and even  a  little  more for-
ward, than it.  However,  as these vessels
proceed up  the  neck, they become  more
laterally situated with respect to the tra-
chea ; and when they have arrived at the
upper  part  of the  neck, where persons,
who attempt to commit suicide, almost
always  cut, they become situated  more
backward, than  the trachea, inclining to-
wards  he angle ofthe lower jaw.
   The oesophagus is  so  deeply situated,
lying close to the bodies of the vertebra,
and behind the trachea, that  it is not
often  interested  in  any  incised wounds,
which do not immediately prove fatal, in
consequence of the division of other im-
portant parts.  We  read of many cases,
in  which this  tube is said  to  have been
 wounded, and what is usually set  down
 as a criterion of the fact,  is the passage of
 victuals through the wound.  The writers
 of many of  these narrations ln.ve proved
 themselves most grossly ignorant of ana-
 tomy, by not knowing, that wounds made
 above the os hyoides, as they  frequently
 are, may enter the mouth, and hence  the
 victuals may  escape  through  tiie cut,
without the oesophagus,  or pharynx,  be
ing at all concerned.
  However, no doubt, tlie oesophagus  has
occasionally been wounded, without  the
patient  perishing so immediately,  as  not
to be capable of  receiving any succour.
Stabs, and gunshot-wounds, might obvi-
ously injure the esophagus, and leave other
important parts untouched.
  Even  were the oesophagus known to be
wounded, its deep  situation would prohi-
bit us from doing any thing to the breach
of continuity in the tube itself.  The best
plan would be to have recourse to anti-
phlogistic  means,  and  to introduce, a
hollow bougie, from one  of the nostrils,
down the oesophagus, for the purpose of
conveying nourishment and medicines into
the stomach,  without  any risk of their
getting out at the wound.  An  instrument
of"this kind will  lie in the above situation,
for any length of time, without occasion-
ing any inconvenience, and, besides being
advantageous for  injecting nourishment
and  medicines  down the  passage, and
keeping them from issuing at the wound,
it  prevents all necessity for the wounded
oesophagus to act, and become disturbed,
when there is occasion  to  take any kind
of liquids, whether in the way of medicine,
or  food.  The   outer wound  should  be
brought together, and treated on common
principles.
  When  persons cut their throats,  we
have explained,  that they do not  often
divide the carotid  artery,  owing to their
incision  being usually made high up in
the neck, where this vessel has attained a
very backward  situation.   When any  se-
rious hemorrhage  does arise,  it is some-
times from the  lower branches of the lin.
gual artery,  but most frequently,  from
the superior  thyroideal  arteries.   Such
arteries  may occasion a  fatal bleeding,
which, indeed,  would more frequently be
the event, than it actually is, did not  the
patient often faint,  in  which state  the
bleeding spontaneously  ceases, and gives
time  for the  arrival of surgical  assist-
ance.
  I need  hardly tell  the  reader, that
these arteries are to be tied, and that this
important object is the first, to which  the
surgeon should direct his attention. The
danger of bleeding to  death being obvi-
ated, as soon as  possible, the other requi-
site  measures may be more  deliberately
executed.
  With respect  to wounds of the trachea,
the  same plan of convey ing food and me-
dicines  into the stomach, through  a hol-
low bougie, introduced from  one  of  the
nostrils,  down  the  oesophagus, is  highly
proper, though too much neglected. For,
nothing creates  such disturbance  of  the 
T H R                                  THY             385
 wound  as the convulsive elevation and
 depression  of the  larynx  and trachea,
 which are naturally attendant on the act
 of swallowing.
   When the trachea is cut,  the patient's
 power of forming the voice is more, or
 less,  impaired, in consequence of the air
 passing into, and out of, the  lungs, chiefly
 through the wound.  Besides air, a con-
 siderable  quantity of the natural mucus
 of the trachea is also continually coming
 out of the wound.     .
   T;ie grand means of accomplishing the
 union of  wounds  of the  trachea,  are a
 proper position of the head,  and a rigor-
 ous observance of quietude.   By raising
 the patient's head with pillows, and keep-
 ing his chin close to his breast, the edges
 of the wound, boih in the skin  and tra-
 chea, are  placed in contact, even without
 any otiier assistance,  unless the division
 of the trachea be  exceedingly large.  It
 is proper, however, to assist  the agency
 of a suitable position with strips of stick-
 teg plaster, and  also, according to most
 authors, with a suture, or two.  But, the
 necessity for sutures must depend on the
 extent of the division of the trachea; for,
 unless most of the circle of  this tube be
 cut, and position be neglected, the wound
 in it will not gape.  Tlie stitches, should
 never be passed through the  lining of the
 trachea, as this method would be likely to
 make  it inflame, and occasion consider-
 able coughing, and irritation, which would
 have very pernicious effects on the wound.
   Should there be much coughing, appa-
 rently arising from irritation and inflam-
 mation in the trachea,  bleeding is proper,
 if other considerations do not forbid it.
 The spermaceti mixture with opium, is
 also frequently of great service.  I  never
 saw a wound of the trachea unite entirely
 by the first intention.
   THROMBUS,  (from fyof*£oc, coagu-
 lated  blood.)  A  clot  of blood.   Ihe
 term  has also  been applied to a tumour,
 formed by a collection  of extravasated,
 coagulated blood,  under the integuments
 after  bleeding.  When such  an extrava-
 sation; though  of some extent, is not con-
 siderable, it  is usually called an ecchy-
 mosis.  (See this word, and also Bleeding,
 Occasional HI-Consequences of.)
   A thrombus sometimes depends on the
 surgeon having totally divided the vein;
 but, much more frequently on his not hav-
 ing made the opening in the vessel,  pro-
 perly correspond to that in the skin.  The
 patient's altering the posture  of his arm,
 while the blood is flowing  into the basin,
 Will often  cause  an interruption to  the
escape of the fluid  from the external ori-
fice of the  puncture; and, consequently,
it insinuates itself into the cellular sub-
    Voi. It
  stance in the vicinity of the  opening yi
  the  vein.   In  proportion as  the  blood
  issues from the vessel,  it becomes effused
  between the skin and fascia,  covering the
  muscles, in tiie interstices of the cellular
  substance,  and this, with more, or leBS
  rapidity, and in a greater,  or lesser quan-
  tity, according as the edges of the skin
  impede more or less the outward escape
  of the fluid.  Sometimes, also, a throm-
  bus  forms  after venesection,  when  the
  usual dressings, compress, and bandage,
  have been put over the puncture, and the
 patient imprudently  makes  use of the
 arm,  on  which  the  operation has  been
 done.  This  is  more particularly  liable
 to happen, when a very large opening has
 been made in the vein.
   The accident is not attended with any
 danger, when the extravasation is incon-
 siderable ; for,  in this circumstance, the
 tumour generally admits of  being easily
 resolved, by applying to it linen, dipped
 in any discutient lotion. If the swelling
 should be more  extensive, applying to it a
 compress wet with a solution of common
 sea-salt, is deemed a very efficacious plan
 of promoting the absorption ofthe extra-
 vasated blood.   Brandy, and  a solution
 ofthe muriate of ammonia in vinegar, are
 likewise eligible applications.
   It sometimes happens, that a thrombus
 induces inflammation  and suppuration of
 the edges of the puncture.  The treat-
 ment is now like that of any little abscess;
 a common linseed  poultice  may be ap-
 plied, and,   any considerable  accumula-
 tion of matter  should  be prevented by
 making an opening with a  lancet in  pro-
 per time.   As soon as  the inflammatory
 symptoms have ceased, discutients should
 be resorted to again,  for the purpose of
 dispersing the remaining clots of blood,
 and surrounding induration.
   When the quantity »f blood is exceed-
 ingly  large, authors generally  recommend
 opening the tumour at once, and, despair-
 ing of the power of the absorbents to re-
 move the extravasation,  they' recommend-
 ed, as much ofthe blood as possible, to be
 pressed out through the incision. I believe,
 however, that making an opening is seldom
 necessary, and often brings on inflamma-
tion, and suppuration, which might be
 avoided.   I  have never seen any case,
 in which there was any real  occasion to
make an opening for the discharge of the
blood.  A case of this kind,  however^
may certainly be conceived.
  THY'MIUM.  (said to be derived from
B-v/mc, thyme, because  of the  colour of
this herb.)  A wart, or kind of excres-
cence on the skin.
  THY'MUS. (from &*>/**> an odour, be-
    3 C 
386                          THYROIB GLAND
cause of its  fragrant smell.)  The herb
thyme.   In surgery, the term is often ap-
plied to warty excrescences on  different
parts of the body, particularly, about the
pudenda and anus,  and  erroneously sup-
posed (as  I conceive) to be of a venereal
nature.
   TH\ROID GLAND DISEASED.  (See
Bronchocele.)
   THYROID GLAND, EXTIRPATION
OF.  Tiiat  such an  operation,  though
attended with great difficulties,  is  not
impracticable, is proved by the following
example :
   In the  year  1784,  J. Hyons,  twenty
years of age, experienced an acute pain
at the  middle  and anterior part of the
neck, in consequence  of a violent exten-
s'on  of the  head : this pain,  which  was
only  momentary,  was  followed  by some
difficulty of motion. About three months
afterwards,  a  small,  hard, indolent tu-
mour .ippeared on the right side ofthe tra-
chea; this swelling was  unattended with
pain or alteration in the colour of the in-
 teguments ;   the  tumour  seemed  to be
raised by a pulsatory action, wliich seem-
 ed to prove the existence ofa large artery
  ituated underneath, and  in fact its base
 was situated on the general course of the
carotid artery.  The  patient, feeling no
 inconvenience,  neglected  it  until June,
 1788.  At this time the tumour was one
inch in diameter; its  progres:;,  which in
 the first  instance was  slow,  now aug-
 mented with proportionable rapidity ; in-
 ternal remedies, and topical applications,
had no effect in preventing its  increase ;
 a fluctuation in  its centre  was  soon evi-
> dent;  an  incision  was  then made  into
 this part,  and a quantity of yellow sero-
 sity discharged. Three  months after this
 operation, which was not of the least ser-
 vice, recourse was had to caustics, which
 were repeatedly applied without  any ad-
 vantage being obtained.   On the 20th of
 March, 1791, she  presented herself for
 admission at the  Hotel Dieu.   At this
 period the tumour was two inches in dia-
 meter, round, hard, and attached to the
 right and  middle part of the trachea, and
 pushed outwards the sterno-mastoideus
 muscle.   Independent of its being  sen-
 sibly raised by each pulsation of the ar-
 teries, it  obeyed the  motions of degluti-
 tion, and  in a slight degree impeded the
 passage of  the  solid aliment.  The pa-
 tient, earnestly desiring to get rid of such
 an  inconvenient deformity,  determined
 to submit to its  extirpation, which ap-
 peared her  only resource. The  danger,
 the length of time, and the pain necessa-
' My annexed to the operation,  were not
 concealed from her.  The operation, af-
 ter a few  day's previous preparation, was
performed in the amphitheatre by Desault
in the following manner : the patient be-
ing laid on her back,  a little inclined on
the left side, with the head and neck more
raised than the rest of the body, the sur-
geon made a longitudinal incision through
the middle of the tumour,  beginning one
inch above, and finishing one inch below,
to allow room to finish the operation with
ease; in the first section he cut down as
far as the gland,  dividing  the integu-
ments, the platysma-myoides, and  some
fibres of the sterno-hyoideii and sterno-
thyroideii  muscles;  an assistant,  with
the view of fixing the tumour, drew to-
wards  the left the inside  edge of the
wound made by- the incision, whilst the
surgeon detached it from the sterno-mas-
toideus muscle. In dissecting the cellular
substance which united ihe parts, two
small arteries were divided, which were
raised by a pair of dissecting forceps and
secured by ligature.   The  external sur-
face of die tumour being thus disengaged,
the internal  part was detached in .he
same way.  The tumour was drawn out-
wards by means of a hook, that it might
be separated with more ease from the an-
terior part and from the side of the tra-
chea.  In the  course  of this dissection,
the branches of the thyroid arteries were
successively tied, as fast as they were di-
vided.  The assistant, to whom the hook
was confided,' directed the gland from
within and forwards,  whilst the surgeon
finished  the   dissection  outwards and
from above downwards.  This part  of the
operation was the most minute and diffi-
cult ;  it  was  necessary by means of a
sponge continually to  wipe  away the
blood, which  necessarily  prevented the
parts from being easily distinguished, and
obliged the surgeon to divide but a little
at a time, and previously to feel with his
finger those parts he  was about to  incise.
By this cautious dissection of parts, the
superior  and  inferior thyroid  arteries
were laid bare, and afterwards secured by
ligature  by  means of a  blunt crooked
needle.   They  were  afterwards  trans-
versely divided, and the remaining part
 of the tumour detached from the trachea,
to  which it strongly adhered. The wound
resulting from  this  operation  was near
three inches in depth .- it was  outwardly
bounded by the sterno-mastoideus muscle,
 and inwa. dly by the  trachea  and oeso-
 phagus ; posteriorly by the carotid artery,
 and by the  nerves of th   eighth pair,
 which were exposed at the bottom of the
 wound. After the wound was well washed
 with warm water,  and cleared from the
 blood, it was filled with coarse lint, pow-
 dered with colophony; square compresses,
secured  by a  bandage moderately tightj 
                   THY

  formed the rest of the dressing.  The
,  extirpated tumour was five inches in cir-
  cumference ; and on  examination  was
  found  to  differ  in  no  particular from
  schirrous glands, except that in the centre
  there was a cartilaginous nucleus.  The
  pa'ient supported this lopg, difficult, and
  painful operation w.tli  uncommon firm-
  ness : she  passed the rest ofthe day with-
  out experiencing any other symptom than
  a slight shivering, generally consequent
  to  large  wounds.  The  following  night
  she  complained of a sense of heat in the
  neck,  and some  difficulty in deglutition.
  The next day a  little  ease was obtained
  by moistening the dressing with a decoc-
  tion of marsh mallows.   A weak dnnk of
  the  herb  dog's  tooth,  acidulated with
  oxymel, was prescribed.   On the third
  day the fever was very moderate,  but the
  difficulty  in swallowing had considerably
  increased  at this  period; the compresses
  and the external  lint were removed, and
  fresh applied.  On the fourth, the fever
  ceased, and deglutition became less pain-
  ful.  Suppuration now became establish-
  ed.  The  next day all  the lint  was  de-
  tached," and  the whole of the dressings
  renewed.   The wound  was in  a good
  state:  it was dressed with soft lint and
  compresses moistened wkh  an emollient
  decoction; a practice  which was conti-
  nued for  the following days. No  parti-
  cular  circumstance occurred during the
  eure.  The wound followed the ordinary
  progress, and was cicatrized at the end of
  a month.   The patient left the hospital,
  perfectly  cured,  the 34th day after the
  operation.  (See Desault's Parisian Chirur-
  gical Journal Vol. II. p. 292—296.)
    To  the preceding case, the editor has
  annexed the few following reflections :
  , The extirpation of the thyroid gland is
  an operation  extremely difficult, and cer-
  tainly  highly dangerous,  when performed
  by an operator  but moderately exercised
  in the practice of his profession. The
 . number and size of the arteries necessary
  to divide,  the proximity of the  trachea,
  (esophagus, and carotid, near which the
  knife must necessarily pass, are the prin-
  cipal dangers that the operator should
  avoid.   These  are  the circumstances
  which  have deterred the majority  of prac-
  titioners from performing it,  particularly
  those who from  long established preju-
  dice have been deterred from using liga-
  tures in cases of wounded arteries.  Ex-
  amples of this operation are very rare.
  The first  time that  Gooch undertook to
  pei-form it, he was deterred from finishing
  it by the hemorrhage, and his patient died
  on the eighth day.  The second time he
  succeeded better, but was incapable of
  securing the vessels,  and succeeded  in
        i
                 TIC             387

stopping the hemorrhage, which would
otherwise have been  mortal, by causing
the parts to be compressed by the hand of
an assistant  for the space of eight diys.
(Gooch's Mul. and Chir. Obs. p 130; Bell's
System of Svrg»ry, Vol. 5, p. 525; and la
Bib. Chir. de Iticrt v,l  2.4epar.ierp. 128.)
  A. F  V igei and Theden have practised
tlie same  operation w.th the most com-
plete success.  All danger from the he-
morrhage, or inconvenience arising from
the discharge of  blood, may be obviated
by  pinching  up the small vessels, tying
them as fist as  they are divided, and by
discovering  and tying the large  vessels
previous to  their division; other parts
that cannot be wounded without  danger,
are to  be avoided by dissecting  slowly
and a little  at a  time, and feeling  with
the finger ev^ry part previous to its divi-
sion with the bistoury.
  TI'.'.IA. ABSCESS  OF.  (See  Canes,
and Spina Ventosa.)
  TIC  DOULOUREUX.  A  painful af-
fection of the nerves ofthe face,  particu-
larly, of the filaments of that branch of
tiie fifth pair,  which comes out of the
infra-orbitary foramen.
  A qu.e has sometimes been accomplish-
ed  by cutting down to, and dividing, the
nerve,  at the place where it emerges on
the cheek.  In other  instances, this has
been done, and the relief has only been of
a temporary nature.
  Similar affections of the nerves may
also take place in other situations, besides
the face.  Mr. Abernethy relates  an ex-
ample, in which a lady became gradually
affected with a painful state ofthe integu-
ment, under and adjoining to the inner
edge of the  nail of the ring-linger of the
left hand.   No injury  to the part was
remembered which could have brought on
this disease.  The pain occurred  at irre-
gular intervals, and was extremely severe
during the time of its continuance, which
was for a  day or two, when it usually
abated. Accidental slight injuries always
occasioned  great pain,  and frequently
brought on those  paroxysms, which how-
ever occasionally occurred spontaneously,
or  without  any evident  exciting cause.
In all these particulars, the disease cor-
rectly  resembled the tic douloureux of
tlie nerves of the face.  As the pain in-
creased, the disorder  seemed to extend
up  the nerves ofthe arm.   After the pa-
tient had  endured this  painful affliction
for seven years, she submitted to have the
skin, which  was  the original seat of the
disorder, burned  with caustic   This ap-
plication gave her intense pan, and, on
the healing of the wound, she found her
sufferings rather . igmented than  dimin-
ished by this experiment.   After  four 
383              T1 C                                 T I N
 more years of suffering, she consulted Mr.
 Abernethy, when the  circumstances  of
 the case was such as to render an opera-
 tion  indispensably  necessary.  The  pain
 of the part was intolerable,  and it ex-
 tended all up the nerves of the arm; and
 this general pain was so constant  during
 the night,  as  to deprive  the  patient  of
 rest.  The muscles of  the  back of the
 neck  were occasionally  affected  with
 spasms.  The integuments ofthe affected
 arm were much hotter than those of the
 opposite  side,  and sometimes  the  tem-
 perature  was so increased as to cause a
 burning sensation in them.   Under these
 circumstances,  Mr. Abernethy did not
 hesitate to divide the nerve of the finger,
 from which all this disorder seemed  to
 originate.   He laid it bare by a longitu-
 dinal incision of about three quarters of
 an inch in  length, from the second joint
 of the finger, and divided it opposite  to
 that joint, by a curved sharp-pointed bis-
 toury, which was conveyed under it.' He
 then  took hold of the nerve with a pair
 of forceps,  and reflecting  it downwards,
 removed  a  portion of it, half an inch  in
 length, that the possibility of a quick re-
 union might be prevented   The  wound
 was brought together by sticking plaster,
 and it united by adhesion; but, the up-
 per part  of the  wound, opposite  to the
 upper end of the nerve,  became slightly
 inflamed,  and was very  painful.  How-
 ever,  the appearance  of  inflammation
 gradually went off in the course of three
 weeks.  After  the operation,  Mr. Aber-
 nethy pinched the originally affected in-
 teguments sharply with his nails, without
 causing any sensation; but if, in so doing,
 he moved tlie  finger,  then pair, was  felt.
 Mr. Abernethy found  it  difficult to  con-
 vince the  patient, that thr skin at  that
 part was actually devoid of sensation, for
 she still  continued to feel similar sensa-
 tions  to those,  which formerly occurred,
 though in  a  much  diminished degree :
 but she  became gradually  as  perfectly
 convinced as any medical man could be,
 that these sensations arose from the irri-
 tated state of the end  of  the nerve, above
 the place where it was  divided.   The
 painful affection of the nerves of the  arm
 still continued, though considerably les-
 sened in violence; however it was suffi-
 ciently severe to make the patient  appre-
 hend, that little permanent benefit would
 arise from the  operation.   This pain con-
 tinued  occasionally about  four  months
 with varying degrees of severity, but the
 temperature of the  skin was not hotter,
 than that  of the opposite side,  as  it  had
 been before the  operation.   At the ex-
 piration of three months, the patient as-
certained, that the integuments at the §nd
of the finger actually felt when any thing
was applied to them, and tiiis  proved- a
new  source  of alarm.   Mr.  Abernethy
adds, that  more than  nine  months, have
now elapsed, since the performance of the
operation,  and the  general pains  iu the
nerves have become very trivial; but, the
sensation of the integuments at the end
of the finger, has during that  time  gra-
dually increased, and  the skin has  now
its natural  sensibility, so as accurately to
distinguish the tangible properties of any
body applied to it.   If also the originally
affected part be compressed slightly, pain-
ful sensations resembling  those  which
formerly occurred,  take place.   (Aber-
nethy's Surgical Observations )
  Mr. Lawrence lately mentioned  to mc
a case resembling the  former, and which •
was  the  consequence of a wound  of the
finger.  This gentleman also cut down to
the nerve,  and removed a  portion of it,
with every  appearance, at present, of per-
manent relief.
  TINCTURA CANTHARIDIS.  (hrttx.)
Surgeons sometimes employ this medicine,
in cases of gleets, and those  of inconti-
nence of urine, arising from a want of
proper action in  the  sphincter  vesicae
muscle, the due power of which it seems
to restore.   The usual dose is from ten
to forty or  sixty drops, twice or thrice a
day;  but its effects  should *be  vigilantly /
attended to; for it is  apt to occasion  dan-
gerous inflammations of the urinary or-,
gans, and  violent  stranguries and reten-
tions of urine.
  Tincture of cantharides  has also been
sometimes  employed as an injection for
exciting  inflammation, in  old, chronic,
callous, fistulous sinuses, with a view of
curing them.  Laying  them open  with a
knife,  however, is now universally  pre-
ferred by all the best surgeons.
  Tincture of cantharides  has occasion-
ally been used as an ingredient  in various
liniments,   and   external   applications,
when the  object  has been  to  stimulate
the skin, rouse the action of the nerves of
the part, or  that of the absorbents. In
this  manner it has been made use of by-
surgeons in some  cases of ptosis, paraly-
sis, &c.
  TINCTURA FERRI MURIATI.  For
an account of the manner of making it,
see the London Pharmacopoeia.  The wri-
ter of the Pharmacopoeia Chirurgica re-
marks, that the tinctura ferri muriati has
sometimes  been exhibited  " for  gleets ;
but a more  important use  has been as-
signed it by Mr. Cline, who orders it in
dysuria, when a consequence of stricture,
in the dose of ten drops every twenty or
thirty minutes. This relaxes the spasm,
through which the retention is occasion- 
                 TIN

■ed,  by a mode of operation  not easily
 explained.
   "Mr. Justamond's  liquid for external
 use in cancers, and which the original in-
 ventor called  his  panacea anticancrosa,
 partook considerably of the nature of this
 tincture,  which,  indeed,  with an equal
 rjiiantrty of spirit of wine, was  sometimes
 substituted for it.
   "Lastly, it is  remarkably  efficacious
 in destroying venereal or other warts, ei-
 ther used alone, or diluted with a small
 proportion of water."
   TINCTURA THEBAICA.   *.  Opii
 purificati gij.  Cinnaiuomi, Caryophyllo-
 rum, sing. £j.  Vini,  albi lib. j.  These
 are to be macerated,  without  heat, for a
 week, and then filtered.
   This was one of the formulae of the old
 London  Dispensatory,  and though  the
 tinctura opii is now substituted for it in
 that work, yet, in one  particular surgical
 case, it is found that ths tinctura thebaica
 cannot be superseded by the other pre-
 paration, without great  disadvantage  to
 the patient: I allude  to inflammation of
 the eyes.  Mr. Ware has  found the  tinc-
 tura thebaica, in this instance, eminently
 serviceable.  His plan has  been to put
 ene drop of it into the  eye, once or twice
 a day,  according as the symptoms  are
 more or less violent.  When first applied,
 Mr. Ware remarks, that it causes a sharp
 pain, accompanied with a copious flow of
 tears,  which  continues  a few  minutes,
 and  gradually abates;  after   which  a
 greater and  remarkable  degree of  case
 generally succeeds.  This gentleman ob-
 serves, that " the  inflammation is often
 visibly adapted by only one application of
 this  tincture; and  many  bad  cases have
 been completely cured by it in  less than
 a fortnight, after every other kind of re-
 medy had been used for weeks, and some-
times months, without any success.  But
 this  speedy good effect is  not  to  be ex-
pected in all cases indiscriminately.   In
 some,  the amendment  is more slow and
gradual, requiring the tincture to be made
use of for a much longer time ; and a few
instances have occurred, in which no re-
lief at all was obtained from its first ap-
plication.   In cases of the latter kind, in
which  the complaint is generally recent,
the eyes appear shining and glossy, and
feel exquisite pain from the rays of light.
However,  notwithstanding  these  symp-
toms, the  application is sometimes found
to succeed; and whether it will or not,
oan only be determined  by making the
trial;  which is attended with no other
inconvenience than  tlie momentary  pain
it gives.  When it is  found to produce
no good effect, the use of it must be sus-
pended, until evacuations, and otiier pro-
              ,   T I N              389

 per means, have diminished the excessive
 irritation ;  after which,  it may again be
 applied,  and bids equally fair for success,
 as in those instances, in which it never dis-
 agreed.
   If two or three drops of the  theb?,ic
 tincture are applied at once to the globe
 ofthe eye,  the pain they occasion will be
 considerably  greater than  if they are
 placed in the inner angle of the eyelids,
 and made to glide gradually on tlie eye,
 by gently drawing down the lower lid. At
 the  same time that this latter mode of ap-
 plying the tincture is much less painful
 than the former, Mr.  Ware has found, in a
 great variety of cases, that it is equally be-
 neficial. (See Ware's Remarks on Ophthal-
 my, £jc. his Additional Remarks on the same
 subject; and the article Ophthalmy in this
 Dictionary, at which  part of  the book,
 the  particular cases,  in which the appli-
 cation can be judiciously made, are point-
 ed out.)  The reader should^be well ap-
 prised, that the tinctura thebaica cannot
 be made  indiscriminate  use of,  for all
 inflammation of the eyes,  without doing
 serious mischief in many instances.
   TINEA CAPITIS.  A disease, so named
 from its eating away the skin, in the man-
 ner that a moth (in Latin tinea.) doesva-
 rious substances.  The Scaldhead. Term-
 ed also Achor, or Achores,  a Greek word,
 said  to be derived from *%„,,  bran,  and
 applied to this disorder, in consequence of
 the branny scales which are thrown off the
 part affected.
   Tinea capitis 'consists of small  ulcera-
 tions which originate  on the scalp, more
 particularly in children, and discharge a
 viscid secretion. The disease begins by
 small vesicles, which  rise above the leftl
 of the skin, which now becomes very ma-
 nifestly red.  The little vesicles burst,
 ulcerate, and emit a  secretion, which, is
 at first fluid, but  afterwards dries more
 or less, so as to  become of a  thicker con-
 sistence,  and  form  scabs.   Several of
 these scabs becoming connected together,
 form very large ones,  of various degrees
 of thickness,  and when  these fall  off,
 others of  a similar nature are  soon pro-
 duced in the same situation.
  Some writers  assert,  that  the  seat of
 this  disease is in  the sebaceous  glands,
 which now pour  out an increased quantity
of their secretion, which is said to be of a
 thicker,  and more acrimonious  nature,
than  natural. This theory, however, rests
unsupported by any  evidence or  facts.
There certainly  is no relative proportion,
between the preternatural  quantity of
matter secreted, and the glands to which
its secretion is ascribed.   Besides, it is
well  known, that the scabs  frequently 
3>)0                           TINEA CAPITIS.
form in situations not remarkable for being
furnished with sebaceous glands.
  Authors have distinguished two species
of the tinea capitis.  One affects children
at the breast, and makes its appearance
promiscuously on every part of  the head,
on the forehead, temples,  and even the
lips.  This case is  considered  as  the
most benign,  and, when cleanliness is at-
tended to, gets well of itself.
  The other species of tinea is of  a more
inveterate nature, and the matter which
it produces is said to be much  more  irri-
tating than that  of the preceding  form of
the disease.  The ulcerations,  attendant
on it, have occasionally penetrated down
to  the  cranium, and  even  rendered it
carious;  an event, however,  which is de-
scribed  as  being exceedingly uncommon,
except in children of very unhealthy  con-
stitutions.  One  may   reasonably infer
also, that whenever the  disease  attains so
high a pitch,  there must have been great
neglect.   The  second kind of tinea ca-
pitis  sometimes  affects  children after
they have  been weaned,  and  even  per-
sons who have  attained the age of pu-
berty.
  The causes of tinea capitis are very im-
perfectly understood.'  Some writers have
imputed  them to a scrophulous constitu-
tion ; but,  I cannot discover any  reason
for  this doctrine, except that some of the
great number of scrophulous  children,
always to be met with,  are affected with
the  scaldhead.   However, so  they  may
be with  many other  disorders,  which no
man,  in  his sound senses,  would  suspect
to  be at all connected with scrophula.
One of  the  greatest  sources of error
among medical men, in the investigation
of the causes of  disease, is their continu-
ally forgetting that two of the kind above-
mentioned  may  happen  quite indepen-
dently of each other, in the same person,
and  that there is no reason, why tinea ca-
pitis, as  well as  the itch,  a chancre,  and
many other affections,  should not occur
in a patient manifestly strumous.   What
I conceive  to be a clear proof that scro-
phula is not a cause  of tinea  capitis,
though it may certainly influence its  pro-
gress, is, that the latter is a very common
disease in countries, in  which  scrophula
is scarcely  ever  seen.  One thing, which
is decidedly very conducive to the occur-
rence of tinea, is uncleanliness, and it is
on this acoount,  that the disease prevails
most among children of the lower classes
of society.  Poor-living seems also to have
some share in keeping up,  at least, if not
in inducing the  complaint.   But, there
are some circumstances,  relative to the
causes of tinea,  with which we are not
at all acquainted ;  for, the disorder now
and  then happens in children wh.ch are
taken  the greatest  care  of, being well
fed,  and carefully washed  and cleaned,
every day.  The tendency  of  the tinea
capitis to spread,  is easily explained, by
the secretion among  the roots ofthe hair,
having the  power of communicating the
morbid action to every part of the surface
of the scalp, with which  it  is allowed to
come into contact.
  The principal objects, in the treatment
of tinea  capitis, are  to soften  and take
away as  many of  the  scabs as possible;
to cover the subjacent ulcerations with
suitable  applications;  to  keep  the scalp
closely  shaved ;  and, in  very obstinate
cases, or unhealthy subjects, to prescribe
proper alteratives.
  In order to fulfil these indications, the
best plan is to have  the hair cut, and
shaved off the whole of the  affected part
of the head, and also off' a good deal of
the surrounding surface.  The scabs are
next to be softened by rubbing them well
with fresh butter, and as many of them
taken away as possible.   This  being ac-
complished, let the head  be next washed
with some strong soap-suds and a flannel;
and  the  common turpentine soap  is the
best for the purpose.
  The scalp ha\ ing  been  dried, is after-
wards  to have applied to it an ointment,
consisting of  the  unguentum picis, and
the unguentum sulphuris, mixed together
in equal proportions,  and spread upon a
piece of bladder, or green oilskin, which
latter substance alone will,  when  aided
by properly washing the  parts, effect  a
cure of itself.
  The dresings are to be changed every
day, and  the parts shaved, and well wash-
ed  with  strong soap-suds equally often.
Cleanliness, indeed, has astonishing effect
in curing tinea capitis.
  I have met with  instances, however,
which resisted the foregoing plan, and,
also,  the application of  the unguentum
hydrargyri  nitrati,  hellebore  ointment,
&c.  The cases in question, however, al-
ways yielded to the  employment of a lo-
tion  composed of  a  dram or two  of the
kali  sulphuratum,  dissolved in a pint of
lime-water.  Linen,  wet with this solu-
tion, was kept constantly applied to the
parts, which were shaved and washed as
often as is above recommended.
   Some  very  obstinate cases demand the
exhibition of internal  medicines.  Small
doses of calomel alone, or conjoined with
cicuta, may be tried.   However, the most
successful alterative is Plummer's  pill,
taken once or twice a day,  according to
circumstances.
  TINNITUS, from timio, to tingle,) 
TONGUE.
391
A noise or ringing in the ear; a symptom
•f some diseases.
  TOBACCO.   The use of this plant  in
surgery is for promoting the reduction of
strangulated hernia.  For this purpose it
is employed either in the form of a fluid
glyster, or of smoke, which latter is in-
troduced up the rectum  by means of  an
apparatus  constructed for this  object,
and  sold  in the shops.  Excepting  the
operation, the power of tobacco, particu-
larly,  when  assisted  with  the  topical
application  of  cold  to the  tumour,  is
most to be depended  upon in bringing
about a return  of the protruded  viscera
into the abdomen.   (See Hernia, and also
 Enema.)
   TOXICS, (from  r»tu,  to strengthen.)
 M-'dicines which strengthen.
   TONGUE, DISEASES OF.   This part
 is subject to various diseases, as ulcers,
 tumours,  and such  enlargements of it as
 sometimes  put  the patient into  imminent
 danger, and claim  the practitioner's  ut-
 most attention.
   Carious   teeth,  having points  and  in-
 equalities,  occasioning incessant  irrita-
 tion, are the most frequent cause of ulcer-
 ations  of  the tongue.  The  sores, thus
 produced,  often resist every  kind of re-
 medy,  and ignorance of the cause some-
 times leads the practitioner  to consider
 them as incurable;  whereas, a cure might
 easily  be  effected by extracting the cari-
  ous  tooth, or simply filing off its sharp
  irregularities and pointed parts.  The ad-
  vice just delivered, is exceedingly ancient,
  and is  the  subject, of a chapter in Celsus,
  who has treated of the diseases of the
  tongue.
   The glandular papillae which are situat-
  ed on the dorsum, or upper surface of the
  tongue, are  naturally formed with a nar-
  row base, and a   broad  termination or
  head,  like a mushroom.   They are capa-
  ble of becoming considerably  enlarged, so
  as to form preternatural tumours which
  may be very improperly mistaken for can-
  cerous excrescences.
    A young man,  eighteen years of age,
  had on the nnddle of his tongue, a cir-
  cumscribed tumour, about as large  as  a
  middle-sized nutmeg.  M. Louis, who was
  consulted,  perceived  that  the  swelling
  was only ofa fungous  nature, and he tied
  its base with  a  ligature, with the noose
  of which  he contracted  tlie  diameter of
  the pedicle, while, with the ends, he kept
  down the tongue.  Then, with one stroke
  of a pair of curved scissars, he cut off the
  tubercle.   M. Louis  afterwards  applied
  caustic, with the requisite precautions, to
  the base of the tumour, and the patient
  got perfectly  well in five  or six days.
  (Mimoires sur les Maladies de la Langue,
dans les Mimoires de V Acad, de Chirurgie,
Tom. 5.)
  Morgagni speaks of  these tubercles,
which  occasionally form on the tongue;
but he  had neveradvised their extirpation,
not even  when they had become hard and
scirrhous : for, though he had not deemed
the operation impracticable, he had had no
confidence in  the skill of  the  surgeons,
who would have  been employed.   (De
Causis et Sedibus Morborum.)
  The tongue is occasionally affected with
a true  cancerous disease; one ofthe most
afflicting cases, indeed, to which mankind
are exposed.  M.  Louis saw a lady, who
had an ulcerated  cancerous  tubercle on
the  left  edge of the  tongue.   The little
swelling was circumscribed ; its size did
not  exceed that of a filbert;  the  pains
were lancinating ; the sore had penetrat-
ed  deeply ; and its tuberculated   edges
were affected with a scirrhous hardness.
Extirpation of the disease seemed to pre-
sent the  only chance of freeing the patient
from the terrible disoider ;  but, she re-
fused to acceue  to any thing but palliative
plans, and she died in the course of a few
months.
   Forestus makes mention of four women,
who were attacked with cancer of their
tongues, and died from the ravages  of the
disease,  andhemorrh ge.   In the writings
of Fabricius Hildanus,  there is a descrip-
tion of  the origin and progress of  a can-
 cerous tubercle on a young man's tongue,
 who had a most  intolerable fetor of the
 breath,  and died, suffering the most ex-
 cruciating  pains. The  same  author in-
 forms us of another case,  exhibiting the
 good  effects of  sedative  remedies in pal-
 liating a cancerous ulcer  of the tongue,
 and the fatal consequences of an opposite
 line of conduct.  In  authors, many other
 examples, of the same kind, are to be met
 with.
   Surgery, however, is not destitute of
 resources against diseases of so formida-
 ble a  nature.  The following case will
 serve to shew,  what benefit may  be ef-
 fected  by this useful profession, when
 not exercised by men of  too  timorous a
 character.
    An elderly woman  had on her tongue an
 ulcerated hardness.  It had been several
 times removed with a knife,  and  as re-
 peatedly returned.  Ruysch was called in
 to a consultation with one of the surgeons,
 who  was attending the patient, and who
 had already  extended his incisions very
 deeply  in removing the disease. The re-
 sult of  their deliberations  was another at-
 tempt to extirpate the tumour, and they
 also  determined, that after it was cut
  away,  the  actual  cautery  should  be
 freely applied,  with a view  of destroy. 
392                               TONGUE.
ing the roots ofthe fungus.  The patient
consented to the plan, and bore  the oper-
ations in question with great fortitude.
The tongue was taken hold  of with a
cloth, and Pierre Le Memnonite, a sur-
geon of eminence, removed the disease
with a  curved bistoury.  The  inside of
the mouth was then  protected with wet
cloths, and the actual cautery applied,  se-
veral times to  tlie wound in the tongue.
The pain  was  appeased, and the separa-
tion of the eschar promoted by  emollient
gargles.   The place soon healed, with the
aid of what were called vulnerary decoc-
tions, containing honey of roses, and the
tincture of myrrh and aloes.
  It is much easier to cut off a  complete
portion of-the tongue, through all its dia-
meter, than to remove a cancerous ulcer-
ation, situated on one  of its edges.
  In both cases, there is a good deal of
difficulty  in fixing it;  for it is so very
moveable, that it is not easy to keep it in
a steady position.  M. Louis recommend-
ed, for this purpose,  the employment of
fotceps, with blades  which terminate in
hook-like  extremities.  With this instru-
ment, the part of the tongue to be ampu-
tated can be  kept  from  slipping  away
from the operator
  Cruel as the operation of removing the
tongue may appear, we  should  not hesi-
tate to perform ii, whenever the disease
has made a certain  progress, and is de-
cidedly ofa cancerous nature.
  It should be  noticed, however, that very
malignant ulcerson the tongue have some-
times been cured by milder means.  Very
bad sores of this description are reported
to have yielded to the repeated application
of leeches under the tongue, after a vast
number of remedies  had been tried  in
vain.  In  the  Encyclopedic  Methodique,
Art. Langue, there is an account ofa very
alarmmg affecti6n ofthe tongue, (reputed
to  be cancerous, though  this may  be
doubted,) which got completely well un-
der a very simple plan of treatment.  A
woman, thirty-five years of age, subject
to cutaneous diseases, and ill-conditioned
ulcers,  complained,   for seven or eight
months, of little swellings, accompanied
with heat and pain,  which made  their
appearance on the edge, and towards the
apex, of" the tongue.   At length, the part
affected began to swell, grow hard, and
cause  lancinating pains.  Its surface  be-
came irregular and  rough; and all the
side of the tongue was considerably swell-
ed. The patient could not  put her tongue
out of her mouth, nor swallow any thing
except  liquids; and her breath was  in-
tolerably  fetid.  Various  sedative  reme-
dies had been  employed without success.
Cicuta had been used as a topical applica-
 tion ; it  had been exhibited internally in
 large does; the patient had taken, for a
 long while, the corrosive sublimate ;  but
 nothing  proved of  any avail.  At length,
 the patient was so tired of trying the ef-
 fect of medicines and applications, that
 she gave them up entirely; and contented
 herself with trying the  experiment  of
 keeping  some honey  continually  in  her
 mouth.  As this method seemed to give
 her some ease, she  was prevailed upon to
 persist in it, and, in this way, the pains
 were gradually appeased;  the swelling
 was diminished,  and, at the end of two
 or  three months, the woman got quite
 well, except  that  an  indurated cicatrix
 remained on the part affected, and consi-
 derably  obstructed the extension  of the
 tongue on that side.
  On this case, however, it might  be re-
 marked, that the retardation of the cure
 seems also ascribable to the injury  of the
 healih produced by  the hemlock, mer-
 cury, &c. and that the amendment,  fol-
 lowing their  discontinuance,  might arise
 from the consequent improvement  of the
 patient's health.
   Many  writers have confirmed the fsict,
 that very inveterate diseases ofthe tongue
 are sometimes cured by hemlock.  In  the
 work, last cited, is mentioned an instance
 of  a  very  unhealthy-looking ulcer, near
 the apex of the tongue, attended with a.
 considerable thickening of the  part, and
"of  some  duration,  which  affection was
 cured by giving large doses of cicuta.
   However,  notwithstanding  many facts
 of  this kind on  record, medicines  should
 not be tried too long, that is to say, so as
 to  let the disease  extend so far  as  not
 even to admit of being cut away.  When
 the disease  makes progress,  the  knife
 should be employed, before it is too late.
   When any part of the tongue is to be
 amputated, the surgeon is to be prepared
 for putting a  stop  to tiie hemorrhage.
 Authors  very  properly  recommend the
 chief vessels to be tied, if possible; but,
 when  this cannot be accomplished, they
 advise tlie employment ofTistringent gar-
 gles, such as a strong solution of alum,
 distilled  vinegar,  or diluted  sulphuric
 acid.  When these methods fail, the ac-
 tual  cautery is advised as the only re-
 source.   Some surgeons,  however,  im-
 pressed  with the horror of red hot irons,
 might think it better to tie the trunks of
 the lingual arteries, as they pass over the
 os  hyoides.  A patient should  undoubt-
 edly never be suffered to die of  bleeding,
 and some bold step ought, certainly to be
 taken; but, I  cannot presume to decide,
 which of the two latter measures is the
 best.  Perhaps* witii a. practitioner, well 
TONGUE.                              393
acquainted with anatomy,  the  last  one
should be preferred.
  The whole ofthe tongue  sometimes in-
flames, and becomes considerably enlarg-
ed, either spontaneously, and without any
apparent cause, or in consequence of some
other disease ; or else from  some particu-
lar irritation ; such as that of  mercury,
or some poisonous  substance.  Slegel, a
German  physician, who was  at Paris
about the middle ofthe 17th century, saw
a patient in a salivation, whose tongue
became so enormously enlarged, that tiie
mouth could not contain it.  Pimprenelle,
an eminent surgeon  of that time, was sent
for, and finding that all trials to relieve
the affection had been in vain, amputated
one liilf of the tongue, with a view of
preventing  it  from mortifying.  When
the wound was healed, it is  said, that the
patient could articulate as well as before.
M. Louis, from whom  this fact is quoted,^
\ery justly remarks, that the measure re-
sorted to by  M. Pimprenelle  was an ex-
ceedingly violent one;  for he  has often
seen urgent symptoms occasioned, during
a  salivation, by  a  rapid and enormous
swelling of the tongue, very quickly yield
to bleedings, purgative glysters,  change
of air, and leaving off mercury.
 - Trincavellius mentions two women, who
had considerable  enlargements of their
tongues.  One of these patients, who was
young, had been rubbed with mercurial
ointment even on her head;  and  the
other, who was about fifty years old,  had
her tongue attacked with the ravages of
the small-pox.. The  excessive  swelling
ofthe tongue, in both these  instances, ter-
minated in resolution,  and a separation of
 ts outward membrane.
  When  the urgency is such,  that an im -
mediate diminution of the  swelling be-
comes necessary for the relief of  the symp-
toms, nothing, it is said, is attended with
so much success, as at once making  one
or two deep  incisions along the  tongue.
This,  it is added, is particularly proved
by the cases, inserted by M. de  la Malle,
in the fifth volume,  4to. of  the  Mem. de
I'Acad. de Chirurgie, and by some others,
related by M. Louis in  the paper above
cited.  Such caaes are extremely interest-
ing, and  seem to  merit an insertion in
this Dictionary.
  A man, who wa3 recovering from a bad
fever, was suddenly  attacked with a pain
in  his  tongue, followed by  a  swelling
equally large  and rapid  in  its formation.
In  less than five hours,  the part became
thrice as  large, as it  is  in its natural state;
and, in this space of time, M. de la Malle,
who had  been consulted, had bled the pa-
tient  successively in liis arm, neck, and
      Xol.  U.
foot.  The man felt very acute pain ; his
skin was excessively hot; his face was
swelled;  his pulse was hard and con-
tracted; and his look  wild.  He  could
hardly breathe; the  tongue filled all the
cavity of the mouth, and  protruded  out
between the lips.  In  this very urgent
case, the surgeon had recourse to no other
expedient, than keeping the mouth a lit-
tle more open than it was made to  be by
the swelling of the tongue, and making
with a knjfe three parallel incisions  along
this organ, one along its middle, and the
other two between the one in the centre
and the edges of tlie part affected.  The
cuts extended through two-thirds of the
preternatural swelling,  and had all  the
good effect, which could possibly be desir-
ed.  There was  a great deal  of hemor-
rhage, and the enlargement of the tongue
subsided so much, that, an hour after the
operation, the patient  was able to speak.
The next day, the incisions had the ap-
pearance of being only superficial scarifi-
cations, and the tongue  was in its natural
state.  In short, the incisions healed in a
few days, the patient haying merely made
use of a simple gargle.
  M.  de  la Malle quotes  several other
cases, all of which tend to shew the suc-
cess, which he has met with in applying
this practice to other similar cases.  He
confirms his own sentiments, by quoting
tiie testimony of some authors, antecedent
to him,  who have recommended  the  me-
thod.   The following case  is taken from
Job a Meckren, an eminent Dutch sur-
geon, who lived about  the middle of the
seventeenth century.   This author relates,
that a sailor's wife, who, for three, or four
days, had experienced a great dryness of
her throat, was suddenly threatened with
suffocation by a quantity of humour, wliich
she made efforts to expel.  The tongue,
the tonsils, and the whole palate, soon
became swelled.   Gargles, poultices, and
glysters, produced no effect.   It was not
deemed advisable to bleed the patient, be-
cause the tumefied parts  had  a whitish
appearance, and  the  swelling  did not
seem  to be of an inflammatory nature.
Purgative glysters;  scarifying and cup-
ping on the nape ofthe neck, and between
the shoulders;  and  blisters behind the
ears ; were recommended, with a view of
promoting, what the old surgeons implied
by the  term, tlerivation.  Such remedies
did not  lessen the disease; on the con-
trary,  it manifestly continued  to  grow
worse, and the livid colour of" the tongue,
and adjacent parts caused  a fear of morti-
fication.  Meckren called  into consulta-
tion Francois de Vicq, a very experienced
surgeon, who acknowledged, that he had
never seen any similar case in  the  whole
     3D 
394                               TONSILS.
course of bis practice.  He advised blood
to be taken away  from  the arm, and ra-
ninal veins, which  latter operation was
effected  with  a good deal of difficulty.
The breathing at first became a little more
easy ; but, as the symptoms still continued
to be  alarming,  it  was determined .to
make a long and deep 'incision  on  the
tongue, to the right and left.  A good
deal of blood was discharged ; the respi-
ration  was immediately  relieved j  the
swelling diminished ; the facility of speak-
ing  returned;  and,  at   length,  all the
symptoms disappeared in an unexpected
manner.   The sirop of roses and purlain
served as a liniment for the wounds, which
soon got well.
   It may be concluded from the preced-
ing cases,  that making incisions into the
tongue would  have saved numerous pa-
tients, who have been suffocated, in con-
sequence of enormous  enlargements   of
this organ.  In the  small pox, the tongue
sometimes became   immensely swelled;
and, it is more than probable,  that,   in
many  instances,  the employment of the
above method would have afforded great
relief to patients, whom  the  disease has
been known to have entirely bereaved of
the power of swallowing.   (See Memoire
sur les Maladies de la I.angue, dans les Me-
moire de  VAcad. de Chirurgie,  Tom.  5.
Mem. de JH  Malle ; same  Work.  Ency-
clopedie Methodique, Partie Chirurgicale,
Art. Langue.)
   TONSILS,  (dim. of rote, the kernels.)
Tonsilltt.  Amygdala. The tonsils, like all
the other parts at the back of the mouth,
are subject to different kinds of swell-
ing, which vary as  much in their nature
as their  consequences.   Some are rapid
in their progress, and these are frequently
observed  to  affect persons of,  what  is
termed,  a  sanguineous  temperament.—
They are also prone to attack young peo-
ple, and such  as labour  hard, and they
have all the essential characters of inflam-
mation.
   Other swelbngs of the tonsils are slow-
er in their progress,  occur in damp cold
weather, and  in  indolent, and what the
old physicians used to  call, phlegmatic
constitutions.
   Lastly, another kind of enlargement of
the tonsils, which is usually contagious,
readily falls into a sloughing, gangrenous
state,  sometimes extends  to the neigh-
bouring parts, and tooofttn proves tatai.
Hence, the various species of angina have
been named  by some writers infiumnia-/
tory,  catarrhal,  and gangrenous.  The
two first kinds frequently terminate in  re-
solution ;  but, sometimes,  ihe  affected
tonsils  afterwards  assume  a scirrhous
hardness, obstruct respiration and deglu-
tition, so that it  becomes  indispensably
necessary, either to extirpate the diseased
parts wi\h the ligature,or the kni'e.
  The cutting away of enlarged  tonsils
was an operation, which was  performed
by the ancients, and, in different ways.—
Sometimes, they tore  with their fingers
the membrane covering the tonsil, and
then pulled this part out of the situation,
wmch  it  occup'es between  the two pillars
of the velum pendulum palati.   In other
instances, in which they experienced too
much resistance,  they seized the d.seased
tonsil with a kind of hook, and then cut
it away  with a  bistoury,  which Paulus
JEgmeta informs  us, was concave on the
side towards the  tongue.
  The moderns, who, for  a long  while,
were  timid in  the employment of both
these methods, adopted plans  of a more
cruel  description.  The  actual cautery
was proposed, and some partial  success,
which followed its use, at once estabi'shed
its reputation.  Caustics were  afterwards
employed, instead of actual fire ; but, the
inconvenience of not  being able to limit
their ac' ion, and  the hazard of their fall-
ing down  the  oesophagus, soon caused
them  to  be relinquished by all  rational
practitioners.   Then  the  operation of
cutting away the  tonsils was revived, and
it was performed, sometime s in the man-
ner of  the old surgeons, sometimes with
various  kinds  of*  curved  scissars,  or
knives.  Instead of the simple tenaculum
used by the ancients, a sort of double one
came  into  fashion.   Every practitioner
seemed to regulate the choice of his in-
struments, by his own ingenuity -, and an
operation,  which was capable  ot  being
doi e at once, became complicated  by be-
ing divided into several i» ocesses.
  Bichat describes the following plan, as
the, common one  practised  at tlie present
day.   The  patient being conveniently
seated, the surgeon is to open the  mouth
very wide, and  depress  the tongue with
any flat  instrument, which is  afterwards
to be committed to the care of an assist-
ant.  The  operator is tlit;n to take  hold
of the diseased tonsil  with a tenaculum,
and with a common  scalpel,  having the
back half of its  blade covered  with rag,
he now removes as much of the  tonsil, as
ought to be taken  away. I.i  common
ca&LS,  it is deemed sufficitnt 0  cut  on a
level will the pilLis ofthe v^lum  pendu-
lum palati.  If any otfn r portion  should
require removal,  this should i.txt be per-
formed  The operation  be ng  finished,
the patient is frequently to wash his mouth
with proper gargles.
  The preceuing plan  seems a very sim-
ple and  easy  one,  and was, for a  long
while, adopted  by Desault.  It is  said, 
TONSILS.                             39S
however, to be liable  to  one objection,
which is, that, when the end ofthe knife
is conveyed far into the mouth, it may do
mischief, not (as has been alleged) to the
internal caro id artery, the backward si-
tuation of which completely keeps it out
of all danger of being wounded, but to the
membranous covering  ofthe palate, in a
place not corresponding to  the tonsils.
Desault  thought this objection was  the
more forcible, as when the hook is intro-
duced into  the tonsil, the danger of the
above mischief is considerably increased
by a general spasm, which seems to affect
every part  of the mouth.,  Hence, this
eminent  surgeon used to employ, for cut-
ting away diseased tonsils,  an instrument,
Which was first invented for dividing cysts
of the bladder.   The  contrivance  con-
sisted ofa sharp-edged blade, which was
included  in a silver sheath.  The  latter
had at its extremity a  kind of notch, in
wliich the gland, which was to be extir-
pated, was received.  The rest ofthe in-
struments were  similar to  those  used in
tiie operation above described.   Desault
used to proceed, as follows :
   1. The patient being seated on  a high
chair, wi h his  head supported on an as-
sistant's  breast,  the surgeon is to  make
him open  his mouth very  wide^ and the
lower jaw is to be kept  thus depressed,
by any solid  body  placed between  the
 teeth, and held there by an assistant.
   2. The tongue is to be kept down with
a broad spatula.
   3. The surgeon is next to take hold of
the tonsil with a double hook, with which
he is to raise and draw  it a little towards
him.  He  is then  to take the above
cystitome, and put the tonsil in the notch,
on a level with the place, where the inci-
sion is intended to be made.
   4. When the portion, wliich is to be cut
off",  is engaged in the notch, the operator
is to draw the part towards him, so as to
stretch it, and press the instrument against
it from below upward.   The blade being
next pushed across the  notch, the neces-
sary section is accomplished.  When  the
division is not complete, which is particu-
larly liable to  happen, when  the diseased
gland is  of considerable magnitude,  the
blade is to be drawn back, and the section
completed by applying the instrument to
the wound, which it has already  made.
Even a third application  may possibly
become requisite on some occasions.
  5. The patient is to be directed to wash
his mouth.  Bichat states,  that this plan
of operating, adopted by Desault, is equal-
ly simple  and easy as the method above
related, with the advantage of being safer.
Such is the construction of the  blade of
the instrument, that when it slides across
 the notch, it presses against, and steadily
 fixes the parts, which are to be  divided;
 an advantage which neither the knife nor
 scissars have, before the action of which
 the  parts are  quite  moveable.  Hence,
 there is difficulty in cutting  them.  When
 the introduction of the instrument from
 above downward, is difficult, it  is  better
 to withdraw it;  and, after  turning the
 notch  in  the opposite direction, pass it
 from below  upward.  In  general, how-
 ever, the first of these methods is prefer-
 able, because the gland, when  half cut
 through,  cannot  now fall back and ob-
 struct the rima glottidis, so as to bring on
 danger  of" a sudden  suffocation ; a cir-
 cumstance which Wiseman and Moscati
 have seen happen.  With a  view of pre-
 venting this occurrence,  M.  Louis  re-
 commended the common scalpel to be used,
 with its edge directed upward, as has been
 advised for the above instrument;  which
 latter  contrivance, however,  being, ac-
 cording to Bichat's account, mot e easy and
 safe, merits  the preference.   Besides tiie
 advantage of fixing the  soft parts, which
 are to be cut, it has that of not confusing
 them, like most other instruments of this
 nature,  as, for instance,  scissars.   The
 oblique disposition of its  blade  makes it
 divide parts, in the manner of a saw.
  The above contrivance, as Bichat al-
 lows, is certainly increasing the number
 of surgical  instruments ; a  tiling,  which
 all the best  modern surgeons endeavour
 to avoid.  But, as this  author remarks,
 this  instrument is not exclusively  appli-
 cable to any particular operation. It may
 be employed for cutting away the tousils
 and  uvula.;  dividing  membranous frsrna
 in the rectum, vagina, and bladder.  am.
 putating fungous excrescences, polypi in
 the nose (if this mode of extirpatingthem
 were preferred) and various tumours in
 general, which are deeply situated in dif-
 ferent cavities of the  body, where instru-
 ments  introduced unguardedly might in-
jure parts which should  be avoided, or
 where the base of the tumour should be
 steadily fixed,  when its division is to be
 accomplished.  The latter object cannot
 safely be effected by scissars.  When the
 base of the tumour is  too large to be re-
 ceived in the noich, one part is first to be
 divided, and  then another, till its whole
 thickness  is  cut through.
  The ligature, as a means of extirpating
 enlarged tonsils, is, in general, only  pro-
per for timid patients, who will not  have
 the knife  employed, or  whose fears  are
 such as  would baffle the opera ion with a
 cutting instrument.  Tying  the tonsils is
 more tedious, and not at  all  less painful,
than cutting  them  away,  and  always
creates a vast deal more irritation.  Miis- 
396
TONSILS.
  cati  having once adopted this plan, very
  severe pain and inflammation ensued; the
  difficulty  of swallowing and breathing
  compelled him to amputate the tumour at
  the place where the ligature was applied,
  and  all the bad symptoms  immediately
  ceased.   Besides, when the  ligature  is
  used, the  ooz'.ng  of blood  cannot take
  place from the ends of the cut vessels, and
  which tends so much to diminish the in-
  flammation. The base of the swelling  is
 ' also  commonly broader  than its  upper
  part,  and does not admit of being pro-
  perly surrounded with a ligature.   And,
  when it has  a narrow base, it can then be
  so easily removed  with a cutting instru-
  ment, or with Desault's instrument, and
  with so little pain, that one or"the last
  modes is always preferable.
    The ligature, however, has had  its ad-
  vocates.  Heister recommends it, in cer-
  tain cases:  Sharp praises it; and  others
  approve its use, and the plans of employ-
  ing it have  been as various  as the inven-
  tive  genius  of the different  partisans of
  the practice. Some make use of Levret's
  double cannula, which is furnished with
  a silver wire noose,  in  which the tumour
  is to be engaged.  By twisting the instru-
  ment, the diseased part becomes constrict-
  ed; and  this plan  being repeated  every
  day, the circulation is intercepted, and
  the gland mortifies, and sloughs  away.
  Some, after putting the noose ofa ligature
  over a kind of tenaculum, hook hold of
  the tonsil, push the ligature over the en-
  larged gland,  which  they  lie,  without
  having any means of increasing the con-
  striction  every day.   Some  employ Bel-
^ toque's instrument for putting the .liga-
  ture over the tonsil.  Others require no
  instrument  whatever  for the purpose,
  and  accomplish the business with their
  fingers.
    Pasting over a more ample  historical
  detail, we need only observe, that two in-
  conveniences generally attend all the above
  plans.  Some of them do not admit ofthe
  constriction being  afterwards increased,
  and, therefore,  are apt to prove insuffi-
  cient.  Indeed,  this is usually the case ;
  and it becomes necessary to apply another
  ligature.   Otliers of the above methods,
  free from this objection, are attended with
  the inconvenience of leaving  in the  mouth
  too large a body, which is very annoying.
  The repeated  twisting of the wire, also,
  sometimes  makes it break,  and renders
  another operation indispensable,  which is
  much more painful than the first one.
    In  order to  obviate these inconveni-
  ences, Desault  employed an instrument,
  which the French call uu serre-naud, which
  is an  exceedingly simple thing, being,  in
  fact, nothing more than a long, narrow,
round piece of silver, terminating  at one
end in a little ring, or hole,  and,  at the
other,  in a kind of groove or notch.  De-
sault sometimes employed the same instru-
ment for tying nasal  polypi, and tumours
in the vagina, and rectum.
   The following was this celebrated sur-
geon's method of extirpating the  tonsils
with a-ligature.
   1. The patient is to be seated on a high
chair,  with his head  held back, on an as-
sistant's breast; his mouth is to be open-
ed very wide,  his tongue depressed, and
the diseased  tonsil taken hold of  with a
double hook.
   2. The surgeon takes the serre-naud, in
which a ligature has been passed, so as to
form a  noose  The noose is to  be put
over the handle of the hook, which is te
be committed to the  charge of an assist-
ant, and the  noose then pushed over the
tonsil, so as to embrace it completely.
   3. The surgeon is  now to  draw the li-
gature strongly towards him, and push
forward the serre-naud, so as to produce
the requisite constriction of the tumour.
In general, the  ligature should  not  be
made very tight the first day.
   4.  When the constriction is such as it
ought to be, the double-hook is to be with-
drawn, and the ligature twisted round the
notch,  at the outward end of the  instru-
ment.
   5.  The next day, the gland becomes un-
usually large,  in consequence of the im-
pediment to  the  return of  the  venous
blood.  The ligature is to be unfastened
from the notched end of the instrument.
and drawn more out, so as to increase the
constrictidh.,   When  this  is  sufficient,
the ligature is to be again  twisted round
the notch  This plan is to be followed
up, till the tumour is detached,  which
usually happens on  the fourth or fifth
day.
   The method just  described, is  more
simple, than  those described in Pare", Fa-
bricius  Hildanus,  Scultetus,  &c.; but,
as Bichat and Desault recommended, the
knife, if possible, should always be pre-
ferred to the ligature. (Desault par Bichat,
Tom. 2.)
   I shall conclude  this article with  ob-
serving, that the  best modern practition-
ers in this country, prefer a common knife
to anyother instrument, for the perform-
ance of this operation.
   TOPHUS,  (said to  be derived  from  a
Hebrew word )  A swelling,  which parti-
cularly affects a bone,  or the periosteum
See Notle.
   TORCULAR. (from torqueo, to twist.)
A tourniquet.  See this word. •
   TORMENTIL.  (from tormentum, pain,
because  it is said to  relieve the  tooth- 
TOURNIQUET.                            397
ach.)   Tormentilla  Erecta.  Linn.   The
root of this  plant  is exceedingly  astrin-
gent, and, on this account, is  sometimes
employed in affections arising from atony,
and a relaxation of certain parts.  It has
been used for  making astringent  poul-
tices, in  cases of prolapsus of the anus,
and also  of  that of the vagina. In relaxa-
tions of  the uvula, ^and  scorbutic  affec-
tions of  the gums, gargles,  made with
tormentil, are said to have proved useful.
Fomentations, prepared with  this  plant,
have been  recommended, as being very
serviceable for relieving the weakness  of
joints consequent to sprains.
  TORTICOLLIS, (fromtorqueo,to twist;
and  collum,  the  neck.)   The  wry-neck.
See Wry-neck.
  TOURNIQUET.  (French,  from tour-
ney to turn.) An  instrument used  for
stopping  the flow of blood  into a  limb,
until some requisite operation has been
performed, or some more permanent plans
of checking hemorrhage, have been put in
practice.             >
  The old surgeons used  to surround the
limb with a band, with which  they made
such a degree of constriction, that the
circulation  was  quite  stopped.   These
practitioners  also"believed, that the pres-
sure of the band was advantageous,  by be-
numbing  the limb,  and moderating the
pain of operations.
  The  violent pain and contusion, how-
ever, which  this tourniquet  occasioned,
being frequently followed by mortification
and -abscesses, surgeons endeavoured to
devise some  other  method of checking
hemorrhage.  The application  of the cir-
cular band was first improved, so that it
caused less pain, and less mischief to the
skin.  The limb was surrounded with a
very thick compress, over which the band
was placed.   Two*small sticks were next
put under the band ; one on  the inside,
the other on the outside of the limb; and
they were twisted till the  band was ren-
dered sufficiently tight.  It is in this man-
ner, says Dionis in his Traite a"Operations,
that carriers tighten the cords which fas-
ten the bales of  goods  in  their carts.   A
French surgeon,  named Morel, is said to
have made this first improvement  in the
application of tourniquets.
  M.  Petit,  in  1718,  presented  to the
Academy of Sciences, a tourniquet  of his
own  invention,   which was much  more
perfect,  than any one ever contrived be-
fore.  It  consists of two pieces of wood,
one of which is  superior, the other  in-
ferior.  The  inferior piece is about four
inches and a half long, and  nearly two
broad.   Is  under surface is  somewhat
concave,  while its upper  one  is a little
convex, aud tlie  ends are hollowed out.
From its middle part rises a round emi-
nence, about seven fines high,' and eight
and a half broad.  The superior piece  is
almost the same as the interior one, just
described, but rather shorter.  The emi-
nence  which  ascends  from  its  middle
part,  is six lines  high, and an  inch and
a  half in  diameter.  This  eminence  is
hollow within, and calculated to receive
a  wooden  screw, the top  of which  is a
sort of button for turning the screw. The
grooves of Petit's screw were about four,
or five, and each  of them four lines  in
diameter, in order that a half turn might
produce  the necessary effect.  Lastly, all
the pieces of the instrument were fastened
together  by an  iron  pin, wliich went
through  the middle  of the two  pieces of
wood, and through  the  whole length of
the screw.  This  iron pin  is  rivetted
under the inferior piece, and at the top
of the button, in such a manner, however,
that the screw is capable of turning on it,
as on a pivot.
   In order to apply this tourniquet, the
limb is to be surrounded with a double
strap,  about four finger-breadths wide,
and' made of chamois leather, wliich  is
the softest material which can be used.
To one end of the strap  a double little
cushion is fastened, of the same length
and breadth  as the  lower piece of the
tourniquet.  A narrow compress,  or cy-
lindrical  pad,  is also  requisite,  for tiie
purpose of compressing the track  of the
vessels.  This compress consists ofa very
firm roll of linen,  covered with  chamois
leather.  The ends of a piece of tape are
sewed to the outer part of the pad, and
thus  the  tape leaves a  passage for the
leather strap. By this  artifice,  the  pad
can be moved to any situation  on  the
strap, which is most convenient, accord-
ing as  the bulk of the limb may require.
The middle of the tape  is to be fastened
to the outside of the leather strap.  The
cylindrical compress,  or pad,  is  to  be
put over the course of the  vessels.  The
double cushion is to be placed on the op-
posite side of the member, while the lea-
ther strap is  to surround the limb in  a
circular manner. All the different  pieces
of the apparatus are next to be  retained
by the tape, which is to be tied at the side
of the cushion.
  The tourniquet is  now to  be put over
the cushion, on that side  of the  limb
which  is furthest from the track of the
large  vessels,  and is to be  fastened iu
this situation  by  a double band, with a
hole in it for the reception of the  upper
part ofthe screw.
  In order to make  the proper com-
pression, the screw is to be half turned 
398
I RA
TRE
round, from the right  to the left.  Tlie
upper piece of the tourniquet, becoming
now further  from  the lower one, the
double band  draws the pad, and presses
it  against the vessels, so as to make the
due degree of compression.
  The following are the advantages, at-
tending the  use  of Petit's tourniquet:
1.  It compresses  the lateral parts of the
limb less, than the  tourniquet previously
in  use.  2. It requires  the aid of no as-
sistant, either to hold,  tighten,  or loosen
it.  3. The operator is able of himself to
stop the flow of blood in the artery, by
means of the screw.  4.  When there is
any danger of hemorrhage after an opera-
tion,  tliis kind of tourniquet may be left
on the limb, and, in case of  the bleeding
coming on,  the patient,  if no one  be at
hand,  can tighten the instrument him-
self,  as  much as is necessary.   5. The
constriction,  which  this tourniquet pro-
duces, does not  create  any danger of
mortification,  because it does not alto-
gether stop the flow of blood through the
collateral arteries.
   The tourniquet just described, is cer-
tainly very complex, when compared with
the one  used by the best  modern  prac-
titioners ? but, still it is the original of
the latter, and both are constructed on
the same principles.  All the  pieces of
modern  tourniquets are kept connected
together, and  instead of  two pieces of
wood, used by Petit, there is contrived a
brass  bridge, which is capable of being
elevated, or depressed, by means of a
screw, made of  the same  metal.  Over
this bridge, a very strong band proceeds,
and by passing under two little rollers, at
each end of the bridge, it always remains
connected with the instrument.  A con-
 vex firm pad  is sewed to the band, and
 put immediately over the artery, where
 the  instrument  is  applied.  There are
 no cushions for the opposite side of the
 limb under the screw ; but a thick piece
 of leather, through which the band pro-
 ceeds in two  places,  is always  situated
 under the lower surface of tiie brass, and
 serves to prevent  any bad  effects  of its
 pressure.  It is usual also for the  surgeon
 to fold some rag, and put it in this situa-
 tion, at  the time of applying the instru-
 ment.  (See some other remarks on the
 tourniquet, in  the article Hemorrhage )
    TRACHEA,  (from r^x^vf,  rough.)
 The  wind-pipe, so  named from its as-
 perities.  For an account of its  wounds,
 see Throat.
    TRACHELO'PHYMA. (fromT^*^uA«5,
 the throat, and pupa,  a tumour.)   A wen,
 or tumour on the throat.
  TRACHEOCE'LE. (from t(«#ii*i the
wind-pipe, and xjjAij. a tumour.)   A tu-
mour on the trachea.
  TRACHEOTOMY, (from Tf »xttet> the
wind-pipe, and rtfMtt, to cut.) Truchcoto-
mia.  The operation of cutting an open-
ing into the wf nd-pipe for various surgical
purposes.  See Bronehotomy.
  TRACHO'MA. (from r^x^vf, rough.)
A roughness on the inner surface of the
eyelids.
  TRAUMATICS.   (from  r^xvfiM,  a
wound.) Traumatica.  Medicines, or ra-
ther applications, which promote the heal-
ing of wounds.
  TREPAN (from rpvirxu, to perforate.)
Trepanum ,-  Terebellum ; Modiolus.  An in-
strument,  which  is  intended  for saw-
ing  out circular portions  of bone.  Be-
fore a more convenient instrument, nam-
ed  the trephine, came into use, surgeons
commonly employed the trepan in various
injuries of the head.  (See Head, Injuries
of)   It is nothing  else,  in short,  than a
cylindrical  saw, and it only  differs from
the  trephine, in having a  different kind
of handle.
  TREPHINE.  The  instrument  now
commonly   preferred for perforating the
cranium,  for purposes  which  we shall
presently explain.   It consists of a simple
cylindrical  saw,  with  a handle  placed
transversely,  like that of a gimblet;  and,
from the centre of  the circle, which the
teeth of the  saw describe, a sharp little
perforator projects, named the centre-pin.
The upper  part of  tlie centre-pin is made
to  screw in a corresponding hole at the
inside of the top of the saw, and is capa-
 ble of being taken  out, or put in, at the
 surgeon's option, by means of a little key
 for  the purpose.   Its use is to  fix the
 trephine, when it is first applied, that  is,
 before  the  teeth of the  instrument  have
 made  a sufficient circular groove,  in
 which  they can steadily  work.  When
 this has been accomplished, the  centre-
 pin  must  always  be removed;  because
 now it  is not only not needed, but, if left,
 it would retard the progress of the opera-
 tion, and inevitably wound the dura mater
 and brain,  when  the teeth of tiie saw
 had cut to  a certain  depth through the
 cranium.  My trephines, which I bought
 of  Mr. Savigny,  have  their centre-pins
 contrived to slide up,  or down, and to be
 fixed in either position by turning a little
 screw.  This method seems to me both in-
 genious and convenient.
    The cylindrical  part of the trephine is
 often termed the crown of the instrument.
 The surgeon should always have at least
 two, or three cylindrical saws of various 
TREPHINE.                            399
sizes; for, it is always  a  commendable
rule never to saw away any more of the
cranium, than is absolutely requisite for
the accomplishment of some assignable
object.  There is no occasion, however,
for  having more than one handle, which
may be mide to screw on any of ihe saws. •
  Trephines are also occasionally applied
to other bones, besides those of the cra-
nium.   In the articles Antrum, Caries,
Exostoses, Spina Ventosa, and Fractures of
the Sternum,  other  cases are mentioned,
in wh ch the employment of these instru-
ments sometimes becomes proper.
  It is certainly not always desirable to
remove a complete circular portion of tiie
cranium;  the  taking away a  piece of
smaller  size, and of a different shage,
would frequently be much more advan-
tageous.  Some surgeons,  I understand,
who object to removing any unnece sary
quantity ofthe cranium,  have been in the
habit of employing a trephine, terminat-
ing only in  a semi-circular,  instead  of a
circular saw, by which means, they can
often cut across the base of a depressed
portion  of the skull,  and take  it away,
without any occasion for removing also a
circular piece of bone.  An instrument of
the latter kind may certainly be sometimes
found useful.
   The  saws,  however,  which  Mr. Hey
has described, should constantly be kept
in  every  case of trephining  instruments.
This practical writer remarks, that  " the
purposes,  for which any portion of the
cranium is removed,  are, to enable foe
surgeon to extract  broken fragments  of
bone, to elevate what is depressed, and to
afford a proper issue to  blood or matter,
that is, or may be confined, &c.
   '• When a broken fragment of bone is
driven beneath the sound contiguous part
of the  cranium,  it frequently  happens,
that  the  extraction cannot  be  executed
without removing some of the  unbroken
part, under which the fragment is de-
pressed.  This might generally  be effect-
ed wtfh very little loss of sound bone, if
a narrow  portion of that, which lies over
the broken  fragment, could  be  removed.
But such a portion cannot be removed by
the trephine.  This instrument  can only
saw  out  a  circular piece.  And as,  in
executing this,  the central pin of  the.
saw must be placed upon the uninjured
bone, it is  evident, that a portion of the
sound bone, greater than half the area of
the trephine,  must  be removed at every
operation.  When  the  broken  and de-
pressed fragment is large, a repeated ap-
 plication  of ihe trephine is often necessa-
 ry, and a great destruction of sound bone
 must be the consequence.
   «« When the injury consists merely of a
fissure with depression, a small enlarge-
ment of the fissure would enable the sur-
geon to introduce the point of the ele-
vator, so as to raise the depressed bone.
But a small enlargement of  the  fissure
cannot be made with the trephine.  When
it  is necessary to apply the  elevator  to
different parts  of the depressed bone, a
great deal of the sound cranium must  be
removed, where a very  narrow aperture
would have been sufficient.
  " The same reasoning will apply  to
the case of openings, made  for the pur-
pose of giving a discharge to extravasated
blood, or matter.
  " if a saw could bf; contrived, which
might be worked with safety in a straight,
or gently  curvilineal direction, it would
be  a  great acquisition to the practical
surgeon.  Such  a  saw  I can now  with
confidence  recommend,  after a trial of
twenty years, during which time,  I  have
rarely used the trephine in fractures of
the skull.  Its use  has  been adopted by
my colleagues at the General Infirmary
in Leeds ; and will be adopted, I hope,
by  every  surgeon,  who has once made
trial of it."   Mr. Hey  next  informs  us,
that the instrument was  first shewn to
him by  Dr. Cockell, of Pontefract;  but
that there  is a saw, formed on the same
principle,  in Scultetus's Armamentarium
Chirurgicum.   Tlie saws alluded to, are
very short ones,  fixed  at the end  of a
longish  straight handle; their edges are
made either  straight,  or semi-circular.
The latter construction qualifies the  in-
strument  for cutting in  a curvilineal  di-
rection, which is often proper.  The edge
of the saw should always be  made a little
thicker, than  the rest of the blade,  by
wliich means  it will work in the groove,
which is cut, with more  facility.
   Saws, made  on the principle just de-
scribed, are also of infinite use in cutting
away diseased portions of  other bones,
besides the skull, exostoses, &c.  In cases
of necrosis, when a dead part of a bone
is quite wedged in the substance of the
surrounding new bony matter, Mr. 1 ley's
saws  may  often  be advantageously em-
ployed for cutting away the parts, which
mechanically prevent the detachment of
tiie dead piece.
   Besides trephines of various sizes, and
the saws just now noticed,  the surgeon
should  also take care to have in his case
of instruments for  this operation, a little
brush for occasionally cleansing away the
particles of bone from  the teeth of the
saw, in the progress ofthe  operation; a
pair of forceps adapted for extracting  the
round piece of bone after it has been  de-
tached  by the saw; a lenticular  for  re-
moving any inequalities, which may pre-
*, 
400
TREPHINE.
sent themselves,  round the sawn edge
of the cranium, after the circular piece
is taken out; a raspatory for  the same
purpose, and, also, for scraping the bone
in order to see whether  it  will bleed,
which  is a circumstance  in  some cases
very important to be attended to; (see*
Head,  Injuries  of;) a largish common
scalpel for dividing the scalp,  &c.;  and
some elevators  for  raising  depressed
pieces of bone.
  The common elevator is now  generally
used by all the best English  surgeons ;
but, several others have been proposed,
as,  for instance, the tripod elevator;  and
another one, invented by  M. J. L. Petit,
and afterwards improved by M. Louis.
  The common elevator is  a kind of lever,
bent in two different directions, and the
ends of which are  made rough, in order
that they may  not easily  slip away from
the piece of bone, which is to be raised.
This instrument may be used by forming
a fulcrum for it in the hand, which holds
it;  or else  by making a fixed point for  it
on  the  edge of the opening,  made with
the trephine, or of that,  which tlie acci-
dental  violence has  occasioned.  In the
first case, the  instrument  cannot be em-
ployed with much  force; the  hand may
give way ;  or the elevator may slip away
from the bone, against which  it presses,
and thus occasion a considerable concus-
sion.  In the second case, the  parts, on
which the  instrument is placed, may be
forced inwards.
  These inconveniences  led  to  the in-
vention ofthe three-footed  elevator, which
consists of three branches  uniting above
into one common trunk. This part of the
elevator  is  pervaded by  a long screw,
having below a kind of hook,  and above
a sort of handle for turning it.   It is with
the hook, that the  depressed  portion  of
bone is to be elevated.  This part of the
instrument is  to  be introduced into the
opening, made in the  cranium, as soon
as the elevator has been put in a proper
position, and it is  to be made to ascend
by  turning the screw.   Formerly, the
tripod elevator was also sometimes used
conjointly with a short screw, which  was
first fixed in the piece of bone to be  ele-
vated, and then drawn upwards by plac-
ing the hook of the elevator  in  a  ring,
which was   attached  to its upper  part.
Those surgeons, who invented the three-
footed  elevator,  were  well  acquainted
with all  the objections to the ordinary
one, and they  endeavoured  to  pbviate
them,  by  procuring a firmer  fulcrum,
and more power.   But it  was  necessary
to change the situation of their elevator,
as often  as there  was  occasion to raise
a different portion of bone, and the hook,
also, being connected with  an  inflexible
piece of steel, the direction of which was
always the same as that of the instrument,
it was troublesome and difficult to place
the hook under the piece of bone, which
required being raised.
  Such were the reasons, which induced
M  J. L. Petit to invent  a new elevator.
This is a lever mounted on a handle, and
straight, throughout  its whole  length,
except  just at  its very end,  which is
slightly curved,  in order that it may be
more easily applied under the bone, which
one wishes to elevate.   The  lever in ques-
tion is  pierced,  at various distances from
its bent end, with several holes, intended
for the reception of a little kind of move-
able screw-peg, fixed on the  top of a  sort
of bridge.  This  latter part of the in-
strument is  a kind of arch, the ends of
which  are long, and covered with little
cushions.  In the middle of  the bridge is
the moveable screw-peg already mention-
ed.  Petit wished the peg to be joined to
the bridge,  by  means  ot a  hinge; and,
as he often  found it necessary to  elevate
several  different pieces  of  bone  in  the
same wound, he thought that the  little
screw should not be completely fastened
in  the hole; but, that  the instrument
should be capable of being turned to the
right,  or  left, or to any  point of the
cranium,  However,  a  screw  is an  in-
clined  surface, which revolves round  in
a cylindrical cavity;  consequently, when
the fulcrum, formed by the bridge, is
once placed, and (instead of moving the
elevator directly upward) one  wishes  to
turn the instrument to the right,  or left,
it can only be applied obliquely, and, with
its edge, under the piece  of bone which is
to be raised.
  M. Louis  learnt from experience the
inconveniences of  Petit's elevator.   The
former of  these  celebrated  surgeons  ob-
viated them  by substituting,  for the hinge,
a kind  of joint, for the purpose of connect-
ing the lever with the bridge.  This  con-
struction,  which  makes the  lever  capable
of being readily moved in every direction,
also adapts  it for being  put under every
point,  which may require  being  raised,
and this, without any occasion for chang-
ing the position of the bridge, forming the
fulcrum.  M. Louis also substituted for
the screw a  pivot.
  I have only to repeat, respecting ele-
vators, that  all surgeons in  this country
prefer, what we have called, the common
one, which is the most simple, and is found
to answer every  desirable purpose.
  Before  beginning  the  description  of
the operation, I  think it highly proper to
remind the reader, of what  has been  so
forcibly dwelt upon in the  article Head, 
TREPHINE.
401
Injuries of,—-that the removal of pressure
oft" tlie brain, which pressure must  also
actually occasion dangerous symptoms,
can form  the only true and' vindicable
reason for employing the  trephine, or
sawing away any  portion of the  skull.
There are a very few exceptions to  this
remark :   it may,  indeed,  be now  and
then proper to saw away the  bony edges,
which surrotmd some fungous excrescen-
ces, which  grow from  the  dura mater,
and make  their  way outward,  by occa-
sioning an absorption  of the  part of the
skuirimmediately over them. (See Dura
Mater.)  It may also be  now  and  then
proper to  saw  out  diseased portions of
the skull,  though, it  must be confessed,
that in general their separation  might be
left to time and nature.   To  have a  pro-
per idea   of all the circumstances  in
which' trephining is indicated, the reader
must  turn  to the article, Head, Injuries of.
  When the operation is  determined on,
it is  more convenient to  have  the  head
shaved; indeed, this  is often  done  im-
mediately  the surgeon is called,  in order
that he may have a better opportunity of
seeing what parts of the scalp have  been
struck; for, it  is in such situations,  that
he has most reason to apprehend fractures
of the bone, or extravasations beneath it.
If, however, the violence  has occasioned
a large wound, or laceration  of  the scalp,
the practitioner, knowing where the force
has been  applied, is frequently content
with having a little  ofv the  hair shaved
off the parts surrounding the  injury.  All
that need be said on this  subject is,  that
it is better to have enough   of the  hair
always taken away,  to afford the surgeon
an uninterrupted opportunity of examin-
ing the scalp freely, and  doing whatever
may  be necessary.  The  loss of a  little
hair w of very little consequence, while
the concealment of the seat of a depressed
fracture, or extravasation, might lead to
fatal consequences.
  When the  propriety and  necessity of
trephining are fully indicated by circum-
stances and symptoms,  explained  in the
article, Head,  Injuries of,  provided the
wound, or laceration ofthe scalp, should
not have  exposed a sufficient surface of
the bone for the application of the crown
of the trephine, an adequate  dilatation of
such  wound  ought  immediately  to be
made. If, in the situation of the blow,
there should only  be a  contusion,  or a
lump, unattended  with  any  wound,  a
division of this part of the scalp  is to
be made by carrying the knife quite down
to the bone.  In those  cases, in which
the swelling, occasioned  by  the violence,
is considerable, and  attended with the
sensation  of a  crepitus;  as well as in
    Vox..  H-
other instances, in which there is  only  a
contusion,  under which a fracture and
displaced pieces of bones may be felt: the
scalp must be divided in the same man-
nerf only with greater caution, lest the
point of the knife should insinuate itself
through the fracture, and do mischief to
the dura mater and  brain.  *
  Authors recommend the shape  of the
incision to  be different according to the
kind of fracture, and the parts  of the
head, on wliich the violence has operated.
When the whole extent of the injury can
be brought into view, by means of an in-
cision, having the form of a letter T, the
surgeon should  be  content with  such a
division : but,  if this be not  sufficient,
he  may render 4t a crucial one.  When
the  trephine is to  be  applied  to the
squamous parts ofthe temporal bone, they
are recommended to make the incision,
as much as possible in the shape of the
letter V, the branches of which are to be
upward,  and the angle  downward,  in
order that  as  little  as  possible of the
temporal muscle may be  cut,  and that
the division of its fibres may be avoided as
far as it is in our power.
  Having divided the  scalp,   the  next
object is to reflect it; but, no man would
be warranted in cutting any part of  it
away, although such practice is advised
by Pott, and many other eminent writers.
The purposes  of the operation  do noli
require any removal  of this kind; and,'
the method would leave a wound, which
would  be long in  heaJing,  and, when
healed,  never  exempt  from deformity.
In short, the reflected' flaps of the  scalp
are capable  of adhering  to the parts, on
which  they are laid, after the operation,
and, consequently,  ought never  to be
wantonly cut away.
  Tl^e scalp being reflected, authors next
advise us to scrape away the pericranium,
either with the  knife, or tlie  raspatory.
Perhaps, this measure may be considered
as one, which does  neither much harm,
nor much good. The design is to facilitate
the  application of the  trephine to the
bone.  However, the teeth of a properin-
strument, in good order, will not  be im-
peded  by the  slendef periosteum ; and
scraping tli^ membrane  away from parts
ofthe skull, which are not to be removed,
must be conducive to exfoliations.
  Sometimes, the bleeding from branches
of the temporal, or occipital artery, is so
copious, that the bone cannot be very con-
veniently perforated before the hemorr-
hage is  suppressed.  If  it be prudent  to
wait a little, and the  case (as it  generally
does) should be likely to be benefited by
the evacuation  of blood, it is  as well  to
let the  bleeding continue  for a  certain
    3E 
402                               TREPHINE.
time.  The surgeon may then just direct
an assistant to put the end of one of liis
fingers  on the mouth of the vessel, and
proceed in the operation.  In some cases,
the  bleeding  might be  so  troublesome,
that it would be better to tie the artery
at once.
  All  parts  of  the  cranium do  not  ad-
mit  of  being trephined  with equal con-
venience and safety.   It has usually been
set  down by surgical authors, that  the
trephine  cannot be  applied  below  the
transverse ridge of  the  os  oecipitis.
There  are some cases,  however, which
prove  that  such an operation  may  be
safely done,  and that we ought not, in
urgent  circdmstances to be afraid of di-
viding the trapezius and complexus mus-
cles, in order to be  enabled to apply the
•trephine to the bone.  (See Hutchinson's
Case in Medico-Chirurgical Transactions,
Vol. 2, />., 104, &c.)
.  The majority ot writers also forbid us
•applying the  trephine to the  fiontal si-
mises, in consequence of the indetermin-
ate  depth of these cavities, and the ap-
prehension of incurable fistula:.  M, Lar-
rey, however, has  deviated  from  this
precept in two instances, and his  practice
confirms  the statement of Mrt  C. Bell,
that by opening the frontal sinus with a
large trephine,  and then using  a  small
one, the  internal parietes of this cavity
may be trephined with perfect safety, and
no risk of injuring the dura mater with
the  saw. (See Larrey's Mem. de Chirurgie
M.litaire, Tom. 2, p.  136—138 )
   Writers also  caution  us  not to  apply
the  trephine  to the  anterior  inferior
angle  of  the  parietal  bone,  in conse-
quence of the middle artery of the dura
mater  lying under it,  generally  in  a
groove of the bone, and occasionally  in a
canal in its very substance.  In the latter
circumstance, this portion of the parietal
bone could  not  possibly be taken  away,
without wounding the vessel.  However,
notwithstanding this  advice, which  has
been unthinkingly handed down by one
 writer  to another,  from  generation to
generation,  1  very much  question  the
soundness ofthe doctrine.  We undoubt-
edly ought to avoid trephining this part
of the cranium, when we can prudently
do  so.  But the causes  demanding  this
operation  are always  so urgent, that the
patient's  sole chance  of existence de-
pends  on their quick removal.  Hence,
 were there pressure on  the brain,  either
from a depressed  portion  of bone, from
blood, or matter, and such pressure could
not be removed without trephining the
anterior inferior angle  of  the  parietal
 bone,  what  operator would be afraid of
domg so ?  Besides, the fear  of tlie he-
morrhage has been very unfounded; fofy
the lodgment of the artery in a bony fur-
row, or canal, which authors Lave point-
ed  out, as rendering the suppression of
the hemorrhage more difficult, is a mere
visionary idea, as it is well known, that
a little plug of lint, pushed in the orifice
of a vessel, so situated, will always  stop
the bleeding, with as much certainty and
ease as can possibly be imagined.
  The foregoing suggestion was made in
the  early editions  of my works, and I
now see  the  safety of the practice has
been  confirmed.  " I have also  applied
the trepan  (says  M. Larrey) over the
track of the  spheno-,spinous  artery,  at
the inferior anterior angle of the  parietal
bone.   The  artery  was divided;  but,
I stopped the hemorrhage  ahhost im-
mediately, by applying an  iron probe
red hot."  (Mem. de Chirurgie Militaire,
Tom. 2, p-138.)
  Writers, until  very lately, also prohi-
bited us  from  trephining  over any  of
the  sutures,  and, especially  over the
sagittal  suture, beneath which the lon-
gitudinal sinus  is/situated.  The fear of
the  dura "mater  being  injured, and  of
this  vessel  being  wounded,   was the
reason fin- the advice.   With  regard  to
the sutures t  general, the trephine may
be  applied to '  em, as  well  as to any
other part; and,   .  for the sagittal su-
ture, many facts confirm the  propriety of
not  being deterred even by  it, though
situated  immediately over the longitudi-
nal sinus.  It is  to be remembered, also,
that the dura mater, in cases of extravas-
ated blood, and matter, beneath the cra-
nium, is  detached by the intervention of
such fluids from the inner table.
   By means of  a  perforation practised
over the  sagittal suture, Gareugeot suc-
cessfully  elevated   a portion  of bone,
which pressed   upon  the  longitudinal
sinus, and  made the patient quite co-
matose.   The depressed piece of the
cranium could not have  been so advan-
tageously  raised, had  the trepan  been
applied  in  any other situation.  But .a
still stronger argument, in favour of this
practice, when the case at all requires it,
is the fact, that wounds of the longitudi-
nal sinus, and the  hemorrhage resulting
from them,  are  not attended  with any
serious danger.   Sharp mentions his hav-
ing twice seen a bleeding of this  kind.
Another  instance  is also recorded  in
 Warner's  Cases.   A child  received, a
wound on itj forehead: the two parietal
bones were fractured,  and a  portion of
each was depressed  on  the dura mater.
 The  child  lived a  month, without am
 operation  being  done; but,  at the end
of this time,  Warner applied die trepan
                          I
/ 
TREPHINE.
403
He  found a splinter of bone sticking in
such  a  way  in  the longitudinal  sinus,
that it could not easily be got out; con-
sequently, he enlarged with a lancet the
opening,  in  which the splinter  was en-
tangled.   The hemorrhage, which  was
copious,  was easily  suppressed by the
application of a little, dry lint,  and the
child was relieved, though it died at the
end of  two months,  after  suffering a
variety of symptoms, which  had no con-
nexion with the wound of the sinus, the
opening  of which  soon healed.   The
fourth case, related  by Marchettis, also
confirms, that wounds of the longitudinal
sinus are not fatal.   Pott has since re-
corded other facts, tending to the same
conclusion.
  [In confirmation of the above remarks,
I take the liberty to state, that I have my-
self seen a case in which the trephine was
applied over the longitudinal sinus ; and
upon removing the bone, this vessel was
found wounded, and  bled profusely : the
application of iint stopped the hemorr-
hage, and the patient recovered.]
   Whenever a depressed fracture can be
elevated to its proper level, without ap-
plying the trephine, and with the mere
aid of a pair of forceps, or an elevator,
trephining should never  be performed,
unless there should be reason to  appre-
hend, that  blood, or matter, lodged on
the surface of the^dura mater, contributes
to  the occurrence of the bad symptoms,
 and ought to be discharged
   The scalp having been divided, if ne-
cessary,  and  the  pericranium scraped
from the surface  of the bone, according
 to  the common  precepts, and  practice,
 the next thing  is the application of the
 crown ofthe trephine.
   The surgeon is first  to  make  a little
 impression with the point of the  centre-
 pin, for the purpose of shewing the place,
 where it will work, when  the crown of
 the trephine  is applied in the  proper
 situation; for, where such  impression is
 made, the operator must make a small
 hole with a perforator, in order to fix the
 point of the centre-pin, on which  the
 crown of the instrument turns backward
 and forward, as on an axis, during the
 first stage of the  operation.   Mr. Sa-
 rigoy's centre-pius  make  a perforation,
 without need of any particular  instru-
 ment for the purpose, and, in this respect,
 are advantageous.
   The  point of  the centre-pin  having
 been fixed, the trephine is to be  turned,
 by  regular  semicircular motions, alter-
 nately to the right and left, wliich^object
 is effected by steady pronations and supi-
 nations  of the  operator's  hand.  The
teeth of the saw having made a tolerable
circular groove, in which they_ can steadily
work,  tiie  centre-pin  becomes  useless,
and, as it  would,  if not withdrawn, or
removed, certainly injure the dura mater
and brain, by reason of its projecting far-
ther, than  any other part of the instru-
ment, it would be an unpardonable blun-
der to  let  it  remain, after  a  proper
circular groove has been formed by the
teeth of the saw.
  The beginning of the sawing may be
executed boldly and  quickly;  for, the
operator runs no  hazard of doing mis-
chief.  It is necessary .occasionally, with
a view of  facilitating  the  action of the
instrument, to  clean away the particles
of bony matter, with allittle brush, usu-
ally kept for the purpose in every box of
trephining  instruments.  Were this plan
neglected,  the  action  of the  cylindrical
saw would be very much clogged.
  The operator, however, must increase
his caution, when the sawing has  made
greater progress;  for, were he to be too
bold, he might sometimes lacerate the
membranes of  the brain with  the  teeth
of the instrument,  particularly, as the
thickness of the cranium is subject  to in-
finite variety, both in different parts of
the same head, and in different subjects.
Let the surgeon,  therefore, never forget
to examine frequently with the point of a
quill,  %vhether any part of the  circular
groove is  cut through, or nearly so ; for,
when  this  is the  case, the  instrument
must only be worked in such a way, as to
make pressure upon, and cut, the part of
the circle, which ye,t remains to be divid-
ed.  In some few cases, it is  said, that
the surgeon can distinctly feel, when the
teeth  of tlie saw reach the diploe, or
medullary   structure,  between  the two
tables of the cranium, and some writers
have rashly directed us to saw with bold-
ness, till the sensation of this  occurrence
is communicated to our hand and finger!-./
 However,  I believe,  this  possibility  of
discriminating the arrival of tiie teeth of
the saw at the diploe is so uncommon,
 and so fall&ous, that it should never be
 expected,  or  relied on. Nor ought the
 surgeon to saw with incautious force and
 rapidity, till he sees the teeth of tlie tre-
 phine bloody, which has been set down as
 another, criterion  of their having reach-
 ed the  diploe.  I have already stated,
 that a great many skulls have hardly any
 space between  several parts  of the two
 tables.  This is particularly often  the
 case in old persons.
   A prudent man will always prefer ex-
 erting a little force  for the  purpose of
 breaking  some of  the  bony connexion,. 
404
TREniTNT*
 retaining the circular piece of bone, to
 running anjjiazard  of injuring the dura
 mater,  by sawing too deeply.   Vfter a*
 certain time, therefore,  it  is  better to
 lay  down  the trephine, and endeavour
 to elevate the portion of bone, with the
 aid of a pair of forceps, constructed  for
 the  purpose,  and kept in most cases of
 trephining instruments, or else by means
 of an  elevator, which  is still more calcu-
 lated for the purpose.
  When the  circular  piece of bone has
 been taken out, and  the edges of the
 perforation  are unequal, and  splintered,
 the  irregularities are  to be cut off" with
 the  lenticular Knife.   When there is ex-
 travasated blood underneath the open-
 ing which has been  made, it sometimes
 spontaneously makes  its escape, and, if
 it should not do so, the surgeon should
 remove it himself.  If one perforation of
 the  skull should not  suffice for letting
 out the blood, as much more of the cra-
 nium ought to be removed  with the tre-
 phine, as  circumstances  may  require;
 there being no comparison  between the
 danger of repeating  the application of
 the  instrument, and  that  of leaving a
 quantity of  undischarged,  compressing
 fluid, on the surface of the brain.  Cer-
 tainly, many facts on record evince, that
 the  dura mater may be very extensively
 uncovered,  without   dangerous  conse-
 quences.  Sarrau saw a whole parietal
 bone exfoliate, in consequence of a blow
 on  the head.  Blegny relates, a similar
 case :  and Saviard  makes  mention of a
 woiUln, who  had  lost  the upper part of
 the  os  frontis, both  the  parietal bones,
 and  a large portion of the  os occipitis,
 all of which had come away at the same
 time.  The  woman,  notwithstanding, re-
 covered   Yaugion,   however, who  also
 seems to relate this identical case, de-
 scribes the exfoliation  as not being quite
 so extensive.
  I am of opinion, notwithstanding these
 facts, that exposing  a large part of the
 dura mater  with  the trephine  is, by  no
 means, an operation exempt from serious
 danger.  And, what  I conceive confirms
 this  statement, is my  having known  in-
 stances, in which persons, who  had  been
rashly advised to submit to being tre-
 phined, for the cure  of violent  pains in
 the head, &c, died, in consequence of the
operation.
  However,  I perfectly coincide  with
writers, who  recommend the removal of
as1 much bone, as  is requisite, in order
to be able to remove the whole of the
pressure  from the surface of  the dura
mater.
  The application of the  trephine, in
cases of  large  extravasation,  must  in
particular he  made  several tinier., when
the situation of the  fluid does not favour
its  escape.   However, in this circum-
stance,  Sabatier says,  that  we  should-
not make numerous perforations all along
the  extent  of  the  extravasation;  but,
only a  counter-opening, as  is done on
the soft parts.   This author expresses his
surprise at there not being on record many
examples of counter-openings  made on
the cranium, since 'analogy demonstrates
their utility.  I cannot help remarking on
this  part of the subject,  that one very
obvious  objection to  making openings
of this  kind in the  cranium, is the im-
possibility  of  knowing*  with  certainty,
whether blood lies under  any particular
part of the  skull; whereas, in  abscesses
of the soft  parts, the surgeon feels the
fluctuation ofthe matter, and knows,  that
his counter-opening will be made  in the
cavity containing it.   One  might  also
have  occasion  to make more  than  one
perforation,  in  order to discharge blood
extravasated beneath the skull, when the
blow  has happened  near a  suture, to
wliich the dura mater continues adhe-
rent ;Vor, it might happen, that an open-
ing made only on one side of the suture,
might only give vent to a part of the ex-
travasation.
  If we  should  not  find  blood  lodged
under the cranium ; but the dura mater
should  seem   elevated,  tense, dark-co-
loured, forming a prominent fluctuating
tumour,  outward, it may  be cautiously
opened with a lancet, or  bistoury, with
a view  to  letting out  any collection of
blood underneath.  In the article, Head,
Injuries of, we have  stated the result of
Mr.  Abernethy's experience, in  regard
to the  operation of opening  the  dura
mater.  This gentleman found, that the
method never effectually  discharged all
the-blood, but only the serous part of it.
The evacuation of any of the compressing
fluid must, however be desirable; and, if
the surgeon  cannot do more,  yet  he has
fulfilled his professional duty.
  The utility of trephining is not limited
to discharging  extravasated blood, or
matter,  lodged  underneath  the  skull.
This operation frequently  enables us to
ele>fcite depressed portions  of bone.   The
latter object can often  be accomplished
by merely making one perforation. Some-
times, several  perforations are requisite
to be made  near each other.  Authors
even state, that it may also  become neces-
sary to remove the  intervening portions
of bone with a pair of cutting forcep3.
The  depressed  part may then  be easily
raised by means of an elevator.  Occasion-
ally, indeed, I  may  say, very often, the
best  practice is to remove  the depressed 
TRICHIASIS.
405
portion entirely, when  its entire sepa-
ration  from the rest of the skull can be
accomplished by cutting across  the base
of the depressed piece.  If any splinter
stick in the dura mater, and not admit of
being  withdrawn, without enlarging  the
wound in  the  membrane, the  surgeon
should not be afraid of doing this with a
sharp instrument.
   The operation  being  completed,  the
flaps of the scalp  are to be laid down,
and a  little soft  lint applied, covered
 with a pledget of simple ointment.  The
 lighter the dressings are, the better, and
,no bandage will serve for retaining them
 so well, as a common elastic night-cap.
   The practitioner should not now con-
 ceive,  that he has done all that he ought
 to do.  Let him remember the urgent ne-
 cessity of  keeping off, or diminishing,
 the inflammation of the dura mater  and
 brain, which is to be feared.  Let  him
 bleed  the patient largely and repeatedly ;
 exhibit saline  purges, glysters, and anti-
 monials ; and, if the symptoms continue,
 let him apply a blister to some part ofthe
 head.   I shall avoid,  however, any repe-
 titions on  this subject,  by  refering to
 Head, Injuries  of.
   The reader may find an account of the
 operation  of trepanning, or trephining,
 in every  system  of  surgery:  but, he
 should particularly consult the writings
 of Sharp,  Le Dran,  Dionis,  Bertrandi,
 Pott,  and  Sabatier, which latter writer
 has materially assisted me in the  preced-
 ing article. Several parts of the. Me moires
 tie I'Acad. tie Chirurgie are also  highly de-
 serving of perusal.
   TRICHIASIS, (from -fy'l,  the hair.)
 Entropeon.   Scarpa  distinguishes  two
 kinds of  this disease;  in one the  eye-
 lashes incline inward, without any change
 in the natural position of the cartilage of
 the eyelid ; in the other, the edge of the
 latter part turns in a preternatural man-
 ner inward, and, of course, the cilia point
 toward the eyeball.
   Scarpa  describes  the first species of
 trichiasis,  as  being exceedingly uncom-
 mon.   Indeed, he adds, that he had never
 seen  but  one  such example, and  in  this
 only some  of the  hairs were distorted in-
 ward.  The common kind of trichiasis  is
 the second one, or that, in which  both
 the tarsus  and eyelashes are  preterna-
 turally turned inward at the same time.
 The disease may either be complete, so as
 to  interest the whole of the eyelid, or in-
 complete, when only the edge  of the tar-
 sus takes  a wrong position.   One eyelid
 alone may be  affected, or both, and  occa-
 sionally the eyelids on each side are thus
 diseased
  Scarpa considers the distiehiasis, or spe-
cies of trichiasis, said to arise from ^here
being two rows of hairs ou each eyelid,
as merely imaginary ;  and he reminds us
of what Winslow.and Albinus have ex-
plained, that notwithstanding the  roots
of the eyelashes seem to be arranged only
in one line, the hairs themselves, by se-
parating  from  each other, may  seem to
form several rows , while their insertions
do not  deviate in the least from the com-
mon,  natural  arrangement.  (See  Disti-
chiasisf)
  It is not easy to determine exactly the
causes which sometimes  make  a few of
the eyelashes deviate from their natural
direction, while the  position of the eye-
lid itself is not at all altered.  The causes
are generally imputed to scars on the tar-
sus, in consequence  of previous ulcera-
tion, which  makes the  hairs fall off", and
hinders others, which grow, from assum-
ing  a proper direction.   However,  this'
cause  is not  the  only one; for, Scarpa
has  seen an  instance, in  which two, or
three  hairs  grew  inward against the eye-
ball, notwithstanding the  tarsus had no
ulceration, nor cicatrix whatever upon it.
  Scarpa says, he is inclined to  think,
that  the little ulcers and scars,  which
sometimes form on the inner edge of the
tarsus, would occasion the second species
of trichiasis, or an inversion of the edge
of the eyelid, and  consequently of the ci-
lia against  the ete, rather thai* the firsf.
species of the affection.   As such  ulcers
eat  deeply  into the part,  and, when ne-
glected, destroy the substance of the lin-
ing of the  ey elid near  the tarsus, it ne-
 cessarily happens, that  as the sores  gra-
dually cicatrize and  contract, they draw
 inward the  tarsus, and even the hairs im-
planted  into it.  Since the little ulcers in
question do not always extend  all along
 the edge of the tarsus ; but, are occasion-
 ally confined to a few lines in its centre,
 or near the outer angle, all the  eyelashes
 do not incline inward after cicatrization,
 but, only a few of them, which correspond
 to the extent of  the ulcers, which were
 formerly situated  along the inner edge of
 the tarsus.   Indeed,  in all cases of imper-
 fect trichiasis, caused by a cioatrix on the
 inside of the eyelid, it may readily be
 seen,  that  the tarsus and the eyelashes
 are in their natural position, except oppo-
 site the place, where the  ulcers on  the
 inner'edge of Sfhe eyelid were previously
 situated.  If the eyelid be turned out, its
 lining, near  its  edge, corresponding  to
 the seat of the trichiasis, will be found
 pale,  rigid, and  callous,  and it will be
 obvious, that the  inversion of its cartila-
 ginous edge, and  tiie faulty inclination of 
406                              TRICHIASIS.
tiie eyelashes against the eyeball, origi-
nate from the contraction of that part of
the inside ofthe lid.
  Besides these causes,  there are some
others, which are capable  of producing
the same bad effect.  First, the inveterate
chronic ophthalmy, which gradually grows
worse and worse, (such  as the scrophu-
lous, or that arising from the small pox,)
and which keeps the Integuments of the
eyelids, for a long while,  in a state of dis-
tention and oedema, next induces a  re-
laxation  of them, and, the cartilaginous
edge  of  the eyelid, not being properly
supported by the skin, falls inward against
the eyeball, and  draws with  it the eye-
lashes into the  same faulty direction.
The same bad effect is  sometimes pro-
duced, independently of any relaxation of
the integuments, by a morbid  softening
ofthe cartilage of the tarsus, occasioned
by  a  long-continued, copious discharge
from  the Meibomian  glands.  In  conse-
quence of,this alteration in the cartilage,
either the whole length, or only a part
of it, becomes incapable of keeping itself
erect, and of  retaining the curve,  which
its perfect coaptation with  the other eye-
lid requires.   Hence the whole or a part
of the cartilage  becomes folded inward,
and  makes  the corresponding eyelashes
incline  inward against the eye.   These
causes are not  unfrequently found com-
bined together, and they are  also often
accompanied with cicatrices of the mem-
brane, which invests the inner edges of
the eyelid.  Some pretend (says  Scarpa,
alluding  to  Mr. B. Bell,)  that trichiasis
sometimes arises  from a spasmodic con-
traction of the orbicular muscle  of the
eyelids;  but, Scarpa owns, that he him-
self has  never seen  such a  case,  and
thinks it scarcely credible, that any spasm
of this muscle, however  violent, can ever
occasion a turning inward of the tarsus
and eyelashes.   Even were it  to have
the power of" doing so, the spasm could
not  be  a permanent cause of the com-
plaint.
  Any one,  however  little acquainted
with  surgery, may readily conceive what
great inconveniences must be occasioned
by the continual  friction  of the eyelashes
against the cornea, and white of the eye.
The complaint is generally rendered still
more aggravated, by the  inverted hairs
becoming far  thicker and longer, than
those, which have not had their natural
direction changed.  Although the affec-
tion may only be  situated in one eye, both
are usually affected from sympathy, and
the sound one cannot be moved,  without
producing pain in the other, which is ir-
ritated by the friction of tiie inverted eye-
lashes.   Roth eyes  of persons, affected
with trichiasis, are generally exceedingly
irritable,  and cannot  bear much  light.
In cases of incomplete trichiasis, as  the
patient has some little power of opening
the  eyelids in order to see, particularly,
towards tiie inner  canthus, his head  and
neck very often  become  inclined  in an
awkward position.   This circumstance at
last   frequently occasions, in  children,
a wryness of the  neck  and shoulders,
which deformity is very difficult to cor-
rect, even after, the trichiasis has been
completely cured.  Children also cannot
endure the  irritation, produced  by  tlie
inflected eyelashes, and  are continually
rubbing  the  eyelids,  which  tends very
much to aggravate  all the bad conse-
quences,  arising from trichiasis,  parti-
cularly, chronic varicose  ophtlialmy,  and
opacity and ulceration of the cornea.
  The second species of this disease, that
is to say, the one which is commonly  met
with in practice, and which consists in  a
faulty inclination of the tarsus, and, con-
sequently, of the  eyelashes against  the
eyeball, is  cured by artificially turhing
out  the tarsus, and replacing it  securely
in its natural position, together with the
eyelashes, which rub  against and irritate
the eyeball.  Such  is  the  mode  of cure,
whether  the disease has originated from
cicatrices, and a contraction of" the inter-
nal  membrane of the eyelids, near their
margin, in consequence of ulcers near the
latter part, or whether the disease  has
been occasioned by  a relaxation of the
skin of the eyelids, a morbid softening of
the  cartilage of the tarsus, or  all these
causes combined together.   Cutting off a
certain portion of the skin, near the edge
of the eyelid, completely fulfils the indi-
cation just  mentioned.    The  piece  re-
moved should be  sufficiently broad  and
extensive to make  the tarsus and edge of
the  eyelid turn outward, far enough from
the  eyeball, when the wound has healed,
and, in such manner, that the eyelid  may
find  in the cicatrix of the skin, a  due
 support for keeping it in its natural po-
sition:  Scarpa confesses, that at the pre-
 sent day, after so  many fruitless trials,
 he  does not believe, that  any  surgeons
 would now  entertain any expectation of
 radically curing the trichiasis,  either  by
 merely plucking out the hairs,  which as-
 sume a wrong position; by bending them
 outward, and keeping them in this man-
 ner, by means of sticking plaster ; or  by
 pulling them out, and then touching the
 situation of their roots with caustic, and
 even the actual cautery.  Scarpa believes,
 that still less reliance would be  put-in
 cutting away with the hairs the edge of
 the  eyelid, or in dividing the orbicularis,
 palpebrarum, from within the  eyelid, on* 
TRICHIASIS,                              407
live supposition, that trichiasis, sometimes
depends <m a spasmodic  affection of this
muscle. All these plans,  which have been
the fruit  of theory, have  been rejected
from practice, as being either insufficient,
hurtful, apt  rather  to exasperate, than
cure, the disease, or liable to induce  af-
fections of the eyelids, not at all less  se-
vere, than the trichiasis itself.
  Scarpa remark's, that the most effectual
mode of curing this disease, comprehend-
ing the method advised  by Kokler (Ver-
such einer  neuen Heilart der Trichiasis;
Leipzig, 1796)  and  known  ever since
the time of Rhases, consists,  as has been  ;
already stated, in the excision ofa certain
portion of the skin of the affected eyelid,
near the  tarsus..  This  operation, when
simplified in the manner  Scarpa describes,
by abandoning the numerous instruments
formerly used, and also sutures,  is easy
of performance to the surgeon, little pain--
ful to the  patient, and constantly followed
by an expeditious cure.
   The  patient being seated,  if an adult,
pr placed on a table of convenient height,
 if a  child,  with "the head raised,  and
 steadily held by  an  assistant  standing
 behind, the surgeon is to push outward,
 with the end of a probe, the hairs, which
 irritate the  eye.  Then, with a  pair of
 dissecting forceps, or the ends of his fore-
 finger and thumb, (which answer equally
 well, and, in many cases  much better,
 tiian forceps,) the. operator should lift up
 a fold of tlie skin of the affected eyelid,
 taking great care,  that the piece, which is
 taken hold of, corresponds exactly to  the
 middle of the whole  extent of the  tri-
 chiasis ;  for, as we have already explain-
 ed from  Scarpa,  sometimes the  whole,
 sometimes a half, and, in otiier instances,
 only a third ofthe extent of  the tarsus is
 inverted.   The surgeon, with  his  left
 hand, must raise the fold ofthe skin, more
 or less, according as the relaxation of  the
 integuments, and  the  inversion  of  the
 tarsus, are  more, or less considerable.
 The  reason  of this  is exceedingly evi-
 dent, viz. that the greater the quantity
 of skin is, which is .raised, the  greater is
 the quantity which will be cut away. Sup-
 posing the patient to be an adult, as soon
 as the fold of skin  has  been raised in a
 certain degree, the surgeon must request
 him to open his eye,  and,  if in this  act,
 the tarsus, and eyelashes resume their na-
 tural place and direction, the portion of
 skin already  raised will  be  sufficient for
 the purpose.  We must trust to our own
 judgment, with regard to children, as they
 seldom let us have recourse  to the mode
 of discrimination just related.  The  for-
 ceps ofBartisch;  of Verduin, and those
 improved bv  Raw,  formerly employed,
are objectionable,  because they raise tlie
skin equally from one end of the eyelid
to the other :  in consequence of which,
too much of the skin must be cut off near
the extremities   of  the eyelid, and not
enough in the middle.   On* the contrary,
when the integuments  are  elevated, by
means of a pair of dissecting  forceps, and
care is taken to  lay hold of the skin  pre-
cisely at the middle point of the whole
extent  of the trichiasis, it  necessarily
follows, that the consequent section of the
skin  will form  an  oval, and that  tiie
greatest width of the wound will corre-
spond exactly, or nearly so, to the middle
of the eyelid, and its narrowest  parts to
the angles, or commissures of the same.
This contributes very materially  to make
the cicatrix correspond to the natural fold
of the eyelid, and hinder the origin of a
-disease of an opposite  nature to the one
about to be remedied, towards the angles
of  the eye, viz. an eversion of the com-
missures of tiie eyelids.  See Ectropium. "**
   Besides this caution, relative to this  si-
tuation and figure of the fold ofthe  inte-
guments to be cut off,  the surgeon must
be careful, that  the division of the skin
 be made very near the inverted tarsus.
 Were this circumstance neglected, the
 operator might have  the displeasure of
finding, after the wound is  healed, that
 although the eyelid is  shortened, on the
 whole, from the eyebrow to  the place of
 the  recision, yet it is not equally so at
 the space, which is between the edge of
 the eyelid, and the cicatrix of  the  skin.
 Hence, the tarsus would remain inverted,
 as before, or not be  sufficiently turned,
 outward to keep the eyelashes  from rub-
 bing against the eye.  This inconvenience  ,
 would oblige the patient to submit to a
 second operation, done lower down, than
 the first.
   Things being thus  arranged,  the sur-
 geon,  holding up the fold of the skin  by
 means of the forceps, in his  left hand, is
 with a pair of probe-pointed, sharp curved
 scissars, to cut  off'the whole ofthe dupli-
 cature, being first sure that one of the
 blades of the instrument is appKed  close
 to the edge of the eyelid. If both eyelids
 should  be affected, the same  operation
 should immediately be done upon both of
 them, with such cautions, and, in  such
 proportion, as the extent of the disease,
 and the degree of inversion inward of each
 eyelid may require.
    Scarpa next dissuades us from employ-
 ing any suture  to unite  the  wound, and
 represents, tlv * it will be sufficient  to
 keep the eyebrow us much downward  a*>
 possible, if the operation has been done
 on tlie upper eyelid, or, if on the lower,
 to support it against  the inferior arch it." 
408                             TRICHIASIS.
 the orbit, by pressing it" from below up-
 wards, so as to keep the edges  of the
 wound from becoming separated.  Then
 the lips of the wound are to be put into
 exact contact, by means of strips of adhe-
 sive plaster, which  should  extend from
 tlie superior arch of the orbit,  to the zy-
 goma, and the support  of the  wound in
 apposition will be still  more securely ef-
 fected by placing two compresses, one on
 the eyebrow, and another on the zygoma,
 together with tiie uniting bandage, ap-
 plied in the direction of  the monoculus.
 (See this word)
  Scarpa seems to think, the surgeons
 have*been led to employ sutures in this
 case,  by seeing, that, after the fold of the
 skin has been cut off,  (as for example,
 that ofthe upper eyelid,) the integuments
 become so  retracted towards  the  eye-
 brow, and downwards towards the tarsus,
 that the whole eyelid seems,  at the time,
 to be entirely deprived of-skin.   But, all
 this is only a mere appearance ; for when
 the eyebrow is  depressed by  means of
 compresses and the uniting bandage,  the
 eyelid immediately becomes covered with
ekin,   as before,  and the edges  of  the
 wound are easily put into contact without
 any occasion for using sutures.  Gendron
 is one ofthe few,  says  Scarpa,  who,  in
these circumstances, prefer strips of stick-
ing plaster to sutures ; he had  often  no-
ticed,  that, when sutures were used, a
great deal of tension and inflammation
followed, and produced a laceration of the
points.   Scarpa adds,  that his own expe-
rience  has  confirmed Gendron's opinion,
and that the disuse of  sutures has been
very beneficial to his  patients,  and in-
creased the  simplicity and expedition of
the operation.
  On taking off the  first dressings, the
third day after the operation, the surgeon
 will find that the  patient can open his
 eye with ease, and that the inverted tar-
 sns and eyelashes have resumed their na-
tural  position and direction. In the pau-
tial, or incomplete trichiasis,  or  that
 which only occupies a half,  or a third of
the whole length ofthe tarsus, and in sub-
jects, who have had the skin ofthe eyelids
very loose, Scarpa  has  often had  the
pleasure of finding  the wound perfectly
 united on removing the first dressing.
  When, however, only a part of the in-
cision  has healed, while the rest seems
disposed to heal  by  suppuration  and
granulation,  the  surgeon  covers   the
 wound with a small piece of lint,  spread
 with the unguentum cerusssc; and, if the
 sore should become  flabby,  it must be
touched, every now and then,  with  the
 argentum nitrat«m, until the cure  is per-
fected, which commonly happens in  the
course of a fortnight.
   Thus far, Scarpa's observations have re-
lated to the radical cure ofthe second, or
most frequent, kind of trichiasis.
   With  regard to the first form of this
disease, or^that, in which tiie eyelashes
project against the eyeball,  without  the
natural position of the tarsus being at all
altered, (a case, which is fortunately very
rare,) the  accomplishment of a cure is
very difficult, since, as we have already ex-
plained,  neither the  pulling out of  the
hairs, nor burning  the  situation of their
roots, are means at all to be depended upon
for producing a complete cure of the dis-
order : and since, turning the tarsus, out
of its natural position, would make the
patient liable to an irremediable flowing
ofthe tears over the cheek, attended with
a chronic thickening of the lining of the
eyelid.   The treatment of this species of
trichiasis is still  imperfectly  understood,
and seems to claim more attention, than it
seems hitherto to have had paid to it. In the
instance of this form ofthe disease, which
Scarpa met with, only two, or three ofthe
eyelashes inclined against the eyeball  He
found, on turning the eyelid a little out,
opposite  to the situation of the faulty
hairs, that  he could not, indeed,  com-
pletely put them in their natural position;
but, he saw,  that he could  thus  remove
them so far from  the cornea, that they
would not rub against it, without altering
the position of the  eyelids so much as to
occasion a perpetual discharge ofthe tears
over the cheek   And,  as in the patient
alluded to, the skin about the eyelid was
very  tense,  Scarpa /leviated  from the
above rule, by making  an  incision with
the back of a lancet,  near the tarsus,
three lines  long,   and he  took away a
small piece of skin of the same length ;
but, very little more, than one line broad.
When the cut healed, the operation was
found to answer as well as the nature of
the case would  allow,  though the cure
was not complete,  nor would it have  ob-
viated all the inconveniences in cases of
greater extent.      '
  The trichiasis being cured, something
more always remains  to be done, for  the
purpose of correcting the cause of  the
disease, as well as curing the disorder of
the eye, occasioned by the previous fric-
tion and irritation of the  inverted  hairs.
The usual indications are,  to restore  the
tone of the vessels of the conjunctiva, to
lessen the  swollen  Meibomian  glands,
and to remove any cloudiness of the cor-
nea.  How to fulfil these  objects,  is  ex-
plained in the articles. Cornea,  Opacity
of; and Ophthalrnr. 
TRICHIASIS.
4C9
  Scarpa  remarks,  that  the celebrated
Albinus is the only writer,  that he is ac-
 auainted with, who has taken notice of
 le trichiasis of tlie caruncula lachrymalis.
As  Scarpa thinks the history of it very
interesting, he quotes  it in  the following
terms: " In subtilibus illis pilis, quos Mor-
gagnus in carunculd lachrymali animadver-
tit, trichiasis speciem vidi.  Unus eorum in-
creverat prxter naturam, crassior longiorque
atque ita se incurvans, ut globum oculi ex-
trend parte attinger'et.  Consecuta est in-
flalumatio dira, cruciatu tetro, et, quod causa
non intelligebatur, pertinax.'' Adhibitafue-
rant quxcumque suggerere ars potuerat, et
empiria; collyria, epispastica,purgantia, san-
guinis missiones, fonticuli, dixta.   Quum
nihil proflciretur, forte itum ad me.  In cau-
sam, si invenire possem, inquirens, eccepilus.
 Quo evulso, subsedit malum."  (Acad. An-
aot. lib. 3. cap. 8.)  Scarpa notices, how-
ever, that Albinus has omitted to mention
a very essential  circumstance, viz. whe-
ther the hair grew  again after  a  certain
time,  and in what  direction.   (Scarpa
 sidle  principali  Malattie  degli  Occhi ;
 1802.)
   Dr. Crampton has published an  essay
 on the Entropeon, in which he found the
 following  mode  of  operating very suc-
 cessful in one instance.   "  Let the eyelid
 be well turned outwards, by an assistant;
 let the operator then with a lancet divide
 the broad margin of the tarsus completely
 through, by two perpendicular incisions,
 one on each side of the inverted  hair  or
 hairs.   Let  him then,  by a transverse
 section of the conjunctiva  of tiie  eyelid,
 unite the extremities of the perpendicular
 incisions.  The portion of  cartilage, con-
 tained  within tlie incisions, can  ihen, if
 inverted, with care be restored to its ori-
 ginal situation,  and retained there by
 small straps of adhesive plaster, or (per-
 haps, what  is better)  bj a suspensorium
 palpebral, adapted to the  length of the
 portion of tlie tarsus, which it is intended
 to sustain,  should one  or two hairs  be
 displaced, without  inversion of  the tar-
 sus."
   The late Mr. Saunders' operation for
 the cure of trichias is  described  in my
 other work, entitled the " First  Lines of
 tlie  Practice  of Surgery," and I  do not
 feel it necessary  to repeat  an account of
 it in the present place.
   [The American Editor considers the ex-
 cision of a portion  of tlie tarsus  the best
 mode of treatment in the present case, and
 therefore subjoins  the  following  extract
 from his « Elements of Surgery."
   In reflecting on the nature of the com-
 plaint,  several years ago,  I was induced
 to think that the eyelid could very readi-
  ly be cut half off, without much incon-
      Vol.. H.
venience, because the orbicularis muscle
is capable of contracting in such a degree
as to  throw tiie folds of skin into nume-
rous wrinkles, thereby demonstrating that
much of it could be removed and the eye
still be closed.   A case of trichiasis came
under my care  in  the Philadelphia Alms-
house, in July 1810, in which several ope-
rations had been performed, but without
effecting a cure : about one  third part of
the cilia were inverted.  In this  case 1
made an incision through the tarsus and
cut out completely all that portion of the
eyelid,  from  which the cilia proceeded.
My patient in a few days was  perfectly
cured,  was extremely  pleased  with the
operation,   and  very little  disfigured;
indeed, compared  with her inflamed eye,
her appearance  was improved.  Encou-
raged by the success of this case, I  have
twice since performed the operation of re-
moving totally the lower  half of the tar-
sus cartilage, together with the skin co-^r
vering it, and the inverted cilia, the suc-
cess has been complete in  both cases, the
wound  healed up very readily, the inflam-
mation  quickly subsided,  and the opacity
of the cornea was soon removed.
   By one  ofithose  coincidences,  which
are often occurring, the late Mr. Saunders
of London, contrived, and performed the
same operation, and with equal  success.
A  small volume, on  the  diseases of the
eyes which for the first time 1 s»w during
the present winter, though it was publish-
ed in  1811, contains an account of this
operation.   Mr.  Saunders remarks  " the
certainty of its  relieving the  pp.tieot,  is
 what I  more value than the credit, if there
 be any, of having suggested it;" and  in
 this sentiment I heartily join him.  I shall
 therefore proceed to describe the manner
 of operating  proposed by  Mr  Saunders,
 and afterwards relate my  own method.
   Mr.  Saunders directs  the operation to
 be performed as follows: " a piece of thin
 horn or a plate of silver having a curva-
 ture corresponding with  that of the eye-
 lid is to be introduced, and its concavity
 turned towards the globe within the eye-.
 lid, which is to be stretched upon it.  An
 incision is to be made through the inte-
 guments,  and orbicularis  palpebrarum,
 immediately behind the roots of the cilia
 to the  tarsus, and should extend from the
 punctum  lachrymale to the external an-
 gle.  The exterior surface of the tarsus
 is then to be dissected until  tlie  orbital
 margin is exposed, when the conjunctiva
 is to be cut through directly by the side
 of the tarsus which  must now be  disen-
 gaged at each extremity; the only caution
 necessary being to leave the punctum lach-
 rymale uninjured."
    The manlier in which I have performed
      3F 
410             T R O                                  T R U
 the operation is extremely  simple.   A
 hook is  passed through the  edge of the
 eyelid in order to gain a secure hold of it,
 and with a pair ot sharp scissars the ne-
 cessary portion of the ey elid is removed by
 two or three cuts.  " Nothing can be more
 simple  than  this piece of dissection."—
 A remark applied by Mr. Saunders to his
 operation, but tvhich is much more appli-
 cable to miie.  The punctum lachrymale
 must be carefully avoided.
    The  wound generally heals in a few
 days; no dressings are necessary, but a
 soft compress may be lightly bound  over
 the eye. Mr. Saunders says a fungus arose
 from the cicatrix in all his cases, wliich  re-
 quired  caustic or the knife ; all  the cases
 1 have seen,  healed immediately without
 any inconvenience, and the  deformity  is
* not so great  as would be imagined.*]
    On the preceding subject, consult par-
 ticularly Scarpa  sulle pnncipali Mulattie
 llegli Occhi;  Crampton's Essay on Entro-
 peon; Saunilers'  Obs on several Practical
 Points  relative to the Diseases of the  Eye ;
  Richter's Anfangsgrunde der Wundarzney-
  kunst,  Band 3.
    TRICHISMUS. (from Jrfig, hair.)   A
 species of fracture,  which appears like a
 hair, and is  almost imperceptible.
    TRICHOMA  (fromS-^fs, tlie hair.)
  The disease called the plaited hair, or,
  plica polomca.
    TR1CHOS1S. The same
    TRIPS1S. (from r^ittu,  to bruise.)  A
  contusion.
    TRISMUS, (from r^<cf», to gnash  the
  teeth.) The locked jaw.   See Tetanus.
     TROCHAR, or TROCAR,   (from  the
  French,  trois-quart,  three-fourths,  from
  its point, being of a triangular  form.)
  An  instrument iised   for  discharging
  aqueous fluids, and now  and then, mat-
  ter from different cavities in the body, par-
  ticularly, those Ofthe peritoneum, and tu-
  nica vaginalis, in cases of ascites and hy-
  drocele.  Trocars are also  employed for
  tapping the bladder, dropsical ovaries, &c.
     A trocar  consists  of a perforator, or
  stilette, and of  a cannula, which latter is
  so adapted to the first piece of the instru-
  [* The  operation  is,  I  believe, new,
though Haller in his Bibliothica Chirur-
gica,. states, that  Rhazes recommended
cutting and burning  the eyelid, in similar
cases ; the nature of his operation I can-
not ascertain, as the  only copy of  Rhazes
which I have been able to see, contains
nothing on the subject.  It is a black let-
ter edition, very ancient, in barbarous La-
tin, belonging to the Loganian Library in
this city.]
ment, that; when the  puncture is made,
they both enter the wound together,  with
perfect  ease, after which the stilette be-
ing  withdrawn, the  cannula remains in
the wounds and gives a ready passage for
the fluid outward.
   Such are,  the use of a trocar, and the
principle, on  which   it should be con-
structed.  It would be unnecessary in this
work to detail  every little particularity in
the  instrument.   1  shall  just  observe,
that the triangular-pointed trocars  seem
to retain the  greatest share of approba-
tion ; for,  altin>ugh,  flat,  lancet-pointed
ones enter parts  with  most ease,  their
cannula; are not large enough for readily
letting fluids  pass out, which  are  at all
thick, gelatinous, or  biended with  hyda-
tids, and flaky substances.
   The trocar,  which  is used for punctur-
ing the bladder from  the rectum, should
be eight,  or nine inches long,  and of a
curved form.
   Surgeons  ought always to have at least
 three trocars;  one of full  size ; another
 of middling  width :  and a third,  small
 one. The latter is often preferable to a
 larger one, in cases of hydrocele.
   TRUSS, (trortsse French.) Bracherium.
 A bandage, or apparatus,  for keeping a
 hernia reduced.
   Trusses are either of an elastic or non-
 elastic kind :  the latter cannot be  much
 depended upon,  and are now seldom em-
 ployed.  The spring, is a very essential
 part of every elastic truss, and it consists
 ofa narrow piece of steel, which is adapt-
 ed to the side  of the  body, on  which the
 hernia is situated.  The front part  of the
 steel spring has  an expanded  form, and,
 when the  truss is properly applied, ought
 to be situated over the mouth  of the her-
 nial sac.  Under the  back  surface  of the
 anterior end of the  spring  is  placed the
 pad, which should be  adapted in shape
 and size to the  passage, which it is in-
 tended to shut  up.   The  steel spring is
 usually covered with leather, is lined with
 soft materials, and, after being put on the
 patient, it is  fastened in its situation by
 means  of a  strap,  which extends  from
 the two  ends of the spring,  round that
 side of the body, on which tlie heniia is
 not -ituated.
    When the pad oT the truss  cannot be
 kept from rising too high, another strap,
 passing under the thigh from the back of
 the spring to  its anterior end, becomes ne-
 cessary.   Sometimes,  a band  extending
 over the shoulder, is requisite for keeping
 the pad from  descending too low.
    The  springs of trusses,  intended for
 children,  and  persons, who do  not  under-
 go much  labour and exertion, need not 
V
!>e made so strong,  as  those dlligned for
hard-working, active people.
  The  idea, that children cannot wear
steel trusses, is as erroneous, as it is dan-
gerous in its practical consequences.  Mr.
Pott has strongly written against tins  ill-
founded supposition.
  When great pressure, and a very strong
spring, are found necessary for keeping  a
hernia securely reduced, and the sperma-
tic cord swells and  inflames  in  conse-
quence of such pressure,  it  is better to
have a little excavation in the pad, for the
reception of this  part.
   Some trusses are formed  with  pads,
which  are moveable  on a rack, so that
their position can be altered, and adapted
to the parts, with the greatest ease.
   A compress of calico, placed under the
pad,  is said both to preserve the  instru-
ment from the effect of perspiration,  and
make  the truss fulfil its object in a better
 manner.
   Mr.  Lawrence  has described a new
 kind of truss, invented by Mr. Whitford,
surgeon's instrument maker, near St. Bar-
 tholomew's Hospital:  The 6pring passes
 on the ruptured side, just below the outer
 edge ofthe crista of the  ilium, as far as
 the posterior superior  spinous process of
 that bone.  It then goes  straight across
 to the same point of the  opposite bone,
 and pursues its course, on the sound side
 of the pelvis, in  the same relation to the
 crista ilii,  as  it  held  on  the  side of the
 rupture, as  far  as the anterior superior
 spinous process, where it terminates as
 usual  in a leathern strap.   In  this mode
 of construction, die motions of the trunk
 and thigh cannot derange the instniment,
 which requires  a still further stability
 froi.-  the extension of the spring round
 the sound side of the pelvis."   ( Treatise
 on Hernia, p. 41.)
   In the article Hernia, we have given an
'account of the truss for umbilical hernia,
 invented by  Mr. Morrison, and described
 by Mr Hey.   In the  same  part  of this
 Dictionary rmiy also  be  found some ob-
 servations,  relative to the place,  against
 which the pressure of the pads of trusses
 should be directed in cases of inguinal
 hernia, in conformity  to Mr. A. Cooper's
 description of the s tuation, at which the
 parts first  protrude from the abdomen.
   TUBERCLE,  (dim. of tuber, a knob.)
 A little tumour.
   TUMEFACTION   (from tumefacio, to
 make swell.)   A Swelling.
   TUMOUR, (from tumeo, to swell.)  A
 swelling.  In the present article, 1 merely
 intend to treat of, what are usually culled,
 sarcomatous andency-ted tumours.  Mr.
 Abernethy thinks,  that   the  manner,  in
 which tumours are formed,  is best illus-
MOUR.                            411

trated by  those, which  hang pendulous
from the membranous  lining of different
cavities.  This gentleman adverts to an
example noticedby Mr. Hunter, in which,
on the cavity of the abdomen being open-
ed, there appeared lying upon tiie perito-
neum, a small portion of red  blood re-
cently  coagulated.   Th s,  on  examina-
tion, was found to be connected with the
surf.ee, upon which it had been deposited
by means of an  attachment, half an  inch
long, and this neck fr.d been formed be-
fore the coagulum had lo-.t its red colour.
(See Transactions of a Society for the Im-
provement  of  Medical  and Chirurgical
Knowledge, Vol. l,p. 231.) Mr. Abernethy
observes, that if vessels had shot through
the  slender neck, and organized the clot
of blood, this would then have become a
living part:  it might  have grown to an
indefinite magnitude, and its nature and
progress would probably have depended
on the organization, which it had assum"^
ed.   He mentions his having in his own
possession  a pendulous fatty  tumour,
which was found growing from  the sur-
face of the peritoneum, and which was
undoubtedly formed in the  same manner
as  the tumour  noticed  by Mr. Hunter,
viz. by vessels shooting into a piece of ex-
travasated blood, or lymph, and render-
ing  it a living organized substance.  Tu-
mour's, in every situation,  and of every
description, are probably formed in the
same way.   The coagulating lymph be-
ing  effused, either accidently,  or in con-
sequence of a disease, is afterwards con-
verted into a living  part, by the growth
 of the adjacent vessels and  nerves into it.
 Mr. Abernethy  remarks, that,  when the
deposited substance has its attachment by
 a  single thread, all its vascular supply
 must proceed through that  part ; but, in
 other cases,  the ve.->sels  shoot into it irre-
gularly at various  parts  of its surface.
 Thus, an unorganized concrete becomes
 a living tumour, which has at first  no
 perceptible  peculiarity  as  to its nature.
 Although its supply of blood is furnished
 by the vessels of the surrounding parts, it
 seems to live and grow by its own  inde-
 pendent powers, w bile its future structure
 seems to depend on  the operation of its
 own vessels.   Mr.  Abernethy  conceives,
 that the altered structure of an enlarged
 gland  affords  no  con'radiction  to the
 above  account, as in this latter case, the
 substance of tlie gland  is the  matrix, in
 which  the matter forming the tumour, or
 enlargement, is deposited.  According to
 Mr. Abernethy, tiie  structure of a tu-
 mour,  is sometimes like that of the parts,
 near which it grows.  Such, as are pendu-
 lous in joints, are cartilaginous, or  osse-
 ous.  Fatty tumours, he  observes, fre- 
 4tJi                              TUMC

 quently form in the midst of the adipose
 substance,  and he has seen some tumours
 growing from the  palate, which  had a
 slender  attachment, and resembled the
 palate in structure.
    However, this resemblance ofthe struc-
 ture ofa tumour, to Ihut ot the neighbour-
 ing  parts, is  not  always observable.  I
 have in my own  possession a  completely
 cartilaginous  tumour, which  I found  in
 the  midst  of  the fat near  the  kidneys.
 The pendulous portion of the fat, growing
 from the peritoneum, and  mentioned by
 Mr. Abernethy, serves as another instance
 ofthe feet; and, one might  add,  that
 every polypus which we  meet with, bears
 no resemblance in structure 10 the neigh-
 bouring parts.   Mr Abernethy mentions
 his having  seen  bony   tumours,  which
 were unconnected with bone, or the peri-
 osteum, and he observes, that the struc-
 ture ofa tumour is, in general, unlike that
"of the part, in which it is produced.
    When the coagulable part of the blood
  is effused, and the absorbents  do not take
  it away,  the surrounding  blood-vessels
  grow into it, and convert it into a vascular
  tumour.  The effusion of the coagulable
  part of the blood may be the effect of ac-
  cident, or of a common inflammatory pro-
  cess, or it may be the consequence of some
  diseased action of the  surrounding ves-
  sels, which (diseased action)  may influ-
  ence the organization, and growth of the
  tumour.
    In the former cases, the parts surround-
  ing the  tumour, may be considered sim-
  ply as the  sources,  from which it  derives
  its nutriment, whilst it grows apparently
  by its own inherent powers, and its organ-
  ization depends upon actions begun and
  existing in itself.   If such a tumour be re-
  moved, the  lurrounding  parts  being
  sound,  soon  heal, and  a complete cure
  ensues.  But, if a tumour, be removed,
  whose existence depended on the disease
  of the surrounding parts,  which are still
  left, and this  disease be not altered by the
  stimulus of the operation,  no benefit  is
  obtained.   These parts again produce a
  diseased  substance, which has generally
  the appearance of fungus, and, in conse-
  quence of being irritated by the  injury of
  the  operation, the  disease is in  general
  increased, [by the means, which were  de-
  signed for its cure.  It appears, therefore,
  that in  some cases of tumours, the newly
  formed  part alone  requires   removal,
  whilst, in others, the surrounding  sub-
  stance must  be taken away, or a radical
  cure cannot  be effected.   (Surgical, Ob-
  servations, by John Abernethy, F. R. S, &c.
  1804.)  This gentleman  cone ives, that
  the irritation of  the tumour  itself, when
  *>nce  the swelling has been produced,
keeps up an increased action in the sur-
rounding vessels, so as to become a suffi-
cient cause 01 the disease continuing to
grow larger.  As the tumour becomes of
greater magnitude, it  condenses the sur-
rounding  cellular  substance,  and thus
makes for itself a sort of capsule. The
close, or loose manner in which tumours
become connected with the surrounding
parts, seems to depend very much on the
degree of irritation, and inflammation ex-
cited in the circumjacent parts.  When a
tumour has been at  all tender, painful,
and inflamed, it is generally found inti-
mately adherent to all the neighbouring
parts.   Mr. Abernethy  conceives,  that
the increased irritation, which a tumour
creates,  when  it has exceeded a certain
size, may explain, why  some tumours,
which are at first slow in their progress,
afterwards  begin to grow with great rapi-
dity.
   The  process, by which tumours arc
formed,   is commonly thought to be at.
tended with an increased action  of the
vessels,  which supply the swellings with
blood.   It is supposed, in short, to be the
same kind of process, which forms all the
thickenings  and indurations, which, un-
der various circumstances, occur in all the
different parts ofthe human body.   It has
sometimes  been named chronic infli mma-
 tion, to distinguish it from that, wliich is
 more quick in  the production of certain
 effects,  and is  attended with  a manifest
 throbbing in the part affected.
   It seems generally to be admitted, that
 the growth of all tumours may be always
 retarded, and that sometimes, they may
 even be diminished  by means of topical
 bleeding with leeches,  and keepir^ the
 parts, in  a continually cool state, by the
 incessant application  of cold  sedative
 washes.  Afterwards, when the increased
 action of the vessels  seems checked, and
 the tumour ceases to enlarge, discutients
 are indicated, such as frictions with mer-
 curial ointment, pressure, electricity, ru-
 befacient  plasters,   solutions  of  salts,
 blisters, and issues.   Very few sarcoma-
 tous or  encysted  tumours,  however, are
 ever completely removed by  these local
 means.  The swelling,  on the contrary,
 generally increases, notwithstanding them.
 and the irritation of  these diseases by the
 latter  stimulants, is  not altogether unat-
 tended with danger of the affections be-
 coming changed by them into very malig-
 nant, and dangerous ones, sometimes  to
 all  appearances,  cancerous.  The most
 advisable plan is  to  recommend  the re-
 moval of all these tumours with •■ he knife,
  while  they are small, and in an incipient
 state    For,  thus,  they are  got rid of
 by  an  operation,  which  is,  certainly 
TUMOURS, SARCOMATOUS.
413
trivial,  compared with the one, which
may afterwards  become requisite, when
the disease has attained  an  enormous
magnitude.
  Tumours, Sarcomatous.  These  have
been so named, from  their firm, fleshy
feel.  They are  of many kinds, some of
which  are  simple, while others are  com-
plicated with a malignant tendency.  Mr.
Abernethy has attempted to form a classi-
fication of  sarcomatous tumours, for the
different species of which he has proposed
names, deduced from the structure, which
they exhibit on dissection.  This  gentle-
man has named the kind of swellings,
which he first considers, Common Vascu-
lar, or  Organized Sarcoma. Under this
title,  Mr.  Abernethy includes all  those
tumours, which  appear to be composed of
the gelatinous part ofthe blood, rendered
more,  or less vascular by the growth of
vessels through it.  The vessels, which
pervade this substance are, in different
instances, either larger, or smaller; and
more, or less numerous; being distributed
in their usual arborescent manner,  with-
out any describable peculiarity of arrange-
ment.   Perhaps, all the  varieties of sar-
comatous tumours are at first  of this  na-
ture. The structure, under consideration,
is met with not  only in distinct tumours,
but, also,  in the testis, mamma,  and ab-
sorbent glands.   When a common vascu-
lar, or organized sarcoma has attained a
certain magnitude, the veins  of the skin
seem  remarkably large, and  their  wind-
 ing under the integuments excites notice.
 This kind of sarcoma is not at all tender,
so that it may be freely handled, and also
electrified, without  giving pain.   The
 tumour sometimes grows to such a size,
 that the skin bursts, the substance of the
 swelling sloughs out, and the disease is
 got rid of.  However, this mode of cure
 is  attended with such terrible  local ap-
 pearances, and  so  much  fever, &c. that
 the removal of  the disease with the knife
 is  preferred.
    The second  kind of  sarcomatous tu-
 mour,  noticed in Mr. Abernethy's  classi-
 fication, is the  Adipose Sarcoma.   Every
 one,  at all in the habit of seeing surgical
 diseases, must know, that fatty tumours
 are exceedingly common.   There can be
 little doubt, that these swellings are forrn-
 ed in the same  manner, as others,  viz. in
 the first instance, they were coagulable
 lymph, rendered vascular by the growth
 of vessels into it, and that their  future
 structure depended on the particular pow-
 er and action ofthe vessels.  Adipose sar-
 comatous tumours always have  a  thin
 capsule, formed by the simple condensa-
 tion ofthe surrounding cellular substance.
 It adheres very slightly to the swelling,
and, chiefly  by means of vessels,  which
pass through this membranous covering
in order to  enter the tumour.  As Mr.
Abernethy has accurately described, the
vessels are so small, and the connexion so
slight, that, in removing the tumour, no
dissection is requisite, as  the  operator
may easily put his  fingers  between the
swelling and its capsule, so as to break
the little vascular  connexions,  and en-
tirely detach the disease.
  Adipose tumours are never furnished
with any large blood-vessels, and the fear
of hemorrhage, which  frequently  deters
surgeons from operating, is very unfound-
ed.  It  is an undoubted fact, that there
is no species of tumour,  that can be re-
moved with so much celerity, with  such
apparent dexterity, or with such  com-
plete security against future consequences,
as those of an adipose nature.  However,
now and then, when the tumour has bee- ,.
at all in an  inflammatory state, the ca|* 's
sule becomes thickened, and intimately
adherent to the surface  of the swelling, so
that the separation ofthe disease is more
difficult, and requires the knife to be more
employed.   The" tumour also sometimes
becomes, after inflammation, closely ad-
herent to the contiguous  parts.  Adipose
tumours often acquire an enormous mag-
nitude;  Mr. Abernethy relates  an exam-
ple  of  one,  which  Mr.  Cline  removed,
which weighed between fourteen and fif-
teen  pounds.  In this state, of  course,
the immense size of a wound, requisite for
the removal ofthe tumour, must be danger-
ous, and it is a  strong  argument in  fa-
vour of having recourse to the operation
at an earlier period.
   [A wen, or "adipose sarcoma," perhaps
the largest on record, was removed by the
American Editor from the back of a black
woman aged forty-five  years, at the Penn-
sylvania hospital.   The dimensions were
as follow .—Circumference at the neck, or
narrowest part, 2 feet  10 inches; circum-
ference at the thickest part, 3 feet 9 inches j
circumference horizontally, 3 feet 1£ in-
ches.   The tumour emptied of  blood,
 weighed 25 pounds.
   The operation  was completed in  28
 minutes, and the patient discharged, cured
 in 52 days.   In re moving these large tu-
 mours, it is of great consequence to dis-
 sect as quickly as is consistent with safety;
 for the bleeding from superficial veins, is
 generally very great.  In the case alluded
 to, the vein-, wert- emptied of blood, at the
 suggestion  of Dr. Physick, by placing the
 patient on  her face, so  as to render the
 tumour the most elevated part.   Gravity
 favoured the descent of the blood out of
 the tumour and varicose  veins,  half an
 inch in diameter  were  thus completely 
414
TUMOURS, ENCYSTED.
emptied, and when cut into didnot bleed.]
  The next species of sarcoma, noticed in
Mr. Abernethy'-  classification,  is what
this gentleman names pancreatic, from the
resemblance of its structure to that ofthe
pancreas.  This kind of disease, aocord-
ing to  Mr.  Abernethy, is  occasionally
formed in  tiie  cellular substance ; but,
more frequently, in the female breast, on
that side of the  nipple,  which is next
to the arm.  When a pancreatic sarcoma
is inaolent, and increases slowly, the sur-
rounding parts, and  the  glands in  the
axilla, are not  affected.  But, some  of
these swellings  deviate from their com-
mon character, and become of a very irri-
table nature, occasioning severe and Ian-
cinating pain, and producing an inflam-
matory state of the skin covering them,
so that it becomes adherent to their sur-
face.   The absorbents lea-ling  to  the
axilla are also irritated, and the glands
rjjlarged.  Pancreatic sarcomas  do not
grow to a very large size ; but, when their
progress is unrestrained, the pain, attend-
ant on the disease, becomes lancinating,
and so severe, as to make the patients fe-
verish, and lose their health and strength.
Mr. Abernethy remarks, that, when the
axillary glands become affected, one ge-
nerally swells at first, and  is extremely
tender and painful; but, afterwards the
pain abates,  and the part remains indu-
rated.  Another  then  becomes affected,
and runs through the same course.
   Another species of sarcoma, Mr. Aber-
nnhy has  characterized by  the epithet
musloidor mammary, from the resemblance
which this gentleman conceives its struc-
ture  bears  to  that  of the  mammary
gland.  This kind of disease, Mr. Aber-
nethy says he has not often seen.   In the
example, which he met with, the tumour
was about as large as an orange, and si-
tuated on a woman's thigh.  The swell-
ing was removed by an operation; but,
the wound aftei wards degenerated into a
malignant ulcer, attended with consider-
able induration of the surrounding parts,
and the woman died of the disease in two
months.  Mr. Abernethy conceives, that
the whole ofthe morbid part had been cut
away, but, that the contiguous parts had
a deposition to disease, which was irri-
tated by the operation, and, that if the
nature ofthe case could have been known
beforehand, it would have been  right to
have made a freer removal of the sub-
stance surrounding the tumour.
   Mr Abernethy places the mastoid sar-
coma, between such sarcomatous swell-
ings  ;.s are attended with no malignity,
and the  following ones, which have  this
quality in a very destructive degree.
   The  tuberculated sarcoma is composed
of a great many small, firm, roundish tu-
mours, of different sizes and colours, con-
nected  together  by cejlular substance.
Some of the tubercles are as large as a
pea; others equal a horsebean in size;
most of them  are of a brownish red co-
lour ; but some are yellowish.  Mr. Aber-
nethy mentions his having seen this spe-
cies of sarcoma chiefly in the lymphatic
glands  of the neck.   The disease pro-
ceeds to ulceration ;  becomes  a.painful
and incurable  sore; and ultimately occa-
sions death.
  Another kind of sarcoma, mentioned in
Mr. Abernethy's classification of tumours,
is distinguished by the  epithet medullary,
from  its  having  the  appearance  of the
medullary  matter of  the  brain.   It ap-
pears to be an exceedingly malignant dis-
ease ;  communicates  to  the  lymphatic
glands  a  similar  distemper;  ulcerates
and sloughs, and at last proves fatal.  It
is particularly apt to make its attack  on
the testis,  and it is treated of in another
part of this book. (See Testicle, Diseases
of)
  Mr. Abernethy includes  also  in  his
classification carcinomatous sarcoma. (See
Cancer.)
  For an account ofthe plan of operating,
in  removing  sarcomatous tumours, see
Mamma, Removal of.
  Tumours,  Encysted.   These,   which
are also commonly named -wens,  consist
of a cyst,  which is filled with different
substances. When the contained matter
is fatty, it is  termed n.tsteatoma ; when
somewhat like honey, meliceris; when like
pap, atheroma. These are the three spe-
cies,  into which writers  usually  divide
encysted  tumours.   However,- some of
these swellings do not conform to either
of the above  distinctions, as  their con-
tents are subject  to very great variety in-
deed, and are occasionally of an  earthy,
bony, or horny nature.  It is said, that
some encysted'tumours of the latter de-
scription have occasionally burst,  and  as-
sumed  the appearance of horns,  by the
gradual projection of the matter secreted
in their cysts.  I remember seeing an ex-
crescence of the kind alluded to, removed
some years ago from the scrotum of a man,
in St. Bartholomew's Hospital. Sir James
Earle  performed the  operation,  and, if
I am  not  mistaken,  the  preparation of
the disease is in  Mr. Abernethy's Mu-
seum.
  Encysted tumours  are  generally of a
roundish shape, and are more elastic, than
fleshy ones.  However, the latter circum-
stance depends very much on the consist-
ence of the contents, anil the,thickness of
the cyst.  >As far as my observation ex-
tends, encysted  tumours form  more fre- 
T U M
TYP
415
quently en the head, than any other part;
but, they are very frequently met with  in
all situations under the integuments, and
sometimes  in deeper  places.  Encysted
tumours are also very  often seen on the
eyelids.
  Some surgeons have tried  to cure en-
cysted tumours by  pricking them with
needles, and squeezing out their  contents ;
or by applying stimulating, and discutient
applications  to them.  This   practice,
however, is  by no means a prudent one;
for, it seldom succeeds,  and sometimes,
in consequence of making the cyst  ulce-
rate,,  it  induces  a terrible disease,  in
which a frightful fungus shoots out from
the inside of the cyst, attended with im-
mense pain and irritation, and often  prov-
ing fatal.  In order  to  confirm this  state-
ment, I shall quote the following  case;
recorded by Air. Abernethy.
  ,A gentleman, of a stout make, and
about forty years of age, had a tumour,
supposed to be sarcomatous, which had
formed beneath the integuments on the
lower edge ofthe pectoral muscle. It was
attended  with severe  pain  occasionally,
at which time it rapidly increased in size,
and produced  a great deal of  fever and
irritation,  which made  him  look very
sickly, and  grow very thin, and caused
some persons to deem tlie disease can-
cerous.
  When the tumour had acquired a  mag-
nitude of about four inches in length, and
three in breadth and depth, he submitted
to its removal; tl^"*feinteguments were di-
vided and turned back, aud  the tumour
dissected off the surface, and, in some de-
gree, from under the edge of the pectoral
muscle.
  When tlie tumour was examined, it was
found to be composed of a  steatomatous
substance, contained  in a  thin capsule.
Tne substance resembled that, wliich I
have described as being sometimes"  found
in cells in the testis, or intermixed with
the diseased organization of that part.  It
was firm, and resembled cheese in its yel-
low colour and unctuous appearance; but,
it was not unctuous to the touch.
  The wound made in the operation soon
healed, and  the patient's health was  re-
stored to as good, or seemingly a better
state,  than  before  the formation of this
disease.   He also regained his  usual ath-
letic form.  But, in less than three months
after his recovery, two  new tumours form-
ed, one above, and  the other  below tlie
cicatrix ofthe wound.  The patient did
not particularly attend to them till they
had attained a size equal  to  that of  a
laige walnut.  To dis  ect out both  hese
tumours, and make so ti ee  a removal  of
parts as to render it probable, that no new
growth would ensue, seemed to be a very
formidable operation;  and,  as the nature
of the former tumour was known, and it
was  supposed, that  these were of the
same  nature, it was agreed to puncture
the upper one",  to  express  the contents,
and await the event.  This was done by  a
puncture of half an inch in length, made
by an  abscess lancet.   The contents were
exactly like those of the original  tumour.
Vehement erysipelatous  or irritative in-
flammation  took  place,  and  sloughing
about the diseased part:  the inflammation
rapidly extended to the  opposite side of
the thorax, and then down  the integu-
ments ofthe abdomen to the groin.  The
derangement of the constitution  was as
violent as tiie local disease, and,  ifl about
a week the patient died.  (Surgical Ob-
servations, 1804, p. 94.)
  Similar, alarming, fungous diseases are
also apt to arise, whenever the  surgeon-
in cutting out  encysted tumours, leaves
any part ofthe cyst behind.
  The most advisable method is to have
recourse  to the knife, before an encysted
tumour   has attained  any  considerable
size.  When it is  large,  however, before
the operation is resorted to, a portion of
the skin  must be taken away  with the
swelling  in the  manner mentioned in the
article Mamma, Removal of.  The  chief
piece of dexterity in the operation con-
sists  in  detaching all the outside of the
cyst  from  its  surrounding  connexions,
without  wounding it.  Thus, the opera-
tor takes the part out in an entire state,
and is sure, that none of  the cyst remains
behind.   When the  cyst  is unskilfully
opened, some of tiie  contents escape,  it
collapses more  or less, and  the dissection
is rendered more tedious and difficult.
  Excepting Mr. Abernethy's Classifica-
tion of Tumours, contained in his Surgi-
cal Observations, 1804, lam not acquainted
with any  particularly good work expressly
on the subject.  However, every system
of surgery treats of it, and Mr. John Bell,
in his Principles of Surgery, Vol. 3, has
written a great deal concerning it.
  TURU'NDA. (d terendo, from its being
rolled up.)  A lent  for keeping open
wounds.
  TYLO'MA, or  Tilo'sis. (from rvXoi,
callous.)   A callous roughness on the in-
side ofthe evelids.  Also, a wart, or a corn.
  TYLOTICA. (from rvXov, to  harden.)
Medicines, which promote  the formation
of callus.
  TYMPANUM.  (tup.txvoi, a drum.)
The cavity of the  drum of the ear.  For
an account of its diseases, see Ear.
  TYPHLOSIS.  (from  rv^oq, blind)
Blindness. 
(  416  )
    ULA,  A  gum  boil.    Also,  a cica-
     trix.
  ULCERATION,  is the  process,  by
which sores, or ulcers are produced in
animal bodies.  In this operation,  the
lymphatics  appear to be, at least, as ac-
tive as the  blood-vessels.  An ulcer is a
chasm formed on the surface of the body
by the removal of parts back into the sys-
tem by the  action of the absorbents.  At
first, it may be difficult to conceive how a
part  of the body can be removed  by # it-
self;  but, there is not more difficulty in
conceiving this, than how a body can form
itself.  Both facts are  equally well con-
firmed. When it becomes necessary, that
some whole living part should be  remov-
ed, it is evident, says Mr.  Hunter, that
nature, in  order to effect  this  subject,
must not only  confer a new activity on the
absorbents; but, must throw the part to be
absorbed into a state, which yields to this
operation.   The absorption  of  whole
parts in disease, arises from five, causes :
pressure;  irritation of stimulating sub-
stances ;  weakness;  inutility of parts ;
death of them.  (Hunter on Inflammation,
&c.p. 442—446.)
  Ulceration, or, in other terms, absorp-
tion,  takes place much  more readily in
the cellular, and adipose  substance, than
in muscles, tendons,  ligaments,  nerves,
and blood-vessels. Hence, in the progress
of pus to the surface of the body, ulcera-
tion  often takes a  circuitous course  for
the purpose of bringing the matter to the
skin.   The skin itself, also, being  highly
organized, considerably retards the burst-
ing of abscesses. It is on  this same ac-
count, that, when ulceration is spreading,
the edges of the skin hang over the ulcer-
ated surface.  (Hunter, p. 447.)
  New-formed parts,  such  as cicatrices,
callus, and all adventitious new  matter,
such as tumours, readily admit of being
absorbed.   The adventitious matter, in-
deed, is more  prone to be absorbed, than
that, which is a substitute for the old.
Mr.  Hunter explained this circumstance
on the principle of weakness.
   When ulceration takes place, in conse-
quence of  the death  of an external part,
it occurs first on the outer edge, between
the dead and living substance.
   Abscesses constantly make their way to
the surface of the body by ulceration; but,
as some textures more  readily admit  of
being absorbed, than others, the matter
often follows a circuitous course, before
it  can arrive at the skin. (Hunter, p. 448,
449.)
   A tumour, when it makes equal pressure
in every direction around, will only make
its way in  an external course, because
what Mr.  Hunter termed interstitial ab-
sorption, only happens  in this  direction.
(P. 449.)
   The parts, which are situated between
an abscess, or any extraneous substance,
and the nearest surface, are those, which
are most susceptible of ulceration.  This
is  one of the  most curious phenomena,
connected  with the process under con-
sideration.   It shews, that there is a prin-
ciple in the human body, by which  parts
are  always prone to  free themselves  of
disease.  Slight pressure from without
will even produce a thickening of  parts,
and hence, Mr. Hunter remarks,  there
even appears to be a corresponding  back-
wardness  to  admit disease.  (P.  449.)
Both these facts, he observes, are shewn
in the case of  fistula  lachrymalis; for,
though the matter is nearest the cavity of
the nose, still it makes its way externally
by means of ulceration, while the Sclinei-
derian membrane even becomes thickened,
so as to become a barrier against the pro-
gress of the disease inward.  (P. 451.)
   There is one difference,  between the
advancement  of an encysted tumour  to
the surface of the body, and the progress
of an abscess in the same direction, viz.'
that the former does not excite ulceration
of the cyst; but, an interstitial absorption
of the sound parts, between the cyst and
skin, till the cyst and external skin come
into contact, at which period,  inflamma-
tion takes place, and absorption becomes
accelerated into ulceration.  In  an ab-
scess, the progressive ulceration begins in
the cyst, at the  same time, that the inter-
stitial absorption in the  sound part, co-
vering the matter, is  going on.   (P. 452
-457.)
   The action of progressive absorption is
to remove surfaces contiguous  to irritat-
ing causes, which Mr.  Hunter referred to
pressure, irritation, and  weakness.   In
cases  of  tumours, pressure  becomes a 
ULCERATION.           "                 417
 cause.  The buttocks and hips of persons,
 who he long on their backs, often  ulcer-
 ate.   The  heels of many  patients, with
 fractures, who he for a great while  in the
 same position, are apt to ulcerate.   In the
 latter  instances, Mr. Hunter conceived,
 that ulceration is a substitute for mortifi-
 cation, and is, at the same time, a proof
 of a certain degree of strength ; for, if the
 patient's constitution were very weak, the
 same parts  would mortify. (P. 453.) That
 pressure is  a frequent cause of ulceration,
 is also evinced by the occasional eff'ects
 of chains on prisoners,  and  harness  on
 horses.
   Thar irritating substances produce ul-
 ceration, needs no illustration.
   Progressive absorp ion may occur  either
 with, or without suppuration.  We have
 instances of the latter  in cases of  extra*
 neous bodies, which travel about the  body,
 without  producing irritation enough  to
 give  rise to the secretion of pus.  In the
 progress of aneurisms of the aorta, and
 of fungous tumours of the dura mater  to
 the surface, the same fact is also illustrat-
 ed.   (P. 455.)           •*
   Absorption with suppuration,  in  other
 words, ulceration,  either happens in con-
 sequence of suppuration already begun,
 in which event the pus acts as pressure;
 or else  absorption attacks  external sur-
 faces from particular irri at ions, or  weak-
 ness, in which case, suppuration must fol-
 low.   (P. 456.)
   The  production  of ulceration requires
 much greater pressure from without, than
 from within.  The process is always dis-
 posed to take  place more quickly  when
 near the surface of the body,  and its pro-
 gress becomes accelerated,  in proportion
 as it arrives near the skin.
  The  adhesive  inflammation  precedes
 the  suppurative,  and  prevents  the pus
 frbm  becoming  diffused, as  soon  as it is
 secreted,  and  when the cyst afterwards
 ulcerates, in order to let the mat«.er ap-
 proach  the  skin, the adhesive inflamma-
 tion still continues to go before the ulcer-
 ative process, and thus  prevents the nut-
 ter from insinuating itself into the inter-
 slices of the cellular substance. (P.  457)
  The pain  of ulceration is,  in some de-
 free, proportioned to its quickness. When
 ulceration begins  on a surface, or  takes
 place for the purpose of bringing  matter
 to the skin, the pain is always considera-
 ble   When ulceration takes place, in or-
 der to separate a dead part, as i.i slough-
 ing, exfoliations, &c. there is seldom any
 particular pain.  (P. 459 )
  The  ulcerating  sore  always exhibits
 little cavities, while the edge of the skin
 is scolloped,  and thin,  at the  same  time,
turning a little out, and overhanging,  more
    Toi. II.
 or less, the ulcerated surface.  The face
 ofthe sore appears foul, and the discharge
 is very thin.
   When ulceration stops, the edges ofthe
 skin become regular,   smooth,   a  little
 rounded, or turned in, and of a purple co-
 lour,  covered  with a  semi-transparent
 white.   (Hunter on Inflammation, &c. p.
 460)
   ULCERS.  Surgeons  usually define an
 ulcer to be a solution of continuity in any
 of the  soft  parts of the body, attended
 with a  secretion of pus, or some kind  of
 discharge.
   In the present part of this Dictionary,
 there will not be occasion to speak of seve-
 ral sorts of sores, which  have been treated
 of in other  articles.  (See Cancer, Scro-
 phula, and Venereal Disease.) .
   Some authors divide  ulcers into  local
 and  constitutional  ones    Other  writers
 make distinctions,  which are more parti-
 cular,  and Mr.  Home has treated of six-
 kinds of ulcers,  viz.
   1. Ulcers in parts, which have sufficient
 strength to cirry on the  actions, necessa-
 ry for their recovery.
   2 Ulcers  in parts, which are too weak
 for th-'t purpose.
   3. Ulcers iu parts, whose actions are too
 violent  to  form healthy  granulations,
 whether this arises from the state of the
 parts, or of the constitution.
   4. Ulcers  in  p.irts, whose actions are
 too indolent, whether this arises from the
 state ofthe parts, or ofthe constitution.
   5. Ulcers in parts, which have acquired
 some specific action, either from a diseas-
 ed state of the parts, or or the constitu-
 tion.
   6. Ulcers in parts, which are prevented
 from healing- by a varicose  state of the
 superficial veins of  the upper part of the
 limb.

 OF ULCERS IV TARTS,- WHICH  HAVE SUFFI-
   CIENT STRENGTH TO C.tnRT ON THE AC-
   TIONS NECESSARY FOR  THEIR RECOVERY.

   Mr. Home remarks, that, in this species
 of ulcer,  the pus is of  a  white colour,
 thick consistence, and readily separates
 from the siivfice ofthe sore, and when di-
 luted,  and examined in  a microscope,  is
 found to  be  made up of small globules,
 swimming in a transparent fluid.  The
 granulations are smdl, florid, and pointed
 at the top.  As soon  as they have risen to
 the level of the surrounding  skin,  those,
 next to  the old skin, become smoo'h, and
are covered with a thin,  semi-transparent
film, wheh afterwards becomes opaque,
and forms cuticle.
  In the treatment of this kind of ulcer,
it  is only necessary  to keep the surface
     3 G 
418                «               ULCERS
clean, and prevent the natural processes
from being interrupted.  Mr. Home ob-
serves, that this  is in general best done,
by the appUcation of dry lint, for the pur-
pose of  absorbing and retaining the mat-
ter, which serves as  a soft covering  for
the granulations,  and by putting over the
lint a pledget of any simple ointment,  in
order to hinder the  matter from evaporat-
ing,  by  which  means  the dressings  will
not become  adherent, and may be easily
taken off, as often as requisite.
  Although healthy ulcers require no me-
dicated application  to be  made to them,
the dressings must be such as do not dis-
agree with the granulations, or surround-
ing skin.
  With some patients, a  roller,  applied
with moderate tightness,  with a view of
retaining  the dressings,  will  cause un-
easiness  in the part, and make the ulcer
lose  its healthy  appearance.  Mr. Home
states, that he has seen several such cases,
in which  the proper  appearance of the
sore returned as soon as the bandage was
discontinued.
  In some patients, ointment irritates and
inflames the neighbouring skin ; and cer-
tain superficial ulcers will not heal, while
kept  in a moist state, and unexposed  to
the air; but heal, when allowed to become
dry and covered  with a scab.
   Mr. Home refers these  particularities
to constitutional causes, and not disease ;
for, the ulcers heal'as soon as the particu-
lar things, which disagree with them, are
discontinued.   These peculiarities in cer-
tain healthy sores may also attend others
of a different description, and  should  al-
ways be discriminated from the effects of
disease.
  Mr. Home very judiciously recommends
enquiring of patients, who have previ-
ously had sores, what kind of applications
they derived most benefit from, and what
dressings were found to disagree.

              TRKATMBHT.

   1. Applications in  the form of vapour,
and  fomentations,  should never be em-
ployed, as they render the texture of the
granulations looser, and diminish the dis-
position to form. skin.
   2. With respect to fluid  applications,
Mr. Home also  very properly  condemns
poultices, as well  as fomentations.  He
speaks of alcohol, as being an application,
which promotes  the formation of a scab,
when this mode of cure is chosen.
   3. In regard to  ointments,  their only
use, in cases of healthy ulcers, is to keep
the matter from  evaporating.  The most
simple ointments are the best for the pur-
pose ; particularly, the one composed of
white wax and olive oil.
  Mr.  Home observes, that the great ob-
jections to the common simple ointments
are, that they sometimes  disagree with
the skin, even when recent, and free from
all  rancidity.  When they have acquired
the latter quality, they still  more frequent-
ly create a greater degree of irritation.
  4. With respect to applications in the
form of powder, Mr. Home remarks, that,
when it is desirable to form a scab on the
ulcer, any inert powder may be sprinkled
on  the  sore;  but, he prefers  dry  lint.
Nothing should touch the powder, or lint,
and, to  prevent this circumstante,  Mr.
Home  recommends applying a little bol-
ster on each side of the sore, and over them
a roller, which will go from  one bolster
to the other, in the manner of a bridge.
  For healthy ulcers, dry lint is to be re-
garded as being, upon the whole, the most
eligible application.  When the sore does
not  secrete  pus  enough  in twenty-four
hours  to moisten the lint, the dressings
are only to be changed every other day.
  When a  moderately tight bandage is
not  forbidden by constitutional peculiari-
ties, it is  useful, both in  supporting the
muscles, and skin, which  are often  in a
flabby  state from the unexercised state of
the  limb,  and  in  defending  the newly
formed parts.  (See Home on Ulcers.)

UICEHS IN FARTS, WHICH  ARE TOO WEAK
  TO CARRT ON  THE ACTIONS NECfSSART
  FOR  THEIR RECOVERT.

  This is  the second of the  classes, in-
to which Mr. Home has divided ulcers in
general.
  The  granulations of these sores  are
larger,  more round on their external sur-
face and of a less compact texture,  than
those formed on ulcers in healthy parts.
Mr. Home  has  also  noticed  their semi-
transparent appearance.  When they have
filled up the cavity of an ulcer to a level
with the surface of the body, they do not
readily form skin, but, rising up in a still
higher manner, often  lose altogether the
power of producing new cutis.   When the
parts are  still  weaker, the granulations
sometimes continue gradually to fill up
the hollow of the ulcer, and then, all on
a sudden,  are suddenly absorbed, so as to
leave the sore, as deep as it was before.
   Ulcers may be weak from the first, or
become  so in the  progress of the case.
Even  granulations of the  most healthy
kind,  if they are not skinned over in a
certain  time, gradually  lose their primi-
tive strength. 
ULCERS
419
   Sores on the legs are greatly under the
 influence of all natural peculiarities ofthe
 constitution, and every thing, which affects
 the  health.  When  the constitution be-
 comes in the least weaker or stronger, the
 appearance of the granulations becomes
 changed  accordingly,  and this  effect of
 constitutional  weakness, or strength,  on
 ulcers is greater, in proportion as the sores
 are further from the source ofthe circula-
 tion.
   While  the  constitution  is undergoing
 any kind of disturbance, the healing of an
 ulcer is  suspended.    Mental anxiety is
 very apt to retard cicatrization.
   Such effects, of the constitutional kind,
 on ulcers are greater in weak, and deli-
 cate persons, than in the strong and ro-
 bust.  Change of weather has considerable
 influence over the healing of sores.  Mr.
 Home mentions, in proof of this fact, that,
 when there were several hundreds of ul-
 cers  in the Naval Hospital at Plymouth,
 in 1778, every time the weather changed,
 from a dry to  a  moist state,  the ulcers
 universally assumed  an unhealthy ap-
 pearance ; but,  put on a  better aspect,
 when the weather became dry again.
   In the  treatment of this kind of ulcer,
 tonics are to  be exhibited, particularly,
 bark and steel, a; id every thing which dis-
 agrees with the constitution, is to be avoid-
 ed.   Wine and cordial medicines are also
 usually prescribed.   Porter, however,  is
 deemed better, than  wine, for  working
 people.
   Mr. Home observes, that the first object
 in the local part  of the treatment, is to
 keep the granulations from rising above
 the edge of the surrouuding skin.  This
 gentleman (in my opinion) very judicious-
 ly represents the greater propriety of pre-
 venting  the  granulations from ever be-
 coming too high  by  the employment of
 proper applications,  than  following the
 common plan of destroying the high gra-
 nulations with escharotics, after they have
 risen to an improper height.  There can-
 not be the smallest doubt, that if the gra-
 nulations could  always be prevented from
 rising up too much, the patient would suf-
 fer a great deal less pain.
  Instead of applying to the surface ofthe
 ulcers, now  under  consideration, lunar
 Olustic, blue vitriol, red precipitate, &c.
 Mr. Home prefers mixing these escharo-
 tics with other substances, so as to render
 them only strong stimulants, and using
 them in  this latter form  He conceives,
 that,  when the high granulations are de-
stroyed with escharotics, the disposition
of the surface  underneath  to reproduce
them is increased, but, that this is not
the case,  when tiie luxuriant parts are
 only  stimulated,  so  as  to become ab-
 sorbed.
   The same gentleman seems to think,
 that, when animal substances  grow with
 great rapidity,  they are,  like vegetable
 ones, weaker, than when  produced in a
 slower manner.  Hence,  Mr. Home is of
 opinion, that the growth of granulations
 ought to  be checked in the early stage of
 their formation, by some resistance, which
 they are just able to overcome,  under
 wliich circumstances, they  derive strength
 from the limited increase of action, which
 they are obliged to undergo.
   On the  same  principle,  according  to
 Mr. Home, the pressure of tight bandages
 is advantageous, and ulcers, which heal,
 while  the patient  is walking about,  are
 not  so apt to break out again, when heal-
 ed, while  the parts are in a state of perfect
 rest.
   In the treatment of these ulcers, when
 the  granulations  have come  to a proper
 height, and do not form a thin, semi-trans-
 parent pellicle upon their surface, they are
 to be considered as weak parts, and treat-
 ed accordingly.   Mr. Home thinks, that,
 in this circumstance, the best plan, when
 no particularity of constitution forbids, is
 pressure,  made with a thin piece of lead
 over the dressings,  and supported with a
 tight bandage.

 OF APPLICATIONS TO CLCEHS ATTENDED WITH
              WEAKNESS.

   Although,  strictly, we have no  topical
 applications,  which can directly commu-
 nicate strength to granulations, there are
 certainly some, which prevent tlie granula-
 tions from exhausting themselves by luxu-
 riant growth, and stimulate them to draw
 more blood from the arteries;  which ef-
 fects, as Mr  Home remarks, render such
 granulations stronger.
   1. This gentleman very properly con-
 demns, as applications to weak ulcers, all
 relaxing fomentations commonly employ-
 ed ; and recommends, instead of them, the
 use of spirits of wine and the decoction of
 poppies, in equal proportions,  not, how-
 ever, to be applied hot.
  2. With regaid to moist applications,
 the same  gentleman expresses  his disap-
 probation  of  poultices, and  mentions a
 weak solution of the argentum nitratum,
 as the  most  eligible  application in  an
aqueous form.
  3.  On the  subject  of powdered sub-
stances, as applications to weak  ulcers,
 Mr. Home says, he  has  often tried bark,
and  the lapis calaminaris,  without per-
ceiving, that the  former had  any power
of strengthening granulations, or the latter 
480                                ULCERS.
any virtue in disposing them to  form new
skin; properties  commonly  imputed  to
these applications.
  Mr. Home entertains no better opinion
of plaster of Paris,  or powdered chalk,
employed with a view of" promoting the
formation of skin.  Powdered carbon,  he
speaks of, a- being more adapted to irrita-
ble,  than weak ulcers.  He praises pow-
dered ihubarb, as particularly applicable
to the latter kind of  ulcer,  because, it  re-
presses the luxuriant growth of the gra-
nulations, renders them  small  and com-
pact, and  disposes  them  to form skin.
When,  however, the  granulations  have
risen above the level  of the skin, it is not
powerful enough to reduce them.  When
the rhubarb is too stimulating,  it is to be
mixed with a fourth  part of crude opium
in powder.
   A piece of lint, a little  less, than the
eore, is always to be put over the powder,
and covered with a pledget  of simple oint-
ment.
   4- Ointments, according to Mr. Home,
are particulary apt to disagree with weak
ulcers.   When  other applications  fail,
however,  greasy  ones may be tried, and
the above gentleman gives a preference to
the ung. hydrarg. nitrat. mixed with hog's
lard, in the proportion of  one to five,  or
else to common  cerate, blended  with a
small quantity of  the hydrarg.  nitrat.
ruber.

OP ULCERS  IN  PARTS, WHOSE  ACTIONS ARE
   TOO  VIOLENT TO FORM HEALTHY GRANU-
   LATIONS; EITHER  FHOM  THE   STATE  OF
   THE PARTS, OR THE CONSTITUTION.

   There are  three states of the constitu-
tion influencing the nature of ulcers:  an
irritable s^ate, in which all the  actions of
the animal economy  are more rapid,  than
in health;  an  indolent  state,   in which
they are unusually languid; and, lastly, a
diseased state, by which they are affected.
   An irritable, and an indolent  ulcer can-
not in general be distinguished  from each
other  by mere appearances, though they
may be so in a few instances.  Mr. Home
informs us,  thai the disposition of an
tilcer, like the di-position of  a constitu-
tion, can only be accurately ascertained
by determinii g the  actions, which  t.rise
from the different impressions made upon
it.
   The same gentleman  notices, that  the
following  appearances at once  shew  the
ulcer to be of an irritable kind.  The mar-
gin of the surrounding skin being j.igged,
and terminating in an eeL-e, which is sharp
and  undermined.  The  bottom  of   the
ulcers being made up of concavities of dif-
ferent  sizes.    T lit re being r.o distinct
appearance of granulations, but, a whitish
spongy substance, covered with a  thin,
ichorous   discharge.   Every  thing,  that
touches tlie surface, gives pain, and very
commonly makes it bleed.  The discharge
is altered from common pus to a thm fluid,
in proportion to the degree of* irritability
communicated  to the sore  by constitu-
tional causes.
  The pain of an irritable  sore in general
gradually becomes less.  When it is not
constant, but comes on in paroxysms chief-
ly  in 'he evening, or  night-time   with
great violence, convulsive motions of the
limb are  apt to occur, and extend  to va-
rious other parts  Mr.  Home refers this
symptom to irritation communicated along
the cour-e of the nerves,  and producing
an action in them, attended with a violent
contraction  ot  the muscles, which  they
supply.
  When the  above-mentioned signs of an
irritable  ulcer  are not  present, we must
forn. a judgment ot the nature of the sore
from listening to  the  history of the case,
the  effects  of  v.rious  applications,  &c.
When this kind of information cannot  be
obtained,   Mr. Home recommends  the
treatment to begin on the supposition of
the ulcer being of an irritable nature.
  When an ulcer occurs just over tlie mal-
leolus externus, it is generally of an irrita-
ble kind,  in consequence of the nature of
the part,  on which it is situated, quite in-
dependently of any constitutional, or local
disposition to irritability.  Mr. Home con-
ceivcs, that the periosteum, which  here
lies immediately under the skin, becomes
tlie seat  of the ulcer, is the cause  of its
being very difficult to heal, and gives it
the irritable appearance.  The fact, that
spires, situated on the ligament of the pa-
te la, and over the periosteum of the an-
terior surface ofthe tibia, assume a similar
app< arance, and  are  equally difficult to
heal, made the above gentleman more con-
firmed in his sentiment.
  In  treating ulcers in general, the sur-
geon will find it exceedingly advantageous
to  be acquainted with  the effects of a
great many different external applications;
for, a very few cases will continue to heal
more, than  for a certain time,, under the
same treatment.  The necessity of chang-
ing the applications,  after they have been
continued for a certain time, is strikingly
illustrated  by the fact, that leaving off a
powerful application, and employing one,
which at first  would have had no effect,
often does a great deal o*  service.   When
the change  is made to  a medicine of
powers, equal to those of the previous one,
the benefit  will be  me:re  lasting, tfeii in
the preceding circumstance.
   Mr. Home compares  the principle of 
ULCERS.
421
this occurrence, with that, by which change
of air, even of a very salubrious air, for one
that is less so, often produces  an infinite
improvement of the health.


  0F APPLICATIONS TO IRRITABLE ULCZRS.
  1.  Mr. Home recommends applications,
in the form  of vapour,  as being particu-
larly  useful, by their quality of allaying
irritation, and soothing pain.
  The steam of warm water is productive
of benefit in  this way, though seldom used
by itself.  Its good effects  are  increased,
when it is mixed with spirits.
  Mr. Home speaks  also in favour of the
benefit  derived from  fonrientations  con-
taining  opium; such as, the tincture of
opium sprinkled on flannel, wrung out of
hot water ;  or the application of flannels,
wet  with a  warm  solution  of the extract
of opium,  or  with  a decoction of"  pop-
py heads.   A  decoction of  chamomile
flowers, the tops  of wormwood,  or hem-
lock leaves, may also be employed for the
same purpose-
   Mr. Home points out particular irritable
ulcers, however, which are rendered more
painful  by   warm applications,  and  he
states, that, the sores, alluded  to, are ge-
nerally attended  with a mottled, purple
discolouration  of  the limb,  for some  way
from them,  and a coldness of the lower
part of the  leg,  and that they are often
disposed to mortify, which event is pro-
 moted by warmth.
   2. As for  moist applications, the poultice
 made of linseed meal is the most simple
 and most easily made, and, as  it does not
 necessarily  require any addition of oil, is
 to be preferred, when this  disagrees with
 the sore.
   Mr. Home does not  say much in favour
 of the use  of  the extract of lead in poul-
 tices ;  for,  though he allows, that it often
 answers verv  well,  he adds, that it also
 frequently  disagrees with the  ulcer,  and,
 if long used,  is apt to bring on  the  lead-

   A decoction of poppy-heads is said to be
  a very good liquor for making  poultices.
   The  carrot-poultice is  also found  to
  agree with a great many irritable sores.
   The great objection to poultices, in these
  cases, being the weight of such applica-
  tions, the limb should always, if possible,
  rest upon the poultice, and not the poultice
  upon the limb.   When the weight cannot
  be avoided, and is hurtful, a lighter appli-
  cation should be chosen.
    If poultices be employed, their use is to
  be continued, as long as the granulations
  are small, and the ulcer is rapidly dimi-
  iMshing ^ sizc>  a"d lbis eve"  t,U lhe c,ca"
trization is complete.  When tiie granula-
tions  become large,  and loose in  their
texture, poultices should be left oft.
  When the weight of poultices prohibits •
their  use, Mr. Home advises die trial of
lint, dipped in one ofthe following lotions,
and covered with a pledget of some simple
ointment :  a solution of the  extract of
opium ; a decoction of poppies ; the tinc-
ture of opium ;  a decoction of cicuta;  the
aqua liihar^yri  acetati composita ; or a di-
luted solution ofthe argentum  nitratum.
  3.  Powdered applications are generally
too stimulating for irritable ulcers. Car-
bon has been found useful; so has pow-
dered extract of opium,  mixed with an
equal quantity of carbon, or linseed flour.
However, opium occasionally  affects  the
constitution, in consequence of absorption,
and it has been known to»excite violent
inflammation, ending in mortification.
  4.  Ointments are not often proper ap-
plications for irritable ulcers ;  as they are
always, more or less rancid, and general-
ly disagree  with the skin of persons, most
subject to such diseases.
   Mr. Home mentions cream, as being a
very  useful application, particularly in
cases, in which warmth  is found  to do
harm.  The same gentleman recommends,
as  a  substitute for it, an ointment, com-
posed of hog's lard, purified by being re-
peatedly washed in spring water, and  then
mixed with a small quantity of white wax,
 and rose water.
   The observations, made respecting solu-
 tions of lead, apply to the unguentum ce-
 russje acetata.
   5.  The pressure of bandages is general-
 ly hurtful to irritable sores, though a slight
 degree of it proves serviceable to certain
 ulcers, which  are somewhat less irritable,
 and arise from weakness.
OF ULCERS  IN PARTS, WHOSE ACTIONS ABU
  TOO INDOLENT TO FORM HEALTH! GRANU- ,
  LATIONS,  WHETHER   THIS  INDOLENCE
  ARISES FROM THE STATE OF THE PARTS, OR
  OF THE CONSTITUTION.

  Such  is  the next division  of ulcers
adopted by Mr. Home  in  his  treatise
on the subject.  The indolent ulcer forms
in its appearance a complete contrast to the
irritable one. The edges of the surround-
ing  skin are  thick, prominent,  smooth,
and rounded.   The surface of the granu-
lations  is smooth and  glossy.  The pus,
instead of being of a perfect kind, is thin
and watery, being composed ot a mixture
of  pus  and   coagulating  lymph.  The
lymph consists of fl.ikes, wliich cannot  be
casilv separated from  the surface of the
sore." The bottom of the ulcer forms quite
a level, or nearly so,  and,  as  Mr  Home 
422                               ULCERS.
very accurately remarks, the general as-
pect conveys an idea,  that, a portion of
the skin and parts underneath has been
for some time removed, without the ex-
posed surface having begun any new action
to fill up the cavity.
  When, however, the indolence of  the
ulcer is not so  strongly marked, the sore
does not correspond to the preceding de-
scription, but resembles in appearance tlie
ulcer,  which possesses an inferior degree
ef irritability, and can only be discrimi-
nated from it by receiving no benefit from
soothing applications.
  The odcl circumstances of some indolent
6ores having the appearance of irritable
ones  is, in some  degree,  explained by
nlcers always being influenced by changes
in the Constitution, and accidental circum-
stances affecting the parts.
  Most of the ulcers, which are to be seen
in the London hospitals, are of the indo-
lent kind.  An indolen  disposition in the
ulcer may  proceed altogether  from   the
long existence ol  the disease, and, hence,
Mr. Home very justly ob-erves, it is  im-
material, whether  at first it was healthy,
weak, or irritable,  for, if not cured within
a certain time, i.  becomes indolent, with
tlie exception of  a few of the irritable
kind, which never  change their nature.
  Indolent  6ores  do  form  granulations;
but, these, every now and then, are all on
a sudden absorbed, and, in the course of
four and twenty hours, the  sore becomes
as much increi.sed in size, as ii  had been
diminished  in  as  many days, or weeks.
This absorption ofthe granulations arises
principally from  their  not  being of a
healthy kind ; but, the event is promoted
by  changes in the weather, anxiety, fa-
tigue,  &c.
  The object in the treatment of indolent
ulcers is not  simply to produce  a cure,
but  to  render such cure as permanent as
possible  This can only be accomplished
by altering the disposition of the granula-
tions, and rendering them strong enough
to stand their ground after the ulcer is
filled up.
  When an ulcer, which has existed six
months, is dressed with poultices for a
week, the granulations,  at the end of this
time, will have in part filled up the hollow
ofthe sore, but, they will be found, large,
loose, and glossy.  Should the poultice be
now discontinued,  and some proper stimu-
lating  appI cation  used for another week,
the granulations will be f mnd, at the ex-
piration ot  this time,  to  hove  become
smaller, more compact, redder, and tree
from* the glossy appearance.   The ulcer,
when  healed  by  th<   ia'ier  application,
will not be so likely  to break out again,
as when  healed with large, loose, flabby,
glossy granulations.
  Mr. Home  states, that the  number  of
indolent sores, which heal under the use of
stimulating applications, and do not break
out again, compared with  similar cases,
treated with mild dressings, are as four to
one.

   APPLICATIONS TO INSOLENT  ULCEIIS.

  1. Medicines in the form of vapour, can-
not  heal indolent sores,  so that the cure
shall be  lasting.   It is only when these
ulcers assume a foul appearance, and are
in a temporary state of irritation,  that
such applications  can be advantageously
employed.
  In general, patients on their first admis-
sion into hospitals with sore legs, have
their ulcers  in a temporary state of irrita-
tion from neglect, exercise, excesses, &c.
Hence, it is generally found advantageous,
for the first few days, or even  a week,  to
have recourse to  poulticies and fomenta-
tions.
  1  believe, that  any  common  fomenta-
tion, whether of chamomile, poppy-heads,
or mere  warm water,  answers  equally
well.  The time for using it,  is  while
a fresh poultice is preparing, and this lat-
ter application should be changed twice a
day.
 . 2. Moist applications, such as poultices,
are to be  employed, when fomentations are
proper, and they may be made of bread,
oatmeal,  or linseed.
  Mr. Home  describes a species of indo-
lent ulcers, which occur in patients of de-
bilitated  constitutions, which put on a
sphacelated  appearance, without any ap-
parent cause,  even after they have made
some progress towards a cure, and in this
way spread to a very large size.  Some of
these ulcers, if judged of from their ap-
pearances, would  be ranked as irritable
ones ; but, as soothing applications do not
agree with them, they are not to be classed
with  the latter kind of sores.  They are
said to occur particularly in seamen, and
soldiers,  who have been long at sea, and
have been  termed scorbutic ulcers.  Mr.
Home represents jhem, however, as not
being necessarily connected  with the
scurvy, and being often met with in pa-
tients, who  have  not  been on  the sea.
This gentleman  states, that these ulcers
are not of necessity joined with any spe-
cific disease; but are common to all kinds
of patients, whose constitutions have been
impaired, either by salt provisions, warm
climates, or drinking.
   From  some trials, first  made  by Dr.
Harness, and afterwards by Mr. Home, it 
ULCERS.
423
appears, that these particular ulcers, when
in a sphacelated  state,  are benefited by
employing the gastric juice of ruminating
animals,  as an  external appUcation.  It
makes the sloughs fall off*, and the sore
assume a better appearance.  Some pain
follows on  its being first applied, and it
is to be regarded as a stimulating applica-
tion.
  Mr. Home mentions, that in the West
Indies,  such ulcers  are advantageously
dressed with the fresh root of the cassada,
grated into a pulp.  Lime juice has also
been found a useful application,  and solu-
tions of vitriol and alum have been recom-
mended.
  When indolent  ulcers are not attended
With certain peculiarities, a solution ofthe
argentum nitratum is one of the best of the
watery applications.   It stimulates  the
granulations, and makes them put on a
more healthy appearance, and its strength
may be increased according to  circum-
stances.   An ulcer, which as first cannot
bear this solution above a certain strength,
without pain,  and  without the  granula-
tions being absorbed, becomes able, after
the application  has been used, about ten
days,  or a  fortnight, to bear it  twice as
 strong,  without  such effects being  pro-
 duced: a proof ofthe granulations having
 acquired strength.
   The  tincture  of myrrh is  often  em-
 ployed as an application to indolent ulcers.
 Hunezowsky has praised  a decoction of
 the walnut-tree leaves, and soft covering
 of the walnut,  for the  same  purpose.
 (Acta Acad. Med. Chir. Viadob. Tom. 1.
 1788.)  Mr. Home gives his testimony in
 fiivour of both the latter dressings.
   The diluted  vitriolic  acid, and the ex-
 pressed juice of the pod of different species
 of pepper in a recent state, are mentioned
 by Mr. Home as having been used as ap-
 plications to indolent ulcers:  the latter
 one in the West Indies.
   This  gentleman  recommends  also a
  scruple of nitrous acid, mixed with eight
 ounces of water, as a very useful medicine
 for external use.  The strength must be
  increased or diminished, according to cir-
  cumstances.   Mr. Home has found, that
  this application  promotes, in a very un-
  common manner, the progress of the cure.
    The first application of diluted nitrous
  acid gives a good deal of pain, which lasts
  about half an hour, and then goes off
    When an indolent ulcer heals with tlie
  diluted nitrous acid, the process of skin-
  ning is accomplished with more rapidity,
  than when other  applications are em-
  ployed; and the new skin is said to be
  more completely formed. The acid coagu-
  lates tlie pus as aoon as it is secreted.
  Mr. Home  says, that several patients,
who had ulcers dressed with the diluted
nitrous acid,  were allowed to walk about,
without finding the progress of tie cure
retarded, although no bandage to support
the limb was made use of.   This gentle-
man,  informs us, also, that in ulcers of
the leg, attended with an exposure of a
piece of bone, which is neither acted upon
by  the absorbents, nor deprived of life,
so as to form an  exfoliation, so that the
ulcer is kept  from healing, the application
of diluted  nitrous acid to  the bone,  re-
moves . the earthy part, and excites the
absorbents to act upon .the remaining ani-
mal portion.
  3. The only application, in the form of
powder, adapted to indolent ulcers, is, ac-
cording to Mr. Home, the hydrargyrus
nitratus ruber.   It is only to be occasion-
ally used for ulcers of the most  indolent
kind.
  4. Ointments are represented as being
particularly  proper applications for   the
sores under consideration.
  The idea of the  air having bad effects
on  ulcers  exposed to it, is now  disbe-
lieved.  That  air has no irritating proper-
ty of this kind, is proved by  the fact, that,
when  the  abdomen of an animal is filled
with it, no  inflammation is excited. When
the cellular membrane is  loaded with it,
in  cases of emphysema, the parts do not
afterwards inflame.   Nor, do ulcers in the
throat, as Mr.  Home justly  remarks, heal
 less favourably than others,  although they
 are of necessity always exposed to the air.
   Whatever ill effects arise, may probably
 be explained by  the consequences of eva-
 poration, which converts the soft pus into
 a scab.  The  granulations are, in all pro-
 bability, most favourably circumstanced,
 when they are covered with their own
 matter, which should only be now  and
 then  removed, in order that such ap-
 plications  may be made, as  will stimulate
 them to secrete a more perfect pus. From
 what has  been just  stated,  it must be ob-
 vious, that indolent ulcers should not be
 frequently dressed,  and that if they are
 so, and the  dressings are stimulating', the
 practice   will do harm.  Changing the
 dressings  once  in  twenty-four hours is
 deemed quite sufficient, unless the quan-
 tity of matter is very great, which very
 seldom happens  in these cases.
    One part of the unguentum hydrargyri
 "nitrati mixed  with three of hog's lard, is
 one of the best applications. Its strength,
 however,  must  be increased after being
 used, for some time, as a dressing for the
 same ulcer.
    The unguentum hydrargyri nitrati has
 the elfect of quickly removing the thick- 
424
ULCERS.
ening of tlie edges of indolent ulcers, and
the surrounding dark  red colour of the
skin.  It seems also to have particularly
great power in  making the  granulations
become small and healthy, and of course,
the ulcer is less likely to break out again.
  With some ulcers, however, this  oint-
ment  is  found to disagree.
  The unguentum resinae flavaee, and the
unguentum elemi, mixed with the balsam
of  turpentine,  or  that  of copaiba, are
other common  applications to indolent
sores.   Mr. Home states, that the resins
and turpentines are not so  powerful, as
the acids and metallic salts,  in giving the
granulations a healthy appearance, and a
oisposition to resist being absorbed.
  Cases attended  with a elegree of indo-
lent  thickening,  are  such  as  are most
likely to be improved,  by camphorated
ointments.
  In  numerous cases,  the  applications,
whatever they are, soon loose their effect,
and others should then be  substituted for
them.   The  past and present states of
the sore are always to be considered. Al-
though, the ulcer may be in its nature in-
dolent,  it  is liable to temporary changes,
from constitutional causes, and hence, a
temporary alteration in the treatment be-
comes proper.
  5. Bandages  are  undoubtedly  of the
most  essential  service in  healing many
kinds of ulcers:  but  their efficacy is so
great in curing numerous  indolent sores,
that they are considered by some as the
principal means of cure.
  Among the advocates for  the employ-
ment of the roller, Mr. Whately is one of
the most zealous. The following extracts
will convey to the reader a tolerably good
idea of  this gentleman's opinions.
  " The efficacy of pressure in counteract-
ing the eff'ects of the dependant posture,
was indeed known to the father of English
surgery;  and the use of the laced stock-
ing was recommendeel to him for this pur-
pose ; nor can there be any  doubt, that,
the good effects of it in his hands, were
very manifest.  His ideas, however, seem
not to have been much regarded by suc-
ceeding surgeons. We finel but little said
by the writers on surgery, on the effects
of pressure in the cure of ulcers on the
lower  extremities, previous to  the ap-
pearance of Dr.  Underwood's   treatise.
Yet, I am aware, that there always have
been practitioners, who  were acquainted
with the importance of this mode ot treat-
ment, and have  adopted it in their prac-
tice.  I  had,  myself, an  opportunity of
seeing the extraordinary  success attend-
ing it, during my apprenticeship in the
country. It K matter of fact, however,"that
the practice is very far from being general.
Even in one of the latest publications on
the subject, and this too by a  surgeon of
the first eminence, the effect of pressure is
not much relied upon for the cure of these
complaints.  It is,  indeed, there stated,
in several passages,  not only  that  no be-
nefit is elerived  from compression in se-
veral species of these  ulcers,  but  that
many ulcers are rendered  worse,  more
painful, and more unhealthy in  their ap-
pearance by its use (as observed in Mr.
Home's Remarks on Ulcers of the Legs.)
That  there are  certain conditions of an
ulcer, which will not bear compression, 1
have allowed, and  have  endeavoured to
point out the proper treatment,  to bring
on a fit state for the application of that
pressure:  but  that an experienced  sur-
geon should pass over so slightly this most
essential part of the cure, and even speak
of it as frequently injurious, is a circum-
stance hardly to be attributed to any other
cause than  that of a careless and ineffec-
tual application of the  bandages.   For
my own part, having now been for twenty
years constantly in the habit of treating a
very large  number  of these cases,  I can
speak so confidently of the good effects of
pressure, properly  applied,  that  I  can
venture to affirm, that he who doubts its
efficacy, has never given it a fair trial.
  " In the cases  which are added to this
essay, (says Mr.  Whately) very  little va-
riety ot dressing was used ; the cure was
almost always  trusted principally to the
pressure  made on  the  limb,  under the
exceptions particularly  specified in the
work.  My success has been so  uniform,
that I cannot but be anxious  to  see  this
practice become established and generally
followed.   Nothing but a conviction, that
in promoting this end, 1 am really doing
an important service to  my  fellow  crea-
tures, could have induceel me to appear
before  the  tribunal of the public,  con-
scious  as I am of my incompetency as a
writer.  But may I not hope, that the
plain tale ofa practical man will be heard,
though not told with the graces of ele-
gant language ?
  " In  h hatever manner this  attempt be
received, I  cannot  doubt but  that  the
practice here ree mmendeel must,  in the
end, prevail, notwithstanding it has this
greai obstacle  to contend with, that sur-
geons must condescend, for the most part,
to  apply the bandages  with their  own
hands.   The clumsy and ineffectual man-
ner, in  which  this business is  too fre-
quently done, can  never be expected to
produce the desu-ed effect.   I am certain,
that if the necessary pains be taken, ac-
cording to the direction here  laid down,
such effects will uniformly follovj, af  must
convince the unprejudiced mind, that to 
ULCERS.
425
Save  recourse to the operation of tying
varicose veins, and the  application of a
great variety of remedies, can  be  very
rarely, most probably never necessary.  I
can safely declare, that all such cases, as
are described by Mr. Home to be cured
by this operation, have  readily yielded,
under the proper management of pressure
alone.
   " Since these papers were preparing for
the press, I have seen with  pleasure Mr.
Baynton's new method of treating these
complaints.  Every thing that is there said
on the efficacy of his method, may be con-
sidered as confirming the doctrine laid
down in the following pages.  His mode,
however, of making the  pressure  with
adhesive plaster, appears to me inconve-
nient, an<i on several accounts objection.
able.   I have no  doubt but  that  the
proper  application  of compresses and
flannel  rollers, would, in  every  case re-
corded  by him, have produced similar
good  effects.  The instances of success
by this  method, after the supposed failure
by the roller,  I can only attribute to this,
that the pressure made  with  the plasters
was  applied by  his own  hands, whereas
that with the  roller, was probably,  as is
usual, so made,  that the  effect  intended
by it could not possibly  have been obtain-
ed.  No surgeon, who will not be at the
trouble of applying them  himself,  can be
ajudge of what may be  effected  by the
proper management of the roller and com-
presses."
   The  following is the calamine cerate,
which Mr Whately has usually employed :
   B». Axung  Porcin. depur. lib. iij.
    Empl. Lithargyr. lib.  iss.
    Lap. Calam. prxp. ap. lib. j.   M.
   " To  this formula, (says Mr. Whately,)
I  shall  add  another for  making a cerate,
which nearly resembles the  unguentum
tripharmacum ofthe old Dispensatory, but
being less oily, it makes a much  more ad-
hesive plaster.  It  should be spread  on
rag, or silk,  as an external covering to the
dressing on lint,  where a tow plaster can-
not be conveniently used ; as  in wounds
of the face or hands, a bubo, or any other
sore, where  an external plaster cannot be
readily retained in  its situation by a band-
age.   This  plaster  is likewise so mild,
that  it  never irritates the skin.  I  have
found it also a very useful plaster in frac-
tures.   The following is the formula :
   fy.  Empl.  Litharg. lib. j.
    Axung. Porcin. depur. une. vj.
    Aceti une. iv.   M."
   With respect to the proper method of
applying the roller and compresses, Mr.
Whately offers the following remarks :
   «' I  have said, that the flannel rollers
shoulel  be four inches wide, to allow for
    "Vol. II.
shrinking in Washing ;  by which I would
have it understood,  that when  they are
made of that  width, they are a little too
wide :  especially for those whose legs are
small.  The best width for a flannel roller,
designed for those who have slender legs,
is three inches ; but for those, whose legs
are of a large size, they should be always
three inches and a half in width.. They
must therefore be at  first torn a  little
wider, that they may be of their proper
width  when repeatedly washed. v It will
likewise  be  found, that rollers made of
fine, soft, and  open  flannel, will  answer
much better, than those  made of coarse
or hard flannel.
  " For those who have full sized legs,
the length of six  yards is bu\ just suffi-
cient to answer all the  purposes intended
by a roller; but in those who have very
small legs, five yards is  a sufficient length.
Care should be taken that the rollers be
washed in very hot water, and they should
be hung up to dry immediately on being
washed.  If these  precautions be not at-
tended to, repeated washing them will, in
some kinds of flannel, make them as nar-
row as tape, by which they will  be ren-
dered almost  useless.   They  should  be
often washed,  as  they  are much softer,
and of course sit easier, when quite clean,
than when they are soiled.
  " In  applying a  roller,  (says this gen-
tleman) the  first circle should be made
round the lowest part of the ankles as near
as possible to the heel;  the second should
be formed  from thence round the  foot;
the third shou d be passed again round
the foot  quite to  the toes.  The roller
should then  be passed from the foot round
the ankle and instep a second time to make
the fourth circle.  In doing this, it should
be brought nearer (out  not over), the point
ofthe heel than it was at the first time of
going round this  part.   The fifth circle1
should pass  over the  ankles again, and not
more than half an inch  higher up  the leg
than the  fourth circle.  The sixth, se-
venth,  eighth, and ninth  circles should
ascend spirally along tiie small of the leg,
at the exact distance of three-fourths of an
inch from each other.  Having proceeded
thus far up  the leg,  we may begin to in-<
crease  the distances of the circles from
each other ;  they may succeed each other
upward to the knee at the distance of from
one to  two inches, according to  the size
and shape of the leg. At that part where
the calf of the leg commences, it is gene-
rally necessary to let the upper  edge of
the roller be once, twice, or thrice, turned
downwards for about half the circumfer-
ence of the leg, in  order  to.  make the
roller lay smooth between the  middle of
the calf, and the small of the leg. When
    311 
426                 -               LLCERS.
the roller has been thus applied as far as
the knee, there will be a portion  of it to
spare, of perhaps  a  yard in length ; this
remainder  should be brought  down by
spiral windings, at greater distances from
each other than those which were made
on the ascent ofthe roller.  The windings
should in general be completed  in the
small of the leg, where the roller  should
be pinned.
  " In many cases, it is necessary to apply
the roller  over the  heel.   It should be
brought  as low as possible round the an-
kle ; as in the former description.   From
thence, the second  circle  of the roller
should pass from the instep over one side
of the heel, and be brought over the other
side ofthe heel to tlie instep again.  The
third circle should be pas>eel round the
ankle a second  time, but still nearer  to
the heel than the  first circle  was.  The
roller should after this be brought back to
the foot,and passed round it to make the
fourth circle.  A  fifth  circle should be
again made (though  it is not in  all cases
absolutely necessity) rounel the  foot,  to
the toes.   To make the sixth  circle, the
roller should be brought back, and passed
round the ankle  again.  The  seventh,
eighth, ninth, tenth, and  eleventh  circles
should ascenel spirally at the exact distance
of  three-fourths   of an  inch  from  each
other; these distances commencing at the
sixth  circle.  The roller shoulel then be
carri-d to the knee, and be brought down
again to the small ofthe leg, as described
in the former instruction.
  " In applying the compresses, it is ne-
cessary in every instance  to  put  them on
one by one, and not all in a mass, though
they  be  of a proper size  and  number.
They should be crossed in elifferent direc-
tions ; the largest of them should in no
cas" be longer than just to  meet  on the
opposite  side of  the  leg, to which  they
are applied.  1 have  in  many instances
seen  the  compresses  applied   by the
patients of such a length as to go round
the leg like a roller, and be fastened to-
gether with pins.   This method generally
wrinkles and  blisters the skin,  anel by no
means answers the purpose  of making  a
compression on the part where it is  most
wanted.   I never suffer a pin to be  used
in the compresses.   If  the same  com-
presses in any  case  be applied two  days
together, they shoulel always be turned
on the contrary  side at each re-applica-
tion, in order to prevent  wrinkles  on the
skin"
   Mr. Whately  notices  two objections
made by Mr. Baynton to rollers.  " The
first is,  that it is difficult  to retain the
roller on the parts to which it is applied ;
the second is, that  it gives pain to the
patient."   Mr.   Whately "s  experience,
however,  warrants him in saying, that
a flannel  roller will, in almost every in-
stance,  keep  the exact petition it wan
first placed in, for a much longer time
than is necessary.  " 1 have  seen these
rollers (says Mr. Whately, many hundred
times keep their situations without any
variation  whatever  for two  clays; and
that too without the least restraint upon
exercise.  This  has happened  in those
cases,   where from the distance of the
patient, or from  the circumstance of his
being  nearly  cured,  I  have  w.shed  to
dress the leg only every forty-eight hours.
1 must go a step further,  anel  observe,
that  I have seen  repeated  instances in
which  these  rollers  have  remained  in
their situation for three or four days, and
even nearly for a week without being ap-
plied afresh.   In  short,  it is  one  of the
best properties   of a flannel  roller, that
it is easily retaineel in its situatie»n, when
well applied. In every instance, in which
it is necessary to use eme, I could pledge
myself to apply it  in such a  manner, as
should prevent its altering its position for
two days.  The method I should use, I
have already described; in  addition to
which,  nothing  more would  be  neces-
sary, even in  those cases where the shape
of  the  leg is peculiarly unfavourable to
the reten'ion of  a bandage, than the in-
sertion ofa few pins.
   " In answer to  the  second objection, I
observe,  that  I  have invariably  found,
that when a  flannel roller has been ap-
plied in the manner here described,  and
has not  been drawn  unnecessarily tight,
it  gives no  pain.  It sits.nearly  as easy
as  a  common  stocking,  and allows a
very free motion anel exercise oflhe limb.
It has been stated in this we>rk,  that the
application of the ceimpresses makes the
necessary  degree  of  pressure   on  the
ulcer, and thereby prevents the necessity
of drawing the  roller so tight  over the
other  parts  of  the leg, as would have
been necessary were  the compresses not
used.
   " There is another circumstance which
Mr. Baynton cemsiders as giving  his  me-
thod a great advantage over  the roller,
wliich is, that by  means of  the  plaster,
the edges of the sore may be made to ap-
proximate in such a  manner,  that the
cicatrix,  or  new-formed. skin,  will  be
less after a cure performed by  this method
than  by any  otiier.  In almost all these
cases, before the cure is attempted, the
leg is more or less enlarged by swelling;
and as this swelling is entirely removed
by  compression,  it readily   allows  the
skin to approximate on the healing of an
ulcer.  Added to this, there is a  process 
ULCERS.
427
In nature always going  on in healing an
Ulcer or wound in any part of the body,
(whether there be a loss of substance or
not,) by wliich a cicatrix is  always  con-
siderably less  than the previous size  of
the sore.  This effect occurs in all cases,
whether the  patient  be cured by the
horizontal position, a roller,  or  by strips
of adhesive plaster.  The  size of this
cicatrix  will  likewise  vary in  different
cases where the ulcers  have been of the
same size, by  whichever of these three
methods they be cured.  It will  be larger
in those'ulcers which  are  accompanied
with  strong  adhesions  of the  adjoining
parts,  than in those where such  adhe-
sions have not  been produced; and this
effect will take place to the  greatest de-
gree where the ulcers  are situated over
the tibia, and by  long  continuance  have
produced  immoveable  adhesions of the
cellular substance to the adjoining  peri-
osteum.   The adhesive plaster,  when
applied as a bandage, will without doubt
leave as small a  cicatrix as any  other
methoel  of cure; but,  for  the reasons
already assigned, I elo not  believe that
the  cicatrix will in any  case be smaller
than that produced by a roller.   In every
case cured by the latter  method, I  have
found the cicatrix very small, when  com-
pared with  the  previous  size of the
ulcer."—(See Practical Observations on the
 Cure of Wounds and Ulcers  on  the Legs,
without Rest; by Thomas  Whately, 1799.)
   6.  We  shall  next  introduce an ac-
count of Mr. Baynton's plan of curing
old ulcers of the leg, by means of adhe-
sive plaster.  Were I  to say,  that any
particular  method of dressing such  sores
is entitled to superior praise,  1 should
certainly decide in favour of this gentle-
man's practice.   I have seen  it most suc-
cessful  myself,  and   I  hear  it highly
spoken  of   by   numerous professional
friends, in whose unprejudiced judgment
I place much reliance.
   Mr.  Baynton acquaints  us,   that the
means  proposed  by him  will,  in  most
instances be  found sufficient to accom-
plish cures  in the worst cases, without
pain or confinement.   After having been
repeatedly disappointed  in  the  cure  of
old ulcers, Mr. Baynton determined  on
bringing the edges  of old ulcers nearer  to-
gether by means of slips of adhesive plasters.
To this he was chiefly led, from having
frequently observed, that the probability
of an ulcer continuing sound,  depended
much on the size  of the cicatrix, which
remained  after the cure appeared  to be
accomplished;  and from well  knowing,
that the true  skin was  a much more sub-
stantial support and defence, as well as
a better covering, than the  frail one,
wliich is  obtained  by the assistance of
art.  But, when he had recourse to the
adhesive plaster, with a view  to lessen
the probability of those ulcers breaking
out again, he  little  expected, that an
application so  simple would prove the
easiest,  most efficacious and most agree-
able means of treating ulcers.
  Although tlie first cases, in which Mr.
Baynton tried  this  practice, were of an
unfavourable nature, yet he had soon the
satisfaction to perceive that it occasioned
very little pain, and  materially accele-
rated the  cure,  while the   size of the
cicatrices were much less than they woulel
have been, had the  cures  been obtained
by any of the common methods.
  At first, however, the success was not
quite perfect;  as, in  many  instances,
he  was  not able to remove  the slips of
plaster, without removing some portion
of the aeljacent skin, which,  by occasion-
ing a new wound, proved a disagreeable
circumstance, in a part so  disposed to
inflame  and ulcerate,  as in  the vicinity
of  an old sore.  He therefore endeavour-
ed to obviate that inconveniente by  keep-
ing the  plasters and bandages well moist-
ened  with spring-water, for some  time,
before they were removed from the  limb.
He had  soon the  satisfaction to observe,
that the inconvenience was not only pre-
vented, but that every succeeding case
justified the confidence he now began to
place in the remedy.  He also discovered,
that moistening the   bandages was at-
tended  with advantages wbich he eliel not
expect; while the parts  were wet and
cool, the patients were much more  com-
fortable in their sensations, and the sur-
rounding inflammation was  sooner re-
moved, than he  had before observed it
to be.
   By the mode of treatment here recom-
mended,  Mr.  Baynton found,  that the
discharge  was lessened,  the  offensive
smell removed, and the pain abated in  a
very short time. But, besides these ad-
vantages, he also found, that the callous
edges were in a few days level with the
surface of the  sore;  that the growth of
fungus  was prevented, and  the necessity
of applying  painful  escharotics  much
lessened, if not entirely done away.  Mr.
Baynton gives the following description of
his method.
   " The parts should be first cleared of
the hair, sometimes found  in consider-
able quantities upon the legs,  by means
of a razor, that none of the discharges,
by being retained, may become   acrid,
and inflame the skin, and that the dress-
ings may be removed with  ease at each
time of  their renewal,  which, in  some
cases, where the discharges are very nv^- 
428                               ULCERS.
fuse, and the  ulcers very irritable, may,
perhaps, be necessary twice in the twenty-
four hours,  but which  I have, in every
instance, been only under the necessity
of performing once in that space of fflhe.
  " The plaster should be prepared by
slowly melting,  in an iron ladle, a suf-
ficient quantity  of litharge plaster, or
diachylon,  which if  too  brittle, when
cold, to adhere, may be  rendered ad-
hesive by melting half a drachm of resin
with  every  ounce of the plaster: when
melted, it should be  stirred till it be-
gins  to  cool,  and  then  spread  thinly
upon slips of smooth porous calico, of a
convenient length and breadth, by sweep-
ing it quickly from the end, held by the
left hand of the person who spreads it,
to the other, held firmly by another per-
son,  with the  common elastic  spatula
used  by apothecaries ; the  uneven edges
must be  taken  off,  and the pieces cut
into slips, about two inches in breadth,
and  of  a  length that will, after being
passed round the limb, leave an end of
about  four or  five inches.  The middle
of the piece so prepared, is to be applieel
to the sound part of the  limb, opposite
to the inferior part of the ulcer,  so  that
the  lower edge  of* the plaster may be
placed about an  inch below the lower
edge of the sore, and the ends  drawn
over the ulcer with as much gradual ex-
tension as  the  patient can well bear  ;
other slips are to be secured in the same
way,  each  above and in contact with
the other, until the whole surface  of the
sore and the limb are completely covered,
at least one  inch below and two or three
above  the diseased part.
  " The whole  of the leg should then
be equally defended with  pieces of soft
calico, three or four times  doubled, and
a banclage of the same, about three inches
in breadth,  and four or  five yards in
length, or rather, as  much as will be
sufficient to  support  the  limb from the
toes to the  knee,  should  be applied as
smoothly as can be possibly performed by
the surgeon, and with as much firmness
as can  be borne  by the patient, being
first passed round the leg, at the ankle-
joint, then as many times  round the foot
as will cover and support every  part of
it, except the toes, and  afterwards  up
the limb till it reaches the knee,  observ-
ing that each turn of the bandage should
have its lower edge so placed as to be
about  an inch above  the lower edge of
tlie fold next below.
  " If the parts be much inflamed, or the
discharge very profuse,  they  should be
well moistened,  ar.d kept cool with cold
spring-water poured upon  them as often
as the heat may indicate to be necessary,
or,  perhaps, at least,  once every hour.
The patient may take  what exercise hr
pleases, and it will be always found,  that
an alleviation of his pain and the promo-
tion of his cure  will follow as its  con-
sequence, though, under other modes of
treating  the  disease,  it aggravates  the
pain, and prevents the cure.
  *' These means, when it can be made
convenient, should be  applied soon after
rising  in  the morning,  as the  legs of
persons  affected  with  this disease are
then found most free from tumefaction,
and the advantages will be greater  than
when they are  applied to  limbs  in a
swollen state.   But at whatever time the
applications be  maele, or in whatever
condition the  parts  be found, I believe
it will always happen, that cures may be
obtained by these means alone, except in
one species of the disease,  which seldom
occurs,  but that  will hereafter be de-
scribed.  The fii st application will some-
times  occasion  pain,  which,  however,
subsides in a  short  time,  anel is felt less
sensibly at every succeeding dressing.  The
force,  with  which the ends  are  drawn
over the limb, must then be  gradually
increased,  anel when  the  parts are re-
stored to their natural state of ease and
sensibility, which wilk soon happen, as
much may be applieel  as  the calico  will
bear, or the  surgeon can  exert; especi-
ally if the  limb be in that enlarged and
incompressible state, which has been de-
nominated  the scorbutic,  or if the edges
of  the wound be widely separated from
each other."
  Mr. Baynton  afterwards takes  notice
of  the breaking of  the  skin,  near  the
ulcers; a circumstance, which sometimes
proved  troublesome, and  arose  partly
from  the mechanical effect of the adhe-
sive plasters, and partly from the irritat-
ing quality of the plaster.   Mr.  Baynton,
however, only  considers  such  sores of
serious  consequence,   when  they  are
situated over the  tendon  of Achilles, in
which situation they are sometimes sever-
ral  weeks in getting well.  This gentle-
man recommends, with  a view of  pre-
venting these ulcers,  a small  shred of
soft leather to be put under the adhesive
plaster.
  Mr. Baynton next adds, " that cures
will be generally obtained without diffi-
culty,  by the  mere application of the
slips and bandage; but, when tlie parts
are much inflamed,  and  the secretions
great, or the season hot, tiie frequent ap-
plication of cold water will be  found a
valuable auxiliary, and  may be always
safely had recourse to,  where the heat of
the part is greater,  than is natural, and
tlie body free from perspiration." (See A 
ULCERS.
429
descriptive Accouht of a New Method of
Treating Old Ulcers of the Legs, by Tho-
mas Baynton, Surgeon at Bristol.  Edit. 2.
1799.)

OF ULCERS ATTENDED WITH SOME SPECIFIC
  DISEASED ACTION, EITHER CONSTITUTION-
  AL, OR.LOCAL.

    1. Ulcers which yield to Mercury.

  Here we shall exclude from considera-
tion venereal ulcers,  as this subject is
treated of in the article Venereal Disease.
At present,  we  shall only notice such
sores, as are produced by other diseases
of  the general  system,  or of the  parts,
and  are  capable  of being  cured  by
mercury.
   Perhaps, there  is no greater source of
error  in the whole practice of surgery,
than  tiie supposition,  that a sore, when
it yields to mercury, must be a syphilitic
one.  Surgeons, however, who  run into
this absurdity,  can  hardly  be imagined
to be unaware, that so potent a medicine
must have effects on numerous diseases
of very different descriptions.  Mr. Home
very  truly remarks,  that many  ulcers,
unconnected  with the venereal  disease,
which receive  no benefit from other me-
dicines, heal under a mercurial course,
or yield to  mercurial  applications.   In
some  cases,  the  ulcer  remains  hi  the
same state,  while mercury is used ; but,
begins to le>ok better,  as soon  as  the
medicine   is discontinued,   in   conse-
quence of the beneficial change, produced
in  the system  by the mercurial course.
In these  cases,  mercurial  frictions  are
the best, because they occasion least  im-
pairment  of the constitution, in  conse-
quence ofthe stomach continuing  undis-
turbed, and capable of digesting well.
   Another description of ulcers, noticed
by Mr. Home,  as deriving benefit from
mercury,  occur on  the instep and foot,
have a very thickened edge, and are  at-
tended with a diseased  state of the sur-
rounding  skin,  so as to bear some re-
semblance to  elephantiasis.   They  are
frequently observed  affecting  servants,
who  live in opulent  families, in  an  in-
dolent and  luxurious way.   Mr. Home
states, that fumigations with  .the  hy-
drargyrus  sulphuratus ruber heal these
ulcers, and  resolve in a great degree tiie
swelling  of the  surrounding parts.  In
some instances, an  ointment of calomel
and  hog's lard; in others, the camphor-
ated weak mercurial ointment, is the best
application.
   Miny  diseased  ulcers,  particularly
superficial ones,  with a thickened edge,
may be healed, when they are dressed
with a  solution of one grain of the hy-
drargyrus muriatus, in an ounce of water,
containing a little spirit.

 2. Ulcers, wliich are curable by Hemlock.

  Mr.  Home  places  more  reliance  on
hemlock,  as  an external, than an  in-'
ternal remedy, for ulcers.  The ulcers,
which usually receive benefit from  hem-
lock applications, look like those of an
irritable sort; but, the surrounding parts
are thickened, in consequence of  some
diseased  action.    Such  sores  occur
near the  ankle; which joint is  at the
same time  enlarged.  Sometimes, but
not so  often, they take place over the
ligaments of the knee.  On account  of
their situation,  and the swelling of the
joint, they may be suspected to be scro-
phulous, though they are  more sensible,
than strumous ulcers  usually are.  The
sores, just described, are rendered less
painful,   their  diseased   disposition  is
checked,  and the swelling of  the  joint
diminished, by hemlock.   Several irrita-
ble  scrophulous  ulcers  are also parti-
cularly benefited by this medicine.
  Mr. Home gives the preference  to hem-
lock poultices, unless their weight should
be objectionable, in  which cases, he  ad-
vises lint to be dipped  in  a decoction of
the herb, and put on the sore.
  Of the  ointment, made with the inspis-
sated juice, Mr. Home  seems  to  say
little, in regard to its efficacy.

3. Ulcers which may be cured by Salt Water.

   Mr. Home takes  notice of other spe-
cific ulcers, which yield to this  applica-
tion,  after  resisting  other  remedies.
Poultices, made with sea-water,lire often
employed ;  but, this gentleman, seems to
prefer keeping the part immersed in  the
water in a tepid state, about a quarter of
an hour, twice a day.
   When  sea-water  poultices bring  out
pimples,  in  cases of scrophulous ulcers
on the  legs and feet, Mr. Home informs
us,  thatv this disagreeable circumstance
may be obviated by diluting such water
with an equal quantity of a decoction of
poppies.   After a time,  the salt water
may be tried  by  itself  again.   While
each fresh  poultice is preparing,  the
part should also be immersed  in such
water warmed.
   M hen there is a tendency to anasarea,
or when  there  is an unusual coldness in
the limb, unattended with any propensity
to mortification, tepid salt-water may b*
used with infinite advantage. 
430
ULCEUS.
4. Ulcers, which may be cured by the Ar-
           gentum Nitratum.

  Mr. Home notices,  under this head,
an ulcer,  which does not penetrate more
deeply, than the cutis;  but, spreads in
all  directions,  producing  ulceration on
the surface  of  the  skin,  and often ex-
tending nearly  through its  whole thick-
ness.    The  part,  first affected,  heals,
while  the  skin  beyond is in a state of
ulceration.
  Of this  description are, a leprous erup-
tion,  mostly seen  in  men  impressed in
Ireland;  a  disease  of the skin induced
by buboes,  which have continued a great
while after the venereal virus has been de-
stroyed ;  and the ring-worm.
  All these  diseases are most easily cured
by  applying to the*  a solution of the
argentum nitratum.
  The leprous  eruption is communicated
by contact,  and makes its appearance in
the form  of a  boil.  This  is converted
into   an ulcer,  which  discharges a fetid
fluid, by  which the surrounding skin is
excoriated,  and the ulceration is extend-
ed over a large surface.  The pain is the
most severe, and the discharge  greatest,
in hot weather.  The parts  first diseased
Deal, while others are becoming ulcerated,
and the disease is always rendered worse,
by spirituous liquors, salt provisions, and
catching cold.
  Mr. Home remarks, that the disease
in the skin, produced  by  the  effects of
very  irritable  buboes, in  constitutions
broken down  by mercury, is   attended
with ulceration of a more violent, deep,
and   painful kind,  than  the  foregoing
distemper.  The progress of this disorder
is, in other respects, very similar to  that
ofthe leprous eruption.
  Although the ring worm only occurs in
the form of an ulcer in warm climates,  a
mild species of tiie affection takes place
in  summer-time in   this  country.    It
seems to be infectious; though it often
occurs  without infection.   It commences
with  an efflorescence, which is  attended
with  very trivial swelling, and spreads
from a central point.   The circumference
of the efflorescence becomes raised into a
welt, while the rest assumes a scurfy ap-
pearance. The welt becomes covereel  with
a scab, which falls off, and leaves an ulcer-
ateel  ring, in general, not more,  than  a
quarter of  an  inch wide.   The outer
margin of this  ring continues to ulcerate,
while the  inner one  heals, so that the
circle gets  larger  and larger.  The dis-
charge consists of  a  thin,  acrid fluid,
which seems to have  a great  share  in
making the disease spread.
  For all the three preceding diseases,
a solution of the  argentum  nitratum i»
strongly-recommended by Mr. Home.

     5.  Ulcers, which yield to Arsenic.

  The  sores,  which are named noli me
tangere,  derive  great  benefit from this
powerful remedy.   Mr. Home observes,
that  they  are nearly  allied to cancer,
differing from it in not contaminating the
neighbouring parts by absorption, and only
spreading by immediate contact.
  From  some  cases,  which fell under
Mr. Home's observation, he discovered,
that arsenic was not only  efficacious as
an  external,  but  also as  an  internal
remedy. I shall not unnecessarily enlarge
upon this subject in the present place, as
the reader may refer to the articles Arse-
nic,  Cancer, and Noli  Me Tangere, for
adelitional  information,  relative  to  the
uses of this potent mineral  in the practice
of surgery.
  Mr. Home is  an advocate for  its  em-
ployment, both internally and exlernal'y,
for  ulcers of untoward appearance on the
legs.  The fungated ulcer  is particularly
pointeel out by  this gentleman as  being
benefited by arsenic.  This ulcer occurs
on the calf of the  leg, and on the sole of
the  foot.  From its surface,  a fungus
shoots out, which  is  entirely different
from common granulations.   The  new
formed  substance  is radiated in its struc-
ture, the bottom of the ulcer being  the
central  point, and the external  surface,
which is continually increasing,  the  cir-
cumference.  The substance of this  fun-
gus is  very tender, and readily bleeds.
The first stage of the disease sometimes
has the appearance of a scrophulous affec-
tion of the metatarsal bones ;  but,  the
parts seem more enlarged,  and, when the
skin ulcerates, a fungus' shoots out,  and
betrays the nature ofthe case.
  One species of  the  fungated  ulcer is
capable of  contaminating  the lymphatic
glands ; the other is not so.  The first is
represented by Mr. Home as being incura-
ble by arsenic, or any other known medi-
cine.
  The second yields to this remedy.  Mr.
Home uses a  saturated solution, made
by  boiling  white arsenic  in  water,  for
several hours, in  a sand heat. He gives
from three to ten drops internally ;  and,
for outward use, dilutes a  dram with two
pints of water, making it afterwards gradu-
ally  stronger and stronger, till  it is of
double strength.   The application  may
 either be maele in the form of  a poultice,
 or  by dipping lint in the lotion.
   The  best  and  safest  preparation of
 arsenic, both  for internal ar.d  external
 use, is  the kali arsenicatum.  The mode 
                                   ULCERS.                               431

of employing it may be leamt by turning operated upon must stand with the inner
to the articles Arsenic, Aqua Kali Arseni- ankle fxing the light, which will expose
cati, Noli Me  Tangere, &c.               very  advantageously  the  enlarged vena
                                        saphena  passing  over the  knee-joint.
   6. Ulcers attended with Varicose Veins.   While  the patient is in this posture, if a
                                        fold of the skin, which is very  loose at
   A certain kind of ulcer  is very apt to this part, is pinched up transversely, and
occur  on the inside of the leg,  and is kept  in that position  by the  finger and
equally difficult to cure, anel  liable to thumb of the surgeon, on one side, and
break out again.   It has the look of a mild, of an assistant on the other,  this fold
indolent, sore;  but,  the  branches  and may  be  divided  by  a pointed scalpel,
trunk  o; the  vena saphena are enlarged, pushed  through with the back of the
and this varix of the veins keeps the ulcer knife  towards  the limb to prevent the
from healing.  The sore is seldom deep, vein  being wounded; much in the same
usually spreads along the surface,  and way, as the skin is divided in making an
has an oval shape, tiie ends of which  are issue.  This  will  expose  the  vein suffi-
vertically situated.  There is a  pain  af- ciently ; but, there is commonly a thin
fecting the limb rather deeply, extending membranous  fascia confining it  in  its
up in the course of the veins, and exaspe- situation ; and, when  that is  met  with,
rated  by keeping the leg a long while in the vein had better  be laterally  disen-
an erect posture.                        gaged by the point of  the knife.  This is
   This is a kind of ulcer, which  derives most  expeditiously done by laying hold
immense benefit from a tight roller,  ap- of the fascia with a pair of dissecting
plied from the toes to the knee, although  forceps, and dividing it; for it is difficult
the direct  operation of  the pressure of to cut upon parts, which  give  little ra-
the bandage on the  sore is itself product- sistance,  and there is a risk of wounding
ive of no particular good.                 the vein.   After  this a  silver  crooked
   Mr. Home  found, however, that many  needle, with  the point rounded off', will
patients could  not bear  to  wear laced  readily force its way through the cellular
stockings,  or tight bandages,  and  that  membrane connected with the vein, with-
somc received no relief from them. Hence,  out any danger of wounding the  vessel,
tliis gentleman  was leel to consider what  and  carry a  ligature  round it.   This
else could be done for the cure of  the  part,  or, indeed, what may be consider-
yaricose state of the veins. He represents,  ed as  the whole of the operation,  being-
that, in consequence of  the size of  the  finished, the patient had better be put to
 vena saphena, and its numberless con^  bed, so as to allow the vtin to be in its
 volutions,  the return of blood  from  the  easiest state, before the ligature is tied,
 smaller  branches  is  so impelled, as to  and  then  a  knot is to be made  upon the
 retard the  circulation  in  the  smaller  vein:  this  gives  some pain; but, it  is
 arteries, and to interfere with their ac-  by no means severe.   The edges  of the
tion  in  forming  healthy  granulations,  wound in the skin are now to be brought
The coats, and valves of the veins  also  together by sticking plaster, except where
 become thickened, so that the latter parts  the  ligature passes out, and a compress
 (the valves) do  not do their office of sup-  and  bandage applied so  as  to  keep up
 porting the  weight  of the column of  a  moderate degree of pressure on the
 blood.                                  veins,  both  above and below the part in-
   These reflections induced Mr.  Home to  eluded in the ligature." (Home on  Ulcers,
 think, that some  benefit might be obtain-  p. 296, edit. 2.)
 ed by taking  off a part of the pressure of    It appears that  A.  Pate" proposed and
 this column of blood, by making a liga-  performed an  operation,  similar  to tiie
 ture round the  vena saphena, where  this  one  described by Mr. Home.   See A.
 vessel  passes over  the knee-joint  Thus  Fare's Works, translated by Johnson ; folio
 the cavity of the vein at this part-would  edition, page 319
 lie  obliterated, and a  kind of artificial     For information on the  foregoing sub-
 valve would be  formed.                  ject, consult Undenuood's Surgical Tracts
   This  gentleman  recommends  the  fol-  on Ulcers, &c. 1799 ; B. Bell's  System of
 lowing way of performing the operation :  Surgery,  Baynton's Descriptive Account of
"As  the  veins  are only turgid in  the  a neno Method of'treating Old Ulcers ofthe
erect  posture,  the  operation should be  l.egs, 1799, edit.  2 ;  Whately's_  Practical
performed  while  the patient is  standing;   Observations on the  Cure of Wounds and
and if  placed  upon, a table,  on which   Ulcers on the Legs, without Rest,  1799;
there  is a  chair, the back of the  chair  Practical Observations on the Treatment of
 will serve  him to rest upon, and he  wdl   Ulcers on the Legs, to which are ad/led, some
have  the knee-joint at a very convenient   Observations on Varicose Veins and Piles, by
 height for  the  surgeon.  The leg to be  Everard Home, F. R. S. 1801, edit.  2.; 
432             U N <fi                                  UNd
Principles of Surgery, by John Bell, Vol. 1.
1804;  Hunter  on  tlie Blood, Inflamma-
tion, &c.
  UNGUENTUM AC1DI VITRIOLICI.-
gf.  Acidi  Vitriolici "5J.  Adipis  Suillse
pra-paratae  §j.—These  are  to  be well
mixed together in a glass mortar.
  This ointment  is  said to have been
used  by Dr. Duncan,  of Edinburgh,  for
curing the itch.  It has the character also
of being  able to  reduce some chronic
swellings  of the joints.  Mr. Naylor, of
Gloucester,  has employed frictions with
this  ointment, containing a good deal  of
camphor,  for the purpose of reducing the
swelling of the thyroid gland, in cases of
bronchocele.
  As the vitriolic acid is particularly de-
structive of vegetable substances, the parts
to which this ointment is applied, should
always be covered with flannel instead of
linen.
  UNGUENTUM  CALCIS   HYDRAR-
GYRI  ALBJE —*.   Calcis  Hydrargyri
Albse jj.  Adipis Suillse  praeparatx §iss.
Misce.—Useful for several cutaneous dis-
eases.
  UNGUENTUM  CANTHARIDIS.—*.
Cantharid. Pulv.  31J.   Aqua Distillatae
3viij.  Unguent.    Resinae  Flavae ^viij.
Boil the water with the  cantharides,  till
one  half  of the  fluid has  evaporated.
Then strain the rest,  to which  add the
ointment of yellow resin.  Evaporate the
mixture in a water bath, saturated with
sea-salt, until  it is of the consistence of
an ointment.
  UNGUENTUM CERjE.—*. Cerae Alb*
3iv. Spermatis-Ceti !§iij.  Olei Olivae lbj.
These are to  be  melted with a slow fire,
and  then  briskly stirred till cold.  This,
spread on lint, serves as a simple dressing
for wounds, ulcers, &c.
  UNGUENTUM CERi£ CUM  ACETO.
—gf. Cerae Albse  §iv.   Olei  Olivae lbj.
Aceti Distillati §ij.  The vinegar is to be
gradually  mixed with the two first ingre-
dients, after these have been  melted  to-
gether.  Dr.  Cheston  recommends this
ointment for superficial excoriations, cuta-
neous eruptions, &c.
  UNGUENTUM  CERUSSA ACETA-
TjE.—£. Cerussa: Acetatse gij. Cerae Al-
ba; 3*ij.  Olei  Olivae  ibss.  Rub the ace-
tated ceruse (previously powdered) with
part of the olive oil.  Then add it to the
wax melted with the rest of the oil. Stir
the  mixture until cold.   This is  a very
good saturnine application, in  cases which
require it to be made in the form of an
ointment.
  UNGUENTUM  CICUTJE— &.   Fo-
liorum Cicuta: recentium, Adipis  Suillse
praeparatae, sing.  3*iv.  The cicuta is  to
be bruised  in a  marble mortar,  after
which, the lard is to be added, and th*
two ingredients thoroughly  incorporated
by beating.  They are  then  to be  gently
melted  over  the fire, and after being
strained through  a cloth,  and the fibrous
part of the hemlock well pressed,  the
ointment is to be stirred till quite cold.
To cancerous or  scrophulous sores, this
ointment may be  applied with a prospect
of advantage.   (Pharm. Chirurg.)
  The Pharmacopoeia  of St. Bartholo-
mew's Hospital directs  the unguentum
cicutae to be made as follows :—j«.  Folio-
rum Cicutae lbj.   Adipis  Suillse Ibiss.
Boil the leaves in the melted hog's-lard,
until they become crisp.  Then strain the
ointment.
  An hemlock ointment might be more
conveniently made, by mixing the succus
cicutae spissatus, with any common salve.
  UNGUENTUM DIGITALIS.—*. Foli-
orum Digitalis Purpureae recentium. Adi-
pis Suillse praeparatae, sing. 3iv. This oint-
ment may be made in the same manner as
the unguentum cicutae, and tried in the
same cases as the latter.
  UNGUENTUM  ELEMI  COMPOSI-
TUM—fy.  Elemi lbj.  Terebinthinse |x.
Sevi Ovilli  praeparati  Ibij.   Olei Olivae
§ij.  Melt  the elemi with the suet;  re-
move them from  the fire, and mix them
immediately  with  the  turpentine  and
oil.  Then  strain  the  mixture—Some-
times  employed   for   dressing  ulcers,
which stand in need of stimulating ap-
plications.
  UNGUENTUM  GALLjE CAMPHQ-
RATUM — *.   Gallarum  Pulveris Subti-
lissimi Jij.   Camphorae  gss.  Adipis Su-
illae praeparatae  ^ij.  Misce.—This is a
very good application to piles, after their
inflammatory state has been  diminish-
ed  by the  lotio  aq.  litharg.  acet.  and
leeches.
  UNGUENTUM  HELLEBORI  ALBI.
—B*.  Hellebori Albi Pulv. Jj.  Adipis
Suillae praeparatae- !|iv.  Olei Limonis J)ss.
Misce.—This  ointment  will • cure  the
itch,  and  several other  cutaneous dis-
eases.  Tinea capitis will sometimes yield
to it.
  UNGUENTUM HYDRARGYRI FOR-
TIUS.—*.    Hydrargyri  purificati Ibij.
Adipis  Suillae  praeparatae  ^xxiii.  Sevi
Ovilli praeparati ^j.  First rub the quick-
silver with the suet, and a little of the
hog's-lard,  until   the  globules  disap-
pear ;  then add  the  remainder of the
lard,  and  make  an ointment—This  is
the common, strong, mercurial ointment.
Of its uses  we need  say nothing in this
place.
  UNGUENTUM HYDRARGYRI CAM-
PHOR AT UM.—*.  Unguenti Hydrargyri
^j.   Camphors  3ss.   Misce.—This  is 
UNG                                   UNI              433
often recommended to be rubbed on thick-
ened, indurated parts,  with a view of ex-
citing the action of the absorbents.   Rub-
bed along the course of the urethra, it is
very serviceable  in diminishing  and  re-
moving chorde.e.
  UNGUENTUM HYDRARGYRI MlTl-
l:S.—gr.   Unguenti  Hydrargyri feirt. lbj.
Adipis Suillae praeparatae "tblj.  Misce.—
The weaker  mercurial ointment  is  often
rubbed on indurated, thickened parts and
tumours,  when  the object is  merely to
promote their absorption ; and, it is not
advisable to  employ the  unguentum hy-
drargyri fort, lest a salivation should  be
 induced.
   UNGUENTUM   HYDRARGYRI  NI-
TRATI— %.    Hydrarg.   Purificati  §j.
Acidi Nitrosi ^ij.   Ail pis Suillae praepa-
 ratae ibj.   Dissolve  the  quicksilver  in
 the nitrous acid; and  whilst the solution
 is yet hot, mix with  it  the  hog's-lard,
 previously melted,  but beginning to con-
 crete,  by being exposed to the air.   This
 ointment is  a celebrated application to
 the inside of  the  eyelids,  in  cases of
 chronic  ophthalmy, and also to specks
 em  the cornea.  When blended with a
 little olive oil, it also forms a very eligi-
 ble stimulating . dressing  for numerous
 kinds  of sores.  It is very efficacious in
 curing tinea  capitis, and many other her-
 petic and cutaneous diseases.
   UNGUENTUM   HYDRARGYRI NI-
 TKATl  RUB8I—1>.  Hydrargyri Nitrati
 Rubri Jiss.  Cerae Albse giv. Olei  Olivae
 5viij.  Misce.— This is  a most  common
 application to  indolent  ulcers, and sores
 in general, which require being stiraulattd.
'   UNGUENTUM-LITHARGYlil  ACE-
 TATI.—&.  Aquae Lithargyri Acetati  s"v.
 Adipis Suillse lbj.  Cerae  Albae 51V. Melt
 the ingredients together, and continue to
 stir them till cold.—This is an excellent
 saturnine ointment for ulcers with inflam-
 ed edges, and it  may be employed with
 great  advantage as a  simple dressing in
 numerous instances.
   UNGUENTUM   OPHTHALMICUM-
 ik.   Adipis Suillx  piseparatae 3*ss.  Tutiae
 prseparatx,  Bol. Arinen. sing. 31 j. Calcis
 Hydrarg.  Albas  £j. Misce.—This is  Ja-
 nin's  celebrated   ophthalmic ointment,
 which  mav  be  used  for  the same dis-
 eases of the  eye and  eyelids, as the  un-
 guentum hydrargyri  nitrati.  It must be
 at  first  we'.keneel  with  about twice  its
 quantity of h igVlarel.
   UNGUENTUM  PICIS.—*. Picis, Sevi
Ovilli  praeparati,  s.ng.  Ibss.  Melt and
then strain them.
  UNGUENTUM I'ICIS COM POSITUM.
 —iv. Unguenti Picis, Unguenti  Ceru^x,
 \ccta *, sing. Ibss. Misce.
   Th<-  two  preceding ointments are  ap-
     VOL. H-
plicable  to cases  of tinea capitis,  and
some eruptive complaints.  Also to some
kinds of irritable ulcers.
  UNGUENTUM  PICIS   CUM  SUL-
PHURE —»;.  Unguenti Picis, Unguenti
Sulpliuris, sing. £iv. Misce.—This is the
most common, and, I believe, the most ef-
ficacious, application fqr curing tinea ca-r
pitis.
  UNGUENTUM Rf",SIN,"£ FLAVJE.-r
Rf. Risii :x Fl.vaj, Ceiae Flavae, sing. lbj.
bl i Olivx lbj.  Melt the  resin  anel wax
with a  slow fire;  then  add the oil, and
strain the mixture  while hot.—This  is a
common application to ulcers, which stand
in need of being i;i-ntlv stimulated.
  UNGUENTUM SAMBUC1.—*.  Flo-
rum Sambuci, Adipis Suillae, singulorum
lbj.  The  hog's-lard being melted, boil
the elder-flowers  in  it till they become
crisn, then si rain the mixture.
  UNGUENTUM SPEKMATIS-CETI.—
%. Spermatis-Ceti  Jvj.   Ceiae A'bx ^ij.
Olei Oli< se 5iij.  Melt them together with
a slow ft" e, and then stir them briskly till
cold —This is the common white dress-
ing,  so extensively used by surgeons as a
simple salve.
  UNGUENTUM   SULPHURIS.---*.
Adipis  Suillx Ibss.  Florum Sulpliuris
3 iv. Misce.
  UNGUENTUM TUTLE— p,.   Tutiae
prxparatx, Unguenti Spermatis-Ceti, q. s.
Misce.—Used for  smearing the  borders
and  inside ofthe eyelids, incases of chro-
nic ophthalmy, 8tc.
  UNGUENTUM  TUTIJE  COMPOSI-
TUM—!*.  Tutiae  pixparatx,  Lapitlis
Calaminaris prxparati,  sing.  ,^vj.  Cam-
phorx ^ij. Unguenti Sambucilbj. Misce.
—This foinmla.is  contained in the Phar-
macopoeia of   St.  Bartholomew's  Hos-
pital.  It may be applieel, in se>me cases,
to the inside of the  eyelids, also to piles;
certain ulcerations, excoriations, &.c.
   UNGUENTUM ZINC1 CALCINATI-
fy.  Florum  Zinci  51J.  Unguentum Sper-
matis-Ceti  ibj. Misce.—Sometimes used
in the same affections of the eye anel eye-
lids, in  which the unguentum hydrargyri
nitrati, and the unguentum ophthalmicum,
are employed.
   UNGUIS.  (A Nail.)  Some surgical
authors have applied this term to a collec-
tion of pus, or matter  in  the eye, when
the  abscess  has  appeared, through the
corne:., to be shap  el like a  finger nail.
   UNCULA.   (A Hoof)   A collection of
matter mnlie eye,  shaped like  a hoof.
   UNION   BY THE  FIRST  INTEN-
TION—When the  opposite  surfaces  of
a  wound are  brought  intei contact, and
grow together at  once, without  suppu-
rating,  union by the  first intention  is
said to have taken place.   When wounds
     31 
434                   v            URETHRA.
heal  by suppurating, granulating,  &c.
they  are  sometimes surgically described
as getting well by the second intention.
See Wounds.
   URETHRA,  STRICTURES OF.  Mr.
 Hunter  informs us that most  obstruc-
 tions  to the  passage of  the  urine,  if
 not  all, are  attended  with nearly the *
 same symptoms.   Few  persons  take no-
 tice  of the  first symptoms of a stricture,
 till they have citheV  become violent,  or
 other  inconveniencies have been the con-
 sequence.   A patient may have  a con-
 siderable stricture, and yet be unconsci-
 ous, that his  urine does not freely come
 away ; he may olten have, in consequence
  of a stricture, a  tendency to  inflamma-
 tion and suppuration in  the perinaeum,
  without feeling any  obstruction  to the
  passage of his urine, or suspecting that
 he has any other complaint.
    There are  three kinds  of strictures ;
  viz. the true permanent one,  which arises
  from an alteration in the  structure of a
  part of the urethra ; the mixed case, con-
  sisting of  a  permanent  stricture and a
  spasm ;  and,  thirdly, the true spasmodic
 stricture.
    In all these obstructions, Mr. Hunter
  remarks, that the stream of water be-
  comes small  in proportion to  the  stop-
  page ; but, though this symptom is pro-
  bably the first, it is not always observed
  by the  patient.   In  some instances, the
  water is voided only in drops,  and then
  it cannot  escape  notice.   In other cases,
  the  stream of urine is forked,  e>r scattered.
  Under such  circumstances,  Mr.  Hunter
  recommends  the passage  to be examined
  with a bougie; and, if  one of a eeimmon
  size  can be readily introduced,  the  diffi-
  culty of voiding1 the urine is likely to ele-
  pend  on a diseased  enlargement of the
  prostate gland, which  shoulel,  therefore
  be examined.   See Prostate Gland.
    The spasmodic  stricture may he known
  by its being only of a temporary eluration.
  This kind  of  case, and more particularly
  the  permanent stricture, are generally  at-
  tended  with  a gleet.  The  latter  com-
  plaint is often for  a lemg while suspected
  as being the  only one, and  the surgeon
  finds  all his  efforts," to  effect  a  cuie,
  fruitless.                             '
    In diseases of the  urethra, and also  of
  the  prostate  gland and blaelder, there is
  commonly  an uneasiness  about the peri-
  naeum, anu*,  anel lower part of  the  ab-
  domen.  (Hunter.)
    The first progress ofthe contraction is,
  in general, veiy  slow; but, when once
  it has so  far increased, that the  urethra
 is not wholly relaxed by the  force of the
 urine, its subsequent advances  are  more
 rapid, and new symptoms  are perceived.
The  urine is voided more tiequent-lr
does  not  pass   without  a  considerable
effort, attended  with pain,  and a strain-
ing sensation continues, after the bladder
is emptied.   If  the patient' accidentally
catches cold, elrinks a glass of spirituous
liquor, acid beverage,  or  punch, com-
mits  an excess in drinking wine, or re-
moves quickly from  a warm  to  a  cold
climate,  the  urine  will, perhaps,  pass
only in drops,  or  be entirely obstructed.
These causes induce, in the  contracted
part, a spasmodic  action, by which  it is
closed.  Cold, externally applied to the
body, has so great an effect upon a spas-
modic stricture, than a patient,  who can
make water without the smallest  diffi-
culty in a warm room, is often quite un-
able  to void a  drop, on making the at-
tempt  in the  open  air.   However, on
returning to a warm room, and sitting
down a little  while, he   becomes  able
again to  expel  the urine.  The symp-
 toms of a stricture are more frequent in
persons, who lead a seelentary life,  than
in others  who lead an active one.  (Home.)
   Strictures in  the urethra, being attend-
ed with  a discharge and pain in making
water, especially after any excess, are fre-
quently regarded and treated as a gonorr-
hoea. These two symptoms  often Come on
a few hours afierconnexions with women;
the degree of inflammation  is very slight;
the eli charge is the first symptom, and is
more violent at the commencement,  than
at  any other period.  The inflammation
subsides in a few days, leaving only tlie
discharge, wl - h also frequently disappears
 in  five or six days, whether  any means
 are employed or  not,  for its  removal.
 (Home.)
   "What  reliefers a stricture particularly
 apt to be mistaken for  a   gonorrhoea, is
 the circumstance that, in  both  diseases,
 the pain  in making water is experienced
 about an  inch and a  half* from  the orifice
ofthe glans penis.
   In a more advanced stage, the strictur-
 eel  part  of the urethra is always much
 narrower,  than the rest   of  the canal.
 However, it retains  the power of becom-
 ing contracted anel relaxed.  In the  con-
 tracteel state,  the  passage  is  closed up;
 in the relaxed, the urine can pass through
 it in a small stream.
   The spasmodic contraction must act
 with considerable  force, since tlie  urine
 cannot even pass in a small" stream, and
 a small bougie, which, in a relaxed state
 of the urethra, met with  no  resistance,
 can  now be scarcely introd-- ed at alL
 Also, if the bougie be allowed to remain
 for a few minutes in the stricture, it  is
 not  unfrequently grasped  so  lightly by
 the  spasmodic contraction, that,  when 
URETHRA.
4jj
P.n attempt is maele to withdraw it, some
force is requisite to succeed.  The bougie
when examined, seems as if it had had an
impression made round it by a piece of
packthread. (Home.)
  In old cases of stricture, the muscular
coat ot  the bladder becomes  thickened
and  stronger,  than  natural,  in  conse-
quence of more  force being necessary to
propel  the urine through  the obstructed
part.  The  bladder,  in this  thickened
state, does not admit  of  the most dila-
tion, so  that  the patient  is obliged to
make water very frequently,  and  he is
unable  to  pass the whole  night without
making this evacuation once  or  twice.
(Home )
  A nocturnal emission of the semen is
smother very common symptom ofa stric-
ture ; and some patients seem to have no
either complaint attendant on the affection
ofthe urethra.
  A periodical  discharge  is  sometimes
brought on  by colel, or other occasional
causes.  The  inflammation  extends  to
the bladder;  the frequency of making
water is  very much increased,  and  the
urine  very  turbid.   It  is  voided  for
twelve,- or twenty-four hours,  once  or
even twice every hour; and, when  allow-
ed  to stand, it  deposits a substance in
the form of powder,  consisting of coa-
gulable lymph.  This is tiie  slightest kind
of attack.
  Sometimes the bladder is inflamed in a
greater degree,  and secretes pus,  which
is discharged with the urine.  In  a still
more  violent  attack,  the  discharge is
similar to the white of an  egg, *and par-
ticularly  adhesive.  Mr.  Home  states,
that it .has been discovered by examina-
tions after eleath, to be the vitiated secre-
tion of the prostate gland.   When the in-
flammation of the bladder  becomes still
worse, the affection sometimes extends to
tlie peritoneum, and the patient dies.
  Since  strictures of  long standing  al-
ways impede the  passage  of the  urine,
the bladder acts with augmented  force
togovercome the  resistance.  In  this man-
ner, the stricture  is  kept  in  a  continual
state of irritation, and made to contract in
a greater degree.
  In a few cases, indeed, the diseased
part of  the urethra is rendered quite im-
pervious ;  and  the patient's  life  is pre-
served by the urethra ulcerating, at some
point within the obstruction, and fistulous
openings taking place  in  the perinxum.
See Fislulx in Perinxo.
  Strictures are frequently attended with
constitutional symptoms, one of the most
comniem of which, in warm  climates, is
a complete paroxysm of fever.  The cold
fit  is very severe; this is  followed-by a
hot fit, and then a very profuse perspira-
tion.  During  the   rigor,  nausea  and
vomiting  generally occur,  and at  this
period the patient has occasion to make
water  frequently,  seldom  experiencing
at the same time any  strangury.   When
the fit is tolerably complete, the patient
suffers, in  Keneral,  only  one ; in the op-
posite circumstance,  two; but, a greater
number  rarely happen.   Such  febrile
paroxysms   are not   frequent  in  cold
countries;  but do  every  now  and  then
take place, particularly  in  consequence
of exposure to cold, excesses, and the
introduction both of common and armed
bougies.
  With regard to the  formation of stric-
tures,  Mr.  Home has  noticed, that the
membrane of the urethra, like every other
muscular structure,  is liable to a spas-
modic  contraction,  in* which  state  the
canal loses the power  of relaxing itself
again; till  the  spasm is  removed.   This
spasmodic stricture  is only a wrong action
of the urethra; and, if the parts could be
examined in their relaxed state, there Would
be no appearance ofdisease.
  A part of the urethra, once disposed to
become preternaturally contracted, gene-
rally becomes  more and more affected in
this  manner, and, at last, becomes  per-
manently narrower.   The case now  be-
comes  both a  permanent stricture  and a
spasmodic one; being  so  far permanent,
that it is always narrower, than the rest of
the canal,  and so far spasmodic, that it
may become contracted in a still greater
degree.
  When  the contraction  is not consider-
able,  it  appears,  on  examination  after
death,  to be merely a narrowing of the
urethra ; but  a permanent  stricture, in
a more advanced state, usually consists of
a ridge, which forms a projection  in the
passage.  (Home.)
  Mr. Hunter informs  us that the  dis-
ease generally occupies no  great length!
of" the passage;  at  least, that this  was
the case in  most of  the instances, which
he had seen.   In these the contraction
was not broader, than if it had  been  pro-
duced by surrounding the  urethra with a
piece of packthread; and in many it had
a good  deal  of  the appearance,  wliich
one may fancy such a  cause  would  pro-
duce.  Mr. Hunter  states, however,  that
he had seen the  urethra  contracted for
above  an  inch in  length, owing  to its
coats,  or  internal  membrane,  being ir-
regularly thickened, and forming a wind-
ing canal.
  A stricture does not  always arise from
an equal contractfon of the  urethra all
rounel;  for, in some instances, the  con-
traction is  only on  one side.   This  con- 
436                               URETHRA.
traction  of one side of the  canal only  from venereal causes, from reflecting tha*
throws  the passage to the  opposite siele",  strictures  are common to most passages
which often renders the introduction of a  in the  human  body.  They often  take
bougie difficult.  The contracted part is  place  in the oesophagus;  the  intestines,
whiter,  than  any part of  the  urethra,  particularly, the rectum; the amis; the
anel  is  harder  in  its  consistence.   In  prepuce,  so as  to  produce  phy mosis;
some few cases, there are more strictures,  anel in the lachrymal duct, so as toocc; sion
than  one.   Mr.  Hunter   mentions  his  a fistula  lachrymalis.  Strictures  some-
having seen half a dozen in one urethra,  time-;  take place, when there  have been
anel he observes, that a stricture is  fre-  no previous venereal complaints.  Mr
quently  attended  with small  tightnesses  Hunter men1 ions his  having  seen an in-
in other parts ofthe urethra.             stance of this kind in a young man, nine-
   Mr.  Hunter remarks, that every part   teen years of age, who had had the com-
of the urethra is  not equally subject to   plaint  tor eight  years, and which there-
strictures,  the  bulbou->  portion  being  fore   began,  when he was   only eleven
much the most subject to the disease.  A  years  old,   He was of a weak, scrophul-
striciure is  sometimes situateel on  this   Otis habit.  Mr.  Hunter  had also seen a
siele  of  the  bulb, but very seldom  be-  stricture  in a  boy only four years olei,
yond  it,  that  is, nearer  the  bladder,  and a fistula iri perinaro in consequence
Mr. Hunter never saw a stricture  in  that  of it.   Strictures happen as frequently  in
part of the urethra, which passes through  persons, who  have  had  the gonorrhtca
the prostate gland; and the bulb,besides  in a slight degree,  as in others, who have
being ihe most frequent seat  of this  dis-  had it in a severe form.
ease, is  also  subject to it in  its  worst    Many believe, that strictures arise from
forms.   (Hunter.)                        the u*e of injections in the treatment  of
   Mr Home has measured  the  lengh of the gonorrhoea ; but, Mr.  Hunter thought,
the tireiliri in different subjects, and ex-  that this  opinion was founded on preju-
amined the diameters of the several parts   dice,  Mid he states,  that he had seen  as
of the pa.-sr<ge.  Strictures, accoreling to   many  strictures  after gonorrhoea^, wliich
this gentleman,  occur  most comm< nly  had   been  cured without  injections,  as
just behind the bulb of the urethra,  the   after those, which had been treated with
dist .nee from  the external orifice being  thee  latter applications.
6£, or 7  inches.   The situation, next in     Mr. Hunter also  disbelieved the idea,
the order of frequency, is about  4£ inches, that strictures are a  ceinsequence of nl-
from the or fice of thj glans.  The  dis-  cers in  ihe urethra; for,  ulcers  hardly
ease does  al-o occur at 3$ inches, and,  ever  occur in this  passage, except when
sometimes, almost close to the external   there  are strictures.  It is now generally
orifice.  The  two parts of the urethra,  admitted, that,  in  gonorrhoea,  no sores
most frequently affected with strictures,  exist  in the urethra.
are naturally the narrowest.  Sometimes
the very orifice of the urethra i- contract- theatmint or stiuctures, with  common
ed, and the circumstance of en  leads to      bougies, ox  the  fhi>cipx.e  of dila-
an erroneous supposition, that the  whole      tatiox.
ca^al  is naturally formed of the same
size.   The prepuce  also  is observed to     Mr. Hunter remarks, that the cure  of
be particularly  often  affected with  a   strictures  maybe, accomplidiee1, either by-
natural phymosis, in persons, who have   a dilatation of  the contracted part, or a
strictures in the urethra.                  destruction of it by  ulceration, or escha-
   In  .ilmost  all the  cases,  which  Mr.   rotics. The dilatation  is  accompli.->ed
Ho.oe has met with,  there has  been one  by means of bougies ; but, Mr. Hunter
stricture,  about seven inches  from  the   considered, that  a cure, thus effected, wis
external orifice, whether there  were  any   seldom or never more, than  temporary.
others, or not.                            The removal of the stricture by ulceration,
   With respect to the causes of strictures,  may also be done wiih  bougies;  its de-
some %v iters have imputed the disorder  struction with caustic used formerly to  be
to the effects of the venereal disease,  and   done through a cannula, contrived for the
often to  the method  of cure.   Mr. Hun-   purpose ; .but, is now performed by means
ter,  however, entertained  very  strong   of what are termed armed bougies.
doubts, whether strictures  commonly, or     The cure by  dilatation is  principally
even ever, proceeded from these c: uses ;  mechanical,  when  effected  by  bougies,
though he acknowledges, t)i2t -ince most  the powers of which  r.re generally those
men have had venereal  complaints, a  re-  of a  wedge.  However,  Sir. Hunter re-
futation of the above  opinion is  very  dif-  marks, that their  ultimate effect h not
ficult.  Mr. Hunter  was  led  to think,  always so simple as that of a wedge upon
that strictures did not commonly arise  inanimate  matter ;  for, pressure  makes 
VRETHRA.                              437
Wing parts either adapt  themselves  to
the.r new position, or else recede by ul-
ceration.  Bougies, of course,  either di-
late strictures, or make them ulcerate.
  The disease has generally made consi-
derable progress, before the patient seeks
surgical assistance, and the stricture may
be so advanced, that a small bougie can-
not be made to pass, without a great deal
of trouble.  If the e-id ofa small bougie,
let  it be ever so small, can  be introduced
through the stricture, the cure is then  in
our power.  However,  a  small  bougie
frequently cannot be passed in the first
instance,  and  even not  after  repeated
trials.
  Often, when the stricture is very consi-
derable, a great deal of  trouble  is given
by occisional spasms, which either resist
the introduction  of a bougie altogether,
or only  allow a very small one to pass.
At  other periods, however, a larger one
may  be introduced.  In   these  circum-
stances, Mr. Hunter mentions, that  he
was sometimes able to  get the point of a
bougie  to enter,  by rubbing the outside
of the perinaum with the finger of one
hand, while he pushed the bougie on with
tlie other.  The  same  eminent  practi-
tioner also often succeeded by. letting the
bougie  remain a  little while close to the
stricture, and then pushing it on.  Some-
times, the spasms may also be  taken off
by dipping the glans penis in cold water.
  Although, in cases of permanent stric-
tures, the  bougie may not pass at first,
yet, after repeateel  trials, it will every
now and then find its way.  In  this man-
ner, future attempts become more certain
anel easy.
  However, the success of the subsequent
trials, to introduce a bougie  does not  al-
ways depend on the instrument having
been once, or twice  passed.  Sometimes,
it can be introduced to-elay;  but, not to-
morrow"; and, in this state, the case shall
continue for weeks, notwithstanding every
trial we can m *ke.  Mr. Hunter observes,
however, that, in general, the  introduc-
tion of the bougie becomes gradually less
difficult,  and,  therefore, that  we ought
not to despair of success in any case.
  When the passage is very small, it  is
not easy to know,  whether the  bougie
has  entered  the stricture,  or  not:  for
bougies, so slender as  those, which must
be at first employed, bend  so very easily,
that the surgeon is apt to fancy, that they
are passing along the ure-lira, while they
are only  bending.  Mr. Hunter  advises
the su;-ge:in to make himself, at first, ac-
quainted with the situation of the stric-
ture, by me ms ofa common-sized bougie.
Then  he is  to  take a  smaller one, and
when its point arrives at the stricture, t{ie
instrument  is to be gently pushed for-
ward ;  but, only for a short time.   If the
bougie has passed further into the penis,
the surgeon may know how far it has en-
tered  the stricture by taking the pressure
off the bougie.  For, if it recoil, he may-
be sure, that it  has not passed; at least,
has not passed far ; but, only  bent.  On
the contrary, if it remain fixed, and do not
recoil, it has certainly entered the stricture.
  Mr Hunter informs  us, however, that
the preceding remarks  are not so appli-
cable,  when a very small bougie is em-
ployed, which may become bent, without
our be'.ng aware of the circumstance.
  A bougie may frequently be introduced
a very little way, for  instance,  only one-
tenth of an  inch, and then it bends and
cannot be pushed further.  To determine
whether this is the case, Mr. Hunter says,
it is necessary  to  withdraw the bougie
and  examine its  end.  If the  end be
blunted, we may be sure that the bougie
has not entered at all ;  but, if it  be flat-
tened, for an eighth, or  tenth, of an inch,
be grooved, or have its  outer waxen coat
pushed up to that extent;  or, if there be
a circular impressiem maele upon the bou-
gie, or only a dent on one side, made by
the stricture; we may  be  sure, that the
instrument has passed as far as  these ap-
pearances extend.  It then becomes ne-
cessary to introduce another of  exactly
the s.ime  size, and in the same manner,
and to let it remain as long as the patient
can bear  it, or  convenience will  allow.
By repetitions of this plan, the stricture
wili be overcome.
   Mr.  Hunter  remarks,  that  the time,
which each bougie ought to remain in the
passage, must be determined by the feel-
ings of the patient;  for, if possible, no
pain should ever be given.   If the patient
should experience very acute  pain when
the bougie is passing, it ought not to be
left in the urethra above five, or, al most,
ten minutes ; or, not  so long, if the  pain
be exceedingly  severe.  Each  time  of
application should  afterwards be length-
ened so gradually' as to be imperceptible
to the feelings of the patient, and  the ir-
ritability  of the parts.  Mr.  Hunter af-
firms,  that,  he has  known many patients,
who could not bear a bougie to remain  in
the passage ten, or even five minutes, till
after several days,  and  even weeks,  but,
who  in  time were able to wear the in-
strument  for hours, and this, at last, with-
out any  difficulty. The  best  time for
keeping a bougie in the urethra, is when
the patient  has least to do;  or,  in  the
morning, while he is in bed, if he can in-
troduce the instrument himself
   Mr.  Hunter  next  observes,  that the
bougie should  be  increased in size, ac- 
4SS
URETHRA.
   cording to the facility, with which the
   stricture becomes dilated,  and the ease,
   with, which the patient bears the dilata-
   tion.  If the  parts are very firm, or very
   irritable, the increase of the size of the
   bougie should be very slow, so as to allow
   them to become gradually adapted to the
   augmented size of the instrument.   But,
   if tlie sensibility of the  parts will allow,
   the increase ofthe size ofthe bougie may
   be  somewhat quicker,  but, never more
   sudden, than the patient can easily bear.
   The surgeon must continue to  increase
   the size of the  bougie, till one of the
   largest size can  freely pass ; nor shoulel
   the use of this be discontinued  till  after
   three weeks, or  a month, in order that
   the dilated part may have time to become
   habituated  to its new position, and lose
   its  disposition to contract  again.  How-
   ever,  Mr. Hunter believed,  that the per-
   manency of a dure, effected on the prin-
   ciple of dilatation, could seldom be de-
   pended upon.

      core or strictures by ulceration.

     This is also accomplished by means of a
   bougie, and the  plan may be tried  both
   when the instrument can,  or cannot,  be
   introduceel through the stricture.  In the
   first instance the method  is less proper;
   because the stricture admits of being di-
   lated.
     In order to cure a stricture by making
   it ulcerate,  the bougie is to be introduced
   as far  through the  contracted  part  as
   possible, and the size ofthe instrument is
   to be augmented, as fast as the sensations
   of the  patient can  well  bear.  In this
   manner,  ulceration  will be produced in
   the part,  which  is  pressed,  and, Mr.
   Hunter  remarks,  that  the  cure  will  be
   more lasting because more of the stricture
   is  destroyed, than when the  parts are
   simply dilated.    This  eminent  surgeon
   notices, however, that  few patients will
   submit to this practice,  and that few, in-
   deed, would be able to bear it, since it is
   apt to bring on  violent spasms in the
v  part, attended with a very troublesome
   retention of urine.
     If the smallest bougie cannot be  maele
   to pass a stricture, by using some degree
   of force, dilatatjon becomes impractica-
   ble ; and,  as the stricture must be de-
   stroyed,  something else must be  tried.
     In many cases, says Mr. Hunter, it may
   be proper to get rid of" the stricture by
   making it  ulcerate, or, in  other words,
   be  absorbed.  Bougies, intended to ex-
   cite ulceration, need not be so small, as
   in the foregoing cases,  as they are not de-
   signed tcrbe passed through the stricture;
 and, in consequence of being of the comv
 mon size,  they may be more surely ap-
 plied to the parts, causing the obstruction.
 The force, applied to a bougie, in this
 case, should not be great; for, a stricture
 is the  hardest part of the urethra ; anel
 if a bougie is forcibly pusheel on, its end
 may slip off the stricture, before ulcera-
 tion has commenced,' and make a false
 passage for itself in the corpus spongiosum
 urethrae.
   In trying to  cure strictures by ulcera-
 tion, the utmost attention must be paid;
 and, if the patient does not make water
 better, notwithstanding the bougie passes
 further, the surgeon may be sure, that he
 is forcing a false passage.
   When the stricture has so far yielded,
 as to allow a small bougie to be intro-
 duced, the treatment is then  to be con-
 ducted on the principle of dilatation.
   Mr.  Hunter observes, that whenever a
 bougie  of a tolerable size, passes with
 ease, and  the parts and the patient have
 become accustomed  to  it, the surgeon
 need no longer  attend for the purpose of
 introducing it.  The patient may now be
 allowed to introduce  bougies himself;
 and when he can do this with case, the
 business may be  trusted to him, as he
 can make use of  the  instruments at the
 most convenient times, so that they may
 be, more  frequently, and longer, applied.
 In the mean while, the surgeon should
 only pay occasional visits.   Mr.  Hunter
 adds, that, this practice of the patient,
 under the surgeon's eye, by which means,
 the former learns the art of introducing
 bougies,  is the  more  necessary,  since
 strictures  are diseases, which  commonly
 recur ; and, therefore, no man, who has
ever had a stricture, and is cured of it,
should rely on the cure as  lasting ;  but,
 should always be prepared for a return,
and always have some bougies by him.
 He should not  go a journey,  even of a
 week,  without  them; and  the number
should be  according to the time, which
 he is absent, and the place, to which he is
going; for, in many parts of the world,
he cannot be supplied with them.
  To prevent the inconvenience ofa bou-
 gie slipping out,  or  the^-mischief of its
 gliding into the  urethra, a soft cotton
 thread must be tied round the end of the
 bougie, which is out ofthe  urethra, and
 then round the root of the glans.  This
 last part  of the  thread shoulel be very
 loose.   The projecting  portion  of  the
 bougie should also be bent down upon the
 penis,  by  which means, it is rendered less
 troublesome, and more secure. (Hunter
 on the Venereal Disease.)  When a con-
 siderable part  of the bougie remains out 
URETHRA.
439
of the urethra, sutgeons usually clip a
piece of it off;

CURE OF STHIOTURES BI THE ARGEHTDM
               NITHATPM.

  Wiseman makes mention of tiie plan of
curing strictures in the urethra by means
of caustic.  He observes, that, when the
obstruction is a caruncle, and you cannot
pass it, you may well  conclude it is cal-
lous :  " in which  case, you  may pass a
cannula into the urethra to that caruncle,
and, whilst you hold it there steady, you
may convey a grain of caustic into the
cannula, and press the caustic to it; and,
whilst you hold it there, you will perceive
its  operation, by the pressing forward of
the cannula."  '                  .
  About the year 1752,  Mr. Hunter at-
tended  a chimney-sweeper,  who  had a
stricture.  Not finding, that any benefit
was derived  from  the use of common
bougies, for a space of six months, Mr.
Hunter,  unaware of the above passage in
Wiseman,  conceived,  that the stricture
might be destroyed by escharotics, and
the first  attempt,  which  he made, was
with red precipitate.   He put some salve
on the end of a bougie, and then dipped it
in red precipitate.  The bougie, in this
state, was  passed down to the stricture;
but, Mr. Hunter found, that it brought on
considerable inflammation  all along the
inside  of the passage,  as he  thought, in
consequence of the precipitate being rub-
bed off, while  the bougie was passing to
the  stricture.   Mr. Hunter then intro-
duced a silver cannula  down to the stric-
ture, and passed the bougie with preci-
pitate, as before, through the tube.  As
the patient, however, did not make water
any better, and the smallest bougie could
not be inteoduced through the stricture,
he suspected, that the precipitate had not
sufficient powerto elestroy the obstruction.
Mr. Hunter was, therefore,  induced to
fasten a  small piece of the argentum ni-
tratum on the end of a  piece of wire with
sealing-wax,  and introduced  tlie  Caustic
through  the  cannula  to ' the  stricture.
After having made  the application three
times,  at intervals of two days, he found,
that the man voided his urine much more
freely, and, on  applying the caustic  a
fourth time,  the cannula went through
the stricture.   A. bougie  was introduced
for  a little while afterwards, till the man
hail completely recovered.
  Iiaving experienced such  success in
the foregoing example, Mr. Hunter was
encouraged to apply his mind to  the in-
vention of some^pstrument, better suited
to the purpose, than the  above contriv-
ance.  He  succeeded in devising  an im-
proved instrument, although he acknow.
ledges,  that it was not perfectly adapted
to strictures in  every  situation  in the
urethra.  He remarks,  that the caustic
should be prevented from hurting the.un-
affected part ofthe urethra by introducing
the active substance.-through a cannula,
down to the stricture; and it should be
capable of protruding a  little beyond the
end  of  the  cannula, by which  means it
will  only act upon the stricture.   The
caustic  should be fixed in a small port-
crayon,  and it is necessary to have a piece
of silver of the  length of the cannula,
with a ring at one end,  and  a button at
the other, of the same  diameter  as the
cannula.  The  button  forms a kind of
plug, which should project beyond the
end of  the cannula in the urethra, so as
to make a rounded end; or, Mr. Hunter
says,  the portcrayon may be formed with
this button at its otiier end.  The cannula,
with the button,  is to be passed into tiie
urethra, and when it reaches the stricture,
the silver plug should be withdrawn, and
the portcrayon with the caustic introduced
in its place ; or,  if the plug and port-
crayon are on the same  instrument, then
it is only necessary to withdraw the plug,
and introduce the portcrayon with the
caustic.   The  plug,  besides   giving «
smooth  rounded end to  the  cannula, an-
swers another good purpose, by prevent-   \
ing the tube from being filled  with the
mucus of the urethra, when the  instru-
ment  is passing  inward, which  mucus
would be collected in the end of the can-
nula,  dissolve the caustic too soon, and
hineler its application to  the stricture.
  When the stricture  was  beyond the
straight part of the urethra, Mr. Hunter
owned, that it was difficult to apply caus-
tic to the disease through a cannula.
  A better mode of applying lunar caustic
to strictures, was afterwards devised by-
Hunter, artel has  since been extensively
introduced into practice by Mr.  Home.
This gentleman  directs  us to take a bou-
gie of a size, that can be readily passed
down to the stricture,  and to  insert a
small piece of lunar caustic  into the end
of it, letting the caustic  be even with the
surface, but surrounding every where la-
terally by the substance of the bougie.
This should be done some little  time be-
fore  it  is  required to be used ; for, the
materials, of which the bougie  is com-
posed, become warm  and soft by  being
handled in inserting the  caustic  ; and,
therefore,  the hold, which the bougie has
of the caustic, is rendered more  secure
after  the wax  has been allowed to cool
and harden.  The bougie thus prepared,
is  to  be oiled and made ready  for use;
but, before passing it, a  common bougie 
440                               URETHRA.
of the same size is to be introduced down
to the stricture, in order to clear the ca-
nal, and to meas'ire the exact distance of
the stricture from the orifice of the  ure-
thra.  This distance  being markeel upon
the armed bougie', it is to be passeel down
to the stricture, as soon as the other is
withdrawn.   The  caustic, in its passage,
is scarcely allowed to come into contact
with  any part of the membrane, because
the point of the bougie, of which  the ar-
gentum nitratum forms the central part,
always moves in the middle line of the
canal; and, indeed, the quickness,  with
which it is conveyed to the stricture, pre-
vents an  injury of the  membrane lining
the passage, when the caustic accidental-
ly touches it.
   In  this  mode  the caustic  is  passed
down with little, or no irritation  to the
lining of the urethra, it is applied in the
most advantageous manner  to  the stric-
ture, and can be retained in that situation
sufficiently long to produce the desired
effect.
   1'he reasons yrged in favour of the em-
ployment of bougies armed with the lunar
caustics, are : that a permanent cure is ef-
fected,  which common bougies  cannot ac-
complish ;  that the pain, arising from the
application of the  argentum  nitratum to
the stricture, is very inconsiderable ; and
that neither  pain,  nor  inflammation are
found to ensue.   The meaning of these
remarks, however, is to be received as a
general one, liable to exceptions.  Indeed,
Mr. Home himself has  candidly acknow-
ledged, that some inconveniences' occa-
sionally follow the use of  armed bougies.
But, what practice, however judicious and
eligible, is altogether free from  occasional
ill consequences t   Mr. Home  remarks,
that  against treating  strictures of  the
urethra with caustic bougies,  numerous
objections have been adduced,  and many
bad consequences  have been attributed to
the practice, without any real foundation ;
" for, whatever,  d priori, might be  sup-
posed the effects of so violent an applica-
tion,  to a membrane so sensible anel irri-
table, as the  urethra, and  1 will admit,
that  it is  very natural to conceive  they
would be very severe, the result of experi-
ence, tlie only thing to be relied on, evinces
the  contrary.  The pain  that  is brought
on, is by no means violent; and neither
irritation, nor inflammation, is found to
take place.
   " That cases do occur,  in which stric-
tures have  produced so much mischief,
and rendered so great  an extent of the
canal diseased, that the use ofthe caustic
has proved unsuccessful, is certainly true ;
and several  of  these cases  have fallen
within my own knowledge.  But, when
it is stated, that none, even of these, were
made worse by its use;  that  no bad con-
sequences attend it;  anel  that  no other
mode, at-present known, is equally effica-
cious ; any  occasional  want  of success,
cannot be considered as an objection to
this mode of practice.
  " But if the apprehension of violent ef- t
fects  from the caustic, however  ill-found-
ed, cannot be removed,  let the alternative
be considered ; namely, the only operation
previously in use, where a stricture cannot
be elilated by the bougie.
  " In those cases, we are obliged to have
recourse to means certainly more severe
and  violent, laying open with a knife the
diseased urethra, and passing through the
divided parts a flexible gum catheter into
the bladder.   This  1 have done -myself,
and  have frequently seen it performed by
Mr.  Hunter, and it  always  succeeded;
neither bringing on so much inflammation
as was expected, nor being attended  with
any symptoms of irritation.
  " This  practice has by other surgeons
been  carried still further; the portion of
diseased urethra  has been dissecteel out,
and entirely removed ;  nor has  so severe
an operation always brought on untoward
symptoms ; and patients have recovered.
  "If the membrane of the urethra when
diseased,  is capable of" suffering so much
injury, without any consequent symptoms
of irritation, it canne>t be doubted that it
will bear with impunity to be touched, in«
a very partial manner,  several different
times with lunar caustic."
  Mr. Home afterwards informs us,  that,
" having  met  with a  number  of  facts,
from  which  a  general  principle appears
to be established, that the irritable  state
of a  stricture is kept up, anel even in-
creased, by the use ofthe  beiugie, but les-
sened anel entirely destroyeel by the appli-
cation of lunar caustic ; I am desirous to
communicate my observations upon these
facts, and to recommenel  the use of the
caustic, in many cases of irritable-stric-
ture, in preference to the bougie.
  " As  the  use of the caustic,  upon this
principle  is, I believe, entirely new, and
is contrary to every  notion," that   had
been formed upon the subject, it will rei
quire something more, than  general as-
sertion, to gain even the attention of many
of my readers, still more  their belief; I
shall therefore detail the circumstances,
as they occurred, by which I conceive the
propriety of  this praclrc,  to  be   esta-
blisheel; and afterwards make  some ob-
servations upon the principle on which it
depends.
  *' My cemnexion  in  jftfactice with Mr.
Hunter, afforded  me opportunities of at-
tending to cases of stricture,  in all  their 
Crethra.
441
different stages;  many of them brought
on during a long residence in Inelia, at-
tended with great irritability, and exceed-
ingly difficult of cure.
  " One case of this  kind (which Mr.
Home has related) admitted the passing
of a  small bougie ; but, in the course of
three  years,  very little was gained by a
steady perseverance in the use of that in-
strument, either  in dilating the canal,  or
palliating the symptoms of stricture -, this
made  me look upon the bougie as less ef-
ficacious,  than  I had always been taught
to believe it.  I was willing, however,  to
consider this as an uncommon case, de-
pending more on the peculiarities of the
patient's constitution, than on the nature
of the disease : but, I found,  on a parti-
cular  enquiry,  that several other gentle-
men,  from  India, were under  circum-
stances  nearly  similar; the bougie only
preventing the increase of the stricture,
but being unable to dilate it beyond a
certain size;  and when it was  left off, the
stricture in less than two months returned
to its  former  state of contraction.
   M What plan ought  to be  followed in
such cases, I was then unable to deter-
mine ; but,  that  the bougie could not be
depended on was evident  During this
suspense, the following case came  under
my care.
   " hi August, 1794,  a  gentleman con-
sulted me for some symptoms, which had
been  considered  as  indicating the pre-
sence of gonorrhoea;  but,  as  they did
not  yield to  the common treatment in
the usual time, he was induced to take
my aelvice respecting  the  nature  of his
complaint.  In the necessary enquiry, to
obtain a perfect history ofthe case among
other tilings  it was stated, that,  nineteen
years before, there was a stricture,  which
became very troublesome, and  that Mr.
Hunter, by the desire of the patient, had
apphed the caustic, by which the stricture
was  removed,  and never afterwards re-
turned.  He said that he was one of the
first  persons on whom the caustic had
been  used.   From this  account,  I was
naturally led to believe that the stricture
had gradually  returned, and was now in-
creased  so much as to produce the pre-
sent symptoms ; a discharge being almost
always a symptom of stricture, when it is
much  contracted; but, upon examining
the canal, a bougie of full size, passed on
to the bladder without the smallest impe-
diment.  I therefore took up  the case as
an inflammation in the urethra; and large
doses of the balsam copaiva, given niter-
Dally, effected  a cure.
   "The  circumstance of a stricture hav-
ing been removed nineteen years before,
and not returning, made a strong lmprcs-
    Vol. 1L
sion on my mind ; and made me desirous
to ascertain,  whether this practice coulel
be  employed in cases of stricture in ge-
neral, and the cure produced by it, equally
permanent.   A short time afterwards, I
had an opportunity of trying it in the
following case.
  " A captain in  the East  India Com-
pany's service, in  September, 17S>4, ap-
plied  to  me for  assistance.  His  com-
plaints were, great irritation in the urethra
and blaelder, constant clesire to make wa-
ter, and an inability to void it, except in
very small quantities.   These symptoms
had been  at  first supposed to arise from
gonorrhoea, afterwards rendered  more se-
vere by catching cold; but, not  yieleling
to  the  usual  remedies for  gonorrhoea,
they  were investigated more minutely,
and a stricture was discovered in the
urethra.  The mode of treatment was now
changed, and the bougie employed; but,
its use aggravated all the symptoms, and
brought on so great a degree  of irritabili-
ty in  the bladder and urethra, that  there
was an alarm for the patient's  life, which
was the reason for applying for my assist*
ance.
  " Besides the local symptoms,  this pa-
tient  had  those of  quick pulse, white
tongue, hot and dry skin, loss of appetite,
a total want of sleep, with frequent at-
tacks of spasm on  tiie bladder and ure-
thra.  A very small flexible gum catheter
was passed, and the  water drawn off", in
quantity  about a pint, which gave  him
^reat relief;  this was repeated  morning
and evening, to keep the bladder in as easy
a state as possible ; but, in other respects,
he continued much the same. v
  " As  the   present   symptoms  were
brought on by the  use of the  bougie,
little  good was to be expected from that
instrument; and where the urethra had
been so easily irritated,  and was disposed
to  continue in that state,  there  was no
prospect of the use of a bougie afterwards
effecting a cure.  These circumstances I
explained  to  the patient; and mentioned,
in proof of my opinion, the case, in which
so little had been effected in three years.
  " I then proposed to him  a trial of
the caustic, with a  view  to  deaden the
edge of the stricture,  as the only proba-
ble means of effecting a cure.   The de-
gree of irritation was already great; I was,
however,  led to believe, that the appli-
cation of the caustic was not likely to in-
crease it;  since, by destroying the irrita-
ble part,  it  might lessen,  and  even re-
move the  spasmodic affection; but, ifj
contrary to my expectation, the irritation
continued, we still should be able to draw
off the water, as the slough formed by
the caustic would prevent the edge of th<;
    a K 
442                              URETHRA.
stricture  from  acting,  and obstructing
the insrument.
   " The application of the caustic was,
upon these grounds, determined on ; and
it was applied in the following manner.
   "  I passed  a  common bougie, nearly
the size of the canal,  down to the stric-
ture, to ascertain its exact situation, and
to make tie canal of the urethra as open
as possible.  The  distance  was then
marked upon a bougie  armed  with caus-
tic of the same size, which was conveyed
down as quickly  as  the nature  of the
operation  would admit.  It was retained
upon the stricture,  with  a slight degree
of pressure; at first,  there was no  pain
from the caustic, but  a  soreness from
pressure ; in less than  a minute, a change
was felt in  the  sensation of the part, it
was at  first  a  heat,  succeeded by  tiie
burning pain peculiar to caustic ; as soon
as this  was  distinctly felt, the  bougie
and  caustic were  withdrawn, having re-
mained in the urethra  about a minute al-
together.   The  soreness,  he satd, was
unaccompanieel • by irritation  along  the
canal, and he thought the uneasiness in
the  bladder diminished by  it.   He  de-
scribed the pain as resembling very ex-
actly the first symptoms of gonorrhoea.
This sensation  lasted half an hour after
withdrawing the bougie.
   "  The caustic was applied about one
o'clock in the forenoon,  and  he  passed
the  d»y  more  free from irritation  than
he had  been  since the beginning of the
attack,  which had  lasted six days.   In
the  evening,  the  water was  drawn off,
with more  ease than  the  night  before.
He passed  a tolerable  night,  and  the
next day, -continued  free from irrita-
tion. On the third  day, the c.uMic was
again applied in  the forenoon ;  the painful
sensation  was less than  on  the  former
application, lasted a shorter  time, and
in an hour after the armed bougie was
withdrawn, he made water freely for the
first time since the commencement of his
indisposition.   He said  the irritation in
the  bladder, was  removed, and he felt
very well. His appetite returned, he sfe.pt
ve ry well, and continued to void his urine
wi'h ease.
   "  In  this state nothing was  done till
the  fifth day, leaving always a elay  be-
tween the applications  ofthe caustic.
   " On  this day a common  sized bongie
wen  readily  into the  bladder;  it was
immediately  withdrawn, and the cure
was  considered  as complete;  no bougie
was  afterwards  passed,  lest  it  might
bring back  an irritation  upon  the  pas-
sage.   I  met  this gentleman  twelve
months  after, and he assured  me,  he
had continued perfectly well, and 1 havf
since  learned, that,  in three years, there
has been no return.
  " From the result of this case, I was
encouraged to  hope  that the  caustic
might  be applied   to  strictures in the
urethra  with  more  confidence, than I
had hitherto  believed, since it evidently
did not bring on, or increase the general
irritation, but, on the contrary seemed to
allay it."
  The foregoing case, together with ano-
ther-one, which Mr.  Home  has related
in his book on  the  present subject, con-
vinced this gentleman,  that he  had dis-
covered an  effectual mode of  treating
such strictures,  as do not admit of being
relieved by the common bougie.  Tlence,
he adopted the use  of armed bougies, as
a general practice :  but, he has  not con-
cealed  the circumstances, under  wliich
the  method  has not proved successful.
Mr.  Home informs  us,  that  " In some
constitutions, where  the  patients have
resided long  in warm climates, every time
the caustic is applied to a stricture, a re-
gular paroxysm of fever, called  by the
patient an ague, takes  place ;  and this
has been so  violent as to render  it im-
possible to pursue this mode of practice.
Of this  I have met with two instances.  I
consider this disposition to fever, as the
effect of climate, anil not of" any natural
peculiarity of constitution ; for the bro-
ther of one of these  patients  laboured
under the same disease, but  as he had
not  been in warm climates, it was  re-
moved by the can tic without his experi-
encing such attacks.
  In  gouty constitutions, attacks of the
gout  have in two instances brought on
spasmodic constrictions,  after  the stric-
ture had been removeel by caustic.  This,
however, cannot be  called a failure of the
caustic.   It only shews, that gout can af-
fect strictures,  and reproduce them.
  "In some  patients,  the strictures are
so obdurate that the use of the caustic is
necessary to be  continued for  a longer
time, than the  parts can bear its applica-
tion, or tven that of the bougie passing
along  the urethra ; irritation therefore
comes on and  stops the progress of the
cure, and whpn the  same means are re.
sorted to again, the  same thing  takes
place.   The cases of f ilure of this kind
that  I have met wi'h, some of which may
yet ultimately  be cured,  if the patients
will take the  necessary steps for that pur-
pose, amount in all to six.
  " In some patients,  the stricture is rea-
dily removed by the caustic, but, in a few
weeks,  contracts  again.  The stricture
being wholly  spasmodic, the caustic, by 
URETHRA.
443'
taking off the spasm, is allowed to pass
through, and cannot  completely destroy
the stricture.  Of this kind,  1  have met
with one instance, which I must consider
as a failure, as  I have  hitherto been un-
able to get the better  of it.
  " In those cases, where the caustic gra-
dually removes the stricture, and brings
the urethra to a  size,  that allows the pa-
tient  to  make  water perfectly  well,  if
there is any return, it is not to be attri-
buted to the failure of the caustic, but to
the want  of proper management, either
from the caustic being too  small, or its
use left off too soon ;  but,  all such cases
are, I believe, within the power of being
cured by the caustic, if its use is recurred
to when that is found necessary."
  For the generality of strictures  in  the
urethra, which certainly  do not occupy
more extent of the canal,  than  if caused
by a piece of packthread being tied round
it, the bougies, armed with the  lunar
caustic, should be preferred.  But, there
are instances, in which the urethrals di-
minished in  diameter, for  an inch or
more : in these cases, I cannot help con-
sidering the employment of common bou-
gies most  advantageous,  that  is  to say,
when they can be introduced through the
stricture, so as to cure it on tiie principle
of dilatation.
   We shall conclude this part of the sub-
ject of strictures,  with inserting some of
the general  directions given by Mr. Home
how* to arm the  bougie, and apply the lu-
nar caustic to strictures.
   In arming a bougie, it will be difficult
to get a piece of caustic of a proper shape
and size for the purpose, unless it be cast
in a small cylindrical mould.  " In  this
state (says Mr. Home) it is to be procured
from Mr. Savigny, instrument-maker, in
King street, Covent-Garden;  and, if these
pieces are  thicker, than the bouge can
readily encl se, by putting them in water,
flie outside quickly dissolves, so as to di-
minish their size,  as much as is required.
The  piece of caustic, so  prepared, is to
be cut into  small portions, about a quar-
ter of an  inch  in length, and  an orifice
bemg made  in the end of a bougie, the
ea i ;tic is to be inserted into it, and  the
bougie rolled, so as to be made perfectly
smooth, taking care, that tlie sides of the
caustic are every where covered, and only
the end exposed.
   " This (continues Mr. Hom<-)  was the
mode, in which I armed bougies, when I
first took up this practice'; but, it happen-
ed, that, hi two. or three instances, the
caustic was  left in the urethra ; that ca-
nal, when in a very irritable state, grasped
the bougie,  and pulled the caustic out; I
was therefore led to consider how such an
accident might be prevented, and applied
to tHfe makers of bougies for that purpose.
Mr. Pass, the late beadle of the Surgeons'
Company, who dealt in bougies, disco-
vered a very ingenious and effectual mode
of securing the caustic.  In  forming the
bougie, a piece of wire, the size of the
caustic, is rolled up along with it, passing
into the substance for half an inch ; when
the bougie is nearly finished, the wire is
withdrawn, and the caustic inserted in its
place ; after this, the  bougie is rolled
again, so that the sides of the caustic be-
come firmly cemented  to  the linen, by
means of the composition  of the bougie,
and when cold,  cannot be separated by
any force.  In this way bougies are now
generally armed.
  " After the bougie has  been thus pre-
pared, the distance of the stricture from
the external orifice is to  be measured, and
the canal cleared by  passing a common
bougie, fully  as large  as that which  is
armed.   The armed bougie, with the dis-
tance marked upon it, is then to be intro-
duced, and applied to the stricture ; when
it is brought in contact with the obstruc-
tion , it is to be  steadily  retained there,
with  a moderate degree  of pressure  at
first,  and less as it is  longer continued,
since the bougie becomes soft by remain-
ing in the urethra, and readily bends, if
the pressure is too great.   The time it is
to remain depenels a  good deal upon the
sensations of the  patient,  and the le.gth
oftime the parts have been diseased ; but
on the first  trial, it  should be less than a
minute, as it then commonly gives greater
pain than on  any subsequent  upplication.
The pain produced by the caustic is not
felt  so  immediately as it would be natu-
ral to expect; the first sensation arises
from  the pressure of the bougie on the
stricture ; a little after, there is the feel-
ing of heat in the parts ; and  lastly,  hat
of pain.
   "  As soon as the caustic begins to act,
the surgeon,  who makes the application,
is  made  sensible of it  by the smaller ar-
teries of the pxrts beating with unusual
violence, which is very distinctly felt by
the  finger and thumb,  that grasp the
penis.
  "  The pain that is brought on  by the
caustic,  lasts for some time  after it  is
withdrawn ;  but this period  differs in al-
most every  patient, being sometimes ex-
tended to half an hour,  and sometimes
only a few minutes.
   " The kind of pain  is heat  and sore-
ness, which  is not severe, not  being ac-
companied by the peculiar irritation, upon
so many occasions experienced by patients
who  have strictures ; an irritation  that
cannot be described, which is most insup- 
 4<U                              VRET

portable, and is too often brought  on by
dilating strictures with the bougie.  After
the caustic has been withdrawn, it  is de-
sirable, that the patient  should make  wa-
ter before  he uses  exercise, as the p-irts
are commonly more tranquil after having
done so;  but  sometimes  no water  will
flow at the first effort.  When that is the
case, it should not be urged, as it is not
of any material consequence.   It happens
not unfrequently, that at the first time of
making Water, sWne blood passes  along
With  it.   This is  rather favourable; as,
when the  parts bleed, the stricture usu-
ally proves to be so far destroyed, that at
the next trial the bougie passes  through
it.  Every other  day, appears in general
to be as often as it  is prudent to apply the
caustic.  I have,  however, done  it every
day, in very obstinate  cases,  where the
parts are  less sensible,  without any detri-
ment.
   " The bougie,  which is passed down to
prepare the way for the caustic, and mea-
sure the distance  for the armed bougie,
must be  made of  soft  materials, that  it
may readily receive an  impression  from
the  part against  which  it  is  pressed,
and its colour shoulel  be light, so as to
 admit of those impressions being more dis-
 tinctly seen.  With the assistance of" such
 bougies, I am able to discover the size and
 shape of the  orifice of the stricture; to
 ascertain with accuracy  the  progress  of
 the caustic upon it; to see whether it is
 on one side of the canal, or equally all
 round; and to apply the caustic accord-
 ingly.
   " Wien the soft bougie passes through
 the stricture,  by leaving it in the canal a
 few minutes, it can be known whether the
 stricture is completely destroyed or only
 relaxed ; in tlie  last case, there is  an im-
 pression on the side of  the bougie.
   " So necessary is the  information, which
 is acquired in this way,  to  enable the
 surgeon to prosecute the cure of stricture
 by means of the caustic, that without it I
 should have  been unable to pursue this
 mode of practice.  I should have wanted
 a sufficient degree of confidence to carry
 me on, which nothing but  an  accurate
 knowledge  of  what had  been already'
 done, could have  given, and, in no other
 way,  is that to  be acquired."  (Home on
 Strictures.)

 cuiie or  sTHicTcnts  by  the kali  PO-
                   RCH.

    Mr. Whately,  in his publication  on
 strictures, has endeavoured to shew, that
 they are not merely contracted  fibres of
 fhe urethra,  but really diseased portions
of the membrane lining  that canal, with
a continueel disposition to  increased con-
traction.  Hence,  this gentleman  seems
to conceive,  that the application of a re-
medy, calculated both to remove the dis-
eased affection, and to dilate the contract-
ed part, might  perfectly cure the com-
plaint, without putting the patient to tha
inconvenience of wearing a bougie.  Mr.
Whately affirms, that such a  remedy is
caustic, when judiciously used.  Hitherto
the  lunar  caustic has been chiefly  em-
ployed; but, this  gentleman states, that
it has been his good fortune to discover a
more efficacious, and at the same time,  a
less painful and hazardous remedy for the
disease in question.  The kali purum is
the application  alluded to, which  Mr.
Whately says, if used in the manner,  and
with the precautions about to be describ-
ed, will be found to possess singular effi-
cacy in curing the complaint.   He avows,  '
that he has already had so much experi-
ence of it, and that he is  so  perfectly con-
vinced of its superiority over  the lunar
caustic, as well as over the common bou-
gie, that he now uses it  in a considerable
number of the cases, which come under
his care.  Of its safety he  is also as well
convinced, as of its efficacy ; for, if used
with  circumspection, experience  shews,
that there is  little elanger of its producing
any disagreeable effect.
  However,  if the kali purum  be applied
while the parts  are in a highly inflamed,
or irritable state,  or  (Mr. Whately adds)
teneling to gangrene ; if the h:<bit be bad,
and  the  patient  very  far  advanced in
y ears; we may expect the most mischiev-
ous effects from the application ;  and this
practitioner censures  the use of any kind
of caustic under such circumstances, for
strictures in  the urethra, as dangerous in
tlie extreme.
   Mr. Whately represents, that if the pa-
tient be affected with fever, or any other
acute disease ; if he be  much  indisposed
from any cause ; if, in particular, he have
a gonorrhoea, attended with much inflam-
mation and  irritation in the  urethra;  if
the  prepuce, glans, or any other part of
the penis,  or the parts adjoining to it, be
swelled and  inflamed; if the urethra, and
especially, the strictured part of it, be so
irritable, as  not to bear the touch of a
bougie ; the use of the  caustic is for the
present forbidden.  Mr. Whately also en-
joins great  caution in applying this re-
medy to persons advanced in years. Even
when no objections of the above kind ex-
ist,  the caustic  should not be resorted to
in the first instance.   Mr. Whately main-
tains, that in every case  of stricture, be-
fore venturing to employ the caustic, we
ought to be able to pass" into thebladder 
IJRBTHRA.
445
a bougie, of at least a size  larger, than
wne of the finest sort.  This  is necessary,
both to enable us to apply the caustic to
the whole surface of the stricture,  and to
relieve a retention of urine,  should it oc-
cur during the use of the caustic.
   When a bougie  of the preceding  de-
scription can  be introduced, without oc-
casioning pain,  faintness,  or great dejec-
tion of spirits, the use of caustic may com-
mence immediately, when  none of  tiie
above described objections exist.
   When the urethra is very iiritable, Mr.
Whately recommends a common bougie to
be introduced every day,  and kept in the
urethra;  at first, for a few minutes only ;
but, by degrees, for a longer time; till the
irritability of the  parts has  been suffi-
 ciently lessened.
   When  tiie urethra is rendered  so  im-
 pervious by a stricture, that a small bou-
 gie cannot be  passeel  into  the bladder,
 which viscus is also in  a painful inflamed
 state, Mr. Whately asserts, that caustic,
 in any form, or quantity, must not be im-
 mediately employed; but, that the stric-
 ture  should be first rendered capable of
 allowing  a bougie a  little larger,  than
 one  of the  finest  size, to be introduced
 into the bladder.  When this is done, the
 urine is more freely evacuated,  and the
 consequent irritation  and  inflammation
 of the bladder lessened,  if not removed,
 together  with the danger of a retention of
  urine.  Caustic may then be  advantage-
  ously conveyed into the centre of the
  stricture.
    Mr. Whately considers the practice  of
  at once thrusting down, in this  sort  of
  case, an armed bougie, considerably larger
  than the narrowest part of the contracted
  canal,  as most dangerous,  and horridly
  painful.  For, says  this gentleman,  it
  frequently happens, that  nearly-the whole
  of the urethra anterior to the bulb,  is  so
  much contracted  by  numerous  and un-
  commonly rigid strictures, that,  it is im-
  possible, by  any  art  whatever,  to  dilate
  the passage to its natural size.  If, there-
  fore, the canal, whilst, in such a state, be
  rudely torn open by a large  caustic bou-
  gie, hemorrhage, pain,  dangerous  sup-
  pressions of urine, inflammation, mortifi-
  cation,  and death itself, must sometimes
  inevitably ensue,—even before the caustic
  can be applied to the principal seat ofthe
  disease.  In cases, like the one just men-
   tioned, the first  step, preparatory to the
   use of  the  caustic, should be, according
   to  Mr Whately, to dilate the strictured
   Dart of the urethra; for  which purpose,
   he  advises the slow and gentle introduc-
   tion of a fine, bougie,  with  its  point in-
   clined to the lower  side of the canal, in
   order to avoid the large lacuna, situated
on its  upper part.  When the  surgeon,
by steady perseverance and dexterity, has
succeeded in getting a fine bougie through
the worst stricture into the bladder, the
instrument  should be worn, for  a  few
hours, every day, till the passage is suffi-
ciently dilated to admit a larger one.
  Mr. Whately, after explaining, that the
kali purum ought not to be  applied  to
strictures of the  urethra, till a  bougie
of a proper size can be passed into the
bladder;  after  having pointed out the
methods to be taken, before applying this
caustic; anel  enumerated certain cases
and circumstances,  in wliich its employ.
ment  is interdicted;  next proceeds  to
describe the mode of practice, which it is
the particular  object  of his book to  re-
commend.
   For the purpose  of arming a  bougie,
 Mr. Whately  advises US' to put a small
 quantity of kali purum upon a piece of
 strong paper, and  to break the bit of caus-.
 tic  with a hammer into small  pieces of
 about the size of large  and  small  pins'
 heads.  In doing this,  care should  be
 taken not  to reduce it to powder. Thus
 broken, it should be kept for use in a
 phial, closed with a ground stopper. The
 bougie  should have a proper degree of
 curvature given to it, by drawing it seve-
 ral times between the  finger and thumb
 of the left hand.
    Mr.  Whately  next acquaints us,  that
 before  the caustic is inserted into  the
 bougie, it is  necessary  to ascertain  the
 exact distance  of the  stricture,   (to
 which the caustic is to be applied) from
 the extremity of  the penis.   For   this
 purpose,  the  bougie, which  should be
 just  large enough to enter the stricture
 with  some degree of tightness, ought
 to be gently introduced into the urethra ;
 and when its point stops at the stricture,
 which it almost always does, before it  w 11
 enter it, a notch is to "be made with the fin-
  ger-nail, on the upper or curved portion of
  the bougie, on the outside of the urethra,
  exactly half an inch from the extremity of
  the  penis. When the  bougie  is with-
  drawn, a small hole, about the sixteenth
  part of an inch deep, should be made at
  the  extremity of its rounded  end. A
  large blanket-pin  two  inches  and a  hdf
  in length, with  the  head  struk  off,  will
  answer the purpose; the hole being made
  with the point of the pin.  The extremity
  of the bougie should then be made per-
  fectly smooth with the finger and thumb,
  tak.iig care,  that, in doing this, the hole
   in its centre  be  not closed.  Some of the
   broken caustic  should then be  put  on  a
   piece of writing paper, and a piece less in
   size, than the smallest pins' head, should
   be selected; the particle,  indeed,  says 
446
URETHRA.
 Mr. Whately, cannot be too small for the
 first  application.   Let this  be  inserted
 into the hole of the bougie with a pocket-
 knife, spatula, or some such instrument;
 and pushed down into it with the blunt
 end of the pin, so as to make the caustic
 sink a very little below the margin of the
 hole.  To prevent the kali from coming
 out, the hole should then be  contracted a
 little with the finger,  and the remaining
 vacancy in it is  to be filled with hog's
 lard. This last substance, (continues Mr.
 Whately)  will prevent the caustic from
 acting on the sound part of  the  urethra,
 as  the bougie  passes to the stricture.
 When the bougie is quite prepared, let it
 be  first oiled, and immediately afterwards
 introduced, hy a very gentle motion, with
 the curvature upwards, as far as the  an-
 terior part of the stricture,  upon which
 the caustic  is to be  applied.  In doing
 this,  the end of the bougie,  that is held
 by  the finger and' thumb, should be a
 good deal inclined towards the abdomen,
 on the first introduction ofthe instrument,
 in order to preserve its curvature. After
 it has passed about five inches, this end
 should be gradually brought  downwards,
 as the bougie passes on, till it forms a
 right angle with  the body.   The bougie
 is known to have arrived at the stricture
 by the resistance  made to  its progress.
  As soon as the bougie has  reached the
 anterior  part of  the stricture, it should
 rest there for a few seconds, that the caus-
 tic  may begin to dissolve.  It  should then
 be  pushed  very  gently forward, about
 one-eighth of an inch ;  after which, there
 should be another pause, for a second, or
 two.  The  bougie should then be  carried
 forward in the same gentle manner, till it
 has got through the stricture.  The sense
 of feeling will generally inform the oper-
 ator when the  point of the  bougie has
 proceeded so far; but, the notch in the
 bougie is to be an additional guide,  by
 becoming very near the orifice ofthe ure-
 thra, when the end of the instrument has
just got through the stricture.
  The bougie should now  be immediately
withdrawn hy a very gentle motion to the
part, at  which  it was first nvde  to rest
awhile.   Then it should be  very slowly
passed through  the stricture a  second
time; but;, without letting the bougie stop
in its passage.   If the patient complain
of pain, or be faint, the bougie should be
immediately withdrawn ; but, if these ef-
fects are not produced, we  may repeat
the  operation of passing and withdrawing
the  bougie through the stricture once or
twice more, before we finish the operation,
which  will take up, in the whole, about
two minutes.
  The first application  of the kali  purum,
 in  this manner, gives, according to fav.
 Whately's account,  a  very  little  pain.
 A  slight  scalding in making water, and
 a trifling discharge, during the first day
 or  two, however, are commonly produced.
   At the end of seven days, the applica-
 tion of the caustic is to be repeated in the
 same manner.  When the first application
 has enlarged the aperture ofthe stricture,
 which may be known by passing a bougie
 through  it, of the same size as that %y
 which the caustic was conveyed, the bou-
 gie used  in the second  operation,  should
 be  a size larger, than the one, used in the
 first; but it must not be too large to pass
 through the stricture.  It the patient had
 no  pain on the first application,  the bit of
 kali purum may also be trivially larger.
 At the end of seven days more, the armed
 bougie should be introduced a third time.
 At this, and all  future applications, the
 bougie should   be   increased  in  size,
 in  proportion  as the  aperture  in the
 stricture becomes dilated.  The quantity
 of  caustic, however,  is  never  to  be in-
 creased in a ratio to the size of the  bou-
 gie.  In  no  cases  whatever does  Mr.
 Whately apply more of the kali purum at
 a time, than  a piece about the  -.ize of a
 common pin's head.   Twelve  bits of the
 largest size,  which this gentleman  ever
 uses, weigh one grain.
  When there are several strictures, the
 kali purum should be generally applied to
 only one at a time.
  An interval of seven days is what Mr.
 Whately generally allows  to  elapse be-
 tween the applications ofthe caustic. The
 rule, however,  may now and then be de-
 viated from ; but, the kali purum ought
 never to  be re-applied,  till the action of
 the last application has completely ceased.
 In a few instances, the interval may only
 be five days ; in some others, it may be
 eight, nine, or even a longer space.
  In the above method of using the kali
 purum, Mr. Whately represents, that this
 substance is  equally diffused over every
 part of the strictured surface,  and  only
 abrades the  membrane of the stricture,
 without producing a slough.  The  degree
 of this abrasion, he says,  may be increas-
 ed,  or lessened, as circumstances dictate,
 by paying attention to tiie quantity of the
 caustic.
  The foregoing  account will suffice for
conveying  an  adequate   idea  of  Mr.
 Whately's method.  1 am sorry I cannot
 add my favourable opnfon ofthe practice.
 To  abrade, without destroying, is to me
 perfectly unintelligible.   Nor can I con-
 ceive, that a liquid caustic (for so it is re-
presented as  becoming)  can be applied
 with the accuracy to strictures, which Mr.
 Whately seems to suppose happens.  The 
               URE

generality of strictures are also like such
mere contractions, which one may sup
pose would be produced by tying a piece
of packthread round the  urethra.   For
these,  the lunar  caustic  bougies  seem
best; and, when  the  stricture  occupies
some extent  ofthe passage, common bou-
gies are the most eligible.
   The works, which contain the chief in-
formation on he subject, which we have
just been treating of, are:  A Treatise on
the Venereal Disease, by John Hunter  Prac-
tical Observations on the Treatment of Stric-
tures in tlie Urethra and  Oesophagus, by
Everard Home, in  2 vols. An improved Me-
thod of treating Strictures  in the Urethra,
by ThomasJVhately, Edit. 2, 1806.
   URETHRA, FALSE  PASSAGE  IN.
One of the  worst consequences of using
catheters,  and bougies,  in an improper
manner, is the rupture of the urethra, or
the formation ofa false passage by ulcera-
tion.  With  bougies, this accident  is ge-
nerally occasioneel by trials to excite ul-
 ceration by the application of the  end of
 the bougie to the stricture, when this in-
 strument cannot  be  passed  through it.
 When once  the new passage has formed,,
 Whenever  the bougie  is  introduced,  it
 cannot be hindered from going  into the
 false track, and its action on the stricture
 i$ altogether frustrated.
   Mr. Hunter has advised the following
 operation to be practised in this kind of
 case.   Pass  a staff,  or any such  instru-
 ment into the urethra,  as far as it will go,
 which will probably be to the bottom of
 the new passage, and this, we may be
 certain, is beyond the stricture.  Feel for
 t(ie end of the instrument externally, and
 cut upon it, making  the wound about an
 inch long, if  the disease be  before the
 scrotum;  and an  inch and a half, or more,
 if in the perineum. If the new passage be
 between the urethra and body of the pe-
 nis, you will  most probably get into the
 sound urethra, before you come to the in-
 strument, or new passage.   If so, intro-
 duce a probe into the urethra, through
 the wound, and pass it towards the  glans
 penis, or,  in  other  words, towards the
 stricture.  When it  meets with  an ob-
 struction, this must be the stricture, which
 is  now  to  be got  through, and  afier-
 wards dilated.   To complete the opera-
 tion, withdraw the  p' obe, and, instead of
 it, introduce a  hollow cannula forwards
 to the stricture.  Then introduce another
 cannula from the glans downward, till the
 two tubes are opposite each other, having
 the stricture between them.  An assistant
 is now to take hold of the urethra on the
 outside, with his finger and thumb, jusi
 where the two cannulas meet, in order to
 keep them  in their places.  Through the
                URI              447

upper cannula next introduce  a piercing
instrument, which  is  to perforate the
stricture, and  enter the  lower cannula.
The piercing instrument is now to be
withdrawn, and  a  bougie  introduced
through  the first cannula and stricture,
into the second cannula.  The tubes are
to be withdrawn, and the end of the bou-
gie, in the wound, directed into tlie blad-
der, through the further portion ofthe ure-
thra.  It may also be necessary to lay the
whole of the false passage open, in order
to make it heal; for otherwise, it might
still obstruct the future passage of bou-
gies into the proper canal.
   When the new passage is between the
skin and urethra, the surgeon must ex-
tend his incision more deeply, for the
purpose  of finding out the natural pas-
sage.  Then he  is to proceed  as above
explained.
   The longer the first bougie is allowed
to  remain in the canal, the more readily
will the second pass.  The bougies must
be gradually increased in size, and used
till  the  wound is healed.  The only im-
provement,  which  seems proper to  be
made  in this plan,  is to employ hollow
bougies, or flex.ble gum catheter, which
might be worn longer than common bou-
gies, as the patient could void his urine
through them.  (See Hunter on the Vene-
fpn} Y)lS€{l&€i l
   URINARY  ABSCESSES.  Extravasa-
tions of urine may be in three different
states.   This may be collected in a parti-
cular  pouch; it  may  be  widely diffused
 in  the  cellular membrane; or, lastly, it
 may present itself in a purulent form,  af-
ter having excited inflammation and sup-
puration in the parts, where it is situated.
 This case is termed by the French writers
an urinary abscess.
   Such  extravasations of urine  always
 imply a rupture  in some of the excretory
 passages for this fluid, either  in  tiie kid-
 nies, or  ureters, the bladder,  or the ure-
 thra.  Ti.is solution of continuity may be
 produced by a variety  of causes,  "ft is
 most  frequently the  effect of a forcible
 distention  of  these passages,  in conse-
 quence  of a retention of urine.  Phleg-
 monous abscesses, formed in the thickness
 of the parietes of these passages, or along
 their course, may also occasion this rup-
 ture,  by bursting internally.  The solu-
 tion of continuity may also be produced
 by a sword, or another foreign  body that
 lias penetrated the parts.  There are like-
 wise  examples  of effusions of urine  de-
 pending up.in the displacement of  the
 cannula of the trocar, after the operation
 of puncturing the bladder.  Several have
 been noticed,  (and, indeed, they are very
 fiequent) caused by false passages in  the 
448                         Urinary abscesses'.
 urethra;  and we have cases of  similar
 effusions,  following violent contusions of
 the perineum,  attended  with laceration
 of tlie urethra.
   It is fun her observed, in Les QSuvres
 Chirurgicales  de  Desault  par  Bichat,
 Tom. 3, that the ravages, which the urine
 makes, when out of its natural receptacles,
 are usually greater, and more extensive,
 when this  fluid is extravasated in the cel-
 lular  membrane, than  when it is  effused
 into a particular pouch.  The mischief is
 also  less,  when the excretory passage is
 free, than when it is closed by any obsta-
 cle, as in  cases of retention.  The more
 or less loose texture ofthe parts, in wliich
 such effusions' happen, likewise makes a
 considerable difference  in their progress
 and formation.   With regard to the place,
 which they occupy, it is ordinarily deter-
 mined by the situation of the rupture, by
 which the  urine has escaped.   When the
 pelvis, or infundibulum of  the kidney, or
 the upper part ofthe ureter, gives way, the
 urine is commonly effused in  the loins
 and the fossae iliacae,  between the perito-
 neum and  the adjacent parts.  When the
 lower part of the ureter, or the bladder,
 near its lower portion, gives way, the ex-
 travasatioh is generally included  within
 tiv pelvis.
   But, when the rupture occurs  in  the
 anterior parietes of the bladder, near its
 upper part, and, especially, when it takes
 place at a time, when this organ is  ex-
 tremely distended and dilated, the urine
 becomes effused behind and above  the
 pubes, sometimes ascends to the epigas-
 tric region, between  the peritoneum and
 the abdominal muscles,  and,  after having
 followed the course of the spermatic ves-
 sels,  it often makes its exit at the ring,
 and is extravasated in the  groins and
 scrotum.   If the rupture has happened in
 the urethra, the  most common situation
 of tlie effusion is  in  the  perineum and
 scrotum.   The  extravasation  frequently
 extends to the penis and upper part of the
 thighs, and even sometimes propagates it-
 self, under the  skin of the abdomen, up
 to  the hypochondria and sieles of the
 chest.  Such is the ordinary course of the
 urine, when extravasated out of the parts,
 which are destined to contain it; but, the
 slightest circumstance may  alter this
 course,' and produce  sinuses  in several
 other parts of the body.
   In the animal economy, there is no fluid,
the extravasation of wliich  is so fatal, as
 that of the urine.  If  it is not promptly
discharged, it soop excites a  putrid sup-
puration iu  the cellular membrane,  which
contains it, makes this ptrt slough, causes
a  gangrenous inflamma'ion of  the skin,
and almost always produces a mortifica-
 tion of the parts, amongst which it flow*r
   While the extravasation of urine is con-
 fined  to the interior of the pelvis, and
 lumbar and iliac regions, without  mani-
 festing itself externally, there  is no cer-
 tain sign of its  existence.   The  circum-
 stances, which  may be  recollected, how-
 ever, joined with the  symptoms,  which
 the patient complains  of, may lead to a
 suspicion of  the  extravasation.   Thus,
 when  in consequence of  a retention  of
 urine in the ureters, or bladder,  the  pa-
 tient, has suddenly experienced great re-
 lief, without any of the urine having been
 discharged tiie natural way;. when he has
 at the same instant felt a kind of pricking
 in the loins, or pelvis;  when to ihe ease,
 which lasted only a few hours, symptoms,
 more severe than the former ones, have
 succeeded, such as ardent fever, hiccough,
 vomiting,  &c.  there is reason for believ-
 ing, that  an internal  extravasation has
 happened.  The  uncertainty in the diag-
 nosis is here not much to be  lamented,
 since art can do nothing for this  kind of
 disorder, and, if there were the clearest
 proofs of  its existence, we should  be
 equally compelled to abandon the patient
 to the resources  of nature,  whose efforts
 are almost always ineffectual.
   This uncertainty in the diagnosis dis-
 appears as soon  as the extravasation be-
 comes apparent externally.   The case is .
 then  announced  by symptoms,  which
 hardly ever deceive. The preceding re-
 tention of urine ; the sudden appearance
 of the swelling caused by this fluid; the
 rapid progress of this tumour ; the kind
 of crepitation perceptible in  it,  like that
 which occurs in emphysema ; the tension
 of the cedematous shining skin,  as  in
 leucophlegmasia  ; the diminution  of the
 symptoms depending upon the retention;
 such are the first  occurrences, which are
 observable,  when the  extravasation  is
 somewhat considerable.
   If the  patient is not speedily assisted,,
 and the urine continues  to be extravasat-
 ed, the tumour spreads  more and more;
 the skin assumes a  red violet colour;
 gangrenous eschars are formed, the sepa-
 ration of which gives issue to a very fetid
 sanies, in which the smell of urine is rea-
 dily distinguishable. Portions of deael cel-
 lular membrane are  presently discharged
 together with the sanies ; the ulcer grows
 larger; anil the dressings are continually
 wet with the urine.
   Tlie indications to be  fulfilled are not
 the same in all c:tses of extravasations  of
 the urine -,  they vary according to the si-
 tuation of the breach of continuity hi the
 urinary passages,  and the particular situ-
 ation and extent  of the effusion.  When
the rupture has happened in  the ureters, 
URINARY ABSCESSES.                        449
and an  urinary abscess is formed in  the
loins,  the aid to be derived from surgery
is  limited  to making  an opening in  the
extravasation, as soon as  it can be  felt
externally.  It is then not in the power
of art to re-establish  the  natural course
of the u»i>e, or to hinder this fiuiel from
passing through the wound, so as to ren-
der it fistulous.  However, there are some
circumstances,  in  which  a radical cure
may be effectually attempted.  For exam-
ple, if the abscess were  produced by  a
calculus lodged in the infundibulum, or
ureter, and it  could be felt, and taken
hold of with a pair of forceps, introduced
into the opening, the extraction of the fo-
reign  body might promote the healing of
the ulcer, by rendering the natural chan-
nel for the urine free.
   When the opening, by which the urine
has become  extravasated, exists in  the
bladder, or urethra, one  indication, that
does  not present  itself in the foregoing
case,  may be fulfilled,  viz. the urine  may
be drawn off by means of a catheter passeel
into the bladder, and kept there. By  this
means we not only immediately stop  the
progress of the extravasation, but attack
the very cause of the malady, by removing
the obstacles, which oppose the natural
course of the urine.  The introduction of
the catheter then is here a matter of the
most urgent  necessity.  This operation
is often attended with the greatest diffi-
culties.  Besides the ordinary obstruction
of the canal, we have also to surmount
the obstacles, which the urinary swellings
situated in the course of the  urethra,
create to tiie passage  of the  instrument.
 When these tumours are considerable,
they ought to be opened before the cathe-
 ter is employed.  The subsidence of the
swellings would render catheterism more
 easy.  Besides, Bichat and Desault were
assured  by daily experience, that with  a
 little skill, exercise,  and  patience,  the
 catheter may always be got into the blad-
der.  If, however, the thing could not be
 done, ought we to puncture the blaelder,
 c«r have recourse to the operation termed
 by the French boutonniere ?
   Desault was an advocate for neither  of
 these proceedings: he thought  it was  a
 more simple and beneficial practice merely
 to make an external  opening in the col-
 lection ot effused  urine.  Tbis  measure
 would both afford an outlet for the urine,
 and arrest the extension ofthe extravasa-
 tion.  Besides such an opening is often
 indispensably requisite for  the purpose
 of putting a stop to the symptoms de-
 pending upon the effusion and stagnation
 of the urine.  But, if  the catheter can  be
 inteoduced, there may be cases, in which
 an opening would not only be useless, but
      Vol. II.
hurtful;  for instance, when the swelling,
caused by the urine, is of little extent, or
when it is situated in  the thickness of the
parietes of the passage, or along its track,
it almost always admits of elispersion by
the simple employment of the catheter.
It  seldom  happens,   however,  that  this
swelling, however  small, ends in resolu-
tion ;  it almost always suppurates;  but,
as it  breaks into the urethra, the matter
escapes between this canal and the cathe-
ter, and re.iders the making of an exter-
nal opening needless.  Experience teaches
us, also, that when the tumour is situated
in  the scrotum, or between the root of the
penis and the  symphysis pubis, even af-
ter the healing of incisions, made in these
situations,  a fistula  will often  remain,
wliich is very d.fficult of cure.  With the
exception of these particular ca^e» De-
sault was an  advocate  for openmg alb
urinary abscesses.
  The manner of opening such collections
varies according as  the  mine may be in
one cavity, or widely effused in the cellu-
lar membrane.   In the first case, a simple
incision, the whole length of the  cavity,
will  suffice  for  emptying and healing it.
In the second, if the extravasation is ex-
tensive, the incisions  must be multiplied-
It would bfe absurd  to spare the parts;
for, all  those, with which the  urine has
come into contact, seldom .escape mot t iff-
tion.   The  incisions, which  are made,
hardly ever have the effect o; saving them;
but, by accelerating  the discharge of pu-
trid sanies and stagnant urine, they  pre-
vent  the mischief, which would originate
from their  further  lodgment  If these
incisions, however, were practised a t*y
hours after  the extravasation, and before
suppuration, the  parts  might  be com-
pletely freed from urine and preserved
When the operation is at all delayed,
their destruction is  inevitable.  The ap-
proach of mortification is indicated by the
crepitation under the  bistoury, resembling
 the  kind of  noise produced by tearing
 parchment.  The extent and depth of the
 incisions  must be proportioned to those
 ofthe abscess.  When  the  extravasation
 occupies the scrotum, long deep scarifica-
 tions should be made in that part, as well
 as in the skin of the penis, and  in every
 place, where tiie urine is effused.
   Practitioners, unaccustomed to see such
 diseases, would be alarmed at the extent
 ofthe sore produced by the separation of
 the eschars.  Sometimes, the who\e  scro-
 turn, skin of the  penis, and  that of the
, groins, perinxum, and upper  part of the
 thigh, mortify, and  the naked  testicles
 hang by the spermatic cords, in the midst
 of this enormous ulcer.  It is hardly con-
 ceivable how  cicatrization  could  take
    :iL 
430
URINARY CALCULI.
place over the exposeel testicles ; but, the
resources  of nature  are  unlimited.  She
unites  the  testicles anel the cords to the
subjacent  parts,  anel drawing the skin
from the circumference  to  the centre of
the ulcer, she covers these organs again,
and  furiislies them  with a sort of new
scrotum. This statement is foundeel upon
numerous cases,  in which nature always
followed this course.  The cicatrization
of the ulcer is e ven more expeditious, than
might  be expected, considering its extent.
In all this business, what dees art do ?  If
the introduction ofthe catheter is except-
ed, which,.indeed, is absolutely necessary
for the radical cure,  her assistance is very
limited, and almost  nothing, in the gene-
rality of instances ; for when the patients
are  not exhausted  by the  teeliousness of
the difcoreler, when tiny are ofa good con-
stitution,  anel in  the prime of life, they
get well as quickly and certainly, with the
aid of a good die't and simple dressings,
as  when  they take  internal  medicines,
and use a multiplicity of compound topi-
cal applications.  The practice of Desault
at the Hotel-Dieu consist*:-• in applying
emollient poultices, until  the sloughs were
detached.  The ulcer was then sometimes
dressed with pledgets charged with sty-
rax; but  frequently  mere  dry lint was
used, and continued till the cure was com-
pleted.  If any complication occurred in
the  course  of*the treatment,  suitable re-
medies were prescribed for  it.   Thus
when  prostration of strength,  and ten-
dency to sloughing existeel, bark, corelials,
anel antiseptics  were ordered.  But,  in
every case,  the catheter is the essential
means of cure; without it, the treatment
is almost always  imperfect, antl the ulcer
will not heal without leaving several uri-
nary fistulx.  (See (Euvres Chirurgicales
de Desault par Bichat, 'Tom.  3, p. 277—
287.)
   URINARY CALCULI.  Dr. Wollaston
has divided  urinary calculi  into  four
species.   1st. The  uric  acid concretion.
2d.  The fusible calculus, or phosphate of
ammonia and magnesia.   3d. The  mul-
berry calculus, or that consisting of oxa-
late and  phosphate  of  lime.  4th. The
bone-earth calculus, or that composed of
tlie phosphate of lime.
   As  the  symptoms of a  stone .in  the
bladder  are detailed in another part of
this Dictionary, it will  only be necessary
in the present place to  refer the reader,
for  information upon that subject, to the
article, Lithotomy.
   The stone being aju«st severe affliction,
and the operation  extremely hazardous
and painful, a variety of experiments have
been instituted, for the purpose of disco-
vering a  solvent for urinary calculi.  Hi-
therto, however, all  the renieelica anel
plans, which  have been tried, have been
attendeel with very limited, and, by no
means, equivocal success, notwithstanding
many persons may have been deceived
into a contrary opinion.
  The dissolution ofthe stones in4he blad-
der, has  been attempted  by lithontriptic
medicines, as they have been termed, and
by fluids injected into this viscus.
  From the  experiments of Fotircroy, it
appears, that almost every ingredient in
calculi is dissolved by the caustic alkali;
and various experiments have shewn, that
the whole  calculus yields to its  powers.
Lime-water has  also been found a solvent
of urinary calculi out of the body.  It is
obvious, however, that what is taken by
the mouth is subject to many changes in
the  alimentary canal, and also the lym-
phatic, anel  vascular systems, : nd that,
in this way, it must  be exceedingly diffi-
cult to get such substances, (even were
they not liable to alterations) in sufficient
quantity into the bladder.  Ineleed, there
are very few weil authenticated  facts of
the urine being  so changed, as to become
a  menstruum for the stone. Excepting
the  case of Dr. Newcombe, recorded by
Dr. Whytt, the instance  of Mr. Home is
almost the only one.  Though lithontrip-
tic remedies, however, may not in general
actually dissolve the  stone  in the  living
bladder, yet it is an incontrovertible fact,
that  they frequently mitigate  the  pa-
roxysms of pain ; and, to lessen such tor-
ture as that of the stone in the bladder, is
surely an object of little importance.
   Lime was  long ago known as a solvent
of urinary calculi,  and  different me-
thods  were  employed to  administer it
with safety.  One of these  plans fell into
the hands  of a Mrs.  Stevens, and  her
success caused  great anxiety for the dis-
covery ofthe secret.   At last, Parliament
bought the mystery for 5000/.  In many
instances, stones which had  been unques-
tionably felt, were no longer to be disco-
vereel; and, as some persons were  et-
amined by surgeons of the  greatest skill
and eminence, both  before, and after, the
exhibition of the medicines, it is no won-
der, that the conclusion was drawn, that
the stones  had been  re illy dissolved.
 From  the  cessation ot  such success, and
 from  its  now   being  known,  that  the
stones  are  occasionally protruded, be-
 tween the fasciculi of the muscular fibres
of the bladder, so as to become lodgcel
in  a kind of cyst, on the outside of the
 muscular coat, and cause no longer any
grievances, surgeons of the present day,
however, are inclined to  suspect, that
 this must have  happened in Mrs. Stee-
vens'  cases.   This was certainly what 
UlilXARY FISTUL.L.
451
happened to one of the persons, on whom
l'ie above medicine was  tried, as  Dr. \Y".
Hunter informs  us.  It is  evident, that a
stone, so situated, would  not only produce
no  particular irritation, but  would also
be  quite indiscoverable by the  sound;
fur, in f.ict, it is no longer in the cavity of
the bladder.
  Mrs. Stevens first gave  calcined  egg-
shells   alone;  but, finding  costiveness
produced, she added  soap.  In time, she
rendered her process  more complicated,
adding snails burnt to  blackness, a de-
coction  of  camomile flowers, parsley,
sweet fennel, and the greater- burdock.
  As soap was with reason supposed to
increase the virtues of the  Tune, it led to
tihe use  of the caustic alkali, taken in a
mucilage of  veal broth.   Take of alkali
prepared, ,"f viij ; of quick-lime %iv ;  of
distilled water ibij.  Mix  them well to-
gether  in a  large  bottle,  and  let them
stand for 24 hours.  Then pour  off' the
ley, filter it through paper,  and keep it in
well stopped phials for use.  Of this the
dose is from  30 drops  to gij, which  is to
be repeated, two, or three times a day.
Mix the cjuantity to be  used in the day,
with three pints of plain broth, made of
the lean part of veal, all the fat, or oily
parts being separated from  the liquor, by
skimming them off when cold.  Let the pa-
tient drink, within an hour, a pint of this
broth  three  times  a  day; early  in the
morning, at  noon,  and  in the evening.
Continue this  plan,  for three or  four
months, living,  during  this  course, on
such things as  least counteract the effect
of the medicine.  The common fixed al-
kali, or  carbonated alkali, and the aci-
dulous soda water, have of late been  used
as litliontriptics.  Honey has  also  been
given, and Mr.  Home,  surgeon  at the
Savoy, has recorded its utility in Ins  own,
and his father's cases.  Bitters have  like-
wise been tried.
  Dismissing all theories, limewater,  soap,
acidulous soda water,  caustic  alkali, and
hitters, are useful in cases  of stone. (Jf
the soap, as  much  may be  taken  as the
stomach will bear, or as  much  as will
prove  gently laxative; but, of the  lime-
water, few can  take  more, than  a pint
daily.
  The acidulous soda  water may be taken
in larger quantities, as it  is more agree-
able.   The acidulous  salt  is now  prepar-
ed, so as to produce this water  extempo-
raneously.  It must be  swallowed,  how-
ever, while the  salt is dissolving ; as the
carbonic acid gas escapes  with great ra-
pidity.
  Medicines, taken  into   the  stomach,
having failed to dissolve urinary calculi,
solvent injections have  beeii introduced
through a catheter directly into the blad-
der.   Foiircrov and Vauqitelin ascertain-
ed, that a ley of potassa, or soda, npt too
strong to be swallowed, softens and dis-
solves small calculi, composed of" the uric
acid  and  urate  of ammonia, when they
are left in the liquid a lew elays.   They
have proved, that a beverage, merely aci-
dulated with nitric or  muriatic acid, dis-
solves, with still greater quickness, cal-
culi,  formed of the  phosphate  of lime,
and of the  ammoniaco-magnesian  phos-
phate.  They have made out, that calculi,
composed of the oxalate of lime, wliich
are the most difficult of solution, may be
softened,  anel almost quite dissolved in
nitric aciel, greatly eliluted, provided they
are kept in the mixture a sufficient time.
  We are then  acquainted with- liquids,
which will dissolve  calculi  of various
compositions; but, mueb difficulty occurs
in employing them  effectually  in prac-
tice.  For, although  we  can easily inject
them  into the cavity of the bladder, this
organ is so extremely tender and irritable,'
that we cannot  bear the contact  of any
fluid,  except that which  it is destined by
nature to  contain, and the action of such
liquids upon it, as would be requisite for
dissolving  a stone  in  its cavity, would
produce  sufferings which no man  could
endure, and the  most dangerous and fatal
effects on the bladder  itself   Another
objection to this practice, also  arises from
the surgeon never knowing what the exact
composition of a calculus  is, before this
body  is  extracted,  and  his consequent
inability to determine what solvent ought
to be tried.  Upon  this, however, it is
unnecessary to lay much stress, since if
the previous more weighty  objections
were  done  away, the  latter difficulty,
might, perhaps,  be obviated.
  URINARY FISTULA.  By  an uri-
nary fistula, strictly speaking,  is implied
a deep, narrow  ulcer,  which  leads into
some  of the urinary passages ; but, this
name   is  likewise  applied to  sinuses,
which,  without  having  any communica-
tion with  these  passages, terminate near
some  point of their course.  Thus, in De-
sault's works (Tom. 3, p. 287), three kinds
of fistutae, in respect to the urinary pas- v
sae>es, are noticed The first sort is called
a blind  external fistula, because it opens
onh externally; the second, blind internal,
because it has only one opening into tiie
urinary  passages; tlie  thirei,  is termed
complete, being attendeel both  with an in-
teriial opening  into the  urinary organs,
anel one or more external apertures.
   Amongst  the  blind external fistulse,
only  such  as  terminate  near   the  ca-
nal of*  the  urethra, are  particularly no-
ticed in  Desault's works. All  fistula: of 
452
URINARY riSTL"L.£.
this kind  are originally owing to an ab-
scess, that has  fbi-mect" in the vicinity of
the urethra ;  and in  the article, Urinary
Abscesses,  it has  been explained, that
these  suppurations frequently  originate
from  disease e>f that  canal.  Whatever
may be  the  cause of these  fistulas, how-
ever, it is not unusual to find, that, after
the pus has made its  way towards the
scrotum  or  perineum,  and discharged
itself outwardly, the ulcer  is converted
into a sinus, which resists all the  efforts
of" nature to heal it.  According to De-
sault, this kind of fistula may be kept up
by a thinning and denudation of the  pa-
rietes  of  the urethra; a very  common
disposition, when the abscess is situateel
about the root of the penis, and towards
that part of the canal, which  is situated
over the  scrotum, in consequence of  the
weight  of this latter organ tending inces-
santly to  separate  it from  the urethra.
The opening of the  fistula  being  too
small";  its orifice higher than its bottom ;
and its  track being narrow and  tortuous ;
may likewise occasion sinuses, and  render
the sore difficult to euro, by opposing the
"free exit  of" the  matter.  It may also be
complicated  with hardness and callosi-
ties, caries of the bones of the pelvis, dis-
ease ofthe tendons ofthe muscles  of  the
perineum, &c.   It is known,  that these
different compile dions operate as so many
obstacles  to the cure of sinuses.  It is
easy to distinguish these kinels of  fistulae
from  such as terminate near the rectum.
Besides the symptoms which may be re-
membered to have  occurred, and which
are sufficient to point out the tlitterence ;
a hardness, resembling a cord, that  ap-
pears to run towards the urethra, may be
felt when the finger is passed along  the
fistulous track.  A probe, introduceel into
the fistula, follows the direction of this
cord, and is at last stopped by the parietes
ofthe urethra.  It may also be ascertained,
that the sinus has no communication with
the urethra, by the  following considera-
tions :  1. No urine has escaped from
the fistula, nor any purulent matter from
the urethra.  2. A probe, when  intro-
duced  into the sinus, cannot be made to
touch a catheter passed into the urethra.
These  symptoms, however,  are not infal-
lible ; for, in complete fistulae, it some-
times happens, when the internal opening
is small, and there  is no obstruction in
the urethra, that the whole ofthe urine is
discharged through  this canal.  Frequent-
ly, also, the probe is stopped  in the tor-
tuosities ofthe fistulous track, and, when
pushed against the parietes of the urethra,
■it does not always penetrate the internal
-opening,  especially  when this is  small,
aad it is situated in some point of the de-
nuded portion of the canal, that does not
correspond to the direction of the fistuht.
The issue of a larger quantity of pus, on
slight pressure being made along  the ca-
nal leaves  no doubt of the existence of
sinuses.  With respect  to othec compli-
cations, such  as callosities, caries of the
bones, fcc. they may be readily ascertained
by their proper symptoms.
  The  inelications to be  fulfilled in the
treatment of these  fistulae, depend upon a
knowledge of the different complications.
When  the sinuses are kept up by a sepa-
ration of the scrotum from the parietes of
the urethra,  Desault recommends exact
compression  to  be made over the part,
which method, he says,  is sometimes suf-
ficient to accomplish a  cure.   When this
plan fails, he states, that the healing of
the sinus may be promoted by practising
an  incision on one siele of the scrotum,
and carrying  it as  far as the denuded
portion  of the  urethra.  When  sinuses
exist, and they depend upon the small-
ness of the opening, or its unfavourable
situation for the discharge of the matter,
the aperture should be  enlarged by mak-
ing an  incision into the  main collection
ofpus.  When there are callosities, which
resist cataplasms, and  the most active '
resolvents, Desault  advises us to intro-
duce into the  fistulae, trochees of minium
for the  purpose of destroying the indurat-
ed  parts.  When the bones  are carious,
and the  tendons  diseased,  exfoliation
must be  awaited ; and, in every instance
the treatment should vary, according to
the cause, upon which the  fistula de-
pends.
   Incomplete internal urinary fistulae, or,
in other words, blind internal fistulae, are
seldom met with in the ureters and blad-
der. The quality of the cellular substance,
which surrounds  these  parts, favours the
effusion of the urine too much  for the
disorder, arising from  a breach of con-
tinuity  in them to  be confined to a simple
internal fistula.  Such  fistulae, however,
are often met with in  the urethra.  The
bursting of an abscess into this canal; the
rupture of the same canal in consequence
of a retention of urine ;  a false passage;
the healing of the external  part of the
wound  maele in lithotomy, while the in-
ternal part is not united; are all so many
causes  of this disease.
   The  diagnosis of these fistulae, is de-
ducible from circumstances, which may
be recollected; together with a discharge
of pus from  the urethra,  before, and
sometimes after the issue of the urine;
the pressure ofa tumour  in the course of
the urethra, which  tumour  increases
while  the patient is making water, and
afterwards disappears  by pressure, at- 
URINARY FISTULA.
453
tended with a fresh discharge from  the
penis of matter blended with urine. This
symptom alone is characteristic;  for, an
old gonorrhoea, complicated  with indu-
rations, may also  keep  up  suppuration
ofthe canal.   Ihe existence of pain gives
no positive information ;  and nothing  cer-
tain can be ascertaineel  by (he introduc-
tion of tlie catheter.  It is true, the be.k
of this instrument may become entangled
in the fistula;  but, its entrance into the
blaelder may  equally be  opposed  by a
variety of other obstacles.
   These  internal  urinary fistula: cannot
 be cured, except by preventing the urine
 from getting into them and lodging there.
 The  catheters employed  should  neither
 be too  large, nor too small.  If too large,
 they would exactly fill the canal,  and the
 pus and  urine, contained in the  fistulae,
 could  not be  discharged. If too small,
 the urine would  insinuate itself between
 them and the sides of the urethra, .and
 enter  the fistulae.  Such inconveniences
 may be avoided  by  using a catheter of
 moderate size.  Its employment must be
 continued till the ulcer is entirely healed.
 The inutility of medicated  bougies, and
 other  internal and external remedies, is
 too manifest to need any comment.
    Of all urinary fistulae, there are  none
 more frequent than those which are term-
 ed complete.  Their  origin may be in the
 ureters, bladder, or  urethra.   Those
 which arise in the ureters, sometimes
 terminate  in  the colon, and the urine is
 discharged per anum mixed with the  feces.
  But, most commonly, these  fistulae  make
  their  appearance externally,  either in
  the lumbar, or  inguinal regions. Those
  which communicate with  the  bladeler,
  have  also  different terminations.  When
  they proceed from the upper and interior
  part of this organ,  they ordinarily pierce
  the parietes of the abdomen  above  the
 pubes,  and  towaixls  the  navel.   They
  also sometimes terminate  in the groins.
  When they  originate in  the   posterior
  parietes of the  bladder, they sometimes
  tend  into the  cavity  of  the  abelomen,
  where they almost always  prove mortal;
  and sometimes  into the intestines, if there
  should  be adhesions  between these and
  the  bladeler so  as to  favour this  com-
* munication.  When the opening  in the
  bladder is near the bottom of this viscus,
  the fistula sometimes terminates   in the
  rectum of  the male,  and the  vagina of
  the female subject; but, most frequently,
  it ends in the perineum,  iu both  sexes.
   With regard to the fistulae, which origin-
   ate  in  the  urethra, they usually open
   externally in the perinaeum, the scrotum,
   or the penis, and sometimes  also  m the
 .  rectum.  It  is not uncommon to see the
external opening of  these  fistulae  at a
great distance from the internal one, and
to find in the middle, and even the lower
part of the thighs, the  groins, parietes
of the abdomen, and as high as the sides
of the  chest.  Often  there  is only one
opening  in the urethra,  while there  are
several  situated externally  more or less
distant from one another.
   Most  of these  fistulae are the conse-
quences of a retention of urine,  and  are
owing to the same causes, as the eliseases
of wliich  they are  a symptom.  Those
which communicate with the rectum, in
the male subject, sometimes elepend upon
this intestine having been woundeel  in the
operation of lithotomy ; and those, which
open into the vagina, are often the effect
 of a violent contusion, caused hy the head
 of the child in difficult labours, or of ulce-
 ration  produced by pessaries, which are
 too large, and the margins of which are
 too sharp and  irregular.   Carcinoma of
 the rectum  and vagina  also  give rise to
 fistulae, by extending into the bladder.
   The  discharge of urine  from the ex-
 ternal  orifice  of the fistulae  is an une-
 quivocal proof of its communication with
 the urinary passages; but  this symptom
 does not always  exist, and, it often hap-
 pens, that,  when  the fistula is narrow,
 and there is no obstruction in tlie urethra,
 the urine more readily escapes the latter
 way than through the fistula.  The kind
 of cord, which is felt in the track of the
 fistula, and which  extends  towards the
 urethra, is  a very uncertain criterion  of
 the communication with this canal. This
 symptom is common to all fistulae com-
 plicated with callosities,  whatever  may
  be their nature in other respects.  The
 fungus, which sometimes  appears round
  the external  orifice, is also observed in
  fecal fistulae.  The situatioh of this outer
  aperture scarcely affords any presumption
  on  the nature  of the  fistula,  since, in
  numerous cases, this opening is very dis-
  tant from the urinary  passages.  When
  the fistula  is narrow and  tortuous, injec-
  tions will not always pass  into the blad-
  der or srethra, but, become  extravasated
  in the  cellular  substance.   It is often
  difficult, sometimes even  impossible, to
  find out the internal orifice of the fistula
  with  a probe. - When  it communicates
  with the rectum, or vaginae, the opening
  may sometimes  be  perceived  with the
  finger,  and occasionally,  a staff*  intro-
  duced through the  urethra, may also be
  felt  in those parts.  When the fistula
   originates  in the  bladder,  the issue of
   the urine is continual;  and when it arises
   in the urethra, the discharge of this fluid
  is only made, when the  patient has  oc-
   casion to make water.  This distinguish- 
454                         URINARY FISTUL.-fi.
ing  sign  is not  constant, and,  in De-
sault's works, mention is made of several
cases,  ill which  the urine  did not issue
from fistula;  communicating  with the
bladeler, except  when  the patients en-
ue-avoured to empty that organ.
  Fistulae of the  kidneys, or ureters, are
entirely beyond the  reach  of art,  unless
they should be kept up by  the retention
of urine in  the bladder,  or the presence
of a foreign  body in  the track of the
fistula.   The re-establishment  of the
natural  course of the urine,  and the ex-
traction ofthe extraneous substance may,
in such a  case, effectually  contribute  to
the cure.   Here, however, we have  no
certain  means of preventing the  urine
from entering the fistula.  This  is not
the case  with respect  to fistulae of the
urethra, where we are, as it were, masters
of that fluid.  It  is particularly in  these
latter disorders,  that elastic  gum cathe-
ters  are attended with inestimable advan-
tages.
  When fistulae ofthe bladeler, or urethra,
are the consequences of" a retention  of
urine,  produced by obstructions  in this
last  canal, these  obstructions often ex-
ist still: sometimes  they have even  in-
creased since the  formation ofthe fistula,
which  circumstance, in  tiie  majority  of
cases,  renders the introduction  of the
catheter extremely difficult.
  It is particularly  when fistulae termin-
ate in the lower part of the bladder, that
the utmost  care  must  be taken to pre-
vent the catheter from being stopped up
by any  foreign body,  which woulel ob-
struct the urine, as  well as to hinder the
instrument from  becoming  displaced, or
slipping  out  of  the  bladder.  Perhaps,
in this instance,   instead of stopping up
the catheter, it would be better to  keep
it constantly open, in order to prevent all
accumulation of urine in the bladder, and
the passage of this fluid through the fistu-
la.   But, when the fistula  communicates
with the urethra,  no advantage  would be
derived from  keeping the catheter open,
and the treatment would be more painful
and unpleasant to the patient.
  In both cases, Desault  recommends us
to continue the  employment of  the  ca-
theter, not only until the fistula is cured,
but also until the obstacles, which hinder
the urine from passing the natural way,
are  removed.  If, besides, there shoulel
exist any  of the complications,  spoken
of in treating of blind external  fistulae,
the methoels there adviseel  are to be pur-
sued ; but, in general, tiie catheter will
suffice to effeet the cure. Certain fistulae,
however, demand a particular mode  of
treatment.   Such are those, which form
communications between the bladder and
the rectum, or vagina.
  Fistulae of  the bladder,  communicat-
ing with the  vagina:, anil  proeluceel by
difficult labours,  are almost  always at-
tended with loss  of substance. The forci-
ble contusion  occasional by  the  child's
head on the anterior  parietes  of the va-
gina anel bottom of the bladder, gives
rise to the formation of sloughs, the se-
paration of which sometimes leaves aper-
tures large enough to admit the  finger,
and hence the cure is exceeel'mgly difficult.
In treating such  fistulae, there  are two
indications to  be fulfilled;  1st.  to keep
the urine from passing into the vagina :
2dly. to keep the edges of the division as
closely as possible together, so as to  give
them an opportunity of uniting.
  The first of these indications demon-
strates more and more  the utility, and
even the necessity  of  the  catheter.  In
women,  its introduction is easy ; but in
them it is more difficult to fix  the  instru-
ment, than in  men.  Desault  contends,
however, that it is very essential to h;.ve
it favourably  fixed  in the bladder, so
that the urine  may escape, immediately
it arrives in  this viscus.  None  of the
means   hitherto  employed, seemed  to
Desault to  answer  this  purpose com-
pletely.   This eminent surgeon  found,
that the only effectual plan  was  to fasteh
the catheter to a point, tlut always retain-
ed the same position, with respect  to the
meatus  urinarius.   He  used  a kind of
machine made after the manner ofa truss,
the circle of  which  was long enough to
embrace the upper part ofthe pelvis, and
had  in its middle an  oval plate to be
placed upon the  pubes.  In the  centre of
this plate was  a groove, to which a piece
of silver was fitted, curved  so- that one of
its end having  an aperture in  it, came
over the vulva, on a level with the  meatus
urinarius.  This  piece of silver admitted
of being fastened to the  plate  with  a
screw.  After having introduced,  and ar-
ranged the catheter  in  the bladder, so
that its beak and eyes may be situated at
the lowest part of this viscus, the enel of
the instrument is to be put through the
aperture of the  piece of  silver, which
slides in  the groove of the plate, and it is
afterwards to be  fixed in the way already
explained.  By means of this machine, the
catheter  is invariably fixed, without in-
commoding the patient even when she is
walking.
  In this  disease, huge catheters with
full sized apertures shoulel be employed,
so that the urine may more  readily es-
cape through   the instrument, than  fall
into the vagina.  In the early  part ofthe 
URINE, INCONTINENCE OF.
455
treatment, the catheters should also  be
left constantly open.
   In order to fulfil the second indication,
an'! keep  the edges  of the division as
near  together as  possible,  Desault ad-
 vises us to  introduce iiuo the vagina, a
 soft kind of  pessary, large enough  to  fill
 the vagina,  without elistending it.  The
 introduction of this instrument changes
 the form of fistula from  round to oval,
 which  is the most favourable  to  its re-
 union ; and  it has also  the  advantage of
 closing  the  fistula,  anel  hindering the
 urine from falling into the vagina.  These
 fistulae often cannot  be cured till after
 much  time,—s.x  months,  and even  a
 year.
    When the rectum  is wounded  in  the
 operation of lithotomy, an event that may
 be known both by the escape of the feces
 through the wound, and the introduction
 of the finger into the incision, or within
 the  rectum, Desault aelvises us to divide
 at once the parts c.ompreheneled between
 the wound  of the operation, the opening
  in the rectum, and  the margin  of the
  anus.  This, he  says,  is the  means of
  preventing  the feces from passing into the
  bladder, and the  urine into the rectum.
  This seconel operation  allows the matter
  to escape readily, and cicatrization taking
  place  from the bottom of  the wound,  in
  the direction outward,  the  patient is cur-
  ed without any fistula;  whereas this last
  grievance  is almost inevitable, when the
  preceding plan is not  adopted early.  It
  deserves attention,  that  the  catheter  is
  then  incapable of effecting  a cure.  It
* effectually  prevents  the urine from en-
  tering the fistulae; but, it cannot keep
  the feces from  doing so,  wliich would
   keep  up the disease.
    For  Desault's particular   method  of
   dividing the parts,  1  must refer to his
   works.   (See  (Euvres  Chirurgicales  de
   Desault par Bichat, Tom. 3- p. 287—300.)
     URINE, INCONTINENCE OF.   This
   complaint  is quite the reverse of a re-
   tention of urine; for, as  in the  latter
   affection, the urine is  continually flowing
   into the bladder, without the patient hay-
   ing the power to expel  this fluid ; so, in
   the former, the urine  flows out, without
   the patient being able to prevent the oc-
   currence.
     An incontinence of  urine may originate
   from several causes.   1. From the irrita-
   tion ofthe neck of the bladder by stones.
   o  lioi.i  a paralysis  of  the sphincter
   vcicae  while the  contractile  power ot
   the muscular coat of the bladder remains
    i„  its natural  state.  3. From laceration
    ,.f the  parts  in the  extraction ot  large
    ■tones, and a consequent paralysis e,t  the
    ^h'mcter after  the  wound  lias healed.
4. From the injury, which the parts suffer
from pressure in difficult labours.
   When  an  incontinence  of urine pro-
ceeds from  an  irritation of the neck of
the bladder by  a stone, it can only be
radically cureel by the ojieration of litho-
tomy ; though  great  relief may be given
by mucilaginous  and  anodyne medicines,
particularly, when,given in the form oi
injections."  In  the other two cases, in
which it is occasioned by  a  paralytic
affection of the  sphincter,  we  can  only
attempt the cure by such medicines as are
proper in other  paralytic cases, viz. the
 Peruvian birk,  chalybeates,  the  cold
bath, and ether  tonics; but, of all topi-
 cal  reroeelies,  cold  applications to the
 perinaeum are found to  be the most effec-
 tual.  The most powerful remedy of this1
 kind is to dash cold water upon the part;
 themgh  it is sometimes found  useful to
 apply cloths dipped in vinegar and water,
 or a solution of" saccharum satumi, in the
 acetous  acid.
   When no relief can be obtained by the
 above proposed remedies, we must then
 have recourse to some mechanical method
 of compressing the  urethra,  and  thus
 preventing the'continual dribbling of the
 urine, which  must  always  be very dis-
 agreeable.   A very proper instrument for
 this purpose is culled  a jugum, or yoke.
  It ought to  be lined with silk or velvet;
  and, bv means of the screw, the pressure
  may be  made  greater  or  lesser at plea-
  sure.  For  women,  we must make use
  of  pessaries.  These  must be made  of
  sponge, only of such  a  size as to be easily
  admitted,  and,  before it  is  introduced,
  it  must be  moistened with the finest
  olive oil, which, according to Mr. Latta,
  most effectually prevents it from becom-
  ing soon  troublesome  by excoriating th-
  vagina.   Pessaries,  made  of  wood, can
  never be used in cases of this kind with
  effect;  for, in placing toem in the vagina
  so as to compress the neck ofthe bladder,
  it is obvious they must at the  same time
  press upon the rectum, and, on thi.t ac-
  count, prevent the natural passage of the
  feces.  In  some particular cases, even
  these palliative  remedies  prove ineffec-
  tual; for, when the disorder proceeds from
  an irritation on the  neck of  the bladder,
  the patient has such a continual desire to
  make water, that it  is impossible to bear
  any confinement of it.   We can then only
  employ proper receptacles for collecting
   it  as it flows.  In women  these can only
   be by pieces of sponge, applied externally,
   and kept in that situation with a T band-
   age ; but  in men, other contrivances may
   be employed.
     In the Mtelical Observations, we have
   some surprising instances of the efficacy 
456                        URINE, RETENTION OF.
of blisters in removing this complaint. A
girl of thirteen years of age, who, for four
j ears, had been  able to retain her water
only a very short time in the day time, and
not at all during the night, was cured in
twenty-four hours by the application of a
blister to the os sacrum.   A man, thirty-
two years of age was attacked by this dis-
ease,  accompanied  with  a palsy of the
lower extremities, in consequence of hav-
ing taken some virulent quack medicines,
probably of the mercurial, or  arsenical
kind.    In  twenty-four  hours after the
application of a  blister to  the os sacrum,
lie  was  able to retain his water for an
hour,  and in  a week after, for two hours.
In about a month,  he was able to retain
it for five hours, and, at  last obtained a
perfect  cure.  He also recovered in some
degree the use of his limbs, which were
paralytic.' The like  good effects  were
produced  on a woman of fifty, in whom
the disease  had been  brought on  by a
strain.  In her  it  was  likewise  accom-
panied  with  a  palsy  of  the lower ex-
tremities, and of this too she got the
better.  In a  woman of  forty-three, in
whom the disease seems to have come on
without any evident cause, the cure was
accomplished, almost  during the  time
that the blister was rising.  In a young
man,  who had  been  attacked  with the
disease, after lifting a heavy load, a cure
was accomplished  in sixteen days.  A
man of forty-four years of age, who had
been  attacked by  the disease,  without
any evident  cause, was  in like  manner
cured on the first application of a blister.
This  man  had likewise  symptoms of
diabetes; but, the blister had no effect in
removing them.  A boy, ten years of age,
had violent  complaints  in the  urinary
passage, which were supposed to proceed
from  an ulcer.  " When about to make
water, he was obliged to  put himself in
a prone posture, and then his urine ge-
nerally  came  away by  drops,  with ex-
quisite  torture. At length,  it began to
come away insensibly during the  night;"
but, by  the application of a  blister, this
 incontinence  was removed in less than
forty-eight hours,  the  other symptoms
 remaining as they  were.   In  all  these
 cases, tlie blisters  were  very large, co-
 vering  not only the os sacrum;  but  ex-
 fending from side to side.  (Lutta's System
 of Surgery, vol. 2.)
  URINE, RETENTION  OF.  Mr. Hey
 has .very truly  remarked, that  a reten-
 tion of  urine  in the  blaelder, when the na-
 tural  efforts are incapable of affording
 relief, is, in  male subjects, a disc.se of
 great urgency and  danger.   Persons, ad-
 vanced  in years, are moie subject to this
complaint, than those, who are  young, or
middle  aged.   It is  often brought on by
an  incautious resistance  to the calls of
nature ; and, if not speedily relieved, ge-
nerally excites some  elegree of fever.
  It is  sometimes attended with a consi-
derable degree eif fever, and an  inflamma-
tory affection  of the bladder, which ter-
minates in a discharge of purulent matter,
and a fatal hectic.
  The distinction, says Mr. Hey,  which
has sometimes been  made, between a sup-
pression and retention of urine, is practical
and judicious. The former most properly
points out a defect in the secretion of the
kidneys; the latter, an inability of expel-
ling the urine when secreted.
.  Tlie retention of urine is, an inability,
whether total  or partial, of expelling, by
the natural efforts, the urine contained in
the bladder. The characteristic symptom
of this disease, previous to the introduc-
tion of the catheter,  is a distention of the
bladder (to be perceived by an examina-
tion of the hypogastrium), after the pa-
tient has dischargeel all the urine, which
he is capable of expelling.
  As this  complaint may subsist, when
the flow of urine from the bladder is by
no means totally suppressed, great caution
is required to avoid mistakes on this sub-
ject.
  "Violent efforts to make  water are often
excited at intervals, and, during these
strainings,  small quantities of urine are
expelled.   Under these  circumstances,
the  disoreler  may be mistaken for  the
stranguiy.
  At other^ times, a morbid retention of
urine subsists, when  the patient can make
water with  a stream, and discharge a
quantity equal to that, wbich is common-
lv elischarged by a person in health.  Un-
der this circumstance, Mr. Hey  has known
the pain in the hypogastrium, and disten-
tion of the blaelder, continue till the pa-
tient was relieved by the catheter.
   And  lastly, it sometimes happens, that
when the bladder has suffered  its utmost
elistention, the urine runs off' by the ure-
thra, as fast  as  it  is brought into  the
bladeler by the ureters.  Mr. Hey has re-
peatedly known this circumstance cause a
serious misapprehension ofthe true nature
of the disease.
   In- every case of retention  of urine,
which this gentleman has seen, the disease
might be ascertained  by an examination
of  the  hypogastrium, taken in connection
with the other symptoms.  The distended
bladder forms there a hard and circum-
scribed tumour, giving pain to the patient
when pressed with  the hand.   Some ob-
scurity may  arise upon the examinatioi. 
URINE, RETENTION OF.
*S7
•f a very corpulent person; but, in all
doubtful cases, the catheter should be in-
troduced.
  Mr. Hey mentions, that he has seen but
a few cases ofthe ischuria renalis, or com-
plete suppression ofthe secretion of urine
by tlie kidneys  The disease proved fatal
in all his patients except one, in  whom it
was brought  on by the effect  of lead,
taken into the body by working in a pot-
tery. It subsisted three days, during a
violent attack of the colica  pictonum, and
was then removed, together with the ori-
ginal disease.  Mr.  Hey found  no diffi-
culty in distinguishing  this  disorder, in
any of the cases, from the ischuria  vesica-
lis, though, for the satisfaction of some of
his  patients, he introduced the  catheter.
(Practical Observations in Surgery, p, 374,
&c.)
  Ischuria, or retention of  urine, may be
the effect of a great many different  causes.
We shall proceed to take notice  of the
causes, which are produced by a paralysis
of tiie  bladder ; by  inflammation of its
neck ;  by foreign bodies in it;  by pres-
sure made on it by tiie gravid uterus; by
an enlargement of the prostate gland ; and
by strictures in the urethra.

1. OF  THE RETENTION OP URINE  CAUSED
    BY  A PARALYSIS  OF THE BLADDER.

   This complaint, to  which persons ad-
vanced in life are  particularly subject,
may occur in subjects of any age,  in con-
sequence of a violent concussion of the,
spinal marrow, or (what is very  common)
if, after having taken a large quantity of
drink at a time, a person  should  neglect
to obey the calls of nature, and  hold his
urine too long.  It is also  observeel to be
a symptom of certain typhoid fevers, and,
consequently, too great attention  cannot
be paid to the state ofthe bladder in such
disorders. The retention of urine is easily
ascertained to exist by the prominence,
which it forms above the pubes; a  promi-
nence, which may be readily distinguished
by its elasticity and circumscription from
the general  tension of  the abdomen, so
common in this disease.  A retention of
urine may either come on in a gradual or
sudden manner.  In the first sort of case,
it begins by a kind  of debility,  wliich
hinders the patient from completely emp-
tying his bladder, so that, after  having
made water, he still feels an inclination
to repeat the evacuation, and is compelled
to  make frequent efforts to do  so.  This
 inconvenience  gradually  increases; at
length, none  of the  urine  can be  dis-
charged ;  and  the  bladder rises  higher
than tiie pubes, above which part it forms
41 round circumscribed tumour, the size
        Vol,  II
and elasticity of- which are more or less
considerable.
  In the  second kind of case, or that
which occurs suddenly, the retention of
the urine is the first symptom, which  the
patient experiences, and his bladder be-
comes filled, and distended, in the same
manner, as in the preceding case.  Most
frequently, the swelling, which this viscus
forms, is at first not very painful, but,  af-
terwards becomes very much so.  Some
patients make  frequent efforts to expel
their  urine; others are more tranquil.
This state lasts two, or three days, after
which  the urine  begins again  to escape
from the  urethra, sometimes  by  drops,
sometimes in a stream, but, almost always,
at the will  of" the  patient. In some in-
stances, as much urine is  voided,  as the
fluid, wliich is drunk ;  yet, notwithstand-
ing this, the bladder continues  to be  dis-
tended with urine, and to form  an  eleva-
tion above the pubes.  This circumstance
has frequently led practitioners into error,
and some of them have even mistaken the
swelling of the hypogastric region  for an
abscess.   Collot mentions,  that, in   his
time, otitis  mistake happened   very  fre*
quently, and that such supposed abscesses
would have  been often  opened, had not
the patients warned their medical attend-
ants of tiie  erroneous opinion.   M. Saba-
tier informs us that he  was  consulted
about a woman, who had been advised to
resort to the mineral waters, with a view
of dispersing  a tumour,  which hud oc>
curred in consequence of a difficult labour,
and which  swelling was supposeel to be
situated in the uterus. The tumour, how-
ever, was nothing else, than the bladder,
distended with an accumulation «if urine,
since it disappeared as soon as  a catheter
was introduced.  No suspicion had been
entertained of  the real nature ofthe case,
in consequence of the patient having void-
ed her urine in a voluntary manner, and
reasonable quantity, for five, or  six  weeks,
duringwhichtimetheswellinghadexisted.
   M.  Sabatier makes mention  of a case,
inserted in a thesis by Dr.  Murray, from
which it appears, that the swelling of the
bladder may become so considerable as to
lead to mistakes of a still more serious
nature.  A  delicate woman found her ab-
domen swell without any apparent cause,
and without  experiencing  any inconve-
niences.  Shr- imagined, that she was preg-
nant.  However, she was soon undeceived
by the rapidity, with which  her abdomen
continueel to enlarge, and by tiie consider-
able  degree of  anasarca  affecting her
lower  extremities.   The  latter affection
extended also to the arms, and  face.  The
patient w;»s considered to be  dropsical;
and a surgeon was  sent for to tap  her.
     3 M 
458
URINE, RETENTION OF
The fluctuation of a fluid in the abdomen
was quite evident.  Some diuretics  were
prescribed, before having recourse to the
operation. While such remedies were put
to a trial, the patient complained of hav-
ing had a total  retention  of urine  for
three days;  a symptom, wbich she had
not previously suffered.  The belly was
elastic, and the  veins on it were  every
where swollen. It was judged prudent to
introduce a catheter, before employing the
trocar.  The surprise was very great when
eighteen pints  of urine were  drawn  off,
and the swelling of the abdomen subsided.
The next day, the catheter drew off twelve
more pints of urine.   The anasarca, which
was entirely symptomatic, disappeared.
The application  of cold  water  re-esta-
blished the tone of the bladder, so that,
when three pints of urine had been drawn
off' by means of the catheter, the patient
herself could spontaneously expel three or
four others, with the aid of some degree
of pressure on  the  hypogastric region.
Dr. Murray endeavoured  to  ascertain,
 whether the woman got completely well;
 but, he could not trace this circumstance.
   The  retention  of urine, produced by a
 paralysis of the bladder, and the swelling,
 which  this  viscus occasions above  the
 pubes,  may  continue for  a long while,
 without patients feeling any other  incon-
 venience, than  a sense of weight about the
 region  of the pubes,  and the frequent in-
 clinations to make water,  which accom-
 pany this state. M. Sabatier  mentions
 his having  seen  patients,  who had been
 attacked by the complaint  for more than
 six months.
   The disorder may  be relieved by intro-
 ducing  a catheter into the bladder, by
 which meuis the urine has an opportunity
 of escaping.   For an account  of the man-
 ner of introducing  this instrument, see
 Catheter.                          •
   It is not enough to empty the bladder,
 care must be  taken to  prevent the urine
 from accumulating again, and, consequent-
 ly, the catheter, according to some, must
 be left introduced. Others are of opinion,
 tliat  it  is better to  pass the instrument
 whenever the patient has any  occasion to
 make water.   According to Desault  and
 Mr.  Hey, the bladder regains its contrac-
 tile power soonest, when the catheter is
 introduced as often as occasion requires,
 instead of being allowed  to remain con-
 tinually in the urethra.
   When the retention of urine has lasted
 a considerable time, when the hypogastric
 region is painful, and the patient is fe-
 verish,  venesection  may  be performed,
 and, in all cases, diluent beverages, of a
 slightly astringent nature, are to be  pre-
 scribed.  The intestines are to be emptied
with glysters, and the regimen is  to  br:
regulated by  the condition, in which the
patient happens to be.
  For a certain length of time, things  re-
main in this state.  When the urine flows
from the catheter in a rapid stream, which
is projected to some distance, and when
it also passes out between the catheter and
the urethra, it is a sign, that the bladder
has regained its power of contraction, and
that it can empty itself, without the aid
of the instrument.  In this circumstance,
the catheter is to be taken away, and the
patient may gradually resume his occupa-
tions, and usual mode of life.  When  the
urine only  escapes through the catheter,
and m a slow stream, the employment of
this instrument is always  requisite, and
its use  cannot be discontinued, without
hazard of the bladder becoming distended
again, and losing whatever degree of tone
it may have  recovered.  However, a  ca-
theter cannot be suffered to remain in the
bladder more than twelve days, or a fort-
night.  Some persons have in their urine
so much mucus and earthy matter, that
an  incrustation  would not fail to take
place on the  instrument, if care were  not
taken,  every  now  then,  to  withdraw
it and  clean  it.  In other persons,  the
pressure, which the catheter makes on the
part of the urethra, corresponding to  the
root of the penis, in front of the  scrotum,
occasions  in this  situation an inflamma-
tion, which ends  in mortification,  so that
a slough about as large as a crown, takes
place, followed by an opening with loss of
substance, which  opening  remains fistu-
lous during the remainder ofthe patient's
life.  The latter inconveniences  do  not
attend the employment of flexible gum-
catheters.
   The time, which  the bladder takes to
regain  the power of  contracting, varies
considerably in different cases. When the
disease is  accidental and sudden, it  fre-
 quently goes off in a few days.   When  it
 has come on in a slow manner,  it  usually
 lasts about  six weeks.  The cure, how-
 ever, is not to be despaired of, if the pa-
 ralytic affection  of the bladder  should
 continue much longer.  M. Sabatier says,
 that he has seen patients wear a catheter
 upwards of ninety days, and yet  ultimate-
 ly get completely well.  When there  is
 reason for believing,  that  the urine  will
 come away of itself, the use of ihe cathe-
 ter may be discontinued,  great  attention
 being  paid  to the state  of the patient.
 When he makes water very slowly ; when
 he is obliged to make frequent  attempts j
 and when  he feels a sense of weight about
 the neck of  the bladder; this viscus has
 not recovered the whole of its tone,  and
 the employment of the catheter is still ne- 
URINE, RETENTION OF.
459
cessary.   Sabatier  states,  that  he  has
•ften successfully recommended the ca-
theter to be worn only in the night-time,
when the patient could make water tole-
rably well in the day, and experienced the
above complamts in the night.
  When  three  or  four months elapse,
witii >ut  the urine resuming its ordinary
course, Sabatier informs us, that, we may
be sure, that the tone of the bladder is
lost for ever. In this unfortunate case, all
that can be done is to advise the patient
to make continual use of a flexible cathe-
ter, which he should be taught to intro-
duce himself, whenever he  has occasion.
(See  De la Medeeine Operatoire par Saba-
tier,  rom. 2.)
  Among  the  means  deserving  of trial,
when the contractile power of the blad-
der does  not return with the use of the
catheter, 1 have to  mention  the  tincture
of cantharides; blisters applied to the sa-
crum, and kept open with the savine oint-
ment ,- and  cold washes to the hypogas-
tric region.

2. OF THE RETENTION OF URINE, OCCASIONED
   BY INFLAMMATION OF THE NECK OF THE
   BLADDER.

   This case makes its  attack with the
most urgent symptoms. Besides the in-
clination to make  water, and the efforts,
which such inclination causes, the patient
is affected with a swelling of the bladder
above the pubes, a deep-seated pain in
that viscus and all the neighbouring parts.
Fever,  nausea, vomiting, a  urinary smell
in the breath, and perspiration, great rest-
lessness, a difficulty of breathing, convul-
sions, and  death, are  the train  of evils,
which may ensue.
   The present kind of retention of urine
demands the employment of the antiphlo-
gistic plan  of treatment; particularly, of
bleeding,  diluent  emollient  beverages,
glvsters, the  warm bath, and anodynes.
When these are unavailing, the  catheter
should be resorted to, and its use should
never be deferred so long as to afford any
chance of  the distention of the bladder
occasioning a paralysis of this  viscus.
When the catheter cannot be introduceei,
the operation of puncturing the blaelder is
immediately indicated. See  Bladder.

3. OF THE RETENTION OF URINE OCCASION-
   ID BY FOREIGN  BODIES  IN THE BLAD-
   DER.

   Several kinds of extraneous matter may
 be lodged in the  bladder; for instance,
stones,  worms, pus, blood, &c.  Here, we
shall only treat of  the  retention ot urine,
originating from the presence of stones, or
of blood, because  these  causes  are  the
most frequent.
  One, or moie stones in the bladder give
rise to  particular symptoms, explained
in tiie articles  Calculus  and  Lithotomy.
They  ^eldom occasion a total reiention
of urine.  If such a case  were to present
itself, it might be easily  understood by
preceding circumstances.  The complaint
might be relieved, and this, perhaps, fe>r a
considerable time, by introducing a sound,
which would push the stone  away from
the neck of the bladder, towards the  fun-
dus of this viscus. Instances  are not un-
common,  in  which  the  patients,  after
having  been  tormented  by  the lodg-
ment  of stones  in  the  bladder, became
afterwards quite free from all kind of un-
easiness.   Sabatier nukes mention  of a
clergyman, who was sounded by a  very
skilful surgeon, and  who finding himself
afterwards free  from the pains, which he
before suffered, thought,  that the surgeon
had been mistaken,  when he  said,  that
there was a stone in the bladder, and that
lithotomy ought to  be  performed.  The
patient also bequeathed his body for dis-
section to the surgical  practitioner,  in
order that the latter might reap instruc-
tion from the examination. The surgeon
accepted this odd legacy; and, when the
body  was opened in the presence of nume-
rous  spectators, a large stone was found
in the bladder.
   Blood may "descend from the  kidneys
into the bltdder; or  it may accumulate in
this lai ter receptacle, in consequence of
some injury, or ulceration of its inner coat.
When the blood remains  in a fluid state,
it may be  voided almost as easily as the
urine itself. But, when it coagulates, the
clots, which are formed, may obstruct the
neck  of the bladder,  and occasion a reten-
tion eif urine; a case, which is the more
alarming, as the collection of blood gene-
rally  cannot  be  drawn off by means  of a*
catheter.  However,  one  of a  very large
size should be introduced, in order to try
whether the thing is practicable  When
this method fails, authors  advise a syringe
to be fastened on and adapted to the outer
end of the catheter, by  which means the
bio d and urine are to be sucked,  as it
were, out of  the bladder.  Sabat ier states,
that  this plan has  been practised  with
success,  in cases, which seemed almost
desperate.

4. OF THE RETENTION OF URINE, CAUSED
   BY THE PRESSURE OF THE GRAVID UTERUS
   ON  THE BLADDER.

   Such pressure often occasions a  diffi-
culty of making water, and a retention of
urine.  Women  relieve  themselves by 
63
URINE, RETENTION OF.
leaning do»~> on their knees and elbows,
in which position, the uterus makes less
pressure on the neck  of the  bladder.
Some introduce one, or two fingers into
the vagina, and push the uterus upward.
Others must have the catheter introduced,
particularly, about the period of parturi-
tion.  When there are  no other impedi-
ments to the passage ofthe ca/heter, than
the cause of the disease, the instrument
may easily be introduced.
   When, however, the course of the mea-
tus urinarius is rendered  crooked, either
5n consequence of  an old prolapsus uteri,
or of the pressure occasioned during la-
bour, the urine can only be  drawn off by
means of a catheter, with a  rounded end,
which instrument  should be first  intro-
duced wi*h its handle as much towards
tlie belly as possible,  after which, this
part of the instrument  is to be brought
downward  by  a  semicircular  motion.
(Sabatier Mededne Operatoire, Tom.  2,
p. 137.)

5. OF TUE RETENTION OF URINE CAUSED BY
   THE ENLARGEMENT OF  TRE  PROSTATE
   GLAND.

   When the swelling of the prostate gland
is of an inflammatory  kinel,  the retention
of urine makes its appearance by symp-
toms, which always attend  an  inflamma-
tion of  the neck  of  the  bladder.  This
affection  sometimes ends in an abscess,
which bursts of itself. Some writers have
considered about the propriety of making
an incision  into the  suppurated gland;
but, such a proceeding, perhaps, can never
be at all justifiable, or prudent.
   The diseased enlargement of the pro-
state gland has been treated  of in another
part  of  this   Dictionary.   See  Prostate
Gland.  The retention ot urine, occasioned
by this disease, begins with  a difficulty of
making water, just such  a  kind of diffi-
culty, as occurs  when the bladder has
been  deprived of some  of its  contractile
power, and receives relief from the use of
slightly diurectic  beverages.  When the
complaint becomes more urgent, and the
urine cannot be any longer evacuated, the
introduction of a catheter becomes indis-
pensable. Although this  operation is,  in
every respect,  perfectly easy of" accom-
plishment, it is not always attended with
the desired success.  The  catheter passes
in as far as it  can ; but, the urine  is not
discharged, because the end of the instru-
ment, according to Sabatier, becomes en-
tangled in the prostate gland, or between
a  swollen portion of this  gland and the
neck ofthe bladder, and does not reach to
the situation of the urine.  Hence,  Saba-
tier recommends the employment ofa ca-
theter with a very  long beak.  From th«
account, however,  which we  have deli»
vered of the alteration produced  in the
course of the urethra by  the meirbid en-
largement of the prostate gland, (see Pro-
state Gland,) it appears, that  the canal
in quc^ion  generally makes, in tfrs case,
a suelden turning upward, just before  it
approaches  the  bladder,  consequently,
when a catheter has its end bent a little
more  upward,  than  usual, it  is  best
adapted for passing into  the bladder,  in
the affection under consideration.  When
the surgeon has succeeded in introducing
a catheter, it is to remain introduceei, till
the bladder has recovered its tone, or con-
tractile power, just as was recommended
in the  case  of paralysis of this  viscus.
When, however, all efforts  to pass a ca-
theter are quite ineffectual, the only re-
maining resource  is  to  puncture the
bladder above  the pubes.  (See Bladder,
Puncture of.) The operation should never,
in this case, be done through the peri-
naeum, or rectum, as  the very great size,
which the diseased prostate gland some-
times  attains,  would  be an obstacle  to
making a puncture  in  either  of these
situations.  Puncturing the bladder, how-
ever, is only a temporary means of relief,
unless this organ recovers its  contractile
power, or the surgeon  succeeds in intro-
ducing a catheter  through the urethra.
When neither of these circumstances oc-
curs, the cannula of the trocar must not
be withdrawn.
  The objections, which immediately pre- ,
sent themselves to leaving in the cannula,
for any considerable time, are :  the irrita-
tion of the extraneous  body:  the fear  of
calculous incrustations forming both on
the outside and inside of the cannula; and
the hazard of not being able to find out
again  the track into the bladder, when
the instrument is ever withdrawn. How-
ever, Sabatier confirms, that the cannula
may sometimes be successfully allowed  to
remain in the  bladder.  Collot  adduces
two instances in which he found this me-
thod very serviceable.  Sabatier also re-
fers to another example of similar success,
related in a thesis by  Murray. An inci-
sion had been made above the pubes,  in
order to be  more easily able to introduce
the trocar into  the bladder. The  wound
inflamed, suppurated, and was in  a heal-
ing state; but, as the urine could not be
voided through  the urethra, the  cannula
was left in the puncture. Things had gone
on in this manner more than a year, when
Dr. Murray saw the  patient.  The  man
was sixty years of age, and  enjoyed very
good health.  He  was  in  the habit  of
taking a stopper out of the cannula, every
four hours.  The wound had healed very 
UR1
UT E
461
  «teU all round the tube, and was quite free
  from redness.—(Sabatier. Medecine Ope-
  tatoire, Tom. 2. p. 140.)              *

  6.  OF THE RETENTION OF URINE PRODUCED
      BY STRICTURES IN THE URETHRA.

    From the  account,  which is given of
- strictures in another part of this Diction-
  ary, (see Urethra, Strictures of) it appears,
  that almost  every  stricture,  how  bad
  soever it may be, is capable of being  ren-
  dered still worse, and tiie morbid part of
  the urethra, more impe vious by a spas-
  modic affection.  Going out of a  warm
  into a  cold situation, d' inking and other
  kinds  of intemperance, will often bring
  on  an irritable  state of the canal, attend-
  ed with  a spasmodic action of  he stric-
  tured  part,  an  increased  difficulty of
  voiding the urine, and even a total reten-
  tion of this  fluid.  The patient makes
  repeated  efforts to relieve himself;  but
  hardly a drop of urine is discharged.   In
  the mean'while, the bladder becomes  fill-
  ed, and ascends  above the pubes;  the
  abdomen grows tense and painful; fever
  comes on ; the countenance looks red;
  the brain becomes affected; and circum-
  stances assume an extremely urgent ap-
  pearance.
     In tlus case, antiphlogistic means should
  be adopted, without delay.  The patient
  ought to be bled, if nothing in his consti-
  tution and age prohibits this evacuation,
  which it may even be proper  to repeat.
  He should also be put into  the warm
  bath,  and fomentations should be conti-
  nually applied  to the hypogastric region.
  Slightly  diuretic  beverages may be  pre-
  scribed ;  and  leeches put on  the peri-
  nacum.  The principal means,  however,
  from which  the greatest benefit  may be
  expected, is a  liberal dose of the tinctura
  opii,  together  with  an anodyne  iriyster.
  When such measures fail  in enabling the
  patient  to empty his  bladder, and  this
  viscus  is  becoming  more and  more dis-
  tended, an immediate attempt should be
  made  to  introduce a small flexibl- elastic
  gum-catheter,  through the stricture  or
  strictures into  the bladder, which object
  mav  be  frequently Accomplished, when
  due care, perseverance, and  gentleness
   are not neglected.
      Sometimes when a small flexible cathe-
   ter cannot be  introduced, a fine bougie
   admits of being passed into the bladeler,
   and, on  being withdrawn,  the  urine fol-
   lows,  and is discharged.
      When all the preceding plans prove un-
   availing, and the danger arising from the
   retention of urine, continues to increase,
   the only remaining resource is  to punc-
   ture the bladder.  The cannula  of the
trocar should then be left in  the wound,
till the  strictures are either cured, or at.
least till tiie urine  seems to resume its
natural course through the urethra.
  Useful information on the subject of
retention of urine, may be found  in De
la Medecine Operatoire, par Sabatier, torn.
2. Hey's Practical Observations in Surgery.
Desault's  Parisian   Chirurgical  Journal.
Home's Practical Observations  on the Treat-
ment of Strictures, &c. vol. 2. 1803.
   UTERUS,  INVERSION   OF.   This
case may either be complete, or incom-
plete.   When it is  incomplete, only the
fundus of the uterus passes  through the
03 tincac.   When the inversion is com-
plete, tiv uterus becomes entirely turned
insiele out, passing through  the opening
in  its  cervix, dragging  along with it a
part of the vagina, and descending more
or less far down, sometimes even between
the patient's th.ghs.
   The  inversion of the  uterus mostly
arises from  the manner in which the pla-
centa is extracted after delivery.   Just
after parturition,  the parietes of the
uterus  have  not had time to  become con-
tracted, and the mouth of this viscus is as
capacious  as it can  possibly be.   It is
easy of comprehension, how it  may hap-
pen, that, When things are thus'disponed,
the  uterus  may follow the  after-birth,"
which is attached  to the parietes of this
organ,  and thus become inverted.  The
event  is particularly lia >le  to  happen;
 1st, When  a premature1 attempt is made
to extract the placenta.  2dly, When the
funis is pulled outward, without any care
beirig taken to support the uterus by the
fingers ofthe left hand.  3dly, When the
operator draws  the after-birth outward
in too rough  and forcible a  manner.  It
is true, that the pi ecenta is sometimes so
 adherent, that its extraction is very diffi-
 cult, and some risk must be encountered
 of dragging  down  the  uterus  with  it.
 However, this unpleasant occurrence may
 generally be avoided by taking care to  se-
 parate  the placenta, by introducing one's
 fingers into the cavity ofthe  uterus.
   The  inversion of the uterus,  following
 parturition, should not always be ascribed
 to unskHfulness on the part of the practi- -
 tioner.   The accident frequently happens,
 notwithstanding every precaution  to pre-
 vent it, either because the p itients make
 too violent efforts to "deliver themselves;
 or  because  the uterus is enlarged and
 heavy;  or else  in consequence of some
 natural disposition  in the uterus, which
 disposition  can neither be  foreseen nor
 prevented.  Ruysch has seen an inversion
 of the  uterus take place, after the expul-
 sion of the placenta, although the delivery-
 bad occurred in the most favourable way. 
462
UTERUS, INVERSION OF.
 This disposition is very common in per-
 sons, who have once been afflicted with
 an inversion ofthe  uterus.  Amand makes
 mention of a case,  in  which a woman,
 who had had an inversion of the uterus
 in her first delivery, and who had been
 cured of it by  this  practitioner.   The
 same  patient was  attended  by Amand
 again in her next accouchement, and  an-
 other inversion of ihe uterus, quite as bad
 as the first, would certainly have happen-
 ed,  had not Am.nd, on  perceiving the
 disposition  to the accident,   introduced
 his finger into the cavity of the uterus, in
 order  to separate  tne placenta from  its
 attachments, before  making any attempt
 to extract it.
  Besides the causes of the inverted ute-
 rus, which are connected wth parturition,
 there are some others, which havt- no con-
 cern  with it whatsoever.  Ruysch, Mau-
 riceau, and  Lamotte,  were  of opinion,
 that the inversion of  the uterus could
 only happen at  the  time, when the  pla-
 centa was extracted, or a little while af-
 terwarels.   The occurrence  seemed to
 them quite impossible at any other pe-
 riod, both because the substance of the
 uterus is very thick and solid, and its
 mouth is very contracted.  However, Saba-
 tier remarks,  that there are many facts,
 which prove that this disease may depend
 on internal causes, and that it may affect
 women who have had no children, as well
 as others,  who have had  them.   Polypi
 ofthe uterus are causes of this kind.   As
 their pedicle is attached to the fundus of
 the  uterus, and is  very  firmly inserted
 into it, they may easily drag it downward,
 when its texture is lax anel soft, particu-
 larly, as their action, arising  from  their
 weight, is continual  and uniform.   We
 may also reckon among the  causes, the
 hemorrhages,  to which women are sub-
ject, both  because they relax the texture
 of the uterus, and because they are usu-
 ally attended with  an acute pain, which
 makes  the diaphragm  and  abdominal
 muscles contract, and act upon the uterus
 with all their power.
  When an  inversion of the uterus takes
 place after delivery,  there are  symptoms,
 by which  it may easily be known.  The
 uterus, when in its natural situation, pre-
 sents itself in the  hypogastric region in
 the form  of" a round circumscribed tu-
 mour; but, when it has fallen downward,
 and  become inverted, the above tumour
 cannot be found, and, a vacancy may be
 felt in the  situation, which it ought to
 occupy.  When  the  inversion is  incom-
 plete,  an examination with  the  fingers
detects in  the vagina a tumour, shaped
like  the segment of a sphere, having a
 smooth surface,  and being  surrounded
with the cervix uteri, as with a  kind of
collar, rounel which the finger may easily
be passes, either between the kind of col-
lar and the uterus, or between the collar
and  the vagina   When the  inversion of
the  uterus  is complete, there is in  the
vagina, and sometimes  quite protruded,
a tumour, apt to  bleed, of an irregularly
round  shape, with a smooth surface, and
hanging by a neck, which is surrounded
by the above circular, thick,  fleshy,  sub-
stance, consisting of the os  uteri itself.
In the  incomplete inversion, patients feel
acute pain in the  groins, and  kieineys, an
oppressiv  sense of heaviness in the hypo-
gastric region, and a tenesmus, which,
compelling them  to make violent efforts,
forces  the uterus down more and more,
and produces a total inversion of  it.   To
such symptoms are often  added hemor-
rhages, which are more or less copious.
But, when the  inversion is complete, the
pain is more acute, the loss of blood more
considerable, and the patient is often af-
fected  with  peculiar weakness,' which is
frequently followed by cold sweats,  con-
vulsions, and delirium.
  The reduction of the uterus is the  only
method,  by which the  above described
sufferings can  be-  appeased, and it ought
to be put in praotice the more quickly, in
proportion  to the urgency  of the symp-
toms.  When these are pressing, the least
delay may be followed by the worst  con-
sequences.   Some women,  indeed, perish
in a few  hours,  and,  when they  live
longer.the reduction becomes exceedingly
difficult, because  the uterus and its cervix
are continually becoming more and more
contracted.
  Sabatier  censures  the advice  to  put
some linen  between the hands and   the
uterus, in  making the  reduction, as an
unnecessary measure,  and one, which be-
reaves  the operator of the information to
be derived from the organ of touch, rela-
tive to the progress of the operation.  The
manner of proceeding can hardly be  de-
termined by a> y  precepts.  It  must be
regulated by existing circumstances; and
tiie trial should not be abandoned as long
as the  patient's strength will allow a  per-
severance.   Perhaps,  however,  if the tu-
mour should be  in an inflamed state, it
might  be  prudent, before attempting to
reduce it,  to take away blood,  put the
patient in the warm bath,  use emollient
applications, exhibit anodyne medicines,
&c.
  W hen  the inversion of the ttterus is
complete and the reduction has not been
accomplished in due time,  an endeavour
must be made  to quiet the spasms  and
pain arising  from the  accident, and  the
surgeon must await what nature  will do 
UTERUS, PROLAPSUS OF.
463
for the patient.  Many die ; while others
survive, subject to an oppressive sense of
weight, and frequent hemorrhages, which
bring on'  great  emaciation.  Sabatier in-
forms us of his having seen two patients,
who had  had an inversion of the uterus,
during six months, and who were still able
to go about their family affairs. The same
author says,  he has heard of some other
persons, who have had an inversion of the
uterus several years.
   One ofthe most afflicting consequences,
which may  result from an inversion of
the  uterus, is so  considerable an inflam-
mation of the part, as  to induce a danger
of its mortifying.  In this circums'tance,
some have proposed to extirpate the ute-
rus ; an operation, however, that has not
been attended with any degree of success,
as the majority of patients, on whom it
has  been  practised have died.  However,
there are instances recorded of women
having recovered after such an operation.
Vieussens has related a case of this kind,
in which a ligature was applied round the
neck of the swelling,  and the part below
amputated.
   The practice of extirpating the inverted
uterus, through apprehension of the part
mortifying, however, cannot be reprobat-
ed in terms too strong.   The only alleg-
ed reason for having recourse to the ope-
ration, is  the very considerable degree of
inflammatory  swelling, which affects  the
part.  But, it is  not  altogether imprac-
ticable  to bring the uterus  into a state
again, in  which the inconveniences, aris-
ing  from  its inversion,  would be very sup-
portable,  so that an operation might be
avoided,  which is always attended with
extreme danger.  Even  supposing morti-
fication were to take place,  the indication
would be to appease the bad symptoms,
and promote the separation of the sloughs
by  suitable   applications.   Rousset  has
recorded an example,  in which the latter
mode of practice  was adopted with suc-
cess.
   Some  writers  have  not been content
with advising the extirpation of the ute-
rus, when it is entirely  inverted, very pain-
ful,  and irreducible,  in consequence of
the  contracted state of the cervix of this
organ;  but, they have also thought such
a proceeding proper in cases  of a com-
plete prolapsus, when the  part is much
swollen   and   inflamed.  Instances  have
been adduced, illustrative of the success
of this operation.   However,  it is now
generally thought, that most of these ex-
amples  are  invalid, as polypi, growing
from the uterus, frequently attain so con-
siderable a size, that they protrude out of
the  vagina,  so as to have occasionally
been mistaken for the uterus itself. These
have been extirpated with a ligature, with
most beneficial consequences  to  the pa-
tient.
  There is no doubt, however, that in a
few instances, the uterus has been ampu-
tated, and the patient has recovered.
  Although it is easy to distinguish the
inversion  of  the uterus, which happens
soon after delivery,  it is not so to make
out the nature of such  cases,  as  happen
in other circumstances, notwithstanding
the presence of the  same kind of symp-
toms.  As cases of the latter kind are ex-
ceedingly uncommon, and,  consequently,
they  are not at all expected, mistakes are
the more liable to be made.   A very little
attention suffices for discriminating  an
inversion of the uterus from  a polypus,
with which it has sometimes been con-
founded.  In short, ihe pedicle of a poly-
pus  is always narrow ;  the tumour is not
very sensible,  and is irreducible ; whereas
the  uterus forms a  semi-spherical swell-
ing,   sometimes  a little oblong, but,  al-
ways broader above, than   below.  It is
very sensible, and may be easdy reduced.
  The reduction of the inverted uterus is
also  the only  step, which can be taken,
whether the accident has arisen from the
weight of a polypus, or from hemorrhages.
However,  this proceeding  is generally
useless,  when the disease originates from
obesity.  In the latter case, as the cause
still  continues in full force, it in general
soon  displaces the  uterus  in the  same
way, as befire, and a pessary  is the only
means,  to  which the patient  can resort.
This instrument is to be worn,  rather with
a view  of supporting the weight of the
abdominal viscera, which pushes the ute-
rus  down  into the vagina,  as  well as the
fundus, through the  cervix  of  the worn}},
than with any design of preventing "the
inversion. (Sabatier,  Medecine  Operatoire,
torn.  2.)
   UTERUS,  POLYPI  OF.    (See  Poly-
pus.)
   UTERUS,  PROLAPSUS  OF.   This
may take place in three different degrees.
When  the  prolapsus occurs  only in  its
first or second degree, the uterus  is  si-
tuated in the vagina, where  may be felt a
pyrifbrm  tumour, round which it is easy
to pass the end  of the finger.   At the
lower part of this tumour, an opening,
placed  transversely,  may also be distin-
guished.  In the first, or slightest degree,
the  uterus is  situated higher up,  than in
the  second.  When  tiie disease has pro-
ceeded  to the third, or last degree, the
uterus is completely  protruded out of the
vulva.  In the latter circumstance,  it al-
ways drags down the vagina, which be-
comes doubled on itself, and it also draws
down a part ofthe bladder,  which is con- 
464                      UTERUS, PROLAPSUS OF.
 nected  with the upper part of  the latter
 tube.  It also  sometimes happens,  that
 some of the abdominal  viscera insinuate
 themselves  into the kind of cul-de-sac,
 formed by the vagina, and they then con-
 siderably increase the size of the tumour.
 The swelling,  occasioned by a complete
 prolapsus of the uterus, is  of an  oblong,
 nearly cylindrical form,  and it terminates
 below,  in a narrow extremity, in which a
 transverse opening, the  os tincae,  may be
 discerned,  from   which the menses are
 discharged,  at  the periods prescribed by
 nature.  The cylindrical shape of the tu-
 mour is the  more apt to leael to mistakes,
 as  the vagina, being doubled  on itself,
 and exposed  to the eff'ects of the air,
 sometimes assumes an appearance very
 similar to that of tlie skin.  Hence, wo-
 men, afflicted with a complete  prolapsus
 uteri, have  sometimes been regarded as
 hermaphrodites,  in  consequence  of the
 tumour having been mistaken for a penis.
 Saviard  has recorded  an  instance, in
 wliich this kind of error was made.
  The  inconveniences, arising  from the
 first and second degrees of prolapsus ute-
 ri,  are a sense of heaviness in the  pelvis,
 anel a degree of uneasiness in the kidneys.
 These complaints are aggravated, when
 the patient sits up or walks about.  On
 the contrary, they diminish, and even en-
 tirely subside,  when the patient  has re-
 mained a certain time in bed.
  The  syrliptoms, attending a  complete
 prolapsus uteri, are  of a more severe na-
 ture.  The patient experiences a greater
 sense of heaviness in the pelvis, and pain
 and dragging in  the loins.  She  is trou-
 bled with tenesmus,  and sometimes feels
 acute pain in the  tumour itself, which is
 subject to inflame, and ulcerate, in con-
 sequence  of its depending  posture, the
 friction, to which it is exposed, and the
 irritation of  the urine, as this fluid runa
 over it.
  The uterus,  when only  affected with
 the first or  second degree of prolapsus,
 mny be easily reduced.  Indeed,  it often
 resumes its  natural situation,  when the
 patient  is put in a position,  in which she
 lies on her back, with her  loins raised a
 little higher, than her chest.  When this
 method is insufficient, the fingers may be
 introduced into the vagina, for the pur-
pose of accomplishing the reduction. The
 patient suffers no  pain, at the time when
the  reduction is performed, which, for the
 most part, takes place  spontaneously.—
 By  the  latter circumstance, a prolapsus
uteri may be discriminated from  polypi,
either of the uterus, or vagina, which tu-
 mours  do not  admit of being  reduced,
which are in shape, broader below, than
above,  and  which present no aperture,
similar to the os tincae
   When the uterus is affected with a com-
plete prolapsus, the  reduction is not so
easy o!  accomplishment. The great num-
ber of parts, which the displaced viscus
drags downward with it, and the tume-'
faction,  wliich sometimes follows, render
it necessary to  take some preparatory
measures, before trying to replace the part
in its natural  situation.  For  this  pur-
pose, the  patient should be kept in  bed,
be put  on a low regimen, be bled, take
purgative meeiicines,  use the warm bath,
and drink diluent beverages, while emol-
lient  applications are to be  made to the
part itself.   This  plan  of treatment  has
often been attended  with complete suc-
cess,  in cases of prolapsus uteri,  6f  long
standing and considerable size.   Ruysch
was  against  making  any attempt to re-
duce the  uterus, while this part was in-
flamed  and  swollen.   He  also thought,
that the operation  should  be postponed
when the uterus was in an ulcerated state.
However, Sabatier observes, that, as this
complication is only  an accielental  one,
anel  merely arises from the friction, to
wliich the tumour is exposed, and the ir-
ritation  of the urine, the plan of immedi-
ately replacing the  part  cannot be at-
tended with  any  danger.   On the  con-
trary, since  the cause which produces
and keeps up the ulceration will cease, as
soon as the reduction is accomplished, it
follows, that, the sores will soon  heal
after  the  uterus is put into its natural si-
tuation again.
  When we reflect on the position of the
uterus,  on the strength of the ligaments,
destined to support it, and on the manner
in which the vagina is connected with the
surrounding  parts, we cannot easily con-
ceive, how the womb can become so much
displaced,  as it is  in cases of complete
prolapsus.  It is still more difficult to
comprehend, how the uterus can become
displaced  during pregnancy, even  when
this  viscus  has attained its utmost state
of distention.  However, this sort of case
has  frequently  happened.   Sabatier re-
marks, that he could adduce several ex-
amples,  and  quotes an instance from the
Traite ties Accouchemens de Portal.
  The prolapsus uteri, which occurs dur-
ing pregnancy, demands the utmost care.
The  part  is  capable  of being reduced,
while the patient is in the early stage of
pregnancy.  When pregnancy has far ad-
vanced,  or the disease is of longstanding,
the reduction is difficult.  Perhaps,  says
Sabatier, it may be more pruelent in these
circumstances, to let  the uterus continue
protruded than to disturb the mother and 
UTERUS, RETROVERSION OF.
465
 fetus with reiterated attempts to reduce
 the part.   The uterus, however, should
 not be left to itself; but be well sup-
 ported with a suitable bandage, and the
 ?£l!ent  °Ught  t0  be keP* m her be<l-
 When the prolapsus  uteri occurs at the
 very period of delivery, every attempt at
 reduction is both useless and dangerous.
 In  this case  every exertion  should  be
 made  to promote the delivery ofthe foetus,
 by gradually dilating tiie os tincae, which
 should, at the same  time, be  carefully
 supported.  The extraction of the pla-
 centa  also requires a great deal of caution,
 and it should  be accomplished by intro-
 ducing a hand into the uterus, with the
 palm turned away from the cavity of this
 viscus, towards the outside of the pla-
 centa, which is to be gradually separated
 by proceeding from one of its edges to-
 wards its centre.
   In cases of complete  prolapsus  uteri,
 Ruysch was an advocate for leaving the
 expulsion of the foetus, if alive, to be ef-
 fected by nature -,  and the same writer
 aelvises us to be content with supporting
 the os tincae.  But,  when the child  is
 dead,  he recommends extracting it  with
 pne hand,  while the uterus is supported
 with the  other.  Sabatier, however, en-
 tertains different  sentiments.  The ex-
 pulsion of the child i-. not less the effect
 of the  contraction of the diaphragm and
 abdominal muscles, than of the womb it-
 self.   Hence, it is easy to conclude, that
 when  either of these  agents fails  in co-
 operating,  tiie  delivery  becomes  either
 very difficult, or impossible.  This is ex-
 actly what happens in the present case ;
 for, the uterus having fallen down, can
 no longer be compressed by the action of
 the  diaphragm and  abdominal  muscles.
 Sabatier sets down the practice, advised
 by Ruysch, as an exceedingly dangerous
 one; because, the efforts, made  by the
 mother to deliver herself, would  have a
 tendency  to  render  the prolapsus uteri
 more  complete,  and  thus  increase the
 dragging of all those parts, with which this
 organ  is connected.   Sabatier,  also, can-
 not discern the reason why Ruysch should
 recommend the line of conduct to differ,
 according  to the different state of the
 child.  This is, probably, quite passive
 in parturition, anel contributes  not  in the
 least to  its  own  expulsion.   Sabatier,
 therefore,  contends, that the treatment
 should not be at all  influenced by the
 consideration of the child  being  dead or
 alive.
  In whatever degree a prolapsus uteri
has taken place, it is not sufficient to have
reduced  the part. The prolapsus  would
soon recur, if it were not prevented by
     Vol. II.
 the employment of astringent injections'
 and pessaries.   (See Pessary.)
   UTERUS, RETROVERSION OF.  A
 retroversion of  the  uterus  is said to
 happen, when the fundus of this viscus,
 carried  by its  own weight, and forced^
 downward by the action ofthe diaphragm
 and abdominal muscles, become^ situated
 between the sacrum and posterior part of
 the vagina, while the cervix uteri becomes
 inclined  towards the  symphysis  pubis.
 This kind of case was not understooe*  -ill
 about the middle of the preceding cen-
 tury.   Sabatier states,  that Gregoire, a
 member ofthe college of surgery at Pans,
 first  mentioned  it in his private instruc-
 tions in midwifery.  Walter  Wall,  an
 English surgeon, who had atteneled Gre-
 goire, suspected that he had met with a
 retroversio uteri in a woman, some months
 advanced in pregnancy,  and  he called in
 Dr. Hunter, in order to have  the advan-
 tage of his advice.  The woman was  at.
 tacked  with an obstinate  constipation,
 and retention of urine, and died in about
 a week.  A large tumour was found oc-
 cupying the whole ofthe pelvis, and push-
 ing the  vagina against  tiie os pubis  It
 had been found impracticable to push the
 swelling back into the abdomen, although
 the patient had been put on her knees and
 elbows, while one hand had been  intro-
 duced into the vagina, and two fingers of
 the other hand  into the rectum-  Some
 curiosity  was   entertained,  concerning
 what state  things  would  be found  in.
 Opening the body shewed, that the bladj
 der, wliich was exceedingly full of urine,
 occupied almost the whole anterior part of
 the abdomen, in  the same manner as the
 uterus does in the last month of pregnancy.
 When the bladder had been emptied, that
 part of it, in which the ureters  terminate,
 and which is connected with the vagina
 anel cervix uteri,  was found raised up„ as
 high as the upper aperture of the  pelvis,
 by a large tumour, which filled the whole
 cavity of the pelvis, and was found to be
 the uterus.  A catheter,  when passed into
 the vagina, could be made to lift up the
 latter viscus, and the upper part  of the
 tumour.   This  portion  of the swelling,
 on which the  bladder lay, consisted  of
 the cervix uteri,  while the fundus of this
 organ was situated downwards towards
 the os coccygis  and anus.   The  uterus
 had attained such a magnitude, that it
 could not be taken out of the pelvis, be-
 fore the  symphysis pubis was divided,
 and the two ossa  innominata  were  pulled
 asunder.   It was  found  impossible to as-
sign any cause for the manner, in  which
the uterus had become eli*placed, as the
patient had been  making no exertion, had
    3N 
466                    UTERUS, RETROVERSION OF.
 met  with no  fall,  and had only been
 frightened at something just beiore the
 complaint commenced.
   Dr. Hunter, struck with the singular
 nature of the case, thought it deserving of
 attentiem  among medical men,  and he
 made it the subject of a lecture, which he
 delivered  to his pupils in 1754.  He was
 afterwards consulted by several persons,
 who  were afflicted  with  the retroversio
 uteri; but, not in  so acute a way, as in
 the above instance.  All the patients were
 in the third month of pregnancy, and first
 suffereel a difficulty of making water, suc-
 ceeded by a retention of urine, anel after-
 wards by constipation.  Dr.  Hunter al-
 ways emptied the blaelder by means  of a
 catheter  and  glysters, which measures
 sometimes effected a cure, the uterus spon-
 taneously  resuming  its natural  position.
 In every instance,  the accident disappear-
 ed, when pregnancy was more advanced,
 and tlie uterus had acquireel larger dimen-
 sions.  Success was not always obtained «
 for in some cases,  in which Dr. Hunter
 was consulted too late, the trials to re-
 place the uterus proved fruitless, and the
 women  died.   Dr. Hunter was  so firmly
 convinced of the impossibility of saving
 patients, circumstanced in the above man-
 ner,  unless extraordinary  means were re-
 sorted to, that he thought one should  en-
 deavour to diminish the si*:e of the uterus,
 by introducing  a trocar  into the  boely
 of this discus, through the posterior pa-
 rietes of ihe  vagina, so as to let out the
 water of the amnios, the relative quantity
 of which is known to be  greater, in  the
 early, than in the advanced, stage of preg-
 nancy.
   Such a puncture might certainly be the
 means of the uterus resuming its natural
 position; but,  there  would be considera-
 ble danger of its exciting  he contraction
 of the utetus, and c. using abortion.  No
 risk of this kind would be encountered by
 puncturing the  bladder above tiie pubes.
 In this manner, a free passage would be
 afforded for tlie escape of tlie urine,  and
 the reduction of the uterus might be ef-
 fected.                      &
   Mr. Lynn, a surgeon in Suffolk, has seen
 the bladder burst, and the ur::ie become
 extravasated in the abdomen, in a case of
, a retroversion  of  the uterus, in conse-
 quence  of the  patient's refusal to submit
 to the preceding operation.  The woman
 was forty years of age, of a relaxed habit,
 mother of several children, and had been
 pregnant  four months. She had been for
 some time before afflicted with  a prolap-
 sus ofthe vagina.  The swelling had been
 a few days reduced,  when, in consequence
 of tripping,  she felt something become
 displaced in  her  abdomen,  and fall to-
wards the lower part of her  back.   She
was immediately attacked with constipa-
tion, retention of urine,  nausea, and pain
in her belly.  The means, which were
employed, not proving effectual, Mr. Lynn
suspected,  that  a  retroversio uteri  had
happened, and introduced his fingers  into
the vagina, in order to ascertain the fact.
His fingers were stopped by a tumour, as
large as  a child's head.  The swelling
occupied the back part of this passage,
and descended as low as  the perinacum.
Being certain, that the nterus was  dis-
placeel, he  attempted to reduce it.  The
patient was put into various positions, and
the fingers of one hand were introduced
into the vagina,  while those of the other
were passed into the  rectum.  The use of
the catheter  was not forgotten ;  but, it
could uot  be introduced far enough to
reach the urine.  Glysters were stopped
at the very beginning ofthe rectum. The
abdomen was exceeelingly tense, especial-
ly, in the hypogastric region.  A proposal
was made to puncture the bladder; but,
the patient refused to submit, and prefer-
reel being left to her fate.  On the seventh
day eif her illness, she was very much re-
duced ; and became affected with nausea,
and hiccough, the forerunners of the mor-
tification, which was about  to happen
At length, she felt something  give way in
her abdomen, and, the ease,  which suc-
ceeded, revived her hopes. These, how-
ever, were not of long duration;  for, af-
ter being delivered ofthe foetus, she sunk
and died the  next morning.  On opening
the body, the bladder was found to have
sloughed and burst at several points,  and
two pints of urine were  consequently ex-
travasated in  the abdomen.
   We may conclude, from what has been
stated, that the retroversio uteri is an ex-
ceedingly dangerous  affection. However,
it is  not invariably  fatal, particularly,
when the patient receives succour, before
the disorder has made much progress. It
only occurs in the early months of preg.
nancy, anel in  women, whose  pelvis is
very wide, while its brim is very contract-
ed.  If the uterus, which occupies a  pel-
vis of this conformation, shoulel be pushed
back by a distended  state of the bladder,
and pressed against the sacrum, while the
soft  parts yield, the  viscus,  in question,
becomes, as it were,  wedged, and is inca-
pable of changing its position.   In  this
immoveable state, it presses upon the sur-
rounding parts, and these upon it, so  that
a very serious tram of bad symptoms are
the consequence.
   The. first  care of  a practitioner,  con-
sulted in a case of retroversio uteri, should
be to empty the bladder and huge intes-
tines, and to relax the parts by every  pos- 
UVULA, AMPUTATION OF.
46/
jnble means.  Then, he should immediate-
ly proceed to replace the uterus, by plac
ing the patient in a suitable posture, and
making methodical pressure in the rectum
and vagina.  Should he be so fortunate
as to succeed, the patient is to be kept  in
beel, her bowels are to be kept open, and
she is to be  advised always  to obey the
calls of nature the first moment she feels
any inclination to make  water.  She  is
also to  be enjoined to  avoid  all  kinds  of
exertion, anel wait,  till the gradual en-
largement of the uterus removes the pos-
sibility of this viscus descending into the
pelvis.  (Sabatier, Medecine Operatoire,
Tom. 2.)
   UVA URSI.  The author of the Phar-
macopoeia  Chir. remarks,  that,this  plant,
which was first brought into notice  by Da
Haen, has been generally  considered as a
powerful remedy in calculus ; but that it
has not  been proved, in any  instance,  to
 tiossess the properties  of a solvent.   The
 ate Dr. Austin, however, recommended it
upon the principle of its lessening the irri-
tability* of the bladder, and diminishing
that secretion of diseaseel mucus, which,
he supposed, greatly to contribute  to the
augmentation of the stone.
   Mr. Bell,  of Edinburgh,  strongly re-
commends it in that state  of a gonorrhoea
where the irritability  of the bladder is1
excited in a high degree, and where ^the
urine is loaded with a viscid matter.   In
these cases, he directs  the pewder  to  be
given in doses ofa scruple or half a elram,
three  times  a day.  A  remedy of this
sort is certainly a great  desideratum  in
6urgery.
   Dr. Saunders  directs  three drams of
uva ursi to be macerated in a pint of hot
water,  and two or  three ounces of the
strained liquor to  be given three times a
day.   (Pharm. Chirurg.)
    UVULA,  AMPOT'ATtON OF.  The
uvula is subject to  several kinds  of en-
largement, in which  it  becomes longer
and more bulky, than natural, or in which
it  merely  has its  length increased.  In
consequence of such changes, it acts  as
an impetliment to swallowing, and  speak-
ing, or else causes a disagreeable tickling
at tlie root of the tonguer with which it
comes into contact, and  thus it may ex-
cite frequent retchings, and an  annoying
cough.
    When things have  attained this state,
 mcelicines are often  ineffectual, and  the
only plan  of relief consists in amputating
a portion of the uvula, a  very simple ope-
 ration, which has been advised to be done
 in various ways.
    The ancients recommended taking hold
 of the uvula with a pair of forceps, and
 cutting off* tlie piece  below the blades of
the instrument.  Celsus remarks: Neque
quidquam commodiut est qudm vosella appre-
hendere, sub eaque, quod volumus, excindere.
Fabricius ab Aquapendente objects to this
method of operating, on the ground, that
it is necessary to employ both hands, so
that there is  a necessity for the  aiel of a
third for holding the tongue  and lower
jaw.  He prefers employing scissars,  and
thus to leave the  left  hand  at  liberty.
When the uvula had been cut  off, he ad-
vised a heated spoon to be applied to the
cut end of the part, with a view  of stop-
ping the bleeding.
   Par£  speaks in favour of the  method,
advised by Celsus.  When the  size ofthe
uvula is considerable, and there is  rea-
son to fear,  that the vessels  will bleed
freely, he  recommends it to be tied with
a ligature, by means of an instrument, in-
vented  by  Castellan,  a physician distin-
guished in his time, both by his  learning
and judgment.  The instrument in ques-
tion consists of a ring, with a  groove on
its convexity, which ring is mounted on
a slender handle. A ligature is put round
the ring with a slip-knot,  which  is to be
tightened  by means  of another ring, of
much smaller size, mounted, like the pre-
ceding  one,  on a  long  slender  handle.
The ligature  is to  be left in tiie mouth,
and, when it  does not seem to make suffi-
cient constriction, it. is to be tightened.
   Fabricius Hildanus has since described
an instrument, constructed on the same
principles, and  applicable to  the  same
purposes..  Scultetus made use of the lat-
ter on a soldier, whose uvula was affected
with the  venereal  disease.  This author
tloes not state, however, whether the liga-
ture, which was applied in this way, was
painful, productive  of considerable inflam-
mation, or whether the patient suffered
much inconvenience from the presence of
the ligature.   Such effects were probably
produced.
   Heister, in plate 21, has given the en-
graving of  an instrument, which was in-
vented by a Norwegian peasant,  in whose
country a relaxed state of the uvula is  a
very common affection.  The  contrivance
 was perfecteel by Raw.  It is  only neces-
 sary  for me  to  state, that it is a kind  of
 knife, concealed in  a sheath.   At the end
 of this last part, when the blade is drawn
 back, a notch is left, in which the uvula
 is to be  engaged,  and then  divided by
 pushing forward the knife.
   Sabatier's plan of cutting off a portion
 of the uvula, is performed in a way very
 similar to the one described  by Celsus.
 After having placed the patient on a liigh
 chair, and in a good light, with his head
 properly supported, he takes  hold of the
 uvula with a pair of forceps, with holes in 
468             V A G                               VAC
the blades, like those used for the extrac-
tion of polypi from  tiie nose.  He then
divides the uvula with a pair of scissars,
made with concave cutting edges, like the
ScibSars recommerdeel by Levret for divid-
ing the  umbilical cord.  As the uvula  is
rendered tense with the forceps, perhaps,
any other kind  of scissars would answer
equally well ;  but,  Sabatier states, that
those, which he  uses, have the advantages
of taking hold of a  larger piece  of the
"uvula, and of not letting it slip away.
   The perforated forceps also take better
hold of the  part, than common ones do,
from which it is apt to slip.  Sabatie r ob-
serves, that he has never seen any bleed-
ing of consequence follow the trivial ope-
ration  just  described.  (See  Medecine
Operatoire, Tom, 3.)
   In the First Lines of the Practice of Sur-
gery will be found an engraving of a pair
of scissars,  which  seem well calculated
for cutting off portions of the uvula, as
they have at the end of one of their blades
a transverse piece, which  prevents the
part, about to be cut, from slipping  away.
V.
    VACCINATION.   The practice of ino-
    culating  witlf cow-pox  matter,  or
lymph, for the purpose of rendering the
inoculateel  subject  insusceptible  of the
effects of the sm; 11-pox contagion.
  VAGINA IMPERFORATE.   It is very
common to meet m ith female infants, born
with  different  kinds of  ^perforations
Of the vagina.  Sometimes, this passage
is not completely shut up,  so  that the
usual evacuations happen  in an uninter-
rupted manner, and it is a  considerable
time before the malformation is  discover-
ed.  Doubtless, there has often been oc-
casion to obviate the defect in  question,
in eirder to qualify young women feir mar-
riage.  Some females have certainly be-
come pregnant, notwithstanding the sort
of  obstruction alluded to, anel,  in  these
cases, the membrane,  which shuts  up a
part ofthe mouth ofthe vagina, has either
been torn by the effects of labour, or been
divided as much as was necessary for pro-
moting this process of nature.
   What  is more curious, is, that  there
should have been found two membranes,
one placed beyond the other, and obstruct-
ing the vagina.   That, which is commonly
met with, is nothing more than the hy-
men, which is thicker, and stronger, than
natural.   Ruysch relates, that  a woman,
who had been in labour three days,  could
not be delivered.  The head  presented
itself; but, was prevented from coming
out by the hymen, which shut up the  va-
gina, and was very  tense   Ruysch  made
an incision into  the membrane; but,  to
no purpose, since there was another mem-
brane, of a thicker texture, anel situated
mere deeply in the passage, hindering the
delivery ofthe child.  On an incision be-
ing made into this second membrane, the
child was expelled, and the case  ended
well.
  When the vagina is completely imper-
fora.e, as soon as the time of the menses
commences, a great many complaints oc-
enr, which afflict the patient with more
severity, in proportion as the blood accu-
mulates in the  passage, and they may
even lead  to a fatal termination, when the
cause is not understood, or not detected
till it is too  late.  The complaints  allud-
ed to, are very  similar to those of preg-
nancy ; for  instance, 'rumbling noises in
the bowels, loss of appetite, nausea, vo-
miting, enlargement  of the  mammae,
spasms, convulsions, swelling of the ab-
domen, &c.  Hence, girls, in this situa-
tion, have often been supposed to be preg-
nant, although they were not in a state
even  to become so ; and some yemng wo-
men have been known to die, after  suffer-
ing the most afflicting symptoms.
   When the only malformation consist*
in the orifice of the vagina being shut up
by a membrane, tiie patient may be easily
relieved by  a crucial incision, or a single
cut, the edges of which are kept apart by
a  tent of suitable shape and  size.  In-
stances of the success of such an operation
are to be founei in numerous writers.  Fa-
bricius ab Aquapendente informs us, that
a female child was born with a membrane,
vdiich completely  shut up the vagina.
The  girl  experienced  no inconvenience
from it, till she was about thirteen years
ot age, when the period of her menses be-
 gan.  As the bloed was retained, she be-
 came afflicted with more severe pains in
 the loins, the lower part of the abdomen,
and about the  upper part of the  i highs.
 It  was supposed,  that  she  was attacked
 by the sciatic gout, and she was treated 
VAGINA, PROLAPSUS, OR INVERSION OF.              469
accordingly.  Notwithstanding the medi-
cines, which were prescribed, she became
hectic, and reduced to a complete state of
marasmus, in  which she passed restless
nights, had lost her appetite, and was de-
liriouj.  A painful,  very elastic tumour
afterwards took pUce in that part of the
abdomen  corresponding to the  uterus.
The pains were  aggravated every  month,
at the period, when the patient ought to
have menstruated.   She was  in a dying
condition, when   Fabricius  ab  Aquapen-
dente Was consulted, who, after ascertain-
ing the real nature of the case, performed
the  requisite  operation.   A  prodigious
quantity of black putrid blood  was  dis-
charged  from the vagina ;  the bad symp-
toms gradually subsided,  and the  patient
recovered.
   It is not always equally easy to cure the
imperforate vagina, when the malforma-
tion is produced by an extensive  accretion
of the sides of this passage to each other.
The success of  the  operation is more
doubtful,  because,  it  is  impossible to
reach the situation of the  blood without
cutting through a considerable  thickness
of parts,  in  doing which  there is some
danger of wounding the rectum, or blad-
derr • A  lady, twenty-four years  of age,
after having  tried, for eight years, such
remedies as seemed best calculated for ex-
citing the menstrual discharge, became.
affected with a large hard swelling of the
abdomen, and a kind of herpetic affection
round the body near the navel. At length,
it was discovered, that tlie imperforation
•f the vagina was the sole cause of all the
bad symptoms,  wliich the  patient  had
long endured.   An incision  was made,
which enabled the operator to introduce
his finger into a large cavity, and which
gave vent to a  considerable quantity of
blood.  It was thought, that an opening
had been  made into the vagina ; but, the
patient  having  died  three days after-
wards,  it was seen, that  a mistake  "Tad
been made, as the cavity, in which the fin-
ger had been introduced,  was that of the
bladder.  The vagina  was closed below
by a substance an inch in  diameter,  and
half an inch thick.  The  upper  part of
this passage, the uterus, and the Fallo-
pian tubes, were exceedingly  enlarged,
and filled with  a dark-brown,  sanious
fluid.  A similar fluid was found extrava-
sated in the  abdomen, and, it was discq-
vered  to  have got there  through a  rup-
ture, which had  taken  place in the Fallo-
pian tube. The ovaries were in a natural
state.   De Haen, who has related  this
ease in the sixth  part ot his work,  intitled
Ratio  Medendi,  was of opinion, that, in
order to  avoid opening the rectum, or
bladder,  only one oblique cut should be
made in  the membrane,  which stops up
the vagina, just as was aelvised, by Meeck-
ren  (Sabatier de la Medecine Operatoire,
Tom. 1.)
  VAGINA, PROLAPSUS, OR INVER-
SION  OF.   This  affection  may  take
place in  various degrees.  The prolapsed
part does not consist of all tl)e coats' ofthe
vagina, in the manner that the inverted
uterus is formed of the whole substance
of that viscus, which becomes turned in-
side out.   The inner fining of the vagina
is  alone displaced, in consequence of the
swelling, and  thickening, with which  it
U  affected.  The inversion of the vagina
appears like a thick, circular substance,
irregularly pleated in the middle, and at
the bottom  of wh.ch the cervex uteri is
situated,  having descended further down,
than natural.  The  prolapsed  portion of
the vagina increases, or diminishes,  ac-
cording as the patient sits up, or  keeps
in  bed a  certain  time.   The complaint is
accompanied by a sense of heaviness in
the hypogastric region; tenesmus;  and a
difficulty of making water, in consequence
of the alteration produced in the direction
ofthe meatus urinarius.
  Such is the prolapsus of the vagina in
an early  state; but, when it  has been of
long standing, and the patients have re-
mained,  for a long while, without any as-
sistance,  the  membranous lining of the
passage becomes more and more thicken-
ed; the tumour, winch it forms, becomes
more considerable,  elongated, and hard-
ened.  In this  state, there still continues
at  the lower,  part of the  swelling, an
opening,  out of which the usual evacua-
tions  are made.   The  grievances,  which
patients  suffer, are similar to those aris-
ing from  a prolapsus uteri, to which, in-
deed, the present case  bears  a great re-
semblance.  The  prolapsus vaginx, how-
ever, differs,  inasmuch  as  the tumour,
formed by a descent of the uterus is very
firm,  and terminates in a narrow end, on
which may be observed  the longish trans-
verse opening, named the os tincx, while
the  tumour,  arising from a  prolapsus
of the vagina, is soft, thicker below, than
elsewhere, and ends in an irregular  aper-
ture.
   When  the prolapsus vaginae is recent,
the part  may be  easily reduced, and kept
up with a pessary; but, when tiie case
has been of long standing, it is neither
easy to effect  the reduction,  nor to  pre-
vent a recurrence of the disorder.   Soft-
ening, relaxing remedies, in this circum-
stance, are recommended, and the patient
shoulel, in particular, confine herself to
her bed, and  wear  a T bandage,  which 
470
VAR
VAR
should be made to press upon  and sup-
port a piece of sponge in the orifice ofthe
vagina.
  The swelling of the membranous lining
of this passage, being folded back on  it-
self, increases  in such a degree, that the
tumour, thus occasioned, falls into a state
of  mortification.  In this  event,  some
writers have advised the extirpation of the
swelling, justifying tiie  practice,  on  the
authority of some  distinguished  practi-
tioners, and the little danger,  attendant
on the operation.
  Even Sabatier only objects to  this pro-
ceeding, on the ground of the danger of
mistaking a prolapsus of the uterus, for
one  of the  vagina.  However, no mo-
dern surgeons in this country would hesi-
tate about  rejecting  such an operation,
and  leaving tiie sloughs  to  separate  of
themselves.
  VARICOCE'LE.  (from  varix,  a dis-
tended vein, and xtiAif, a tumour.)   Many
writers mean by the term varicocele, a va-
ricose enlargement of the spermatic veins,
which latter affection, we have, with Cel-
sus and Pott,  treateel of under the name
of Cirsoeele.
  Pott remarks, that the varicocele (which
is i an enlargement and  distention  of the
blood-vessels of the scrotum) is very sel-
dom an original disease,  independent of
any other,  and,  when it is, is hardly  an
object of surgery.  The blood-vessels  of
the scrotum areofdifferentsize in different
people ; and like the vessels in other parts
ofthe body, are liable to become varicose;
but, they are seldom so much enlarged,
as to be troublesome, unless such enlarge-
ment is  the  consequence  of a disease,
either of the testicle, or spermatic chord.
When this is the case, the original disease
is  what  engages our  attention, and not
this  simple effect of it; and,  therefore,
considered abstractedly,  the varicocele is
a disease of no importance.  (Pott's Chi-
rurgical Works, Vol. 2.)
  VARI'CULA. (dim. of varus, a dilated
vein.)   A  varicose enlargement of  the
blood-vessels of the tunica conjunctiva of
the eye.
  VA'RIX.  (from varius, unequal.) The
term varices is applied to a kind of knotty,
unequal, dark-coloured swellings,  arising
from a dilatation of different parts of the
veins.  Varices most frequently occur in
the feet, near the ankles, and, sometimes,
higher up,  in the legs, thighs,  and other
parts,  as, for instance,  the scrotum,  and
even the abdomen, as  Celsus  has accu-
rately remarked.  Pregnancy is one of the
most common causes of varicose veins.
The disease, however, may be occasioned
by the pressure of other swellings,  be-
sides that  of the  gravid uterus;  it may
also be produced by leading too sedentary
a life, and,  in  short, by every kind  of
cause, capable  of retarding the return of
the blood, through the veins, towards the
heart.  The larger the diseased vessels
become, the more painful and troublesome
they are, in consequence of the great dis-
tention of their  coats.  Sometimes,  they
even burst, and emit a considerable quan-
tity of blood; while, in other instances,
they give rise  to very  obstinate ulcers.
When the affected veins are  not of large
size,  they seldom  cause any very serious
inconveniences.  Hence,  patients  com-
monly make no complaint, and the neglect
of the case gives  it an opportunity to ac-
quire an aggravated form.
  When  varicose veins are in a painful
state, the patient (if other circumstances
do not forbid) should be bled, and be put
on a cooling regimen.   A roller should
also  be applied with due tightness, and
its employment continued for a consider-
able  time.
  Celsus  informs  us,  that the ancients
used to relieve  patients, afflicted with va-
ricose veins, by the actual cautery, or  an
incision.   The first is  a very objectiona-
ble method; and  the   latter is  seldom
necessary, except  as formerly described
by Pare"  and latterly by  Mr. Home,  in
particular cases of  ulcers on the  legs.
(See Ulcers.)  However, some writers are
of opinion,  that, when the varicose veins
are  exceedingly painful,  and likely to
burst, it is  best to  make a longitueiinal
opening into the largest  of them with a
lancet, in order to give  vent to a certain
quantity of blood,  proportioned to the pa-
tient's strength, and, they advise a com-
press and bandage to be afterwards ap-
plied.
  Dionis assures us, that he did not know
any better means of compressing varicose
veins, than buskins, made of dog-leather,
and  so contrived as to  be laced on the
part, with the requisite degree of tight-
ness.   Thus the leg might be compressed
in an  equal, regular way, without any oc-
casion for removing the pressure at night.
Since the time of Dionis, laced stockings
have  been  very commonly  and  usefully
employed for the cure of varices, situated
in the leg.
  Some have spoken in favour of apply-
ing  astringent  applications  to  varicose
veins, as, for instance, compresses dipped
in vinegar.  But, though such remedies,
perhaps, ought  not  to  be altogether  re-
jectee! as useless, little dependence can be
put on them, unless they are  employed  in
conjunction with compression, wliich,  in
the  majority of cases, has e»f itself much
greater effect,  than any other plan, pro-
vided it is  methodically made, and duly 
VENEREAL DISEASE.
471
 maintained.  For this  purpose a  laced-
 stocking is certainly better, than any kind
 of roller.
   For an  account of the method of curing
 a particular sore on the leg, depending on
 varicose veins, see Ulcer.  For a descrip-
 tion ofthe varicose affection of the veins of
 the rectum, see Hemorrhoids.
   VAR1.   Persons born  with  their  feet
 deformed and turned inward are  so term-
 ed.
   VALGI,  on the contrary, was used to
 express subjects born with their feet de-
 formed and turned  outward, which  is a
 less frequent case.
   VENEREAL DISEASE.  (Lues Vene-
 rea.  Morbus Gallicus.  Syphilis, or Siphi-
 lis.)  About the year 1494, or 1495, the
 venereal  disease is said to have made its
 first appearance in  Europe.  Some wri-
 ters are  of opinion, that the  distemper
 originally broke out at the siege of Na-
 ples ; but, most of them have supposed,
 that, as Columbus returned from his first
 expedition to the West Indies, about the
 above  period,  his followers brought the
 disorder  with  them from the new to the
 old world.  Other authors, among whom
 is Mr. B.  Bell,  maintain the opinion, that
 many  arguments  might be adeluced to
 show,  that the venereal disease was well
 known  in the old continent, and that it
 prevailed among the Jews, Greeks,  and
 Romans,  and their descendants, long be-
 fore the discovery of America.
   Marcellus Cumanus, Johannes de Vigo,
 and other early writers on the liies vene-
 rea have  left an account of some of the
 symptoms, and their description, as far as
 it extends, is found  to agree with the ap-
 pearances, observed eVen at the present
 day.   Marcellus remarks : " I observed
 many of the  officers and foot soldiers in
 Milan, while 1 was in the camp at Navar-
 re, to  have  several scabs, or pustules,
 breaking out on the face, and spreading all
 over the rest of their bodies.  The first of
 which appeared  usually under the prx-
■putium, or on the outside, like a grain of
 millet,  sometimes behind the glans, with
 a small itching.  At other times,  a single
 pustule would arise, like a little bladder,
 without much pain, but, itching also.  If
 rubbed, or scratched, there arose an ulcer,
 corrosive, and smarting, like the sting of
 an ant," &c.  (Vide Astrue, Vol. 2. p. 226,
 translated by Dr. Barrowby.)
  Johannes  de Vigo notices the way in
 which  the disease is communicated by a
 chancre, in a still more particular and ac
 curate  manner:  " ejus origo in partibus
genitalibus, viz. in vulvd in mulierib.rs, e't in
virgd in  hominibus, semper fere fiat cum
pustulis parvis,  interduni lividi coloris,  ali-
quando nigri, nonnunquam subalbidicnm cal-
lositate eas circumdante."   De Morbo Gal-
lico.  These quotations shew,  that the
venereal disease was propagated from the
beginning, as it now is, by what tiie old
writers called a pustule, and we name a
chancre.
   The venereal disease arises from a mor-
bid poison,  which,  when  applied to the
human  body, has the power of propagat-
ing, or multiplying itself, and is capable
of acting both locally and constitutionally.
It may also be communicateel to  other
persons, in all the various ways, in wliich
it is received, producing, as Mr. Hunter
remarks,  the same  disease in some one of
its forms.
   The  same celebrated  writer notices,
that,  in whatever  manner  the venereal
poison arose, it certainly began  in the hu-
man race, as no other animal seems capa-
ble of being affected by it.  The parts of
generation were,  probably,  also, the first
affected ;  for, if the disease had  taken
place in any other part ofthe body, in all
probability,  it  would  never have  gone
further, than the person,  in whom it first
arose.   However, since it was situated in
the parts of generation, where  the only-
natural connexion  takes  place, between
one human being and another, except that
between the mother and  child, it was in
the most favorable situation for being pro-
pagated ; and Mr. Hunter infers, also, that
the first effects of the disease must have
been  local,  in consequence of the fact,
now well established, that none  of" the
constitutional effects are communicable to
other persons.
   The particular properties of the venereal
poison are quite  unknown,  its effects or:
the human  body being the  only informa-
tion, which we possess concerning it. Mr.
Hunter  says, that it is  commonly in ihe
form of pus,  or mixed with  pus, or some
other secretion.  The   virus excites,  in
most  cases,  an inflammation in the parts
contaminated, which inflammation is  at-
tended  with a specific  moele  of action,
which is different from all other actions at-
tending inflammation, anil, according to
Mr. Hunter, produces the  specific quality
in the matter.
  The formation of matter, though a very
general, is not a very constant  attendant
on this disease ;  for, inflammation, pro-
duced by  the venereal poison, sometimes
does not terminate  in suppuration.  But,
if Mr. Hunter's sentiments are correct,  it
is the matter produced, whether with,  or
without  inflammation, which alone con-
tains the poison. Hence, a person, having
the venereal irritation  in  any form, not
attended with a discharge,  cannot  com-
municate tlie disease to another.   In proof
of  this   doctrine,   the   above-mention- 
47"2
VENEREAL DISEASE.
ed distinguished writer states, that, though
married  men often  contract the disease,
and continue to cohabit with their wives,
even  for weeks, yet, in the whole of his
practice, he never  once  found, that the
complaint was communicated under  such
circumstances,  except  when  connexion
had been  continued, after the discharge
had appeared.
  It is possible to conceive, that the vene-
real  poison  may be in  so diluted a state,
that it would be incapable of exciting any
degree of irritation,  and, consequently,
that no effects would be produced. How-
ever, when  the  poison has the power of
irritating the part, to which it is applied,
tlie same  consequences will follow, whe-
ther from a large, or small quantity; from
a strong, or  weak solution.*
  The same  matter, however, may affect
different persons very differently.  Two
men  sometimes have connexion With the
same woman ; both catch the disease; but,
one  may have very  severe symptoms;
the other exceedingly mild ones.  Mr.
Hunter adds, that he has known one man
give the  disease to  different women, and
some of the women have had it with great
severity, while others  have suffered  very
slightly.
  It is a great contested question, in  the
subject of" the  venereal e"*6case, whether
this  malady and gonorrhoea arise from
the same  poison ?   Mr. Hunter acknow-
leelges, that the opinion, of their originat-
ing from  two distinct poisons, seems  to
have some foundation, when  we consider
the difference in the symptoms, and me-
thod of cure.  But, the same author  con-
tends, that,  if we  take up this question
upon  other  grounds, and, also, have re-
course to experiments, the result of which
we  can also  safely depend upon, we shall
find this notion  to  be erroneous.  I shall
not repeat, in this place,  the arguments,
adduced  by  Hunter  in  support of tiie
doctrine, that both diseases are produced
by the same virus : the reaeler will find
some notice taken of them in the  article
Gonorrheah.
  Mr. B. Bell, and several other  writers,
have  supported an  opinion, contrary  to
the one, set  forth by John Hunter, rela-
tive to the poison, from which  lnes vene-
rea,  and  gonorrhoea arise, and, indeed,
after  impartially  considering  the  evi-
dence brought forward by the two oppo-
site parties,  I  feel .much  inclined to be-
lieve, that the  two diseases do not origi-
nate   from the same virus.  Mr.  Hunter,
it is true, has brought forward some ob-
servations tending to shew, that, a chancre
and other venereal  symptoms, following
absorption from  such chancre,  might be
communicated  by  inoculating a  person
with the matter of a gonorrhoea.  How*
ever, in  speaking of gonori'hxa,  I have
suggested some reasons for not  pl.xing
implicit  belief in the  inferences, wliich
Mr. Hunter has drawn.
   Mr. B. Bell adduces some facts, from
which an almost decisive conclusion may
be made, that the poisons of the venereal
disease, and the gonorrhoea, are entirely
different and distinct.  Mr. Bell observes,
that,  on  a subject such as this, the names
of persons,  by whom the following expe-
riments were  conducted, cannot be men-
tioned ;  but, he is personally acquainted
with all of them, and he believes his friend,
Dr. Duncan, saw the progress of some of
the  cases.  Mr.  Bell knows,  that all,
which they relate, may be with certainty
relied on, and he explains, what was done,
in nearly their own words.
   One gentleman states:  " My  experi-
ments were  made a good many years ago,
and were meant to form the subject of a
paper^for a medical society,  of which 1 am
a member.   1 had no theory to support,
nor any other view in making them, than to
support the  opinion, at that  time generally
received   among  practitioners,  namely,
that lues venerea and gonorrhoea virulen-
ta, are one and the same disease, arising
from the  same matter of" contagion, acting
in a  different manner on  different sur-
faces.  I was  soon, however, convinced,
by the very distressful and unexpected
event of my  experiments of the fallacy of
this opinion.
  " Matter  was taken upon the point of
a probe, from a chancre on  the glans pe-
nis, before any application  was made  to
it,  and completely  introduced into the
urethra, expecting thereby  to produce a
gonorrhoea.  For  the first  eight days, 1
felt no kind  of uneasiness; but, about
this^period, 1 was attacked  with pain in
passing my water.  On dilating the ure-
thra, as much as possible, neai ly the whole
of a large chancre was discovered, and, in
a few clays thereafter, a bubo formeel in
each groin. No elischarge took place from
the urethra,  during  the whole course of
the disease;  but another chancre was soon ,
perceived in the opposite side of the ure-
thra, and red precipitate was applied  to
it, as well as to the other, by means of a
probe  previouly moistened  for the pur-
pose.   Mercurial  ointment, was  at the
same time rubbed on the outside of each
thigh, by which a profuse salivation was
excited.   The buboes,  which, till then,
had  continued to  increase, became sta-
tionary, and, at last,  disappeared entire-
ly ; th* chancres became clean, and, by a
due continuance of mercury, a complete
cure was at last obtained."
  Mr. B. Bell  informs us  that the  nest 
VENEREAL DISEASE.
47S
experiment  was made with the matter of
gonorrhoea;  a portion of which was in-
troduced between the prepuce and glans,
and  allowed to remain there without be-
ing disturbed.   In  the  course of the se-
cond day, a slight degree of  uiflammation
was produced, succeeded by a discharge
of matter, which, in the course of two or
three days, disappeared.
  The same experiment was, by the same
gentleman, repeated once and again, after
rendering the parts tender,  to which  the
matter of gonorrhoea was applied;  but,
no chancre ever ensued from it.
  Mr. B. Bell also acquaints us, that two
young gentlemen, while prosecuting  the
study of medicine,  became anxious to as-
certain the point in question; with w hich
view, they resolved on making the follow-
ing experiments, at a time,  when neither
of them  had ever laboured  under either
gonorrhoea, or syphilis, and  both in these
and  in  the  preceding exp-  riments,  the
matter of infection was taken from pa-
tients, who had never made use of mercury.
  A small dossil of lint, soaked  in  the
matter  of gonorrhoea, was,  by each of
them inserted between  the  prepuce and
the glans, and allowed to remain on the
same spot for the space of twenty-four
hours.  From this, they expec ed, that
chancres would be produced;  but, in  the
one, a very severe degree of  inflammation
ensued over  the whole glans and praepu-
tiuro, giving all the appearance of, what
is usually termed, gonorrhoea  spuria. A
considerable quantity of fetid matter was
discharged from the surface ofthe inflam-
ed  parts, and, for  several days,  he iad
reason to fear, that an operation would
be necessary for the removal of a para-
phymosis.  By the use of saturnine poul-
tices, laxatives,  and low diet, hovrever,
the  inflammation abated, the discharge
ceased, no chancre took place,  and he
soon  got entirely well.
  The other gentleman, says Mr. B. Bell,
was  not so  fortunate.   The external in-
flammation,  indeed, was slight,  but, by
the matter finding access to the urethra,
he was attacked, on the second day with
a sevei* degree of gonorrhoea, which con.
tinued for a  considerable time to give him
a great deal of distress, nor did he, for up-
wards ofa year, get entirely  free of it.
  The latter gentleman, impressed with
a sense of the imprudence and hazard of
all such experiments,  could not be pre-
vailed upon to  carry them furtlier, al-
though they were prosecuted by his friend.
This younu  man, soon after  the mflamma-
tion, arising  from his first experiment,
had been removed,  inserted  the matter ot
jronorrheca on the  point of a lancet, be-
neath the  skin of the  praputium, and,
     Vol  H.
likewise, into tlie substance of the glans;
but, although this was repeated three dif-
ferent times no chancres ensued.  A slight
elegree of inflammation was excited j but,
it  seion  disappeared, without any  th.ng
being done for  it.  His last  experiment
was attended with  more  serious conse-
quences.  The matter of a  chancre  was
inserted on th* pointof a probe to the depth
of a quarter of an inch, or more, in the ure-
thra. No symptoms of gonorrhoea ensued;
but, in  the course of five, or six days, a
painful  inflammatory  chancre was  per-
ceived on the spot, to which the matter
was applied.  To this succeeded a bubo,
which ended in suppuration, notwithstand-
ing the immediate application of mercury,
and the sore, that  was produced, proved
both painful and  tedious.   Ulcers were at
last perceived in  the throat, nor was a cure
obtained, till a veiy large quantity of mer-
cury was given under a state of close con-
finement for thirteen weeks.  (Treatise on
Gonorrhaa Virulenta and Lues Venerea. Vol.
l,Edit  2,p.4S,8,&c)
   Some  have  supposed that the poison-
ous quality of venereal matter arises from
a fermentation taking place  in it as soon
as  it  is  formed.  However, Mr. Hunter
conceives,  that  the  animal body has a
power of producing  matter according to
the irritation, given,  whereby the  living
powers,  whenever irritated in a particular
manner, produce  such an action in  the
parts, as to generate a matter,  similar
in quality to  that wliich excited tlie  ac-
tion.
   It does not seem  necessary to adduce
the arguments,  by wliich the idea of fer-
mentation being concerned  in the pro-
duction ofthe venereal virus might be re-
futed, as no modern practitioner now  de-
fends the doctrine.  Mr. Hunter was of
opinion, that the effects, produced by  the
venereal poison, arise from its peculiar,
or specific  irritation, joined with  the
aptness  of the living principle to be ir-
ritated  by such a cause,  and the parts,
so irritated,  acting accordingly.  Hence.
he considered,  that the venereal  virus
irritated the living parts in  a manner pe-
culiar to itself, and  produced an inflam-
mation,  peculiar to  that irritation, from
which a matter is  produced, peculiar to
the inflammation.
   The  venereal poison  is capable of af-
fecting the human body in two different
ways;  locally, that is,  in  those  parts
only, to which  it is first  applied; and,
constitutionally, that is, in consequence
of the  absorption of  the  venereal pus,
which affects parts, while it is  diffused
in the circulation.
   Though  Mr. Hunter uses the  term
constitutional,  he explains  in  a  note,
    3 0 
474                         VENEREAL DISEASE.
that the word is not  altogether correctly
applied, as every complaint of a venereal
nature . is truly  local,  and produced by
the simple application of  the poison to
the parts.  The  latter circumstance may
happen, either by the immediate contact
of the mater with the skin, before any
absorption has taken place,  or it may
happen by the matter coming into contact
with  such parts, as are  susceptible of
the venereal  disease,  after  absorption
has taken place, and while the virus  is
circulating in the system.
  Mr. Hunter  believed, as the  reader
already  understands,  that  gonorrhoea
was only one form ofthe venereal disease.
In  gonorrhoea, he observes, there is  a
formation of matter  without a  breach in
the  solids,  while, on the contrary,  a
chancre is attended with a breach of this
kind ;  and, he imputed the two different
ways, in which the disorder appears, not
to any thing peculiar in the kind ot poison
applied,  but,  to the  difference  in the
parts   contaminated.  When the poison
Was applied to a secreting surface,  which
had no cuticle,  he believed,  that,  it
never produced  ulceration, but, only an
alteration in the  quality of  the secretion.
Thus, in the urethra, instead of* mucus,
pus became  secreted, and a  gonorrhoea
arose. On the  otiier hand, Mr.  Hunter
thought, that, when  the  virus was ap-
plied to a surface, that is covered with a
common  cuticle, as  the common skin  of
the body, ulceration would be the  effect.
In this manner, he accounts for the same
p< ison producing two such different con-
sequences, as gonorrhoea, and chancre.

             or CHANCRES.

  From the account, already delivered,
that ihe venereal disease can only be im-
pai ted from one person to another by the
actual contact of" the matter,  it must be
obvious, that the first effects ot the dis-
order must  in  general make  their ap-
pearance on  the purts of generation,  in
cc sequence of the virus being applied to
them durfeg coition.
   Mr. Hu' rer reminds us,  however, that
the penis, which in  men,  is the common
seut ofa chancre, is,  like every oilier part
ofthe body, liable to diseases of the ulcer-
ative k nd, and that, on account of some
circumstances, it  is rather more so than
other p;.rts   When  attention  is not paid
to cleanliness, excoriations, or superficial
ulcers often originate in consequence of
such neglect.   The genitals,  also, like
almost every other  part  that  has  been
injured,  when  once they  have  suffered
from the . venereal disease, are very liable
to  ulcerate again.  Since,  therefore, the
penis is not exempted from the  common
diseases of  the  body,  Mr. Hunter very
properly  remarks, that  an opinion, con-
cerning ulcers  situated on it, must  be
formed with great attention, particularly,
as every disease in this part is suspected
to be venereal.
  "  Venereal  ulcers (says Mr. Hunter)
commonly have   one  character,  which,
however, is not entirely peculiar to them;
for, many sores,  that have no disposition
to heal,  (which is the case with a chan-
cre) have so far the  same character. A
chancre has  commonly a, thickened base,
and, although, in some, the common in-
flammation spreads much  further, yet  the
specific is confined to this base."  (fr*. 215.)
  Mr.  Hunter  notices,  that  there   are
three ways,  in which  chancres may  be
produced; first, by the poison being in-
serted into a wound;  secondly,  by being
applied to a non-secreting surface; and,
thirdly, by  being applied to a  common
sore.   To which ever of these three  dif-
ferent  surfaces it is applied, the pus pro-
duces its specific inflammation and ulcera-
tion, attended with a  secretion  of pus.
The matter produced, in  consequence of
these different modes of application, par-
takes of  the same nature, as the matter,
which was  applied,   because,  as   Mr.
Hunter  observes,  the   irritations   are
alike.
  Mr. Hunter takes  notice,  that   the
poison much more readily contaminates,
when it is applied to a fresh wound, than
to an ulcer.
  Though chancres commonly occur on
the parts of generation, this circumstance
is entirely owing to their being the only
parts,  with  which the virus ever comes
into contact, the application being made
during the connexion  between the sexes.
Every part of the body may be  affected
by the application of  venereal matter to
it, particularly,  when  the cuticle is thin.
Mr. Hunter mentions, his having seen
on the red part ofthe lip a chancre, which
was as broad as a sixpence.  The vene-
real virus had most probably been inad-
vertently  applied to the  part by the pa-
tient's own  fingers.  Mr. Huntefcfcad  not
the  least doubt of the sore being really
a chancre;  for, besides its diseased ap-
pearance, it was attended with a bubo in
one  of the glands under the lower jaw.
   Chancres  have occasionally occurred on
the  fingers, particularly,   when there has
been any previous  cut,  or scratch   on
these  parts,  and they  have been   em-
ployed in this state ih dressing venereal
sores.
   Mr. Hunter computed,  that claps  oc-
cur more frequently, than chancres, in the
proportion  of four, or five to one.  As 
VENEREAL DISEASE.
W
this  celebrated writer conceived, that
both these diseases originated from the
same virus, which only produced different
effects of its having to act on a secreting,
or non-secreting surface, he  attempts to
explain the less frequent occurrence of
chancres by the operation of the venereal
poison, being often prevented by  the in-
tervention of the cuticle.
  The same author states, that, in men,
chancres generally make their appearance
on the fraenum, glans penis,  prepuce, or
on the common skin  of the body of the
penis; and, sometimes, on the tore part
of the scrotum; but, he  thought, that
such sores took place most frequently on
the  fraenum, and in the angle-, between
the  penis and glans.   He refers the cause
of the venereal poison  affecting these
parts to  the manner,  in  which the dis-
ease is caught, and not to  any  specific
tendency in these parts to  catch the com-
plaint ; and he  imputes the circumstance
of  the  fraenum  being more frequently
affected, than other parts of the penis, to
the  external firm of that part being ir-
regular, and allowing the venereal mat-
ter to lie undisturbed in its folds.  Thus
the  virus has time to irritate, and inflame
the  parts, and to produce the suppurative
and ulcerative inflammation in them.
   Mr.  Hunter next  observes, that the
interval,  between the application of tiie
poison, and its effects upon  the parts, is
uncertain;  but, that, on  the whole,  a
chancre is  longer* in  appearing, than  a
gonorrhoea.  However, the nature of the
parts  affected  makes  some difference.
When  a chancre occurs  on  the  fraenum,
or at the termination of the prepuce, in
 the  glans,  the disease in general comes
 on earlier; these parts being more easily
 affected, than either the glans penis, com-
 mon skin of this organ, or the scrotum.
   Mr. Hunter adds, that, in some cases,
 in  which  botii  the glans  and  prepuce
 were contaminated from the same appli-
 cation of the  poison, the chancre made
 its appearance earlier on the latter part.
   Mr. Jlunter states his having been ac-
 quainted  With some instances, in which
 chancres appeared twenty-four hours after
 the application of the matter;  and with
 others,  in which  an interval of seven
 weeks, and even two months elapsed, be-
 tween the time of contamination and that,
 when the  chancre commenced.
   A chancre first begins with an itching
 in  the part.  When the inflammation is
 on  the glans penis,  a small pimple full
 of  matter, generally arises, without much
 hardness,  or  seeming inflammation, and
 with very little tumefaction;  for,  the
 glans penis is not so apt to  swell, in con-
 sequence of  inflammation, as many other
parts are,  especially, the prepuce.  Mr.
Hunter also explains, that chancres, si-
tuated on  the glans, are not attended
with so much pain and inconvenience, as
sores of this nature on the prepuce. When
chancres occur on the fraenum,  or, par-
ticularly, on the  prepuce, a much more
considerable degree ot inflammation soon
follows, attended with effects, more ex-
tensive and visible.  These latter  parts,
being composed  of very  loose  cellular
me.nbrane, afford a  ready passage ior
the extravasated  fluids.  The itching  is
gradually, converted  into pain ;  m some
cases, '.he surface of the pn-puee  is ex-
coriated and afterwards ideerates; while,
in  other  examples,  a  small pimple or
abscess appears,  as on the glans, and
then turns into an ulcer.  The parts be-
come affected  with a thickening,  which,
at first, while  of the true venereal kind,
is very  circumscribed ;  not diffusing it-
self, as Mr. Hunter observes, gradually
and imperceptibly into the surrounding
parts ;  but, terminating rather  abruptly.
Its base is hard, and the edges a In tie
prominent.  When  it begins on the fr«;
num, or, near it, that  part is very com-
monly  wholly destroyed,  or a  hole it
often  made through  it  by ulceration.
Mr. Hunter thought it better, in general,
under the  latter  circumstance, to divide
the part at once.
   When the  venereal matter is applied
to the body  of  the  penis,  or  front of
the scrotum, where the cuticle is thicker,
 than that of the glans penis and prepuce,
 the chancre generally makes its appear-
 ance in the form of a pimple, which com-
 monly  forms  a  scab,  in  consequence  of
 evaporation.  The first  scab is generally
 rubbed  off; after which a second, still
 larger, one is  produced.
   When the disease is more advanced, it
 is often attended with such inflammation
 as is peculiar to the habit,  becoming in
 many instances more diffused, and often
 producing phymosis, and paraphymosis,
 However, says Mr.  Hunter, there is  yet
 a  hardness, around  the  sores, which is
 peculiar to such as are caused by  the ve-
 nereal virus, particularly, those on  the
 prepuce.
    The local,  or immediate effects of the
 venereal disease are seldom wholly spe-
 cific; but, are usually attended both with
 the  specific and constitutional  inflamma-
  tion.   Hence, Mr.  Hunter, advises par-
  ticular attention to be paid to the manner,
  in which a chancre first appears, and to
  its progress.   If the inflammation spreads
  in a quick  and  considerable  way,  the
  consiuition must be more disposed to in-
  flammation,  than  is natural.  When  the
  pain is   severe, Mr.  Hunter  remarks, 
m
VENEREAL DISEASE.
 there is a strong disposition to irritation.
 Chancres also, sometimes, soon begin to
 slough, there being a strong  tendency to
 mortification.
   It is also observed by Mr.  Hunter, that
 When tn re is a considerable  loss of sub-
 stance, either from  sloughing, or ulcera-
 tion, a profuse bleeding is  no uncommon
 circumstance, more  especially, when  the
 ulcer is on the glans.  The adhesive in-
 flammation does not appear to take place
 sufficiently to unite the veiAs of this part
 of the penis, so as to prevent their cavity
 from being  exposed, and  the blood es-
 cap"S from  the corpus spongiosum ure-
 thra;.  The  ulcers,  or sloughs, often  ex-
 tend is deeply as the corpus cavernosum
 penis, and similar bleedings are the conse-
 quence.
   W>th respect to  chancres in women,
 the   labia  and nymphae,  like the  glans
 penis in men, are subject to ulceration,
 and  the ulcerations are generally  more
 numerous  in  females,  than  males,  in
 consequence ofthe surface, on which the
 sores  are  liable to form, being  much
 larger.  As Mr. Hunter observes,  chan-
 cres are occasionally situated on the edge
 of the labia; sometimes on the outside
 of these parts; and even on  the perinaeum.
 When the sores are formed  on the  insiele
 of the  labia or nymphae, they can never
 elry,  or scab; but, when they are  exter-
 nally situated,  the  matter may dry  on
 them, and produce a scab, just as happens,
 with respect  to chancres situated on the
 scrotum, or body of the penis.
   Mr. Hunter remarks, that tiie venereal
 matter  from these  sores is very apt to
 run   down  the  perinaeum  to  the  anus,
 and excoriate the parts,  especially, about
 the  anus, where the  skin is thin, and
 where chancres are  liable to be thus oc-
 casioned.
   Chancres  have been  noticed  in the
 vagina ; but, Mr. Hunter suspected, that
 they  were  not original  ones; but, that
 they had spread to this situation from the
 inside of the labia.
   Before any of the virus has been taken
 up by the absorbents, and conveyed into
 the circulation, a  chancre is entirely a
 local affection.

       TREATMEUT OF CHANCRES.

  It was one of Mr. Hunter's opinions,
 that the ulceration, arising from venereal
 inflammation, generally, if  not always,
continues, till cured by art, and his theo-
retical reason for this circumstance was,
that, as the inflammation in the  chancre
spreads, it is always attacking new ground,
so as  to produce  a  succession of  irrita-
 tions, and hinder the disease from curing
 itself.
   We have alreaely noticed, that chancres
 are not wholly venereal, but  are attended
 with effects,  dependent on constitutional
 peculiarities, to which the variety in the
 treatment must  be  adapted.  The  vene-
 real symptoms,  abstractedly considered,
 may beamed hy mercury ; but, the  treat-
 ment of the symptoms, which depend on
 peculiarity of constitution, have no speci-
 fic remedy, and  demand  different means
 in different cases.
   Though the  treatment of a chancre
 may be  attempted  both constitutionally
 and locally, it is commoniy a considera-
 ble  time before the sores appear to be
 affected  by  mercury.   Sometimes the
 circulation must be loaded with mercury
 for three, or four weeks, or  even  longer,
 before a  chancre begins to  separate its
 discharge from  its surface, so as to look
 red,  anel  exhibit a living surface ; but,
 says  Mr.  Hunter,  when once it  does
 change,  its progress towards  healing is
 more  rapid.   This  author  describes a
 chancre  as being generally much longer
 in getting well, than the other local effects
 of the venereal disease, arising  from the
 absorption of the poison into the  consti-
 tution.
   Mr. Hunter  enjoins  the  practitioner
 to consider,   also,  whether  weakening,
 strengthening,  or   quieting  medicines,
 should  be  exhibited;  sometimes,  one
 kind ; sometimes, another being proper-
   Chancres (observes the same celebrated
 writer) admit of two modes of treatment.
 The object of one is to destroy or remove
 them by  means of escharotics, or  by ex-
 tirpation.   That of the other is to over-
 come the  venereal irritation  by means of
 the specific  remedy for  the   syphilitic
 poison.
   That chancres  are local complaints, is
 confirmed  by  the circumstance of their
 admitting  of  being  destroyed,  or cured
 merely by local  treatment  It  has  been
 a question, whether mercury  should  ever
 be locally  applied  to chancres, or not.
 On this subject, Mr.  Hunter considers,
 that, in the cure  of such sores, there are
 two  objects to be aimed at; one is the
 cure oftiie chancre itself; the other is the
 prevention  ofa contamination of the habit.
   The cure ofthe chancre is  to be effect-
 ed by mercury, applied either in  external
 dressings,  or,  internally, through   the
 circulation, or in both ways.  The  pre-
 servation  of  the constitution from  con-
 tamination  is  to be  accomplished,  first
 by shortening the duration ofthe chancre,
 which  shortens  the  opportunity for ab-
sorption ; and also by internal  medicine, 
VENEREAL DISEASE
477
which must be  in proportion to the time
that  tlie absorption  may have been go-
ing on.
  If,  says  Mr. Hunter, the power  of  a
chancre to contaminate the constitution,
or, what is the same thing, if the quantity
of the virus absorbed is proportioned to
the size of the chancre, and the lime of
absorption,  wliich  most probably  it is,
then  whatever  shortens the time, must
diminish  the above power, or  the  quan-
tity of the poison absorbed.  Also, if ihe
quantity  of mercury, necessary to pre-
serve the constitution, is proportioned to
the quantity of the virus absorbed, then
whatever lessens the quantity absorbed,
must  proportionally preserve  the consti-
tution.  For instance, says Mr. Hunter,
if the power of a chancre to contaminate
the constitution in  four weeks is equal to
four,  and the quantity of mercury neces-
sary to be given internally, both for the
cure of the chancre and the preservation
of the constitution, is also equal to four,
then  whatever shortens the duration of
the chancre, must lessen in the same pro-
portion the quantity of mercury necessary.
Hence,  if  local  applications,  together
with  the internal use of mercury, will
cure  a chancre  in  three weeks, then  it
will "only  be necessary to exhibit  three-
fourths  of  the  quantity of  mercury in-
ternally.    Mr. Hunter observes,  there-
fore,  that local  applications,  inasmuch
as they tend to shorten the duration of
a chancre,  shorten the  duration of ab-
sorption,  and,  in this manner,  shorten
the necessity for the continuance of an in-
ternal course of mercury, all in the same
proportion. For example, if four ounces
of mercurial ointment will cure a chancre
and  preserve the  constitution  in four
weeks, three ounces  will be sufficient to
preserve the constitution, if the cure of
the chancre can be,  by any other means,
forwarded, so as to  b" effected in three
weeks.   Mr. Hunter  affirms, that this  is
not  speculation;  but, the result of ex-
perience,  and confirmed by the destruc-
tion of chancres.

          DESTROYING CHAKCRES.

   Mr Hunter notices, that the simplest
method of treating a chancre is to destroy,
or  extirpate it, whereby  t is reduced  to
the state of a common sore,  or wound,
and heals up as such.  This can only be
done on the first appearance of the chan-
cre,  when the surrounding parts are not
yet  contaminated; for, it  is  absolutely
necessary to remove the whole of the dis-
eased part, and this object is exceedingly
difficult  of accomplishment,  when the
disease  has  spread considerably.  The
plan may be  effected  either  with the
knife,  or  caustic.   Mr Hunter states,
that, when the chancre is situated on the
glans penis, touching the sore with the
lunar caustic  is preferhble to cutting  it
away, because the hemorrhage from the
cells of the glans would be considerable
in the latter method.
  The caustic will not  give a great .deal
of pain, as the glans is not  an exceeding-
ly sensible pan.  The caustic  employed
should be pointed at the end, Uke a pen-
cil, in order that it  may only touch such
parts as  are really diseased.  This  treat-
ment should be  continued, till the sur-
face of the sore  looks red and healthy,
after the separation of the last sloughs.
When  it has  attained  this condition,  it
will heal, Uke any other sore,  made with
caustic.
  When  the sore is on the  prepuce, or
the common skin of tiie penis,  and,  in
an  incipient state, the same practice may
be  adopted  with  success.   When the
chancre is  large,  however, it cannot be
destroyed  with the argentum nitratum,
which  does not extirpate the  increasing
sore eleeply enough. In such  cases, Mr.
Hunter thought,  that the lapis septicus
would  answer very  well.  When the
latter caustic cannot be conveniently era-
ployed, this author  recommended the
chancre  to be cut away.  He mentions
his  having taken  out such a  sore by dis-
section,  and  that  the part   afterwards
healed with  common  dressings,   How-
ever, says  he, as our knowledge of tlie
extent of the disease is not  always cer-
tain ; and  as  this  uncertainty increases
with  the  size of the  chancre, the cure
must be in some measure promoted by
proper dressings, and, it will be prudent to
dress the sore with mercurial ointment.
.When this plan is  followed,  Mr. Hunter
believed, that there is but little danger of
the constitution  being  infected,  parti-
cularly, when the chancre has been de-
stroyed  almost immediately  on  its first
appearance; for,  then it is reasonable  to
conclude, that there has not been time for
absorption to  have taken place.  But,
observes tlie same author, as  it must be
in  most  cases uncertain, whether  there
has been absorption or not, this  practice
should  not always  be trusted  to, and,
perhaps, never should be relied in. Hence,
even when the chancre has been destroy-
ed in  its incipient state, some mercury
should be given  from motives  of pru-
dence, the quantity of  which  medicine
should be proportioned to the duration
and progress  of the sore.   When the
chancre 19 large, before it is extirpated, 
478                         VENEREAL DISEASE.
 mercury is absolutely necessary, and Mr.
 Hunter conceived, that very little good is
 done by the extirpation.

     LOCAL APPLICATIONS TO CHANCRES.

   The cure of a chancre  (says Mr. Hun-
 ter) is a different thing from its extirpa-
 tion, and consists in  destroying its  ve-
 nereal disposition, which object being
 effected, the parts heal of course, as  tar
 as they are venereal.
   The employment of mercury, both as
 a topical application, and a constitutional
 remedy,  is necessary in order to cure a
 chancre.
   Mercurial ointments have been com-
 monly  used as  dressings to chancres; but,
 Mr. Hunter was of opinion, that  if the
 mercury  were joined  with  watery sub-
 stances, instead of ody ones,  the applica-
 tion, by mixing with  the  matter,  would
 be continued  longer  to   the  sore,  and
 would  prove  more effectual.   This, he
 observes, is one advantage,  which  poul-
 tices have  over common dressings.  He
 has often used  mercury rubbed down with
 some conserve, .instead of ointment, and
 it  answereel  extremely  well.  Calomel
 used in the same way,  and also the other
 preparations of mercury, mixed  with
 mucilage, or   honey,  answer  the same
 purpose.  Such dressings,  according  to
 Mr. Hunter, will effect a curt, in cases,
 which  are truly venereal, and free  from
 other morbid tendencies.
   Some  chancres  are  indolent, and re-
 quire a little  warm balsam  or red pre-
 cipitate to be joined with the mercurial
 dressing.   Mr.  Hunter says, that  calo-
 mel mixed wi'h salve is more active, than
 common  mercurial ointment,  and is at-
 tended with better effects, when the case
 requires stimulants.
   Solutions of blue vitriol,  verdigrease,
 calomel,  &c  have been   recommended.
 But,  Mr. Hunter  very judiciously  ob-
 serves,  that, as all  these applications are
 only of service  in remedying any peculiar
 disposition of the  parts, as they have no
 specific power  over the venereal poison,
 and as such dispositions are innumerable,
 it is almost impossible to say,  what ap-
 plications will  be effectual in every in-
 stance.   Some  kinds  of  dressings will
 answer in one state of the sore ; some in
 another.  The  parts  affected  are often
 found extremely irritable, in  which cir- '
 cumstance the  mercury should  be  mixed
 with opium or preparations of lead.
  Mr. Hunter was an advocate for  chang-
 ing the  dressings, very often, because the
 matter  separates them fqr the sore,  so
 as to diminish  their effects.  He  states,
that changing  the applications, thrice a
 day,  will  not  be found  too  often, par-
 ticularly, when they are  in the  form of
 an ointment.
   When the venereal nature of a chancre
 is removed, the s6re frequently becomes
 stationary,  in which case, Mr. Hunter ob-
 serves, that the new dispositions have been
 acquired,  and the quantity of disease in
 the part has been increased.  When chan-
 cres are only stationary,  Mr. Hunter says
 they  may  often be cured, by touching
 them slightly with the lunar caustic.  No
 cicatrization, in this case, seems possible,
 till the contaminated surface, or the new
 flesh,  which grows  on that  surface, has
 either been destroyed or altered. It is
 often  surprising,  how quickly the sores
 heal up, after being touched with the ap-
 plication.   (See Hunter  on  the  Venereal
 Disease.)

 INTERNAL EXHIBITION OF MERCCRV FOR
               CHANCRES.

 t  At the same time that topical applica-
 tions are made  to chancres, mercury must
 be internally exhibited, both with a view
 of curing these ulcers, and preventing a
 lues venerea.   Mr. Hunter believed, that
 the venereal disposition  of the  chancre
 would hardly  ever withstand both local
 and internal mercurials.
   When local  applications cannot easily
 be made to chancres, as in a case of phy-
 mosis,  there is a still greater necessity
 for giving  mercury internally, by which
means, the cure may in the end be effect-
 ed.
   Mercury  should always be given in-
 ternally in  every case of chancre, let it
 be ever so light, and even when -the sore
has been destroyed on its very first ap-
pearance.   The remedy should always be
exhibited the whole time of the cure, and
continued for some time after the chancre
has healed;  for,  says Mr.  Hunter,  as
there  are,  perhaps,  few  chancres with-
 out absorption of the matter,  it becomes
absolutely  necessary  to give mercury  to
act internally,   in order  to hinder  the
venereal disposition  from  forming.  How
much mercury  should be  thrown into the
constitution in  the  cure  of  a chancre,
with a view of keeping the system from
being  affected, cannot easily be deter-
mined,  as  there  is no disease  actually
formed, by which we can be guided.  Mr.
 Hunter states,  that the quantity must in
general be proportioned to the size, num-
ber, and duration, of the chancres; or,
in  other words, proportioned  to the op-
portunity,  which  there has  been given
 for absorption.
   The mercury,-  which is  exhibited  to
art internally,  may be conveyed into the 
VENEREAL DISEASE.
479
system, either by  the  skin, or stomach,
according to circumstances, and, it should
be so taken, as to produce a slight  affec-
tion of the mouth.
  Mr.  Hunter next  remarks,  that  when
the sore has put on an healthy look, when
the hard basis has become soft, and the
ulcer  has skinned  over in a  favourable
manner, it may be regarded as cured.
  The same distinguished writer notices,
however,  that, in very large chancres, it
may not always be necessary to continue
the application of mercury, either for ex-
ternal, or internal action, till the sore is
healed; for, the venereal action  is just
as soon destroyed in a large chancre, as
it is in a small one, since every part of
the sore is equally affected, by the medi-
cine, and, of course,  cured  with  equal
expedition.   But, in regard to cicatriza-
tion, circumstances are different, because
a large sore is  longer than  a small one,
in becoming covered with  skin.  Hence,
Mr. Hunter very justly explains, that a
large  chancre may be deprived of its ve-
nereal action, long before it has  healed;
while, on the  other hand, a  small  one
may heal before  the  syphilitic affection
has been destroyed.  In the latter case,
this gentleman represents it as most pru-
dent,  both on account of the chancre and
 constitution, to continue the employment
 of mercury, a little while after the sore
 has healed.
   Mr. Hunter, in  the valuable  work,
 which he has left on the present subject,
 takes  notice of sloughs, which occur  in
 the tonsils, from the effect of mercury on
 the throat, and are apt to be mistaken
 for venereal  complaints.  He also men-
 tions,  that, sometimes, when  the original
 ehancre has been doing well, and been
 nearly healed,  he  has seen new sores
 break out on  the prepuce,  near the
 first,  and assume all  the  appearance  of
 chancres.                    *
   When, in the treatment of chancres, a
 bubo  arises, while the constitution  is
 loaded with a sufficient quantity e>f mer-
 cury to cure such sores, which medicine
 has also been rubbed  into the lower  ex-
 tremity,  on the same  side as the bubo,
 Mr. Hunter suspects, that the  swelling
 in the groin is  not venereal,  but is  pro-
 duced by  the  mercury.  In  these cases
 he always  preferred conveying  mercury
 into the system in some other manner.
    With respect to the treatment of chan-
  ores in women, since it is difficult to keep
  dressings  on the parts, Mr. Hunter ad-
 vises the sores to  be frequently washed
  with  some mercurial solution, and, speaks
  of one,  made  with corrosive sublimate,
  as  perhaps being the best, since it will
  act as a  specific, and stimulant also,
when this is requisite.  When the chan-
cres however, are irritable, they are to
be treated in the same manner, as similar
complaints in  men.  When the sores ex-
tend into the  vagina, this  passage  must
be  kept from becoming constricted, or
closed, by the introduction of lint.
  Sometimes, after  a  chancre and all
venereal diseases are cured, the prepuce
continues thickened  and elongated, so
that the glans cannot be uncovered.   Per-
haps, the case is often without remedy.
Mr. Hunter, however, very properly re-
commends trying every possible means,
and he  informs us,  that  the  steam of
warm  water,  hemlock fomentations, and
cinnabar fumigations,  are  frequently of
singular service.
   When the thickening and enlargement
of the  prepuce cannot be removed by ap-
plications, all the portion,  anterior to
the glans penis, may be cut away.   (See
Phymosis.)                     +
   Mr. Hunter has very ably explained,
that chancres, both in  men and women,
often acquire, during the treatment, new
dispositions,  which are of various kinds,
some retarding the cure, and leaving the
parts in an indolent thickened state, after
the cure is accomplished.  In other in-
stances, a new disposition arises, which
utterly prevents  the  parts from  healing,
and often produces a much worse disease,
than  that,  from which  it originated.
 Such  new dispositions may lead to the
 growth of tumours.  They are  more fre-
 quent in men, than women, and generally
 occur  only when  the  inflammation  has
 been  violent from some  peculiarity of
 the parts,  or constitution.  They  have
 sometimes been considered as cancerous.
    Among the diseases in  question, Mr.
 Hunter notices those continued, and often
 increased  inflammations,   suppurations,
 and  ulcerations, which become  diffused
 through the  whole prepuce, and,  also,
 along  the  common  skin  of the  penis,
 which  become of a purple hue, attendeel
 with such a  general thickening of the
 cellular membrane, as makes the whole
 organ appear considerably enlarged.  The
 same writer observes, that the ulceration
 on the insides of the prepuce will some-
 times increase, and run between the skin
 and the body of the penis, and eat  holes
 through in different places, till the whole
 is reduced to a number of ragged sores.
 The glans often shares the same  fate, till
 more, or less of it is gone.  Frequently,
 the urethra in this situation is wholly de-
 stroyed by ulceration, and  the urine  is
 discharged some way farther back.  The
 ulceration, if unchecked, at length de-
 stroys all the parts.   In this acute case,
 prompt relief is demanded; but,  often 
480                         VENEREAL  DISEASE.
 the  proper moeic of treatment cannot be
 at once  determined, owing to our ignor-
 ance, in respect to the exact  nature of
 the  pecuUar cause of the disease.  Mr.
 Hunter states, tliat tlie  decoction of sar-
 saparilla is often  of service, when given
 in  large quantities,  and that he  has
 known the German diet drink effect a
 cure, after every other remedy had failed.
 The following diet drinks, he says, have
 been much recommeded.
  Take  of crude  antimony and pumice-
 stone, pulverized, and  tied up in a bit of
 rag,  of  each  one ounce;  China root,
 sliced, sarsaparilla root, sliced and bruis-
 ed, of each half an ounce ;  ten walnuts
 with  their rinds  bruised ; spring-water,
 four pints ; boiled to half thai  quantity ;
 filter it,  and let  it be drunk daily in  di-
 vided doses.
  Take  of sarsaparilla, Saunders-wood,
 white  and red,  of each three ounces;
 liquorice and mezereon,  of each half an
 ounce ;  of lignum rhodium, guaiacum,
 sassafras, of each  an ounce ; crude anti-
 mony, two ounces ; mix them and infuse
 them in   boiling water,  ten pints,  for
 twenty-four hours ; and, afterwards  boil
 them to five pints, of which  let the dose
 be  from  a pint and a half to four pints
 a day.
  Mr. Hunter also states, that the extract
 of hemlock is sometimes  of service, and
 that  he  has known sea-bathing effect a
 perfect cure.
  Sometimes, when such sores are heal-
 ing, it becomes  necessary  to  keep the
 orifice of the urethra from closing, by the
 introduction of a bougie.
  Sometimes,  after a chancre has healed,
 the cicatrix breaks out again,  and puts
 on the appearances of the preceding sore.
 Occasionally, similar diseases break out
 in different places from that of the cica-
 trix.  Mr. Hunter  represents,  that they
 differ from a chancre  in generally not
 spreading  so fast, nor  so  far;  in  not
 being so  painful, nor so much inflamed;
 in not having such hard  bases, as vene-
 real sores  have ;  and  in not producing
 buboes.  This writer was of opinion, that
 they were not venereal.  They are very
 apt to recur.
  Mr. Hunter  does not specify any parti-
 cular mode of cure for all  these cases;
 but, he  mentions  one  instance, which
seemed to be cured by giving forty drops
of the lixivium saponarium, every even-
ing  and  morning, in a  basin of broth;
and he adverts to  another  case, which
was permanently cured by sea-bathing.
  In some instances, after a chancre  has
healed, tiie parts, as Mr. Hunter remarks,
do not ulcerate; but, appear to become
thickened, and indurated.  Both the glans
 and prepuce seem to swell, so as to form
 on tlie end of  the penis, a tumour, or ex-
 crescence, shaped very much like a cauli-
 flower, and, wheit cut into, shewing radii,
 running from  its base, or origin, towards
 the external surface.   It is extremely in-
 dolent   It is  not always a consequence
 of the venereal disease; for, Mr. Hunter
 has seen it arise spontaneously.
   No medicine seems to be at all likely to
 cure  the  disease : the only successful
 means is to amputate a considerable part
 of the penis,  and then to keep a proper
 catheter introduced into the urethra.

                WARTS.

   Another disposition, induced by the pre-
 vious occurrence of chancres,  is a dispo-
 sition to form  excrescences, or cutaneous
 tumours, called  warts.  These  are con-
 sidered by many not  simply as  a conse-
 quence of the venereal poison,  but, as
 possessed  of its specific disposition, and,
 therefore,  says Mr. Hunter,  they have
 recourse to mercury for the cure of them;
 and, it is said, that such treatment often.
 removes  them.   This   eminent practi-
 tioner  never  saw mercury  produce this
 effect, although the medicine was given
 in  sufficient   quantity  to cure  recent
 chancres, and  a lues venerea, in the same
 person.
   Mr.  Hunter observes, that as these sub-
 stances are excrescences from the body».
 they are not to be  considered as truly a
 part of the animal, not being endowed
 with  tlie  common, or  natural  animal
 powers.    Many   trifling  circumstances
 make them decay.  An inflammation of
 the sound parts round the wart, or stimuli
 applied to  its surface, will  often make it
 die. Electricity  will also  induce an ac-
 tion in such  excrescences,  wliich they
 are not able to support;  an inflammation
 is excited round them, and they drop off.
   From this account,  we must perceive,
 according  to Mr. Hunter, that the knife
 and escharotics are not always necessary,
 although,  these  modes will act  more
 quickly, than any other, especially,  when
 the neck of the  wart  is small.   When
 such is the form of the excrescence, per-
 haps, a pair of scissars is the best instru-
 ment;  but, says the above distinguished
 writer, when cutting instruments of any
 kind are horrible  to the patient, a silk-
 thread,  tied round the neck of the  wart,
 wiU do very well.   However, which ever
plan is  adopted, it is in general necessary
to touch with caustic the base ofthe little
tumour, after this has separated.
  Mr. Hunter  remarks,  that  escharotics
act upon  warts in two  different  ways,
namely, by deadening a part, and stimu- 
VENEREAL DISEASE.
481
lating the remainder, so that,  by the  ap-
plication of escharotic, after  escharotic,
the whole excrescence decays moderately
fast; and it is seldom necessary  to  de-
stroy them down to the very roo,t,  which
is often thrown off.  This, hoWever, is
not^ always the case, and the wart grows
again,  in  which circumstance, it is pro-
per to let the caustic destroy even  the
root itself.
   The kali purum cum  calce  viva, lunar
caustic, and blue vitriol, are all proper
applications.  But, one of the  best stimu-
lants is the  xrugo ajris and  powder of
savin leaves, mixed together.  (Hunter
on the Venereal Disease.)

                BUBOES.

   The immediate consequence of a chan-
cre, which is called  a bubo, and also the
remote effects, implied by the term,  lues
venerea,  arise from the absorption  of
recent venereal matter from some surface,
where  it has either been  applied  or
formed.
   We are already aware, that Mr. Hun-
 ter believed the matter of  gonorrhoea
capable  of communicating the venereal
 disease.   Hence, he explains  in the  fol-
 lowing terms, the three  ways,  in which
 he thought  a bubo might  arise in con-
 sequence of absorption.   He  observes,
 that the first and most simple manner, is
 when the matter, either of a  gonori hoeq,
 or chancre, has only been  applied  to
 some sound surface,  without having  pro-
 duced any local effect on the part;  but,
 has been absorbed,  immediately after its
 application.  Mr.  Hunter affirms,  that
 he has seen  instances of this kind,'though
 he confesses they are very rare, and, that,
 in most  cases apparently of tins  nature,
 a small chancre may be found to have ex-
 isted,         i
   The second mode of absorption, or that
 taking place in  a gonorrhoea, Mr. Hun-
 ter represents as more frequent.
   The third mode  is  the  absorption of
 matter from an  ulcer, which may either
 be a chancre, or a  bubo.  This mode is
 by far the most  common, and it  proves,
 with  many  other circumstances, that a
 sore, or ulcer, is the most favourable for
 absorption.   Mr. Hunter believed,  that
 absorption was more apt to take place
 from sores on the prepuce,  than those on
 the glans,  and he says,  he had  seen
 more buboes from  chancres in the  first
 .situation.
    A fourth mode of absorption  from a
 wound is also ah occasional occurrence.
    Mr. Hunter notices, that, what is  now
 commonly understood by  a bubo,  is a
 swelling, taking place in  the  absorbing
      Vo*. IL
system, especially, in the glands, arising
from  the absorption of some poison, or
other irritating matter. When such swell-
ings  take  place in the groin,  they are
called buboes, whether they proceed from
absorption, or not.
  Mr. Hunter regards every abscess in
the absorbing system as a bubo, whether
in the vessels, or  the glands, when tiie
complaint originates from the absorption
of venereal matter.
  The matter is taken up by the absorbent
vessels, and is conveyed by them into the
circulation.   In its passage through these
vessels, it  often affects  them  with the
specific inflammation.  The consequence
is the formation of buboes, which are ve-
nereal abscesses.  These are exactly simi-
lar to a chancre in their nature and effects,
the only difference being in regard to
size.  As the lymphatic vessels and glands
are irritated by the specific matter, before
it has undergone any change in its pas-
sage,  the inflammation produced, and the
matter secreted,  partake of the specific
quality.
   Inflammation of the absorbent vessels
themselves is not  nearly so frequent, as
that of the glands.  In men, such inflam-
mations, in consequence of chancres upon
the glans,  or prepuce, generally appear,
like a cord, leading along the back of tiie
penis  from the sores.  Sometimes, the
absorbents inflame, in consequence of the
thickening and excoriation ofthe prepuce
in gonorrhoea.  The indurated lympha-
tics  often terminate insensibly near the
root  of the  penis,  or near the pubes ;
while, in  other instances,  they extend
further to a lympathic gland in the groin.
Mr. Hunter  believed, that  this affection
to the absorbent vessels is truly venereal.
The formation of a hard  cord,  the  same
author conceived,  arose from a thicken-
ing  of the coats of the absorbents, and
from  an  extravasation   of coagulable
lymph on their inner surface.
   A  cord, of the above kind, often sup-
purates, sometimes in more places than
one,  so as to form  one,  two, or three
buboes,  or small abscesses in the body of
the penis.
   Inflammation  much more  frequently
affects the  absorbent glands, than the ves-
sels.  The structure  of the former parts
appear to consist of the  ramifications and
reunion of the absorbent vessels.  From
this structure, observes Mr. Hunter, we
may  reasonably suppose,  that  the  fluid
absorbed is in some  measure detained in
these glands,  and  thus has  a greater op-
portunity of communicating the disease
to them, than to tiie distinct vessels.
   SwelUngs of the  absorbent glands may
originate from other diseases,  and such
     3P 
4&
VENEREAL DISEASE.
should be carefully  discriminated  from
those, which  arise  from  the  venereal
poison.   With this view, Mr. Hunter ad-
Vises us first to enquire into the cause, in
order to  ascertain, whether there is any
venereal complaint at some greater dis-
tance from the  heart, such as chancres
on the penis, or  any  preceding disea^e m
this situation.   He recommends us to en-
quire, whether  any  mercurial ointment
has been at all  applied to the leg and
thigf on the diseased  side; for, mercury
appUed to those parts for the cure of a
chancre,  will sometimes cause glandular
enlargements,  which  are  occasionally
mistaken for venereal  ones.   Mr.  Hun-
ter also reminds us to observe,  whether
there has been any preceding  disease in
the constitution, si'ch as a cold, fever,
&c.   The  quick,  or slow, progress of
the swelling, is likewise to  be  marked,
and  the  tumour must be distmguished
from  femora!  hernia, lumbar  abscesses,
anel aneurism* of the crural artery.
  Sometime;-,  the  venereal  matter does
not produce its  effects on the absorbent
glands,  fe>r some time  after  absorption
has tnken place  In  certain  instances,
Mr.  Hunter  notices, that, at  least, six
days have elapsed ; a circumstance, which
could only be known  by the chancres hav-
ing been healed six days before the  bubo
began to appear.  However,  Mr.  Hunter
infers, that the  matter  had been much
longer absorbed, as the last  matter of a
chancre is probably not venereal.
  Mr. Hunter  next remarks, that the
glands, nearest to the seat of absorption,
are in general the only ones,  which are
attacked.  Thus, when the  matter  has
been taken up from the penis in men, the
inguinal glands  are  affected;  and, when
from  the vulva  in women,  those glands
swell, which  are situated between the
labia  and thigh,  and  the  round  liga-
ments.
  It  was one  of Mr. Hunter's opinions,
that  only one glanel at a time  is commonly
affected by the  absorption  of  venereal
matter.   If  this sentiment  be  correct,
the circumstance n ay be- considered as a
kind  of  criterion  between venereal and
other  buboes   The  second  order  of
lymphatic  vessels  and glanels are never
affected ; as, for instance, those along the
iUi.c  ve^els, or back   Mr. Hunter in-
forms us, that he has al.«.o eibserved, that
when 'he disease was contracted by a sore,
or cut upon the finger, ihe bubo occurred
a Uttleabove 'he be-m! of the arm, by the
side ofthe biceps muscle, and no swelling
of this sort formed in the- arm-pit.   How-
ever, b/  mentions  h's having  heard of a
few  rare cases, in wlich a swelling in
the axilla was also produced.
  When buboes arise  from  a venereal
disease on the penis, they are  situated
in th" glands of the groin.  When a bubo
arises  from  a gonorrhoea,  either groin
may be Attacked.   But when the disease
originates from a chancre, the bubo most
frequently takes place  in  the  nearest
groin.
  The situation of the absorbent glands,
however,  is not  always exactly the same,
and the course of the  lymphatics there-
fore is subject to some variety.  Hence,
Mr. Hunter has  seen  a  venereal bubo,
produced by a  chancre  on  the penis,
situated a considerable  way  down the
thigh; he has also often seen  buboes as
high as the lower part ofthe belly, before
Poupart's ligament;  and sometimes near
the pubes.

           BUBOES IN WOMEN.

  The seat of absorption is more exten-
sive in the female sex,  and the course of
some of  the absorbents is alsd" different.
Hence, buboes in women may occur in
three situations, two of which are totally
different from those in men.
  When chancres are situated forwards,
near the  meatus urinarius, nymphae, cli-
toris, labia,  or  mons  veneris,  the ab-
sorbed matter is generally conveyed along
one, or both of the round ligaments, and
the buboes are formed in those ligaments,
just before they enter the abdomen.   Mr.
Hunter suspected such  buboes not  to be
glandular ones ;  but, only inflamed ab-
sorbents.
  When chancres are  situated far back,
near, or on the perinseilm, the absorbed
matter is carried  forward along the angle,
between the labium and the thigh, to the
glands in the groin, and often, in this
cour e, there are formed small  buboes in
the absorbents, similar to those abscesses,
which  occur on the penis in men.
  When the effects of the pbison elo not
rest here, a  bubo in the groin  may be
occasioned,  in  the  same  manner  as in
men.
  It is more difficult to learn, whether a
bubo is venereal in women, than  men,
owing to  the frequent difficulty of as-
certaining, that  there is no infection pre-
sent.   In  men, who have had  no  local
complaint, the bubo can only be venereal,
when  direct absorption  from the  sur-
face of the sk.n has taken place.

MANNER IN  WHICH  BUBOES  MAKE THEIR
             APPEARANCE, &C

   A  bubo, says  Mr. Hunter, commonly
begins with a sense of pain, which leads
the patient to examine  the part,  where a 
VENEREAL DISEASE.                         483
 small hard tumour is to be  felt.  This
 increases,  like every other inflammation,
 that has a  tendency to suppuration, and,
 unless checked,  pus forms, and ulcera-
 tion follows, the matter making its way
 to the skin very fast.
   The above celebrated writer  remarks,
 however, that there are some cases, which
 are slow  in their  progress.  This cir-
 cumstance  he  imputes  either to tiie in-
 flammatory process being kept back by
 mercury, or other means, or by its being
 retarded by a scrophulous tendency.
   The inflammation, he says,  is at  first
 confined to the  gland,  which  may be
 moved about in the cellular membrane ;
 but, when  the part has become enlarged,
 or when the inflammation, and  suppura-
 tion, are more advanced, the surrouneUng
 parts become more inflamed,  and  the
 tumour is more diffused.  Some buboes,
 become complicated with an  erysipelat-
 ous and cedematous affection, by which
 means, they are rendered more  diffused,
 and less disposed to suppurate.
   Mr. Hunter allows, that to distinguish
 with  certainty, the true  venereal  bubo
 from swellings of the glands in the groin,
 may be  very difficult.  He represents the
 true venereal bubo, in consequence of a
 chancre, as being most  commonly con-
 fined to one gland.  It preserves its spe-
 cific distance till suppuration has taken
 place, and then becomes more  diffused.
 It is rapid in its progress from  inflamma-
 tion to suppuration  and ulceratibn.  The
 suppuration is commonly large,  consider-
 ing the  size of the gland, and there is
 only one abscess.  The pain is very acute;
 and the inflamed part of the skin is of a
 florid red colour.
   Mr. Hunter describes such buboes, as
 arise without any visible cause, as being
 of two  kinds.  One  sort  inflame and
 suppurate briskly.   These he always sus-
 pected to be venereal, although he allows,
 there was no proof of it,  and only a pre-
 sumption deduced from  the quick pro-
 gress of the disease.
   The second kind  are  generally  pre-
 ceded, and  atteiuled with slight fever, or
 the common symptoms ofa cold, and they
 are generally indolent and slow  in their
 progress. If they are quicker,  than or-
 dinary, they become more diffused, than
 venereal one*, and thev may  not  be con-
 fined  to  one' gland.  When  very slow,
 they give but little  sensation; but, when
 quicker,  the sensation is more  acute,
 though not  so much so as  in  venereal
 cases.  They  usually do  not suppurate,
 and often become stationary.  When they
 do suppurate, it  is in a slow manner, and,
frequently,  in  more glands, than one.
while tlie inflammation is more diffused,
 and not  considerable,  in relation to the
 swelling.  The matter makes  its way to
 the skin  slowly, and -the part affected is
 of a more purple colour.  Sometimes, the
 abscesses are very large, yet not painful.
   In  considering whether  the swellings
 of  the inguinal  glands are,  or,  are not
 venereal, the first thing to be attended to
 is,  whether, or  not, there are  any ve-
 nereal complaints.   If there are none,
 Mr. Hunter  observes,  that  there  is a
 strong presumptive proof, that the swell-
 ings are not venereal.  When the swelling
 is only in one gland, very slow in  its pro-
 gress, and gives but little, or no pain, it
 is  probably merely scrophulous.  How-
 ever, when the swelling is considerable,
 diffused, and attended with some inflam-
 mation and pain,  the constitution is  most
 probably affected with slight fever, the
 symptoms of which are lassitude, .loss of
 appetite, want of sleep, small quick pulse,
 and an appearance of approaching hectic.
 Such swellings are long in getting well,
 and do not seem to be affected by mercu-
 ry, even when very early apptied.
   Mr. Hunter mentions his having  seen
 the above affection of the groin, together
 with the constitutional indisposition, take
 place, when there  were chancres ; and
 he was puzzled to determine, whether the
 disease in the  groin  was  sympathetic,
 from derangement of the constitution, or
 from the  absorption of matter.   He had
 long suspected, that there  was a mixed
 case,  and was at last certain, that such a
 case may prevail.  He says, he had  seen
 instances, in which  the venereal  matter,
 like a cold, or  fever, only  irritated the
 glands to disease,  producing  in them
 scrophula, to which they were disposed.
   In  such  cases, says Mr. Hunter, the
 swellings commonly arise  slowly, give
 but little pain,  and  seem to  be  rather
 hastened in their progress, if mercury is
 given  to destroy the venereal disposition.
 Some suppurate while under this resolv-
 ing  course; and others, which probably
 had a venereal taint at first, become so
 indolent, that mercury has no effect upon
 them,  and,  in the end, they either  get
 well of themselves, or by other means.
   Mr.  Hunter  states,  that buboes  are
 undoubtedly local complaints.

        TREATMENT  OF BUBOES.

   When a bubo is certainly a venereal
one,  and only in an  inflamed s ate, an
attempt is to be made to resolve the swell-
ing.  The propriety of the attempt, how-
ever", depends on the  progress, which the
disease has made.   If the bubo be very
large, and  suppuration  appears  to  be
near  at hand, resolution is not likely to 
»
484                        VENEREAL DISEASE.

be  effected.   When suppuration has al-  and is still continuing to pass into  the
ready  -taken place,   Mr. Hunter much  constitution,  from acting there.   Thus
doubted the probability of any success at-  the bubo is cured, and the constitution,
tending the endeavour, which now might  at the same time, preserved.
possibly only retard suppuration, and pro-    Mercury alone, however, is not always
tract the cure.                          capable of effecting the cure of buboes.
  The resolution of these inflammations,    When the inflammation rises very high,
says Mr. Hunter, depends principally on  bleeding,  purging,  and fomenting, are
mercury,  and almost absolutely on the  generally recommended.   When  the in-
quantity,  which can  be made to  pass  flammation was erysipelatous, Mr. Hun-
through them.   When suppuration has  ter had a  high opinion  of  bark;  andi
taken  place,  the cure also depends on the  when it was scrophulous, he used to re-
same circumstances.                     commend hemlock,  and  poultices made
   The quantity of mercury, whieh can be  with sea-water.
made to pass through a bubo, is represent-    The same eminent  writer also takes
ed by  Mr. Hunter, as depending principal-  notice of the fact of emetics sometimes
ly on the quantity of external surface for  occasioning tlie  absorption  of buboes,
 absorption beyond the bubo.              even after they contain matter.
   The mercury is to be applied to such
 surfaces,  as allow the remedy,  when ab-  1. Resolution of the Inflammation  of the
 sorbed,  to  pass  through  the  diseased           Absorbents on the Penis.
 gland. In  this  manner, the disease in
 the groin is subdued, and the constitution     Though there is not surface enough
 is less liable to be* contaminated.          beyond the bubo, for rubbing in  a suffi-
   However,  Mr.  Hunter accurately no-  cient quantity of mercury, to prevent the
 tices,  that the situation of many  buboes  effects of absorption, Mr.  Hunter  still
 is such, as not to have much surface for  advises this surface to be kept constantly
 absorption  beyond  them;  for  instance,  covered with  mercurial ointment.   In
 the buboes on the body of the penis, aris-  consequence of the surface in question
 ing from chancres  on the  glans,  or pre-  being so small, more mercury must also
 puce.                                  be conveyed into the system by the mouth,
   When  the bubo  is in  the groin, Mr.  or frictions on some other part.  Mr.
 Hunter recommends  surgeons to pay at-  Hunter observes, that this is  necessary,
 tention to  whether the swelling is in the  both in order  to prevent a lues venerea,
 upper part of the thigh and groin, on the  and to cure the parts themselves.  The
 lower part of the belly before  Poupart's   quantity'of mercury must be regulated
 ligament, or near the pubes.  When the  by the appearances  of the original  com-
 buboes are situated  on the body  ofthe pe-  plaint, and the readiness, with which the
 nis, the absorbents, leading directly from  disease gives way.  The  same method, he
 the seat of absorption are themselves dis-  adds, is to be followed in women, and the
 eased.  When the  bubo is in the groin,  ointment should be kept continually ap*
 and,  at the  upper  part of the thigh, we  plied to  the inside and outside  of the
 may  conclude, that the lymphatics, both  labia.
 from  the penis and thigh, run to -the af-
 fected gland. When the bubo-is high up,    2. Resolution of Buboes in the Groin.
 or on the lower part of the belly, before
 Poupart's  Ugament,  probably, the ab-     The inflammation of  the  absorbent
 sorbents, which arise"  from  about the  glands, is to be treated on the same prin-
 grom, lower part of the belly and pubes,  ciple as that of the vessels.  In the first
 pass  through the bubo.   When the bubo  case, however, we are able to  make a
 is far forward, the absorbents ofthe penis  larger quantity of mercury  pass through
 and  skm about the pubes, pass through  the diseased parts.  When the bubo is in
 the swelling.  Mr.  Hunter contends, that  the groin, the  mercurial ointment is  to be
 the knowledge of these circumstances is  rubbed on the thigh.  This surface,  as
  very  necessary, m order to apply mercury  Mr. Hunter remarks, will  in general ab-
  in the most advantageous situations.     fceorb as much mercury as will.be sufficient
    The utdity of rubbing the mercury into  to resolve the bubo, and preserve the con-
 surfaces, the absorbents of which lead  stitution from being contaminated; but,
 through the bubo, must be obvious, when  when  resolution  does  not  readily take
 it is considered, that the medicine cannot  place, the same author advises us to in-
  pass  to the common circulation,  without crease the surface of friction, by rubbing
  going through the diseased parts; that the ointment upon the leg.
  it must  promote the cure, as  it passes    When the bubo is on the lower part of
 through them ; and  that it also prevents the belly, the ointment should be rubbed
  the  matter, which  has  already passed,  also  on  the  penis, scrotum,  and belly, 
VEKEREAL DISEASE.
485
The same plan should be followed when
the bubo is still more forward.
  Mr. Hunter states, that when the bubo
gives  way, the mercurial frictions must
he continued, till it has entirely subsided,
and, perhaps, longer, on account of the
chancre, which may not yield so soon as
the bubo.  After the bubo has suppurated,
Mr. Hunter is doubtful, whether rubbing
in mercury is useful, or not.

    3. Resolution of Buboes in Women.

  When the swellings are situated be-
tween the labia  and thigh,  Mr.  Hunter
recommends the mercurial ointment to be
rubbed  in all about the anus and buttock,
from  whieh parts the  absorbents proba-
bly run through the seat of the diseases.
When the buboes are  in  the round Uga-
ments,  the surface for  absorption  will
not be large enough, and more mercury
must  be internally given, or rubbed into
other surfaces.
  When the bubo is in one ofthe inguinal
glands,  the same plan is to be adopted,
as in the same case in men.

     4.  Buboes in unusual Situations.

  When buboes forW in tlie  arm, or arm-
pit, in consequence of the  absorption of
venereal matter from wounds on the hands,
or fingers, mercurial ointment should be
rubbed  on the  arm and fore-arm.   Mr.
Hunter  adds, however, that this surface
may not be  sufficient, so that it may be
proper to convey more mercury into the
system in other ways.  He states, that he
has seen  a true venereal chancre on the
middle of the lower lip, attended with a
bubo, on each side of the neck, under the
lower jaw, close to the maxillary gland.—
The swellings were resolved by applying
mercurial ointment to them, and the chin,
and lower lip.

5.  Quantity of Mercury  necessary for the
          Resolution of a Bubo.

   Mr. Hunter observes, that the quantity
of  mercury,  necessary for the  resolution
of  a bubo, must be proportioned to the
obstinacy of the  complaint;  but,  that
care must be taken not to extend the em-
ployment of the medicine so far as to pro-
duce certain effects on  the constitution.
When the bubo is  in a situation, which
admits  of a large  quantity of mercury
being rubbed in, so as to pass through the
swelling, and when the complaint readily
yields to the use of half a drachm of mer-
curial ointment, every night, the mouth
not becoming sore, or at most, only ten-
der, the  above  author thinks it sufficient
to pursue this course,  till the gland is re-
duced to its natural size.  In this man-
ner,  the constitution will probably be
safe, provided the chancre, which  may
have caused the bubo, heals at the same
time.  When the mouth  is not affected in
six,  or  eight days, and the gland  does
not readily  resolve, then two scruples, or
a drachm,  may be applied every night;
and,  (continues  Mr.  Hunter,)  if  there
should still be no amendment, even more
must be rubbed in.   In short (says he) if
the reduction is obstinate, the mercury
must be pushed as far as can be done with-
out a saliVation.
  When there is a bubo on each side,  so
much mercury cannot be made to  pass
through each, as the constitution in genet
ral will not bear this method.  However,
Mr. Hunter sanctions the plan of mind-
ing the soreness of the mouth less in this
kind of case ; though, he adds, that it is
better to let the buboes proceed to suppu-
ration, than to  load the system with too
much mercury.
  When the situation of buboes will not
allow an adequate  quantity of absorbed
mercury to pass through them, the fric-
tions must be continued in order to affect
the constitution; but, according to Mr.
Hunter, more mercury  in this  case will
be requisite, than  when  the remedy can
be made to pass directly through the dis-
eased gland.
  Many buboes  remain swollen, without
either coming to resolution, or suppura-  ■*
tion ; and,  notwithstanding every attempt-
to promote these changes, the glands be-
come hard and scirrhous.   Mr. Hunter
conceived, that cases of this sort are either
scrophulous at first, or become so as soon
as the venereal disposition is  removed.
He advises  the use of  hemlock, sea-water
poultices, and sea-bathing.

 6. Treatment of Buboes which suppurate.

  The suppuration of buboes frequently •
cannot be prevented by any known means.
They are then to be treated,  in some re-
spects, like any other abscess.   Before
opening  buboes,  Mr. Hunter conceived
it was advantageous to let the  skin be-
come as thin as possible, as a large open-
ing would then become  unnecessary, and
no measures would be requisite for keep-
ing the skin from closing, before the bot-
tom of the sore had healed.
   Mr. Hunter thinks  it doubtful whether
the application of mercury should be con-
tinued through  the whole  suppuration,
He was inclined to continue it; but, in a
smaller quantity.
   There has been much  dispute, whether
a bubo should  be opened, or allowed to 
486                         VENEREAL DISEASE.
 burst of itself, and whether the opening
 should  be made with a cutting instru-
 ment, or  caustic.  On this subject, Mr.
 Hunter  remarks, that there is no peculi-
 arity in  a venereal abscess to make one
 practice more  eligible, than another. The
 surgeon, he says, should in some degree
 be guided by the patient,   borne patients
 are afraid of caustics; others, of cutting
 instruments.   But, when the surgeon has
 the choice, Mr. Hunter expresses a pre-
 ference to opening the bubo with a lancet,
 in  which method,- no skin is lost.  But
 he observes,  that  when  a bubo is very
 large, and there will be  a great deal of
 loose skin, after the discharge of the mat-
 ter, he thinks,  that caustic may, perhaps,
 be better, as it will destroy some of the1
 redundant skin, and occasion less inflam-
 mation, than what  is caused by an inci-
 sion.   The kali purum with the calx viva,
 is the caustic commonly employed.
   Afier  the bubo has been opened, sur-
 geons usually poultice it,  as long as  the
 discharge and inflammation  are  consider-
 able,  and  then they   employ dressings,
 which must be of  such a quality, as nu-
 merous undescribable circumstances may
 indicate.   The  use of mercury, in  the
 mean while,  is to  be continued, both to
 make the bubo heal, and prevent the bad
 effects, which might otherwise arise from
 the matter being  continually absorbed.
 The mercury shoulel also be rubbed in, so
 as to pass, if possible, through the diseas-
 ed groin.
   The mercurial course is to be pursued,
 till the sore is  no longer venereal.   But,
 in general, since  this point is difficult  to
 ascertain, the mercury must be given till
 the part  has healed, and even somewhat
 longer, when the bubo has healed  very
 quickly ; for,  the  constitution is after-
 wards very apt to become contaminated.
   However, mercury  is  not to be  con-
 tinued thus long in  all cases ; for, as Mr.
 Hunter explains, buboes  often  assume,
 besides the venereal,  other dispositions,
 which mercury cannot cure;  but, will
 even exasperate.

       CONSEQUENCES OF BUBOES.

  Sometimes, the sores, when  they are
 losing, or  entirely  deprived of the ve-
 nereal  disposition, become  changed into
 ulcers of another kind,  and, most  pro-
 bably, of various kinds.  How far it is a
 disease arising from a  venereal taint, and
 the effects of a mercurial course jointly,
 says Mr. Hunter, is  not  certain.  Tins
 writer suspected, how ever, that the nature
of the part, or  constitution, had a prin-
cipal share in the  malady.
  Mr.  Hunter  observes,  that such  dis-
 eases make the cure ofthe venereal affec-
 tion much more uncertain, because, when
 the sore becomes stationary, or the mer-
 cury begins to  disagree, we are  ready to
 suspect, that  the virus is gone ; but, this
 is  not  always  the case.  Perhaps,  the
 action of the  venereal poison is only sus-
 pended, and will  commence  again, as
 soon as  the other disease ceases.
   In these cases, Mr. Hunter recommends
 attacking  the predominant disease; but,
 he allows  there is difficulty in ascertain-
 ing its nature, and  finding out, whether
 it is venereal, or not.
   The  same  author also  acquaints  us,
 that he  has seen some buboes exceedingly
 painful and tender  to almost every  thing
 that touched them, and the more mild  the
 dressings were, the more painful the; parts
 became.
   In some instances, the skin only seems
 to  become  diseased.    The  ulceration
 spreads  to the surrounding integuments,
 while a  new skin forms in the centre, and
 keeps pace with  the ulceration, so that
 an irregular sore, which Mr. Hunter com-
 pares with a worm-eaten groove, is form-
 ed all round.   It appears only to have the
 power of contaminating the parts, which
 have not  yet been affected;  and those,
 which have, readily heal.
   When buboes become stationary, and
 seem little inclined to  spread, attended
 with a  sinus, or two, hemlock,  joined
 with bark,  is, according to Mr. Hunter,
 the medicine most frequently serviceable.
 It is best to use it both externally and  in-
 ternally.  The same author also speaks
 favourably  of sarsaparilla,  sea-bathing,
 and sea-water poultices.  He states, that
 at the Lock Hospital, gold-refiners' water
 has   been  found a  useful  application;
 that, in some c;.ses, drinking  large quan-
 tities of  orange-juice,  and in others tak-
 ing mezereon, have been  found service-
 able.

            LUES VENEREA.

   Surgeons imply, that a lues venerea has
 taken place, when the  venereal virus has
 been absorbed into the circulation.  Mr.
 Hunter does not think the epithet consti-
 tutional strictly proper in its application
 to this form of the  venereal disease.   By
 constitutional  disease, he  observes,  he
 should understand, that, in which every
 part of the body is acting in one way,  as
 in  fevers of all kinds; but, the venereal
 poison seems to be only diffused through
 the circulating fluids, and, as it were,  to
 force certain parts of" the body to assume
 the venereal action, which action  is per-
 fectly local. To use Mr. Hunter's phrase,
it takes place in different parts in a regu- 
VENEREAL DISEASE.                        487
lar succession of susceptibilities.  Only a
few parts are acting  at the same time ;
and a person may be constitutionally af-
fected m this way, and yet almost every
function may be perfect.
  The yenered poison  is generally  con-
veyed int.- the system  from  a chancre.
It may,  also, according to  Mr.  Hunter's
doctrine, be absorbed from a gonorrhoee.
There is likewise a possibility  of its  get-
ting into the circulation from the surface
of the body, without any previous ulcera-
tion.  It may be absorbed from common
ulcers, without necessarily renderingthese
venereal; and  it may be taken up from
wounds, in which cases, it  in  general
induces  a  previous  ulceration in  the.
wound.

            VENEREAL ULCERS.

  In consequence of the blood being con-
taminated with real venereal pus, it might
be expected, that the local effects,  thus
produced, would  be similar in their na-
ture  to those,  producing  them.    Mr.
Hunter believed, that this is not the case.
He notices, that the local effects, from a
constitutional contamination,  are  all of
one kind, viz. ulcers, let the effects make
their appearance  on any  surface what-
ever, either the throat, or  common skin.
But,  Mr. Hunter conceived,  that if the
matter, when in the constitution,  were to
act upon the same specific principles, as
that, which  is  externally  applied, a go-
norrhoea would arise, when it  affected a
canal, and, only sores, or chancres, when
it attacked other surfaces.
  Mr. Hunter found, that even the sores,
which are caused in  the throat, are  very
different from chancres.  He says, that
the true chancre  produces considerable
inflammation, often attended with a great
deal  of pain,  and  quickly followed by
suppuration.  But, the local effects, aris-
ing from the virus in the constitution, are
slow in their  progress,  attended  with
little  inflammation,  and are  seldom or
ever  painful, except in  particular parts.
However,  Mr. Hunter allows,  that  this
sluggishness in the  effects of the poison
depends on the nature ofthe parts diseas-
ed ;  and, he owns, that when  the  tonsils,
uvula, or nose, are affected, the progress
ofthe morbid mischief is rapid, and bears
a greater resembl-mce to a chancre,  than
when it occurs on  the skin.  Even, in
those parts Mr. Hunter  thought, the ul-
cers  were attended  with less inflamma-
tion, than chancres, which were spreading
with equal celerity.
   The matter, secreted by such sores, as
arise from a constitutional contamination,
 was alwavs considered, before the time of
Mr. Hunter, as being ofa poisonous qua-
lity, like the matter of a chancre.  At
first,  one would certainly  expect, that
this  was* actually  the  case, because ve-
nereal matter is the cause, and mercury
cures chancres, and also ulcers proceeding
from  a lues venerea.   Mr.  Hunter re-
marks-, however, that the latter circum-
stance is not a decisive proof, since mer-
cury is capable of curing many diseases,
besides the venereal.  He also takes no-
tice, that, when  pus  is  absorbed  from a
chancre,  it generally produces a bubo;
but, that  a bubo is never occasioned by
the absorption of matter from a venereal
sore, arising  from the virus diffused in
the circulation.  For instance, when there
is a venereal ulcer in the throat, no bu-
boes occur in the glands of the neck; when
there are syphilitic sores on the arms, or
even  suppurating nodes  on  the ulna, no
swellings form in the glands of the arm-
pit, although  these  complaints   occur,
when fresh venereal matter is  applied to
a common sore  on the  arm,  hand, or fin-
gers.  No swelling  is  produced in the
groin, in consequence of nodes, or blotches
on the legs and  thighs.
   Some very important  experiments arc
related in Mr.  Hunter's Treatise on the
Venereal Disease, in  order to shew,  that
the matter from a gonorrhoea, or chancre,
is capable of affecting  a man locally, who
has already got  a lues  venerea, and  that
the matter from secondary syphilitic sores
has  not the  same power.  The particu-
lars, however, are too long to be inserted
in this book.

PARTS MOST  S' SCEPTIBLE OF  THE LUES
             VF.NEHEA, &C.
   Some  parts of the  body seem to be
much less susceptible of the lues venerea,
than  others; indeed,   Mr. Hunter ob-
serves, that, as far as our knowledge ex-
tends, certain parts cannot be affected at
all.   The  brain, heart, stomach,  liver,
kidneys, and several other  viscera, have
never been known to be attacked by the
lues venerea.
   The first order of parts, or those, which
become affected in the early stage of the
lues venerea, are the skin,  tonsils, nose,
throat, inside ofthe mouth, and sometimes
the tongue.
   The  second  order of parts, or those,
which are affected at a later period, are
the periosteum,  fascia, and bones.
   Mr. Hunter conceived, that one great
reason ofthe superficial parts of the body
suffering  the effects of the lues venerea,
sooner than the deep-seated one-, depend-
ed on the former being more exposed to
external cold.  Even the second order of
parts do not all become diseased at the 
488                     * VENEREAL  DISEASE
 same time, not every where at once.  But,
 on the  contrary, it  is observed,  that,
 those,  which  are  nearest the external
 surface of the body, are first diseased, as,
 for instance, the periosteum, or bones of
 the  head, the  tibia,  ulna, bones  of the
 nose, &c.  Neither does the disease affect
 these  hones on  all sides, equally; but,
 first on that side, which  is next to the
 external  surface.  Mr. Hunter  notices,
 however, that  the susceptibility of parti-
 cular bones does not  altogether depend
 on their nearness to the skin; but, on
 this circumstance, and  their hardness to-
 gether.
   After many ingenious observations, Mr.
 Hunter  presents the reader of his trea-
 tise with the  following summary  of his
 doctrines of the lues venerea.
   First; that most parts, if not all, that
 are affected in the lues venerea, are af-
 fected with the venereal irritation at the
 same time.
   Secondly; that the parts,  exposed to
 cold, are the first which admit the vene-
 real action; then the deeper-seated parts,
 according to their susceptibility for such
 action.
   Thirdly;   tlie  venereal   disposition,
 when once formed in a part,  must neces-
 sarily go on to form the venereal action.
   Fourthly ; that all parts of the  body,
 under such disposition, do not run into
 action equally fast, some requiring six or
 eight weeks ; others, as many months.
   Fifthly ; in the parts, which first come
 into action, the disease continues to in-
 crease, without wearing itself out;  while
 those, which are second in time,  follow
 the same course.
   Sixthly; mercury hinders a disposition
 from  forming,  or,  in other  words, pre-
 vents contamination.
   Seventhly; mercury does not destroy a
 disposition already formed.
   Eighthly; mercury hinders the action
 from  taking place, although the disposi-
 tion be formed.
   Ninthly; mercury cures  the action.
   On these principles, Mr.  Hunter as-
 serts, that the cure of the disease may be
easily explained.

       SYMPTOMS OF LUES VENEREA.

   Mr.  Hunter  remarks, that the  time,
necessary for the appearance, or produc-
tion of the local effects,  in parts most sus-
ceptible of the disease, after the virus has
got into the constitution,  is uncertain;
but,  he says, in general, it is about six
weeks; in many cases, the period is much
longer; in other instances, it is shorter.
Sometimes, the local  effects make their
 appearance within a fortnight alter the
 possibility of absorption.
   The effects, on other parts of tlie body,
 which are less susceptible of the venereal
 irritation, or  slower in  their action, are
 of course much later in  making their ap-
 pearance.  Mr. Hunter also notices, that
 when the first and second order of  parts
 are both contaminated, the  effects, gene-
 rally, do not begin to appear in the latter,
 till after a considerable time, and, some-
 times, not till those  affecting the  former
 parts have been cured.
   Mr.  Hunter,  however,  mentions his
 having seen instances, in which the pe-
 riosteum, or bone, has been affected be-
 fore any of the first order of parts: but,
 he was  uncertain, whether the skin, or
 throat, would  afterwards have  become
 diseased, as the disorder was not allowed
 to go on.
   In  the  first order of parts, most  sus-
 ceptible of the effects  of lues venerea,
 the disease is much quicker in  its pro-
 gress, than in the second order of parts.
 Mr.  Hunter represents, that the symp-
 toms  in   each succeeding  part', which
 becomes affected, are slower and  slower
 in their progress, and of a more fixed
 kind.   It was   also   an   observation,
 made by the  same  ingenious   writer,
 that  similar parts come sooner into ac-
 tion,  and appear to go  on  more rapidly
 with  it, in proportion  as they are  nearer
 the source of the circulation. The dis-
 ease  appears earUer on  the  face, head,
 shoulders, and breast,  and  the erup-
 tions   suppurate  sooner,  than on   the
 legs.

 SYMPTOMS  OF  THE FII18T STAGE  OF  THE
            LUES VENEREA.

   According  to  Mr. Hunter, the  first
 symptoms of  the disease, after  absorp-
 tion, appear either on the skiu, or in the
 throat, or mouth.

         VENEREAL ERUPTIONS.

  The appearances on the  skin  gene-
 raUy occur all over the  body  The dts-
 colourations make the skin appear  mot-
 tled,  and  many of the  eruptions disap-
pear,  while others  continue,  and" in-
crease with the disease.
  In other cases, the eruption comes on in
 distinct blotches, which are often not ob.
 served, till the scurfs have begun to form.
 At other times, the eruption assumes the
 appearance of  small  distinct  inflamma-
 tions, containing matter, and resembling
pimples,  not  being,  however  so  py-
 ramidal, nor   so red  at  the base.   Mr.
Hunter also  observes,  that  venereal 
VENEREAL DISEASE.
489
blotches, on their first coming  out, are
often attended with inflammation, which
gives  them  a  degree  of transparency,
which is generally greater in the  summer,
than the winter, especially, if the patient
be kept warm.  In a little time, this in-
flammation  disappears,  and the cuticle
peels off in the form of a scurf.  The lat-
ter occurrence often misleads the patient
and the surgeon,  who look upon this dy-
ing away of the inflammation,  as a decay
of the disease,  till a succession of scurfs
undeceives them.  Mr. Hunter adds, that
the discolourations of the cuticle arise
from the  venereal irritation, and are  to
be seldom regarded as a true inflamma-
tion,  since  they  rarely have  any of its
characteristics, such as tumefaction and
pain.   However,  he  explains,   that  in
parts, which are well covered, or which
are constantly in contact with other parts,
there is more of the true inflammatory
appearance, especially, about the anus.
  The parts affected' next begin to alter
their  appearance, and form a copper-co-
loured, dry, inelastic cuticle,  called  a
scurf.   This is thrown off, and new ones
are formed.  Mr.  Hunter relates,  that
these- appearances spread to the breadth
of a sixpence, or shilling; hut, seldom
more extensively, at least, for a consi-
derable time.  In the mean while, every
succeeding  scurf becomes  thicker  and
thicker, till at last it becomes a common
scab.   Then the disposition for  the form-
ation of matter takes place  in  the cutis
underneath, and a true ulcer is formed,
which commonly spreads, although in a
slow  way.
   Mr. Hunter  states, that these appear-
ances arise first from the gradual loss of
the true sound cuticle, which the diseased
cutis cannot  reproduce.   As a kind of
 substitute  for this  want of cuticle,  an
 exudation takes  place, and forms a scale.
The  matter afterwards  acquiring more
 consistence, at last forms a scab.  How-
ever, before the  disease has attained this
 condition, the cutis has  ulcerated,  after
 wliich  the  discharge is  more  like true
 pus.  When this form of  the lues venerea
 attacks the palms of the hands and soles
 of the feet, where the cuticle is thick, this
 latter part first becomes separated, and
 peels off   A  new  one is  immediately
 formed,  wliich  also separates.    In  this
 manner,  a series of  new cuticles take
 place,  in consequence of scurfs not being
 so readily formed as on the common skin.
 When the disease is confined to the palms
 of the hands, or soles of the  feet, Mr.
 Hunter mentions, that there  is difficulty
 in determining whether it is venereal, or
 not; because, most diseases of the cutis,
 in these situations, produce a  separation
     Vol. II.
ofthe cuticle, attended with the same ap-
pearances in all,  and having nothing cha-
racteristic ofthe venereal disease.
  When  the affected part of the skin is
opposed by another portion of skin, wliich
keeps it  in  some degree more moist, as
between  the nates,  about tiie arms, be-
tween the scrotum and the thigh, m the
angle between the two  thighs, on the red
part of the  lip,  or in  the  arm-pits,  the
eruptions, instead of being attended with
scurfs and scabs, become accompanied by
an elevation of the skin, which is swollen
with extravasateel  lymph  into  a white,
soft, moist, flat surface, which discharges
a white matter.
  A venereal eruption often attacks that
part of tiie  fingers, on which the nail is
formed  Here, the disease renders that
surface red, which is seen shining dirough
the nail; and, if allowed to  continue, a
separation of the nail takes place, similar
to that of the cuticle  in the above cases.
However, Mr. Hunter states, that there
cannot be the same regular succession of
nails, as  of cuticles in other instances.
  Such surfaces of the body, as are cover-
ed with hair, may also be  attacked, and
the hair separates, and cannot be produced
as long as the disease lasts.
VENEREAL 11ISEASE OFTHE THROAT, MOUTH,
              AND  TONGUE.
   In the throat, tonsils,  anel inside of the
mouth,  the disease generally makes its
appearance  at once in the form of an ul-
cer, without much previous tumefaction.
Consequently, the  tonsils  are not much
enlarged.  It  is observed  by  Mr.  Hun-
ter, that, the venereal inflammation at-
tacks  the surface of these parts, and very
soon forms an ulcer.
   A venereal ulcer in the throat should
 be  carefully  distinguished  from  other
 kinds of sores in the same situation  The
 syphilitic one is in general tolerably well
 marked.  However,  Mr.  Hunter  con-
 fesses, that, it  may not in every instance
 be distinguishable  from an ulcer of a dif-
 ferent nature. Sores in the throat, which
 are really venereal, may resemble others
 which are nut so.  The same  celebrated
 author  mentions, that there are several
 diseases of this part,  which do not pro-
 duce  ulceration on die surface.  One of
 these is common  inflammation' of  the
 tonsils.   The inflamed place often sup-
 purates in  the  centre, so as to form an
 abscess, which bursts by a small opening ;
 but, never looks like an ulcer, that has
  begun upon the surface, like a true vene-
  real one.   The case, just alluded to,  is
  always  attended with too much inflamma-
  tion, pain, and tumefaction, of the parts,
 to be venereal.   Also when it suppurates
      3 Q 
490                         VENEREAL DISEASE.
and bursts, it subsides directly, anel it is
generally attended with other inflamma-
tory symptom- in,the constitution.
  Mr.  Hunter nexi t;kes notice of ano-
ther disease, consisting of  un indolent
tumefaction  of the  tonsils, and peculiar
to many persons, whose constitutions are
disposed to scrophula.  The  complaint
produces a thickness in the speech, home-
times coagulable lymph is thrown out on''
the surface of the parts affected, and oc-
casions appearances, which  are by some
called  ulcers ; by some, sloughs ; and oc-
casionally, by others, putrid sore-throats.
The case U  attended  with  too  much
swelling to be venereal, and, with a little
care, it may easily be distinguished  from
an ulcer, or loss of substance.  However,
when tiiis difference is net obvious at first
sight, it is proper to endeavour to jemove
some of the lymph, and, if the surface of
the tonsil unelerneath  should  appear to
be free from ulceration, we may conclude
with certainty, that  the disease is not ve-
nereal  Mr."Hunter sates,  that  he has
seen a chink filled with coagulable lymph,
so as to appear very much like an  ulcer ;
but, on removing that substance, the ton-
sil underneath was foune} perfectly sound.
He adds, that he  has  seen  cases of a
swelled  tonsil,  having a slough  in its
centre, wh'cli  slough,  before its detach-
ment, looked very like  a foul ulcer.  The
stage of the complaint, he says, is even
more puzzling, when the slough has come
out ; fort then the disease has most of the
characters uf the venereal ulcer.  When-
ever he met with the  disease in its first
stage,  he always treated it, as if it had
been of the nulure of erysipelas, or a car-
buncle.  When the complaint is  in  its
second sta.ire, withou*  any preceding lo-
cal >\ mptoms, he recommends the practi-
tioner  to suspend his judgment, and to
wait a little, >n order 10 see how far nature
is ;.ble to relieve herself.  It there she-uld
have been : ny preceding fever, the case
is still less  likely  10 be venereal.   Mr.
Hunter informs us,  that he has seen a
sore-throat of th s  kind, mistaken for  ve-
nereal  and mercurv giten, till it affected
the memth,  when she  medicine  brought
on  a  mortification of all  the  parts  con-
cerned in the first disease.
  Another comph-int ot these parts, which
Mr. Hunter represents  a->  beng  often
taken for a venereal one, is an ulcerous
excoriation,  which  runs al.mg their sur-
face, becoming very broad anel sometimes
foul, having a  regular termination, but,
never going deeply into the substance of
the parts, as the venereal ulcer does.   No
part ofthe  inside  of the-  memth  is  ex-
empted from this  ulceroi s  excoriation;
but, Mr. Hunter thought, that the dis-
ease most frequently occurred about tlie
root of the  uvula, and spreael forwards
along the palatum  mollt.  He re-marks,
that the complaint is evidently not vene-
real, since it does not  yield to mercury.
He has seen these ulcerous excoriations
continue for weeks, without undergoing
any change,  and a  true  venereal ulcer
make its appearance on the surface ofthe
excoriated part.  He says, ihat the  ex-
coriations in question i have been  cured
by  bark, after  the  end  of the  mercu-
rial course, which cured  the  syphilitic
sore.
  This author describes tiie true venereal
ulcer in the throat, as a fair loss of sub-
stance,  part  being  dug out, as it were,
from the body of the tonsil;  it has a de-
termined  edge, and  is  commonly very
foul, having  thick white matter, like  a
slough, adhering to it, and not admitting
of being washed away.  Ulcers in such
situations are.  always kept  in  a moist
state, and the matter cannot dry and form
scabs,  as it does on sores upon  the skin.
The ulcer is  also much more rapid in its
progress,  and  generally has thickened
eelges.
  When lues venerea attacks the tongue,
it sometimes produces a thickening and
hardening of the part.  However, it also
frequently gives rise to ulceration, as in
other parts of the mouth.
  Venereal sores on the tongue, are ge-
nerally more painful, than  those on the
skin ; but less  so,  than   common sore-
throats  from  inflamed tonsils   They
oblige the patient  to  speak thick, as if
his tongue was  too large for  his mouth,
with a small degree of snuffling.
  Mr. Hunter  doubted the  reality of a
venereal ophthalmy, though he owns there
are inflammations  of  the  eyes,  which
yield to mercury. ' The case, commonly
supposed to  be venereal, is described  in
the article Ophthalmy.

SYMPTOMS OF THE  SECON11  STAGE OF  THE
             LUES VEJ1EIIEA.

  The second  order  of parts, or those,
which are commonly affected at a later
period, may occasionally assume the ve-
nereal action, before the disease has pra-
ducecfiis focal effects  on the first order of
parts ;  and they may even go on with the
action, in many cases, after  these latter
have taken on the action, and been cured.
   The  periosteum, fasciae, tendons,  liga-
ments, and bones, are the parts, which
are usually affected in the second stage
of the  hie-  venerea  Mr.  Hunter  re-
mark*, howe-.er, that we  cannot  always
know  with  certainty what parts m;y be-
come affected in this stage  of the disease. 
VENEREAL DISEASE.
4M.
He  says, he has known  the distemper
 (iroduce a  total deafness, sometimes fbl-
 owed by suppuration, and  great pain in
the ear, and ->ide of the head.  We  have
already explained, that it  was one of this
gentleman's doctrines, that  the second
order of parts were generally deep-seated.
When these become irritated by the poi-
son, he  observes, that the progress of the
disease  is more gradual, than in the first
order of pans.   It assumes very much the
character of  scrophulous  swellings, or
chronic rheumatism ; only  it affects the
joints, less  frequ ntly,  than the  latter
affection deies.  A  swelling sometimes
makes  its appearance on a bone,  when
there has been no possible means of catch-
ing tiv- infection for ma'iy  months; and,
in consequence of the little pain experi-
enced,  the tumour may be of some consi-
derable size, before it is noticed.   Some-
times, a great de«l of pain is felt ; but,
no swelling comes  on, till utter a long
while.   Mr Hunter states,  that these  re-
marks are  als >  applicable to swellings of
the tendons, and fascae.  As tumours of
 this kind only  incieise by  stow degrees,
 they are not attended with  sympu>ms of
 much inflammation.  When tht-y  attack
 the  periosteum, they >eem  like  an en-
 largement of the bone itself,  in   conse-
 quence of being very firm, and  closely
 connected with the latter part.  Mr. Hun-
 ter also further observes,  that, in these
 advanced  stages of the  disease, the in-
 flammation can hardly get beyond the ad-
 hesive  kind,  in winch state, it continue*
 to become worse and worse,  and  when
 matter is  formed,  it is not   true pus, but
 of  a slimy  description.  Some   nodes,
 he says, both  of the  tendons and bones,
 last for years,  before they  form any mat-
 ter at  all.  These cases,  he mentions as
 not being certainly venereal, though -com-
 rttonly  considereel as such.
   It is not easy to explain the   reason,
 why, when lues venerea attacks the bones,
 or the  periosteum, thp p.-iin should some-
 times  be  very  considerable, and,   some-
 times, very trivial.  The pains are usu-
 ally of a periodical kind, being, in gene-
 ral, most severe in the night-time.

      TREATMENT OF LUES  VENEREA.

   Tlie first order of parts, or those wliich
 are most susceptible of being iffected in
 lues venerea, are  <lso the easiest of cure,
 while the second order of parts take more
 time to be remedied.
   l:i the ci si of complaints, arising in the
 second stage*!  of the lues vcierea,  M •.
 Hunter believed, tint it  was unnecessary
 to continue the employment of mereury,
 till all ihe swelling bad disappeared. For,
it is observe!  by this distinguished wri-
ter, that,  since  these local  complaints
cannot contaminate  the  constitution  by
re-absorption,  and since the venereal dis-
position and action from the constitution
can be cured,  while the'local effects still
remain, and this evert whea the tumefac-
tion, firming nodes on the bones, fascia,
Ike. has proceeded to suppuration, there
can be no occasion  for  continuing  the
course, after the venereal action has been
destroyed.  Mr. Hunter  thought, that in
this  latter stage of the lues venerea, the
syphilitic  irritation  was more  easy' of
cure, than the swelling and other effects
of that irritation.
   Mercury, in the  lues venerea, as well
as incases of chancres, is the  great spe-
cific.  In  the present state of our know-
ledge, nothing else is to  be   depended
upon.
   For an  account of the various ways of
exhibiting this valuable medicine, I must
refer the reader to the article Mercury, in
this Dictionary.
   In curing the lues venerea, mercury can
only have two modes of action ; one on
the poison;  the other on  the constitution.
If, says  Mr.  Humer, mercury acted on
the  poison  only,  one might  conceive it
did so, either  by destroying its qualities,
by decomposing it, or else by attracting it
and cir-'ynifC it out of the circulation   If
mercury sicti-d in tiie first of these ways,
one ■ ouhl expect, that  the cure  would
depend on  the quantity  of the medicine
taken into the system. If it acted in the
second maimer, one would infer, that, the
progress of the cure would be proportion-
ate to the  quantity of evacuation.   But,
pb.ei-ves  Mr.  Hunter, if it aci upem the
principle-  of destroying the diseased ac-
tion of the living  parts,  and of counter-
acting the venereal irritation, by produc-
ing one of a different kind, then, neither
 quantity  alone*,  nor  evacuations,  will
avail much.  He  states, that the quick-
 ness of the cure depends  on  quantity,
joined  wi h visible effects  However, it
 is aelded, that although the effects, which
 mercury  has  upon the venereal  disease,
 are in some  degree proportioned to the
 local effects of the medicine on  some of
 the glands, or particular parts ofthe body,
 as the  mouth, skhi,  kidne> s,  and  intes-
 tines, yet such effects are  not  altogether
 proportioned to ihese other circumstances.
 When mercury disagrees'with  the consti-
 tution, so as to produce  great  irritability
 and hectic  symptoms, this action, or  irri-
 tation, :;s  Mr. Hunter explains, is not a
 couiiter-irr.tation to the  venereal disease.
   L wis  also  noticed by the same author,
 that the effects of mercury on lues venerea,
 are always in  proportion to the quantity 
492                          VENEREA"^ DISEASE.
of the remedy, exhibited in a given time,
and the susceptibility of the constitution
to  the mercurial  irritation.   He  says,
that these circumstances require the mi-
nutest  attention, and that,  in order to
obtain the greatest action of mercury with
safety, and in^the most effectual manner,
the  medicine  must be given,  till it  pro-
duces eff'ects  somewhere.   However,  it
must not be exhibited too quickly, in or-
der  that a  sufficient quantity may be
given, before we are obliged to stop,  in
consequence of the effects.  Mr. Hunter
justly informs us, that when the local ef-
fects are produced too quickly, they pre-
vent a  sufficient quantity of the remedy
from being taken into the system to coun-
teract the venereal irritation at large.
   Mr. Hunter mentions his  having  seen
some cases, in which mercury acted  very
readily  locally, and, yet the constitution
was hardly affected by it, for the disease
would not give way.  He states,  that he
has met with  other  cases,  in which the
mere quantity of mercury did not answer,
till it was given so quickly as to affect the
constitution in such a manner, as to pro-
duce local irritation, and, consequently,
sensible evacuations.  This, he observes,
is a proof, that the local effects of mer-
cury are often the sign of its specific ef-
 fects  on the constitution at large, and
shews, that the susceptibility of the dis-
eased parts to be affected by the medicine,
is in proportion to its effects on the mouth.
Its effects, he contends, are not to be im-
puted to evacuation; but, to its irritation.
Hence, he inculcates, that mercury should
be given, if possible, in such a  manner,
as to produce sensible eff'ects upon some
 parts  of the body, and in the largest
   Siantity that can  be given,  to produce
   ese effects within certain bounds.  Mr.
Hunter also remarks, that these sensible
effects should be the means of determin-
 ing, how far the medicine may be pushed,
*o as to have the  greatest effect on the
 disease, without endangering i he consti-
 tution.  The  practice must vary accord-
ing to circumstances; and, if the disease
is in a violent degree, less regard must
be had to the  constitution, and mercury
 must be thrown into the system in larger
 quantities.
   Mr. Hunter likewise acquaints us, that,
 when the disease is in  the first order of
 parts, a smaller quantity «of  mercury is
 necessary, than when the second order of
  arts are affected,  and the disease has
  een of long standing, its  first appear-
 ances alone being cured, and the. venereal
 disposition  still remaining in tlie second-
 ary parts.   For the purpose of curing the
 Tenereal disease,  whether in the form of
 chancre, bubo, or lues venerea, Mr. Hun-
ter was of opinion, that  probably the
same  quantity of mercury is  necessary.
He represents, that one sore requires as
much mercury as fifty sores in the same
per>on, and a small sore as  much  as a
large one.    He  thought,  that  the  only
difference,  if there is  any, must depend
upon  the nature ofthe  parts affected, that
is, on their being naturally active or in-
dolent.  He conceived, however, that, on
the whole, recent venereal complaints are
generally more difficult of cure, than the
symptoms  of lues venerea, and that this
may make a difference, in  regard to the
quantity of mercury necessary.
   The principles above  laid  down, and
other observations, contained in the ar-
ticle  Mercury, must suffice for the direc-
tion  of the cure  of lues venerea  by thie
great specific remedy.   Other informa-
tion,-connected with tiie subject, will he
found by referring to Acidum Nitricum,
 Guaiacum  Mezereon, Sarsaparilla, &c.
   With respect  to the local treatment of
the symptoms of lues venerea, Mr. Hunter
thought, that none would in general be
necessary, since  the constitutional treat-
ment would commonly effect a cure.
   The same writer notices, however, that
sometimes the local eff'ects will not give
way, and the parts remain swollen in an
indolent inactive state, even after there is
every reason to believe, that the constitu-
tion is perfectly cured.  In such cases, he
recommends assisting the  constitutional
treatment  by local applications of  mer-
cury to the part, either  in  the form of a
plaster, or  ointment.  The latter appU-
cation, he says,  is the best.  When these
are hot sufficient, he advises  an attempt
to be made to excite inflammation of an-
other kind.  He says, he has seen a ve-
nereal  node,  which  gave excruciating
pain, cured by merely making an incision
down to the bone, the whole length of the
node.  The pain ceased, the swelling de-
creased, and the sore healed up kindly,
 without the assistance of a grain of mei<-
cury.  He mentions,  that blisters  have
 been appUed to  nodes with  success, re-
 moving the pain,  and taking away the
swelUng.

  DISEASES  RESEMBLING THE VENEREAL.—-
            FSEUDO-STPUILIS.

   Sores on the glans penis, prepuce, ike.
 in the form of chancres,  as  Mr. Hunter
 notices, may and do arise without any ve-
 nereal infection, although in general they
 are a  consequence of  former venereal
 sores, which have been cured.
   The symptoms, produced by tlie vene-
 real poison in the constitution,  are  such
 as are common  to many other diseases. 
VENEREAL DISEASE.
934
For instance, Mr. Hunter remarks, that
blotches on the skin are common to what
is called scorbutic habit; pains are com-
mon to rheumatism;  swellings  of  the
bones,  periosteum, fasciae, &c  to many
bad habits, perhaps, of the scrophulous
and rheumatic  kind.   Thus,  says this
valuable writer, most of the symptoms of
the venereal disease, in all its  forms, are
to  be  found in  many other diseases.
Hence,  the original  cause,   and many
leading circumstances, such as dates,  ef-
fects of the disorder dpon others, from
connexion, when only local, the previous
and present symptoms, &c must be consi-
dered, before we can aetermine absolutely
what the disease truly is.  All the cir-
cumstances  and  symptoms, taken toge-
ther,  may be such,  as will  attend  no
other  disease.    However,  Mr.  Hunter
confesses, that with all our knowledge,
and with all the application of that know-
ledge to suspicious symptoms of this dis-
ease, we are often mistaken, calling dis-
tempers venereal, which are not  so, and
sometimes supposing really syphiUtic af-
feotions'to be of another nature.
   Mr, Hunter takes notice, that,  in some
constitutions, rheumatism, in many of its
symptoms, resembles  the lues venerea.
The nocturnal pains, swelling of  the ten-
dons, ligaments, and periosteum, and pain
in those swellings, are symptoms both of
the rlieumatism, and also of the venereal
disease, when it attacks those  parts.  Mr.
Hunter,  however, did not know,  that he
ever  saw the  lues venerea  attack  the
joints, though many rheumaticcomplaints
of such  parts are cured by mercury, and
 therefore supposed to be venereal.
   Mercury,  given without caution, often
 produces the same symptoms  as  rheuma-
 tism.  Mi-. Hunter has seen  such com-
 plaints supposed to be venereal, and the
 medicine continued.
   This  interesting author also explains,
 that some diseases not only resemble the
 venereal in appearance, but, in the mode
 of contamination, proving themselves to
 be poisons by affecting the part of con-
 tact; then  protlucing immediate conse-
 quences similar to buboes; and also re-
 mote consequences similar to  the lues ve-
 nerea.
    Mr. Hunter observes, that it is nearly
 as dangerous,  in some  constitutions to
 give mercury, when the disease is not ve-
 nereal, s£ to omit it in other cases, which
 are reaUy  syphilitic.   Many  of  the con-
 stitutions, which put on some of the ve-
 nereal symptoms, when the disease is not
 really present, are those, with which mer-
 cury" seldom agrees, and commonly does
 harm.  Mr. Hunter  has  seen mercury,
 which was exhibited  for a supposed ve-
nereal ulper of  the  tonsils, produce  a
mortification of those glands, and the pa-
tient was nearly destroyed.         ,
  Mr. Abernethy, in his Surgical Observa-
tions, 1804, has treated at some lengxh of
diseases resembUng syphilis, and has ad-
duced  several very  interesting  cases,
wliich I advise every surgical practitioner
to read with ihe greatest  attention.   The
following case, recorded by this gentle-
man, I shall take the liberty of quoting.
  " A gentleman (says Mr. Abernethy)
thought, that  he had  infected  a_ slight
cut on his hand (wbich was situated  in
front of and just below the little finger)
with the discharge from  a bubo in the
groin, that he had occ ision to open,  The
wound fretted out  into a  sore about the
size of a sixpence,  which he, shewed me,
and which I affirmed had not the thick-
ened edge anel base,  and other characters
of  a  venereal chancre.  I therefore re-
commended him to try the effect of local
means, and not to use mercury.
  " In  about  a month  the sore, which
had spread a little, became -«gain  con-
tracted in its dimensions, and assumed an
healing  appearance.    At this time pain
was felt extentUng up the arm,  and sud-
denly a considerable tumour arose over
the  absorbing vessels,  which  proceed
along the inner  eelge of the biceps  mus-
cle.  This tumour became nearly as big
as a  small orange.  As the original sore
seemed now disposed to heal, anel as  there
was no  surrounding induration, I could
not believe it venereal, and therefore re-
commended  him  still to abstain  from
mercury, and apply leeches  and  linen
moistened in the aq. litharg acet. comp.
to  the  tumour formed over the inflamed
 absorbents.  For it seemed to me, that if
 the venereal  poison  had  been  imbibed
from the sore, it would have passed  on to
 one of  the axillary glands,  and would
have caused  induration  anel  inflamma-
tion  to takfe  place  there, * more slowly,
 than  had occurred on the present  occa-
 sion.
   " Under this treatment the tumour was
 discussed, and the sore at the same time
 healed.   About three weeks afterwards
 the patient called on  me, and said that
 there were venereal ulcers in his throat;
 and  in  each  tonsil  there was an  ulcer
 deeply excavated, with  irregular edges,
 and with a surface covered by  adhering
 matter ; ulcers,  in short, which every sur-
 geon, who depends on  his sight as  his
 guide,  would have pronounced to be  ve-
 nereal.  Shortly after also, some copper-
 coloured eruptions appeared on his face
 and  breast.   He shewed his diseases to
 several  surgeons,  on whose opinion he
 relied, who, without hesitation, affirmed 
494                         VENEREAL  DISEASE.
 that they were venereal, and that  the
 mercurial course had been improperly de-
 layed.
   " Whilst the patient  was looking  out
 for lodgings, in  order that he might go
 through the mercurial process, a  circum-
 scribed  thickening and  elevation of the
 pericranium  covering the frontal  bone,
 appeared ;  it was of the  circumference of
 an half-crown piece; and was, in short,
 what every surgeon, who is  guided  only
 by his sight  and touch,  would,  without
 hesitation,  have called a fair corona ve-
 neris.   I now told the patient that I was
 more inclined to believe his disease was
 not syphilitic, from the  sudden  and si-
 multaneous occurrence of this  node with
 the  sore throat, &c.   Other surgeons
 thought differently;  and 1  believe this
 very  sensible and  amiable  young  man
 imagined, that his  health would  become
 a  sacrifice, if he any longer attended to
 my opinion.  He was preparing  to  sub-
 mit  to a mercurial course, when very im-
 portant  concerns called him instantly into
 the country.   He went with great reluc-
 tance, taking with him mercurial ointment,
 &c.: and after a fortnight  I received a
 letter from him, saying that he found his
 complaints benefited by his journey,  that
 business had prevented him from begin-
 ning the use of mercury for a few days,
 that he  now found it was unnecessary,
for his symptoms had almost disappeared,
and  shortly afterwards   he  became  per-
fectly well"
   Mr. Abernethy considers this  case as
the most unequivocal instance extant of
a disease occurring, which could not from
appearance be etistinguished  by surgeons
of the greatest experience from syphilis,
and which, however, was undoubtedly of
a  different  nature.  He believes,  that
there is  no one, who would  not have de-
cided on this case,  as those did who de-
clareel it to be venereal,  unless they had
had  an opportunity of watching its  pro-
gress very attentively.
   Mr.  \berne'hy,  in|the course of  his
remarks,  makes  it  appear, that cases,
which are venereal,  and others, which are
not, cannot, in general be  discriminated by
 the mere aspect of the affections.  He be-
 lieves, however,  that there are some cir-
 cumstances, in the progress of such differ-
 ent distempers,  from which a line of dis-
 tinction might be drawn.
   A  very  simple fact has  enabled this
 gentleman  in most cases to distinguish
 the two diseases: " yet,  simple  as it is,
 (says Mr.  Abernethy,) if ii  be generally
 true, it is very important; anel if it were
 universally true,  it would be of the high-
 est consequence.  The fact alluded to is,
 that  the*constitutional symptoms of the
venereal disease are generally progressive,
and  never disappear unless medicine be
employed.  It may be  added  too,  they
are as generally  relieved under  an  ade-
quate  effect of mercury on  the constitu-
tion, &c.
   " I have askeel  the  opinion of several
surgeons  of great  practice and  abiUties
respecting this question;  W hether  con-
stitutional symptoms of syphilis  do  ever
spontaneously amend?  and no  one  has
decidedly replied in the affirmative, whilst
all, without hesitation, agreed that  they
were  generally  progress,ve till  checked
by the effect of mercury.  It seemed use-
less  to  seek further  information;  for
what  surgeon is  there, at present, if he
sees diseases, that cannot be distinguished
by the sight from syphilis, and hears that
they arose in consequence of a  chancre,
that would su-pend  hi*  judgment, and
forbear to administer mercury ? If I have
lived in the habit of so frequently detect-
ing the imposing  appearances of the se-
condary effects of these diseases,  it is be-
cause I have been  upon the watch, and
because they  have occurred in  patients,
in whom  I have  seen  the primary sores,
the appearance  and progress of which
have excited my suspicion as to their na-
ture.   I have stated the rule as  general,
but not universal; for I could myself re-
late cases  of" diseases, in whch, from the
great abatement,  and even disappearance
of symptoms, I have concluded tiie disease
was not syphilitic; yet, from the duration
of the disorder, or from  the subsequent
aggravation of its  symptoms, the patient
has ele-sired, and I have recommended the
use of, mercury, and the disease has been
treated as venereal, without its  real na-
ture being ascertained.
  " The rule, which has been mentioned,
relates to the  constitutional symptoms of
the  venereal  disease,  for the   primary
ones,  chancres, do sometimes heal spon-
taneously,  generally, •  however,  though
not constantly, leaving a  thickening or
induration of the  affected part.  They
may also  be induced to heal  by topical
means,  without  mercury,  with  similar
events.  Sume enlargements of glands in
the groin  will also in like manner subside.
   " It  may be fairly  supposed,  that if
some chancres heal spontaneously,  that
constitutional diseases  arising from  the
same  cause,  may, in  Uke manner, some-
times get better  without medicine.  The
administration  of  nitrous  acid,  opium,
and other remedies have  been  saiel  to
have amended, if not entirely cured, these
constitutional diseases.  But the question
is, will they  get better  spontaneously ?
anel the  question  can  only be solved by
experience.  Delay wiU frequently enable 
VER                                VER               495
a surgeon to decide;  but, there are cases,
in which no amendment  takes place,  and
the surgeon is as it were forced, from" the
progress of the disease, to employ, mer-
cury.
  " In recommending prudent delay and
attentive observation, I hope and believe,
(coninues Mr. Abernethy,) that I am not
recommending any tiling  likely to be  of
dangerous  consequence.  The  venereal
disease is generally soon  checked by the
use of  mercury; and  in  constitutions,
where  much medicine is  required  to
counteract its effects, that meelicine may
be given  with freedom.  By delay and
observatiem,  we  perhaps  ma\  perceive,
that  eruption-, and  sore throats,  winch
could  not  from   appearance  be  distin-
guished'  from  venereal,, spontaneously
amend:  that some  eruptions  scale and
become well, and the probability will  of
course  be that the  rest will do so  like-
wise :  or that an ulcer mends in one part,
though it  may spread in  another, when
the natural inference is that the  diseased
actions in the  sore  will gradually cease,
and  health  return  spontaneously;  and
that what has occurred in one part of  an
ulcer,  will successively take place in an-
other,                             v,
  " In recommending delay it cannot, I
suppose,  be thought that  1 would  aelvise
any one to wait  till an ulcer destroyed
the velum pendulum palati,  or did mate-
rial injury to any important part.  There
are cases  where the progress  of the dis-
ease obliges a surgeon to use mercury,
even though he may be  suspicious that it
is not syphilitic.  The effect of exciting
a mercurial affection of the constitution
in diseases resembling  syphilis is, as far
as my observatiem enables me to determine,
very various.   It  sometimes  cures them
very suddenly and  very differently from
the  gradual amendment,  which it pro-
duces  in  truly venereal, diseases.  Some-
times, however, these diseases yield more
slowly  to its operation,  and are  cured
permanently.   Sometimes  the  diseases
recur  in  the  same  parts  after a severe
course of mercury ; sometimes mercury
merely checks the disease, and can scarce-
ly be  said to cure  it;  in which case it
seems important to support the strength
of the constitution,  and to keep  up that
mercurial effect which  controuls the dis-
ease, and can be borne without material
derangement  of the  constitution  for a
great  length  of time.  Sometimes also
the  use of mercury aggravates these dis-

   " Again, in some constitutions,  the  ve-
nereal  disease may assume unusual cha-
racters, and be very difficult of cure.  It
 must  then be scarcely possible to discn-
minate between these anomalous cases  of
syphilis and those of diseases resembling
it, unless some new distinctions ..re dis-
covered "  (St-e Surgical Observations, by
John Abernethy, F R. S)
  For  information  concerning  the vene-
real  disease, the  reader should  particu-
larly consult Astrue de Morbis Venereis.
John Vigo's Whole Works in Chirurgerie, by
Gale, 1586; or the Latin edition published
at Lryden, in 1518.  Fallopius de Morbo
Gallico   Antonius Musa Brasavolus in the
Aphrodisiacus. Ulricus de Hutten de Morbo
Gallico  Boerhuaviu8 de Lue Veneres, 12mo.
1751.   lion dele tti Opera Omnia, 4to ;  Ge-
nevx, 1610  Morgagni de Sedibus et Causit
Morborum  Francuntianus de Morbo Gal-
lico, 8-no Patav. 1563 Gataker on Venereal
Complaints,  1754.  Chapman on the Vene-
real Disease, 1770.  Fordyce on the Venereal
Disease, with an Appendix, 1777.  Plenck
Doctrina  de Morbis  Venereis.   B  BelVs
Treatise on  Gonorrhatt Virulenta, and Lues
Venerea, edit. 2,  1797.  Lalonette's  New
Method of Curing Diseases by Fumigation,
8*no. 1777.  Hunter's Treatise on thi$ Vene-
real Disease, edit.  2.; which is by fur  the
most valuable work ever published on the sub-
ject. An Enquiry into some ofthe Effects of
the Venereal Poison, &c. by S. Sawrey. 1802.
 Observations on the Effects of various Arti-
cles of  the Materia Medica  in the Cure of
Lues  Venerea, edit  2, 1807.   Practical
 Observations on  the Natural History and
 Cure of the  Venereal Disease,  2 vol  8vo
edit.  2- 1806  Practical Observations  on
 Venereal Complaints, by F. Swediaur,  edit.
3.   Abernethy   on Diseases  resembling
 Syphilis, in his Surgical Observations, 1804.
Adams on Morbid Poisons, edit. 2.
   VENESECTION,  (from  vena, a  vein,
and sectio,  a division.)  The operation of
opening a  vein.   Phlebotomy.   This  sub-
ject has already been spoken of in the ar-
ticle Bleeding.
   VERRU'CA.   A wart.  (See Wart.)
   VE'RTEBRjE,  DISEASE   OF.    In
the present part of the Dictionary, I have
 little more to do, than insert some of the
 very excellent  account,  which  Mr. Pott
has left us of the affection about to be con-
sidered.
   The  disorder,  which we  are going
 to consider, .is  a  disease  of the spiae,
 attended with  a  more,  or  less,  com-
plete loss  of  the power  of using  the
legs.
   Mr. Pott mentions,  that it has in gene-
 ral  been called a palsy, and treated  as a
 paralytic affection; to which it is in al-
 most every respect perfectly unlike.
   This author observes,  that the  occa-
 sion ofthe  mistake is palpable; the  pa-
 tient is deprived  of the use of his legs, 
496
VERTEBRJE, DISEASE OF.
and has a  deformed incurvation of the
spine; the incurvation is supposed  to be
caused by a dislocation of the vertebra;;
the displaced bones are thought to  make
an unnatural pressure on the spinal mar-
row, and a  pressure  on that  being very
likely to  preiduce a  paralysis  of  some
kind, the loss of the use of the legs is in
this case  determined to  be such: the
truth is, that there  is no dislocation, no
unnatural pressure made  on the  spinal
marrow, nor are the Umbs  by any means
paralytic, as will appear to whoever will
examine the two complaints with any de-
'gree of attention.
   In  the true paralysis, (says Mr. Pott,)
from whatever cause, the muscles of the
affected limb are soft, flabby, unresisting,
and incapable of being put  into even a
tonic state ; the limb itself may be placed
in almost any position, or  posture; if it
be lifted up, and then let go, it falls down,
and it is not in the power  ol  the patient
to prevent, or even to retard  its fall: the
joints are perfectly and easily moveable
in any direction; if the affection be of the
lower limbs,   neither  hips, knees,  nor
ankles, have any  degree  of rigidity, or
stiffness;  but,  permit the  limb to be
turned, or  twisted,  in almost any man-
ner.
   Mr. Pott  next notices, that, in the pre-
sent case, the muscles are indeed extenu-
ated, and lewened in size ;  but,  they are
rigid,.and always at least in a tonic  state,
by which the knees and ankles acquire a
stiffness not very easy  to  overcome; by
'means of this stiffness, mixed with a kind
of spasm, the legs ofthe patient are either
constantly kept stretched out straight, in
which case considerable force is  required
to bend the  knees, or they are, by the ac-
tion of the stronger muscles, drawn across
each Other,  in such manner as to require as
much to separate them: when the  leg is
in a straight position, the extensor muscles
act so powerfully, as  to require a  consi-
derable degree of force, to bend the joints
of the knees;  anel, when they have been
bent, the   legs are  immediately, and
strongly,  drawn up,  with the  heels to-
ward the buttocks : by the rigidity of the
ankle-joints, joined to the  spasmodic ac-
tion of the gasirocnemii muscles, the' pa-
tient's toes are  pointed downward, in such
manner as to render it impossible for him
to put his foot  flat to  the ground:  which
makes one of the decisive  characteristics
of the distemper.
   These (says  Pott) are srtong marks of
fhe distinction, which  ought to be maete
between the two diseases;  and, fully suf-
ficient  to shew the  impropriety of con-
founding them with each other.
  The majority of those, who labour un-
der  this disease,  are  infants, or  young
children : adults are by no means exempt
from it;  but Mr. Pott never saw it at an
age beyond forty.
  Mr Pott remarks, that, when it attacks
a child, who is old enough to have walked
properly, its awkward and imperfect man-
ner of using its legs, is the  circumstance,
which first excites  attention, and the in-
capacity of using them at all, which very
soon  follows,  fixes that  attention,  and
alarms the friends.
  Mr. Pott tells us,  that the account,most
frequently  given, is, that for some time
previous  to the incapacity, the child  had
been observed to be languid, listless,  and
very soon tired; that he was unwilling to
move much, or briskly ; that he had been
observed frequently to  trip and  stumble,
although no impediment lay in his way ;
that  when he moved hastily, or unguard-
edly,  his legs would cross each other in-
voluntarily, by which  he  was  often  and
suddenly thrown down  ; that if he endea-
voured to stand still, and upright, unsup-
ported by another person, his knees would
totter anel bend under him; that  he could
not, with any degree of precision, or  cer-
tainty, steadily .direct ei'.her of  his feet,
to any particular point, but,  that in at-
tempting so to do, they would  be sudden-
ly, and involuntarily brought across each
other; that soon after this, he complained
of frequent pains and   twitchings in his
thighs, particularly when in bed, and  of
an uneasy sensation at  the pit of his  sto-
mach ; thft when he sat on a chair, or a
stool, his legs were  almost always found
across each other,  and drawn up uneler
the seat; and that  in  a little  time after
these particulars had  been observed, he
totally lost the power of walking.
  These, continues  Pott, are the general
circumstances, which are found,  at least,
in some degree, and that pretty uniformly,
in most infants and children ;  but, there
are others, which are different  in different
subjects.
  The same author observes,  that if tlie
incurvation be of the neck, and to a  con-
siderable degree, by affecting several ver-
tebra;, the child finds it inconvenient and
painful to support  its own head, and is
always desirous of  laying it on a table or
pillow, or any thing to take off the weight.
If the affection be ofthe dorsal vertebrje,
the  general murks Of  a distempered ha-
bit,  such  as  loss  of  appetite,  hard  dry
cough, laborious respiration, quick pulse,
and disposition  to  hectic, appear pretty
early, afid in such a manner as to demand
attention : and as, in this state of the case,
there is always, from  the connexion be
• 
VERTEBRAE, DISEASE OF.                     497
   t-ween the ribs,  sternum, and  spine,  a
   great degree of crdokedness of the trunk,
   these complaints, are by every body set to
   the account of the deformity merely.  In
^   an adult, the attack, and the progress of
   the disease,  are  much  the  same;  but,
   there are some few circumstances, which
   may he learned from  a patient of such
   age, which either do not make an impres-
   sion on a child, or do not happen to it.
     Mr. Pott states, that an  adult,  in  a
   case, where no violence hath  been com-
   mitted, or received, will tell you, that his
   first intimation was a sense of weakness
   in his back-bone, accompanied with what
   he will call a heavy dull kind of pain, at-
   tended with such a lassitude as rendered
   a small elegree of exercise fatiguing : that
   this was  soon followed  by an unusual
   sense of coldness in his thighs, not ac-
   countable for from theNweather, and a pal-
   pable diminution of their sensibility. That
   in a little time.more, his limbs were fre-
   quently convulsed by involuntary twitch-
   ings, particularly  troublesome  in  the
   night; that soon  after  this,  lie not only
   became incapable of walking, but that his
   power either of retaining or discharging
   his  urine and feces, was considerably  im-
   paired, and his penis became incapable of
   erection.
     The adult also finds all the offices of his
   digestive, and respiratory organs much
   affected, and complains constantly of pain
   and tightness at his stomach.
     Mr. Pott next continues:  In  infants,
   tlie curve is seldom noticed till it has  got
   to such size  and state, as to demand at-
   tention from  the  deformity : previous to
   this, all the marks of distemper, which
   appear in the child, pass for the effects of
   general weakness, and are treated as such ;
   differently  by different people, and under
   different "circumstances, but  never  with
   any permanent good  effect;  some  of the
   adventitious  symptoms,  if I  may so  call
   them, are, in some degree, relieved,  but
   the  principal remain  in full force, or,
   what is much more frequent, go on in-
   creasing.
     In an  adult it passes  for rheumatism,
   or gravel, or a  strain, and the defect in
   the  limbs  is  the  first  thing, that occa-
   sions an enquiry into the .state of the back-
   bone.
     When  a curvature,  says  Mr. Pott, is
   perceived in  an  infant, it is always  sup-
   posed to have received  a hurt by a blow,
   or fall, and an adult has always  recourse
   to some exertion in pulling, drawing,  lift-
   ing, or earning, by which  the spine is
   thought to have been eleranged, or injur-
   ed ; but  which  supposition is seld»m,  if
   ever UVe, in  either case
          Vol.  II.
  The true cause of tlie disease, is a mor-
bid state ofthe spine, and of some of the
parts connected with it;  which  distem-
pered state of parts will, upon careful en-
quiry, be always found  to have preceded
the  deformity  some length of time; in
infants, this is the sole cause, and exter-
nal  violence  has nothing to do  with it.
In the  adult, (continues Mr. Pott,) I will
not assert, that external mischief is always
and  totally  out of the enjestion; but, I
will venture to affirm, what is equal, as
tar as regards the true nature of the  case,
which  is, that although accident and vio-
lence may in some few instances be allow-
ed to have contributed to its more imme-
diate appearance, yet the part, in which
it shews itself, must have been previously
in a morbid state, and thereby predisposed
for  the production of it,  1 do not  (says
Pott,)  by this mean to say, that a violent
exertion cannot injure the spine, nor pro-
duce a paralytic complaint, that would be
to say more  than I  know ; but, I will ven-
ture to assert, that no degree of violence
whatever is capable of producing  such an
appearance as I am now >peakmg  of, un-
less the bodies of the vertebrae were  by
previous distemper disposed to give way;
and that no supposable dislocation, caused
by mere violence done to the bones of the
back, which bones were, before the receipt
of the injury, in a  sound state, can possi-
bly be atteneled with the peculiar symp-
toms of a curved  spine.  In which dis-
tinction, accoreUng to my judgment, (ob-
serves Mr.  Pott,)  consists the very  es-
sence ofthe disease.  Violence may easily
be  supposed to bring the two vertebra;
nearer to  each other than they ought to
be,  and by crushing  an intermediate one
to produce  a curvature ;  but,  then tlie
body of  the vertebrae  so crushed  must
have been in a distempered state previous
to such violence : great violence may also
suddenly and immediately displace a per-
fectly  sound vertebra,  from its  proper
anel natural situation, with regard to  those
annexed to  it: but,  the necessary conse-
quences of these two kinds of injury,  must
be so very different, that they never can
be  confounded together, or mistaken  for
each otiier even by the most inattentive
observer.
  Mr. Pott  next acquaints us, that the
true curvature is  invariably  uniform, in
being from within  outwards ; but, it  va-
ries in situation, in extent, and in degree ;
it affects the neck, the back, or the loins ;
it comprehends one vertebra only,  or two,
or more ;  and.as few or more are affected,
or, as these are more or less morbid, anel,
consequently give  way more or less, the
curve  must  be different; but, whatever
     3R 
498
VERTEBRA., DISEASE OF.
   variety these circumstances may admit,
   the lower limbs alone,* in general, feel
   the effect.  Some are, very soon after the
   curvature, rendered totally and absolutely
   incapable, not only of walking,  but  of
   using their legs in any manner; others can
   make shift to move about with the help
   of crutches, or by grasping their thighs
   just  above the knees  with  both  hands;
   some can  sit in an armed  chair, without
   much trouble or  fatigue; others cannot
   sit up with any help; some retain such a
   degree of power of using their legs, as to
   be able to shift their posture when in bed;
   others have no such power, and are oblig-
   ed to be moved upon all occasions.
     Mr. Pott adds, that weak anil delicate
   children are the most frequent subjects of
   this  distemper; and  when in  these,  it
   seizes on the dorsal vertebrae, great defor-
   mity of the trunk, both before, and be-
   hind, is the almost inevitable and neces-
   sary consequence; this will be different
   in different persons ; but, let the differ-
   ence in this be what it  may, it is an ad-
   junct circumstance, anel upon due enquiry
   it will always be found, that the curvature
   from within outward, preceded the other
   deformity, and was, at one time, the only
   one to be seen.
     Before  the alteration of figure in the
   back-bone has been discovered,  says Mr.
\   Pott, all the attention is paid to the limbs,
   in which the whole disorder is  supposed
   to reside; and all  the applications for re-
   lief  are  made to  them:  frictions, lini-
   ments, embrocations, blisters, &c. to which
   is generally added cold bathing and elec-
   tricity ; when the  curvature has been  no-
   ticed, recourse is immediately had to back-
   boards, collars,  steel  boddice,  swings,
   screw-chairs, and other pieces of machi-
   nery, but all to no purpose; the patient
   becomes  daily more and  more  helpless
   and unhealthy, languishes  for more or
   less time, and at  last dies,  either in an
   emaciated state, from  an hectic,  or by a
  * Since 1 began to put these papers to-
gether,  (says Pott,)  1  have seen two
cases,  in one of  which the aims only
were affected, in the other both legs and
arms.
  Mr. E. Ford, of Golden-square, has  fa-
voured me with the examination and case
of a lad, who lost the use of both legs,
and both arms, from a curvature, which
Mr. Ford cured by means of the caustics.
—Mr. Parke, of Liverpool, has also oblig-
ed me with an account of two persons,
both under his  care, both  with  useless
arms and legs, and both cured by the same
means.  (Pott.)
drain from an abscess, formed within the
body.
  That this  is  tiie  case,  frequent  and
melancholy experience evinces ; but, why
it is so, is perhaps not generally so well
understood, or  attended to  as it ought
to be.
  Mr.  Pott contends, that the primary
and  sole cause  of all the  mischief,  is a
elistempered state ofthe parts composing,
or in immediate  connexion with the spine,
tending to,  and most frequently ending
in, a caries of the body,  or  bodies, of one
or more of the vertebrae:  from this pro-
ceed all the ills,  whether general, or local,
apparent or  concealed; this causes the
ill health of the  patient, and, in time, the
curvature.   The  helpless  state of the
limbs,  is only one consequence of several,
proceeding  from the same  cause; but,
though this effect is a very frequent one,
and  always  affects  the limbs  in  nearly
the  same manner;  yet, the disease not
having its origin in  them,  no application
made to them only, can ever be of any
possible use.
  The same failure  of success (observes
Mr.  Pott) attends the use ofthe different
pieces  of machinery,  and, for reasons,
wliich  are equally obvious.
  They are all,  (says this  author,) from
the  most simple, to the most complex,
but particularly  the swing and tiie screw,
calculated to  obviate  and remove what
does not exist.  They are  founded upon
the  supposition  of an actual dislocation,
which  never is  the case,  and therefore
they always have been, and ever must be,
unsuccessful.
  To understand this in the clearest and
most  convincing manner,  we need only
reflect on the nature of the disease, its
seat, and the state, in which the parts
concerned must  necessarily be.
  Mr.  Pott states,  that  the bones are
either  already carious, or  tending to be-
come so; the parts connected with them
are diseased, and not unfrequently ulcer-
ated; there is no  displacement ofthe verte-
brae, with regard to each  other, and the
spine  bends forward only because  the
rotten bone, or bones, intervening between
the sound ones, give way, being unable,
in such state, to bear the  weight of the
parts  above.  The  most  superficial re-
flection on  this, must point out to every
one, why attempts of this  kind cui do no
good,  and a little more attention to the
subject will shew, why they may be pro-
ductive of real,  and great mischief.   The
bones  are supposed to be sound, but dis-
placed; these machines are  designed to
bring  them  back to their former situation,
and thereby to restore to the spine its pro- 
VERTEBRA, DISEASE OF.
499
 per rectitude; if, therefore, they have any
 power, that power must be exercised on
 the parts in connexion with the curve;
 which parts, when the disease is at all ad-
 vanced, are incapable of bearing such a
 degree of violence, without  being much
 hurt thereby : this, if it were merely theo-
 retical,  being a  conclusion drawn from
 the obvious and demonstrable state of the
 distempered parts, says Pott,  could not
 be deemed  unreasonable ; but, unfortu-
 nately for the afflicted, it is confirmed by
 practice. They  who have had patience
 and fortitude to bear the use of them, to
 such a degree as to affect the  parts con-
 cerned,  have always found increase of
 pain and fever, and an exasperation of all
 their bael symptoms, and (observes Mr.
 Pott)  I have known more  than one in-
 stance, in which the attempt has proved
fatal.
   The use of some or other of these pieces
 of" machinery was so general, and the vul-
 gar prejudice in their favour so great", that
 notwithstanding  Mr. Pott was long con-
 vinced of their perfect inutility, yet it" he
 had had no other objection to them, he
 says  he would not have attempted to rob
 the afflicted of what they seemed to derive
 such comfortable expectation from.  How-
 ever, as he was satisfied of their mischiev-
 ous effects, not  only in the case  of the
 present subject,  but  in many others ; he
 could  not help  bearing his  testimony
 against  the indiscriminate and very im-
 proper use,  which   was  daily made of
 them.                         I
   Mr, Pott says, they are used With de-
 sign  to prevent  growing children from
 becoming crooked or misshapen, and this
 they are supposed to do, by supporting
 the back-bone, and by forcing  the shoul-
 ders  unnaturally backward; the former
 they cannot  do,  and in  all cases  where
 the spine is weak, and thereby inclined to
 deviate  from a right figure,  the latter ac-
 tion of these instruments must contribute
 to, rather than prevent such deviation;
 as will appear to whoever will, with any
 attention, examine the matter-  if, instead,
 of adding to the embarrassments of chil-
 dren's dress, by  such iron restraints, pa-
 rents would throw oft* all of every kind,
 and thereby give nature an opportunity
 of exerting her  own powers;  and if, in
 all cases of manifest debility, recourse
 was had to friction, bark, and  cold bath-
 ing wiih a due attention to air, diet, ex-
 ercise, and rest, the children of the opu-
 lent would perhaps,  stand a chance of be-
 ingas stout, as straight, and as wellshap-
 en, as those of the laborious poor.
   Mr.  Pott observes: When a child ap-
 pears to be what the common people call
 naturally weakly, whatever complaints it
may have, are supposed to be caused by
its weak state, and it is generally believ-
ed, that time  and common care will re-
move them; but, when a curvature  has^
made its appearance, all these marks of
ill health,  such as laborious respiration,
hard  cough,  quick pulse, hectical heat
and flushing, pain and tightness of  the
stomach, ike. are more attentively regard-
ed, and set to  the account  of the defor-
mity consequent to the curve, more espe-
cially if the curvature be of the dorsal
vertebrae, in which case the deformity is
always greatest: but, whoever will care-
fully attend to all the circumstances of
this disorder, will be convinced, that most,
if not  all the complaints of children, la-
bouring under this infirmity, precede  the
curvature,  anel that a  morbid state of
the spine,  and of the  parts  connected
with it, is the  original and primary cause
of both.
  1 have (says Pott) in the former edi-
tion, informed the reader, that my parti-
cular attention to this  disease, was first
excited by an  instance of its being cured
by a seemingly accidental  abscess;  that
this first gave me reason to suspect, that
we had mistaken an effect for a cause, and,
that upon a mature deliberation upon the
matter, I was still more inclined to think
so, for the following reasons.
  1. " That I  did not remember ever to
have seen this useless state of the limbs
from a mere mal-formation of the spine,
however crooked  such  malformation
might have made it.
  2.  " That  none  of those  deviations
from  right shape, which growing girls
are so liable to, however great the defor-
mity might be, was  ever attended with
this effect.
  3. " That the kind of deformity, which
was  attended  with  this  affection of the
limbs, altliough it was different as to its
degree, and its extent,  in different peo-
ple; yet, it was uniform in one circum-
stance, which was, that the curvature al-
ways was from within outwards.
  4. " That since I had been particularly
attentive to the disorder, I thought that
1 had  observed, that neither the extent,
nor elegree  ofthe curve, had in general
produced any  material difference in  the
symptoms, but that the smallest was, when
perfectly formed, attended with the same
consequences as the largest.
  5. " That altliough it had sometimes
happened, that a blow,  or a  strain, had
preceded the appearance of tlie curve, yet
it much more frequently happened, that
no such cause was assignable.
  6. "That I  had observed exactly  the
same symptoms in infants, and in young
children, who had neither exerted them- 
50<J
VERTEBRA, "DISEASE OF.
selves, nor were supposed to have receiv-
ed any injury from others; and that the
case was still the same  in those adults,
who had no such cause to look to.
  7. " That although it might be expect-
ed, that a dislocation of any of the verte-
brae, would be attended with symptoms of
the paralytic kind, yet they woulel be very
unlike to  those which affected the limbs
 in the present case."
   Mr. Pott next continues :  The  suspi-
cions, which these circumstances had ex-
cited  in my mind,  were confirmed*  by
what I had a few opportunities of observ-
 ing, in the dead bodies of  some who  had
dieel afflicted with this disorder, and alto-
gether satisfied  me,  that  there  must be
something predisposing  in  the parts con-
 cerned ; and that when we attribute the
useless state of the  limbs  merely to  the
 Curvature, we mistake, as I have just said,
 an effect for a cause.
   At the same time, says Mr. Pott, I gave
 an account of a conversation which passeel
 between me and the late Dr. Cameron, of
 Worcester, who told me, that having re-
 marked in Hippocrates, an account of a
 paralysis of the lower limbs, cureel by an
 abscess in the  back, he had, in  a case of
 useless limbs, attended with  a curvature
 of the spine,  endeavoured to imitate  this
 act ol nature,  by exciting  a purulent  dis-
 charge,  and that it had pn-oved very bene-
 ficial"; wliich  was  confirmed to me by
 Mr Jeff'rys, of Worcester,  who had made
 the same  experiment with the same  suc-
 cess. N
   If the  cure  of this most dreadful  dis-
 temper, observes Mr. Pott, had dependeel
 upon an  application to the constitutfon in
 general, it might have required a variety
 of medicines, the administration of which
 must have demanded judgment,  in adapt-
  • In the  first  edition,  (says  Pott,) I
had described the bones, on wliich  the
disease  hael  seized,  as  being  enlarged
and spread; upon repeated enquiry  and
examination, I am convinced that they
are not.
  The bodies of the vertebrae concerned
are often affected,  while the ligaments
bear but little  mark  of distemper ;  but
whether the ligaments be affected, or not,
the boelies of the vertebra are always dis-
eased, which disease do s not so  properly
enlarge as erode:  the state also of the in-
tervertebral cartilages, I find to be  sub-
ject to great variety, they beu>g sometimes
totally destroyed, while the caries is small
in degree, sometimes apparently but little
injured,  where  the caries has done consi-
elerable mischief, and sometimes totally
destroyed and annihilated.  (Pott )
ing them to particular persons and  con-
stitutions ;  anel it must also, in the nature
of things,  have  happened, that many in-
divkluals could  not  have been benefited
at all.  But, fortunately for the afflicted,
the means of relief are simple, ..uniform,
and safely applicable to every individual,
under almost every possible circumstance,
not attended  by die smallest degree  of
hazard, and capable  of being executed by
any body,  who has the least portion of
chirurgie  knowledge : it consists merely
in procuring a large discharge of matter,
from unelerneath the membrana  adiposa,
on each side of the distempered bones
forming the curvature,  and  in maintain-
ing such discharge until the patient  shall
have recovered  his health  and limbs.
They who are little  conversant with  mat-
ters  of this  sort,  (continues  Mr. Pott,)
will suppose the means very inadequate to
the  proposed end;   but they who  have
been experimentally acquainted  with the
very  wonderful effects of purulent drains,
made from the immediate neighourhood
of eliseases, will not  be so much surprised
at  this  particular one ; anel  will imme-
diately sec how such kind of discharge,
made, and continued from the distemper-
eel part, checks the further progress of
the caries, gives nature  an opportunity of
exerting her own powers, of throwing oh'
the diseased parts,  and of producing,  by
incarnatieni,  an  union of the bones  (now
rendered sound,) and thereby estabUshing
 a cure.
   Mr.  Pott stAtes,  that  it is a matter of
 very little importance  towarels "the  cure,
 by what means the discharge be procured,
 provided  it  be large, that it come from a
 sufficient elepth, and, that it be continued
 for a sufficient length of time.
   I have tried, says Ik-, the different means
 of seteins,  issues by incision, and  issues by
 caustic, and have found the last in  gene-
 ral preferable,  being least painful,  most
 cleanly, most easily manageable, and ca-
 pable of being longest continued.
    The caustics, he observes, should be
 applied on each side of the curvature,  in
 such a manner as to leave the portion of
 skin covering the spinal processes of the
 protruding bones, entire and unhurt, and,
 so large  that the sores, upon  the separa-
 tion of the eschars,  may easily hold each
 three  or  four  peas, in  the  case of the
 smallest curvature  ; but, in large carves,
 at least as many more.
    The issues,  which  modern  surgeons
  usually make, for the relief of the  symp-
  toms arising from  diseased vertebrae are
  larger, than such as Mr. Pott himself was
 in  the habit of forming.  Practitioners
 now commonly prefer racking an issue on
 each side  of the spinous processes,  about 
VERTEBRJE, DISEASE OF.                       501
three, or four inches long,  and half an
inch broad.  This leads me to speak of
the method of making  caustic issues in
general, anej of the best way of keeping
them open.
  The size  of the issue, intended to be
made, being determined, the place, where
it is to be made, should be accurately
marked out with  ink.   All  the skin im-
mediately around should then be covered
with adhesive plaster, in order that it may
be protected from the action of the caus-
tic.  Let the surgeon next take a piece of
the kali purum,  or kali  purum cum calce
viva,  and wrap a little tow round one end
of it, so that  he may take hold of  it with
safety and  convenience.  The other  end
of the caustic should then be moistened a
little,  and  rubbed  vfery quickly  on the
pbrtion of the integuments which is to be
converted into an eschar.  The part is to
be rubbed in  this manner, till it turns of
a dull brown colour,  when the caustic
should be carefully washed off with a lit-
tie wet tow, and a poultice applied.
  As soon  as the eschars admit of being
removed, a row of peas, or beans,  con-
nected together with thread,  should be
laid on the sore, and confined there with
sticking plaster.  A  compress, containing
a piece of  pasteboard,  or sheet lead, is
then  to be bound over the peas, or beans,
with  a  roller.  In  consequence  of  the
continued  pressune* the peas, or beans,
soon  form  little hollows for themselves,
in which they should be regularly placed
every day.   When the pressure is not duly
maintained, tlie granulations  are  apt to
rise so high, that the peas cannot be well
kept on the  part.   In this circumstance,
the  surgeon must try to repress the high
surface of  the sore, by sprinkling on it
a little of the pulvis sabinse et xruginis
Biies, mixed together in.equal proportions.
When this  plan is unavailing, the re-ap-
plication of the caustic  becomes indispen-
sable.
   With respect to the treatment  of dis-
eased vertebrae, Mr. Pott observes, what-
ever length of time  it may take to obtain
a complete cure, by restoring the health
as  well  as  the  limbs,  the issues must be
continued   at least  as long ;  and in his
opinion, a  considerable time  longer, espe-
cially in the persons of  infants and grow-
ing children ;  the necessity of which will
appear more  strongly,   when it shall be
considered, that infants and young chil-
dren of" strumous habits, are the subjects,
who are most liable to this distemper, and
that, in  all the time previous to menstru-
ation  in  one sex,  anel puberty in the
other,  they  are in  general  more served
by artificial drains, than any other persons
whatever.
  Mr. Pott maintains,, that this,  and this
only, does, or can, alleviate the misery at-
tending this distemper, and in proper time
effect a cure.
  By means of these discharges, says  he,
the eroding caries is first checked, and
then stopped ;  in consequence of which
an incarnation takes place, and the cartila-
ges between  the bodies of the vertebrae
having  been previously destroyed, the
bones become united  with each otiier, and
form a kind of anchylosis.
  Mr. Pott observes, that the time neces-
sary for the accomplishment of this, must,
in the nature of things, be  considerable
in all cases ; but, very different, according
to different circumstances.
  No degree of  benefit or relief, nor any
the smallest tendency towards a cure, is to
be expecteel,  until the caries be  stopped,
and the rotten bones have begun to  in-
carn ;  the larger the  quantity of bones
concerned, and the greater degreeof waste
and havock committed by the caries, the
greater  must be the length  of time  re-
quired for the correction of it,  and  for
restoring  to  a  sound state  so large a
quantity of distempered parts—and vice
versa.*
  In the progress toward a cure, (accord-
ing to Pott) the same gradation, or suc-
cession of circumstances,  may be observ-
ed, as was found to  attend the formation
of the disease,  with this difference, that
those which  attenel  the latter, are much
more  rapid, than those which accompany
the former.
  This author represents, that after the
discharge has been made some time, very
uncertain what, the patient is found to be
better, in  all general respects, and if of
age to distinguish, will acknowledge, that
he feels himself to be in better health ; he
begins to recover his  appetite,  gets  re-
freshing sleep, and has a more quiet, and
less hectical kind of pulse ;  but, the  re-
lief, which he feels  above all others, is
from having got rid of that distressing
sensation of tightness about the stomach ;
in a little time more  a degree of warmth,
and a  sensibility is fell in the thighs,
which they had been  ..trangers to for some
time; and generally much about the same
time, the power of retaining and discharg-
ing the urine  and feces  be0ins  to  be in
some degree exerted.
  * Nothing (says Pott) can be more un-
certain than the time required for the cure
of this distemper.  I have seen it perfect-
ed in two or three months, and  I  have
known it  require two years ; two-thirds
of which  time passed before there  was
any visible amendment. 
AQJ
\ ERTEIIR^, DISEASE OF.
    The first return ofthe power of motion
  in the limbs, says Mr. Pott, is rather elis-
  agreeable;  the  motions  being  involun-
  tary, and  of the spasmodic  kind,  prin-
  cipally in  the  night;  and  generally at-
  tended With a  sense of  pain  in  all the
  muscles concerned.
    At this point  of amendment, if it may
  be so called, it is no uncommon thing, es-
  pecially  in bad  cases,  for the patient to
  stand  some  time,  without making  any
  farther progress;  this,  in  adults, occa-
  sions impatience, and in parents, despair;
  but, in the milder kind of case, the power
  of voluntary motion generally soon fol-
  lows the involuntary.
    Mr. Pott next notices,  that the knees
  and ankles, by degrees, lose their stiffness,
  and the  relaxation  of the latter  enables
  the patient to set his  feet flat upon the
  ground,  the certain  mark that the power
  of walking will soon follow;  but those
  joints, having lost their rigidity, become
  exceedingly weak, and are not for some
  time capable of serving the purpose of
  progression.
    The first voluntary  motions are weak,
  not constantly performable, nor even every
  day, and liable to great variation, from a
1  number of  accidental circumstances, both
  external and internal.
    The first attempts to walk (continues
  Mr. Pott) are feeble, irregular, and un->
  steady, and bear every mark of nervous
  and muscular debility;  the patient stands
*  in need of much help, and his steps, with
  the best support, will be irregular  and
  unsteady;  but,  when they have arrived
  at this, this eminent surgeon had never
  seen an instance, in which they did  not
  soon attain  the full power of walking.
    Mr.  Pott adds, that when the patient
  can just  walk,  either with  crutches, or
  between  two  supporters, he  generally
  finds much trouble and inconvenience, in
  not being able to resist, or to regulate the
  more powerful action ofthe stronger mus-
 cles of the thigh over the weaker, by which
 his legs are frequently brought involun-
 tarily across  each other, and he is sud-
 denly thrown down.
    The same writer informs us, that adults
 fold assistance in crutches, by laying hold
 of chairs, tables, &c. but the  best  anel
 safest assistance  for a child,  is what is
 called a go-cart, of such height as to reach
 under the arms, and so made as to inclose
 the whole body : this takes all inconveni-
 ent weight off from the legs, and at  the
Same time enables the child to move them
 as  much as it may please.
   Time anel patience, says Mr. Pott, are
very requisite ; but, they do, in this case,
as in  many others, accomplish our wishes
at last
    The  deformity remaining  after reco>
  very, he observes, is subject to great un-
  certainty, and  considerable variety, as it
  depends on the degree of caries, and the
  number of bones affected ; in general, it
  may be said, that where one vertebra: only
  is affected, and  the  patient young,  tiie
  curve will in length of time almost totally
  disappear; but, where  two or three are
  affected, this cannot be expected ;  the
  thing aimed at is the consolidation and
  union of the bones, which had been cari-
  ous, and are now become sound ; this is
  the sine  qud non of the  cure, and this
  must, in such cases, reliefer the curvature,
  and, consequently, the deformity  per-
  manent :  the issues will restore the  use
  of the limbs, but not the lost figure of tlie
  spine.
   Mr. Pott, after having  paid  much at-
  tention to the subject, was convinced, that
  the complaint arises  from what is com-
 monly called a strumous,  or scrophulous
  indisposition, affecting the parts compos-
  ing toe spine, or  those  in its  immediate
 vicinity.
   /This morbid  affection,  says he, shews
 itself in a variety of forms: but, although
 its appearances be various,  yet they are
 always such as determine the true nature
 of the distemper.
   Sometimes it appears in  a  thickened
 state of  the ligaments, connecting the
 vertebrae  together, without any apparent
 affection of the bones.
   Sometimes in the form of a distempered
 state of the intervertebral substances, call-
 ed cartilage^.
   Sometimes in that of diseased glands,
 either in a merely indurated and enlarged
 state, or, what is more  frequent, in that of
 a partial suppuration.
   Sometimes it  is found in  the  form of
 bags, or cysts,  containing a quantity of
 stuff, ofa very unequal consistence, partly
 purulent, partly sanious, and partly a curd-
 like kind of substance;  and not unfre-
 quently entirely of the  last.
   Sometimes under these  bags, or cysts,
 even while they remain whole,  the subja-
 cent bones are found to  be distempered,
 that is, deprived of periosteum, and tend-
 ing to become carious.
   Sometimes (continues Mr. Pott) these
 collections  erode   the containing mem-
 branes,  and' make  their way downward
 by the side  of the psoas muscle, towarei
 the groin, or by the side .of the pelvis,
 behind the great trochanter, or, in some
cases, to the outside of the upper part of
the thigh.
  Sometimes (says the  same author) each
ofthe distempered states of these parts is
accompanied by a greater or le^s degree
of  deformity, and crookedness of the 
VERTEBRiE, DISEASE OF.
603
spine, without any apparent disease  of
the bones composing it.  Sometimes the
deformity is attended with an erosion, or
caries of the body, or bodies, of some  of
the vertebrae; and sometimes  the same
bones are found to be carious, without any
crookedness, or alteration of figure.
  Mr. Pott next acquaints us,  that these
different affections ofthe spine, and ofthe
parts in its immediate neighbourhood, are
productive of many disorders, general and
local, affecting the whole frame and habit
ofthe patient, as well as particular parts;
and,  among the rest,  of  that curvature
which is the subject of this inquiry ; and
it may not be amiss to remark, that stru-
mous tubercles in the lungs, and a dis-
tempered state of some of the  abdominal
viscera, often make a part of them.
  From an attentive examination of these
morbid  appearances, and of" their  eff'ects
in different subjects, and under different
circumstances, Mr. Pott deduces the fol-
lowing observations:
   1. That  the disease, which produces
these eff'ects on the spine, and the parts
in its vicinity, is what is in general called
the scrophula; that is, that same kind of
indisposition as occasions the thick upper
lip,  the tedious obstinate ophthalmy, the
indurated glands under the chin,  and  in
tiie neck, the obstructed  mesentery, the
hard dry  cough, the glairy  swellings  of
the wrist and ankles, the thickened liga-
ments of the joints, the enlargement and
caries of the bones, eke. -Sec. ike.      ,
   2. That this disease, by falling on the
spine and the parts connected with it,  is
the cause ofa great variety of complaints,
both general and local.
   3. That when these complaints  are not
attended with an alteration of  the figure
of  the  hack-bone,  neither the real  seat,
nor true  nature  of such distemper are
pointed out by the general symptoms,
and,  consequently, that they  frequently
are unknown, at least  while the  patient
lives.
   4.  That when, by means of this distem-
per, an  alteration is produced in the figure
of the back-bone, that alteration is differ-
ent in different subjects, and accordiug to
different circumstances.
   5.  That m hen the ligaments and carti-
lages of the spine become the seat of the
disorder, without any affection ofthe ver-
tebrae,  it sometimes happens, that tiie
whole spine, from the lowest vertebra  of
the neck downwards, gives way laterally,
forming sometimes one great curve to one
side, and sometimes  a  more irregylar
figure,  producing  general  crookedness
and deformity of the whole trunk of the
boely, atteneled with many  marks of"  ill
health.
  6.  That these complaints, which are by
almost every body supposed to be the ef-
fect  of the deformity merely, are really
occasioned by that distempered  state of
the parts within the thorax,  which is, at
the same time, the cause both of the de-
formity and ofthe want of health.
  7.  That the attack is sometimes on the
bodies of some of the vertebrae ;  and that,
when this is the case, ulceration or erosion
of the bone, is the consequence,  and not
enlargement.
  8.  That when this erosion, or caries,
seizes the body, or bodies, of one or more
of the vertebrae, it  sometimes happens,
that  the particular kind  of curvature,
which makes the subject of. these sheets,
is the consequence.
  9.  That this curvature, which is always
from within outward, is caused by the ero-
sion, or destruction, of part of  the body
or bodies of one or more of the vertebrae;
by which means that immediately above
the distemper, and that immediately below
it, are brought nearer to each other than
they should be, the body of the patient
bends forward,  the  spine is curved  from
within outward, and the  tuberosity ap-
pears behind, occasioned by the protru-
sion  of the spinal processes of the dis-
tempered vertebrae.
  10. That according to the degree of ca-
rious erosion, and accoreUng to the num-
ber of vertebrae affected, the curve must
be less or greater.i
  11. That when the attack is made upon
the dorsal vertebrae, tiie sternum and ribs,
for want  of proper  support, necessarily
give way, and other deformity, additional
to the curve, is thereby produced.
   12. That this  kind of caries is always
confined  to the  bodies of the vertebrae,
seldom or never affecting  the  articular
processes.*
   13. That without this erosive destruc-
tion  of the bodies of the vertebrae, there
can  be  no curvature of the kind  here
treated of; or,  in other words, that ero-
sion  is the sine  qua  non of this  disease;
that  although there can be no true curve
without caries, yet there is, and that not
infrequently, caries without curve.
   14. That the  caries with curvature and
useless  limbs, is most frequently of the
cervical  or dorsal vertebrae; the caries
without curve, of the lumbal, though this
is by no means constant or necessary.


   * Mr.  Pott mentions his having  seen
two  cases in which the bodies of the ver-
tebrae were totally separated from all con-
nexion with the other parts leaving the
membrane,  wliich  inciuded the" spimd
marrow,  perfectly bare. 
m                    VERTEBRJE, DISEASE OF.
  15. That in the case ©f carious 9pine,
without curvature, it most frequently hap-
pens, that internal abscesses, and collec-
tions of matter are formed, which matter
makes its way outward,  and appears in
the hip,  groin, or  thigh ; or, being de-
tained within the body, destroys the pa-
tient : the real and immediate cause of
Whose death  is  seldom  known, or  even
rightly guessed at, unless the dead  body
be examined.
  16. That what are  commonly called
lumbal and psoas abscesses, are not unfre-
quently proeluced  in this  manner, and,
therefore, when  we use these terms, we
should be understood to mean only  a de-
scription of the course which such matter
has pursued  in its  way outward, or the
place where it makes its appearance ex-
ternally, the terms really meaning nothing
more, nor conveying any precise idea of
the nature, seat, or origin of a distemper
subject to great  variety, and from which
variety its very  different symptoms and
events, in different subjects, can alone be
accounted for.
 ' 17. That contrary to the  general opi-
nion, a caries of the  spine  is more fre-
quently a cause, than an effect of these
abscesses.
  18. That the  true  curvature  of tlie
spine, from within outward,  of which the
paralytic, or  useless  state  of the lower
limbs, is  a too frequent  consequence, is
itself but one  effect cf a  distempered
spine ; such case being  always attended
with a number of complaints, which  arise
from the  same cause : the  generally re-
ceived opinion, therefore, that all the at-
tending symptoms  are derived from the
curvature, considered abstractedly,  is by
no means founded in truih,  and may be
proeluctive of very erroneous conduct.
  19. That in the case of true curvature,
attended with useless limbs, there never
is a dislocation, properly to be so  called ;
but that the alteration in the figure of the
back-bone, is caused solely by the erosion
and destruction of a part of one or  more
of the corpora  vertebrarum ; and,  that
as there can be no true curvature without
caries, it must be demonstrably clear, that
there must have been a distempered state
of" parts  previous to such erosion ;  from
all which it follows, that this distemper,
call it by~what name you please, ought to
be regarded as the  original  cause of the
whole, that is, ofthe caries,  ofthe curva-
ture, and all  the attendant mischiefs, be
they what they  may, general or particu-
lar ;  a consideration, as it appears to me,
of infinite importance to  all such infants
and young children, as shew, either  from
their general complaints, or from  their
shape, a tendency  to  this kind of  evil:
and whose parents and frienels  generally
content themselves with a swing, or piece
of iron machinery, and look no further.
  20. That whoever w ill consider the real
state ofthe parts, when a caries has taken
place,  and  the parts  surrounding it are
in a state of ulceration, must   see  why
none of the attempts, by means of swings,
screws, &c. can  possibly do any good,
but, on the contrary,  if they act so as to
produce any effect at all, it must be a bad
one.
  21. That the discharge, by means of tiie
issues, produces in due  time  (more or
less under different circumstances) a ces-
sation of the erosion  of the bones;  that
this is followed  by  an  incarnation, by
means of which the bodies  of  the verte-
bra;, wliich had been the seat of the dis-
ease, coalesce, and unite with each other,
forming a kind of anchylosis.
  22. That the different degrees and ex-
tent of the caries, in  different subjects,
must render all attempts to cure, uncer-
tain, both as to the time required, and as
to the  ultimate event: the  least and small-
est degree will (every thing else being
equal) be soonest relieved  and cured : the
larger and more  extensive will require
more time,  and where the rottenness is to
a great degree, and all the surrounding
parts in a state of distempered ulceration,  ,
it must foil all attempts, and destroy the
patient.
  23. That when  two or  more vertebrae
are affected, forming a large curve, how-,
ever perfect the success may be with re-
gard  to  the  restoration  of health and
Umbs^et the curvature will and must re-
main,  in  consequence  of the union of the
bones with each other.
  24. That the useless state of the limbs
is by no means a consequence of the alter-
ed figure of the spine, or ofthe disposition
of the bones with regard to each other,
but  merely of the caries  ; of this  truth
there needs no other proof, than what may
be drawn from the cure ofa large and ex-
tensive curvature, in which three or more
vertebrae were concerned : in this the de-
formity  always  remains  unaltered and
unalterable, notwithstanding the patient
recovers both  health and limbs.
  Upon  the whole, after  due considera-
tion of what has been said concerning the
nature  of the complaint, its  producing
cause, and the method by  which it  is ca-
pable of  being cured, Mr.' Pott  says, he
would ask,  whether the diseased state of
the spine, and  of the parts.connected  with
it, {which if not prevented, must produce
some of its very dreadfal effects,)  may
not, by a timely use of proper means, be
prevented ?
  He contends, that a morbid state of the 
WART.
505
jjarts,  previous to  deformity, caries, or
curve, must be allowed :  every complaint
of the living, and every appearance in the
deael, he says, prove it beyond contradic-
tion or doubt.   All tlte general complaints
of persons,  afflicted with this  disorder,
will  always, upon  careful  inquiry,  be
found to have preceded any degree of de-
formity, to  have  increased as the curve
became apparent, and to have decreased
as the means used for relief took place :
the pain and tightness about the stomach,
the indigestion, the  want of appetite, the
disturbeel sleep, &c. Ike.  gradually disap-
pear, and the marks of returning health
become observable, before the limbs reco-
ver the smallest degree of their power of
moving.
  Mr.  Pott .remarks, that on the other
hand, it is as true, that when from extent,
or degree, or inveteracy of the caries, the
issues  are found  to be  unequal to the
wished-for effect, the general complaints
receive  no amendment; but  increase un-
til die patient sinks under them.
  If all this  be true, says Mr. Pott, which
that  it is, the  manifold  and  repeated ex-
perience of  many, as well as myself, can
amply  testify; and  if  it be  found, that
the issues are capable of effecting a perfect
cure, even after a caries has taken place,
and that to  a considerable degree, which
is also true to demonstration, is it not rea-
sonable to conclude, that the same means,
maele use of in due time, might  prove a
preventive ?
  If this was  a matter of mere  specula-
tion, or opinion, observes this  celebrated
surgeon, I  would be very cautious how I
spake on the  subject; but it is  really a
matter of experiment;  anel  as far as  I
have had it in my power  to put it to that
test, it has succeeded, by the restoration
of lost health, anel the prevention of a de-
formity, which was advancing rapidly.
  It may, perhaps, be said, contiilues Mr.
Pott, that  if  no  such  means had been
used, the same space of  time might have
produced the same effect: to this it is im-
possible to  make an answer.  I  shall,
therefore,  content myself  with  having
given my opinion, with the circumstances
and reasons on which it is founded.
  Mr. Pott concludes :  I should be sorry
to be misunderstood on this point, or  to
have it thought, that I meant to  say, that
every weak  or ricketty child  was  neces.
sarily liable to a curved spine;  or that
issues were  to be deemed an infallible re-
medy for the ills arising  from  a  strumous
habit : far be it from me to  say either :
what I  would wish to be understood to
mean is, that such kind of habit appears
to me to be  most apt to produce some of
the  mischiefs mentioned  in  this tract;
that, as  a  purulent discharge, derived
from the neighbourhood  of the spine, is
found, from repeated experience,  to be a
successful remedy, even after the  disease
is confirmed by  a caries, it seems to me
to bid fairer than any thing else,  if used
in time, to become a preventive; and, that
as some otiier kinds of deformity are found
to follow attacks of the same kind of con-
stitutional disorder, seizing on these parts,
and which, though not causing precisely
the same effect, are nevertheless attended
with the same  general symptoms  ; I can-
not help thinking,  that it may be well
worth while to try whether benefit be not
obtainable by the same means, in the one
case as in  the other ;  and if the  old
maxim, " anceps remedium quam nullum,"
be admissible, surely an experiment, which
is in  its nature perfectly incapable of harm,
is worth making.  (Pott on tlte Palsy of
the Lower Limbs.)
   VERTIGO,  (from verto, to  turn, be-
cause all things seem to turn  round.)  A
giddiness of the head ; a symptom of  se-
veral eliseases.
   VINEGAR.  For an account  of  its
uses in surgery, see Acetum.
   VIPER,  BITE OF.  See Wounds.
   VOLVULUS, (from volvo,  to roll up.)
See  Intussusception.
>gea-»
w.
      WART.  Mr. Hunter observes, that
      a wart appears to  be  an  excres-
cence from  the cutis, or a tumour form-
ing upon it, by which means, it becomes
covered  with a cuticle, which is either
strong and hard,  or thin and soft, just as
tbe cuticle is, which covers the parts, from
    Vol. H-
which the excrescence arises.  Warts ape
radiated from their basis to their circum-
ference.  The surface ofthe radii appears
to be pointed,  or granulated,  like the
surface of healthy granulations, with the
exception of being  harder, and' rising
higher.   The surface, on which a wart is
    3S 
506
WHITLOW.
formed, seems only to be capable of pro-
ducing one;  for, the  surrounding  and
connecting surface does not throw out a
similar substance.   Thus,  when  a wart
Lias once  begun to  grow, it rises higher
and higher, without becoming  larger at
its  basis.  Such excrescences  seem to
have  within  themselves the  power of
growing larger; for, as  Hunter  remarks,
after they have risen above the surface of
the  skin, on  wliich  their  basis cannot
grow larger, they swell out into a round
thick substance, which becomes rougher
and rougher.
  In consequence  of having this  struc-
ture,  warts are very liable to be hurt by
bodies rubbing  against them, and, from
such a cause, they  often bleed  very  pro-
fusely, and are  renelered  >ery painful.
( Treatise on the Venereal Lisease,  p.  250,
Edit. 2.)
  As warts are adventitious substances,
and not any part of the original struc-
ture of the body,  their powers  of lite
are weak.  Hence, when  stimulated by
particular applications, these excrescences
generally become  smaller  and smaller,
and,  at  length, altogether disappear, or
drop off.
  On this principle, warts may frequently
be cured by stimulating them with a pow-
der, composed of aerugo xris and Ravine
leaves, in equal proportions.
   However, the employment of escharo-
tics , the removal  of  such  excrescences
with a knife or pair of scissars ; or tying
their necks with a ligature;  is a mode
frequently preferred, because the cure is
sooner accomplished.
   The .wo last methods are certainly par-
ticularly eligible,  when the wart has  a
narrow neck; but,  after the removal  of
the excrescence, it is still proper to touch
the  root with caustic; for,  unless the
whole be completely destroyed, the  wart
will inevitably grow again.
   With respect to  caustics, the practi-
tioner may use the kali  purum cum calce
viva, the argentum nitratum, or  the cu-
prum  vitriolatum.   I  think a strong so-
lution of  the  argentum nitratum is  as
efficacious an application  of the caustic
kind, as any, which can be used in these
cases.
   Warts on the pudenda, and  about the
anus,  which  are often  supposed to  be
venereal, scarcely ever withstand the ef-
fect of the powder of savine, and xrugo
seris.
   WHITLOW. (Panaris, Panaritium,Pa-
ronychia.) A whitlow is an inflammation,
which occurs about the end of the finger,
and  is  exceedingly  painful,  and  veiy
much disposed to suppurate.  The affec-
tion  is  commonly  j,een attacking the
fingers, but the toes are undoubtedly, in
a few instances, the seat of the disease.
  Writers  usually  divide whitlows  into
four kinds, or degress.
  The first one is the mildest.  In this
case, a vesicle, filled with matter, com-
monly arises  near the root, or side of the
nail, after a preceding superficial inflam-
mation of trival extent.   The matter is
situated immediately under the cuticle.
Sometimes the abscess takes place under
the nail, in which case, the pain is,  very
severe, and not unfrequently  shoots up-
ward as far as the external condyle.
  The second kind of whitlow is chiefly
situated in the Cellular substance under
the cutis, and, for the most part, occurs
at the very enel eif the finger.  In this sort
of case, the inflammatory symptoms, es-
pecially the  pain,  are  far more  violent,
than they usually are in inflammations  of
such  little extent.  However,  although
the  pain is  thus  severe, it does not in
general extend far from tlie part affected,
unless the tendon  partake of  the inflam-
mation.  Writers usually impute the vio-
lence of the puin,  anel the inconsiderable
degree of inflammation attending the  com-
plaint, to the hard and unyielding nature
of  the skin on the finger.  To the  same
cause they also ascribe  the elifficulty of
perceiving any  fluctuation, after matter
has  formed ;  and the slowness, with which,
the  pus makes its way outward.
   The third kind of whitlow is elistinguish-
able from the others by the following cir-
cumstances.   With the most excruciating
pain,  there is very little swelling in the
affected finger, but, a vast  deal in the
hand, particularly, about the  wrist, and
over the whole fore-arm.  The pain ex-
tends to the hand, wrist, elbow, and even
the   shoulder.  When  suppuration has
taken place, a fluctuation can never be
felt in  the   affected finger,  though the
undulation of matter may very often  be
distinctly perceived in the hand, at the
wrist,  or even somewhere  in the  fore-
arm.  The case is frequently accompanied
 with a cons derable elegree of fever.  In
 this  species  of whitlow,  the disease  is
 seated in the tendons and  their sheaths,
and the power of moving the fingers, and
even the whole hand, is lost.
   Authors describe the fourth  kind  of
 whitlow, as  arising principally  from  an
 inflammation of  the periosteum.  Tlie
 case is  attended  with  one  peculiarity,
 which is,  that, however violent  the pain
 may be, it never  extends  to the  hand,
 anel  fore-arm, nor is  there any external
 swelling of the affected finger.  Suppura-
 tion generally very soon follows, the  usual
 consequence  of which is a caries of the
 subjacent finger-bones. 
WHITLOW.                              507
   Whitlows  commonly begin  on the in-
side of the fingers; but, they do occasion-
ally commence on the back of these parts,
and even  on  that of the hand.   Though
pain about the wrist is usually  the effect
of the inflammation in the ' finger, yet
Acrel makes mention of a case, in which
the disortfer was altogether confined to
the hand itself.  (Vorfalle, 2 B.  p. 191 )
   Besides the above species of  whitlows,
Richter takes notice of a very painful af-
fection of the finger, that  has been term-
ed the dry whitlow.  Acrel relates,  that
a man,  without any particular  preceding
cause, was seized  with  a very  violent
darting pain, near  the nail of the little
finger.  The pain sometimes ceased for a
few minutes, or hours, and then recurred
and lasted for weeks, and months.
   At length, it became still more intoler-
able and  unremitting, and extended all
up the arm.  Hence, the removal of the
first painful portion of the finger  was de-
termined  on.  Nothing  unnatural  was
found  in  the appearance  of the  integu-
ments and tendons; but,  the texture of
the bone was quite  destroyed, and chang-
ed into a fatty substance.   (Acrel,  Vor-
fdlle,2B. p. 210)
   The causes of whitlows  are  generally
ofa local  nature. Writers enumerate the
following as the most  common  ones : a
centusion ; suddenly warming  the finger
when it is exceedingly cold ; pricks with
needles, or other sharp  instruments; and
the insinuation  of  irritating matter into
scratches  on the finger.   A surgeon, in
operating for a  fistula in ano, has been
known to cut his finger, and have in  con-
sequence  of the accident  a very severe
and dangerous kind  of whitlow.  Richter
also  mentions  a  person  having had a
most obstinate whitlow, in consequence
of getting a slight  wound on the finger,
in  examining the head of a horse, that
had the glanders.  Sometimes, the cause
of a whiilow depends on a  splinter, which
still continues lodged in the part.  Very
often, no particular cause whatever can be
assigned for the complaint.
   The  different kinds of whitlows are
not all to  be treated in the same  manner.
   The first case, which occurs  about the
root of the nail, ought to  be  opened  as
soon as possible.  When this plan is not
adopted,  the matter not  only  makes its
way rouiul the nail, but penetrates more
deeply, so as  to reach the root of the
nail,  and occasion a  loss  of the part.
When an effectual   opening is  not made,
the matter  is apt  to collect  again. In
general, a detachment ofthe cuticle takes
place,  as tar  as  the  abscess  extends.
When  the inflammation  has  been  very
 violent, and the matter has made its way
as far as the root of the nail, the  nail
itself is in general gradually detached,
while the denueled portion of the root of
the nail acts on the sore as a foreign boely,
and hinders it from healing. Hence,  the
surgeon  should  repeatedly cut away as
much of the lower edge ofthe nail as he
can,  and insinuate a little soft lint be-
tween the margin of the nail and the sore,
in order to keep  the  latter from being
irritated by the former.  In  proportion
as  the  old nail gradually separates, a
new one makes its appearance.
  When matter lies under the  nail, an
opening should be made through the part,
as speedily as possible, for the discharge
of the abscess.  In order to perform  this
operation, Hichter advises the  surgeon
to scrape, with a piece  of glass, the part
of the nail to be opened, till it is as thin
as it can well be, and then to cut  through
it with the point  of a bistoury.
  In the second species of whitlow, sup-
puration may sometimes  be  preventeel,
and the inflammation be resolved, by the
timely   employment  of proper  means.
When the  pain  is exceedingly  violent,
and there is acute fever, it may be ad-
visable  to bleed  the  patient in the arm.
In a few severe cases,  the application of
three,  or feiur leeches to the  affected
finger, has been known to procure prompt
relief*.    (Schmucker.)   Theden  thinks,
that applying a reller round  the finger,
hand, anel  arm, and  frequently wetting
the two first parts with  a  lotion, the
most  certain means  of resolving the in-
flammation.  Platner advises  the  finger
to be for some time  immersed in water,
as warm as the patient can bear.  Some
recommend the external use of camphor-
ated spirit, or the volatile alkali; while
others  advise the affected finger to be
plunged in a very warm solution  of soap,
or kali.  When the whitlow has been oc-
casioned by a prick, particular care must
be taken, that there is no extraneous sub-
stance remaining in the puncture.
  When the symptoms dp not lessen by
the fourth day, Richter recommends mak-
ing an opening in the finger.  Even when,
no  fluctuation  is discovered, the same
surgeon approves  of  making a crucial
incision in  the seat of the pain, and, he
states, that  although  no matter may be
discharged, the patient always derives in-
finite  relief from the operation.  The
benefit, he  says,  may either be imputed
to the bleeding, or to the division of the
hard  tense  skin,  which compresses the
subjacent  nfiamed  parts.  Sometimes,
the collection of  matter  can  be plainly
felt, and, in  this case,  there can  be no
hesitation about the  place,  where  the
opening should  be made. However, it 
508                              WOUNDS
 may be proper to remark, that the open-
 ing should always be  made sufficiently
 large.  When the surgeon makes a small
 puncture, it very soon closes again,  and
 a  repetition  of the operation becomes
 necessary.  When opening the abscess is
 delayed,  the theca of the flexor tendons
 easily  becomes affected,  or  the  matter
 may make its  way to a considerable ex-
 tent around under the  skin.   Sometimes,
 the matter gets  through the cutis by ul-
 ceration,  and elevates the cuticle, in the
 form of a pustule.  In this case, as soon
 as the  cuticle has been opened, a director
 should be introduced into the aperture in
 the skin, and  the latter opening be en-
 larged with a bistoury.
   The third  species of whitlow seldom
 affects the last phalanx of the fingers  ;
 but, generally, the second, or third one.
 In this case, Richter enjoins us never to
 defer making  an opening longer,  than
 the third  day.   If we wait till suppura-
 tion  happens, we shall wait till the ten-
 dons are  destroyed, and the use of the
 finger  lost.  In the case under considera-
 tion, the matter is always of a bad quality,
 and very small in quantity. A fluctuation
 in the  finger  can very  seldom  be  felt.
 However,  in  a very few  instances,  the
 matter becomes  perceptible  at the ex-
 tremity of the finger, or about the finger-
 joints,  but, more  often, in the palm of
 the hand, or near the  wrist.  In  these
 circumstances, the tendons are in gene-
 ral already destroyed, and a stiffness of
 the finger anel hand is to be apprehended.
 When the complaint is the consequence
 ofa puncture, the best plan, according to
 Richter, is at once to enlarge the wound;
 for, m this sort of case, all other methods
 are quite unavailing.  It is not enough,
 however,  to cut through  the  skin;  the
 tendinous  theca  itself  must  be  laid
 open.
   When the pain does not undergo any
 diminution, after the  tendinous sheath
 has been   opened, or,  should the  pain,
 after subsiding,  recur again,   the  first
 opening should be dilated by means of a
 knife and  director.  Also, if the patient
 should  experience in any  other part  of
 the  hand an acute pain, which  does not
 diminish in consequ. ne/of this first open-
 ing ;  or if signs of the formation of mat-
 ter should  be  observed elsewhere in the
hand ; an opening should be made there,
of sufficient depth to reach through the
theca of the flexor tendons.  When a col-
lection of matter forms towards the wrist,
or the patient  feels violent pain in  that
situation, an opening must also  be made
there.   If an opening should  have  been
alreaely  made in the hand, a probe may
be  introduced  into the  wound, and  an-
 other  aperture made in an eligible situa-
 tion by cutting on  the end of" flie instru-
 ment.   In  the same way,  Richter aelvises
 making an opening  iu any part of the fore-
 arm, where  great pain, or the symptoms
 of suppuration, indicate.
   In the fourth kind of whitlow,  early
 incisions,  made  down  to  the bone, are
 the  most certain means of obviating the
 danger.  When  such incisions  are not
 made  early  enough, suppuration  takes
 place,   and  the  bone  becomes carious.
 The cut is to be made in the  place,  where
 the  pain is most severe.  When the first
 phalanx is affected, the incision may  be
 made  in front of tiie finger; but, when
 the  second,  or third, is tiie seat of the
 complaint, the opening had better be raaete
 on one  side.   However,  in order that
 the  opening  may be at all  useful, it is
 absolutely  necessary to make it down to
 the  bone.   When  the  incision  has been
 delayed too  long, a small quantity of un-
 healthy  matter is usually  detected, and
 the  bone is found to be carious.   As an
 exfoliation can  hardly be expected in this
 situation, ii is best to remove the diseased
 piece of bone at once, which can generally
 be effected without difficulty. When the
 last  phalanx alone  is affected, the  finger
 retains its form, with the exception of its
 end  being a little shorter  and flatter.
 When  the disease,  however, is situated
 in the  third  phalanx, Richter  thinks it
 better  to amputate tiie finger  than re-
 move the diseased bone, as the  finger, if
 lefi, would always remain stiff and  unser-
 viceable.   (See Anfangsgr. der Wundarz-
 neykunst, vol. 7.)
   WOUNDS.  A great deal of the sub-
ject  of woynds is  already treated  of in
 several parts of this work;  for  instance,
 the articles Abdomen; Hydrophobia; Gun-
 shot  Wounds; Head, Injuries of; Parotid
 Duct;  Sutures; Thorax; Throat, &c.
   A wound may be defined  to be a recent
 solution  of continuity in the soft  parts,
 sueldenly occasioned by external  causes.
   Wounds m general are  subject  to a
 great deal of variety, both in their nature
 and external  appearance. The differences
 depend,  in a very great measure, on the
 nature  of the injured parts, the manner in
 which  the wounel has happened, and its
 extent.
   Wounds  of fleshy parts are exceedingly
 different from  those of tendinous  ones,
 both in regard to their appearance, and
 nature, and the degree of danger.  There
is  also  an  essential difference,  between
such" as are made with a  sharp cutting
instrument,  and  others,  in   which the
fibres,  besides being divided, have suf-
 fered considerable contusion  and lacera-
tion.  A wound, made with a narrow- 
WOUNDS.                               509
pointed instrument,  is  also  of a  very
different nature from one that has an am-
ple orifice
  Wounds are distinguished  by surgical
Writers  into  several  kinds,  viz. incised,
punctured, contused, lacerated, and poison-
ed ones, and gun-shot injuries.
  The latter cases have been treated of
in the article Gun-shot Wounds; but, of
the other kinds of wounds,  we shall pre-
sently treat.
  The degree of danger, attending every
wound,  depends very  much  on some of
the following circumstances.   The  ex-
tent ofthe injury ; the additional violence,
which the fibres of the part have suffered,
besides  their  division ; the nature of the
blood-vessels, or nerves,  which happen
to be cut;  the nature: of the  wounded
part,  in respect to its general power of
healing favourably, or not; whether the
operations of the system at  large, and
life itself, can be well supported, or not,
while the functions of the wounded part
are disturbed, interrupted, or suspended,
by tlie accident;  the age of the patient ;
the goodness, or badness of his  constitu-
tion ; and the opportunities,  which there
may be, of" receiving proper surgical aid,
and assistance of every kind.

           INCISED WOUNDS.

   As a general observation, we may state,
that,  cxteris  paribus, a wound,  which is
made  with  a sharp cutting  instrument,
which is,  in short,  a mere incision,  is at-
tended  with less  hazard of dangerous
consequences, than  any other kind of
wound  whatever.   The  fibres have only
been  simply  divided ; they have suffered
no contusion, nor laceration ;  they are
consequently  less likely to inflame much
so as to suppurate, and slough ; and they
commonly admit of being united again in
a veiy expeditious manner.
   Simple incised wounds commonly bleeJl
more freely,  than contused and lacerated
ones, which  at first frequently emit no
blood at all,  although considerable blood-
vessels may be injured. But, this circum-
stance,  apparently diminishing the dan-
ger of contused and lacerated wounds, is
deceitful, and serves rather to render the
case  in reality more perilous, by induc-
ing  the inexperienced practitioner  to be
off his  guard against hemorrhage.  Cer-
tainly, it often happens, that, on the im-
mediate occurrence of such wounds, there
is no bleeeling of consequence.  However,
the  side of some large artery having suf-
fered great  violence at  the time of the
accident, it  may ulcerate, or slough, a
 week or  ten days afterwards, and an
alarming, and even fatal effusion of blood
be the result.
  This  unpleasant occurrence of sudden
hemorrhage is  particularly apt to occur
in cases of gun-shot wounds,  which are
injuries always  attended  with  a con-
siderable degree of contusion and lace-
ration.
  In cases of simple incised wounds, the
bleeding, which at  once takes place from
all the divided vessels, is a source of very
useful information  to  the  surgeon, inas-
much as it enables him to judge, what
danger  is  to be apprehended from the
hemorrhage,  whether  the cut vessels are
large enough to demand the ligature,  or,
on the contrary, whether they are such as
will cease to bleed, either  by slight pres-
sure, or of their own accord.
  A  surgeon,  called to a recent simple
uicised  wound, has three  objects which
he should endeavour to accomplish, with-
out  the least delay.  The first, and that,
which requires h'.s immediate interference,
is the bleeding, which must be checked.
The second is the removal  of all extrane-
ous matter from the surface ofthe wound.
The third  object is to unite the opposite
sides ofthe injury.
  When the divided vessels are not above
a certain size,  the bleeding  soon spon-
taneously   ceases,  and no  surgical mea-
sures  need  be taken on this particular
account.  When the wounded vessels  are
even somewhat  larger,  and their situa-
tion is favourable for compression with  a
bandage, it is often advisable to close  the
wound anel apply compresses and a roller,
rather  thn  have  recourse to ligatures,
which always create  a certain degree of
suppuration".   However,  though 1 have
maele this  observation, I  should be  ex-
ceedingly  sorry to appear at all against
the general preference to ligatures, when-
ever the   wounded arteries  are  above  a
certain magnitude.  In this circumstance,
tying the bleeeling vessels is the only safe
mode of proceeding.   When the artery is
of considerable size,   and  its mouth can
be readily seen, the  me>st proper instru-
ment for  taking hold of it, is a pair of
forceps. In  applying the ligature,  the
surgeon must  take care to pull its end in
such a manner,  that  the  noe>se  will  not
rise above the  mouth of the vessel, and
for  the purpose of altering the direction
of the force  employed in  tightening  the
ligature,  the  ends of the  thumbs  are
generally  made use of  The tenaculum
is  commonly  employed  for taking  up
arteries, which are not exceedingly large
and  distinct.   How< ver,   I  need  not
expatiate  on the mode of  tying arteries,
as  the subject is fully considereel in an*. 
510                               WOUND*.
 other part  of the Dictionary.  See  He-
 morrhage.
   The bleeding having been suppressed,
 the next object is to remove any extrane-
 ous matter, such as  dirt,  bits of glass,
 clots of  blood, &c. from the surface of
 the wound.   Were this circumstance neg-
 lected, the  plan  of uniting the opposite
 sides of the cut by tiie  adhesive inflam-
 mation, or  by, what is more frequently
 termed, union by the first intention, would
 in general be frustrated.
   As soon  as  the foregoing  indications
 have been attended to, the surgeon must
 approximate the lips  of the wounel, put
 them in  contact,  and take proper pre-
 cautions for keeping them in this state,
 until they have  firmly grown together.
 The sides of wounds are kept in a state of
 apposition by the aid of adhesive plaster,
 a proper position, the  pressure of a roller,
 and,  in a few  particular instances, by
 the employment of sutures.   Of this last
 means, nothing need be saul in this  arti-
 cle, as all the requisite information may be
 found in another place.  See Sutures.
   The best  and most common  method of
 keeping the  surfaces  of divided parts in
 contact is by means of strips of adhesive
 plaster.  At the  time, when they^areto
 be applied,  the surgeon should put the
 wounded parts in such  a  position,  as
 shall  render  them  capable of being
 brought  into a  state of apposition with
 most facility. With this view, a position
 should generally  be chosen, which re-
 laxes the skin  and  subjacent muscles.
 An assistant shoulel then place the eelges
 of the wound as  evenly together as  pos-
 sible, and hold them in  this state,  until
 the surgeon  has secured them in this con-
 dition  by stiips of adhesive plaster, ap-
 plied across the line  of the wound.  In
 general, it is deemetl advisable to leave a
small interspace of about a quarter of an
 inch between each two strips of plaster,
 by  which means  the matter  cannot be
 confined  in  case of   suppuration.  Over
 these first strips,  lint is  to  be applied,
and kept  in its  place with  some more
pieces of adhesive plaster.  Then, if ne-
cessary, a pledget, and compresses are to
be  put on the part, and, lastly, the band-
age, or roller, is to be  applied.
  In this  manner, the fresh-cut surfaces
are brought into contact,  and to preserve
them quietly  in  this state, is the next
great aim, which the surgeon should have
in  view.   The  wounded part  should be
laid in the posture, which was found the
most  favourable  for  approximating the
sides of the  cut, at the time of applying
the dressings, and the patient should be
directed  to  keep the  part in a perfectly
quiet state.
  When attention is paid to these circum-
stances,  it  often happens, that the two
opposite surfaces of the weiund grow to-
gether again in the course of forty-eight
hours, without  the   occurrence of  the
least  degree  of suppuration.  The pro-
cess, by which this desirable  event is ac-
complished,  is  well  known  among sur-
geons, by the name of union  by the first
intention.  Besitles the advantage  of the
cure being effected in this way with the
greatest expecUtion possible, there is sull
another thing much  in favour of always
promoting this method of healing wounds,
wliich is, that the scar is much less, than
after any other plan,  and the  part is co-
vered with original skin, which is always
much  stronger, than any  winch can be
formed as a substitute for it.
  It is wonderful with what celerity union
by the first intention takes place  under
favourable circumstances.  Iu the course
of three days, the large  wound, made in
the operation of  amputation, is frequently
all healed,  except just  where  the  liga-
tures are situated.
  When the two sides ofthe wound have
been brought together, before the oozing
of blood has entirely ceased,  it is  proba-
ble,  that, blood itself becomes the  first
bonel of union, and this  connection must
happen indeed almost immediately.  In
other instances,  what Mr.  Hunter "called
the  adhesive inflammation  occurs. In
this  process,  coagulating  lymph  either
issues from  he half-closed mouths of the
vessels, or from the surface of the opened
cells of the cellular substance.   This be-
comes the first uniting medium, and,  very-
soon afterwards,  in  some inexplicable
manner, a  vascular   intercourse is esta-
blished between the opposite sieles of the
wound.
  The power, which parts of the animal
body  have,  of growing  together  in  the
above manner,  in  strikingly  evinced by
the possibility of removing a part of one
body, and then  uniting  it to some  part
of another.   In this latter case, there can
be no  assistance given   to the union on
one side, since the detached part, as Mr.
Hunter observes,  can hardly  do  more,
than just preserve its own  living prin-
ciple, and accept of  union.   In this way,
says the same  writer, the spurs  of tlie
young  cock can be made to grow  on his
comb,  or on that  of another cock; and
its testicles, after having been removed,
may be made to unite to the inside  of any
cavity of an  animal.
  Mr. John Hell describes the process of
adhesion  to  be this:  either the arteries
of the opposite surfaces inosculate mouth
to mouth,  or rather  each  cut surface
throws out a gluten;  the gluten fills up 
WOUNDS.                                511
the intermediate space;  into that gluten,
tlie lesser arteries of each cut-surface ex-
tend themselves, and it is thus, perhaps,
by the generation of a new intermediate
substance,  that the  continuity and en-
tireness of the part  are  so quickly re-
stored.  If any one point  fail  to  adhere,
there the wound must run into suppura-
tion ; because, says Mr. J. Bell, at that
point there is a separation of parts, which
is equivalent to a loss of substance.
  The same writer observes, that there
are, no  doubt,  accielents, both of the
cfinstitution and the wound,  which will
prevent adhesion.   If the patient  be of a
bad habit of body; if he  be  lying in a
foul hospital, in the midst of putrid sores,
and breathing a contagious air;  if he be
ill of a fever, or flux, or any general dis-
ease ;  then  the properties of the body
being' less  perfect, the  wound  will not
adhere.  Mr.  J. Bell also notices, that,
if the wound be foul, maele with a poison-
ed weapon, or left with foreign bodies
loelged in it;  or if a considerable quantity
of blood be poured out into the cavity  of
the wounel;   or if there  he  a wounded
lymphatic, or  a wounded  salivary duct,
a wounded intestine, or a bleeding artery
or  vein, the immediate adhesion of the
whole of the wound may  be  prevented.
However, 1 cannot help remarking, that,
though  Mr. John  Bell,  in  imitation  of
most  surgical  writers,  sets down the
wound of a lymphatic, as preventive of
the union of wounds, I  cannot say, that
I ever saw such an  effect imputable to the
cause just mentioned.   Also, when  an
artery, or vein is cut, and  requires being
tied, the adhesion of the wound  would
only be prevented just where  the liga-
ture lies.
   Tliere is no wound, observes Mr. John
Bell, in which we may not try with per-
fect safely to procure this aelhesion ; for,
nothing can  agree  better with one surface
of the wound,  than the opposite one,
wliich  has  been jus* separated from  it.
They may immeel lately  adhere  together,
 and even  if  they  should not do so,  no
 harm  is done,  and the wound  will yet
 suppurate as favourably, as if it had been
 roughly dressed wiih dry caddis, or some
 vulnerary balsam,  or acrid ointmem.   If
 one part should suppurate, while one half
 adheres, then, says Mr.  John  Bell,  one
 half of our  business, is done.  In  short,
 this simple  duty of immediately closing
 a wound is  both natural and  safe.  (Dis-
 courses on the Nature and Cure of Wounds,
 vol. 1.)
    Sometimes, the  attempt to procure an
 union  by the first intention fails, even
 in cases of  incised wounds.  The mo-
 ment, where we observe pain, inflamma-
tion, and swelling of the wound, a sepa-
ration or gaping of its lips, the stitches
tense (when these have been used,)  and
the points, where the stitches pass, par-
ticularly  inflamed,  Mr.  John Bell  ad-
vises us to undo  the bandages, draw out
the sutures,  and take away every  thing,
wliich acts like a stricture on the wound.
These  prudent  measures,  he observes,
may abate the  rising  inflammation,  and
prevent the total separation of the skin.
while an endeavour may still be made to
keep the  edges of the wound tolerably
near each other by the more gentle ope-
ration of sticking plasters.
   However, when  the inflammation rises
still higher, and it is evident that a total
separation of the sides of the wound  can-
not be avoided, the above author recom-
mends leaving the parts quite loose, and
applying- a large soft poultice; for,  says
Mr. John Bell, should you, in this criti-
cal j'ancture, persist in keeping the parts
together  with sutures, the inflammation,
in the form of erysipelas,  would extend
over the  whole  limb, attended  with a
fetid and bloody suppuration.   After the
wound  has got into a favourable state,
another attempt  may now be  made to
bring the edges near each other, not  with
sutures, but, strips of adhesive plaster, or
tiie gentle appUcation of a bandage.
   Mr. John Bell concludes with remark-
ing, that the suppuration, proiluction of
granulations  and  all that  follows, are
the work of nature.  The only thing,
that the  surgeon can usefully  do, is to
 take care ofthe health.  When thewound
 does not  suppurate favourably, the dis-
 charge generally becomes profuse,  thin,
 and gleety.  This state is to be amended
 by bark, wine, rich diet, and good air.
   I shall  conclude this subject of union
 by  the  first intention with  an extract
 from the writings of Mr.  Hunter,  who
 observes that
   " It  is with  a view to this principle of
 union, that it has been recommended to
 bring  the sides (or lips) of  wounds to-
 gether;  but as the natural elasticity of
 the parts makes them recede, it has  been
 found  necessary to employ art for that
 purpose.   This necessity first suggested
 the practice of sewing wounds, and after-
 wards gave rise  to various inventions in
 order to answer this  end, such as band-
 ages,   sticking-plasters,  and  ligatures.
 Among  these,  the bandage commonly
 called the uniting bandage is preferable
 to all the rest, where it can be employed ;
 but its application is very confined,  from
 being  only adapted  to  parts  where a
 roller can be used.  A piece  of sticking-
 plaster, which has been called the dry
 suture, is more general in its appUcation 
512
WOUNDS.
 than the uniting bandage, and  is there-
 fore preferable to it on many occasions.
   " 1 can hardly suppose (says Mr.  Hun-
 ter) a wound, in any situation,  where  it
 may not be applied, excepting penetrat-
 ing wounds, where we wish the  inner
 portion of the wound to be closed equally
 with the outer, as in the case of hair-lip.
 But even in such wounds, if the parts are
 thick, and the wound not large,  the  sides
 will seldom recede so far as to make any
 otiier means necessary.   The dry suture
 has an advantage over stitches, by bring-
 ing a large surface of the wound together,
 by not inflaming the parts to which it  is
 applied, and by neither producing in  them
 suppuration nor ulceration, which stitches
 always  do.   When  parts, therefore, can
 be brought together, and especially where
 some force is required for that purpose,
 from the skin not being in large quanti-
 ty, the  stitching plaster is certainly the
 best  application.    This  happens  fre-
 quently to  be the case after the removal
 of tumours, in amputation, or where the
 sides ofthe wounel are only to be brought
 together at  one  end, as  in the hare-lip ;
 and  I think  the difference between Mr.
 Sharp's cross-stitch,  after amputation, as
 recommended in his  Critical Enquiry,
 and  Mr.   Allanson's  practice,  shews
 strongly the  superiority of the sticking-
 plaster (or  dry suture.)  In those parts
 of the body where the skin recedes more
 than in  others,  this treatment becomes
 most necessary ;  and as  the  scalp proba-
 bly recedes as little  as any, it is therefore
 seldom  necessary to apply  any  thing in
 wounels of that  part; the practice will
 certainly  answer   best   in  superficial
 wounds, because the bottom is in these
 more  within its influence.
   " The sticking plasters  should be laid
 on in strips, and these should be at small
 distances from each other, viz.  about  a
 quarter of an inch  at most, if  the part
 requires close confinement; but when it
does not, they may be at greater distances.
 This precaution becomes more necessary
 if the bleeding is not quite stopped; there
 should  be passages  left  for the  exit of
 blood, as its accumulation might prevent
the union, although  this does not always
 happen.  If any  extraneous  body,  such
 as a ligature, should have  been left in
 the wound, suppuration  will take place,
 and the matter should be allowed to vent
at some of those openings, or spaces, be-
 tween the slips of plaster.   I have known
 a  very  considerable abscess formed  in
 consequence of this  precaution being ne-
glected, by which the whole of the recent-
 ly united parts has been separated.
   " The interrupted suture, which has
 generally been  recommended  in large
 wounds, is still in use, but seldom proves
 equal  to the intention   Th.s  we  may
 reckon to be  the  only one that deserves
 the name of suture; it was formerly used,
 but is  now in a great measure  laid aside
 in practice, not from  the impropriety of
 uniting parts  by this process, but from
 the ineffectual mode of attempting it.  In
 what  matter better methods could be
 contrived, I have not been able to suggest.
 It is  to  be  understood, that the above
 method of bringing  wounded parts toge-
 ther,  in  order to unite  them, are only
 to be put in practice in such cases as will
 admit  of it; for if there was a  method
 known, which in  all cases would bring
 the wounded surfaces  into  contact,  it
 would, in many instances, be improper,
 as some  wounds are  attended with con.
 tusiejn, by  which  the  parts  have been
 more or less deadened ; in such cases, as
 was  formerly  observed, union   cannot
 take place according to our first prin-
 ciple,  and  therefore  it   is  improper to
 attempt it.
  " In  many wounds, which  are not at-
 tended with contusion, when we either
 know,  or suspect, that extraneous bodies
 have been  introduced into the  wound,
 union by  the first intention should not be
 attempted, but they should be allowed to
 suppurate, in order that the extraneous
 matter may be expelled.  Wounds, which
 are attended  with laceration, altliough
 free  from  contusion, cannot  always  be
 united by the first intention, because  it
 must frequently be impossible to bring
 the external parts, or skin, so  much in
 contact, as to  prevent  that inflammation
 which is naturally  produced by exposure.
 But even  in cases of simple  laceration,
 where  the external influence is but slight,
 or can  be prevented (as  we  observed in
treating ofthe compound simple fracture)
 we find that union by the first intention
 often takes place ;  the blood, which fills
 up the  interstices of, the  lacerated parts,
having prevented the stimulus of imper-
fection in them, and preventing suppura-
tion, may afterwards be absorbed.
  " Many operations may  be so performed
as to admit of parts uniting by the first
intention  ; but the practice  should be
atloptetl with great circumspection ;  the
moele of operating  with that view, should
 in all cases be a secondary,  and  not  a
first consideration,  which it has unluckily
 been too often among surgeons.   In cases
of cancer, it is a most dangerous attempt
at refinement in surgery.
  " In  the  union  of  wounded  parts by
the first  intention, it is  hardly or never
possible,  to bring them so close together
at the  exposed edges, as to unite them
perfectly by these means ; such edges are 
WOUNDS.
513
therefore obliged to take another method
ot heahng.  If kept moist, they will in-
name as deep between the cut surfaces as
the  blood fails in the union, and  there
suppurate and  granulate;  but if  the
blood be allowed  to dry and form a scab
between, and along the  cut edges, then
inflammation  and  suppuration of  those
edges will be prevented, and  this  will
complete the union, as will be described
by-and-by.
  " As those effects of accidental injury,
which can be cured by the first intention,
called up none of the powers of the con-
stitution to assist  in the reparation, it is
uot the  least  affected or disturbed by
them ;  the parts are  united by the extra-
vasated  blood alone,  which was thrown
out by the injury, either from the divided
vessels, or in  consequence of  inflamma-
tion, without a single action taking place,
even in the part itself, except the closing,
or  inosculation of the  vessels ;  for the
flowing of the blood is  to be considered
as entirely  mechanical.  Even  in  cases
where a small degree  of inflammation
comes on, it is merely a local action, and
so inconsiderable, that the constitution is
not affected by it;  because it is an opera-
tion to which the powers belonging to the
parts themselves are fully  equal.  The
inflammation may produce a small degree
of pain, but the  operation of union  gives
no  sensation  of  any kind whatever."
(Hunter on the Blood, Inflammation,   and
Gunshot Wounds.)

  CONTUSED AND LACERATED WOUNDS.

  Lacerated wounds are those, in which
the fibres, instead of being divided by a
cutting  instrument, have been  torn asun-
der  by  some  violence, capable  of  over-
coming   their force of  adhesion.  The
eelges of such wounds, instead of being
straight  and  regular, are jagged and un-
equal.
  The term contused is applied to those
wounds, which are occasioned  by some
blunt instrument,  or surface, which has
violently struck a part of the body.
  These two species of  wounds  greatly
resemble each other, and as they require
nearly the same  kind of treatment, wri-
ters usually treat of them together.
  Lacerateel, and contused, wounds differ
from simple incised ones in appearing, at
first view, much less  alarming, than tlie
latter,  while,  in  reality,  they _ are  in-
finitely more dangerous.  In  simple cut
wounels, the  retraction  of the parts,
and the hemorrhage, are generally much
more considerable, than in a  lacerated
wound of the same size.  However, not-
withstanding these circumstances,  they
    Vol. II
commonly admit of being healed with by
far the greatest ease.   It  is even proper
to remark, that lacerated and contused
wounds are scarcely  ever attended wkh
any serious effusion of blood, even though
some large blood-vessels may be injured.
This circumstance often  leads inexperi-
enced practitioners to commit great mis-
takes, by inducing them to promise  too
much in the prognosis, which they make.
Surgeons, versed  in  practice,  however,
do not allow  themselves to be deceived
by  the absence, of hemorrhage, and, in
proportion as there   is little   bleeding,
they apprehend that the violence, done to
the fibres and vessels  has  been consider-
able.   Whole limbs have frequently been
torn from the body, without any hemorr-
hage of consequence taking place.
  Cheselden  has described, in  the  Phi-
losophical Transactions, a very remark-
able case, in which  a  man's   arm was
suddenly  torn  from  his body.  Samuel
Wood, a  miller, had  round his  arm  a
rope,  which got entangled  with the wheel
of a mill.   He was lifted off the ground,
and then stopped by a beam, which pre-
vented his trunk  from passing further,
at this instant,  the  wheel, which  was
moving with  immense force, completely
tore, anel carried  away,  his   arm  and
scapula from  his body.  The appearance
of a wound,  occasioned in this manner,
must of course be horrible, and the first
idea, thence  arising,  must naturally be
that the patient cannot  possibly survive.
Samuel Wood, however, escaped with his
life.   The limb had been  torn off with
such velocity, that he was unaware of the
accident,  till he  saw  his arm moving
round on  the  wheel.  He immediately
descended by a narrow ladder  from the
mill, and even  walked some paces, with
a view of seeking assistance.  He now
fell down with weakness.  The persons
who firsi came  to his  assistance, covered
the wound with powdered sugar.  A sur-
geon,  who afterwards  arrived,  observing
that there was no hemorrhage,  was con-
tent with bringing elown the skin,  which
was very loose, so as to make' it cover the
surface of the wound.   For this purpose,
he u**ed two cross-stitches.  The patient
was conveyed, the  next day, to St. Tho-
mas' Hospital,  and put under  the care
of Mr. Fern,  who was then the  head sur-
geon of that  charity.   This practitioner
employed the means usually resorted  to,
with  a  view  of  preventing   the  bail
symptoms to be apprehended in this sort
of case.  The first dressings came away
without any bleeding ;  no  alarming con-
sequences ensued ; and the patient got
completely well in the  course of a couple
of months.
    3T 
514
WOUNDS.
  When  the arm was examineel, it was
found, that the muscles, inserted into the
scapula,  were torn through near their in-
sertions ;  while other  muscles,  arising
from  this bone, were carried away with
it.  The  skin, covering the scapula, had
remained in its  natural  situation, and
seemed as if  it had been divideel pre-
cisely  at the  insertion of the  deltoid
muscle.
  In La Motte's Traite des Accouchemens,
may be feiund an account of* a little boy,
who,  while playing near ihe  wheel of a
mill,  got  his hand,  fore-arm, and arm,
successively entangled in the machinery,
and the  limb was violently torn  away at
the shoulder joint, in consequence of the
lad's body not  being able to  pass  in the
direction,  in wliich  the arm was drawn.
The bleeding was so trivial, that it was
stopped  with a little lint, and the boy
very soon recovered.
   In  the fifth volume of the Edinburgh
Medical  Commentaries, may also be per-
used the history of a child, three years
and a half old, which  had its arm torn
off by the wheel ofa mill. Mr. Carmichael,
who  saw the child  about an hour after
tie accident, found  it  almost in  a  dy-
ing state, with cold  extremities,  small
faultering pulse, anel all the right side of
the bod) convulsed.   However, there had
been hardly any bleeding.  The arm had
been broken about  an  inch  and  a half
above the elbow;  the stump hael  a very
dreae'ful appearance; all  the soft parts
were in  a contused  anel lacerated  .state,
and the  humerus  was laid bare as high
as  the articulation,  which was itself ex-
poseel.   The skin  and muscles were lace-
rated to a much  greater extent, and in
different directions.   The remainder of
the humerus  was  removed from  the
shoulder-joint  by amputation,  only  as
much .skin  and  mi/scle  being  left,  as
w.is sufficie nt to cover  the wound.  The
child got completely well in two months.
   In  the second volume of the Me moires
de I' Academie de Chirurgie, is an account
of  a  lerg b. ing  torn away at the joint by
a cart-wheel.   The  pft.ent was  a boy,
about nine  or ten years of age.  This ac-
cident, like the foregoing ones, was  ac-
cempaniee'.  with  nri hemorrhage.  The
Jower portion  of  the os  femoris,  which
was  exposed,  was  amputated, together
with  such portion of the soft parts, as
was in  a contused  and lacerated  slate.
The  patient experienced  a  perfect re-
covery.
   The preceding ei-ses strikingly confirm
the observation, which  I  have  alreaely
made, in regard to   the  little bleeding,
which usually arises  from contused and
lacerated wounds.
  In these instances, the pain is also  m
an inverse ratio to the cause of  the acci-
dent :  It is  generally very severe,  when
the wound is only moderately contused;
and, on  the  other  hand,  the patient
scarcely suffers any pain  at all,  where
there has been so violent a degree of con-
tusion, as almost to destroy the  organiza-
tion ofthe nerves ofthe part.
   When the bruiseel  fibres have not been
exceedingly injured, the part suppurates ;
but, such portions of the wound, as have
suffered  greater violence,  inevitably die,
and  are cast off" in the  form of sloughs.
Granulations   are  afterwards   formed,
and  the  breach of continuity is repaired
by the process of cicatrization.   (See this
word.)
  When a still greater degree of violence
has been done  to the parts,  and, especi-
ally,' when arteries  of  a certain magni-
tude  have been  injured, a mortification
is too frequently the  consequence.  How-
ever, if the constitution is good, and the
mischief is  not too extensive,  the case
may still end well.   But, in   other in-
stances, the event is  always alarmingly
dubious;  for,  the mischief  is  then not
limited to the wounded parts, which have
suffered the greatest degree of contusion;
but, too  frequently,  extends over such
parts,  as were not at all interested by the
wound itself.
  The mortification,  ariing directly from
the  impaired organization  of   parts,  is
not what  is  the  most  alarming circum-
stance.  The  most  dangerous  kind  of
mortification  is that,  which is apt to ori-
ginate from the vieilent  inflammation, oc-
casioned by  the  accident.   This conse-
quence elemands the  utmost attention on
the part of the surgeon, \^ho must  let no
useful means  be  neglected,  with a view
of diminishing the inflammation, before
it has  attained so high  a pitch,  as  to in-
duce fatal effects.   He should not- be
afraid of letting the  wound bleed a little,
if it should be disposed to  do  so  in the
first instance.  The  edges of the wound
should then be approximated with  a few
sti ips  of sticking plaster, so as  to  lessen
the extent of" the exposed surface: but,
no sutures are  proper.  Not  much of the
wejund can  be expected to  unite by the
first intention ; the  whole, or the greater
part  of  it,  will  necessarily suppurate,
after the detachment ofthe sle-ughs. The
surface will  then granulate, new skin will
form, and the part  heal just like a com-
mon wound.   Perhaps,  until the sloughs
hHve separated, the best application over
the adhesive  plaster  is a  soft  poultice,
which  should be-put  on  cold, lest  it
should bring  on  too  great  an  oozing of
blood. When, however,  there is  much 
WOUNDS.
£15
bleeding,  lint,  and a simple pledget must
be employed for the first few hours.  The
healing of a contused, or lacerated wound,
is. to be accomplished  on the same prin-
ciples, as  the  cure of sores in  general.
(See Ulcers.)

          PUNCTURED WOUNDS.

- A punctured wound signifies one, that
is made  with  a narrow-pointed  instru-
ment,  the  external orifice  of the injury
being  small  and contracted, instead  of
being of a size  proportionate to its depth.
A wound, produced by the thrust  of a
sword, or bayonet, affords us an example
of a punctured  wound.
  Wounds of this description are  in gene-
ral  infinitely more dangerous, than incis-
ed  ones,  notwithstanding the latter have
the appearance of being by far the most
extensive.  The greatest  degree  of dan-
ger, in cases  of punctured wounds,  al-
ways   depends on the  additional injury,
anel rough violence, which the fibres have
suffered, besides being divided.   Some of
the disagreeable consequences, apt to fol-
low, are also to be  imputed to  the fre-
quent  great depth, to  which punctured
wounds are liable  to  extend, in conse-
quence of  which circumstance,  import-
ant parts  and  organs  are often  injured.
These cases are likewise less easy of* cure,
owing to  the  difficulty of extracting any
extraneous  substances, which may  hap-
pen to be lodged in the wound. All punc-
tured \itiunds,  and stabs  are at the same
time dangerous, inasmuch as they are par-
ticularly liable  to be followed by a great
deal of inflammation, fever, deep-seated
abscesses, sinuses, -See.
  A strange notion  seems to pervade the
writings of every systematic author, that
all  the danger and disagreeable conse-
quences of punctured wounds are entirely
owing to  the narrowness of the orifice,
which  prevents suitable  applications  to
the bottom  of  such  wounds.   Hence,  it
is absurdly recommended  to dilate the
opening of every st.ib, with a view, as  is
generally  addeel, of  converting  the  ac-
cident into  a  simple  incised  wound.
Some of" these  writers are advocates for
making the dilatation  with a cutting in-
strument,   while  others,  with equal  ab-
surdity,  advise enlarging  the  opening
with tents.
  Certain   authors  regard  a punctured
wound, as a recent  sinus,  an I, in order
to make  the inner  surfaces  unite,  they
recommend exciting a elegree of inflamma-
tion in them,  either by means of setons,
or injections.
  In the First Lines of the Practice of Sur-
Tery,  I have taken particular pains to ex-
pose the folly and error, wbich prevail in
most writings on  this part of practice.
In the above work, I have remarked, that,
certainly,  if the notion were  true, that
an important punctured  wounel, such as
the stab of a biyonet,is actually changed
into  a wound partaking of the mild,  na-
ture of an incision, by the mere enlarge-
ment of  its orifice,  the corresponding
practice would be highly commendable,
however  painful it  might  be.   But the
fact is otherwise ; the rough violence done
to the fibres ofthe body by the generality
of stabs, is little Ukely to be -suddenly re-
moved by  an enlargement of the wound.
Nor can the distance, to which a punctur-
ed wounel  frequently penetrates, and  the
number and nature of the parts injured
by-it, be at all altered by such a proceed-
ing.   These,  wh:ch are the grand causes
of the collections of" matter that  often
take place  in the cases under considera-
tion,  must exist, whether the mouth and
canal of the wound  be enlarged or not.
The time when incisions  are proper, is,
when there are foreign bodies to  be re-
moved, abscesses to be opened, or sinuses
to be divided. To make painful incisions
sooner than they can answer any  end, is
both  injueUc'eius and  hurtful.   They  are
sometimes rendered quite unnecessary, by
the  union  of the wound  throughout its
whole extent,  without any suppuration
at all.
   Making a free incision in the early stage
of these cases,  undoubtedly seems a rea-
sonable method of preventing  the forma-
tion  of sinuses, by preventing the con-
finement of matter, and,  were  sinuses
an inevitable consequence of all punctur-
ed wounds, for  which no  incisions  had'-
been practised at the moment of their oc-
currence,   it would  undoubteelly be  un-
panlonable to omit them.  Fair, however,
as  this  reason  may  appear,  it is only
superfic ally plausible, and a sm.dl degree
of reflection seion discovers its want of
real solieliiy.  Uneler what circumstances
do sinuses form ?. Do they not form only
where there is some cause e*xistiug to "pre-
vent  the  healing of  an abscess1.'   This
cause may either be the indirect way, in
wliich the abscess communicates extern-
ally,  so that  the pus  does not  readily
escape;  eir it  may  be the presence of
some foreign body, or carious  bone ; or,
lastly, it  may be an inelisposition  of the
inner surface of the abse ess to form  gra-
nulations, arising from its  long duration,
but  remove-ible  bylivng the cyst  com-
pletely open to the influence  of the,  air.
Thus it becomes nunifest, dial the occur-
rence of suppuration in punctured wounds,
is only folio>ved by  sinuses in cases,  in
which tlie surgeon neglects to procure a 
616
WOUNDS.
free  issue for the matter, after its accu-
mulation; or  in which  he neglects  to
remove any  exu-aneous  bodies.  But, as
dilating the  wound at first  can only tend
to augment the inflammation,  and render
the suppuration more extensive, it  ought
never to be practised in these cases, ex-
cept for the  direct objects,  of giving free
exit  to matter already collected, and of
being able to  remove extraneous bodies
palpably lodged.  I  shall once more re-
peat, that it is an  erroneous idea, to sup-
pose tiie narrowness of punctured wounds
so principal  a cause ofthe bad symptoms,
with which they are  often attended, that
the treatment ought invariably to aim at
its removal.
   Recent punctured wounds have ab-
surdly  had  the same plan of treatment
applieel to them, as old and callous fistulx.
Setons and stimulating injections, which,
}n the latter cases, sometimes act  bene-
ficially by exciting such inflammation as
is productive of the effusion of coagulat-
ing  lymph,  and of the granulating pro-
cess, never prove serviceable when the in-
dication is to moderate an  inflammation,
which is too apt  to  rise to an improper
height.  The counter-opening, that must
be formed, in adopting the use ofa seton,
is al-o  an  objection.   However,  what
good can possibly arise from a  seton  in
these cases ? Will it promote the discharge
of foreign bodies,  if  any  are  present.'
By  occupying the  external  openings  of
the wound,  will it  not  be  more likely to
prevent  it ?  In fact,  will it not itself act
with all the inconveniences  anil irritation
of an extraneems substance  in the wound ?
Is it a likely  means of diminishing the
immoderate pain, swelling, and extensive
suppuration, so often attending  punctur-
ed wounds ? It will  undoubtedly prevent
the  external openings from  healing too
seion ;  but cannot this object be effected
in a  better way ? If the surgeon  observes
to insinuate a piece  of lint into the sinus,
and  pass a  probe through its track once
a day, the danger of its closing too soon
will be removed.
   The  practice of  enlarging punctured
wounds by  incisions, and of introducing
setons, is often forbidden by the particular
situation of these injuries.
   In the first stage of a punctured wound,
the  indication is to  guard  against the
attack  of violent  inflammation.   When
no considerable quantity of blooel has been
lost, general and topical bleeding should
be practised.  In short,  the antiphlogistic
plan is to be followed.  As no  man  can
pronounce,  whether such  wounds will
unite, or not,  and  as no harni cm  result
from the attempt, the orifice ought  to
be closed with strips of adhesive plaster
and gentle compression applied along the
whole* course of the'puncture.  Perfect
quietude is  to  be observed.   When the
pain is  very severe, opium is to be ad-
ministered.
  Sometimes, under this treatment, the
surgeon is agreeably surprised to find the
consequent  inflammation mild,  and the
wound speedily united, by the first  in-
tention.  More frequently,  however,  in
cases of deep stabs, the pain is intolera-
ble ; anel the inflammatory symptoms run
so h'gh as to leave no hope  of avoiding
suppuration. In this condition, an emol-
lient poultice is the  best  local applica-
tion ; and, when  the matter  is formed,
the treatment is like that of abscesses in
general.  (See  Suppuration.)

           P01S0NF.D WOUNDS.

   Wounds of this description  are not very
common in this country.  The stings and
bites of certain insects ; and the bites of
vipers, mad dogs, cats, &e.  are the only
instances, which we meet with.
   In this article, I shall dismiss from con-
sieleration  the  symptoms and treatment
of the alarming indisposition arising from
the bite of particular rabid animals,  and
content myself with referring the reader
to Hydrophobia.
   With  respect  to the sting6 of bees-,
wasps, hornets, &c. and the bites of gnats,
and other inserts, these cases are seldom
of sufficient consequence to  require the
assistance of* a  surgeon.  However, were
his advice  requested, he shoulei be pre-
pareel to give it.
   The hornet is,  to appearance, the most
formidable  creature of the winged kind
in Britain.  Mr. Latta says, it is not to
be met with in Scotland; though there
are nests of them in some ofthe woods in
England.   The fact, however, is, that its
sting, though more painful,  than that of
ei'her the wasp  or bee, is not attended
 with any material consequence.  Wasps
 seldom sting,  unless irritated by the de-
 struction of their nest, and then they at-
 tack in great  numbers every  one who
 passes by.  It is an error to suppose that
 bees sting more frequently;  and that  the
 human breath  is  particularly offensive to
 them.  It  has  even been  representee), as
 part of the secret of those, who make
 them swarm at pleasure,  without danger
 to themselves, upon  any part  of  their
 bodies, to keep their breath from them,
 as much as possible,  lest  they should
 thereby be provoked to sting them.  Bees
 are, however,  the most harmless of all
 creatures,  if noi toucheel or interfereel
 with, and use their weapons only in their
 defence.  The stings of all these insects 
WOUNDS.                               517
 are attended with  a sharp pain in the
 part, very quickly succeeded  by an  in-
 flammatory  sweUing, which in  no  long
 time goes off of its H.  It rnav, however,
 be relieved, by rubbing  the part, imme-
 diately after the injury, with honev, oil,
 vinegar, or spirits of wine, or even by im-
 mersing  it  in  cold water.   There are
 several other insects  known to us, which
 do not fly, that seem to  have  something
 poisonous in their bite.
   Were any material degree of inflamma-
 tion to be induced by the irritation, oc-
 casioned by  the bites  and  stings  of
 insects, the best plan  would be to keep the
 part continually covered  with linen, wet
 with the satumine lotion,  and  to exhibit
 one or two  doses of some saline  pur-
 gative.
   With regard to the bites of serpents,
 those  inflicted  by   the  rattle-snake  of
 America, and the cobra de capello of the
 East-Indies,  are  said  to be  the most
 speedily  mortal.  Indeed, writers state,
 that this is so much  the case, that there
 is scarcely time  to  apply any  remedy,
 although it be at hand the very moment,
 when  the bite is received.   Mr.  Latta
 takes  notice, that Mr.  Catesby, in  the
 Preface  to his Natural History of Caroli-
 na, informs  us,  that the Indians, who,
 by their  constant   wanderings  in  the
 woods, are liable to be bit by those venom-
 ous animals, know,  as soon as they re-
 ceive  the injury, whether it will prove
 mortal or not.  If it be on any part at a
 distance  from  large blood-vessels,  or
 where  the  circulation is not  vigorous,
 they  apply their remedies; but, if any
 vein,  of considerable magnitude, happens
 to be hurt, they quietly resign themselves
 to their fate, as knowing that they could
 then be of no benefit.  It is not well known
 what the remedies  are,  on  which  they
 chiefly depend.   Seneka root and volatile
 alkali, are among the number;  anel, more
 particularly,  strong eloses of arsenic,  as
 we shall have occasion to  notice again.
   Mr. Latta  observes, that the only per-
 son, who has particularly consielered this
 subject,  of the bites of serpents, is the
 Abbe  Fontana.   This  latter gentleman
 agrees with  Dr.  Meael, that the  poison
 of the viper  is neither acid nor alkaline ;
 but, denies that he coulel perceive in  it
 any thing like salts, by means of a micro-
 scope, wliich Dr. Mead says he .saw. He
 even denies, that "it has any determinate
 taste when put upon  the tongue ; though
 Dr Mead assures us, that both he anel
others, who have tasted i:, felt it exceed-
ingly  sharp ard  burning  to the  taste ;
and he  particularly  takes notice, that
pne gentleman, who could not be sati tied
without  lasting a large drop uneliluted
 with water, had an inflammation of his
 tongue, and the inside of his lips, of some
 continuance.
   Mr.  Latta remarks,  that it  is  of  no
 small consequence, towards the csre  of
 such bites,  to  consider attentively the
 •ymptoms, which take  place in the pa-
 tient, whether they indicate any  violent
 stimulus suddenly applied, in consequence
 of wh ch,  the person dies of an  universal
 inflammation ; or  whether it operates,  by
 suddenly checking  the  vital power,  to
 such a degree, that it cannot be restoreel.
 From a vast number of experiments made
 by M. Fontana, he conclueles,  that the
 bite  of an ordinary viper" will not prove
 fatal to a full grown person, nor even  to
 a large dog, though it  certainly will  do -
 so to smaller animals.  Five  bites from
 three strong and healthy vipers  were not
 able to kill a dog weighing sixty pounds ;
 anel,  as this dog was little more  than a
 third part of the  weight of any ordinary
 man, he concludes,  that a single bite can
 never be fatal to an adult.  In confirma-
 tion of this, he says, that he has seen a
 dozen of cases himself,  and that he has
 heard of fifty more, only two of whom
 died.  Concerning one of these  cases  he
 could get  no information ;  the either pe-
 rished  of a gangrene, twenty days after
 the bite, and  which began  in three days
 after it, the  bitten place  having been
 deeply  scarified almost immediately after
 the injury  was received.   Fontana be-
 lieves,  that much  of the faintness, &c.
 which ensue upon the bite of a viper, are
 the mere effects of terror.  " Upon a per-
 son's being bit, (says he,) the fear of ita
 proving fatal, terrifies himself  and the
 whole family.   From the persuasion  of
 the disease being  mortal, and that not a
 moment is  to be lost, they apply violent,
 or hurtful remedies.  The fear increases
 the complaint.  I  have known a person,
 that was imperceptibly bit,  in  the hands
 or feet, and who,  after seeing the blood,
 and observing a viper near him,  has sud-
 denly fainted away ; one, in particular,
 continued  in  a swoon  for upwards of
 an  hour, until he was accidentally ob-
 served,  and recovered out of it, by being
 suddenly drencheel in cold  water.  We^
 know, that  death  itself"  may be brought
 on  by very violent affections ofthe mind,
 with  any  internal disea-e.   Why  may
 not  people,  that  are  bit,  die  from  a
 disease,  produced  entirely from  fear,
 and who would not otherwise have died
 from a*ny complaint produced  by the ve-
 nom .■"'
  Mr. I.atta acknowledges,  that M. Fon- "
 tana has bestowed  a  great deal of atten-
 tion upon this subject; but, he rightly
contends, that the above  reasoning is hy. 
518                               WOLNDS.
  pothetical  and inconclusive.  Mr.  Latta
  owns, that some very timid, delicate, or
  nervous people might die from fear alone ;
  but, he remarks, that  it is by no means
  fair to conclude from thence that the ge-
  nerality of people will do so.  It is easy to
  see, that tlie bite of a viper must be more
  or less  dangerous,  according  to  circum-
  stances.  It depends on the creature it-
  self, to "throw out more or less of this
  poison ; and the greater the rage is, into
  which it is thrown, the greater quantity
  it will throw out.   If it has bitten any
  creature soon  before it  bites  a man, tiie
  latter will be  in less danger, because the
  quantity is but small.   In like manner,
  when the person is bit through his clothes,
  they will  absorb a quantity  of it,  and
  therefore  the  wound will also be  the less
  dangerous : and the same thing must hap-
  pen when  only the small vessels are
  wounded ; for then only a  small quantity
  is likely to be conveyed immediately into
  the  system   It  must be otherwise, how-
  ever, when the bite is  inflicted upon a
  bare place of  the body,  and the poison is
  conveyed directly into  a large vein ;  in
  this case,  says  Mr. Latta,  it  is quickly
  conveyed to the heart, anel there can be
  little doubt,  that it will very soon mani-
  fest  its deleterious  effects.   Nay,  M.
  Fontana himself informs us of a woman
  in Tuscany, who, though bit only in the
  little finger by a viper,  fell into an hemi-
  plegia,  which could  not be  removed;
  and, Mr. Latta argues, that if such a vio-
  lent disease could be induced by a wound
  inflicted  at such  a distance from tiie
  heart, we  can have no reason to suppose,
  that, had the viper been  large, anel the
  poison  quickly conveyed to  the heart,
  that death would not have ensued.
    Writers  usually  notice the following
i  symptoms,  as those which result from
  tlie bite of a viper:—1. A violent burn-
  ing pain,  with tension in  the injureel
  part.  2  The whole of the affected limb,
  and sometimes  the whole  body, become
  tense  and  inflamed in  like manner.  3.
  The patient becomes extremely faint, the
  pulse low and feeble; he has a giddiness
  in  his head,  nausea, and  vomiting.  4.
  There is a fixeel pain in the region of the
  heart.  5.  The  urine becomes tinged, of
  a deep yellow,  the skin becomes yellow,
  like one who has the jaundice, anil there
  is an evident diffusion of bile  throughout
  the  whole  vascular  system.   6.  Cold
  sweats,  with slight convulsive  motions,
  ensue ; and, if relief be not soon obtained,
  death is the consequence.  These symp-
  toms come on within twelve, or fourteen,
  hours after the bite, sooner or later, ac-
  cording to the violence ofthe injury  and
the sooner they make their appearance,-
the more dangerous they are.
  The medicines  recommended for die
bites of vipers are,  according to M. Fon-
tana,  not onlv of very different,  but even
opposite,  qualities.  "  In  no  country,
(says he) through which I passed, could I
ever find any two people or  persons, bit
by  the viper, either in the mountains  or
valleys,  that  used  the same remedies.
Some used  theriaca alone,  either exter-
nally  or internally  applied;  others com-
mon oil:  a third  6et  used  stimulants,
such as the strongest spirituous liquors ;
whilst others, on the contrary, tried every
different  kind  of  sedative.   In short,
there is hardly any active kind of medi-
cines that has not been tried as a cure in   *>
this disease: while, at the same time, it
is certain, that, under all the varieties of
application,  none of them tUed."  Hence,
our author concludes, that none of the re-
medies made use of had  any effect in cur-
ing the disease ; which, indeed,  is by no
means improbable,  considering that many
of*  them must have acted in  a manner di-
rectly contrary.  But  this   only proves
that  the  bites of the vipers of Italy are
not mortal.  In a hotter climate,  they
certainly will be attended with more dan-
gerous  consequences.   Hence,  in  the
island of Malta, even in  the winter-time,
when the viper came out of the fire,  no
doubt enraged to the utmost degree,  and
f.istened on the hand of the  Apostle Paul,
the people  expected,  that   " he should
have  swollen, or fallen  down  dead sud-
denly ;" whence  we may  see,  that, in
Malta,  which  is  indeed very  hot,  the
symptoms attending the bite of these crea-
tures, were then extremely  violent;  and
it was thought miraculous to escape death
in  consequence of it.   And we have the
most undoubted authority  for believing,
that, in America, as well as the East  In-
dies, the bite of some serpents is attended
with  very speedy death.   With regard to
the cure of the bite of vipers, in such ani-
mals as were liable to be killed by it, our
author  says,  from his  own experience,
that  neither scarifications,  nor even the
excision of the part, are beneficial, but,
on the contrary, hurtful.    We may, in-
deed, readily conclude,  that scarifications
 can elo no good, because they do not tend
 to take away the poison, but rather to al-
 low  it  more  free access to the blood;
 but,  we  cannot so wt-11 say this of exci-
 sion,  if  properly  performed.  Indeed,
 there can be no doubt,  that it  is a most
 prudent plan, when care is taken to make
 a complete removal of the parts as deeply
 as the- bite  extenels.  Font-ma also found
 oil,  volatile  alkali, theriaca, &c. either 
Wounds.
519
useless, or absolutely hurtful, particularly
the  volatile   alkali.   The only  thing,
which  he fbunelof any avail, was the ty-
ing of a  ligature  round the bitten  limb,
to stop the progress of the blood towards
the heart.  This  method,  however, can-
not  prevent  the   poison  from  entering
the mouths of the absorbents, nor from
getting into the system, when the ligature
is removed.   The  constriction of  the
limb might 'also  briii*-?  on  swelling, in-
flammation,  and  mortification, and it
must evidently  be inferior, in point of
efficacy,  to the careful excision of the bit-
ten parts.
  The practice of sucking the wound has
been recommended to be employed very
early; ahd, indeed, if it .could be de,ne
with safety to the person  who  sucks, it
affords some chance of success.  Dr. Mead
endeavours to shew, that it may be done
with  safety ; but, Mr. Latta is altogether
at a loss to account for the  difference be-
tween this author and M. Fontana,,con-
cerning the taste  of the  poison; the  for-
mer affirming, from his  own experience,
and that of several others,  that it  had a
violent,  hot, and fiery tin*.**, as if the
tongue was struck through with' something
burning, or scalding; while M. Fontana
as confidently affirms, that it has no taste,
nor raises any inflammation on the tongue.
Dr. Mead relates, that,  in a gentleman
already  mentioned, an  inflammation  was
raised on the tongue, which did not go off
in two days.
   In treating "this  disease,  Dr.  Mead
seems  to lay considerable stress upon
emetics; and, indeed, in all cases where
the poison seems to be diffused through
the body, this remedy has a chance of be-
ing useful, by relieving the extreme sick-
ness and nausea,  with wliich the patient is
affected.
   In cases of this kind, external applica-
tions can avail but little.   Oil  has  been
recommended; but,  the trials made by
Dr. Mead proved  it to be insufficient.
He seems to have some confidence in tiie
fat of the viper  itself; but, it is evident,
that the success  of this, or any other re-
medy of tlie kind, must depend entirely
upon an accidental circumstance.   It  is
not impossible, that,  if any oily matter
could get at tlie  poison,  it might so blunt
or soften it,  that its deadly effects would
be prevented ; but, it is easy to see, that,
by reason of the narrowness and depth of
the wound,  we have but a small chance
 of mixing it with the poison, after it has
 once  been  injected.  Nevertheless, this
 has perhaps  been sometimes done;  and,
 thus, both oil olive, and viper's fat, have
gained their reputation, though, in by far
the greatest number of  instances,  they
could be of no efficacy.
  To complete the cure, Dr. Mead re-
commends  the  use of  warm  cordials,
among  which  he mentions volatile sal-
ammoniac, to produce a sweat, and seems,
indeed, to  insist upon these medicines as
necessary for the recovery of the  patient.
Indeed, Mr. Latta  thinks  it  probable,
that the cure  can only  be adcomplished
by the  exhibition  of the very strongest
cordials. He approves of applying a li*-
gature; but, I would advise excision of
tiie parts.  He also  speaks in  favour of
t ying wine, bark, and vegetable acids.
  Dr*-Temple directs the use of caustic
volatile  alkali and eau de luce, as specifics
against the bite of the  viper, in  the fol-
lowing way :
     9c.  Alkal. volatil. caust. gutt. xz. in
        quovis vehiculo sumend.
     9-.  Sp. ammonia; succinat. (vulgd eau
        de luce) gutt. xl. quovis yehiculo
      '  sumend.
  This, he observes, should be given as
soon  as possible,  after  the accielent, re-
peating the  dose in five  minutes, and
also embrocating the parts well with it.—
(See Catesby's History of Carolina.   Mead
on  Poisons.   Fontana  on  the  Venom of
the Viper.   Latta's  System of Surgery,
Vol. 3.)
  Mr Chevalier  was induced to recom-
mend  the  trial of arsenic  in these cases
from the facts recorded in Dr. Russell's
History of  Indian Serpents,  on the autho-
rities of  Mr. Duflin and  Mr. Ramsay,
and  from which it appears, that the Tan-
jore pill, of which  arsenic is  in all pro-
bability the chief ingredient, is exhibited
with  considerable success  in India after
the bites of venomous serpents.
   Mr.  Ireland  surgeon to the fourth
battalion of the sixtieth  regiment of foot,
had   formerly  heard Mr. Chevalier  re-
commend.the trial of arsenic for the bites
ot serpents, and he was resolved  to make
the  experiment  whenever an opportunity
offered.  On his  arrival in  the island of
St. Lucia,  he  was informed, that an off!
cer  and several  men,  belonging to the
sixty-eighth regiment, had died from the
bites of serpents,  supposed to  be the
coluber carinatus of Linnaeus.  Mr. Ire-
land  also  learnt, that  every thing had
been tried by the attending medical men
to  no purpose, as all  the  patients had
died, some in six, and  others, in  about
tweive hours, from  the  time of their re-
ceiving the wound.
   A case, however, toon came under Mr.
Ireland's own  observation, and, as no-
thing, that had  been done  before, seem- 
520
WOUNDS.
 ed to have been of any service, he was
 determined  on gjving arsenic a full trial.
   " Jacob  Course, soldier  in  the York
 light  infantry volunteers,  was bitten in
 the left hand, and the  middle finger was
 so  much lacerated, that I found it neces-
 sary to amputate  it  immediately at  the
joint with the  metacarpal bone.
   " I first saw him about  ten  minutes
 after  he  had  received the  wound, and
 found  him  in a torpid senseless  state :
 the hand,  arm, and breast  of the same
 side were  much swelled, mottled, anel of
 a dark purple, and livid colour.  He was
 vomiting,  anel appeared  as  if much  in-
 toxicaed.  Pulse  quick  and hard:  he
 felt little or  no pain during  the  opera-
 tion.
   " The  wound being dressed, and the
 patient put to bed, I ordered a cathartic
 clyster, and the following medicine to be
 taken immediately,  fy. Liquor. Arsenic.
 ^ij. Tinct. Opii gt. x. Aq.  Menth. Pip.
 5iss;  which was added to half an ounce
 of lime juice, and  as it produced a slight
 effervescence,  it was given in that state :
 this remained on his   stomach, and was
 repeated  every half hour  for four suc-
 cessive hours.  In the mean  time, the
 parts were frequently fomented with com-
 mon fomentation, and rubbed with a lini-
 ment  composed of 01.  Terebinth. 5ss.
 Liquor. Ammon. j|ss.  and 01. Oliv. giss.
 The cathartic clyster was repeated twice,
 when the patient  began to be purged ;
 and the arsenical medicine was now dis-
 continued.  He had become more sensi-
 ble when touched, and, from  that time, lie
 gradually recovered Iiis faculties ; he took
 some  nourishment, and had several hours
 sleep.
   " The  next  day,  he appeared  very
 weak, anel fatigued; the fomentation and
 liniment  were repeated.  The swelling
 eUniinished  gradually; the natural colour
 and feeling returned, and, by proper dress-
 ings to the wound and attention  to  the
 state of his bowels, he soon recovered and
 returned to his duty."
   Mr.  Ireland recites  about  four  other
 examples, in which arsenic was exhibited
 with similar success.
   It deserves  particular  notice, that  the
 liquor arsenic i employed by Mr.  Ireland
 was prepared according to  Dr. Fowler's
 prescription,  which  directs  sixty-four
  trains  of arsenic,  and as  many of the
  xed vegetable alkali, to be dissolved in
 a sand heat, and the solution to be made
 an exact  pint, so that two drachms con-
 tain one grain of arsenic in solution. (See
 Medico Chirurgical Transactions, Vol. 2, p.
 393.  &c.)
    The best doctrines, relative to wounds
 in general, are those contained in  various
 part3 of A Treatise on the Blood, Inflamma-
 tion, &c by John Hunter.
   WRY-NECK.  (Torticollis.)  An  affec-
 tion,  in which the head becomes inclined
 to  one side.  The ancient wrKeis have
 taken no notice  of the disorder.   Some
 of  the modern ones have termed it caput
 obstipum; a word, indeed, which has been
 employeel by the best Latin authors, to
 denote the affliction about  to  be consi-
 dered.  The wry-neck should  be discri-
 minated from  the  "tension  and stiffiiess
 of the neck, occasioned by  a rheumatic
 affection of this part, and also from  the
 faulty position of the head, arising from
 deformity in  the cervical vertebrae.
  Tulpius, who was a learned physician
 at Amsterdam, about the middle  of  the
 seventeenth century, gives an account of
 the cure of a boy, twelve years old, who,
 from   his  earliest  infancy,  hael had  his
 head drawn down towards the left shoul-
 der, by a contraction of the scalenus mus-
 cle.   Fomentations  had  been applied in
 vain,  with  a  view of relaxing  the parts,
 the stiffness and corrugated state of which
 seemeel to  produce the disorder.  Stecl-
 coUars also proved ineffectual in bring-
 ing the head into a right  posture.  Tul-
 pius had a consultation with two other
 skilful physicians, about the case,  anel it
 was decided to put the  boy under  the
 care of an  eminent  surgeon of  the name
 of Mmnius,  who hael performed several
 operations  with  success  in  similar in-
 stances.  He first made a large eschar by
 applying caustic, and  then with a knife
 divided the muscle, which drew the heael
 to one side.   Tulpius, who has left only
 a "Very confused account of the operation,
observes, that  it  was  performed with
 great  slowness  and circumspection,  for
 fear of wounding the carotid artery, and
jugular vein.
  The author  expresses his disapproba-
 tion of] this  manner of proceeding, and
 advises such persons, as will run the risk
 of doing so  dangerous an operation,  not
 to  make any preliminary application of
 caustic.  The latter measure only caused
 useless psin, and could  not possibly  be
 of  any  service.   Tulpius  also  recom-
 mends  the operation not to be done  by
 little and little, at  repeated  times; but,
 to make a complete division of tiie muscle
 at once, with the necessary degree of cau-
 tion.
   Meckren, a surgeon at Amsterdam, who
 has  published a -valuable, collection of
 medico-chirurgical cases, also treats of
 the operation applicable to the wiy-neck,
 He states,  th-.t he had seen it performed
 on a  boy,  f urteen years old.  The ten-
 don ofthe sterno-cieide-mastoicleus mus-
 cle was divided with one stroke of a sharp 
WRY-NECK.
521
pair of scissars, and  in a very  skilful
manner, by a  surgeon named Flurianus,
and as soon  as  the incision  was made,
the head  took  its  right position.   The
author has also noticed the remarks made
by Tulpius, relative to  the plan of ope-
rating.
  On  approaching  nearer  to   modern
days, wc  find, that the celebrated Mr.
Samuel Sharp  considered the wry-neck
as  mostly arising from  a contraction of
the sterno-cleido-mastoideus muscle.  He
has proposed dividing this muscle, when-
ever the disorder seems  to proceed from
the kind  of cause, which we have just
now mentioned. However, he  makes an
exception,  in  regard  to those cases, in
which the affliction has existed a consi-
derable  time,  and, particularly, in  in-
stances,  in which  it has prevailed from
infancy.   He  remarks,  that  it would be
impossible to  rectify the position of the
head, if the cervical vertebrae should have
grown  in a  distorted  direction.  The
following is the operation, which this au-
thor  recommends  to be done in proper
cases.  After placing the patient on a  ta-
ble, a transverse incision  is to be made
through the skin and fat, of a size some-
what  more extensive,  than  the breadth
of the muscle, and about one-third of its
length from the clavicle. A probed-razor
 is then to be passed underneath the mus-
 cle, and to be drawn out, so as to make
 the requisite division of the  part.  After
 tlie incision  was  made,  Mr.' Sharp  re-
 commended the wound to be filled with
 dry lint, and  to be always dressed in a
 way,  that would keep the extremities of
 the muscle from growing together again.
 For  this  purpose, he  advised  the cut
 ends to be separated from each other as
 much as  possible, by  the assistance of
 a  bandage to  support  the head, during
 the whole time of the cure, which,  he
 says,  will generally be about a month.
 (See Treatise on tlie Operations of Surgery,
 chap. 35.)
    According to Mr. Sharp's account, the
 operation above described, ought to be a
 very common one.  However, if attention
 be paid  to the nature  and causes of the
 disease, and to the differences, resulting
 from whether the eUsorder be recent, or of
 long  standing; constant, or periodical;
 idiopathic, or sympathetic ; dependent on
 spasm, or merely on paralysis of the  an-
 tagonist muscles;  and,  lastly, if it be re-
 collected, that the affection may be pro-
 duced by other muscles, besides the ster-
 no-cleido-mastoideus ; we shall find, that
 cases, in which ihe foregoing operation
 can be judiciously undertaken, are not so
 very frequent.                      .
    With  regard to the  manner in which
      Vol. II.
Mr.  Sharp operated, Mr. B. Bell con-
ceived,  that it was attended with hazard
of wounding the large blood-vessels. But,
though  it  seems to me  better to use a
probe-pointed bistoury and  a director,
than the kind of razor, which Mr. Sharp
employed,  I do not coincide with  Mr.
B. Bell in  thinking, that the latter  sur-
geon's plan was at all objectionable on the
score of danger, in respect to wounding
the vessels. Perhaps, some might think
Mr.  B.  Bell's  method most likely to in-
jure the large vessels; for, he advises the
operator to cut the muscle from without
gradually inward, as deeply as seems ne-
cessary.
  The most prudent method of operating,
in my opinion, is first to divide the  cla-
vicular  portion of the contracted muscle,
near the clavicle, and even to cut out a
sufficient piece, to  remove all chance  of
the two ends  uniting again.   This  step
would  weaken the muscle considerably,
and, perhaps,  might answer every  pur-
pose.   It could easily be accompUshed,
by means of a director,  and  curved bis-
toury, after making the requisite divison
ofthe skin with a common scalpel. Were
this proceeding only to produce a partial
amendment of the wry-neck, the operator
might then venture to divide the sternal
portion of the muscle.  A director should
be passed under it, and the division made
with a probe-pointed curved knife.
   Although the  wry-neck may occasion-
ally depend on a contraction  of the  ster-
no-cleido-mastoideus muscle, this case is
far from being  very frequent.  The de-
formity is  much oftener owing to  some
affection of the integuments.  M. Louis
often divided with  success  contractions
of the  skin,  which  had kept  the  head
drawn  to one side for  many years, and
had been occasioned by burns.  He re-
marks, that he has met with  contractions
of this kind, which might  have been mis-
taken for a part of the sterno-cleido-mas-
toideus itself.
   Mr. Gooch  has related a case of  wry-
neck,  which was caused by a  contraction
of the  platysma myoides  muscle.   The
patient was a young gentleman, fourteen
years of age, who appeared to have always
enjoyed very good health in every other
 respect.  He had had his head, for seve-
 ral months, strongly drawn to one side  by
 a constant contraction of the  platysma
 myoieles muscle, which  had become ex-
 ceedingly rigid,  especially just where it
 is inserted at the basis of the jaw, and
 it nude the skin, from the angle of the os
 mtxillare inferius to the chin, seem like
 the cicatrix of a burn.   The same side of
 the face, quite from the  p<int ofthe  chin,
 was  much shrunk, and  distorted by the
     3  U 
522
WRY-NECK.
 contraction of the muscle, and the corner
 of the mouth, in particular, was so drawn
 to one side and downward, when the pa-
 tient turned his head, that a vast deal of
 deformity was  the  consequence.  From
 the inferior part of the eye-brow, at the
 internal angle of the eye, to near the top
 of the head, there was a kind of furrow
 upon the  skin, about half an inch broad,
 having  a shining, poUshed  appearance,
 like the cicatrix of a wound, and destitute
 of hair, which had fallen off'.  From the
 cornerof the eye downwards, there was the
 same kind of appearance in a less degree.
 The patient was subject to repeated at-
 tacks of spasms, which began at the inser-
 tion of the muscle, and terminated at tlie
 eye, attended  with a great deal of pain.
 The ear,and, also, the temporal and frontal
 muscles, were sometimes affected in a
 similar manner.  The parts,  in the course
 ofthe insertion of the muscle into the jaw-
 bone, were considerably thickened,  with-
 out being  in the least inflamed externally,
 anil they were only a little painful,  when
 touched, except they were at  the same time
 stretched. The subjacent muscles did not
 seem to be at all affected.
  It appears from the account, given by
 Mr. Gooch,  that, in the treatment of this
 affection,  every  known means had  been
 tried, by the advice of the most eminent
 practitioners;  but, without  effect.   Mr.
 Gooch determined  to  try  what benefit
 would be produced by dividing the muscle
 in the situation of the disorder.  He first
 divided the integuments a little below the
jaw, and thus  exposed tiie whole breaelth
 of the platysma myoides muscle, the fibres
 of which seemed to be in a state of violent
 extension, especially, when  the  patient's
 head  was inclined towards  the opposite
 side.  Mr. Gooch then divided the  mus-
 cle completely across, by a very careful
 dissection, until he had brought into view
 the fasciae of the  muscles  underneath.
 The patient was then directed to turn his
 head towards  the  opposite side, and Mr.
 Gooch had the satisfaction of observing,
 that the patient could perform this  mo-
 tion, without his face, and corner of his
 mouth being affected, as they had  been
 before.  The wound was treated in the
 ordinary way, and no particular symptoms
 arose.  As soon  as the inflammation had
 subsided, the patient was directed to move
 his  head about very frequently, in order
 to  prevent  any  kind of stiffness, which
 might ensue, in  consequence of the con-
 traction ot the muscular fibres, and inelas-
 ticity of the cicatrix.
   The patient found himself perfectly re-
 lieved by the foregoing operation, and had
 no return of the painful spasms, to which
 he  had  been previously subject.   The
 side of his face, however, never recover-
 ed  the proper  degree of ■**> plumpness.—
 (Chirurgical Works  of B.  Gooch,  Vol. 2,
p. 81.)
  Whenever an attempt has been made
 to cure  a  wry-neck, by dividing any of
 the  muscles, or merely the integuments,
 it becomes  necessary to take some mea-
 sures for keeping the  head  in a proper
 position, during  the treatment  of  the
 wound, lest, in  consequence of the head
 inclining in the  direction,   in which it
 was before  the  operation,   the  divided
 parts should immediately grow together
 again, and bring the patient almost into
 the same condition, as he was before any
 thing had  been done.  With  a  view ©f
 preventing this unpleasant  circumstance,
 Mr., Sharp recommends filling the wound
 with lint, and making it suppurate.  Mr.
 B.  Bell, on the other hand, advises the
 employment of a proper machine for keep-
 ing  the head in  a due position.  Some
 writers think the use of a bandage quite
 sufficient  for  the purpose.   Perhaps, as
 prudent a  plan as any, when the sterno-
 cleido-mastoideus is affected,  is to  cut
 out a certain portion of it.   (See Sharp's
 Treutise on the Operations of Surgery, chap.
 35.  Chirurgical Works of B. Gooch, Vol. 2,
p. 81.  B. BelVs System of Surgery.  En-
 cyclopedic Methodique, Partie Chirurgicale,
 Tom. 2, Art. Torticollis.)
THE  END. 
 
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