~ --..ri. UNITED STATES OF AMERICA WASHINGTON, D. C. OPO 16—67244-1 **% *i <£ (~v C 6 & ^t \ Boston Medical Library Assbc^iATiow, 19 BOYLSTQN PLjftE Received By Gift 0 A I , V > 7 / THE FIRST LINES OF THE PRACTICE OF SURGERY: DESIGNED AS AN INTRODUCTION FOR STUDENTS, AND A CONCISE BOOK OF REFERENCE FOR PRACTITIONERS. BY SAMUEL £OOPER, SURGEON TO THE FORCES ; MEMBER OF THE ROTAL COLLEGE OF SURGEONS, AND OF THE MEDICAL AND CHIRURGICAL SOCIETY OF LONDON ; MKM- BEIi OF THE MEDICAL SOCIETY OF MARSEILLES; HONORARY ..'. ( V^ FELLOW OF THE ACADEMY OF NATURAL SCIENCE* ' *J* AT CATANIA, &C, &C. ., %-wJi\ IjLtn....... OFFICE WITH NOTES, &ECr5""*l901 BY ALEXANDER H. STEVENS, M.D.'iOL$$ / PROFESSOR OF SURGERY IN THE UNIVERSITY OF NEW-YORK ; SURGEON nP | -—~ THE NEW-YORK HOSPITAL; CONSULTING PHYSICIAN OF TMl^-tlW TOWt •*■- »■ ~ BISPENSARY ; MEMBER OF THE NEW-YORK LITERARY AND PHILO- SOPHICAL SOCIETY ; OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA ; AND OF THE L1NNEAN SOCIETY OF NEW-ENGLAND. AND ADDITIONAL NOTES AND AN APPENDIX, BY A PHYSICIAN OF PHILADELPHIA. SECOND AMERICAN, FROM THE FIFTH LONDON EDITION, REVISED AND CORRECTED. WITH SEVERAL NEW PLATES AND WOOD CUTS. IN TWO VOLUMES.—VOLUME I. PHILADELPHIA- PUBLISHED BY T. DESILVER AND H. COWPERTHW.MT L. Jl. nAILKY FH1NTFR. 1828. V EASTERN DISTRICT OF PENNSYLVANIA, to wit ri c . BE IT REMEMBERED, That on the eighteenth day of Sep- *• > tember, in the fifty-third year of the Independence of the United States of America, A. D. 1828, Thomas Desilveh and Hulings Cowper- thwait, of the said District, have deposited in this office the Title of a Book, the right whereof they claim as proprietors, in the words following, to wit : "The First Lines of the Practice of Surgery : designed as an introduc- "tion for students, and a concise book of reference for practitioners. By Sa- "muel Cooper, surgeon to the forces; member of the Royal College of Sur- "geons, and of the Medical and Chirurgical Society of London; member " of the Medical Society of Marseilles; honorary fellow of the Academy of "Natural Sciences at Catania, &.c, &.c. With Notes, by Alexander H. Ste- "vens, M. D. professor of surgery in the University of New-York; surgeon " of the New-York Hospital; consulting physician of the New-York Dis- pensary; member of the New-York Literary and Philosophical Society ; "of the Academy of Natural Sciences of Philadelphia; and of the Linnean "Society of New-England. And additional notes and an appendix, by a "Physician of Philadelphia. Second American, from the fifth London edi- "tion, revised and corrected. With several new plates and wood cuts. In "two volumes." In conformity to the Act of the Congress of the United States, intituled, "An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned." And also to the Act, entitled, "An Act supplementary to an Act, entitled, ' An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etch- ing historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. NOTICE TO THE SECOND AMERICAN EDITION. In presenting to the notice of the medical profession, a second American, from the last London edition, of the va- luable work of Mr. Cooper, the publishers have spared no expense to render it, independent of its intrinsic merits, still more interesting and valuable to the American practi- tioner. To accomplish this end, the valuable suggestions and improvements which have emanated from distinguished American surgeons, as Physick, Gibson, Mott, Stevens, Jame- son, Dudley, Warren, Davidge, Barton, &c, have been intro- duced, and, in some instances, illustrated by additional cop- perplates. These, together with the valuable notes of Pro- fessor Stevens, which are also contained in this edition, will give a fair view of what has been accomplished in this coun- try within a very few years. The notes of the Philadelphia Editor, are designated by the initials P. E., which will be found at the end of each; those of Professor Stevens are contained at the end of each volume. In the appendix to the second volume, will be found accounts of Dr. Rhea Barton's operation lor anchylosis; Jameson's treatment of stricture of the oesophagus; Mat- thews's stomach pump, (all accompanied with plates,) and several other subjects not alluded to by Mr. Cooper. In ad- dition, several chapters, omitted by Mr. C. in this edition, and which are considered important, have been introduced. Philadelphia, October, 1S28. PREFACE TO THE FIFTH LONDON EDITION. The favourable reception, which this publication has met with, has encouraged me to revise the present edition with particular care. Several of the chapters in it are entirely new, as will be immediately perceived, on comparing those on the diseases of the eye and its appendages, with the ac- count of the same subjects in former editions. A chapter on amputation of the lower jaw is introduced; an operation, of which I could find no satisfactory description in any general treatise on surgery, though its performance has now been repeatedly accomplished in France, America, Germany, and this kingdom, with a degree of success, that affords a con- vincing proof, in addition to many others, of the inestima- ble value of operative surgery, for the cure of the most in- tractable diseases. I am perfectly aware, that every new operation, upon its first introduction to the common notice of the profession, is liable to be occasionally practised under circumstances not absolutely requiring it. This sometimes ens from want of discrimination, but still more fre- quently, (I am ashamed to say,) from the base motive of making the operation itself a step to notoriety and unmerited reputation. Hence, I feel myself called upon to exhort the admirers of operative surgery, and every practitioner inter- ested in the credit and improvement of his profession, never to suffer their love of extraordinary feats with the knife, or their greedy desire of fame, to make them forgetful of the happ VI PREFACE. truth, that there is more real merit in removing the necessi- ty for the practice of any one severe operation already fa- miliarly adopted, than in the invention and performance of a hundred new ones. Let not the young surgeon be led to amputate the jaw, for a disorder with which it is often at- tacked, and which is well known by the name of necrosis. I believe, that no simple necrosis of it, unattended with a fungous or medullary tumor originating within the bone it- self, can ever be an instance in which amputation of the lower jaw is justifiable. Very large exfoliations take place of themselves; new bone is produced, as a substitute for what is lost; the swelling, thickening, and ulcerated state of the soft parts, all disappear; and, in the end, the patient recovers without deformity, and without the agony and dan- ger of an operation, frequently long and severe, and always more or less mutilating. These observations seemed to me proper, as a caution that might usefully accompany this edi- tion, in which a newish operation, attended with all its usual attractions, good and bad, is submitted to the notice of the profession. At the same time, I particularly request the reader to observe, that, in the chapter on this subject, the kinds of disease, for which the operation was deemed indis- pensably necesssary, by surgeons of great eminence and judgment, are faithfully described. May llth 1826. CONTENTS OF YOL. I. PART I. Page Chap. I. Inflammation......1 II. Sympathetic Inflammatory Fever - - 21 III. Suppuration......24 IV. Hectic Fever - - - - - - 40 V. Mortification ------ 46 VI. Erysipelas......69 VII. Furunculus, or Boil.....83 VIII. Anthrax, or Carbuncle ... - 86 IX. CEdema......-'92 X. Burns - -.....94 XL Effects of Cold - - - - - #- 104 XII. Wounds - - ' : - - - - 118 XIII. Hemorrhage - - - - - - 12-t XIV. Extraction of Foreign Bodies—Union by the First Intention.....149 XV. Process by which the Wound is united - 161 XVI. Punctured Wounds.....16: XVII. Contused and Lacerated Wounds - - 172 XVIII. Granulations and Cicatrization - - 177 XIX. Gun-shot Wounds.....181 XX. Poisoned Wounds.....203 XXI. Contusions --......214 XXII. Ulcers.......217 XXIII. Encysted Tumors.....230 XXIV. Ganglions......234 XXV. Sarcomatous Tumors .... 235 XXVI. Cancer.......242 XXVII. Fungus Haematodes.....269 XXVIII. Syphilis.......272 XXIX. Aneurism.......311 XXX. Fractures......3-16 XXXI. Dislocations.....- 360 PART II. Chap. I. Injuries of the Head - 371 II. Hernia Cerebri......390 III. Fungous Tumors of the Dura Mater - 39-4 viii CONTENTS. Chap. IV. Wounds of the Face V. Salivary Fistulae - VI. Hare-lip..... VII. Cancerous Diseases of the Lip VIII. Diseases of the Antrum IX. Fistula Lachrymalis X. Diseases of the Eyelids XI. Ophthalmy - XII. Iritis -..... XIII. Closure of the Pupil XIV. Prolapsus of the Iris - XV. Diseases of the Cornea XVI. Pterygium and EaCanthis XVII. Dropsy of the Eye XVIII. Cancer and'txtirpation of the Eye XIX. Fungus Haematodes of the Eye XX. Amaurosis - XXI. Cataract..... DIRECTIONS RESPECTING THE PLATES. Plate I. to face page 142 II. ... 348 III. - - - 389 IV. ... 409 V. - - - 443 VI. - 450 VII. 482 Page - 396 398 - 401 404 - 406 409 - 414 422 - 436 442 - 448 450 - 454 456 - 458 462 * - 466 472 THE FIRST LINES OF THE PRACTICE OF SURGERY. CHAPTER I. INFLAMMATION. In almost all the cases which fall under the care of sur- geons, inflammation is more or less concerned, either as a cause, a symptom, a complication, or even as a means, or mode of cure. It may occur in any texture where blood- vessels are situated, and consequently nearly all parts of the body are liabk to it. The symptoms, commonly indi- cating its presence, consist of pain, swelling, heat, and redness in the parts affected; but each of these effects does not prevail equally in every form of inflammation, and sometimes one or more of them may be nearly, or quite absent. Thus, in erythema, the redness is attended with little or no swelling; while, in particular states of chronic inflammation, a great deal of swelling may be ac- companied with little or no redness, and with no sensation amounting to pain. Inflammation, then, is a process, lia- ble to considerable variety, which is often regulated by the nature of its exciting cause, and frequently by that of the constitution, or the situation and structure in which it takes place. The differences, noticed in the character of inflam- mation, have led to the division of it into several kinds, as acute and chronic; healthy and unhealthy; simple and complicated. By acute is implied, that which produces all its effects quickly: its varieties are numerous, comprehend- Vol. I. A 2 INFLAMMATION. ing not only every instance of healthy, simple inflamma- tion, but many other cases, justly regarded either as un- healthy or complicated. Chronic inflammation, on the other hand, signifies that which is slow in its progress; fre- quently beginning almost imperceptibly; but sometimes coming on as the consequence of acute inflammation. It is to the changes produced by it, that the moderns impute almost all the slow thickenings of various textures, and the formation of the generality of indolent tumours. Many of its effects are exemplified in the ravages of scrofula, while the decline of acute inflammation into it is seen in every case of ophthalmy and gonorrhoea. By healthy in- flammation, is meant that which is not characterized and modified by any particular disease in the part or constitu- tion ; while the term unhealthy, is applied to cases, in which the appearances, progress, and termination of the inflam- mation, are under the influence of some determinate dis- ease in the parts affected, or the system at large. By sim- ple inflammation, surgeons understand, not only that it is of a healthy kind itself, but unconnected with any specific disease, like syphilis, fungus haematodes, cancer, &c, all which affections are frequently surrounded by inflamma- tion, not of their own peculiar nature, yet deserving the appellation of complicated. Inflammation may also be said to be complicated, when attended with the lodgment of bul- lets, dead portions of bone, or other foreign bodies, which cannot be immediately removed. Amongst the most remarkable effects of inflammation, is the permanent adhesion of parts to each other. * The process by which such an union is formed, is certainly one of the most interesting operations of which the animal economy is capable; for it is by means of it that wounds, fractures, and other serious injuries of the body are re- paired, while numerous diseases not only receive a bound- ary from it, but are cured in a great measure by the changes to which it gives rise. Another frequent and im- portant effect of inflammation is suppuration, or the pro- duction of the fluid named pus; a third, is ulceration; and the last to which I shall now advert, gangrene, or mortifica- tion. Hence, another common division of inflammation into the adhesive; suppurative; ulcerative; and gangrenous. Frequently, an original disposition to one of these conse- quences prevails: thus, in boils and whitlows, there is al- ways a tendency to suppurate, and in carbuncles, to slough. Certain kinds of inflammation, however, rarely, or never INFLAMMATION. 3 end either in suppuration, ulceration, or mortification; but, however violent, ultimately subside without producing any of these effects, as exemplified in gout, and the inflam- mation called mumps. The course, indeed, which some inflammations follow, is so fixed, that it is very difficult, and generally impossible to alter it: thus, the gradual sub- sidence of the swelling, known by the name of mumps, without any sore or abscess, is as constant as the suppura- tion of a whitlow.* Also, whether inflammation is to be the adhesive, suppurative, ulcerative, or gangrenous, often depends upon the particular situation and structure of the parts affected. In the cellular membrane, the body in ge- neral, its circumscribed cavities, deeply seated organs, and serous membranes, the adhesive inflammation is most dis- posed to happen ;f while nearness to the surface of the bo- dy, and the texture of a mucous membrane, are circum- stances facilitating the occurrence of suppuration.:}: In parts of inferior vascularity, like tendons, fasciae, &c, in- flammation readily occasions mortification. Healthy inflammation, especially when situated near the surface of the body, is often named phlegmon, the symp- toms of which are a throbbing pain, a firm, circumscribed swelling, an increased heat, and more or less redness of the parts affected. The redness does not terminate in an abrupt edge, like that of many other kinds of inflamma- tion, but fades away imperceptibly in the surrounding skin. These local symptoms, when the disorder is severe, either on account of its degree, extent, or the nature of the parts affected, are constantly accompanied with a febrile disturb- ance of the whole system, named accordingly the sympa- thetic or symptomatic injlammatory fever. There is reason to believe, that acute inflammation ex- tends its effects to the whole of the circulating blood; for, when a portion of this fluid is discharged by bleeding, and afterwards examined in the basin, the appearances follow- * See J. II. James on Inflammation, p. 16. 8vo. Lond. 1821. \ The cellular membrane is also lkble to a species of inflammation, in which one remarkable feature is the little tendency to the effusion of co- agulating lymph, so that the disorder is not circumscribed, but spreads un- der the integuments to a vast extent, attended with typhoid symptoms, and followed by suppuration. It is well described by Dr. Duncan, in the Med. Chir. Trans, of Edinb.; and by Dr. Scot, in the Edinb. Med. and Surg. .loum. No. 75. They name it diffuse inflammation of the cellular membrane. Authors mostly represent it as inflammation of fasciae, or as a consequence of some kinds of erysipelas. * Consult J. Hunter on the Blood, &c. 4to. Lond. 1794. 4 INFLAMMATION. ing its coagulation, are very different from those remarked inordinary blood. The coagulation takes place more slow- ly, and generally more firmly than usual; and, when it is finished, a stratum of fibrine, which is generally of a yel- lowish buff colour, or rather like glue, and of .greater or lesser thickness, is left upon the surface of the crassamen- tum, which itself often floats in an extraordinary quantity of serum. The stratum of fibrine, or of fibrine blended with coagulated albumen, here described, is well known by the name of the inflammatory crust, or buffy coat; and blood, presenting the above-mentioned phenomena, is called sizy, in consequence of its being supposed to contain a preter- natural quantity of fibrine, or glutinous matter. I know of no subject to which an intelligent experimenter could more usefully direct his researches, than that of the buffy coat of the blood, particularly with the view of ascertaining the circumstances influencing its formation. The surface of sizy blood is generally described as hollow, or cupped, as the phrase is; but whether it assumes this shape or not, always depends upon the particular state of the buffy coat itself. This is so much the case, that when the crust is thin and soft, the crassamentum adheres a good while to the sides of the basin, and the surface of the blood, instead of becoming concave, with its edges drawn inwards, or to- wards the centre, as the serum separates, is really flat, or even slightly convex. It is only when the buffy coat is thick and compact, when the coagulated mass soon sepa- rates from the sides of the basin, and floats in a large quan- tity of serum, that sizy blood presents a concave appear- ance. Another fact, made out in modern times, is, that when the buffy coat is thick and compact, the firmness of the coagulum, and its proportion of fibrine, are according- ly lessened; a circumstance, well deserving of attention, as it is a proof of the great tendency which there is in fibrine, during the existence of inflammation, to separate from the other constituent parts of the blood. Sometimes minute bubbles of air are seen under the buffy coat, resem- bling, in a particular light, small particles of oil; but the causes of this peculiarity are not understood. The buffy coat is disposed to occur in the generality of inflammatory complaints, and occasionally in continued fe- ver, intermittents, the scurvy, certain nervous affections, and most cases productive of febrile disturbance. De Haen noticed it on the blood of healthy persons, who had been bled in the spring as a matter of custom. Pregnant women INFLAMMATION. f, individuals who work hard in frosty weather, and soldiers, keeping watch at night in the cold season of the year' usually have sizy blood. The late Dr. Parry also met with persons whose blood was in this state, though no vestige of local inflammation could be discovered about them, and their pulse did not exceed sixty. On the other hand, cases are related, where inflammation prevailed in a severe degree, yet the blood discharged by venesection, was quite free from the buffy coat.* Sometimes, in the same bleed- ing, the blood is buffy in one basin, but not in another.f The causes of these and several other anomalies respect- ing sizy blood, make it a subject yet requiring investigation, and, in truth, nothing whatever is known about the imme- diate cause of the buffy coat itself. The slow coagulation of the blood in inflammation, and the consequent gravita- tion of the red globules ;\ the size of the stream in which it issues from the vein; the shape and temperature of the basin or cup in which it is received; its exposure to, or exclusion from the air; are various circumstances, the ef- fects of which have been attentively considered; but, hi- therto, without throwing any material light on the present subject. The particulars, however, here explained, should lead us not to adopt, without some limitation, the doctrine that the buffy coat is a sure criterion of inflammation, and always a sufficient reason for bleeding. Considered with the state of the pulse, the situation and nature of the pain experienced, and other symptoms, it certainly forms a va- luable guide in practice; and there are even some cases oi internal inflammation, especially those in which the bowels are affected, where, on account of the small pulse, and general appearance of weakness, the practitioner would often be afraid to bleed, were it not for the instruction de- rived from the sizy quality of the first two or three ounces of blood drawn for the sake of experiment. Several of the symptoms of inflammation may be ob- scured, or essentially altered, in consequence of the par- ticular situation, structure, and nature of the parts affect- i-d. The different effects, also, resulting from the disturb- ance of the functions of various organs, must obviously produce a material diversity in the symptoms. Thus, when the viscera, or other deeply seated parts, are inflamed, of • C. lleineker, Lond. Med. Kepos. Feb. 1820. f Diet, des Sciences Med. torn. 7. p. 182. % Hunter, Op. cit. pp. >13—315. 6 INFLAMMATION. course the swelling,redness, and throbbing, are not mani- fest to the eye or touch. But, though the diagnosis may receive no elucidation from these symptoms, the nature ot the disorder still betrays itself by the inflammatory fever; the situation of the pain ; the particular functions imped- ed or disturbed ; and the sizy appearance of the blood. The redness of inflamed parts arises from the dilatation of small vessels, veins * as well as arteries, which become large enough to admit the red globules in abundance.] This change being completely visible, is one that must be received as undoubted truth, whatever may be the theory established respecting the state of other minute, secerning, or capillary arteries, which are sometimes inferred to be, not in a dilated, but a constricted state. Mr. Hunter had an idea that the redness sometimes partly depended upon the generation of new vessels. In ordinary cases, how- ever, none of the redness can be ascribed to it; for, a part may be reddened in a few seconds by friction, the applica- tion of heat, &c, in which circumstance, there cannot be time for the formation of additional vessels. The fact, al- so, of many parts, which are naturally colourless, being ren- dered quite red by anatomical injection, tends to prove that the distention of such vessels as already exist, may account for a great increase of redness. Yet we are duly to remember the curious circumstance of blood-vessels becoming visible during inflammation in organs, which can never be made to indicate any vascularity, as far as can be learned from the use of fine anatomical injections ; a fact, which induces Meckel ^ to adopt the Hunterian doctrine, that new vessels are sometimes actually produced in in- flammation, particularly when it affects parts of inferior vas- cularity, like the cornea. Perhaps, however, his view of this question does not gain much support from the circumstance of inflamed parts exhibiting a vascularity, which could not be demonstrat- ed in their healthy state. On the contrary, I believe, that inflammation can never happen, except where vessels are situated. All the phenomena of this process are a proof of their presence. That it enlarges them, and renders * Hunter on the Blood, &c. p. 282. Thomson's Lectures on Inflamma- tion, p. 87. Op. cit. p. 283. ■j- See Note A. * See Meckel's Handbuch der Pathologischen Anatomie 2ter. b. 2ter abth. p. 23. Leipzig. 1818. INFLAMMATION. / them capable of receiving red blood, is perfectly certain; and it is on this principle, that we can account for their becoming visible, when no injection would perviate them in their ordinary state. In short, no sound physiologist will argue, that parts are not vascular, because the vessels cannot be discerned; and he judges of the question more accurately, by considering what mutations each structure exhibits in health and disease. Whatever doubts, how- ever, may attend this subject, with respect to the more fa- miliar examples of inflammation, it is universally allowed, that new vessels are frequently developed in the coagulat- ing lymph, on the surfaces of inflamed, serous membranes, in fresh wounds, in many instances of chronic inflamma- tion, and in new growths. In cases of ophthalmy, the surgeon has an excellent op- portunity of observing the dilatation of the vessels, and the consequent appearance of redness: enlarged vessels, which naturally held only a colourless fluid, not only pre- sent themselves in myriads upon the conjunctiva, but ex- tend their branches over the cornea itself. The enlarge- ment of the smaller vessels, and the increase in the num- ber of those, which become capable of containing red blood, are facts which can be seen with the naked eye ; and they may be rendered still more obvious by means of the microscope, and the art of injecting. Hunter froze the ear of a rabbit, and thawed it again. A considerable inflam- mation, and an increased heat, and thickening of the part, ensued. While the ear was violently inflamed, the animal was killed; its head injected ; and its ears removed and dried. The uninflamed ear, when dried, was clear and transparent, and its vessels could be plainly seen ramify- ing through its substance ; but, the inflamed ear, when dried, was thicker and more opaque, its arteries being con- siderably enlarged.* The swelling and tension of inflamed parts proceed from the dilatation of the vessels; their turgid state ; the extravasation of serum and coagulating lymph ; and the interruption of absorption, f That the extravasation of coagulating lymph has a remarkable share in producing the swelling of inflamed parts, is unquestionable; for it fills up all their interstices, glues their whole structure to- gether, and consolidates them into one mass. Frequently, * Hunter on the blood, &c. p. 280. f See Soemmering Dc Morbis Vasorum Absorbentium, 8vo. I79n 8 INFLAMMATION. when its quantity is considerable, it is converted into a true cellular, or membranous texture, or assumes, more or less, the peculiar qualities of different organs. This is very evident in the bones. By means of such change, also, several loose parts may acquire the external proper- ties of denser organs. Thus, the lungs are sometimes turn- ed into a liver-like substance, a morbid alteration long since described by Morgagni, under the name of " hepa- tisation."* According to Hunter's experiments, the temperature of an inflamed part, as indicated by the thermometer, is much lower than what the feelings of the patient would lead one to suppose; and he was inclined to think, that it never ex- ceeds that of the blood in the heart. By artificial means, he excited inflammation in the chest of a dog, and in the ab- domen, rectum, and vagina of an ass, without being able to detect any considerable rise in the temperature of those parts. In a patient, however, upon whom he had operated for hydrocele, the rise was much more remarkable; for, a thermometer, introduced into the tunica vaginalis imme- diately after the operation, indicated a temperature of only ninety-two degrees; but, on being again introduced the fol- lowing day, the quicksilver rose to ninety-eight and three quarters. Yet, even in this case, it was supposed, that the temperature of the inflamed parts was less than that of the blood near the heart.f It is more easy to conceive than describe how any quick deviation from the natural state of parts must excite pain. In chronic inflammation, the graduality of the change allows the nerves to become adapted to it, and the degree of pain only amounts to a dull uneasiness: but, in phlegmon, the change being quick, the pain is considerable. Each kind of inflammation seems to have its particular sort of pain. Thus, phlegmon excites a pain, which is joined with a sense of throbbing and heaviness; erysipelas gives rise to a pungent itching kind of pain; and anthrax causes a pain, character- ized by a sensation of burning and stiffness. Some organs, which naturally possess little sensibility, are remarked to become exquisitely painful, when inflamed; a curious fact, of which there are continual proofs in the practice of sur- gery. * De Sedibus et Causis Morb. Epist. An. Med. XXI. 2. 13. 17. 19. 27 Meckel, Handbuch der Pathologischen Anatomie, b. 2. abth. 2. p. 26. f Hunter on the Blood, &c. p. 293. INFLAMMATION. 9 The throbbing is sometimes described as depending upon the strong pulsation of the arteries, which are alleg- ed to beat in many instances with preternatural force, not merely in the seat of the inflammation, but for some way from it towards the heart. " Inflammation," says Mr. Hun- ter, " is not only an action of the smaller vessels in the part itself, but in the larger vessels leading to it. This is prov- ed in whitlows, where the inflammation and throbbing pain are confined to the extremity of the finger; yet, when we grasp the finger, a strong pulsation is felt in the two arte- ries leading to the inflamed part, while no such pulsation can be felt in the other fingers. If the inflammation be very considerable, the artery, as high as the wrist, will be sen- sibly affected."* The preceding fact, though not advanced by Hunter for any such purpose, is always strongly in- sisted upon by certain authors and lecturers, who inculcate the doctrine of the arteries contracting with increased force in inflammation, as a complete proof of their hypothesis. But this mode of accounting for the throbbing is not uni- versally admitted; and Hunter himself was far from draw- ing any such conclusion; for all that he presumes to say, is, that the increased throbbing, felt in the inflamed part, and for some way from it, proves that the arterial system is dilating itself, and allowing more blood to pass than usual. The very first act of the vessels, when the stimulus which excites inflammation is applied, is exactly similar to a blush; simply, an increase or distention beyond their natural size. Afterwards a new action begins, which is pro- bably the separation of the coagulating lymph, and the throwing of it out of the vessels,! together with a propor- tion of serum, which is the cause of the soft, doughy, (Ede- matous tumour often seen about an inflamed part. Inflamed serous membranes very readily effuse coagu- lating lymph, which also becomes vascular and organized, with great rapidity, so as to complete the stages of adhe- sive inflammation. In this way are produced those un- changeable adhesions, which are so commonly found be- tween the lungs and pleura costalis; and between the intes- tines and peritoneum. A similar effusion may take from in- flamed mucous membranes, especially those of the aliment- ary canal, larynx, and trachea, the products of the effused * Op. cit. p. 278. •• Hunter, p. 279 Vol. I B 16 INFLAMMATION. lymph, assuming the form of hollow or solid cylinders, cor- responding to these canals in shape;* but this only hap- pens when mucous membranes are the seat of violent, or peculiar inflammation-, and, under other circumstances, they more readily effuse pus, than coagulating lymph. Also, when coagulating lymph is effused upon the surface of a recent wound, or the ends of a broken bone, it changes into a vascular mass, which ultimately forms a permanent bond of union between the parts. New vessels are sometimes developed in coagulating lymph with surprising quickness. One morning, at seven o'clock, Sir E. Homef operated upon a man, who had a strangulated femoral hernia. The hernial sac was opened, and found to contain a portion of bowel six inches in length, which, on careful examination, seemed quite smooth, and without any extraordinary appearance of vascularity. Nine- and-twenty hours after the operation, the patient died, hav- ing had scarcely any pulse during the last five hours of his existence. On dissection, the strangulated part of the bow- el was, found highly inflamed, its external surface soft, and covered in several places with coagulating lymph. A fine injection penetrated all these distinct portions of lymph, demonstrating in each a considerable artery, accompanied with a large vein. The coagulating lymph then had been manifestly effused after the operation; and, as from the al- most lifeless state of the patient during his last five hours, we cannot suppose that any new vessels could be formed during that period, it follows, that they can be produced in a space of time less than twenty-four hours. The case also proves that such vessels inosculate with the old, or origi- nal ones. According to Meckel,:): the new vessels are only exten- sions or continuations of the old ones. Soemmering^ relates several cases in which it was demonstrated by injections, that the vessels, produced in membranous adhesions of the' chest, did not proceed from the lungs to the pleura, but originated from this last membrane in the situation of every intercostal artery. The thing is represented in the same waybyMonro.|| A large membranous adhesion, which con- • Meckel, Op. cit. b. 2!. abth.2. p. 30. See also the appearances in Croup, as delineated in Bailhe's plates of Morbid Anatomy. f On the Properties of Pus, p. 41. * Handbuch der Pathol. Anat. b. 2. abth. 2. p. 32. § Transl. of Baillie's Morb. Anat. p. 32. note 67. || Obs. on the Nervous System, pi. 13. INFLAMMATION. 11 nected the intestine and peritoneum together, derived its vessels also from those of the latter membrane. In the centre of the extravasated substance, which con- nected inflamed parts, and on the surfaces after separation. Hunter frequently noticed small specks of red blood: these could hardly have been extravasated with the coagulating lymph; for they would then have been more diffused, plain- ly connected with the vessels, and not situated within the lymph. A corresponding extravasation would also have resulted from injections, which was not the case. Hence Mr. Hunter was led to conclude that the blood was pro- duced in the new-formed coagulum itself, exactly as in the incahated egg, blood is formed at distinct unconnected points; and Meckel thinks the account is rendered more probable, by the fact of the formation of blood and vessels in this new structure, going precisely through the same stages as the incubated egg; inasmuch as at first merely tubes for the blood can be discerned, but nothing like re- gular vessels.* However, if a statement made by Sir A. Cooper in his lectures be correct, Mr. Hunter renounced this doctrine previously to his death; and adopted the opin- ion, that the new vessels always shoot from the old ones into the coagulating lymph. This is also the view which Sir Astley himself entertains. Whatever may be the situation of inflammation, it is al- ways most violent on the side nearest to the external sur- face of the body; a curious fact, first pointed out by Mr. Hunter, and so constant, that it may be regarded as a sort of law in the animal economy, the usefulness of which in creating a tendency in many diseases not to spread deeply, must be sufficiently manifest. The causes of inflammation are divided into the remote and proximate. The epithet remote is badly chosen ; for it comprehends many things which contribute immediately, as well as remotely, to the production of inflammation. In most instances, we are able to trace the origin of this pro- cess to causes, which act either directly upon the part af- fected, or indirectly upon it through the medium of those inexplicable sympathies, which connect distant parts of the body with one another. As illustrations of the latter re- mark, Professor Thomson, of Edinburgh, adverts to the effects of particular kinds of food, and of small doses of mercury, or arsenic, which, after being taken into the sto- * B. 2. abth. 2. p. ST 12 INFLAMMATION. mach, sometimes produce distinct and specific inflamma- tions of the cutaneous texture. The exposure of the feet to cold, he also observes, occasions in one person an in- flammation of the throat; in another, an inflammation of the chest; and, in a third, an inflammation of the belly.* The expression, exciting causes, which is sometimes em- ployed, is more correct than the term remote. These remote or exciting causes of inflammation are very numerous; but, as they mostly admit of being referred to external violence or irritation, from mechanical or chemical means, a full de- tail of them would be superfluous. Suffice it to say, then, that wounds, fractures, contusions; the lodgment of a thorn, bit of glass, or other extraneous bodies in the flesh; a scald, or burn ; exposure to cold; and the application of in- numerable irritating substances to parts; are common ex- citing causes of inflammation. Fevers often appear to have a similar effect. Sometimes inflammation arises spontane- ously, or (to speak more correctly) no perceptible cause can be assigned for it. By the term proximate cause, pathologists generally im- ply that state of the part affected, upon which the pheno- mena peculiar to inflammation immediately and primarily depend. They mean, in fact, that secret process, that first essential action in the part, which constitutes the very be- ginning of inflammation, keeps up its progress, and is in- separably connected with its existence. While Galen and Boerhaave ascribe the proximate cause of inflammation to particular states of the blood and hu- mours, Stahl, Gorter, Hunter, and Cullen, all concur in im- puting it rather to an affection of the vessels. If the state of the whole mass of the blood were the cause, why should in- flammation be confined to any particular part? It is a ge- neral opinion, that a larger quantity of blood is determin- ed to an inflamed part than in the natural state.f If an in- cision be made into it, the blood gushes out more profuse- ly than from a cut in a similar part free from inflammation. Now, although this does not completely prove that there was actually an accelerated flow of blood through the in- flamed part previously to the incision, it is a phenomenon which cannot arise from any peculiarity in the action of the heart; an organ, which drives the blood equally into * Lectures on Inflammation, p. 50, 51. | Mr. Hunter every where expresses his belief, that the blood *\„ i * in greater quantity, and with increased velocity, through inflamedpS INFLAMMATION. VS tiie whole arterial system. The fact must be referred either to the augmented diameter of the vessels of the part affected, or to the peculiar property of the arteries, which, in the healthy state, at least, are not simple mechanical tubes for the transmission of the blood, but active instru- ments in the promotion of the circulation, possessing, be- sides their elasticity, a vital power of action, arising from their muscular structure. We have mentioned the dilatation of the small vessels, as one of the earliest perceptible changes in the process of inflammation. Several lecturers, I observe, do not describe the dilated state of the small arteries of an inflamed part as regular and permanent, but as joined with alternate, pro- portionately increased contractions. No doubt, this notion of the nature of the increased action in inflammation, is de- rived partly from the throbbing in phlegmonous swellings, and partly from the recollection of the natural systole and diastole of the arteries in the healthy state; but its cor- rectness has not yet been proved either by experiment or observation.* Professor Thomson and Dr. Parry could see no such motions in the small arteries, which were micro- scopically examined in their experiments relative to inflam* mation, and Mr. Hunter is so far from countenancing this supposition, that he*gives a decided opinion, " that in in- flammations the muscular coats of the arteries do not con- tract."! When, therefore, he describes inflammation as an increased action of the vessels, he does not imply that such action consists in increased dilatations and contractions, al- ternately performed. The dilatation of the vessels of. an inflamed part is a subject on which he displays a great deal of ingenious reasoning. The muscular power of the arte- ries seems to him to give way in inflammation, because they are more dilated than their natural elasticity would allow, which must also be increased. He conceives that this change is something more than simply a common re- laxation ; u we must," he says, " suppose it an action in the parts to produce an increase of size for particular purposes," and this he would call the "action of dilatation." He com- pares it with the increase of the size of the uterus in preg- nancy, with the enlargement of the os tinea? in the time of labour; the consequence of the preceding actions, and ne- cessary for the completion of those which are to follow.}: • Thomson's Lectures on Inflammation, p 7S. f On the Blood, 8tc. p. 283. I Op. cit. p. 282 14 INFLAMMATION". That the proximate cause of inflammation cannot be sa* tisfactorily explained, upon any principle hitherto suggest- ed, must be acknowledged; for, there must be something besides merely an increased action of the vessels; there must be something besides an enlargement of their diame- ters, to constitute inflammation. Both these changes hap- pen to the external carotids in the growth ot the stag s horns; to the spermatic arteries of animals, which copu- late only at certain seasons of the year; and to the arteries of the uterus in pregnancy. Such changes probably al* ways happen, whenever there is any process going on in the animal economy requiring an extraordinary supply of blood:* still, in the instances now mentioned, there is no inflammation, no pain, no symptomatic fever. A simple inequality in the distribution of the blood, therefore, un- combined with other causes, cannot account for the origin of this process. A very opposite theory to that which prevails in the schools of medicine in this country, was entertained by Vacca,f Mr. Allen, of Edinburgh, &c. They supposed the action of the vessels of every inflamed part to be diminish- ed; and that there actually existed in it a congestion of blood, proved by the increase of bulk and redness of the small arteries, and by the increased flow of blood, when an inflamed part was divided. The sense of throbbing, Allen, Callisen, &c. attribute to the difficulty which the blood meets with in passing from the arterial trunk into the capillary branches;}: and the former considers it as no criterion of the force with which the artery contracts, since it is produced during the dias- tole of the vessel, and by a power foreign to it. Attempts have been made to support the doctrine of the diminished action of the inflamed vessels, by an appeal to experiment, and Dr. Philip and Mr. Boraston, undertook some investigations, from which it was concluded, that, in the arteries of inflamed parts, the circulation is slower, than in those of uninflamed parts.§ Professor Thomson * Hunter, p. 288. f Liber de inflammationis morbosae, quae in humano corpore fit, natura causis, effectibus, et curatione. Flor. 1765. * Arteriae minores pressione sanguinis irruentis calidioris diktats atque elongatx, in ductos serpentarios flecti, et sanguinem prementem xgre pro- movere videntur, non in ipsa parte adfecta solum, sed in vasis circumiectis quoque ; inde pulsatio in parte inflammata. (Callisen. t. i. p. 191 \ § Wilson Philip on Febrile Diseases, part 2. Callisen expresses a similar INFLAMMATION. l-'i also instituted experiments, for the purpose of settling this disputed point, arid he infers, that inflammation is some- times attended with an accelerated, and sometimes with a retarded circulation through the capillary vessels of the inflamed part; consequently, that neither of these changes ought to be included in a definition of the process.* Whatever may be the real state of the capillary vessels in a part affected with acute inflammation, I believe that none of the experiments, hitherto made in relation to this point, have cast any doubt on the truth of the generally received doctrine, that there is an increased determination of blood to the part itself. Such augmented flow of blood to a limited point of the animal machine, cannot be pro- duced by the action of the heart, but must arise, independ- ently of it, from a power possessed by the vessels them- selves; the same kind of power which occasions an in- creased determination of blood to the cheeks when a per- son blushes, and which injects the corpora cavernosa under venereal excitement. Unless it be admitted, that there is an accelerated flow of blood at least to an inflamed part, if not completely through all its minute arteries and veins, it is difficult to account either for the rise in its tempera- ture, or the efficacy of measures calculated to lessen the force of the circulation.! TREATMENT OF PHLEGMONOUS INFLAMMATION. The first object in the treatment naturally consists in removing the causes of the disorder. If the irritation ot a splinter were to give rise to phlegmonous inflammation, who would not of his own accord extract the offending substance? But the removal of the stimulus producing inflammation will not always put an immediate stop to it; for the living parts have been injured, and this process is necessary for their reparation. In this point of view, it can only be regarded as hurtful, when its violence and in- tensity are likely to prevent the accomplishment of the sa- lutary ends for which it generally commences. In whatever manner the several differences, respecting belief: •• Neque tamen ideo obstructio sanguinisve stagnatio adest in arte riis sic adfectis: quern certe propulsant atque transmittunt in venas respon- dentes, licet non satis expedite, nee integra quantitate accepta." S>>». <;hir. Hod. Pars 1. p. 191. • Lectures on Inflammation, p. 75, &c. I See- Quarterly Journal of Mi-dical Sciences for Oct. 1825, p. 650. 16 TNFLAMMATI0>. the nature of inflammation, may be hereafter reconciled, it will always be a primary indication to diminish, by means of bleeding, or other expedients, the quantity and impetus of the blood flowing towards the inflamed part. lne utility of this maxim is so confirmed by experience, that, whatever may be the theory espoused concerning the state of the capillary vessels in an inflamed part, no difference of opinion prevails with respect to the rule of practice. Indeed, at the present day, surgical ingenuity is constant- ly active, in devising plans for carrying this principle into execution with the greatest effect; and even the bold mea- sure of tying large arteries, for the relief of inflammation, has been both recommended and tried.* Such treatment, though unnecessary in ordinary cases, may not be decided- ly improper in others of a more urgent nature ; like the dangerous kind of inflammation resulting from wounds of the knee, and bad compound fractures and dislocations. General bleeding, by which we are to understand the ex- traction of blood from a largish vessel at a distance from the inflamed part, is sometimes less advisable tha» topical bleeding, or the taking away of blood from the aceti et spirit, vini rectif. sing. Jfej. M., or one composed of the liquor ammonia? acet. alone, or mixed with equal parts of spirits of wine, and distilled water. When the inflammation is slight, and the swelling and extravasation great, the surgeon may sometimes ven- ture to use liniments. The fact is curious, but perfectly confirmed by experi- ence, that inflammation is sometimes most benefited by cold applications, and sometimes by warm emollient poul- tices and fomentations. Although, in the early stage of the greater number of phlegmonous inflammations, cold as- tringent lotions are preferable to warm applications, it is occasionally otherwise, and either from singularity of the patient's constitution, or, in consequence of the structure, situation, and nature of the inflamed part, they do not pro- duce their usual good effect. An inflamed testicle, and the 20 INFLAMMATION more incipient stage of acute ophthalmy, generally receive benefit from emollient fomentations and poultices, than from cold astringents. Inflammations, not admitting oi a cure without suppuration, should also be treated with emol- lients; for the sooner the matter is formed, the sooner the inflammation will end. Such is the inflammation caus- ed by fevers, contused wounds, boils, and carbuncles. One of the best emollient poultices is that made of lin- seed meal, which should be gradually mixed with hot wa- ter, until the mass is of proper consistence. A little oil is often added, which prevents the poultice from becoming dry and hard. An eligible fomentation is thus made: R lini contusi 5j. chamoemeli §ij. aqua? distil, tbyj. paulisper coque et cola. When the pain is exceedingly severe, the following one frequently produces great relief: R papaveris albi ex- siccati ^iv. aqua? purae tbyj. coque usque remaneant thy- et cola. The most common way, in which inflammation ends, consists in a gradual abatement of the pain, redness, swell- ing, throbbing, and heat of the part, without any formation of matter, or permanent injury of structure. This is term- ed resolution, and is the best manner in which inflammation can terminate. The next most frequent termination of phlegmon is in the production of pus, termed suppuration; a state, how- ever, in which there is rather a modification of the inflam- mation, than a cessation of it. The other manner in which inflammation ends, is in the death of the part affected—mortification; the worst, but, happily, the least frequent, result of common inflamma- tion. Every part, just recovered from the violence of phleg- monous and other kinds of inflammation, may be regard- ed as still imperfect, and, sometimes, in consequence of the loss of tone, induced in the vessels, a languid or chronic inflammation succeeds, which cannot be overcome, without great difficulty. Hence, however improper stimulants, astringents, and corroborants may be, as local applications, during the violence of inflammation in very sensible or- gans, they are generally highly proper the moment that stage ceases. Thus, emollients, which, for the first day or two, are serviceable in acute ophthalmy, afterwards act pre- judicially, in consequence of their relaxing nature. IM'LAMMATORY FEVEK. CHAPTER II. OF THE SYMPATHETIC, OR SYMPTOMATIC, INFLAMMATORY FEVER. After being informed that the mass of circulating blood becomes affected in cases of inflammation, we must expect to find traces of constitutional, as well as of local disturbance. The name of the fever attendant on inflam- mation is derived from its being, as it were, one of the symptoms or effects of the local disorder, and the sympa- thy of the whole constitution with the disturbed state of a part. It is called inflammatory, because it is accompani- ed with an increased action of the heart and arteries, and with what is termed ^.phlogistic type. The symptoms are, a frequent, strong, and full pulse; Tieadach; loss of appe- tite; nausea, and sometimes vomiting; constipation; an increase of the temperature of the whole body; a hot dry state of the skin ; a dry, white, furred tongue; great thirst; universal disturbance of the nervous system; restlessness; anxiety; loss of sleep; and, in some cases, there is deli- rium. Perspiration is not the only secretion which is di- minished: all the other secretions are similarly affected. For instance, the flow of saliva into the mouth is diminish- ed, and ulcers and other surfaces secreting pus are dried up upon an attack of fever. The urine is not only dimi- nished in quantity, its chemical properties appear to under- go considerable alterations. Though of a high colour, it deposits upon standing no lateritious sediment, or uric acid, as it almost constantly does the moment the fever be- gins to abate.* The impediment to the various secretions in the alimentary canal may also account for the constipa- tion. Such is the general nature of the febrile symptoms, when any considerable degree of phlegmonous inflammation af- fects common parts, like the integuments; the disturbance of the system being in a great measure proportioned to the extent and violence of the local affection. The effects of inflammation on the constitution, how- ever, are not simply in a ratio to its extent; but are influ- • See Thomson's Lectures, p. 115. 22 SYMPATHETIC, OR SYMPTOMATIC. enced as much by the nature of the parts, in which it is situated, as by its quantity. When muscles, cellular membrane, skin, &c, are inflam- ed, the pulse is, as we have described, strong and full. These may be said to be common structures. If the inflammation be in tendinous, ligamentous, or bo- ny parts, the stomach sympathizes more than when mus- cles, &c, are inflamed. The pulse is quicker, but not so full, and the blood, not being propelled so far into the small vessels, forsakes the skin. When inflammation is in vital parts, or such as sympa- thize with the stomach, there is great depression blended with the constitutional symptoms; the pulse is frequent and small, and the blood is not pushed into the minute vessels. A remarkable depression of strength frequently attends an inflammation of the intestines, and the pulse is small and hard; whereas, when the surface of the body is the seat of the affectio% there is often a temporary aug- mentation of tone, with a full, strong, and hard pulse. In fact, when the peritoneum and intestines are inflamed, the patient frequently seems so reduced, and his pulse so small, that the surgeon is afraid to use the lancet. Perhaps, how- ever, he ventures to do so; the blood is found to be sizy, and the pulse gains strength, in proportion as the disease is benefited by the evacuation. When the constitution is good, and parts not very essen- tial to life are inflamed, the strength and fulness of the pulse are increased. When the same parts are affected in weak irritable persons, and in women who lead sedentary lives, the pulse is quick, hard, and small, at the commence- ment of the inflammation, just as if vital parts were con- cerned. Thus, we see, that all the varieties of inflammatory fe- ver depend chiefly on four circumstances; viz. the extent of the inflammation; the structure of the parts affected; their functions; and the nature of the constitution.* If continued beyond a certain period, the common in- flammatory fever always has a tendency to change into hectic; a species of constitutional disorder described in a future chapter, and invariably attending all long-continued profuse suppurations, as well as every other surgical dis- ease, which keeps up for a considerable time a general dis- turbance of the health. * Hunter on the Blood, &c. p. 322. INFLAMMATORY FEVER. 23 As the cause of the sympathetic inflammatory fever is the local inflammation, it is obvious, that while we are en- deavouring to cure the latter, we are taking the most ef- lectual steps for the relief of the constitutional disorder. But, as excessive febrile disturbance may, in its turn, have a bad effect on the local complaint, it is sometimes proper to endeavour to palliate the constitutional symptoms, by having recourse to such means as would not be necessary, were the inflammation not likely to be aggravated by the fever. The frequency, strength, and fulness of the pulse are to he diminished by the use of the lancet, the exhibition of saline purgatives, the nitrate of potassa, and, in urgent cases, by giving nauseating doses of tartarized antimony, or digitalis. Several of these remedies, however, are gene- rally employed rather on account of the particular state and situation of the inflammation, than the degree of fever. Bleeding, for instance, is hardly ever necessary on account of the fever itself; consequently, it is not usual to pursue this practice with the view of altering the state of the pulse, except where the local inflammation is dangerous by rea- son of its extent, or situation : and where the increased ac- tion of the whole sanguiferous system might seriously ex- asperate the local mischief. Here, also, we should proba- bly use the lancet, on account of the inflammation, were it possible to have at the same time a fever ever so inconsid- erable. In short, if the inflammation does not require bleed- ing, it is difficult to suppose the evacuation necessary for the fever, which invariably subsides with the local disturb- ance, or when suppuration comes on. In compound frac- tures and dislocations, which are often followed by a great deal of local inflammation, and symptomatic fever, vene- section is not found to be in general an advantageous prac- tice; for it debilitates too considerably, and is apt to leave the system incapable of bearing the tedious suppuration, which very commonly ensues. Nor is it here necessary even for the relief of the fever itself, the strong actions of which naturally subside of themselves in three or four days, either on the occurrence of suppuration, or the union of the external wound. The constitution then remains in a less reduced state, and better qualified to support itself through the rest of the treatment, than if bleeding had been em- ployed. The secretions are to be promoted, and a gentle diaphoresis in particular ought to be excited. For these purposes, small doses of tartarized antimony are the best y4 SUPPURATION. medicine. The cure and treatment of this fever are, on the whole, so blended with those of the inflammation, from which it originates, that what has been said in the forego- ing chapter, makes it quite superfluous to enlarge the pre- sent. CHAPTER III. SUPPURATION. Suppuration is that process, by which pus, or the mat- ter of sores and abscesses is formed; and the word abscess signifies nothing more than a collection of purulent matter. Like inflammation, suppuration may be either acute, or chronic; simple, or complicated with some specific morbid action, the lodgment of extraneous substances, &c. Thus, we see acute suppurations exemplified in common whit- lows; in milk-abscesses; and many gun-shot wounds, and compound fractures; while chronic suppurations are illus- trated in that frequent and serious form of disease, the lumbar abscess, and in several of the effects of scrophula. Abscesses of the scrophulous kind afford us also striking instances of what may be called chronic suppurations, com- plicated with specific morbid action, just as true venereal buboes present us with specimens of acute abscesses, com- plicated also with specific disease. At present, my obser- vations will be confined to the simple, acute form of sup- puration, arising from phlegmonous inflammation. When, notwithstanding the foregoing treatment, the in- flammation is attended with more severe pain, a distressing pulsatory sensation, a much harder tumefaction, and a co- nical, but softer prominence in its centre, suppuration is likely to ensue. Sometimes this event may from the first be prognosticated; because there are inflammations, which, from their peculiar nature, necessarily terminate in suppu- ration ; as boils and carbuncles, and the inflammation, in- duced by fevers, occasionally termed critical. When the patient is seized with reiterated shiverings; when the fever and all the symptoms of inflammation sud- denly diminish, without any perceptible reason; when the patient expriences a heavy, cold, dull uneasiness, instead SUPPURATiuN 25 of acute pain, in the part affected; when the most elevated point of the tumor appears soft and white, while the rest has its redness increased; and when, at the same time, the surgeon can feel a fluctuation, matter is undoubtedly al- ready formed. The latter symptoms only occur, when the matter is su- perficially situated. In other cases, the quick subsidence of all the inflammatory symptoms, the repeated rigors, and the sense of weight and coldness, only afford grounds for suspecting that matter is formed. This suspicion, however, is afterwards strengthened by the patient having nocturnal sweats, with emaciation and othtr hectic symptoms. Also, an (Edematous swelling, which is at first not very exten- sive, takes place over the situation of the abscess, and af- terwards spreads, so as sometimes to extend over a whole limb. These circumstances leave no doubt of there being a deeply-seated collection of matter. A man endued with great nicety of touch, can often feel the undulation of mat- ter, even when deeply lodged. The exposure of the internal surfaces and structure of the bodv, continued for a certain time, necessarily occa- sions suppuration. Here the influence of the air is not the cause; for, were a wound made into a cavity naturally closed, pus would be formed, after a certain time, even in a vacuum. When matter forms in circumscribed cavi- ties without a wound, the air cannot be suspected as a cause: nor does the air, in emphysematous cases, excite suppuration. The sympathetic fever attendant on inflammation, has been considered an essential step to suppuration; but with little foundation. Is there not a regular secretion of pus from the most indolent ulcers? Is there not the same pro- cess on every blistered surface ? In such cases is there not often a total absence of fever ? That dead animal matter cannot be converted into pus, is^n-qyed by sloughs of the cellular membrane, tendons, fascia?, &c. &c. remaining unchanged in abscesses a con- siderable time, and by dead bone lying unaltered in pus for many months. Whatever diminution of these substan- ces mav happen under such circumstances, occurs only on that side which is next to the living solids, and it can be satisfactorily accounted for on the principle of absorp- tion. The idea, that fermentation contributes to the formation •f pus, is quite destitute of inundation. The discharge of Voi. i. n 26 >UriU'ItATIO>- pus from secreting surfaces, without any loss of substance , the, stationary state of many abscesses; the backwardness of matter to become putrid, while unexposed to the air; sufficiently evince, that no fermenting power is present. The opinion, that extravasated blood can in time be con- verted into pus, is equally erroneous.* When suppuration is about to take place in the cellular substance, or membranes of circumscribed cavities, the ves- sels are supposed to alter their mode of action, so as to se- crete pus. This change happens gradually. Hence, pus and coagulating lymph are often found blended together in-the same abscess. The fact, that pus may be formed without a breach of the solids, or dissolution'of parts, seems to have attracted the notice of several eminent men about the middle of the last century, especially Dr. W. Hunter, De Haen,f Ques- nay4 Peyronie, and Morgagni. It was in the year 1749 or 1750, that Dr. W. Hunter was first struck with this truth, in the dissection of a subject, who had died of empyema; and M. Quesnay inserted in one of the early Memoirs of the French Academy of Surgery, a case which fell under the observation of Peyronie, in which a very copious sup- puration of the brain took place : the patient died, and the head was examined, when the proportion of brain wanting was so trivial, compared with the quantity of pus that had been discharged, that it was justly concluded the matter had not been formed from the solids, but from the fluids, of the part.§ The modern doctrine of suppuration is, that the pus is separated from the blood by the inexplicable operation of the secerning arteries, just as ordinary secretion takes place ; and that the peculiar mode of action in the arteries, is the reason why pus should be separated from the-circu- lation, rather than coagulating lymph, mucus, &c. It is further believed, that the solids never suffer any dissolu- tion, so as to enter into the composition of pus ; and Aat the deficiency frequently apparent in them arises from ab- sorption. The arteries, in producing pus, a fluid so dissimi- lar from blood, and of which, at least it is to be consider- * A complete and masterly refutation of all these hypotheses is contain- ed in Hunter's Treatise on the Blood, &c. p. 417, et seq f Ratio Medendi, Vindob. 1750. H" i Traits de la Suppuration, Paris, 1749. § Mem. de. 1' Acad. deChir. t. 2. p. 163, edit, in 12mo. -UlTtf RATION. >^d as a new combination, seem to assume all the power of glandular secretion. The kind of fluid which is discharged from healing sores, or phlegmonous abscesses, receives the name of healthy pus; and, in this state, it has the following proper- ties: it is of a yellowish colour; has little smell; is void of acrimony; of the consistence of cream ; and when micro- scopically examined, exhibits white globules in a transpa- rent fluid. At its first formation, however, no globules are perceptible, but it has the appearance of a transparent, ge- latinous fluid, and it is not till about fifteen minutes after it has continued on the surface of the sore, unexposed to the air, that they are distinguishable. The globules swim in a fluid which at first might be supposed to be the serum of the blood ; for, like the serum, it is coagulated by heat, though not by the gastric juice of animals. It probably contains a small quantity of coagulating lymph, since it partly coagulates after being secreted. But although the colourless fluid, in which the globules swim, is thus far similar to serum, in other respects, it is different; and, ac- cording to the observations of Mr. Hunter, it differs from every other animal secretion, in being coagulable by a so- lution of the muriate of ammonia.* Dr. G. Pearson found, however, that this test would not answer in the examina- tion of matter expectorated from the lungs. He suspects also, that the globules of pus are composed of the red par- ticles of the blood* an opinion, to which another intelligent physician appears to incline, when he says, that the mag- nitude of the globules of pus, as ascertained by the most accurate tests, is not sensibly different from that of the cor- puscles of the blood, reduced to a round form by the ad- dition of water, or otherwise ; while the globules found in other animal fluids, for instance, in milk, are of totally dif- ferent dimensions.! The perfection of pus seems to depend upon the large proportion which the globules bear to its other parts. Pus sinks in water, and will not readily unite with it: at least, in the common temperature of the atmo- sphere, it will not mix with it, but falls to the bottom. The caustic fixed alkalies triturated with pus, combine with it * Hunter on the Blood. Inflammation, p. 429. \ Dr. T. Young, in an Introduction to Medical Literature, p. 548, 8vo. Loud. 181.3 ; and in a Practical and Hist. Treatise on Consumptive Diseases, deduced from original Obs. and collected from authors of all ays, p. ?fi 8vo. Lond. 1815. 28 SUPPURATION. into a soapy fluid: with ammonia, it forms a gelatinous compound. In the voltaic circuit, it coagulates rapidly, and yields a substance very analogous to albumen. It has been an object with pathologists to have some cer- tain method of discriminating pus from mucus, two secre- tions, which in their external appearance greatly resemble each other. According to Dr. C. Darwin, the three follow- ing characters of pus are correct: 1. Sulphuric acid dis- solves it, and the solution is decomposed by water, which precipitates thr pus. Sulphuric acid also dissolves mucus; but the addition of water separates it in flakes, which float Upon the surface. 2. Pus is diffusible through dilute sul- phuric acid, and through water and brine; but, mucus is not. 3. Caustic alkalies dissolve both pus and mucus; but, when water is added, a difference is exhibited, the pus be- coming separated, but net the mucus. Mr. Brancle, how- ever, has not found the last of these criteria accurate ; and, (says he,) even supposing all these statements correct, they are of no practical utility; because where pus is mixed with mucus in various proportions, the tests are not suffi- ciently delicate to distinguish it. Another test of pus, recommended by Grasmeyer, is the following: triturate the substance to be examined with an equal quantity of warm water, then add to it an equal quan- tity of a concentrated solution of subcarbonate of potass. If pus be present, a transparent jelly subsides in a few hours, which is not the case where only mucus is present. Mr. Brande repeated these experiments, but the results were by no means satisfactory.]- Besides these chemical tests, and the general distinction of pus sinking in water, while mucus floats, an optical criterion has been proposed by Dr. T. Young, as a very simple and certain means of ascertaining the nature of matter expectorated from the lungs. He regards the globules as the essential character- istic of pus, and it is from their presence, that the test about to be described is derived, while the colour indicates, that there is no mixture of blood. If we put a small quan- tity of the substance to be examined between two pieces of plate-glass, and holding it near the eye, look through it at a distant candle, we shall observe the appearance, even in the daytime, of a bright circular corona of colours, of * Brande, in Lecture on Animal Substances. Vid. Lond. Med. Repc tory, vol. iv. p. 75. \ See Lon. Med. Repository, p. 76. SCPITBATION. 29 which the candle is the centre ; a red area, surrounded by a circle of green, and this again by another of red; the co- lours being so much the brighter, as the globules are more numerous and more equable. If the substance be simply mucus, there will be no rings of colours, although some- times there is a sufficient mixture of heterogeneous parti- cles even in mucus, to cause the appearance of a reddish area just about the candle.* When pus is pure, it does not readily putrefy; but in specific diseases, cases of necrosis, &c, it is often mixed with blood, or coagulating lymph, in which circumstance, it has more tendency to putrefy, and become offensive. It alwavs partakes of the nature of the sore which produces it. To the surface secreting it, pus is quite unirritating, though sometimes its qualities are such, that they will greatly irritate any other parts with which it happens to come in contact. Hence, the inutility of wiping the mat- ter so completely off the surface of granulations, as some are wont to do, though it is always highly proper to keep the surrounding skin free from it. When any disease attacks a suppurating surface, or the constitution, the pus becomes thinner, more transparent, and more disposed to putrefy, and grow offensive. Sanies is the term frequently given to it in this degenerated state. Sanies may be very irritating to parts, so as to cause their absorption, but it never has the power of corroding them. The changes in the appearance of pus, arise more from the indolence and irritability of the parts producing the matter, than from disease. Many specific diseases, in healthy constitutions, produce no alteration in the appear- ance of the matter. Thus, the matter of gonorrhoea, of the small-pox pustule, and of chicken-pock, seems in each case to be made up of similar parts, consisting of globules floating in a transparent fluid, like the pus of a common sore, the specific properties of these diseases being super- added.f Flakes of opaque coagulating lymph are frequently ob- served in the matter of indolent sores, and scrofulous ab- scesses. The discharge from irritable ulcers is often thin, being ihiefly composed of an irritating aqueous fluid, mixed with blood. * Op. cit. \ Sir E. Home on the Properties of Pus, 8vo. Lond. 1789. to §UPI'UJRATION. With regard to the uses of suppuration, the secretion of pus upon sores and wounds appears to promote the heal- ing process, by hindering the granulations from becoming dry, which state would be very unfavourable, not only for their requisite growth, but for all the minute processes, which take place in the advancement of cicatrization. An- other design, answered by means of suppuration, is the discharge of extraneous substances, bullets, pieces of dead bone, &c. Here also we see the utility of the generally greater disposition to suppuration in superficial, than in deeply- seated parts; for, were a foreign body always to excite an abscess very remotely from the surface, the suppuration would only be an increase of mischief; whereas, when the extraneous substance is near the skin, and suppuration oc- curs, the abscess bursts, and the irritating body is discharg- ed. From some late experiments, made by Sir Everard Home, it appears, that pus naturally contains a large quan- tity of carbonic acid gas, which, when the fluid containing the globules is inspissated, diffuses itself, and quickly pro- duces, by the passage of its bubbles, a net-work of anasto- mosing tubes or channels, supposed to become afterwards vessels. This is a subject, however, which requires further investigation.* If there were not some boundary to an abscess, some partition between the pus and the cavities of the cellular substance, the matter would diffuse itself extensively on all sides, like the air in emphysema, or the water in oede- ma. To prevent this circumstance, we find, that coagulating lymph is deposited immediately around the collection of matter; and, becoming organized, assumes the appearance of a membranous cyst. In abscesses of long standing, the cysts are often of very considerable thickness, while in other collections of matter, that have been sudden in their form- ation, and have not existed long, the surrounding lymph has scarcely had time to be converted into a vascular mem- branous cyst. The cysts of all abscesses are both secret- ing and absorbing surfaces. When the pus has been com- pletely discharged by a puncture, the cavity soon becomes filled again with the same kind of fluid. Large and pal- pable collections of matter often disappear entirely, and in a manner only to be explained by the action of the absorb- ents. Matter always tends to the surface of the body, making * See Phil. Trans. 1818, p. 180—194. SUPPURATION. <■> 1 its way through a considerable thickness of parts, in order to arrive there. Even when there is but a delicate mem- brane between the matter and some internal cavity of the body, the abscess generally bursts externally, though it may have to make its way through a remarkable thickness of substance. Its progress is always aided by the relaxa- tion of the skin situated immediately over the abscess. Here the skin is invariably looser, than when it yields to mere mechanical distention, unless the increase of the abscess be very rapid; and as the matter advances towards the surface, the intervening solid parts are absorbed. The danger of abscesses depends upon their size, num- ber, situation in vital, or other organs of consequence, or the effect of their pressure in impeding the functions of th<- heart, brain, respiratory organs,* urethra, oesophagus, &c. TREATMENT OF PHLEGMONOUS ABSCESSES. The generality of phlegmonous abscesses soon burst of themselves, and need not be opened. When punctured unnecessarily or prematurely, fresh inflammation is excit- ed, the pain is increased, the seat of the matter cannot be easily reached, and the cure is seriously retarded. The majority of abscesses which are superficial, or at a distance from parts of importance, may be left to burst of them- selves. We may also defer opening such abscesses as ait- slow in their formation, and surrounded by a good deal of hardness of the contiguous parts.f Particular cases, however, should be opened as soon as the existence of matter is ascertained. When suppuration takes place in the sheaths of tendons, or beneath fasciai, which invariably retard the progress of matter to the surface of the body, an early opening ought to be made. When this is not done, the matter spreads to a great extent, separating such ligamentous expansions from the muscles, and the * {The following highly instructive case is related by Sir A. Cooper in his Lectures:—" A gentleman came to me who was labouring under great dif- ficulty of breathing, and requested me to examine his throat; having put my finger on the back of the pharynv, and felt fluctuation there, 1 imme- diately passed a trochar into the phan nx, when a considerable quantity of matter was discharged, and the patient relieved." In all probability this case would have terminated fatally by the pressure of the matter on the glottis and epiglottis, had not the operation been so promptly performed.— P. E.J r Thomson's Lectures, p« 336. CalRsen, t. i. p. 318. .m SL'PI'URATIO'M muscles from each other. The necessity of this practice is often demonstrated in whitlows, abscesses under the pal- mar fascia?, or the fasti* of the thigh and fore-arm. Phleg- monous abscesses should not be left to break of themselves, when situated in extremely sensible parts, the distention of which would create intolerable pain. An opening is likewise necessary, when the collection of matter lies in a mass of adipose substance, and only presents itself exter- nally, at a very limited point* Of this nature are abscess- es about the anus. Whenever the matter produces evils, re- sulting from its pressure upon particular organs, its dis- charge isurgentlv indicated; as in abscesses near the ure- thra and neck of 'the bladder; near the trachea, or larynx ; very close to a bone, or in contact with it, under the perios- teum, f The best surgeons, however, do not exactly agree, whether the vicinity of an abscess to certain parts is a pro- per reason for making an early opening in it. Thus, Pro- fessor Thomson, and many others, conceive, that the situa- tion of an abscess near a bone, or a large artery, renders an early opening necessary, because it is feared, that, in the first instance, the matter will cause disease of the bone; in the second, weakness of the parictes of the ves- sel, and hemorrhage, or aneurism. But, says another emi- nent author, when suppuration happens near a bone, the periosteum becomes thickened, as it were, for the protec- tion of the part. Besides, pus is neither of a corroding, nor irritating nature. When in opening an abscess, which lies near a bone, this part is found affected with caries, or necrosis, it is because it has been originally affected; and, in this case, the abscess is the effect, and not the cause of the altered state of the bone4 On this point, however, it is but fair to state, that the most experienced surgeons, and amongst them Sir A. Cooper, generally consider the near- ness of an abscess to a bone a good reason for making an early opening; for though the bone may sometimes be af- fected as soon as, or even sooner than, the soft parts, and though healthy pus has no corroding quality, yet, in other instances, the bone may really be secondarily affected in consequence of the pressure of the collected matter. As exceptions to this rule, Sir A. Cooper, in his lectures, in- * Delpech, Precis des Maladies reputees Chimrgicales, t. i. p. 29. 8vo. Paris, 1816. Boyer, Tra'ite des Maladies Chir. t. i. p. 60. -j- Callisen, t. i. p. 319. Thomson's Lectures, p. 337. * Boyer, Traite des Mai. Chir. t. i. p. 61, 62, and Widemann de Necrosi Ossium. SUPPURATION. 82 stances cases, where a fluid exists between the pericranium and bone, unattended with any blush of the skin; but, says he, when such blush is present, an opening must be made, for the matter now formed will not be absorbed, and exfo- liation is often unavoidable. With regard to the vicinity of a considerable artery to the abscess, it always happens that when, in cases of suppuration, the cellular substance around the vessel is destroyed, the arterial coats are rather thickened than rendered thinner, and they are afterwards covered with granulations, and blended with the surround- ing parts. The truth is, I believe, that, although in open phagedenic ulcerations, arteries sometimes give way, such an event is never caused by the vicinity of a simple ab- scess. When matter is so situated as to be liable to insi- nuate itself into the chest, or abdomen, or into the capsu- lar ligaments of joints, it is highly proper to prevent such an extension of mischief, by making a timely opening into the abscess. As Boyer observes, however, the risk of such an evil has been unduly magnified; for, besides the ge- neral security arising from that law, by which the matter tends towards the surface of the body, there is a further protection, derived from the thickening of the adjacent por- tion of the serous membrane, investing the above-mention- ed cavities. Authors describe three principal ways of opening ab- scesses; viz, with a lancet; caustic; and a seton. In al- most all cases, the lancet should be preferred; for, it opens the abscess more quickly than caustic, and with less pain; it occasions no loss of substance, consequently, a smaller cicatrix;* and, by its employment, the opening may be made in the most advantageous direction, and of the ex- act size necessary. The place, where the puncture ought generally to be made, is where the fluctuation is most perceptible ; or where the conical eminence, or, as it is termed, the pointing appears; for, in this situation, the integuments are thinnest. It is * Jin many instances it becomes a matter of considerable importance to open an abscess in such a manner as to produce the least possible deformity, particularly in exposed parts, as in the necks of females. For this purpose we have been for some time in the habit of using a very fine knife, as re- commended by Sir Astley Cooper, having the blade about an eighth of an inch wide. The opening should be made before the skin is much affected, and as soon as a blush lias appeared; observe that it be always made trans- versely, and not in the axis of the neck, so that when it heals, scarcely any vestige of a wound will remain, and an ugly scar is thus prevented.— 34 SUPPURATION. also desirable, (if practicable with due regard to every thing else,) to make the opening in a depending situation, in order to allow the matter to escape as soon as it is form- ed. Collections of matter, beneath the fasciae of the fore- arm and thigh, particularly demand attention to this pre- cept, as they commonly point, where those ligamentous bands are naturally thinnest, not where the matter can most readily escape. With respect to the size of the opening, the only gene- ral direction which can be given, is to make it large enough to let the matter escape with facility. When the pus is of thick consistence; contains flakes of coagulating lymph; or lies under a tendinous expansion; the opening should be larger than in ordinary cases. A grand object in the treatment of most abscesses, after they have burst, or been opened, is to maintain such an open- ing, as will prevent any future lodgment of a large quantity of pus. When this indication is fulfilled, the cavity of the abscess soon contracts, and becomes filled up with granu- lations. When an abscess bursts spontaneously, the opening is not likely to heal, as long as it communicates with a cavity into which pus is secreted; and, consequently, there is no occasion to take any measures to prevent its closing. But, when a collection of matter is deeply situated, and has been opened by an incision, the wound is very likely to close again, especially, if not in a depending situation. In this case, the surgeon must take care to insinuate a piece of lint between the edges of the puncture, and at every visit, introduce a probe. When a phlegmonous abscess is extensive, and the skin thin, the opening should be made large, and in a depending situation. But, if the shape and size of the cavity of the abscess should prove impediments to the easy escape of the matter through a single puncture, or incision, one or more additional apertures ought to be practised in such places as seem most advantageous. When, however, a de- pending opening can be made, others are scarcely ever re- quisite. When the collection of matter is extensive and deep- seated, or when the opening has not been practised in the most favourable situation for the escape of the pus the matter burrows passages for itself, which sometimes reach a long way from the original and main cavity of the ab- scess. These passages, or sinuses, seriously increase the SUPPURATION. 35 extent of the disorder, and, often having little tendency to heal, before they are laid Open, render the treatment more difficult, and the cure more distant. Their direction, ex- tent, and number, can only be discovered by the probe,and sometimes not without the utmost difficulty. As they take place from the matter not having a ready outlet, of course, the first indication in the treatment of them is to make such an outlet; and, then, if they will not heal spontaneously, or with the aid of pressure, thevmust be traced with a probe, and fairly laid open to their very terminations, by means of a curved bistoury. Some abscesses will not heal, though the matter easily finds its way out; and their internal surfaces will not pro- duce granuiations, unless a complete exposure of the cavi- ty be made, and fresh inflammation excited. Abscesses about the arms, axilla?, groins, scrotum and labia pudendi, are often so circumstanced. It is true, however, that many of these cases are hindered from getting well by the cavi- ty of the abscess not having an adequate, or a very direct external communication. Whichever of these explanations be most correct, no sooner is it certain that a cure cannot be effected by the milder means of a judicious posture, compression, or the use of a stimulating injection, than it becomes the duty of the surgeon either to enlarge the ex- ternal opening, or lay the cavity completely open to its bottom. When from any circumstances, preceding the formation of an abscess, there is reason to suspect the complication of a foreign body, the next indication to that of letting out the matter, is to search gently for the extraneous sub- stance, and if loose, to remove it with the least irritation possible. It was formerly the custom, after puncturing abscesses, to squeeze and press out every drop of matter, which they contained; a practice, attended with a good deal of pain and irritation, and no material advantage. It is there- fore not imitated by the best surgeous of the present day, who generally leave the matter to ooze out of itself under the poultice. The old method of stuffing the cavity of the abscess with lint, or charpie, is also condemned, as occa- sioning needless pain, and opposing the gradual contrac- tion of the hollow, in which the abscess is lodged.* ♦ Boyer, Trait e" des Mul. Cbir. t. i. p. 67. 36 bUTPURATION. When a surgeon prefers to open an abscess with caustic, he generally employs the potassa pura, or this substance mixed with quicklime. The part is first to be covered witn> a piece of adhesive plaster, which has a portion of it cut out, of the figure and size of the opening intended to be made in the abscess. The usual way of making the eschar is to dip the end of the caustic in water, and 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 removed, and an emollient poultice applied. This method of opening abscesses is rarely advisable. Indeed, I know of hardly any case in which the practice is decidedly advantageous. It has been fancied, that the method is proper when the abscess consists of a small col- lection of matter, which has been long in forming, and is surrounded by a good deal of indolent hardness. The caus- tic, it is supposed, may then have a desirable effect in de- stroying some of the induration, and exciting the absorb- ents to remove the rest. It is believed, that the stimulus of the caustic will kindle a fresh and more lively action in the parts: one, that will be very serviceable in the cure. The most intelligent observers find, however, that all indura- tions proceeding from acute inflammation, are more likely to be increased than diminished, by caustic applications ; and the plan, therefore, if proper at all, should be chiefly restricted to the preceding imperfect suppurations. It is sometimes adopted in cases of buboes, accompanied with much surrounding induration, partly on the foregoing prin- ciples, and partly for the purpose of making a largish, and more permanent opening, than a mere puncture, so as to lessen the chance of the skin healing too fast before the bottom of the cavity is sound, and to remove the hazard of the formation of sinus.es.* The method,however, is always painful and severe, and certainly ought not to be indiscri- minately nor frequently practised. It is a great objection to it,, that it is impossible to prescribe any precise bounda- ry to the action of the caustic, and that, unless the eschar be made sufficiently deep, the lancet must after all be em- ployed. Caustic also invariably produces an ugly scar; a consideration of importance in abscesses about the necks and faces of females ; and sometimes the eschar is not de- tached for nearly a fortnight. Professor Thomson, who entertains a just aversion to * See Pearson's Principles of Surgery, edit. 2. p. 68. SUPPURATION. 37 the method of opening abscesses with a seton, notices the circumstances in which the plan is ordinarily recommend- ed. First, in large abscesses, where the skin is healthy, and capable of uniting to the opposite side, or bottom, of the ab- scess. Secondly, in cases where it is wished to draw off the matter of an abscess slowly. And, thirdly, in cases where it is wished to excite a certain degree of irritation in the cavity of the abscess. The seton has also been supposed to be particularly useful in large deep abscesses into which we wish to prevent the entrance of air.* Now, as Dr. Thomson has not sufficiently exposed the absurdity of set- ons, and I conceive that the employment of them in the treatment of abscesses, especially those of the phlegmon- ous kind, is altogether wrong and pernicious, it behooves me to examine the reasons alleged in support of the prac- tice. With respect to the first instance specified, why are we to use a seton because the skin is healthy and disposed to unite to the subjacent parts ? Is it not as much as to say, a seton, a painful, irritating, extraneous substance, a foreign body, must be drawn across an abscess, because such ab- scess is already inclined to heal? As for the second instance, in which the slow evacua- tion of the matter is desired, and given as the reason for a seton, such an indication never can occur in acute phleg- monous abscesses, though possibly it may do so in certain large chronic collections, especially lumbar, or psoas ab- scesses. After these have been opened, and their contents discharged, a series of alarming febrile symptoms not un- frequently ensues, which has been referred by some to the sudden evacuation of the matter; by some to its absorp- tion ; and by others, with more reason, to the inflamma- tion of the extensive cyst of such an abscess, induced by making too free a puncture and leaving it open.f Now, ad- mitting what may be rationally doubted, that suddenly emptying an enormous chronic abscess is worse practice than a gradual evacuation of its contents, cannot the sur- geon avoid what is objectionable by making only a small puncture, which is on other accounts judicious instead of a free incision? A large puncture, besides letting out the matter in the manner apprehended, excites too much irri- tation, at the same time that it facilitates the entrance of air into the cavity of the abscess, and the consequent pu- * See Thomson's Lectures, p. 342. ■5 See Abernrthy'* Surgical M'orks. vol. ii Oh- on Lumbar Ah>ce-wr>;. 3S SUPPURATION. trefaction of whatever matter remains behind. The air, it is true, does not irritate the cyst; but, it promotes such changes in the pus with which it comes in contact, as ren- der this fluid itself a source of considerable irritation and danger. None of these reflections, however, have any thing to do with acute phlegmonous abscesses, which are of a totally different nature. No dangers arise from their being suddenly emptied, or sufficiently opened to let the matter freely escape; and, of course, the reasons for applying setons to them entirely fail. The third reason, above specified, viz. the wish to excite irritation in the cavity of an abscess, would, I am con- vinced, never be urged by the strongest admirer of setons in cases of acute phlegmonous abscesses, where the wisest, most successful, and scientific practice, as universally ac- knowledged, consists in the use of soothing applications, and the avoidance of every thing irritating. All further comment on this reason is, therefore, superfluous. A fourth alleged advantage of the seton is its prevent- ing the entrance of air into the cavity of the abscess. But, how are we to suppose, that it can act in this way, while it allows a thick fluid, like pus, to issue ? Besides, is the great and certain irritation, which the seton itself causes, to be rated lower, than that unproved, questiona- ble kind of irritation, formerly imputed to the entrance of air into the cavities of the animal body ? This doctrine ori- ginated, because irritation was often seen following inci- sions in such cavities. But, as the air in emphysema causes no irritation, and there is reason to suspect, that the same cavities would inflame if opened in a vacuum, the opinion seems entitled to little credit. It was a prejudice of this sort which blinded the eminent Dr. A. Monro* so com- pletely, as to lead him to impute a man's death to the en- trance of air into the pericardium, though a hot poker had been thrust into the chest! I can conceive, however, with Mr. Abernethy, that the admission of air into large chro- nic abscesses may be hurtful by causing putrefaction of the contained matter. I have never known any evils arise from the effects of the air on phlegmonous abscesses. The best applications to phlegmonous abscesses are fo- mentations and poultices. While the skin covering the col- lection of matter continues entire, they are the best dress- osae, p. 41. Also Di ell, p. 347, edit. 3. SUPPURATION. 3P ings, because they favour its relaxation, and accelerate the progress of the matter to the surface of the body. When the abscess has been opened, or has spontaneously burst, they are the most proper applications; for they promote the continuance of suppuration, without which, granula- tions cannot be produced to fill up the cavity. As soon as the cavity is nearly filled up, the more simple and super- ficial the dressings are, the better. After inflammation has arrived at a certain pitch, cold applications and continued evaporation from the part af- fected avail nothing; on the contrary, they seem to aug- ment the pain, and they probably do so by preventing the relaxing process of the skin. All the changes of phleg- monous inflammation are quick; if it is to terminate in re- solution, it will generally do so in about a week or ten days: if it continues unabated beyond this period, suppu- ration may be expected, and perseverance in the use of cold astringent lotions only prolongs the disorder, by retarding what cannot be avoided. When the abscess has completely formed; when it has been opened, or has burst, so as to emit daily a considera- ble discharge; and when the violence of the surrounding inflammation abates; the patient must be allowed a more generous diet. Animal food, wine, and fermented liquors, may now be given with advantage. When the discharge is so copious as to induce debility, attended with loss of ap- petite, bark, especially the sulphate of quinine, should be administered. Opium may also be given, either with the view of relieving the aggravated pain that immediately precedes the formation of matter, or of procuring sleep. Attention must of course be paid both to the prevention of costiveness, and of diarrhcea. The favourable progress of all considerable abscesses is very materially influenced by letting the patient have the benefit of a pure air, and re- moving him from a close, or crowded apartment. 4') HECTIC FEVER- CHAPTER IV. HECTIC FEVER. Hectic Fever is essentially characterized by a frequent weak pulse, flushings in the face, the hands, or the feet, and profuse night sweats or diarrhoea.* The irritation of a local injury upon a healthy constitution produces that dis- ordered state of it, termed the symptomatic, or sympathet- ic inflammatory fever. This is the immediate consequence of local irritation. The system, fatigued and debilitated by the continuance of a disease, which it cannot subdue, at length loses the power of entering into those strong actions, which characterize the preceding description of fever. However, exhausted as it is, it still sympathizes with the local irrita- tion. The exciting cause, as Dr. Young remarks, is almost always some local disease, and generally a great, if not an incurable one; so that this fever seems to be a feeble and hopeless struggle of a constitution about to be overpowered, without any apparent tendency to the removal of the cause.f Hectic fever, contrasted with the sympathetic inflammato- ry fever, is to be regarded as the remote consequence of lo- cul injury, or disease. The constitutional symptoms, which attend the forma- tion of pus, in long-continued, profuse suppurations, or which arise as effects of many obstinate and incurable lo- cal diseases, even without any suppuration, are generally comprehended under the name of hectic fever. There are, however, some well-informed surgical writers, who still believe, that hectic fever is in every instance connect- ed, if not with the absorption, at least with the formation of pus4 My own observations do not allow me to enter- tain such an opinion. How commonly do we see patients suffering considerably from hectic symptoms in cases of white swelling, diseased hip-joints, tuberculated lungs, and curvature of the spine, long before any suppuration has tak- en place ? I should say, that the long-continued irritation * See a Practical and Hist. Treatise on Consumptive Diseases Young, M. D. 8vo. 1815, p. 4. f Op. cit. p. 10. i Thomson's Lectures on Inflammation, p. 326. HECTIC I'EVER. 11 ol any severe local disease upon the constitution, whether accompanied with suppuration, or not, generally produces hectic symptoms. Dr. T. Young informs us, that, when he was 15 years of age, he had himself severe hectic, and eve- ry other symptom, ususally attending the formation of pul- monary tubercles, though they never arrived at the period of suppuration. And, in another place, he correctly re- marks, there are cases, in which a particular change in the state of the fluids, secreted by diseased parts, seems to bring on hectic symptoms, as when an abscess is opened, and the pus is exposed to the air. But, says he, this state of the fluids is not the only cause of hectic; for it often oc- curs, not only without an open abscess, but without any ab- scess at all. And, on the other hand, in cancerous cases, where there is a very unhealthy suppuration, with great pain, there is often no material hectic, to the last.* It is true, at the same time, that hectic fever is most common- ly preceded by suppuration; but the only reason of this fact probably is, that the greater number of local diseases, which come under the care of the surgeon, are in their advanced stages accompanied with ulceration, or abscesses. We see that certain local diseases, which cannot be called severe, though they secrete for a long time a great deal of puru- lent matter, do not bring on hectic symptoms. We may keep open an issue for a year, or the urethra may discharge a good deal of pus daily for an immense length of time in tedious cases of gonorrhcea, and yet hectic fever does not arise. Suppuration alone, unless exceedingly profuse, in which circumstance it must always be the effect of a severe form of local disease, is not to be regarded as the essen- tial cause of hectic. Neither does the hypothesis, which ascribes the cause of this fever to the absorption of pus, appear to have a better foundation. The inside of every abscess is both a secret- ing and absorbing surface, and by the combined action of the arteries and lymphatics, the matter is incessantly un- dergoing changes. This is a doctrine which is now pro- fessed by every modern pathologist. If then the absorption of pus were a cause of hectic symptoms, they would ac- company every abscess, without exception. Yet, experience teaches us, that this is far from being the case; and that pus frequently lies in abscesses for a very long time, with- out the patient becoming hectic. Nay, we observe, that •P. 6. 10. and 53. Vol. I. F 433 HECTIC FEVER. pus, even of the worst quality, may be absorbed without producing o single hectic symptom ; for we daily see the matter of phlegmonous abscesses, scrofulous suppurations, and venereal buboes, manifestly and entirely removed by the absorbents, and yet no hectic symptoms are the conse- quence Hectic fever comes on at very different periods after the commencement of anv serious local disease. This is probably owing to peculiarities of constitution; or the par- ticular structure and functions of the part, whose disease operates as a cause. The more delicate and feeble the pa- tient naturally is, and the more severe and incurable the local disease, the sooner do the hectic symptoms generally begin, and the more rapid is their progress. Sometimes the first accessions of this fever are almost imperceptible; a very slight degree of emaciation; a pulse a little quicker than ordinary, with a trivial increase of heat, particularly after meals, being the tmly early symp- toms.* As the fever becomes more established, the symp- toms generally run as follows: a frequent small pulse, which quickens towards evening, but is always ten or twen- ty strokes in a minute faster than in health; a moist skin; pale copious urine, with sediment;f a good deal of debili- ty ; the tongue seldom so much furred:}: as in most other fevers, its edges being of a bright red colour, and the pa- pillae swoln and prominent; a florid, circumscribed suffu- sion of the cheeks; loss of appetite; sometimes an ejec- tion of all food from the stomach; a great readiness to be thrown into sweats ; profuse nocturnal perspirations; fre- quently a constitutional purging; repeated chills and flushes of heat; derangement of the nervous system ; loss of sleep; indigestion; heartburn; flatulence. When,however,the bi- liary system is undisturbed, the digestive powers are lit- tle impaired, and the appetite remains good to the last. In an advanced stage, the hair falls off; and the nails become bent.§ Hectic fever is more or less remittent, but never wholly intermittent. It is observed, that the frequency of the pulse is generally from 100 to 140 in a minute; seldom falling » Thomson Op. cit. p. 323. f According to Dr. T. Young, however, the state of the renal secretion is too various to assist in the distinction of the disease, Op. cit. p. 4. 4 Where, however, the biliary system is deranged, the tongue is cover- ed with a white coat. (Same author, p. 6.) § Dr. T. Young, p. 6. and 9. HECTIC FEVER. 4n below 100, even in the time of a remission, and, in some cases never being under 120: while, in other constitutions, the pulse of health may be so slow that 90 strokes in a minute would be enough to indicate an exacerbation.* The principal exacerbations generally occur about five in the afternoon: and, if we are to credit Galen, Vogel, and Wilson, who differ from Cullen on this point, an in- crease of the febrile symptoms always follows a full meal at any time of the day. The exacerbations, which are most- ly preceded by chills, are marked by a sensation of burn- ing heat in the palms of the hands, which become red and mottled, and frequently in the soles of the feet. A circum- scribed redness is seen in the cheeks, the colour of which, in persons of a florid and delicate complexion, has also, during the remission, a more abrupt termination than in health. It has not been ascertained by the thermometer whether the temperature of the blood is actually reduced during the chills, which usually precede an exacerbation. Whatever may be the form of the exacerbation in the day time, they are generally succeeded towards the end of the night by copious sweats. When a diarrhoea supervenes in the latter stages of the disease, the sweat generally disap- pears. The reddish sediment of uric acid in the urine i3 generally observable after the sweats, and absent during the hot fit, when the secretion is usually pale and limpid.f Mr. Hunter divides hectic fever into two kinds ; viz. one, which arises from the absolute incurability of the local complaint; another, which depends upon a disease that is ourable, if the patient's constitution had powers sufficient.! TREATMENT OF HECTIC FEVER. The exciting cause of every disease must be removed, ere a perfect cure can be expected. If copious and long- continued suppuration give rise to that affection of the constitution, denominated hectic fever, how can the febrile disturbance cease, while the discharge of matter con- tinues ? If the irritation of a scrofulous joint were to ex- cite hectic fever, we should in vain expect to put an end to the constitutional disorder, unless the local cause were first removed. In short, as Dr. T. Young observes, the ra- • Dr. T. Young, p. 4. f Op. c.t. p. 7—9. i Treatise on th& Blood, Inflammation, &c. p. 497 44 -HECTIC FKVEK. dical cure of symptomatic hectic fever can only be at- tempted by.remedies calculated to remove the pnmar\ disease on which it is dependent. When the local complaint, connected with the fever, is totally incurable, the diseased part must, if possible be re- moved by a manual operation. But, when the local disease presents the prospect of being cured, provided the state of the constitution were- improved, the surgeon is to en- deavour to accomplish the latter desirable object, rre- quently, however, the nicest judgment is requisite to de- termine, how long it is safe to exert the power of medical surgery against the influence of an obstinate local disease on the constitution; for, although patients in an abject state of weakness, arising from irremediable local disease, have often been restored to health, by a removal of the morbid part, yet many have been suffered to sink so low, that no future treatment could relieve them. Clemency in the practice of surgery does not consist so much in with- holding strong and vigorous measures, as in deciding to practise them the very first moment when they are indi- cated. When an incurable disease in an extremity is removed by amputation, the hectic fever immediately begins to .abate. " I have known," says John Hunter, " a hectic pulse at 120 sink to 90 in a few hours, upon the removal of the hectic cause; I have known persons sleep soundly the first night, without an opiate, who had not slept tolerably for weeks before; I have known cold sweats stop immedi- ately, as well as those called colliquative; I have known a purging stop immediately upon the removal of the hectic cause, and the urine drop its sediment." But, though a radical cure of hectic can never be effect- ed, unless the primary disease be cured or removed, the severity of this fever may often be palliated, and its pro- gress retarded by appropriate remedies. As weakness is one of the strongest features of hectic fever, blood-letting is never admissible; except, perhaps, in a very few exam- ples, where the disorder is attended with unequivocal marks of inflammation in some vital organ. For the same reason, purging, particularly with the neutral salts, must be avoided. - I am afraid no medicine has the direct power of com- municating strength to the human constitution ; and, it is more than probable, that bark itself only proves service- able in cases of hectic fever, by its sometimes improving HECTIC FEVER. 45 the appetite, and tone of the digestive organs. While the patient eats and digests well, I believe it is never of any service. Bark was a medicine that filled the old practitioners with a blind sort of confidence in the worst of cases. They saw dreadful forms of disease, accompanied with hectic symp- toms, sometimes get well, while their patients were taking bark ; but they forgot the vis medicatrix naturae, whose ef- ficacy often conferred an undeserved reputation on this, as well as on many other articles of the materia medica. When first I entered the profession, it was the fashion to prescribe bark to a very great extent. Patients were some- times literally crammed with it; they were frequently purged, sickened, and weakened by it, instead of being strengthened. Nature, however, occasionally overcame both the disease and the supposed remedy; and the ruling prejudices were confirmed. The best surgeons of the pre- sent day use bark much less frequently and copiously, than their predecessors. They sometimes give it in hectic fever, with the view of improving the appetite, but never on the supposition, that it can directly strengthen the patient in proportion to the quantity taken into the stomach. The in- fusion, decoction, or extract, is to be preferred to the pow- der, which has often been known to cause distressing sick- ness and obstinate diarrhoea*; but a still better preparation, now much used, is the sulphate of quinine. Dr. Young looks upon steel as the best tonic, when the hectic symp- toms have somewhat abated, and general debility has taken place. It may sometimes be joined with myrrh, bark, and other bitters.f The patient is much more likely to be strengthened by nourishing food, easy of digestion, than by bark, and it should be taken frequently, and in small quantities at a time. Residing in a pure, salubrious air, is also a matter of great importance. In these cases, wine, gentle cordials, and aromatic draughts, are sometimes useful, especially in relieving the heartburn, and flatulence. Opium is also a valuable medicine, not only procuring sleep, and alleviating pain, but acting, especially when join- ed with ipecacuanha, as one of the best remedies for check- ing the diarrhcea frequently present. Digitalis has been praised for its beneficial effects in • Thomson's Lectures on Inflammation, p. 3^8. f On Coimnnptive Diseases, p. 50. 46 HECTIC FEVER- hectic fever; but Professor Thomson, who tried it, did not find this commendation well founded. The frequency of the pulse, says Dr. Young, may indeed often be reduced by it from 120 to 50 strokes in a minute; but it is extremely uncertain in its operation, and frequently violent and un- manageable in its effects; nor is it either immediately or ultimately beneficial in simple hectic affections* For check- ing the nocturnal sweats, diluted sulphuric acid is general- ly considered the best remedy, when the bowels will bear it. When the local disease is curable, if the constitution could bear it long enough, or the health were improved, medicine may be availing; but the utmost which can be expected from it in all other instances, is a temporary pal- liation of the symptoms. These, however, will recur, and in the end prove fatal, unless the diseased part, and the cause of the febrile disorder, admit of removal by a surgi- cal operation. —»»♦«©«««•— CHAPTER V. MORTIFICATION. By the term, mortification, surgeons always mean the death of a part of the body, or the conversion of such part into a dark-coloured, black* fetid, cold, insensible mass, with which the general nervous and vascular systems no longer have any organic connexion. In the bones, the state, corresponding to mortification of the soft parts, re- ceives the name of necrosis. The entire and unalterable cessation of every action and function in the part is absolutely essential in what is un- derstood by mortification; for, sensibility and power of motion may be annihilated, and yet the part affected con- tinue to live, as is daily exemplified in cases of paralysis.! Recent observations prove, that the temperature of a pal- sied limb is diminished^:; and so probably is the momen- * P. 49. f See Beyer's Traite des Maladies Chir. torn. i. p. 105. Paris 1814 % Earle in Medico-Chir. Trans, vol. vii. p. 173, &c. MORTIFICATION. 47 turn of the circulation in it; still, the fluids pursue their usual course ; nutrition and absorption are carried on; and the parts continue to retain, for an indefinite length of time, an inferior degree of vitality. One of the properties of living matter consists in the power of resisting putrefaction, which the laws of chemi- cal affinity would otherwise produce; but, as soon as a part mortifies, this characteristic property is lost; a spontaneous decomposition begins ; different kinds of gas are formed; and the exhalations become fetid, and highlv offensive. Numerous are the examples upon record, where the heat, sensibility, motion, arterial pulsation. &c. have been abo- lished in parts for several days, but afterwards gradually returned. This affection is as different from mortification as suspended animation is from actual death; and the dis- crimination of it is of the utmost importance, as otherwise there would be a continual risk of amputating limbs, not altogether past recovery. Such mistakes maybe avoided, by observing, that where the limb is only apparently lifeless, the cuticle does not separate as in a case of real mortifica- tion, nor does the spontaneous decomposition of the part begin, from which the putrid and intolerable smell, pecu- liar to the latter disorder, is derived. . The aspect and progress of mortification will be found to vary according to the cause by which it is produced. The following are the principal causes by which the dif- ferences and peculiarities of the several cases are deter- mined. 1. Inflammation attended with violence. 2. In- flammation attended with weakness, whether from a local cause, as certain modifications of structure, or from con- stitutional causes. 3. Inflammation of a specific or malig- nant nature, like particular forms of erysipelas, the car- buncle, boil, small-pox pustule, pestilential bubo, &c. 4. Great impairment of the constitution, whether brought on by previous disease, as in dropsical or scorbutic persons, or by intemperance, or by a gradual decay of the vital pow- ers from old age. 5. Stoppage of the arterial or venous circulation in parts, with or without interruption of the nervous influence in them. 6. Great and severe degrees of mechanical injury from external violence, amounting to, what the French surgeons term, a disorganization of parts. 7. Applications which immediately and chemically destroy the flesh, like high degrees of heat, lightning, and a variety of corroding caustic substances. 8. Sudden exposure to warmth after intense cold. 9. Particular organic diseases 43 MORTIFICATION. of the heart and larger blood-vessels. 10. Certain delete rious kinds of food, such as the ergot or vitiated rye,* or barley mixed with the raphanus.f 11. Specific contagion, as exemplified in hospital gangrene. _ . . When mortification arises from external injury, it is uniformly preceded by inflammatory swelling and erythis- mus; the epidermis is detached, and vesications, contain- ing a bloody serum, are produced; the cutis is softened, and acquires a blackish hue; the cellular substance and other textures are decomposed, so as to occasion not only the emphysema and crepitation, which are perceptible on touch- ing the parts, but the formation of an abundance of fetid exhalations and moisture. Hence, this species of mortifi- cation is often named humid gangrene. We find, however, in the midst of this putrefactive mass, especially if the disease be not too rapid, some muscles, arteries, and nerves, still in possession of a part of their living powers, and re- sisting, in a certain degree, the tendency to gangrene. In- deed, it is particularly to the early stage of mortification, while some marks of vitality yet continue, that many au- thors restrict the term gangrene. In it there seems to be a partial, but not a total destruction of the part; the blood still circulates through some of the larger vessels; and the nerves retain a portion of their sensibility. In the language of Galen, gangrene is a mortification, which, strictly speak- ing, is not actually formed, but forming, being the interme- diate stage betwixt the height of inflammation, and the complete death of the part. The latter event receives the technical denomination of sphacelus, in which state the parts are generally of a dark brown or black colour, void of all natural heat, circulation, sensibility, &c; and, in the language of surgery, called sloughs. Mortification always spreads more extensively in cellular membrane, than in the * See Dodard's Obs. in .Tourn. des Savans, 1676 ; Duhamel in Mem. dd, l'Acad. des Sciences, an. 1748 ; Langius Descriptio Morborum ex F.su Cla- vorum Secalinorum.- Phil. Trans, vol. iv.; Tessier, in Mem. de la Soc. Iloyale de Medecine, t. i. &. ii., &c. &c. The accuracy of the statements concerning the deleterious effects of the ergot has been sometimes doubt- ed ; and all the evils which are supposed to arise from it, imputed to po- verty and starvation. (See Bateman's Practical Synopsis of Cutaneous Dis- eases, p. 135. edit. 3.) But the experiments instituted by Tessier, and cer- tain observations made in America, (See Gibson's Institutes of Surgery, ■u>l. i. p. 38.) incline me to believe with Professor Thomson, of Edinburgh,' that the ergot, taken in certain quantities, has really a specific effect in producing mortification. See Lectures on Inflammation, p. 547. •(; Linnaeus, Amcenit. A:ji vol. v. MORTIFICATION. 4!> skin or muscles ; a fact, particularly worthy of recollection when amputation is to be performed. Such are the phenomena of that species of mortification which is produced by wounds and other modes of external violence, and which is named by Larrey traumatic* It is very different from other forms of the disorder which are sometimes termed chronic, or idiopathic, and are' occasioned by internal causes, severe cold, &c. These last ordinarily attack the more remote parts of the body, wher« the vital powers are weakest, as the feet, hands, nose, and ears. The part affected becomes black; but, instead of be- ing swelled, as in traumatic gangrene, it rather shrinks, becomes dry, and sometimes hard; on which account, such mortification has also acquired the name of dry gangrene; particularly differing from the former in there being no effusion of fluids. When any considerable portion of the body mortifies the whole system generally undergoes a sudden and re- markable depression of all its powers. In such cases,how- ever, as are accompanied with a high degree of inflamma- tion, the disorder is attended in its first stages with inflam- matory fever, the strong actions of which usually cease either before or as soon as the parts are in a state of spha- celus; and the alarming disorder of the system, sometimes called sympathetic irritative fever, ensues. The patient's countenance all at once assumes a wild cadaverous look: his stomach is severely disordered, vomiting generally oc- curs, and the diaphragm being affected with a frequent spasmodic contraction, a loud and troublesome hiccough is produced. The pulse becomes small, rapid, and irregu- lar; the brain, especially in bad examples of traumatic gan- grene, is soon affected with coma and delirium; the surface of the body is covered with cold, clammy perspirations; and the patient dies. In other cases, the course of the dis- ease is slower; and the mortification would stop, and life perhaps be saved, if the weakening effects of a diarrhcea could be averted, or the state of the stomach improved. The hiccough, which I have noticed, is a symptom which deserves particular attention; for it is an effect which is al- most constantly excited on the first occurrence of gangrene and sphacelus. In particular, it is a symptom, of which every man of experience has a well founded dread in cases • De la Gangrene Traumatique, ou de"terminee par une cause vulnerante. See Memoires de Chirurgie Militaire, torn. iii. p. 142. Vol. I. G 50 MORTIFICATION. of strangulated hernia, where it is nearly a sure indicator of gangrenous mischief within the hernial sac* Besides the two principal varieties of mortification, which receive the names of humid and dry from the state and ap- pearance of the sphacelated parts, there is a third species of disorder, which is peculiar in being of a contagious na- ture, and, as Delpechf observes, in being followed by a yery rapid and singular mode of decomposition in the mortified parts, of which hardly any vestiges appear. No ordinary sloughs are seen; but, in lieu of them, the surface of the diseased part is covered with a whitish, or ash-coloured viscid matter, which exhibits at particular points specks of blood. This case is now well known amongst surgeons by the name of hospital gangrene. The prognosis in cases of mortification differs according to the nature and inveteracy of the causes of the disorder, and the possibility or impossibility of diminishing or re- moving them. Much also depends upon the strength, con- stitution, and age of the patient; the greater or less im- portance of the part affected; the rapid or slow progress of the disease; and its extent. Great prostration of strength; a low, rapid, faltering pulse; a stomach which can retain neither food nor medicine; and the bowels much disorder- ed with diarrhoea; especially when joined with coma and delirium; are symptoms which leave little or no hope of recovery. As it is impossible to understand the present subject, without taking a separate view of each different species of mortification, I shall next endeavour to fulfil this task, with as much brevity as is consistent with truth and perspicuity. 1. In the account which has been given of inflammation, mortification was specified as one of its occasional termina- tions. This unpleasant occurrence is not, however, a com- mon consequence of phlegmonous, or healthy, inflamma- tion, in a sound constitution; except when the exciting causes have been unusually severe, or protracted in their operation. Thus, in cases of burns, gun-shot injuries, con- tused lacerated wounds, compound fractures, and other effects of great external violence, some of the flesh is fre- quently destroyed at once, and must be thrown off in the form of a slough; while other parts of it, not actually kill- ed, are yet so injured, that they are seized with a violent degree of inflammation, which quickly ends in sphacelus. * See Pott's Chirurgical Works, vol. ii. p. 63. edit. 1803. t Precis des Maladies reputees Chirurgicales, t. i. p. 75, MORTIFICATION 51 In other instances, as I have said, the inflammation ends in mortification, because the exciting cause continues to operate a long time, as we see exemplified in cases of ex- travasation of urine in cellular membrane. Here the irri- tation of the urine immediately gives rise to inflammation; and its lodgment and increase of quantity in the parts, are ordinarily followed by dangerous degrees of local mischief, in which urine, purulent matter, and sloughs, are blended together. The symptoms of mortification, as originating from in- tense inflammation, have been already detailed; and I shall, therefore, proceed without delay to the consideration of the treatment. In every species of the disorder there are three important indications to be fulfilled; namely, to stop its progress; to promote the separation of the mortified from the living parts; and to heal the ulcer resulting from the loss of substance. 1. With respect to the first of these indications, it na- turally leads to the important object of ascertaining and removing the original cause of the disorder: I mean that cause which first gave rise to the intense inflammation of the parts, and which, perhaps, may still continue to operate. This is a common principle, which should be observed here, as well as in all other parts of surgery. Sometimes we have it in our power to remove the exciting cause alto- gether; as, when we let out, by suitable incisions, extrava- sated urine, and hinder its further effusion by the judicious employment of the catheter; or when we take away extra- neous substances, splinters of broken bone, and remove and diminish irritation in a variety of forms. Frequently also sloughing is produced and kept up by the employment of hurtful remedies, and then the change to a better practice is the same thing as removing the cause of the disease in other instances, and has an equally beneficial effect. In general, however, when gangrene arises from intense in- flammation, the exciting cause is only momentary: it has already ceased; but the injury which the parts have sus- tained from it, is of a more lasting nature, and must be fol- lowed by a high degree of inflammation, and sloughing to a greater or lesser extent. There can be no doubt, that the extent of mortification may be considerably influenced by the mode of treatment adopted during its incipient stage, termed gangrene. When the disorder is the effect of inflammation, we are bound to believe, nay, we see, that the living circumference is in- 52 MORTIFICATION- flamed in the highest degree. Reason and observation, therefore, seem both to concur with respect to the general propriety of antiphlogistic measures in this state and spe- cies of mortification. The plan, however, is to be pursued with moderation and caution. It is right, as long as in- flammatory fever and acute local inflammation are co-ex- istent with mortification; but, even under these circum- stances, evacuations must not be resorted to with the same freedom and frequency, as in examples of inflammation unaccompanied with mortification. In particular, bleeding is to be ventured upon only in young, robust, plethoric sub- jects. The necessity of this kind of circumspection de- pends upon the fact/that, whenever a considerable portion of the body mortifies, the constitution immediately feels the shock in every part of it. There is hardly any inter- val between the genuine inflammatory fever, in which the action of the sanguiferous system seems to proceed even with preternatural force, and another state of the constitu- tion, in which the predominating symptoms are prostration of strength, and violent agitation of the whole nervous sys- tem. In fact, more or less debility always rapidly super- venes; and if the patient be further lowered by the lancet, purgatives, artd too spare a regimen, his condition will be rendered hopeless. Some years ago, the treatment of gangrene and sphace- lus was often conducted upon principles which had little foundation. It was presumed, that cinchona had a specific virtue in stopping and resisting the progress of the disor- der. To this medicine, diluted sulphuric acid, or alum, was added, when a general tendency to putrefaction was suspected in the system; or cordials and aromatics, as wine, brandy, musk, ammonia, confectio aromatica, &c. when there was great prostration of strength; and opium, when severe nervous symptoms, and extreme pain were experienced. This opinion, respecting the specific power of bark in the stoppage of mortification, is rejected by every modern surgeon of judgment and experience; without denying, however, that it is a medicine, which in particular states of the disorder, may be administered with advantage. Even then, the benefit never arises from the specific power, which it was formerly supposed to have, of stopping mortifica- tion, but from its being an eligible bitter, by which the tone of the digestive organs may sometimes be improved. It is not long since it was the custom to prescribe it in pow- MORTIFICATION. 53 der, or substance (as it was termed,) and in as large quan- tities as the patient could be prevailed upon to swallow. But as soon as it was clearly ascertained that the utility of bark did not really depend upon its specific virtue in stopping the disorder, the plan of cramming patients with it was universally abandoned; and it is now only administered in such moderate and reasonable doses, as are not likely to disorder the stomach and bowels, and defeat the very pur- pose for which alone it can ever be trulv recommended. It is not, however, in the early stage of mortification, com- bined with acute inflammation, that bark, prescribed in any way, can be of service. When mortification happens from an external local inju- ry in a sound constitution; when it no longer spreads, and the living margin appears red for a small distance from the line of separation, bark is clearly unnecessary. Mortification, according to its particular nature, causes, and circumstances, may be attended either with sympathe- tic inflammatory fever; or with another fever, which is characterized by extreme debility, and is either like typhus, or the disorder sometimes described under the name of sympathetic irritative fever. The first fever takes place when mortification arises from external causes in a healthy constitution. Here bark is usually hurtful. The other state of the system may un- doubtedly require it, though, if the fever be what is called svmpathetic irritative, and great excitement of the nervous svstem, delirium, picking of the bedclothes, subsultus ten- dinum, &c. prevail, anodynes, antispasmodics, blisters, and local treatment, will do a thousand times more real good, if any chances of life still remain, than bark in any dose or formula whatever. In condemning this medicine, however, for certain states of mortification, I am far from wishing the reader to sup- pose, that even in the progress of these very identical cases, it may not sometimes become necessary, although not at all indicated at an earlier period. Every experienced sur- geon knows, that the natural change of circumstances in the course of numerous diseases, renders the exhibition of some medicines absolutely indispensable, which, had they been given at first, would have had the most pernicious effects. When the inflammation surrounding the sphace- lus has abated, the patient is low, the appetite bad, and the kind of fever and state of the chylopoietic viscera are not such as to prohibit bark, it should be administered with ,54 MORTIFICATION. aromatic confection, wine, fermented liquors, and a light nutritious diet. The sulphate of quinine should also not be forgotten, as a verv convenient preparation, which the sto- mach and bowels will generally bear well. If delirium oc- cur, camphor or musk ought to be prescribed, and a blister applied to the head. In many of these cases, also, the pa- tients would be carried off by diarrhcea, were not the surgeon particularly attentive to the diet, and prompt in the judicious administration of opium, the mistura cretse, &c. Indeed, with respect to opium, it is one of the most valuable reme- dies in the generality of cases of mortification, and it should be employed in every stage and form of the complaint, at- tended either with severe pain, or spasmodic, or nervous symptoms. It ought not to be given merely at night, but every four or six hours, so as to keep the constitution un- der its influence. With regard to local applications, in cases of mortifica- tion, attended with acute inflammation, experience appears to decide in favour of common emollient linseed poultices and fomentations. Mr. Hunter, however, did not think this practice always right, because warm applications seem- ed to him calculated to promote the increased action of the vessels supposed to exist in the process of inflammation, and, therefore, Says he, " such remedies should be well ad- justed to the case." On the other hand, he conceived, 44 that cold, when carried too far, debilitates or lessens pow- er, but first lessens action." He concludes, however, with saying, "that the parts should be kept cool,and that all the applications should be cold." He justly condemns stimu- lants as improper, where the actions are already too violent; but he had seen benefit arise from opium applied to the part.* In general, however, as I have said, the preference is now given to emollient poultices and fomentations.! When the gangrenous part is turned into a darkish, or black, fibrous, insensible mass, it is, indeed, of little con- sequence what is applied to it, as the living circumference claims almost exclusive attention. Both during the ex- tension of the disorder, and afterwards, when the sphace- lation has stopped, a simple linseed poultice, or one con- taining a proportion of finely powdered, recently burnt charcoal, is as good an application as can be employed. Some surgeons are partial to fermenting poultices and * Treatise on the Blood, &c. p. 9. | See Notk B. MORTIFICATION. 55 with these not much fault can be found; for though per- haps no particular good can be strictly imputed to their supposed antiseptic quality, the carbonic acid gas produced by them is not stimulating enough, nor sufficiently in con- tact with the living flesh, to counteract their good effects as emollient applications.* They have always appeared to me better calculated for mortification, unattended with intense inflammation, than for the particular cases which we are here considering. A few additional remarks on the topical treatment of mortified parts, will be presently intro- duced. 2. The second general indication is to promote the sepa- ration of the mortified from the living parts. Although a slough may be scratched, or cut, without pain or harm to the patient, it cannot be pulled away im- mediately after its formation, without pain, hemorrhage, and, even a risk of renewing the spreading of mortification. The dead part is yet adherent to the living flesh, and can- not be prudently taken away before the absorbents have removed the particles of matter, which compose the unit- ing medium. As a late author! remarks, " the separa- tion of dead from living parts is a vital process, not expli- cable on physical principles, nor by the laws of dead mat- ter." When it is about to take place, a red line, varying in breadth in different cases, and said to be produced by the adhesive inflammation, usually appears on the living- surface, contiguous to the dead. The adhesive inflamma- tion, in fact, seems to be the means which nature employs for stopping the progress of mortification, and preparing the living surface for the separation which is about to be produced. By it, she fills the cavities of the cellular mem- brane, with coagulating lymph, assists in closing the ex- tremities of the blood-vessels, and establishes the com- mencement of those operations, by which granulations are to be formed, and the loss of substance repaired. Soon af- ter the formation of the red line of separation, slight so- lutions of continuity may generally be seen, beginning at various points, and resembling very minute ulcers, which> uniting together, form a hollow line or chink, which ex- tends all round between the dead and living parts.!, This • The following is the formula used at St. Bartholomew's Hospital. R Parinae Tritici, Cerevisiae Spumae Yest dictx sing. lbss. Misce et calori mo- dico expone, donee effervescere inceperit. f Thomson's Lectures on Inflammation, p. 38*5. -. Op. cit. p. 381. 5(5 MORTIFICATION. loss of substance, which is at first superficial, generally proceeds more and more deeply, till the separation ot the sloughs is entirely effected. In this process, which does not materially differ from that of common ulceration, the absorbent vessels are actively engaged, and it is by them that the particles which form the link between the dead and living flesh are removed. From the moment that the separation commences, a discharge at first of a serous, and afterwards of a puriform appearance, begins to take place from the line of detachment, and it becomes more and more abundant, in proportion as the falling off of the slough exposes the subjacent, raw, granulating surface. In young subjects, and in vigorous constitutions, the separation of the sloughs is accomplished with much more celerity than in the old and feeble. The texture and situation of the parts affected, make also a considerable difference in this respect, and, generally speaking, the harder and less vas- cular they are, and the more remote from the source of the circulation, the longer they are in throwing off their sloughs. When a part, or limb, is seized with mortification, the blood coagulates in the large vessels, for some distance from the line which bounds the sphacelation. Hence, the separation of the sloughs is not usually attended with hemorrhage, and the security is generally still further in- creased by the effects of the adhesive inflammation already described. The cause of the formation of the coagulum in the ves- sels, as Mr. Hodgson remarks, is by no means evident, al- though it is probable, that the condition of a mortified ves- sel may interrupt the passage of the blood through it, and, consequently, a coagulum is formed, extending to the next important collateral branch. It is also the coagulation of the blood in the arteries, near a sphacelated part, which accounts for there being sometimes no hemorrhage of im- portance, nor any occasion for ligatures, when amputation is performed a little above the line of separation.* Excepting in cases where amputation of the limb is ur- gently*indicated, the separation of a slough should gene- rally be left as much as possible to nature. All that the sur- geon can usefully do is to take away every portion of the * See Petit's Obs. in Memoires de l'Acad. Royale des Sciences an. 1732. Thomson's Lectures, p. 552., and Hodgson's Treatise on the Diseases, ot Arteries and Veins, p. 13. 8vo. Lond. 1815. MORTIFICATION. 57 slough as soon as it is entirely separated from the living flesh. An opposite line of conduct would often excite un- necessary irritation, pain, hemorrhage, and even a renewal of the spreading of the disorder. It is almost inconceiva- ble what little violence will sometimes bring on the latter evil, nor can we be surprised at it, when we advert to the deranged state of the whole constitution, always resulting from the effects of an extensive mortification. If it be at all practicable to expedite the process by which a slough is thrown off, the good is to be derived rather from ge- neral, than from local treatment. I know of no applica- tions which have any particular virtue of this kind, and the more simple they are, the better. In fact, none are better than common linseed poultices, with or without a propor- tion of powdered charcoal; or, if the surgeon like, he may have recourse to the fermenting cataplasm already specifi- ed. Much stress has been laid upon the topical use of an- tiseptics and tonics. Of the former, various powerful sti- mulants, like oil of turpentine, camphorated spirit, Sec, have, been tried; of the latter, bark, in a variety of shapes, has been used for covering the parts affected. As I have repeatedly said, it matters not what is put upon such parts as are actually dead, and, if the surgeon choose, he may lay upon them turpentine, spirituous balsams, camphorated spirit, or any thing else which he may prefer, with a view of checking the fetor and putrefaction of the sloughs. But, it is of high importance, that the living flesh around and underneath a slough, be not injured and irritated by any sort of applications. No one who has sound ideas of the nature of the animal economy, would talk of invigorating the parts with spirits and balsams, in order to avert morti- fication. Yet, once so prevalent was this doctrine, that it was a frequent practice to cut and scarify the parts for the express purpose of letting such applications have free in- gress to the subjacent living flesh. Incisions and scarifications in gangrenous parts can do no good, if they are merely made in the sloughs; and, if they extend through the dead to the living flesh, they are not only likely to effect no rational purpose, but must be pro- ductive of pain, hemorrhage, and frequently of fresh slough- ing. When, however, a slough is large, and a part of it loose, the cutting away such portion is commendable on the principle of lessening the fetor. Were also such sanies to lodge under a slough, a careful incision through the dead part might be useful in affording an exit to the mar- Vol. I. H :~kS MORTIFICATION. ter. But the proceeding can never be justifiable, when the living parts are to be at all irritated or wounded. OF AMPUTATION IN CASES OF MORTIFICATION. I have remarked, that, in general, it is the best practice, to leave the separation of a slough as much as possible to nature. This observation,however, does not apply to cer- tain cases, in which the sphacelus affects the whole thick- ness of a limb; for here the surgeon is to seize the right opportunity of performing amputation. It is true, that, even in these examples, if the patients lived long enough, nature would also complete the detachment of the dead parts; the soft parts would first separate down to the bone, the bony connexion itself would afterwards be destroyed by the slow process of exfoliation, and the ulcer finally heal.* But, in general, the patient would not outlive the effects which these tedious changes must have upon his health; and sometimes the extension of the mortification itself would carry him off before they had well commenc- ed. In the most favourable cases, also, the sore would not generally heal so as to leave the extremity of the bone well covered with flesh, and with a cicatrix capable of bearing pressure. Therefore, besides the risks and tediousness of this mode of cure, the production of a sound and service- able stump commonly renders the operation indispensable. The exact time when amputation should be done, is a question of the first-rate importance. The rule, generally laid down, is never to perform the operation before the mortification has stopped, and a line of separation appears between the dead and living parts. This maxim, when fol- lowed, in regard to mortification proceeding from internal or constitutional causes, is entitled to every degree of re- spect, and, were it neglected, the stump would often be- come gangrenous, and the patient's death only be accele- rated. In a few instances, amputation may even be deferred be- yond the period when the sphacelation of the limb has ceased to spread, and the red line on the living edge de- notes the commencement of the separation. Such is the case, when the patient is so reduced at this critical mo- • See facts on this point in Kirkland's Enquiry into the Present State of Medical Surgery, vol. ii. p. 380.;and Sir A. Cooper's Lecture™ Gangrene, MORTIFICATION. 59 ment, that he would be likely to die under the opera- tion. Here, a little delay may sometimes be allowed with advantage; the dead parts will separate from the living down to the bone, and, if the discharge be moderate, the constitution, with the aid of suitable diet a*nd medicines, will soon recover sufficiently from its depressed state, to be capable of bearing the operation with a better chance of success. Baron Larrey, as I have already mentioned, has applied the term traumatic to the species of gangrene which fol- lows wounds and external injuries. In cases of this nature, which expose the life of the patient to danger, he says, " amputation should be performed without awaiting the ap- pearance of the line of separation between the dead and living parts." Here, he observes, " it would be dangerous to defer the operation, because the mortification is readily transmitted from the part primarily affected to the rest of the extremity, and he has seen instances in which it proved fatal, in the short space of six hours." He asserts, that there is no reason to fear the re-appearance of gangrene upon the stump, for, whenever mortification arises from external injury, it can only be propagated by absorption and the continuity of vessels.* Therefore, says Larrey, if amputation be performed at a proper place, that is, where the skin preserves its integrity, it will arrest the progress, and prevent the fatal termination of the disease. These ob- servations are accompanied with many interesting cases, which, with others recorded in this country, seem to es- tablish the propriety of the practice beyond dispute.f When mortification originates from the united effects of external violence and the injury of the main artery of a \* Dr. Hewstis of Cahawba, Alabama, relates in the New-York Medical & Physical Journal for January 1827, a case of extensive injury of the fore arm, where gangrene came on the third day—th'e inflammation, swelling and incipient mortification had extended nearly to the shoulder joint, by the fourth, when, although it was deemed hazardous, as there was no line of demarcation between the sound and diseased parts, and as the gan- grene was rapidly extending, the operation of amputation high up was de- termined on, as affording the only means of saving the patient, and was ac- cordingly performed. On the third day it was found that mortification had attacked the stump, which was now dressed with the bark and charcoal poul- tice, and the patient put upon the use of bark and wine. The sloughs sepa- rated in a few weeks, and the man recovered.—P. E.J f Larrey's Mcmoires de Chirurgie Militaire, t. iii. p. 141. Lawrence in Mcdico-Chir. Trans, vol. vi. p. 184. A. C. Hutchison's Pract Obs. in Sur- gery, p. 73, &c. 60 MORTIFICATION. limb, we are not to be governed by the old rule of waiting for the line of separation, before resorting to amputation. Thus, as Mr. Guthrie has particularly pointed out, when a gun-shot injury of the femoral artery and vein is followed by gangrene, wnich begins at the extremity of the limb, the surgeon must not defer the operation till the mortifica- tion stops; for, if the wounded vessels be in the middle ot the thigh, it will extend to the seat of the injury, and de- stroy the patient before anv line of separation is formed. Here amputation should be done as high up as the wound of the vessels, and earlv, that is to say, as soon as the na- ture of the case is certain, and before the sphacelation has extended beyond the foot.* Analogous to the preceding species of gangrene is that sometimes following the application of a ligature to the main artery of a limb for the cure of aneurism, or the sup- pression of hemorrhage. Here, the mortification also ge- nerally commences at the extremity of the limb. What- ever may have been inculcated, with regard to other in- stances of gangrene, this is a case in which the early per- formance of amputation at some distance from the dead part has always been recommended. In many accidental injuries, the operation should be per- formed without any delay, so that mortification may have no time to begin. Numerous gun-shot wounds of the extremi- ties, badly lacerated and contused wounds, and severe compound fractures, will inevitably be followed by gan- grene, and the patient's death, if an imprudent attempt be made to save the part.f Here amputation should be done immediately after the accident, the wound of the opera- tion being infinitely less hazardous than an extensive and spreading sphacelus. • See Guthrie on Gun-shot Wounds of the Extremities, p. 59, &c. 8vo. Lond. 1815. { f The following case we abridge from the account of it given by I. A. Washington, M. D. in the American Journal of the Medical Sciences, of February 1828. It is highly interesting and instructive, and shows how much may be accomplished by judicious management, in the most despe- rate cases. A boy aged eleven years, was admitted into the Pennsylvania Hospital with a gun-shot wound of the leg, above the ankle, in which it was estimated that five sixths of the structure at the seat of injury was de- stroyed. More than an inch of the tibia and fibula was removed, also of the corresponding portions of the tibialis posticus, and the flexor muscles, leaving the tendo Achillis with a sound strip of skin covering it. The ex- tensors and peroneal muscles, and the anterior tibial artery were found un- injured ; these were covered with a sound strip of skin MORTIFICATION. 61 3. The third general indication in the treatment of mor- tification is to heal the ulcer, or, in the event of amputa- tion, the wound, resulting from the loss of substance. But on this topic I need not dwell at present, as the principles, on which this indication is to be fulfilled, are explained in the respective chapters on wounds, ulcers, and amputa- tion. MORTIFICATION FROM INJURY OF LARGE ARTERIES AM) NERVES. In the arrangement of the arterial system, nature seems as if she had foreseen the danger that would arise from an interruption of the supply of blood, and she has, there- fore, so multiplied the reciprocal communications or inos- culations, in all the different orders or branches of this sys- tem of vessels, that the largest trunks are tied almost daily by the enterprising hand of the modern surgeon, and yet, if there be not other causes concerned, this single one is rarely followed by mortification. She appears, however, not to have extended in an equal degree a similar cautious and provident arrangement to the nerves. The destruc- tion of a principal trunk, in this latter system, is invariably followed by paralysis; and, when this circumstance is cou- pled with the division or ligature of the principal artery of the same limb or part to which the branches of that nerve are distributed, the chances of mortification are much in- creased. There are, however, some facts recorded, which prove that the communications of some of the smaller nerves are sufficiently direct to qualify them to become, in point of function, substitutes for each other. I have said, that the division or ligature of the main ar- tery of a limb and of the principal nerve, together, may oc- In consultation, Drs. Parrish, Hewson, and Barton, determined to at- tempt to save the limb. At the suggestion of Dr. Barton, wheat bran was applied to the wounded surface ; the limb placed in a fracture box, upon a soft bed of cotton, previously spread over with bran, and the parts properly adjusted. The bran served to absorb the discharge, and was thus converted into a poultice, whilst by its compression, it would prevent in- ordinate hemorrhage. For five days the bran was only partially removed, and fresh applied; on the sixth the wound was entirely cleansed by means of a syringe. The details are given, constitutional irritation of course arose, and was combated by the ordinary measures. In sixty days the wound had entirely healed, with the exception of a small sinus, his strength had in creased, and he was able to be moved about the ward—he is at this time completely well.—P. E.} 62 MORTIFICATION. casion mortification. Cases are related, however, in which the consequences were only a paralysis and wasting of the member. But Delpech, in considering this subject, re- marks, that he knows of no instances of this kind, where the lower extremity was the part concerned; and, with re- spect to the arm, which is not supplied by a single nerye, hardly anv sort of accident can injure the whole of the brachial plexus; the median being the nerve, which is com- monly wounded, or tied, with the artery. He observes, however, that notwithstanding the advantage of several nerves, it has almost always happened, that when the nerve accompanying the axillary artery has been included in a ligature with it, the limb has mortified.* It is true, that in many of these cases, we are also to take into the account, the share which a large extensive wound of the soft parts, or their contusion, laceration, &c, have in the production of gangrene. We rarely or never see a case, in which the injury simply consists in the divi- sion, or ligature, of the main artery, and one of the prin- cipal nerves of a limb, unaccompanied either with great additional injury, much weakness from the profuse and sudden hemorrhage, the irritation of a previous operation, the injection of the cellular membrane with blood, or a diseased state of the member, any of which conditions may be such as to have considerable influence in bringing on gangrene. On the whole, perhaps, we are not yet au- thorized to infer, that the mere interruption of the circu- lation through the main artery of a limb, and the simulta- neous stoppage of the nervous influence derived from one of the principal nerves of the member, would generally occasion mortification, if there were no other additional violence, nor injury, existing in the part or constitution.! * Precis des Maladies reputtes Chirurgicales, t. i. p. 98. f In company with Mr. George Young, I assisted Mr. Lawrence at an operation, in which he divided, by a circular incision, not only the principal arteries and nerves of the finger, but every fibre of the part, with the ex- ception of the tendons and bone. Yet, contrary to all expectation, the blood still gushed profusely from vessels, which could only receive their supply of blood through the medium of such ramifications as passed through the tendons and bone. It was equally curious, that though the principal arteries and nerves were all fairly divided, and the cut carried entirely round the part, mortification was not the consequence. The operation succeeded in checking the progress of an aneurism by anastomosis, which had increas- ed and become attended with many unpleasant symptoms, notwithstanding the radial and ulnar arteries had both been previously taken up by Mr. Hodg- son. Some account of this case is given in Medico-Chir. Trans, vol. ix. part i. p. 216. MORTIFICATION. 'j.» Whatever may be the result of future experiments upon this point, no doubt, I think, can be entertained of the fact, that when the stoppage of the circulation through the main artery of a limb is conjoined with loss of the nervous in- fluence in the same member, there is always a much greater risk of mortification, than if the case were simply an in- terruption of the flow of blood through the vessel. In- deed, so great is the success which now attends operations on aneurism, that I might perhaps assert, with perfect ac- curacy, that gangrene never arises solely from the ligature of an arterial trunk, unless the patient be of advanced age ; the circulation languid from previous debility; many of the collateral branches destroyed, or injured; or some other important cause co-operate in producing the evil. When mortification follows the ligature, or division, of a principal artery and nerve, the partis from the first cold» insensible, heavy, benumbed, and motionless; its natural heat is permanently lost; the pulsation of its arteries can- not be felt; the cuticle separates: the skin becomes brown and shrivelled; and fetid exhalations soon leave no doubt of the nature of the mischief. This species of gangrene is usually very extensive, being a sphacelus affecting the whole of the limb. It is somewhat less dangerous when it comes on later, and begins at the extremity of the limb; under which circumstances, its progress is ordinarily slower, and its effects sometimes restricted to a partial de- struction of the member. When once this kind of mortification has arisen, every means which it is in the power of the surgeon to adopt will be found insufficient to stop its progress. Hence, in tying the main artery of a limb, too much care cannot be taken to exclude from the ligature the accompanying nerve. We should also avoid every thing which is likely to ob- struct the circulation through the collateral branches and capillary system of vessels. In operations for aneurism, the wound should not be larger, nor deeper than necessary; all compression should be removed; and the limb kept moderately warm. Several eminent surgeons have thought, that the best way of preventing this species of mortification, in aneu- rismal cases, would be to effect a gradual constriction of the artery, so that the flow of blood through it might part- ly continue, until the circulation was well established in the branches of the vessel. But, as Delpech judiciously . remarks, this plan cannot be kept up long enough to be 64 MORTIFICATION. of much service in promoting the circulation; and expe- rience has proved, says he, that it is liable to the very great objection of partially destroying the circumference of the artery, without holding its parietes in contact, and of thus occasioning a dangerous, and even fatal hemor- rhage* Besides, as I have already observed, gangrene rarely or never comes on simply from the ligature of the trunk of an artery; and under favourable circumstances, the inosculations are always sufficient: other causes must, therefore, be concerned. The avoidance, or (if possible) the removal, of these would be a much more important object in the prevention of gangrene, than the dangerous experiment of a gradual and incomplete compression of the arterial trunk. When the case is decidedly an extensive sphacelus, I believe the only chance of preservation depends upon the immediate performance of amputation, high up; and, if practicable, above the place where the artery, or the artery and nerve, have either been divided or tied. In certain examples, however, in which the first appearance of mortifi- cation does not happen till some days after the injury, when the sloughing occurs at the extremity of the limb, and is slower in its advances, the disorder will sometimes termi- nate in a partial destruction of the integuments of the hand, or foot, and the limb may be saved. ; But here the surgeon must be most vigilant: for if, in his anxiety to avoid operating, he give the disease time to extend up the limb, the patient will certainly lose his life. MORTIFICATION FROM PRESSURE. Somewhat related to the kind mortification, which we have just now described, is that which originates from pressure, whereby the circulation in the smaller vessels, and the nervous influence in the parts, are interrupted. However, the great extent of the capillary system, and the prodigious number of its inosculations, make the circula- tion in it so free, that it must be a powerful and long- continued pressure to stop this important function. The cause may act either upon a limited point of the external surface of the body, or upon the whole circumference of a limb; and, in both instances, the effect may extend to a * Precis des Maladies reputees Chirurgicales, t. i. p.'lOO. MORTIFICATION 65 greater or lesser depth.* When the constitution is en^ feebled, pressure much more readily brings on mortifica- tion. Of this, every surgeon of experience must have seen repeated proofs in the mortification which attacks the in- teguments covering the sacrum, os ilium, trochanter ma- jor, and scapulae, in patients who have been long confined in bed by fevers, injuries of the spine, bad fractures, &c. The constant pressure of such parts of the skin, between the bed- ding and bony prominences, obstructs the circulation through them at a period when the flow of blood is already languid from general debility. They become soft, lead- coloured, red at the circumference, cedematous, and, at last, black and senseless.! The sloughing commences at the point where the pressure is greatest; thence spreads more or less widely, and terminates in the formation of a foul, ill-conditioned, gangrenous ulcer. Some cases present themselves, in which the skin is so extensively destroyed, that, upon the separation of the slough, the sacrum and neighbouring bones are denuded, and visible at the bot- tom of the ulcer, the discharge and irritation from which are terrible. Patients sometimes get over severe fevers, bad fractures, &c. and ultimately fall sacrifices to this se- condary disease. With respect to the treatment of this particular case, I need not remind the practitioner, that he should always be apprehensive of this species of sloughing in patients, who are weakened by disease and long confinement, and com- pelled to lie for several weeks and months in bed. He ©ught, therefore, to prevent the occurrence, by now and then shifting the posture of the sick; and, especially, he should not forget to examine from time to time the state of the parts, most subject to attack. On the first appear- ance of any redness, or discoloration in them, they maybe bathed with the liquor plumbi acetatis dilutus, and then covered with a piece of the emplastrum plumbi, or, what is still better, the emplastrum saponis. The posture should at the same time be so altered, that the parts affected may not be lain upon. The judicious arrangement of small pil- lows, or cushions, under particular points, will often give the surgeon essential assistance in the accomplishment of this highly important indication. When sloughing and ulceration have actually taken place, some surgeons apply * Precis des Maladies reputees (Jhirurgicales, t. i. p. 101. ! Richter's Anfangsgr. der Wundarzuejtkunstj bi, p. 75. Vol. I. I 6.6 MORTIFICATION. lint, dipped in camphorated spirit, or turpentine; others, carrot, or emollient poultices; others, a solution ot opium and common pledgets. This indetermination, respecting what is really the best kind of dressing, sufficiently proves to my mind, that not much is to be expected from the vir- tues of local applications. Improving and strengthening the constitution; changing the patient's posture; and, above all things, the strictest attention to keeping the parts aftect- ed clean, and to the avoidance of whatever is irritating to them; are the great leading principles by which the sur- geon should be governed. . The circular compression of limbs by tourniquets and tight bandages, if continued too long, will induce mortifi- cation. The smaller the extent of the compression, the greater is the risk; and bandages, which operate equally upon every part of a limb, though they may be somewhat tenser, can be borne with greater safety than a narrow band, or ligature, which acts only upon a very confined space. Yet, let it not be imagined, that the danger of im- moderate, long-continued compression is entirely obviated by equalizing the pressure, and increasing the extent of the compressed surface. There are few surgeons who have not beheld melancholy proofs of the fatal consequences of tight bandages. The greater skill now generally evinced in equalizing the pressure upon the whole limb, we must admit, has much diminished the number of these unfor- tunate examples; but they do still sometimes happen. A surgeon, therefore, should never forget, that, frequently when he is applying a roller, the nature of the disease or injury will necessarily be followed by a great deal of swell- ing, and for this due allowance should be made in first put- ting on the bandage. For the same reason, the part should be from time to time carefully examined, and if found to be too much constricted, it should be instantly liberated. Compression is only safe, while it gives no uneasiness; and, when it appears to produce pain, the suspicions of the practitioner ought to be immediately awakened to its dan- gers. In the practice of surgery it is sometimes proper to wet bandages with cold water, or particular lotions ; but, whenever this is done, the fluid makes the bandage shrink so considerably, that, if the change be not guarded against, the constriction produced will often bring on a rapid mor- tification of the limb, and the death of the patient. Let surgeons also continually bear in mind, that tourniquets are only designed as temporary means of suppressing he- MORTIFICATION. 67 morrhage, and that if their application be long continued, they will surely have the most disastrous consequences.* The perils of immoderate circular compression of limbs proceed, no£ only from the obstruction which it causes in the circulation, both through the arteries and veins, but also from the interruption of the nervous influence and ac- tion of the absorbents. With regard to the treatment, the indication in an early stage of the mischief is'very simple, viz. to remove the bandage, or tourniquet, and have recourse to fomentations, or applications of a discutient, spirituous quality. When the disorder has advanced further, and actually amounts to gangrene, the conduct of the surgeon must be regulated by the extent of the mischief. If it be partial, let him, after removing the compression, foment the parts, and vigilantly observe the changes which occur; for it is the nature of this species of mortification, often to spread with incredible rapidity up to the very trunk, and thus in a few hours destroy every possibility of saving either the patient's limb, or his life. Whenever there is reason to apprehend, that the case will be of this serious description, if amputation be delayed, the operation should be adopted as the only possible means of affording the patient any chance of life. MORTIFICATION FROM DERILITY, IMPAIRED CONSTITUTION, ADVANCED AGE, AND OSSIFICATION OF ARTERIES. The next examples of mortification, which I shall no- tice, are those which probably arise from the combined effects of great general debility, and impaired constitution, advanced age, and, perhaps, an ossification of the arteries. Whether this last occurrence, however, should be received in the list of causes, is not entirely settled.! We know that, in elderly subjects, some of these vessels are com- monly found in an ossified state, and yet the parts which • Amongst the thousands of cases recorded in proof of this fact, I shall merely refer to one related by a distinguished modern writer, Flajani, Col- lezione d'Osservazioni et Reflessioni di Chirurgia, tomo ii. p. 26. Roma, 1800. J! In Johnson's Journal for January, 1828, there is a highly interesting account, translated from Broussais' Journal, of a case of "gangrene of the feet from obstructed aorta." On dissection, it was found that about an inch and a half below the origin of the cocliac artery, the aorta had become com- pletely ossified, and its bore almost entirely obliterated. To this circum- stance was attributed the gangrene of the feet, which caused the death of ♦he patient.—P. Y \ • 63 MORTIFICATION. they supply with blood appear in general to have no ten- dency to gangrene. This fact is established by observa- tions daily made in every dissecting room, and it is an un- deniable proof, that ossification of the arteries cannot alone, and without the occurrence of other causes, produce mor- tification. As also the species of mortification about to be described, mostly occurs in elderly persons, one must na- turally expect to find these vessels sometimes ossified in the limbs affected; which is actually the case. But the co- incidence of this state of the vessels with gangrene, is far from justifying the conclusion, that the disorder arises from it as a cause; since, in subjects of the same age, the arteries are often found similarly changed, and yet the parts, which they supply with blood, are not at all disposed to gangrene. At the same time, I am far from denying that ossification of the arteries may not, when joined with other causes, facilitate the access of mortification; because one can hardly suppose such an alteration of structure un- connected with some diminution of the momentum of the circulation through the ossified vessels. The case of mor- tification, now engaging our attention, is one which differs, as much as any example which can be pointed out, from that which follows common, or any other species of active inflammation. It is peculiar in being often only preceded by a burning pain in the part, which undergoes no swell- ing, and is sometimes of a pale red, or livid colour. It con- stantly attacks parts at the greatest distance from the source of the circulation, and hence frequently begins in the toes, and sooner or later passes on to the foot and ankle, and sometimes to a part of the leg. In a few instances, it make its appearance with little or no pain; but, in most cases, the patient feels great uneasiness through the whole foot and ankle-joint, particularly in the night, even before these parts show any mark of distemper, or any thing else than a small discoloured spot on the end of one of the lit- tle toes. If the patient has lately cut his nails, or corns, it is frequently, though very unjustly, set to the account of such operation. It is most frequent in men, and oftener attacks great eaters, than free drinkers. I have never seen it in any patient under forty-five. When once the morti- fication is fairly established, the constitution sinks with great rapidity. The sympathetic irritative fever generally comes on in its worst form, attended with intolerable rest- lessness; a small, frequent, irregular pulse; delirium and spasmodic twitches; and many patients die by the time the MORTIFICATION. 09 disorder has extended as high as the ankle. This case is further remarkable, on account of the inefficacy of bark in its treatment. Pott regarded opium as the best medicine for stopping the extension of the disease;* though his ac- count of its effects in this case have been considered by some others as exaggerated-! Wine, camphor, and sub- carbonate of ammonia, have also obtained repute. The topical applications should be of an emollient, unirritating kind. Amputation scarcely ever succeeds, if done while the mortification is spreading. CHAPTER VI. ERYSIPELAS, Is the name commonly given to a peculiar kind of in- flammation of the skin, characterized by a diffused redness and fulness of the part, a burning, or itching pain, and fre- quently vesications and fever. When touched with the end of the finger, a white spot is left, which immediately turns red again. The skin has a shining appearance, feels as if it were a little thickened, and somewhat less pliable than natural; and whether complete vesications have been form- ed, or not, the cuticle peels off on the decline of the inflam- mation. The affection has a tendency to spread extensive- ly and rapidly; coagulating lymph is not freely effused in the cellular membrane as in common inflammations; and when suppuration unfortunately occurs, as it sometimes does, the matter not being bounded by adhesions, diffuses itself, and becomes blended with sloughs under the integu- ments. According to some writers, erysipelas is distin- guished from erythema, by swelling and vesications;! DUt these two symptoms frequently rather depend upon the stage and degree of the complaint, than upon its essential nature ; because its beginning is never attended with them. • See Pott's Observations on the Mortification of the Toes and Feet: Ohirurgical Works, vol. iii. Also, Quesnai's Traite" de la Gangrene, p. 324 8tc. Paris, 1749. ! See Kirkland's Medical Surgery, vol. ii. and Gibson's Institutes of Sur- gery, vol. i. p. 31. 8vo. Philadelphia, 1824. t Bateman's Synopsis of Cutaneous Diseases, p. 125. ed. 3. ft ERYSIPELAS. If the terms erysipelas and erysipelatous inflammation, as applied to the local affection of the skin, could be conve- niently exchanged for erythema and erythematous,, as Dr. Good has suggested, a great deal of confusion in this sub- ject might be avoided; for the word erysipelas might then be restricted to the idiopathic fever, which is necessarily followed by this kind of inflammation as a symptom, and the inflammation itself, in this, as well as other examples from different causes, might have the generic name of ery- thema, with an epithet expressive of its particularity. Thus, in erysipelas, it is proposed to call it erysipelatous erythe- ma* Certainly a specific fever, followed by this cutaneous efflorescence merely as one of its symptoms, should not be confounded with other cases, in which no general febrile disturbance of the system precedes the local complaint, which arises from causes of a different kind, and itself con- sists of several varieties. Mr. Hunter seems not to have limited his conception of erysipelatous inflammation always to an affection of the integuments, but believed, that though the skin is the part which it mostly attacks, there might be constitutions in which every inflammation, wherever it existed, would be of this kind. Here Mr. Hunter probably meant, that the inflammation, so situated away from the skin, would be chiefly marked by a greater tendency to spread than sim- ple inflammation, and less disposition to effuse coagulating lymph; for many of the other characters of erysipelatous inflammation, noticed in the skin, would be lost in deeper textures. When, also, erysipelas shifts its situation, and moves either to a distant part of the skin, or to an inter- nal organ, (erysipelas metastaticum,) as described by me- dical writers, the possibility of this kind of inflammation taking place in other parts besides the skin, is distinctly implied. At the same time it is admitted, that the skin is the most susceptible of erysipelatous inflammation, which will spread extensively over it without materially affecting, at least in ordinary cases, the subjacent cellular membrane-! The margin of erysipelatous inflammation is abrupt, the redness not being imperceptibly lost in the surrounding surface, like that of phlegmonous inflammation. In ery- sipelas, there is less extravasation than in phlegmon and • See Dr. Good's Study of Medicine, vol. ii. p. 350, and vol iii n 69 cd.2. 8vo. Lond. 1825. " ' *' ' | Hunter on the Blood, &c p. 270. ERYSIPELAS. 71 redema, and little or no effusion of coagulating lymph. Ad- hesions, therefore, are seldom formed, by which the spread- ing of the complaint can be checked, or boundaries set to abscesses when they unfortunately occur. In these cases, indeed, suppuration rarely happens, without being attend- ed with considerable sloughing of the fasciae, tendons and cellular substance under the skin, which latter part being itself highly organized, frequently escapes, even when the sloughing of other less vascular parts is very considerable. This kind of suppuration and mortification is principal- ly seen, either in severe cases of phlegmonous erysipelast where the inflammation extends more deeply than com- mon, so as to affect a great deal of the cellular membrane; or else in those forms of the disease, which are attended with typhoid fever, and have been distinguished by the epithets gangrenous and malignant. Whenever erysipelas falls into this unfavourable state, the surgeon finds air, matter, and sloughs, all blended together under the skin, and, on handling the part, a strange feel is communicated, neither like that of fluctuation, nor that of crepitation.* The discharge also becomes peculiarly offensive; not be- ing genuine pus, but a purulent secretion blended with sloughs and other extraneous matter. To some cases of this description, the name of diffuse inflammation in the cellular membrane has been lately appli- ed: it having appeared to several judicious observersr| that the examples in question should not be regarded as erysipelas. The two diseases, says Dr. Scott, with which this diffuse inflammation of the cellular membrane is most likely to be confounded, after the disease is fully formed, are erysipelas and typhus fever. From the first it is distin- guished in all the pure cases, by some evident cause of ir- ritation having been previously applied;! by the absence of inflammation of the skin; by the swelling having a pecu- liar elastic or boggy feel; by the disease concentrating itself in the axilla of the affected limb and surrounding parts: and by its universal termination in suppuration. From ty- * See Hunter on the Blood, &c. p. 272. ■)■ Dr. Duncan jun., in Edinb. Med. Chir. Trans, vol. i. Dr. David Scott, in Edinb. Med. and Surg. Journ. No. 85. \ This circumstance does not distinguish it from erysipelas in general, according to the common acceptation of the word, but only from the idio- pathic fever, of which the erysipelatous inflammation of some part of tht; surface of the body, is a mere symptom. Many other cases are excited by various forms of irritation. 72 ERYSIPELAS. phus fever, he says, it is distinguished by the febrile affec- tion being symptomatic of a previously existing local ac- tion; by the fever corresponding in intensity to the intensi- ty of the local affection; by the brain being much less impli- cated, excepting where the disorder arises from dissection (erythema anatomicum ;*) by its history; and by its non- contagious character. Erysipelas, in the sense of an idiopathic fever, giving rise to an erythema, or efflorescence as a symptom, comes on with various degrees of severity. In its mildest form, it is preceded by no particular complaints, or merely by a very slight indisposition, languor, restlessness, loss of ap- petite, &c. These symptoms are of short duration, and abate as soon as the erythema appears, which increases for a couple of days, then remains unchanged about a similar space of time, and afterwards turns yellowish, and gradu- ally fades away, the cuticle at the same time peeling off. During the whole course of the disorder, the fever is slight, the pulse being sometimes only a little disturbed previous- ly to the appearance of the redness. In a more severe degree of the disorder, the patient ex- periences, for a couple of days before the erysipelas breaks out, unusual debility, heaviness in the limbs, headach, loss of appetite, nausea, actual vomiting, oppression about the stomach, ike. After two days (generally on the third) the erythema appears, attended with a gentle perspiration, and an increase in the secretion of urine, when the fever, and all the other complaints subside. The disease then follows the same course as the first case already de- scribed. In the third and most violent degree of erysipelas, which mostly attacks the face, the patient is affected with severe fever, headach, lethargic drowsiness, a symptom generally very strongly marked, shiverings, vomiting, delirium, &c. These symptoms do not, as in the foregoing examples, subside upon the breaking out of the erythema on the third day; but continue with undiminished vehemence, until the local disorder itself goes off, which usually happens * So named by Dr. Good (Study of Medicine, vol. ii. p. 363.) who de- scribes, as one ot its characters, a deep crimson blush, chiefly over the pectoral muscle, which account corresponds with what I have seen. Iu- stc-.-d, therefore, of representing non-inflammation of the skin as a distin- gu.shing feature, I conceive that it would be more correct to say that the skin is less widely .nflamed, than in common erysipelas 5 and does not so soon exhibit discoloration. ERYSIPELAS. 73 about the eleventh day, attended with copious evacuations from the skin and kidneys.* The vesications generally form on the inflamed parts about the third, fourth, or fifth day ; and contain a thin irritating fluid, under which the skin generally heals, but sometimes ulcerates. They gradually burst when scabs are produced. The causes of erysipelas, in the sense of a fever, cha- racterized by this peculiar inflammation of the skin, are as obscure as those of most other fevers, the origin of which cannot be fairly imputed to contagion, or epidemic circum- stances. Why an inflammation of the skin, also unpreceded by such fever, should assume the erysipelatous character, is what cannot always be explained. A deranged state of the bilious secretion, disorder of the digestive organs in general, sudden stoppage of perspiration by cold, and a peculiar condition of the system, induced by these or other circumstances, are all conditions which have been repeat- edly suspected as having a great share in determining the character of this inflammation. That there is a great and intimate sympathy between the alimentary canal and the skin, seems, indeed, to be proved by the effects of certain kinds of food in bringing out eruptions, resembling urti- caria and roseola !; but I am not aware, that the origin of erysipelas from this cause has ever been clearly proved. It is evident, also, that without some idiosyncrasy, which cannot be defined, none of the foregoing exciting causes would produce erysipelatous inflammation, as it is not in every person, or even the generality of individuals, that such a consequence ensues. The same may be said of every species of external irritation. A suspicion has been enter- tained, that erysipelas is sometimes propagated by con- tagion J§; but whether the commencement and extension * See Kichter's A nfangsgr. der Wundarzneykunst, b. 1. p. 98, 99. ! Unwashed muscles. Montegrc, in Gazette- de Sante, Mars 1812. Bur- rows, in Lond. Med. Repository, vol. iii. p. 445., Orfila, Toxicologic Gene- rate, t. 2. Rice. I.asMis Pathol. Chir. t. 1. p. 10. $ Wells, in Trails, of a Society for the Improvement of Med. and Chi- rurg. Knowledge, vol. ii. art. 17. § {The opinion respecting the contagious nature of erysipelas has been considerably strengthened of late. Mr. A. C. Hutchison, in his valuable work on military surgery, says, that from many facts which have come un- d:M- his observation, there is much in favour of this opinion. In the second volume of the Transactions of the Medico-Chirurgical Society of Edin- burgh, J. Stevenson, M. D., in a letter to Dr. Thomson, gives an account of a number of cases illustrating its contagious nature * and a communication Vol. I. K 74 i:rysipela> of the disorder amongst patients in certain hospitals, as has been sometimes noticed, might not be better accounted for by the operation of epidemic causes, is a point not al- together decided. That erysipelas generally depends upon some particular state of the constitution cannot be doubted; and this may account for the greater efficacy of internal remedies, than of topical applications. Persons, who lead intemperate lives, and who, in a state of intoxication, meet with local injuries, often have erysipelatous inflammation; while other subjects, of more regular habits, when they receive similar injuries, experience healthy inflammation. At the same time it must be acknowledged, that erysipelas some- times arises in constitutions, with which we can find no manifest fault; and females and children,leading perfectly regular lives, are frequently attacked. The obscurity of this topic has not hitherto been removed by pathologists; and even the doctrine of constitutional causes seems to be shaken by the well-known fact, that it is the common course of the disease to be actually getting well on one side, as fast as it is spreading on another. Perhaps, here, the only mode of reconciling things is to suppose, that parts which have been affected, lose for a time their sus- ceptibility of the complaint. Erysipelas may be attended with inflammatory, or typhus fever. In the first case, which is often named phlegmonous, or acute erysipelas, the external inflammation is redder, more prominent, and indurated than usual; the pain shoot- ing and throbbing; the pulse full and hard; and the fever ardent. In the second case, which is sometimes called ma- lignant, or gangrenous erysipelas, and seems to me to in- clude also the disorder named by some modern writers, diffuse inflammation in the cellular membrane, the patient is much debilitated, the redness is lead-coloured, dusky, or bluish, and the fever plainly typhoid. Most writers describe vesications as one of the essential characters of erysipelas; but this statement is only cor- rect, as applied to the affection of the skin in the idiopa- thic exanthematous fever, called erysipelas; for many cases which surgeons have to deal with, and which are of the same kind is to be found in the London Med. & Phys Journal for March 1827, by Dr. Arnott, who refers to cases to be found in'the writings of Wells, Pitcairn, Whitfield, BaUlie, and others, tendine to establish the fact.—P. E.} erysipelas. 75 mostly connected with local irritation, wounds, &c. are not attended with any vesications.* The habitual, or chronic erysipelas, often arises as an idiopathic disease, and always in the same place. It is very tedious: but is not generally attended with much fe- ver, or other serious symptoms. Sometimes the disorder is periodical, recurring in the same person regularly at cer- tain seasons of the year, especially in the spring and au- tumn. It principally affects persons of advanced age, or women about the period of life when the menses cease.! The oedematous erysipelas, is another variety which must not be forgotten. Its attack is not so sudden as that of the phlegmonous and bilious erysipelas; nor is the disease at first so severe. It increases gradually, and is attended with a greater degree of swelling, which is more diffused. The pain is less severe. The fever is accompanied with prostration of strength, and a soft, frequent, and sometimes irregular pulse. The system is not relieved on the appear- ance of the local affection; on the contrary, the danger in- creases with the progress of the external disease. The part affected is of a pale red, or yellowish brown colour, and if pressed with the finger, a slight pit remains for a little while. When the face is attacked, it has a bloated appear- ance ; the features can scarcely be discerned ; and the eyes are concealed by the swelling of the eye-lids. The vesica- tions are smaller and more numerous than in the acute erysipelas, and, after a few days, change to dark-coloured scabs, much resembling those of the confluent small-pox. The disease, when situated about the head, is accompani- ed with rigors, vomiting, and often with coma and deliri- um ; frequently proving fatal about the seventh day, or a little later.! It never occurs except in bad constitutions, and subjects guilty of excesses in their mode of living. With regard to the prognosis, cases of idiopathic erysi- pelas, when properly treated, are generally cured about the eleventh day. Considerable danger may arise, how- ever, when external parts of importance are affected; when the disease shifts its situation, and internal organs, such as the brain and lungs, are disordered; or when the case • See also Pearson's Principles of Surgery, p. 198. edit. 2. ! Lassus, Pathologie Chir. t. i. p. 9. Richter, Op. cit. p. 102. Pearson, p. 200. Callisen says : •* Habituale erysipelas ex infarctu hepatis ortum du? ceresolet." t. i. p. 219. t See Pearson's Principles of Surgery, edit. 2. p. 201, 202 76 ERYSIPELAS. terminates in suppuration and gangrene, either from bad treatment, peculiaritv of constitution, or epidemic causes. Erysipelas of the face, caeteris paribus, is more dangerous than that of any other external situation.! The coming on of delirium and coma, subsequently to the eruption, is a threatening circumstance. The malignant or gangrenous erysipelas, attended with low typhus fever, and the forms of disease named diffuse inflammation in the cellular mem- brane, are always dangerous ; and so is the edematous ery- sipelas, when it occurs as an idiopathic disease, is situated on the head and face,! and accompanied with disturbance of the intellectual faculties. Mild cases of the idiopathic fever, characterized by ery- sipelas, are in general soon relieved by the exhibition of saline, purging, and sudorific medicines. Here, however, only such diaphoretics are allowable as operate without stimulating ; like the potassa,' nitras joined with small quan- tities of antimonial powder, or the liquor antim. tart. The patient is to be kept in a warmish, but well ventilated apartment, and strictly upon the antiphlogistic regimen. In a more severe form of the complaint, in addition to these remedies, venesection is sometimes useful,§ especi- ally when the pulse is full, and the face is the part attacked. There is an ancient doctrine, that erysipelas is essentially connected with debility; and hence has arisen a common aversion to bleeding as a means of relief; but the experi- ence of Dr. Duncan, and some other modern practitioners, tends to prove, that the practice may be adopted with as much success in cases of erysipelas, as in those of other kinds of inflammation. The nature of the fever, however, should be considered, as a typhoid state of the system will not admit of loss of blood. When the tongue is foul, with a bitter taste in the mouth, and inclination to sickness; or when the signs of visceral disorder, and the febrile symptoms, yield little, or not at all, to purgatives; and the alvine evacuations have not a very bad smell and appearance; an emetic should be given. Sometimes, during the use of purgatives, the disorder abates for a little while, and then becomes stationary and * Callisen, Syst. Chirurgiac Hoil'iem*, t. i. p. 220. ! Callisen, Op. et loco citato. Richter, Anfangsgr. &c. b. i. p. 103. % See Bateman's Practical Synopsis of Cutaneous Diseases n 128 edit 3. Pearson's Principles of Surge: y, p. 202. edit. 2. » J • » • S> See Note C. ERYSIPELAS. 77 tedious; here an emetic generally does immense good. When, notwithstanding the administration of gentle pur- gatives, the gastric complaints repeatedly return, diluted sulphuric acid may often be exhibited with decided be- nefit.* In the treatment of erysipelas, joined with bilious dis- order, Desault used to administer, in the first instance, a grain of antimonium tartarizatum, dissolved in a liberal quantity of water. The symptoms are said to have fre- quently subsided immediately after the effect of this me- dicine, even though a mere increase of perspiration and urine was occasioned by it. When the case proved more obstinate, the emetic beverage was continued, till the fe- brile disorder and bitterness in the mouth were removed. The cure was then completed, with a dose, or two, of the mildest purgatives. After a few days, the patient was not restricted to a very low regimen.! Bark has been almost as extensively recommended for erysipelas as for mortification. When great weakness pre- vails, the appetite is bad, and evacuations have been duly practised, it is indeed, a medicine which may often be given with advantage, especially the new preparation of it, called the sulphate of quinine. It is also frequently proper, when the disorder, besides being attended with these symptoms, is combined with suppuration, gangrenous mischief, and a profuse discharge. In the gangrenous erysipelas, which i sometimes afflicts new-born infants, and with which, indeed, they appear to be actually born,! bark is said to be an in- dispensable remedy.§ Bark, however, is no more a speci- fic for erysipelas in general, than it is for mortification. In the acute or phlegmonous form of the disorder, both this medicine and opium are now considered quite unneces- sary ;|| but in erysipelas ozdematodes and erraticum, they may be exhibited after the first three or four days, during which evacuations are the chief means of relief. The diet and regimen must conform to the rest of the treatment; being generally at first low and antiphlogistic, and after- wards of a cordial and strengthening kind. When deliri- * Richter, Anfangsgr. &c. b. i. p. 105, 106. | (F.uvres Chir. de Desault, par Bichat, torn. ii. p. 588. t Sometimes called, therefore, congenital. % Sec Underwood's Treatise on the Diseases of Children, vol. ii. p. 31. edit. 5. Garthshore and Uromfield's Obs. in Med. Communications, vol. ii. Callisen'* Systema Chirurgia: Ilodicrnx, vol. i. p. 223. || See Bateman's Practical Synopsis of Cutaneous Diseases, p. 132. edit. 3. 78 ERYSIPELAS. urn prevails, camphor may be administered, and a blister applied between the shoulders, or rather to the head itself, unless it happen to be the seat of the erysipelas. Blisters have been extensively employed in the treatment of erysipelas, especially where the disorder appeared to have undergone a metastasis to internal organs. Here, they were of course laid upon the part originally affected, with the view of bringing back the erysipelas to it. This is a practice which is yet not altogether discontinued, many practitioners having full faith in the principles upon which it is founded. Sometimes, in obstinate cases of erysipelas erraticum, affecting only the surface of the body, blisters were laid upon distant parts, with a view of relieving the disorder in the parts actually suffering. Dupuytren some- times attacks the erysipelas erraticum with blisters; but in a very different way, for he lays them directly upon the erysipelatous part, thus following up the disorder in every situation to which it may remove; and Delpech has fre- quently seen suppuration, gangrene, &c, prevented in other forms of the complaint, by repeatedly blistering the part affected. According to Professor Gibson, also, blisters are very efficacious.* Nay, Dupuytren sometimes applies the actual cautery to it, as is alleged, with the greatest benefit.! In the cases which have been described by Drs. Duncan and Scott, under the name of diffuse inflammation of the cellular membrane, blisters, and even the application of caustic, have been of great service, as I shall presently have occasion to explain. According to some surgeons, external applications fre- quently do harm, and are never of much service; and every thing wet, whether warm or cold, emollient, repellent, or astringent, is generally disapproved of!. With respect to the dry, mealy, or earthy powders, which were preferred by Cullen, we have good authority for pronouncing them always useless, and often injurious, since they are apt to form, with the fluid which exudes from the vesications, hard, irritating crusts. Indeed, very disagreeable and dan- gerous consequences have ensued from their use§. Unctu- ous substances are generally condemned; but, in Ame- * Institutes of Surgery, vol. i. p. 45. 8vo. Philadelphia, 1824. f Precis des Mai. Chir. t. i. p. 54. t Richter, op. cit. b. i. p. 106. Callisen, Systema Chirureise Hod vol i p. 221. " § Pearson's Principles of Surgery, p. 218. edit. 2. Callisen, op. et loco cit Bateman, op. cit. p. 133. Richerand, t. i. p. ccvii. edit. 4. ERYSIPELAS. 71« rica, mercurial ointment, made up without any stimulating ingredients, has been found the best of all local applica- tions.*! Some modern authors! sanction covering the part with little bags, filled with aromatic herbs, to which cam- phor is added in a more advanced stage of the disorder. Others prefer rubefacients, and mild, warm cataplasms, composed of the powders of aniseed, fennel, camomile- flowers, mixed with oatmeal, or linseed meal, and a strong decoction of poppy-heads.§|| When there are vesications, they should be punctured with a needle, and the fluid absorbed with a fine sponge.^f When the fever and local redness have mostly or entire- * See Gibson's Institutes of Surgerv, vol. i. p. 45. 8vo. Philadelphia, 1824. ■j" jThis remedy was first recommended by Drs. Dean and Little, of Chanibersburgh, and has since been very extensively employed in this country. In the London Medical and Physical Journal, for February 1822, we find it stated, that Mr. Hrodie having tried tliis practice, found it efficacious, but that it was attended with the serious inconvenience t»f induc- ing salivation. It at the same time occurred to him, that the benefit deriv- ed was due more to the adipose matter, than to the metallic oxide combin- ed with it; and on employing a simple ointment in several instances he was convinced of the correctness of his opinion. He found that after its appli- cation, the patient experienced almost immediate relief, and the disease ap- peared to go through its stages in a more favourable manner than under ordinary circumstances.—P. E.J $ Richter, Callisen, &c. § Pearson, p. 219. U {In a case of extensive erysipelatous inflammation, involving the whole surface of the lower extremities, and which had resisted all the ordinary re- medies, immediate benefit resulted from the application, to the parts aflect- ed, of the leaves of the datura stramonium, or Jamestown Weed. An ex- tract made from the leaves, when the recent plant cannot be procured, will be found equally efficacious. Dr. C. D. Meigs, of Philadelphia, in the North American Medical and Surgical Journal, for July 1828, says that he has for some years employed Kentish's ointment in the treatment of erysi- pelatous inflammation, with very great success;—and in the American Me- dical Recorder, for the same month, Dr. C. B. Matthews, of Philadelphia, recommends the application of spirits of turpentine in similar cases, con- ceiving its modus operandi to be that of "a stimulant to the cutaneous ca- pillaries, restoring their natural tonicity, while the evaporation tends to carry oft' the redundant heat from the inflamed surface." The method of Ueating phlegmonous erysipelas of the limbs, by means of tight bandaging, as recommended by M. Brettoneau, of Tours, has many advocates in France. In the Archives Generates de Medecine, for September, 1827, M. Guerin has published a notice of its utility; and M. Velpeau, of Paris, has selected a number of cases from the practice of " fhospice de la Faculty," (which are published in Johnson's Journal, for Oct. 1826,) illustrating its success,—he conceives that this measure "will secure all the advantages of free incisions, without the pain or formidable appearance attendant on the operation."—P. E. { 1 Richter, b. 1. p. 107- so ERYSIPELAS ly gone, and merely a pale cedematous swelling remains, camphorated or ammoniacal liniments,* and the use of a bandage, will remove the remains of the disease ; or the part may be covered with a piece of green oil-skin-! On the same authority, we may, when the pain and burning are violent, lay on the part a piece of flannel, wet with warm milk, or a decoction of elder or camomile-flowers, or poppy-heads; a kind of practice which is also recom- mended by another eminent writer,! as the best means of preventing any ill consequences from the acrid discharge of the broken vesications. Both in the phlegmonous and bilious erysipelas, arising from internal causes, Desault made use of no topical appli- cations, and left the part exposed as much as possible to' the air. But, when the erysipelas, whether phlegmonous or bilious, was the consequence of a contusion, wound, or ul- cer, he deemed regimen and internal means insufficient, unless assisted by such applications as were best calculated to allay local irritation, and promote suppuration in the sore or wound. With these principles, he employed poul- tices, the beneficial effects of which are said to have been fully confirmed in his extensive practice. He considered it an essential precaution, however, not to let the poultice extend much beyond the contused place, or the margin of the wound, or ulcer; and over the rest of the erysipelatous surface, if he applied any thing, it was the liquor plumbi acetatis dilutus, 5j to a pint of water. Even refrigerants may be safely applied to erysipelas arising from external causes.^ As for the local treatment of the idiopathic forms of the disorder, I confess, that I entertain no opinion of the real merit either of rubefacients or stimulating poultices; and join Richter, Willan, and Bateman, in giving a preference, when the redness and heat are very great, to fomentations and tepid bathing, or else to a lotion consisting of the di- luted liquor ammonia? acetatis.||f| In the phlegmonous erysipelas, attended with risk of gangrene, the making of several incisions** in the part is * Pearson, p. 219. f Richter, p. 107. * Willan. § Richerand, Nosogr. Chir. t. i. p. ccvii. edit. 4. H Practical Synopsis of Cutaneous Diseases, p. 134. edit. 3. "5 See Note D. \** The following is the method recommended by Mr. Hutchison__he ERYslPEL.Vi. 81 iaid to have averteo this unpleasant consequence.* But, when suppuration and gangrene have occurred, the treat- ment must be regulated by the principles laid down in the foregoing chapters. In particular, early and free incisions are here absolutely necessary, in order to prevent the ex- tension of the mischief under the skin, and to enable the surgeon to draw out the sloughs of tendons, fasciae, cellu- lar membrane, &c, as soon as they are completely loose. I shall conclude this chapter, with a summary of the treatment that has been found to answer best in the cases described by modern writers, under the name of diffuse in- flammation of the cellular membrane. When the complaint arose from irritation, the patients possessed moderate strength, and only the extremity was affected; the means used, were generally blood-letting in the beginning, some- times repeated; leeches; cold applications; and a purga- tive of Epsom salts and tartarized antimony. When the disorder had reached the arm-pit, the depleting system was relinquished, and hot fomentations and poultices applied. When the complaint had much tendency to spread, blisters and caustic potassa were applied, with the view of exciting inflammation in the skin, so as to limit the diffusive charac- ter of the disease, by producing an effusion of coagulable lymph. Then poultices were used again, and the parts opened, as soon as possible, with a lancet, even although matter had not yet been formed, as the effusion of even serum was serviceable. When there was great irritability, tincture of opium, joined with antimonial or ipecacuanha wine, was adminis- tered, with a cooling but nutritious diet. When suppura- tion had taken place, the antimonials were discontinued, and wine and porter allowed. In the cases arising from directs the incisions to be made (with a scalpel) longitudinally, an inch and a half in length, from two to four inches apart, and varying from four to eighteen in number. By this means, blood to the amount of xv. or xx. oz. may be abstracted, which will relieve the over-distended skin, and form ready channels for the free exit of fluids, as soon as secreted. When the periosteum is involved, the incisions should be carried down to the bone, as the most efficient means of preventing necrosis. Fomentations, hot or cold, for a period of twenty-four hours, are next to be employed. In making the incisions, we should carefully avoid superficial arteries, nerves, tendons, and lymphatics.—P. E.} • A. C. Hutchison in Medico. Chir Trans, vol. v. p. 278, 8cc Vol.. I L 3-i KRYSirELA^. dissection, every thing that tends to maintain a vigorous circulation of the blood, is found most successful.*! * See Dr. Scott's Obs. in Edinb. Med. Joum. No. 85. t fin the London Medical and Physical Journal, for January, 1827, there is a communication on diffused cellular inflammation, by Henry harle, fc,sq. in which he strongly recommends Mr. Hutchison's mode of treatment, vby incisions) which, he says, if adopted in time, seldom fails to arrest its pro- gress. A number of cases are given by Mr. E., an abridged account ot one ot which, we select as illustrating the success of this mode of treatment in dif- fuse cellular inflammation from morbid poison. Mr. C. E. B. wtat. 21, one of the dressers in St. Bartholomew's Hospital, on the 21st of April, in opening the cranium of a man who died ot gangren- ous erysipelas, pricked the middle finger of the right hand, with a spicula of bone. The usual symptoms of a dissection wound, arose, and the usual practice in such cases, continued until the 28th, when he was much worse. "The inflammation had extended to the deltoid muscle on the outer side, but did not appear to have leached the axilla on the inner side; nor waa there any pain at this part, or disposition to extend over the pectoral mus- cle. From the insertion of the deltoid downwards, the whole arm was as tense as possible, and felt remarkably firm when pressed. The colour was a dusky red, rather more vivid at the upper margin. He had been delirious all nighl, and appeared rather comatose. His countenance was shrunken, wild, and ghastly. He was so weak that he could not sit up in bed; his pulse was irregular, feeble, and fluttering; his tongue was covered with thick brown fur. It was evident that he could not long survive under these circumstances, and, although I had no evidence in favour of the practice in a similar case, I resolved to make large and deep incisions, provided it met with Mr. Lawrence's concurrence, who was so obliging as to visit him with me. Mr. L. entertained the same view of the case* and in his presence I made three deep incisions,—one commencing a little above the insertion of the deltoid, and more to the outer side, which extended down to the ole- cranon; a second, about six inches long, from just below the olecranon to the wrist; mid a third, about three inches in extent, on the inner side of the forearm. No suppuration or sloughing was apparent, but the wounds gaped much, and the fat was very firm and granular. The wound at the outer side of the forearm bled very freely, to the extent of from thirty to forty ounces; after which the limb was enveloped in a large bread and water poultice. In the evening, when I saw him, his countenance was much improved; and his pulse was steady, soft, full, about eighty beats in the minute. The pain had nearly subsided, except in his finger. He was ordered a dose of calo- mel and jalap, and to continue the opium after its operation. 29th. He passed a tranquil night, but without sleep; countenance improv- ed; pulse stronger, and quite soft; arm quite easy. 30th. As yesterday; no sleep. In the evening, restlessness and slight wandering. Two grs. of opium and six of camphor, procured repose, for the first time since the receipt of the injury. Next morning improved in every respect. Suppuration had taken place at the wounds; bowels moved with infus. sennae, and tinct. jalapse. anodyne repeated at night. From this time he continued to go on most favourably: healthy suppuration was esta- blished, and by light dressing and bandaging, the whole rapidly filled up and skinned over. In a few days he was ordered sulphate of quina, and ge- nerous diet. Rapidly recovered.—P. E. J BOH. *•"* CHAPTER VII. OF THE FURUNCULUS, OR BOIL. The boil is a circumscribed, very prominent, hard, dark- red, painful, inflammatory swelling, of a conical shape, hav- ing its base below the skin, and its apex above it. The colour of it is a dusky-red, inclining to purple, and on its summit is a whitish little eschar, under which is a mass of destroyed cellular membrane, called a core. A boil is sel- dom larger than a pigeon's egg, and for the most part sin- gle; but sometimes a great number of similar tumors show themselves at once in different parts of the body, or come out in succession, more particularly in children, or just after the termination of an acute disease.* Boils are rarely attended with fever, except when they affect very tender parts, or are large and numerous. Under these cir- cumstances, they sometimes cause in delicate children, restlessness, loss of appetite, and even convulsions, &c. In certain instances, as Heister remarks, the whole body is so miserably infested with them, that the patient can hardly tell how to stir, or on what part to lie.f The parti- cular form of inflammation attending boils, and which Scarpa observes might be called furuncular, differs in se- veral respects from common phlegmonous inflammation. The former commences in the skin, extends itself down- wards into the subjacent cellular membrane, and pro- duces a more or less extensive destruction of it. Phleg- monous inflammation, on the other hand, originates in the cellular membrane, the vitality of which it does not de- stroy, and is afterwards propagated externally to the skin. The furuncular inflammation is quickly arrested, and forms a small, circumscribed, hard, and very painful tumor, which, though elevated upon the skin, does not contain extravasated coagulable lymph, but consists entire- ly of mortified or disorganized cellular membrane; while, on the contrary, phlegmonous inflammation is disposed to spread far through the cellular membrane, into the cells of * Pearson's Principles of Surgery, p. 72. edit. 2. f General System of Surgery, p. 213. edit. 6. 84 BOIL. which a considerable quantity of coagulable lymph is in- cessantly poured, occasioning the tumefaction. In conse- quence of the furunculus being completely filled with mor- tified or disorganized cellular membrane, suppuration in it is very imperfect, and never takes place in the centre of the tumor, but only at its circumference, where it is in con- tact with the sound parts; while, in phlegmon, a true and complete suppuration is formed precisely in the centre of the inflamed part, which, after the discharge of the matter, spontaneouslv recovers its natural state and functions. In the second stage of the furunculus, the skin, which covers it, ulcerates and bursts at one or more points, and dis- charges a very small quantity of serous fluid ; and the por- tion of mortified cellular membrane, which composes the body and base of the tumor, then comes away in the form of an extraneous substance, and the cavity which remains, closes and soon heals.* Boils mostly arise from a particular state of the consti- tution, and depend upon internal causes. Hence, the com- plaint is most frequent in the spring months, and in chil- dren, and young persons of full plethoric habits. It is also very often noticed in that state of the system, which im- mediately follows the recovery from certain febrile dis- eases, the measles, small-pox, &c. The common circum- stance of many boils being formed either simultaneously, or in succession, in the same patient, is another fact tending to prove the agency of internal causes, of which, if there were yet any doubt, it would be dispelled by the consider- ation, that in some instances, evident marks of constitu- tional indisposition, for two or three days, precede the lo- cal disease. Boils of the latter description were thought by the old surgeons to be critical. Boils, which form in children at the breast, are alleged to proceed very frequent- ly from the bad quality of the milk; and, the instances, in which they are numerous, and disposed to return, are said often to be caused by a disordered state of the digestive organs. I know nothing of the accuracy of the common notion, that a boil commences in one of the small glands of the skin.f As every attempt to resolve swellings of this kind by bleeding, evacuations, and discutient applications, mostly * Scarpa on the Principal Diseases of the Eves. p. 58, transl bv Briesrs lit. 2. " ' 8fa f Richter, Callisen, &c. BOIL. S5 fails, and the longer it is continued the more protracted the disease is, the best general practice is to promote sup- puration. It seems, indeed, to be the nature of a boil not only to suppurate, but to destroy a portion of the cellular membrane; and in a few rare examples, in which the sur- geon, by means of particular applications, succeeds in bringing about resolution, it is very incomplete, the inflam- mation alone being removed, and an induration left, which produces more or less inconvenience, from time to time inflames again, and is never totally dispersed, until a free suppuration is excited.* In all ordinary cases, emollient poultices are the right applications, to which, if the pain be very severe, some of the extractum conii, hyoscyami, vel opii, may be added. In some excellent works on surgery, we are directed to conti- nue the use of poultices, until the tumor spontaneously bursts. But, as the generality of boils are slow in break- ing, and the patient never gets relief, until the matter is discharged, the most judicious practice is to make an early and rather a free opening with a lancet. The contents should then be gently pressed out, and every portion of the gangrenous cellular membrane, nucleus, or core, extracted, if it can be done without giving too much pain. When boils are left to burst of themselves, the duration of the disease is generally considerably longer, than when they are opened; and chiefly for two reasons: first, as already observed, because the spontaneous aperture is slow in form- ing; and, secondly, because when formed, it is not large enough for the ready evacuation of the sloughs, and flakes of dead cellular membrane, contained in the swelling. The presence of the mortified cellular membrane is now known to be one of the principal impediments to cicatrization, and the wisest practice must therefore be, to make such an opening, as will facilitate as much as possible the discharge, or removal of that noxious substance. When this has been done, the employment of emollient poultices, and sim- ple dressings, a few days longer, will generally complete the cure. Many surgical writers recommend the applica- tion of escharotics, and particularly the pulv. hydrargyri nitrico-oxydi, with a view of promoting the separation of the slough, and dispersing the remaining hardness. This, however, is a painful practice, which is no more necessary • Richter's Ansfangsgr. der Wundarzn. b. i. p. 133. Also Scarpa, op. cit p. 60. 86 BOIL. here, than it is in other abscesses, the hardness around which always subsides in proportion as the inflammation abates; and, with respect to the portion of gangrenous cel- lular membrane, it will not in general be considerable, nor its detention in the part long, if the surgeon follow the above rule of making a proper and an early opening. Boils always present a very prominent, conical apex, while then- base is, comparatively speaking, broad.* The knowledge of this fact must at one convince us of the insufficiency of a small aperture, whether formed by art, or nature. In severe and obstinate cases, internal remedies, adapt- ed to the particular complications of the disease, are not to be omitted, such as bleeding, aperient medicines, eme- tics, and a proper regimen. Where several boils occur in a patient advanced in years, bark is said to prove useful; and in children at the breast, the mother, or nurse, should take some purging medicine, and be put on a strict regi- men. The infants should also take small doses of antimo- ny with an absorbent powder.f If these plans fail, the milk must be changed.:}: The disposition to boils may some- times be removed by the use of bark, sea-bathing, acids, steel-medicines,§ and mineral waters.|| When boils are very large, and attended with severe pain, opium should be administered. CHAPTER VIII. OF THE ANTHRAX, OR CARBUNCLE. A Carbuncle is an inflammatory, broad, flat, firm, dis- tinctly circumscribed, very painful swelling, of a dark-red or dull-brown colour, somewhat resembling a boil, but larger, and, like it, containing a portion of gangrenous cel- lular membrane. It begins in the skin, almost like a pim- ple, and goes more and more deeply, spreading with a broad base in the subcutaneous cellular membrane.^} It is * See Pearson's Principles of Surgery, p. 70. edit. 2. f Heister, General System of Surgery, p. 214. i See CaUisen's Syst. Chir. Hodiernx, vol. i. p. 328. § Pearson, p. 76. II Heister, p. 215. ? Hunter on the Blood, &c. Part II. Chap. iv. CARBUNCLE. S7 certainly more like an aggravated description of boil, than any other tumor with which it can be compared, though it differs not only in being larger, but also in not present- ing so conical a protuberance; the chief part of the swell- ing lying deep, and none of it being much elevated above the level of the skin. While boils seldom exceed a pi- geon's egg in size, a carbuncle is sometimes as broad as a common dinner-plate, as I once saw an instance of in a poor woman, who was in 1808, a patient in St. Bartholo- mew's Hospital. This magnitude, however, is only seen in very severe cases, and the average diameter of the tumor, though greater than that of boils, will admit of no such comparison. Sometimes the superincumbent skin, besides being discoloured in the manner above described, becomes so remarkably hardened and thickened, that it feels like brawn. The disease in fact is always attended with extra- ordinary pain and induration, and the patient is generally much afflicted with a sensation of burning, and stiffness in the part. The dark-red or dull-brown colour of the skin is for the most part chiefly seen upon the centre of the swell- ing, though, in some instances, the pain and discoloura- tion extend far around. As the disease advances, one os more livid or darkish vesicles, filled with an irritating sa- nies, form upon its surface; a certain mark of the subja- cent gangrenous mischief. On the apex of the swelling, a dark livid spot, bounded by an inflammatory circle, next makes its appearance, followed by the formation of one or several small inadequate apertures, through which a yel- low, greenish, bloody, highly fetid discharge flows out, while the great mass of matter, and sloughy cellular mem- brane still remains confined. As in the boil, the greatest degree of sloughing in all carbuncles is at their deepest part, or base, which occupies a much wider space than the more superficial portion of the tumor. In many cases, indeed, the deeply-seated gangrene is extensive, even when the unaltered state of the superincumbent integuments \ auses little suspicion of the mischief. By slow degrees, all the sloughs composing as it were tne nucleus of the car- buncle, are discharged, leaving a deep ulcer, at the bottom of which one may sometimes see the exposed muscles and tendons- Carbuncles seem mostly to arise from internal causey being most common in persons who have lived well, and rare in subjects under the middle age ;* a point, in which * Hunter on the Blood, &c. Chap. iv. 38 CARBUNCLE. this disease particularly differs from boils. Great prostra- tion of strength, violent headachs, sickness, loathing ot food, and a variety of low febrile symptoms, are the com- mon forerunners and companions of the local disorder, and, in bad cases, syncope, extreme anxiety, restlessness, and delirium. The anthrax is well known to be among the symptoms of the plague, and, in this country, it is often attended with severe illness, not unlike the worst sort ot typhus fever. The milder forms of anthrax, where the swelling is not very large, nor the general indisposition at all dangerous, sometimes receive the appellation of simple or benign. When circumstances are the reverse of this state, and, more especially, when the fever is of bad type, the carbuncle is termed malignant. In this case, the swelling exhibits a darker colour, and the surrounding cedema of the skin is more considerable. The carbuncle of the plague is called symptomatic or pestilential. To these varieties we have lastly to add another, which is endemial in some of the southern provinces of France, which does not arise like all the preceding, from internal causes, but from the applica- tion of a specific contagion, resembling, on its first attack, a flea-bite, but afterwards putting on an alarming charac- ter, and being well known on the continent under the name of the malignant pustule* While other kinds of carbun- cle may present themselves to the number of two, three, or more, in the same patient, the malignant pustule is almost invariably single. In all other cases, some fever or indis- position always precedes the tumor; but, in the malignant pustule, the local disease at first exists by itself, and the low, febrile, typhoid symptoms follow. On its first appear- ance, it resembles a flea-bite, causing a painful itching, and changing into a small serous vesicle, which is about as large as a millet seed, and quickly turns livid or brownish. In the substance of the integuments, a circumscribed flat tu- bercle is next perceived, of the size of a lentil; this be- comes gangrenous, and is converted into a hard black slough, which is bounded by a reddish, shining, violet, ve- sicular areola. Considerable swelling follows, and the skin has a glossy appearance. If the pustule be on the finger or hand, the swelling reaches high up the arm, even to the * See Methode de traiter les Morsures des Animaux Enrages, &c. suivie d'un Precis sur la Pustule Maligne, par. MM. Enaux et Chaussier Diion 1785. J CARBUNCLE. 8b arm-pit; and, if the disease be in the neck or face, the tu- mefaction spreads over the shoulder. The progress is sometimes alarmingly rapid, the pulse is weak and falter- ing, and the utmost prostration of strength observable; the patient often dying in the course of two or three days, and the body putrefying with extraordinary rapidity. That common carbuncles originate, or, at least, are es- sentially connected with an idiosyncrasy, or some peculiar state of the general health, is a fact of which no doubt can be entertained; but, in what that peculiarity consists, me- dical writers have not yet been able to specify. This dis- ease is seldom met with in hospitals, because the individu- als, in whom it presents itself, are generally persons, whose constitutions have been impaired by excesses at table. It is also seldom noticed in persons below the. middle age; but mostly in elderly, debilitated subjects. The cause of the pestilential carbuncle, as its name implies, is the plague. The malignant ptlstule, if the accounts of its origin be cor- rect, is a very singular and peculiar disease; for, instead of proceeding from internal causes, like all other carbuncles, it arises from a contagion derived from animals affected with malignant fever, or carbuncular diseases. The infec- tion is represented as being communicated to the human subject by contact, respiration, deglutition, or the bites of insects. Slaughtermen, tanners, fellmongers, tallow-melt- ers, and other workmen whose business it is to clean and comb out wool, are said to be particularly liable to the disease. Notwithstanding the multiplicity of authorities in support of this account, some doubts may be rationally entertained respecting its accuracy, when it is remember- ed that the alleged causes exist in this country, yet we have no disease which exactly corresponds, to the malig- nant pustule. The French writers also specify want, po- verty, uncleanliness, marshy situations, and the autumnal season, as predisposing causes. Were all these circum- stances, however, of themselves adequate to the production of the disease, it would certainly be seen, in some parts of this kingdom. Tiiere must, therefore, be other things which contribute to its production, and render it endemial in the southern provinces of France. In all cases of carbuncle, the prognosis depends very much on the size and situation of the swelling; on the number of such tumors; and, above all, on the state of the constitution. If together with a carbuncle of considerable magnitude, we remark great prostration of strength, a Vol. I. M 90 CARBUNCLE. small, rapid, irregular pulse, syncope, frequent vomiting-, delirium, &c. the danger is urgent. When, in the beginning of the disease, a good deal of in- flammatory fever prevails, moderate venesection, mild sa- line or calomel purges, and the antiphlogistic regimen, are indicated. But as the change from strength to weakness is often extremely sudden, the lancet should be employed with caution, and few patients will bear the loss of much blood with advantage. Indeed, the antiphlogistic plan can seldom be continued beyond the first two or three clays, af- ter which the typhoid state of the constitution comes on, and tonics are strongly indicated. Where there is reason to suppose the origin of a carbun- cle to be connected with disorder of the digestive organs,* nothing is more useful, prior to the accession of much de- bility, than the exhibition of an emetic, followed by ape- rient medicines,! such as a few doses of the hydrargyri submurias, or some cooling febrifuge drink, containing a sufficient quantity of the antimonium tartarizatum to keep the bowels well open. In this case, however, as in all other examples of anthrax, so great is the tendency to sud- den prostration of strength, and typhoid symptoms, that a tonic plan must immediately follow the means here recom- mended. In particular, bark, the sulphate of quinine, sul- phuric ether, and light nutritious food, are the remedies which produce most benefit. As the pain of carbuncles is severe, opium is another remedy which can seldom be dispensed with; and it is fre- quently a good plan to prescribe it in repeated doses, so as to keep the patient under its influence. In very bad cases, attended with delirium, the head should be shaved and blistered, and, with the other medicines, cam- phor should be combined. On the necessity of letting the patient enjoy the benefit of plenty of fresh air, in every instance of a typhoid kind, it is scarcely requisite to insist: it is a measure fully as im- portant as the choice of medicines, and in some respects more so, as without it all the articles of the materia medica will be ineffectual. In the local treatment, the surgeon should be impressed with the inutility of endeavouring to resolve a carbuncle • See Note E. f See Richter's Ansfangsgr. der Wundarzn. b. 1. p. 138 Lassus Pa thologie Chir. t. i. p. 41. * CARBUNCLE. 91 by any cold or astringent applications, a method, which (to say the best of it) is only loss of time. The most judicious practice is always to have recourse at once to emollient poultices and fomentations. The openings which form in the tumor are sometimes numerous, but so small that the matter and sloughs cannot readily escape. As they are likewise slow in forming, as well as inadequate to give a free outlet to the contents of the tumor, the best practice is to make an early and free in- cision. The surgeon should then press out as much of the matter and gangrenous cellular membrane as he can, with- out causing too much pain. An emollient poultice is now to be applied; the rest of the sloughs gradually loosen; the discharge improves in quality; the surrounding induration diminishes; the ulcer becomes cleaner and granulates; and the cavity is at length filled up and healed. In other less fortunate examples, however, the patient's constitution sinks; no healthy changes occur; and death soon follows.* The ancientsf made it a rule to apply the actual cautery to carbuncles in general; and this method is still pursued in France. Our brethren abroad adopt the old notion, that the heated iron stops the progress of the gangrene, and pro- duces a salutary irritation, which invigorates the debilitat- ed parts. They also occasionally employ the strongest caustics, such as the muriate of antimony; sulphuric acid; the muriatic acid, &c. A bit of charpie is dipped in them, and laid upon the centre of the swelling; or a small punc- ture is first made, and the caustic liquid then introduced with a pointed piece of wood. In America, the treatment with caustic also has advo- cates. " When openings form, and discharge a bloody se- rum (says Professor Gibson,) the poultice should be laid aside, and the surface of the tumor, as far as the openings extend, covered freely with the caustic vegetable alkali. The caustic gives some pain, but this soon subsides, and the severe burning pain, peculiar to the disease, is from that time entirely removed. Dr. Physick, to whom we are chiefly indebted for our knowledge of the proper applica- tion of this remedy, states, that in all the cases, in which he has used the caustic in this manner, the suffering of the patient ceased as soon as the pain from the caustic subsid- ed. It should be recollected then, that the caustic will • See Note F. f A. Corn. Celsus, lib. 5. cap. 28. 92 CARBUNCLE. prove hurtful in the commencement of carbuncle, but ex- tremely beneficial in the second stage, or that period when openings form in the tumor. From inattention to these circumstances, (continues Professor Gibson) there is rea- son to believe much mischief has resulted,—from deep ill- timed incisions, from the actual cautery, and from caus- tics." Blisters have been greatly praised for their good effects in.carbuncular diseases;* but the latter writer, who has made trial of thein, only admits that they are useful in lessening the pain.f CHAPTER IX. (EDEMA. (Edema is a preternatural accumulation of an aqueous fluid in the interstices of the cellular substance of a part. It is the same sort of disease, as anasarca, only less both in degree and extent. The tumor is uncircumscribed. The skin of the swollen part retains its natural colour: if at all changed it is rather paler. The part has a cold feel, and the pressure of the finger occasions an impression, or pitting, which remains some time, and slowly disappears. There is no acute pain; but an uneasiness, or sense of weight, and tightness. When the cedematous limb is in a depending posture, the magni- tude of the tumor is increased; et vice versa. In a few rare cases, the tumor is quite circumscribed, and of remarkably small extent: Mr. Pott mentions his having seen an affection of this kind, entirely confined to one side of the skin of the scrotum. This is to be won- dered at, as the fluid is situated in the common cellular substance. Sometimes, oedema is conjoined with erysipelatous, or phlegmonous inflammation; the case which Mr. Hunter called (edematous inflammation, and which is attended with an extravasation of water, and the appearance of common * Dorsey's Elements, vol. i. p. 25. f Institutes, &c. vol. i. p. 51. (EDEMA. 93 inflammation, the skin having a scarlet colour, which, how- ever is more diffused. The effused fluid being principally serum, the swelling is even more diffused than the inflam- mation itself. The part affected is very painful; but is not attended with much of the throbbing sensation which ac- companies common phlegmonous inflammation. The af- fection seems only superficial, though it probably extends to some depth. According to Hunter, the difference be- tween this and common inflammation, arises from the prin- ciple of inflammation acting upon a dropsical disposition, which is always weak. A stronger constitution would have produced the adhesive stage of inflammation, from the same cause. He adopted this belief, on account of the common occurrence of exactly this kind of inflammation, from distention in many cases of anasarcous legs. (Ede- matous inflammation is more lasting than common inflam- mation, and seldom suppurates. Should it do so, the cel- lular substance, in the interstices of parts, is apt to slough, and extensive, uncircumscribed abscesses to occur.* (Edema may depend on constitutional or on local debi- lity. Contusions, sprains, the long-continued use of splints, bandages, relaxing poultices, and washes, are often local causes of oedema. A part which has undergone acute inflam- mation, often remains cedematous for some time after- wards. In all these instances, the tone of the vessels being impaired, is the cause of the disease. The complaint is very often owing to some impediment, preventing the re- turn of blood towards the heart. The pressure of the gra- vid uterus on the iliac veins, often renders the lower ex- tremities cedematous. Aneurisms frequently compress the chief veins of an extremity, and bring on this affection. (Edema must in many instances be a mere symptom of other diseases, which operate as a cause. It accompanies ascites, hydrothorax, deeply-seated abscesses, &c. &c. The particular cause of oedema, whatever it may be, must be removed, ere a cure can be effected. When this important indication has been fulfilled, the next aim should be to promote the absorption of the extravasated fluid, and re-establish the original tone of the vessels. The limb should be kept in a horizontal position. Gen- tle frictions made on the part with flannel; fomenting with a decoction of camomile flowers containing a little campho- rated spirit; the repeated application of cold water from a • Hunter on the Blood, &c. p. 269. 94 (EDEMA. spring or pump; liniments; electricity; and a moderately tight roller; will tend to quicken the action of the absorb- ents. The operation of these means maybe promoted by giv- ing internally purgatives, diuretics, and emetics. If the tumor should not soften under this plan, but be- come so tense as to occasion pain, inflammation, and the danger of gangrene, the fluid may be discharged by means of small punctures. These, however, are not void of dan- ger ; for all wounds in dropsical constitutions, and parts, easily become gangrenous. The punctures, therefore, should be as small as possible. It is chiefly, however, in cases of anasarca, or those at- tended with a general dropsy of the whole body, and an extensive extravasation of water in the cellular substance, that scarifications become necessary, and not for the local swelling, implied by the term oedema. When the cedematous part is inflamed, every thing irri- tating should be removed. No bandages should now be employed. The limb should be placed in a horizontal po- sition, and covered with the lot. plumbi acet. Cooling pur- gatives are to be given, and the antiphlogistic regimen ob- served. Such inflammation is apt to occasion dangerous sloughing. CHAPTER X. BURNS. The injuries of the human body from the application of fire, or heated substances, are all comprised under the name of burns; with this understanding, that when the ac- cident is occasioned by boiling water, or other hot liquids, it is generally called a scald. Callisen,* and others, con- sider a burn to be nothing more than inflammation, witA its ordinary consequences, brought on by the action of high degrees of heat upon the texture of the body. With this idea, we must associate another, in order to render the de- finition accurate; viz. that in many severe burns some of • Sytema Chirurgiae Hodiernae, t. i. p. 298. BURNS. 95 the flesh is destroyed instantaneously by the fire, which actually kills, and even decomposes it, without there being any time or opportunity for previous inflammation. Burns are mostly divided into four species, or rather degrees. In the first, or mildest, there is but a slight red- ness of the skin, without any swelling or fever, and only a gentle inflammation is excited, which soon subsides. In the second degree, the redness is attended with swelling, the pain is sharp, and, if the burn be of much extent, and the constitution delicate and irritable, the injury gives rise to more or less symptomatic fever. The inflammation is acute, but it commonly terminates in resolution. In the third degree, vesicles arise either suddenly or gradually, containing a limpid or yellowish fluid, and indicating that the burnt or scalded surface has suffered more from the ap- plication of the heated or ignited substance, than in either of the preceding examples. The symptomatic fever is also more severe, the pain greater, shiverings and convulsions sometimes occur, and, unless the vesications be few and small, suppuration cannot be avoided. In the fourth, more or less of the burnt part is deprived of its vitality, or is so injured, that after an attack of violent inflammation, the flesh rapidly mortifies. In large or deep burns, attended with this fourth degree of injury, the constitutional symp- toms are usually very severe, the pulse is quick, small, and sometimes irregular, and the disposition to shiverings and convulsions great. However, when the burnt surface is at once destroyed, the case is generally less painful, than other instances in which the degree of injury is somewhat less violent. Thus, the two slighter kinds of burns generallv admit of resolution, the third case is followed by suppuration, and the fourth by mortification. The quantity of injury depends upon the intensity and duration of the heat ap- plied, and upon the extent of surface upon which it has acted. As heated fluids part with their caloric in being diffused, scalds are often attended with various degrees of injury at different points. It has been correctly remarked, that every division of burns must be in many respects arbitrary. The phenome- na, which occur in the milder species, present themselves also in the more severe ; and, we frequently see in one and the same burn, simple inflammation in one place, suppura- tion in another, and elsewhere, ulceration, gangrene, and mortification. Probably, it is partly from inattention to yd BURNS. this circumstance, that so great a diversity of opinion has prevailed, with regard to the best method of treatment Nor may it have been duly recollected, that the state of a burn is constantly changing, so that the remedies which are proper in one stage, may become useless and hurtful in another. The peculiarities of constitution also cause striking diversities in the appearance of burns, and in the effects of remedies upon them. Hence, of several burns resembling each other at first, and treated exactly alike, not two will heal precisely in the same manner.* The danger of burns is proportioned to the extent as well as the violence of the injury; hence, cases of even the fourth kind, not occupying much space, may be insig- nificant, while others of the first and second descriptions may be dangerous, and, indeed, actually fatal from their large extent. The danger of scalds is often considerable on account of their size; but burns may be attended with great risk, not merely in consequence of their magnitude, but also by reason of the depth to which the parts are in- jured or destroyed. The age and constitution of the patient make a good deal of difference in the chance of reco- very; burns in delicate unhealthy subjects, and in young children, being more dangerous, than in strong, healthy, adult subjects. The situation of the burn is another con- sideration of importance; for burns about the head, throat, chest, and abdomen, generally have worse consequences, than similar injuries of the limbs. Burns of the first and second degrees, unless they occupy a large surface, may be said to be usually free from danger, and by proper treat- ment, the inflammation may almost always be resolved. In cases of the third degree, suppuration commonly fol- lows, and, if the injury be extensive, there may be a great deal of fever, and considerable danger. Large chronic ul- cers are also a frequent consequence. Cases of the fourth degree, caeteris paribus, are the most dangerous of all, and never can be cured without a detachment of the dead parts from the living. Burnt patients may die from the violence of the inflammation, from the size and depth of the injury, and the shock of it upon the whole constitu- tion, from the severity of the symptomatic fever, from con- vulsions, from the profuseness of the discharge, or from the effects of gangrene. Extensive burns of the skin fre- * See Thomson's Lectures on Inflammation, p. 586. BrjK-V.v 9; quently bring on great difficulty of breathing; an effect of which every experienced surgeon is aware. Severe suppurating burns often produce disfiguring, ir- regular scars, stiffness and contractions of joints, wryness and distortions of parts, irremediable blindness, specks upon the cornea, concretions of the fingers, toes, or eyelids, a closure of the lachrvmal passages, or of other ducts and apertures, eversions of the eyelids, and a variety of other deformities and mutilations. With respect to the treatment, perhaps, we shall find in no branch of surgical practice a stronger disposition to pre- judice and credulity. A preposterous belief in the possi- bility of discovering some particular application, calculated for every sort of burn, and (what is more wonderful) for every stage and state of it, has not been one of the least absurdities which have disgraced this part of the healing art. Yet, one would suppose, it requires but little intelli- gence to discern, that as all burns are not alike, no single plan of treatment can be invariably right. Too often the salutary operation of the vis medicatrix naturae has been mistaken for a sort of proof of the good effects of several inert, or pernicious remedies, and it has not been properly remembered how many burns would get well of them- selves; nay, how many do actually undergo a cure, not- withstanding all the difficulties created by bad and unskil- ful surgery. If, however, a proposition at the beginning of this chapter be correct, viz. that the effects of burns are analogous to those of inflammation in general, inclusive of suppuration and mortification, then the same common principles which guide us in the treatment of inflammation and its consequences, ought undoubtedly to form the rule of our conduct in the treatment of burns. Nor can it be questioned, that these accidents must require as much va- riety of management, as any other cases, in which are ex- emplified all the different states and stages of inflammation, ulceration, mortification, &c. It would not be more ridi- culous to suppose, that all the numberless varieties of gun- shot wounds, should be left to the efficacy of some favour- ite plaster or ointment, than to fancy, that burns of every degree and condition, should have only one sort of dress- ing; or, that if a change be made, this is not to be regu- lated by the state of the injury, but rather by the time or period of it. Thus, if we follow the advice of some writ- ers, we are to dress all burns the first day with a certain application; the second day with another; and other alter- Vol. I. N ^ BUii-Ns- ations follow every rise of the sun. But this mechanical and unscientific wav of legislating in surgery by the clock or sun-dial, is totallv inconsistent with every notion which I can form of right practice. It must be wrong, inasmuch as the state of burns, at fixed periods after their occurrence, must be infinitely various, not only on account of the dif- ferent degrees of primary injury, but also because the na- ture of the patient's constitution, his age, strength, weak- ness, health, &c, constantly have vast influence over the subsequent appearances of the injured part. _ In the treatment of superficial burns and scalds, the in- dications are to remove the inflammation, and, by this means, prevent the formation of blisters; but, if we fail in this purpose, we must endeavour to hinder the vesications from becoming painful and troublesome ulcers. In a pre- ceding chapter, I have explained the acknowledged effica- cy of cold applications in diminishing inflammation, and most of the observations which have been there introduc- ed, might be here repeated. The practice of employing cloth dipt in cold water, or in rose-water, cooled with ice or snow, as dressings for the less severe cases of burns, is as ancient as the time of Rhazes. The plan should be adopted as soon after the accident as possible, it being, as Avicenna has remarked, one of the best ways of prevent- ing the formation of blisters. Another good method, when the situation of the injury will admit of it, is to immerse the scalded or burnt part, in very cold spring or ice water; or else to pour fresh cold water plentifully over the injur- ed surface. Pounded ice,* enclosed in folded linen, or mixed with hog's lard, is another excellent application for scalds and superficial burns, situated on the head, back, and other parts which cannot be conveniently immersed in cold water. It would be endless to enumerate all the different local remedies, which at least in burns unattend- ed with any separation of the cuticle, exposure of the cutis, or ulceration, operate chiefly, if not entirely on the princi- ple of reducing the temperature of the part. Suffice it-to mention various spirituous lotions, spirit of wine itself, the lotion of the liquor plumbi acetatis, and the dressing so much in vulgar repute, raw potatoes scraped into a soft pulp. All these applications being colder than the burnt surface up- on which they are laid, tend directly to lower its tempera- • Essay on the Means of lessening the Effects of Fire on the Human Body, by Sir J. Earle. BURN3. 99 ture, an effect which they must further produce bv their continual evaporation. But, in order to derive the utmost benefit from cold applications, they should be frequently renewed, as they soon become of the same temperature as the parts with which they are in contact. Although it seems to be generally admitted, that no local remedies are better than such as are cold, for the relief of scalds and superficial burns, there is nearly the same una- nimity amongst surgical writers respecting the danger of extending this practice indiscriminately to large or severe injuries of this nature, especially when situated upon the trunk. In extensive burns, however superficial they may be, the patient is liable to be affected with cold shiverings, and these shiverings may be greatly aggravated by exposure, and the application of cold.* Here the liniment of lime- water and linseed oil, and fomentations, will generally be found better, and more agreeable dressings, than refrige- rant washes. In speaking of the treatment of inflammation, I had oc- casion to notice the curious and seemingly inconsistent facts, of that process being sometimes most benefited by cold, and sometimes by warm applications. We find the same thing exemplified in the milder kinds of burns, and even more; for, if we are to credit a long list of writers, including Aristotle himself, as well as several distinguish- ed'moderns, holding the burnt part near the fire immedi- ately after the accident, is an effectual plan of rendering the symptoms milder. This method of burning the burn, as the phrase runs, is then not merely a vulgar practice, but a plan sanctioned and seriously commented upon by men of the greatest eminence. Yet, as Professor Thom- son justly remarks, the plan, notwithstanding so many au- thorities in its favour, has never come into general use. The inflammation of superficial burns has a natural ten- dency to resolution, and, as this happens under the influ- ence of both hot and cold applications, one is almost in- clined to believe, that nature, in effecting the cure of most cases of superficial burns, needs but little assistance from art: and that, whatever degree of credit practitioners may take to themselves for the spontaneous results, which oc- cur under different modes of treatment, the cure in reality ought to be ascribed to nature.f • Thomson's Lectures on Inflammation, p. 591." f Lectures on Inflammation, p. 592. 100 BURNS. Perhaps we should view in a similar light certain appli- cations, which are said to do good by keeping the burnt surface from the effects of the external air: as,for instance, olive oil, the- linseed oil, and lime-water liniment, &c. In those milder burns, where the insensible cuticle is for the most part unbroken, how are we to imagine that the exter- nal air could prove so hurtful, even were it possessed of those noxious irritating qualities, which the imaginations of surgical writers, rather than nature, have conferred up- on it? If oily liniments, therefore, be really useful in as- suaging the effects of superficial burns, (as I believe them to be,) it is better and more philosophical to be content with saying, that experience proves such efficacy, than to venture into fanciful and unfounded explanations of the fact. Small vesications, if not opened, may subside, but larger blisters should be pricked with the point of a needle, and the fluid let out, without removing the cuticle. In gene- ral, every superficial burn of much extent, requires anti- phlogistic treatment, venesection, mildly aperient medi- cines, and other means known to be beneficial in relieving inflammation. Opium is also indispensable in every in- stance attended with much pain, as it not only diminishes the suffering, and procures sleep, but lessens the disposi- tion to those dangerous convulsions, which carry off a large number of burnt patients. When the injury has been caused by the explosion of gunpowder, the grains are often lodged in the skin, from which they should be delicately removed with the point of a needle. We come now to the consideration of the mode of treat- ing the third species of burns, or those which suppurate. As Professor Thomson observes, the suppuration in severe cases may take place by the second or third day, but fre- quently it does not begin till a later period. It often hap- pens without any appearance of ulceration, just as it does from a blistered surface; and, after continuing some time, it is stopped by the formation of a new cuticle. In other instances, small ulcer itions appear on the surface, or edges of the burn. These spread into extensive sores. When suppuration takes place, unaccompanied by ulceration, any mild simple dressings will generally heal the part without difficulty. The applications in most repute, are the lini- ment composed of linseed oil and lime-water ; the unguen- tum zinci; the ceratum plumbi; either of which may gene- BURNS. 101 rally be employed with advantage, immediately after cold applications cease to produce benefit. In the other description of suppurating burns, while the injury is in a very painful state, and the ulceration is ex- tending itself, no applications are better than emollient poultices. Afterwards, when this destructive process has stopped, the secretion of good pus begun, and the surface of the ulcer become clean, and covered with healthy gra- nulations, the unguentum zinci, the ceratum plumbi, or common lint, with a pledget of any simple ointment, may be used as dressings. Should the sore require gentle sti- mulation, a little of the powder of myrrh and lapis calami- naris may be sprinkled upon it, before the other dressings are applied. No ulcers, however, are so disposed as those of burns, to throw out with surprising rapidity, high fun- gous granulations, over which the cicatrization proceeds with slowness and difficulty, and, when completed, leaves the part deformed with several indurated knobs and ine- qualities. The grand means of preventing this exuberance of the granulations, formerly consisted in the skilful appli- cation of pressure, by means of a roller, and in touching the surface of the ulcer with the nitrate of silver, or dress- ing it with unguentum resinae, with every ounce of which 3j of the pulv. hydrargyri nitrico-oxydi was blended. So freely, indeed, was this mercurial escharotic employed, that patients were frequently salivated by its absorption, and almost daily teazed with its irritating operation on the sore. But, the improvements in modern surgery have, in a great measure, superseded the necessity for this practice; for, when the situation of a burn is such as to admit of the part being compressed, and the edges of the ulcer approxi- mated with straps of adhesive plaster, it is found, not only that the granulations keep their proper level, but that cica- trization goes on with much greater expedition. The sur- geon should always recollect, however, that this is a method which is as improper for burns, which are in a painful irri- table state, with the ulceration spreading, as the use of tight bandages, or of caustic itself, would prove under the same circumstances. So various and multiplied, however, are the conditions and appearances of the sores resulting from burns, that a knowledge of this branch of practice implies that of the right method of treating ulcers in general; a subject to which we shall advert in a future chapter. The concretion of parts is to be prevented by the interposition of lint, the introduction of a probe, tube, bougie, or piece 102 BURNS. of sponge; and the frequent separation of the surfaces like- ly to grow together. It is particularly necessary to remem- ber this advice, in burns about the toes, fingers, ears, nos- trils, &c. When burns are situated near a large joint, like the knee or elbow, the limb should be chiefly kept in the position in which it would be most useful in the event of an anchylosis taking place. But every possible effort should be made to avert this unpleasant consequence, by gently moving the joint as soon as the state of the burnt part will allow. Should the evil, however, be unavoidable, the fu- ture position of the limb is a very important consideration; and, I need hardly observe, that while the lower extremity is most valuable, in the extended or straight posture, the arm, on the contrary, is most serviceable with the elbow bent. The anchylosis, of which I am speaking, is not what is termed true, but arises partly from preternatural adhe- sions, partly from long inaction of the muscles and tendons, and partly from the absorption of the granulations, after cicatrization, and the subsequent contraction of the skin. The simple division of such shortened portions of the inte- guments is rarely succeeded by any permanent removal of the wryness, deformity, and immobility of the parts, and after the wound has healed, things generally fall into the old state again. Here the practice suggested by my friend, Mr. Earle,* to cut away the cicatrix, bring the sides of the new wound together in a longitudinal line, and maintain the observance of a better position for a certain time, by means of splints and other mechanical aids, has sometimes materially and permanently lessened the deformity. A mo- dification of the same treatment, introduced by Mr. James, of Exeter, has also proved successful.! Burns of the latter kind require, from the first, constitu- tional as well as local treatment; for, when at all extensive, they are always accompanied with a good deal of symptom- atic fever, in which the pulse, instead of being strong, full, and hard, as after most other accidental injuries, is gene- rally small, quick, and vibratory. It is this weakness of the pulse which deters practitioners so much from bleed- ing: a practice, however, which is indispensable in the early stage of severe cases. Perhaps, indeed, the more frequent use of the lancet in this part of surgery, would form a real improvement. As Dr. Thomson observes, in * Medico-Chir. Trans, vol v. p. 96. and vol. vii. p. 173, &c. f Op. cit. vol. xiii. BUHN3. 103 the dry and hot state of the skin, diaphoretics maybe used with advantage. Laxatives are often necessary; but, in general, only the gentler sort should be given, on account of the pain which moving always gives to the patient. Here likewise anodynes are frequently necessary, not only to pro- cure sleep, but an alleviation of pain. During the symp- tomatic fever,a mild, vegetable farinaceous diet is proper; but afterwards, in the suppurating stages, it is essential to support the patient with animal food, wine, and cordials.* With regard to the treatment of the fourth species of burns, or those attended with sloughing, I believe we ought to pursue the same general principles, which should regu- late our conduct in the treatment of other causes of morti- fication. The faith put in the superior efficacy of vinegar, spirit of wine, and the linimentum terebinthinse, as first dressings for these cases, ought certainly not to be un- bounded ; and I cannot help thinking with Dr. Thomson, that in the early stage of many of these injuries ; that is to say, while the skin is unbroken and free from ulceration, it matters little whether we apply vinegar, spirit of wine, or oil of turpentine. None of these substances then come into contact with any raw, exposed, sensible parts, and, therefore, cannot be supposed to do cither much harm, or good, at least, as far as any specific quality is concerned. The evaporation of the vinegar, and spirit of wine, how- ever, will tend to cool the parts, and, on this principle, per- haps may be useful. As for the linimentum terebinthinae, employed in the manner which Dr. Kentish directs, I en- tertain exactly the same views of the practice as Professor Thomson of Edinburgh. The turpentine is used dhly*j"ust at first, while it can do no harm ; that is to say, while it cannot touch or irritate any raw, or ulcerated surface ; and then the applications are gradually altered to a milder de- scription. We may, therefore, see a reason for the success of Dr. Kentish's method, without placing the least confi- dence either in the visionary theories which he suggests, or in the alleged superior virtue of the oil of turpentine, as a general first dressing for burns. With these reflections, Tarn induced still to profess myself rather an advocate for simple emollient applications in cases of sloughing burns. Common poultices, the liniment of linseed oil and lime- water, and fomentations, are the means which I prefer • Lectures on Inflammation, p. 594. 104 BURN*. until the eschars have separated.* The remaining sores should then be treated according to the precepts already hinted at in the present chapter. The constitutional treat- ment of these cases is precisely similar to that of mortifi- cation arising from violent inflammation. ■—w»6 £ ft4*»—« CHAPTER XI. EFFECTS OF COLD. Of the general exciting, or stimulant power of heat, as a modern writer observes, there can be no doubt. And, with regard to cold, the disputes, concerning its operation, have been perpetuated only by logical illusion. In common lan- guage, we are accustomed to speak of cold as a positive and active energy, while philosophy can acknowledge it only as the expression of a relative decrease of tempera- ture ; for any degree of temperature designated by the ap- pellation of cold, is still heat.f The very same temperature may be called hot or cold, according as it is compared with a colder or a hotter temperature. If we warm one of our * f M Lisfranc has reported a number of cases of burns, treated with great advantage in the Hdpital de la Pilii, by means of a dilute solution of the chlorujet of lime. He divides burns into six degrees of intensity; " 1. superficiarinflammation, without plyctenae ; 2. inflammation of the skin, with plyctenae; 3. a portion of the papillary substance of the skin blacken- ed, the vital powers of this portion extinguished, but the alteration not ex- tending deep ; 4. the whole of the skin burnt and deprived of life ; 5. all the tissues disorganized, the bones only left untouched ; 6. the soft and hard parts reduced to a state of carbonization." The cases detailed by M. L. were nearly all of the third degree of the above scale, and were produced in various ways, and by different burning substances. The solution of the chlo- ruret was sometimes made directly after the accident—sometimes with the precaution of previous emollient cataplasms. The burnt surface is first co- vered with fine linen slit in various places, and spread with cerate; over this is placed a quantity of lint wet with the solution of chloruret of lime, more or less strong according to the idiosyncrasy of the patient. The dress- ings should be frequently moistened with the solution, and never permitted to get dry.—P. E.} f Kellie, in Edinb. Med. & Surg. Journ. vol. i. p. 305. The latter part of the above remark may be said to be generally true, with respect to any de- gree of cold of which we ever speak j though rules for calculating the zero of heat have been given. See Essays on Subjects chiefly Chemical, by \V. Irvine, M. D. ; 8vo. Lond. 1809. EFFECTS OF COLD. 1Q£ hands at a fire, while we cool the other by means of ice and then plunge both of them into water of the common temperature of the atmosphere, the water will feel cold to the hand which has been heated, and warm to the other which has been cooled. In a physical sense, every temperature of the air, or other surrounding medium, below 98% might be denomi- nated cold, because this is the common heat of the human body ; but with regard to the feelings and the health, a de- gree much lower, namely, from 60° to 66"°, is the most grateful and invigorating. The external medium at the temperature of about 62° appears to abstract the heat of the body in the same proportion in which it is generated, without any extraordinary exertions of the system; and, therefore, neither contributes to exhaust its powers, nor to excite uneasy sensations. Hence, also, the denominations of temperate, warm, hot, cool, and cold, are given to par- ticular degrees of the thermometric scale. The sensations of different men may vary, however, according to the pow- er which their respective constitutions possess of evolving heat. This depends much upon the original vigour of the system, especially of the heart and arterial system. It is also much influenced by habit, or by a person's being sea- soned to the cold. Hence, people who from vigour of con- stitution, or from habit, readily evolve a considerable quan- tity of heat, especially during moderate exercise, can bear with pleasure and benefit to their health, the very same de- gree of cold, which to the weak and unhabituated, is a source of painful chilliness. The first effects of certain degrees of cold applied to the human body, is to weaken the circulation through the small cutaneous vessels, more especially those which are situated in extreme parts, like the hands and feet; or, in projecting parts, as the ears, nose, scrotum, &c. which ex- pose a larger surface to the atmosphere, or medium, by which their caloric is abstracted. Hence the skin becomes pale, and contracting round the miliary glands and roots of the hairs, exhibits a roughness which is compared to the skin of an unfeathered goose, and is technically named the cutis anserina. The action of the heart and arteries in ge- neral becomes weakened; and the blood, being partially delayed in its course through some of the cutaneous ves- sels, and not undergoing the change of colour, which a cir- culation through the lungs produces, it gives a bluish or livid colour to the fingers, ears, and other projecting parts. Vol. I. O 106 EFFECTS OF COLD. If the cold be intense, or the exposure long-eontinued, the circulation in the extreme parts becomes altogether inter- rupted, and the power of evolving heat being completely destroyed, mortification is the consequence. Parts killed in this manner are said to be frost-nipped or frost-bitten. From the languor and weakness of the arterial system, produced by the application of cold, other effects on the constitution necessarily accrue. A free circulation of well- oxygenated blood seems essential to the perfect execution of the functions of the brain and nervous system, and to the support of sensibility. If the circulation is suspended for a few moments, as in syncope, the sensibility is also suspended; and, on the other hand, when there is more than an ordinary supply of blood to any part, as in inflam- mation, the sensibility is highly augmented. Hence an- other immediate effect of the agency of cold on the human body, is a diminution of the sensibility of parts. This is universally felt, in the nunibnesss of the hands and fingers, which, under the impression of cold, are altogether inca- pable of accuraie discrimination of touch : and the whole of the surface of the skin partakes of the imperfect feeling. The tongue is also incapable of distinguishing the peculiar flavour of sapid bodies, if they be extremely cold; and the sense of smell is considerably enfeebled by cold. If the cold be intense, or its application long-continued, the pow- ers of the whole system yield ; a torpor of the animal func- tions ensues; the action of the muscles becomes feeble, and scarcely"obedient to the will; an unconquerable languor and indisposition to motion succeed; and drowsiness comes on, ending in sleep, from which the person, if not speedily roused, frequently awakes no more.* The strong propensity to sleep, following the anxiety and lassitude experienced at an earlier period, is noticed by most writers as the precursor of imminent danger;! and it is certainly a symptom of usual occurrence. But, as an intelligent author remarks, it is doubtful how far the state of sleep is the necessary consequence of simple expo- sure to cold ; or, at least, what other circumstances besides cold are necessary for its production, since this exposure may be made to an intense degree of cold for a considera- * See a description of the effects of the cold at Terra del Fuego, on the persons who landed there with Dr. Solander and Sir J. Banks, as detailed in Cuptain Cook's first voyage. t Richter, Anfangsgr. der Wundarzn, b. 1. p. 117. Larrey, Me"m. de Chir Mil. t. iv. p. 106. Callisen, Syst. Cbir. Hod. pars i. p. 308. ■EFFECTS OF COLD. Itri ble length of time, without sleep being induced.* The case of Elizabeth Woodcock,f who lay buried under snow more than a week without sleeping a great deal, and those of some shipwrecked sailors, who were more or less im- mersed in water, in severe weather, for 23 hours, without being seized with drowsiness, are proofs that an irresisti- ble propensity to sleep is not constant.:}: In describing the manner in which the French soldiers perished from the severity of the cold in Russia, Larrey remarks, that their death was preceded by a paleness of the countenance, by a sort of idiotism, difficulty of speech, weakness of sight, and even a total loss of these faculties. In this state, some of the men continued to march for a greater or lesser time, led by their comrades. The action ot the muscles gradually grew weaker; the men reeled about as if they were drunk; and their debility increased until they fell down, a certain sign of the total extinction of life. The incessant and rapid march of the troops in close masses, obliged those who could not bear it, to quit the centre to walk along the side of the road. Separated from this compact column, and left to themselves, they soon lost their equilibrium, and fell into the ditches of snow, from which it was hardly possible for them to get out. Here they were immediately seized with a painful numbness, followed by lethargic drowsiness, and in a few minutes their miserable existence terminated. Frequently, before death, there was an involuntary emission of urine, and sometimes hemorrhage from the nose. Almost all the men who perished in this manner were found lying witht their faces downwards. The skin was without alteration of colour, or any appearance of gangrene. In general, death took place more or less rapidly, according as the subject had been fasting a longer or shorter time.§ It has been a question whether the human body, after being frozen, can ever be restored to life. Richter asserts the possibility of recovery, when the blood in the heart itself is not turned into ice; when this organ and large blood-vessels still retain a degree of vitality ; and there is no • Thomson's Lect on Inflammation, p. 624. | Hi-evr's Essays on Torpidity. * I'hil. Trans. 1792, and dime's Med. Reports on the Effects of Water, vol. i. chap. 15. § Larrey, Memoirs de Chir. Militaire, t. iv. p. 127-129. His description however, is rather that of people dying from the combined effect*! of cold. hunger, and fatigue, than from cold alone. I OS EFFECTS OF COLD, extravasation in the brain to render the thing impracticable. And he declares that persons, who have lain in a frozen state as long as four and six days, have been restored to life.* After a full consideration of this subject, 1 think there can be no doubt that Richter is in error; and that the eases of recovery to which he adverts, were only instances of restoration from a state in which suspension of sensation, voluntary motion, &c. had been induced by cold, and not examples in which the whole body, or even the greater part of it had been frozen. In order to ascertain the truth or falsity of an assertion, that some animals, especially ser- pents and fish, can recover their vitality after being frozen, Mr. John Hunter instituted a number of interesting expe- riments on the power of different animals in resisting the agency of cold. Two carps were gradually frozen, with the aid of a freezing mixture, and did not recover. It was with great difficulty that he succeeded in freezing a dor- mouse, such were its powers of evolving heat, and the non- conducting quality of its integuments; and it was not till the hair had been wetted that life was destroyed. This animal also did not recover. When a toad was exposed to a similar cold mixture, the water froze round the animal so as to enclose it, but without destroying life : yet, though not frozen, it hardly ever recovered the use of its limbs. The conclusion drawn from these experiments was, that an animal must be deprived of life before it can be frozen.] On the other hand, Hearne says, that spiders frozen so hard as to bound from the floor like a pea, were revived ■(^by being brought to the fire. Leeches, snails, grubs, and frogs, have been frozen to a certain degree by artificial cold, and revived. Other experiments have also proved, that frogs would revive even if the heart was frozen, but not if the brain congealed, after which they could not be affected by the galvanic action4 Captain Franklin, in his Northern Expedition, repeatedly saw fish, especially carp, recover after having been congealed by cold into a solid mass of ice; and one carp recovered so far as to leap about with much vigour, after it had been frozen for thirty- six hours.§ We learn from Professor Thomson, however, that in the year 1785, a variety of experiments were made • Vol. cit. p. 119. f See Philosoph. Trans, vols. Ixv. and Ixviii.; and Hunter on certain Parts of the Animal (Economy, p. 100,101. % Quarterly Review, No. Ivi. p. 382. § Franklin's Journey to the Shores of the Polar Sea, p. 248. 4to. 1823. EFFECTS OF COLD. 109 at the Royal Medical Society of Edinburgh, in order to discover some of the effects which exposure to intense de- grees of cold produces upon warm-blooded animals. In these experiments it was uniformly observed that death took place long before the irritability of the heart and other internal parts was destroyed, and at a time when the temperature of the blood, circulating in the heart and larger blood-vessels, was but little, if at all, reduced below 60* of Fahrenheit.* How far these various facts can be re- conciled by the different effects of artificial and natural freezing, or by the less pernicious operation of severe cold upon similar classes of animals in the polar regions, than in milder climates, I cannot presume to conjecture; but I have no doubt, that in whatever manner this physiologi- cal question may be hereafter settled, with respect to the lower animals, the truth of Mr. Hunter's inference with regard to the human subject, will remain unshaken. Who- ever will advert to any of the most remarkable examples on record, where persons have recovered after being ex- posed for a length of time to extraordinary cold, will find that the particulars by no means justify the conclusion that such cases were instances in which the whole body, or the greater part of it, had been frozen. We may be sure that this did not happen in the case of Elizabeth Woodcock, who lay buried six feet under the snow, and without food, from Saturday Feb. 2d, to Sunday Feb. 10th, 1799; for it is expressly related that she was sensible the whole time;; a state which cannot be supposed to be compatible with a general congelation of the blood, and other fluids in the system. The French peasant Boutillat was lost in a snow storm on the Black Mountains, which separate France from Spain, and lay asleep under the snow four days; but on the ♦ fifth morning he awoke with a sensation of thirst. How could this return of sense and intellect have happened, had ihe whole mass of the blood been in a frozen state ? Or, if it be thought that the fluid was in a state of congelation only while the man lay asleep and senseless, by what alter- ation of circumstances is the thawing of the blood to be accounted for, since he awoke buried under the snow, breathing through a hollow cone, which, as in the instance uf Elizabeth Woodcock, extended from his body to the * Thomson's Lcct. on Inflammation, p. 64!?. f Reeve's Essay on Torpidity, p. 109 110 EFFECTS OF COLD. surface of the snow?* Nor could the circulating fluids have been frozen to a great extent in three other individu- als, whose remarkable case is upon record, since in such condition, they would not have been in constant dread of being starved.f The very existence of sensation and in- telligence proves, that, in none of these cases, a complete- ly frozen state of the body or of the blood, could have ta- ken place. Had this last state been induced, no doubt re- covery would have been out of all possibility, notwith- standing the contrary sentiments which have been publish- ed on this point, by Fabricius, Hildanus, Richter, &c.±: TREATMENT OF PERSONS IN A STATE OF TORPOR OR SUS- PENDED ANIMATION FROM COLD. One great principle, insisted upon by practical writers, is to let caloric be communicated to the body in the most gradual manner.^ From observations and experiments, (says Mr. Hunter,) it appears to be a law of nature, in animal bodies, that the degree of external heat should bear a proportion to the quantity of life. When life is weakened, this proportion must be adjusted with great accuracy, but, when the powers of life are considerable, a greater latitude is allowable. "I was led (he observes) to make these ob- servations, by attending to persons who are frost-bitten, the effect of cold in such cases being that of lessening the living principle. The powers of action remain as perfect as ever, but weakened, and heat is the only thing wanting to put these powers into action; yet, that heat must at first be gradually applied, and proportioned to the quantity of the living principle, which increasing, the degree of heat may likewise be increased. If this method is not observed, and too great a degree of heat is at first applied, the per- son, or part, loses entirely the living principle, and morti- fication ensues. Such a process invariably takes place with regard to men: and the same thing, I am convinced, hap- pens to other animals. For, if an e|l is exposed to a de- gree of cold, sufficiently intense to benumb it till the remains * P.lhes, in Journ. de Medecine, Paris, 1767, torn, xxvii. f Narrative of three women saved, who were buried 37 days under the snow, in a stable at Bergemoletto in Italy, by F Soumis, 12mo. 1739. * For many judicious observations on this topic, consult Thomson's Lect. on Infla mation, p 642-644. § Richter, Anfangsgr. b. i. p. 123. Callisen, Syst. Chir. Hodiern, t. i. p -309. EFFECTS OF COED. Ill of life are scarcely perceptible, and still retained in a cold of about 40°, this small proportion of living principle will continue for a considerable time, without diminution or in- crease ; but, if the animal is afterwards placed in a heat of about 60°, after showing strong signs of returning life, it will die in a few minutes. Nor is this circumstance pecu- liar to the diminution of life by cold. The same pheno- mena take place in animals, which have been very much reduced by hunger. If a lizard or snake, when it goes to its autumnal hiding place, is not sufficiently fat, the living powers are, before the season admits it to come out, very considerably weakened, perhaps so much, as not to permit of the animal being again restored. If animals in a torpid state are exposed to the sun's rays, or placed in any situa- tion, which by its warmth would give vigour to those of the same kind, possessed of a larger share of life, they will immediately show signs of increased life, but quickly sink under the experiment, and die ; while others, reduced to the same degree of weakness, as far as appearances can discover, will live for many weeks, if kept in a degree of cold proportioned to the quantity of life they possess. " I observed many years ago, (says Mr. Hunter,) in some of the colder parts of this island, that, when intense cold had forced blackbirds or thrushes to take shelter in outhouses, such of them as had been caught, and were, from an ill- judged compassion, exposed to a considerable degree of warmth, died very soon."* I have deemed it advisable to cite these sentiments of Mr. Hunter, with some of the facts upon which they are founded, in consequence of my having read, in some mo- dern works of high repute and extensive circulation, that, in cases of suspended animation, or torpor from cold, the patient may be safely brought into a warm, but well ven- tilated room, chafed with warm flannels, and his feet and legs immersed in warm water.f Dr. Kellie does not think the same caution and reserve necessary in the application of heat to a case of general torpor, as to benumbed and frost-bitten limbs. In the latter occurrence, he admits, heat should be very gradually communicated, but (says he) surely we would not commence the treatment of a case of * Observations on certain Parts of the Animal (Economy, by J. Hunter, 4to. p. 137. 2d edit. Lond. 1792. f Kellie, in Edin. Med. and Surgical Journ. vol. i. p. 312. Rees's Cycl* pxdia, art. Cold. 112 EFFECTS OF COLD. general torpor, nearlv approaching to death, by applying snow to the body. lie argues, that there does not appear to be the same danger of violent re-action, or of destroy- ing by premature stimulation, an accumulated excitabihty in general torpor, where the sensorial functions have been all along suspended, as in a partial affection, where, not- withstanding the injury done to the part, the general pow- ers of the system have remained excitable. Notwithstand- ing the ingenuity of the reasoning which Dr. Kellie has adopted, I am far from thinking the practical principles, to which the observations of Mr. Hunter tend, are at all erroneous. The case related by Dr. Kellie was not an ex- ample in which the vital powers were reduced altogether by cold. The temperature to which the individual had been exposed was not indeed depressed to a degree gene- rally incompatible with activity and life, but he was re- duced by fatigue and fasting, and the effects of the atmo- spheric cold were increased by the drizzling rain which fell The blood which flowed from the arm was judged to be of its natural temperature. This was, therefore, a ease in which the temperature of the patient could hardly have been low enough to afford any criterion of the safety or danger of suddenly exposing a person to much warmth, who has been subjected to the effects of intense cold. If the facts mentioned by Hunter had left this matter doubt- ful, we might still be convinced of the truth of his observa- tions by other events upon record. The limbs of the pea- sant Boutillat, whose case I have already noticed, were covered with warm linen, dipped in aromatic liquors; his feet mortified, and he lost his life. These consequences. Dr. Pilhes thinks, might have been avoided by the use of cold applications.* The ample experience of Larrey, who was an eye-witness of all the disasters of Napoleon's cam- paign in Russia, appears also to confirm the truth of the principle inculcated by Hunter, Richter, Callisen, &c. In describing the sufferings of the French army from the rigour of the climate, Larrey exclaims, "Wo to the man benumbed with cold, whose animal functions were nearly exhausted, and especially whose external sensibility was destroyed, if he entered too suddenly into a warm room, or came too near the fire of a bivouac! The prominent parts, benumbed or frozen at a distance from the centre of the circulation, were seized with gangrene, which made its • Journ. de Medecine, torn, xxvii. EFFECTS OF COf.D. 1W appearance at the very instant, and spread with such ra- pidity, that its advances were perceptible by the eye, or the individual was suddenly suffocated with a kind of tur- gescence, which appeared to affect the brain and lungs: he perished as in asphyxia. Thus died the chief apothecary of the Guards. He had arrived at Kowno without any ac- cident, but his strength was much reduced by cold and ab- stinence. An asylum was offered him in a warm apartment in the pharmacy of the hospital. He had scarcely been a few hours in this atmosphere, so new to him, when his limbs, in which he had lost all feeling, became considera- bly swelled, and he expired soon afterwards in the arms of his son and one of his colleagues, incapable of uttering a single word. We saw some individuals fall down stiff-dead in the fires of the bivouacs," See* In describing the treatment of a person in a state of tor- por, or suspended animation from cold, Callisen and Rich- ter rigorously adhere to the principle, that caloric should be very gradually communicated to the body. The former recommends long-continued frictions with snow, or cloths wet with very cold water. This is to be done in a cold room, and he advises the surgeon not to let his endeavours cease too soon, as patients, after lying without signs of life for several days, have yet been snatched from the jaws of death. On the return of sense, motion, and warmth, aro- matic spirituous applications may be used; the temperature in which the body is placed may be raised, and cordials administered.! When signs of vitality return, Richter di- rects strong volatiles and sternutatories to be applied to the nostrils, air to be blown into the lungs, and the fauces to be tickled with a feather. He also recommends the in- troduction of tobacco-fumes up the rectum, a practice, how- ever, the propriety of which is questionable in all cases of suspended animation, on account of the debilitating, and even deleterious, effects of that plant. It might be better to throw warm wine into the large intestines, or inject it by means of a hollow bougie down the resophagus. When the signs of returning animation increase, the body is to be rubbed with brandy, and conveyed into a warmer situation. A diaphoretic drink is then to be given, and, as soon as the * Mem. de Chir. Mil. torn. iv. p. 134, 135. f Callisen, t. i. p. 309. Vol. I. P 114 EFFECTS OF COLD. patient has been well dried, he is to be put to bed, and re- main there till he begins to sweat.* Possibly these eminent surgeons may have extended the principle too far, in directing the body to be at first cover- ed or rubbed with snow. But I think we have every rea- son to believe, that their method of allowing the heat to be communicated only by degrees, is the most likely to be conducive to recovery. TREATMENT OF FROZEN PARTS. As in all the experiments which Mr. Hunter made upon the freezing of whole animals, he had never seen life re- turn by thawing, he was desirous of ascertaining how far parts were similar to the whole in this respect. He froze the ears of rabbits, and the combs and wattles of cocks, till the parts were so stiff and hard, that when cut, they flew from the blades of the scissors like a chip, and no pain nor bleeding ensued. After being thawed, they inflamed considerably; but, in the end, perfectly recovered. There was thus a material difference in the result of his experi- ments, on the whole of some of the more perfect animals, and on parts of them. But, though it was thus fully prov- ed, that parts of such animals might be frozen, and restor- ed to their natural state, it was not known whether this would happen in the more imperfect animals. Mr. Hun- ter, therefore, froze the tails of a tench, and two gold fishes, and endeavoured to restore the vitality of the parts, by putting the fish into cold water; but the tails, when thawed, did not resume their original appearance, the fish were sus- pended with their heads perpendicularly downwards, and ultimately died. All his other trials to restore the life of other cold-blooded animals, or of parts of them, after they had been frozen, also entirely failed.f Spallanzani also found, that the irritability of the muscles of frogs, toads, and lizards, was not destroyed by keeping these animals a good while in snow; but that, if the cold was increased, so as to freeze any part of them, the frozen part was invaria- bly killed, and rendered insensible to stimuli.:}: The experiments, however, on warm-blooded animals, corroborate what has long been believed, that when a part * Ridker's Anfangsgr. b. i. p. 125. f Obs. on certain Parts of the Animal fEconomv, p. 124 12.7 i Opuscules de Physique, t. 1. p. 118. EFFECTS OP COLD. 11a of the human body is simply frozen, without any impair- ment of its organization, it may often be recovered by the gradual communication of caloric to it. What parts of the human body admit of being frozen, without the destruc- tion of life, and how long they may remain in this state with impunity, (as Dr. Thomson remarks,) are points, which observation does not hitherto appear accurately to have de- termined : but we know, that portions of the cheeks, ears, and nose, have often been frozen by exposure to cold, and yet, that by a proper management the vital functions of these parts have been restored. It seems probable, there- fore, that a small part of the cutaneous texture may be frozen for a short period, without the necessary destruc- tion of its vitality. But Dr. Thomson considers the resto- ration of a frozen limb a matter of impossibility; and in the course of his reading, he has not met with a single un- equivocal instance of such an event.* On this point he differs from Callisen and Richter, quite as much as upon the other question of the possibility of reviving the whole body, after it has been frozen. Whatever doubts may have been suggested, concerning the propriety of keeping pa- tients out of a warm temperature, who are in a state of torpor and insensibility from cold, none exist with respect to the prudence of extending this principle to the treatment of very cold or actually frozen parts of the human body. If a limb, that is not indeed frozen, but excessively cold, be suddenly warmed, chilblains, frost-bite, and other more extensive forms of inflammation, are the result. The part swells, turns livid, and becomes affected with insupporta- ble darting pain. And when a part actually frozen is thus quickly warmed, the same symptoms arise, but in an aggra- vated degree, and rapidly end in mortification.f In this chapter I have already cited some facts,:*: strongly illustrative of the danger of exposing very cold or frozen parts to the fire; but, perhaps, on no occasion has the thing been more forcibly proved, than in the campaign of the French army about the period of the battle of Eylau. During the three or four severely cold days previous to this action, the mercury had fallen to 10,11,12, 13,14, and 15 degrees below the zero of Reaumur's thermometer, and yet, until the second day after the battle, not a single sol- • Lectures on Inflammation, p. 628. 642. | Richter, Anfangsgr. der Wundarzneykunst, b. i. p. 120. i From Larrey's Mem. de Chir. Mil. t 4. 116 EFFECTS OF COLD. dier complained of any accident from the effect of the cold. "We had, however," (says Larrey,) "passed these days, and a great part of the nights of the 5th, 6th, 7th, 8th, and 9th of February, in the snow, exposed to the most incle- ment frost." In the night, however, between the 9th and 10th, the temperature suddenly rose to 3,4, and 5 degrees above zero, accompanied with sleet. A thaw then com- menced, and, from this moment, numerous soldiers began to complain of acute pain in their feet, numbness, sense of heaviness, and annoying pricking pains in their limbs. The parts were but little swelled, and of a dark-red colour. In some individuals, a slight redness was observed at the base of the toes, and upon the instep; while, in others, the toes had lost all power of motion, all sensation and warmth, and become black and dried. These patients, without excep- tion, declared, that they had felt no uneasiness while the severe cold lasted, and that their complaints first began at the commencement of the thaw. From, these facts, Lar- rey argues, that cold is not an exciting, but only a predis- posing cause of inflammation and gangrene ,* a truth which Richter appears to have been well aware of, when he ob- serves, that cold alone, even the most intense, will never produce chilblains.f In order to thaw a frozen part gradually, it is best to rub it with snow, or ice and cold water, until sensibility and motion return. If the ear, or tip of the nose, be the part concerned, care must be taken to avoid breaking it. As soon as marks of sense and motion are discerned, the friction may be made with brandy, or camphorated spirit of wine. The patient may then have some gently diapho- retic drink, such as a little mulled wine, a basin of tea, &c. and be put to bed, in a chamber where there is a fire. Here he is to remain until he begins to perspire, when a perfect recovery of whatever sensibility may have been lost gene- rally succeeds. When a part is almost in the state of gangrene, in con- sequence of improper exposure to sudden heat, sometimes its recovery may still be accomplished by immersing it in water of a temperature nearly as low as the freezing point. The part must be kept immersed, until the swelling, pain, and marks of discolouration begin to diminish, when fric- * Memoire sur la Gangrene seche causae par le Froid &c i ii. p. 60. ' f Richter, b. i. p. 124. EFFECTS OF COLD. 117 tions with brandy, &c. may commence, and the warmth be gradually increased. CHILBLAINS. A chilblain, in the mild stage, is a moderately red tu- mor, occasioning heat and itching. The complaint after a time spontaneously disappears. In a more severe state, the tumor is larger, redder, and sometimes of a dark blue colour, and the heat, itching, and pain, are so vehement, that the patient cannot use the part. In a still severer case, small vesicles arise, which bursting and leaving excoria- tions, soon change into sores. The ulcers secrete a thin matter, penetrate deeply, and are very slow in healing. In the worst cases, the inflammation ends in mortification, which is often preceded by the formation of bloody vesi- cles on the tumor. The sudden warming of a cold part, and the sudden cool- ing of a heated part, seem particularly conducive to chil- blains; hence, parts most exposed to the vicissitudes of heat and cold, are most subject to the complaint; as, for instance, the toes, fingers, nose, ears, and lips. When a part is exposed to sudden cold, while it is in a state of perspiration, it is more likely to be affected with chilblains, than when thus exposed while simply warm. The most intense cold alone cannot produce true chilblains, though analogous complaints do remain in limbs which have been frozen. The more irritable and tender the skin is, the more readily the complaint arises. Children, especially those subject to scrophula, young persons, females, and all who are brought up tenderly, who keep themselves warm, and unexposed to the air, and who perspire much in the feet, are particularly liable to chilblains. One of the best applications to chilblains of the first and second sort, is ice-cold water. The part affected is to be immersed in it a few minutes, two or three times a day, until the complaint quite disappears. This event usually happens in less than four days. After every application, the part is to be well dried and covered with leather socks. In some cases, tonics and astringents have the best effect, such as diluted muriatic acid; the saturnine lotion; spir. vini camph.; tinct. myrrhae; the alum lotion, and vinegar. In other instances, oleum terebinthinas mixed with the bal- sam, copaivae; the linimentum camphorae; the linimentum ammonia?; tincture of cantharides diluted with soap lini- IIS EFFECTS OF COLD. ment; and a mixture of two parts of spir. vini camph. and one part of liquor plumbi acet., have proved the best ap- plications. Suppurating chilblains require topical stimulants, such as warm vinegar; a mixture of liquor plumbi acet. and aq. calcis; or a salve containing the hydrarg. nitrico-oxydum; touch the ulcers with the argentum nitratum.* Gangrenous chilblains must be treated according to thr rules explained in the chapter on mortification. CHAPTER XII. WOUNDS. By a wound, surgeons imply a recent, suddenly-formed breach in the continuity of the soft parts, attended at first with hemorrhage, and generally produced by an external mechanical cause. In a few instances, however, breaches of continuity both in the soft and hard parts, are suddenly caused by the vio- lent action of the muscles, which either tear themselves asunder, break the bones, or rupture the tendons with which they are connected. Sometimes, also, the sharp point of a broken bone wounds the superincumbent integuments, and changes the case into a compound fracture. Here we see that the cause is mechanical, but not of an external kind, as in ordinary examples. Wounds are divided into several kinds, the distinctions being founded either upon the sort of weapons with which the injury was inflicted, or upon the circumstance of a venomous matter having been inserted into the part; or, lastly, upon the particular situation of the wound, and the nature of the wounded parts themselves. Hence we have cuts, incisions or incised wounds, which are such as are pro- * {The Rev. Medicale, for February 1826, contains an account of a cure effected by M. Lisfranc, of an obstinate case of chilblains, where the back of the hand was extensively ulcerated, by dressing the ulcers with plasters of cerate, perforated with holes, over which compresses of charpie, dipped in a solution of the chloride of lime, were applied. The dressings were renewed every twenty-four hours. This mode of treatment, as well as that of burns by the cbloruret are worthy of further trial.—P. E.} WOUNDS. 119 duced by sharp-edged instruments, and are generally free from all contusion and laceration. The fibres and texture of the wounded part have suffered no injury but their mere division, and there is, consequently, less tendency to in- flammation, suppuration, gangrene, and other bad conse- quences, than in the generality of other wounds. Incised wounds also may usually be healed with greater quickness and facility than others, which are more or less contused or lacerated: the surgeon has only to prevent the solution of continuity from gaping, or, in other words, he has sim- ply to bring the opposite sides of the wound into contact with each other, and keep them in this state a few hours, and they will unite and grow together. Another class of wounds is stabs, or punctured wounds, caused by the thrust of pointed weapons, like bayonets, lances, swords, daggers, &c, and also by the accidental and forcible introduction of considerable thorns, large nails, Sec. into the flesh. These wounds frequently penetrate to a great depth, so as to injure large blood-vessels, nerves, viscera, and other organs of importance; and as they are generally inflicted with much force and violence, the parts suffer infinitely more injury than what would result from their simple division. It should also be noticed, that a great number of the weapons, or instruments, with which stabs are inflicted, increase materially in diameter, from the point towards their other extremity; and hence, when they penetrate far, they must force the fibres asunder, like a wedge, and cause a serious degree of stretching and con- tusion. It is on this account that bayonet wounds of the ordinary soft parts are very often followed by violent in- flammation, extensive swelling, large abscesses, fever, de- lirium, and other very unfavourable symptoms. The open- ing which the point of such a weapon makes, is quite in- adequate for the passage of the thicker part of it, which can only enter by forcibly dilating, stretching, and other- wise injuring the fibres of the wounded flesh. A third description of wounds is the contused and lace- rated, which strictly comprehend, together with a variety of cases produced by the violent application of hard, blunt, obtuse bodies to the soft parts, all those interesting and common injuries denominated gun-shot wounds. Many bites also rank as contused lacerated wounds. In short, every solution of continuity which is suddenly produced in the soft parts by a blunt instrument or weapon, which does 120 WOUND*. not operate by means of a sharp edge, or point, must be a contused or lacerated wound. Poisoned wounds are those which are complicated with the introduction of a venomous matter, or fluid, into the part. Thus the stings and bites of a variety of insects af- ford us examples of poisoned wounds. But a more serious and dangerous instance, which we meet with in this cli- mate, is seen in the cuts accidentally received in the dis- section of dead bodies, or in handling instruments infect- ed with any irritating or venomous matter, as sometimes happens to the surgeon in the performance of operations on gangrenous limbs, and in dressing venereal and other infectious ulcers. The most dangerous, however, of all the poisoned wounds which ever occur in this kingdom, are those caused by the bite of the viper, and by that of se- veral rabid animals, especially the dog and cat. Wounds are farther divided by surgical writers into those of particular regions, or parts of the body: thus, we have wounds of the head, face, throat, chest, abdomen, limbs, arteries, veins, nerves, lungs, liver, &c. £s?c. Wounds may likewise be universally referred to two other general classes, viz. simple and complicated. A wound is called simple when it occurs in a healthy subject; has been produced by a clean sharp-edged instrument; is un- attended with any serious symptoms; and the only indica- tion is to re-unite the fresh-cut surfaces. A wound, on the contrary, is said to be complicated, whenever the state of the whole system, or of the wounded part, or wound itself, is such as to make it necessary for the surgeon to deviate from the plan of treatment requisite for a common simple wound. The differences of complicated wounds, therefore, must be very numerous, as they depend upon many inci- dental circumstances, the principal of which, however, are hemorrhage; nervous symptoms; excessive pain; tetanus; a great degree of contusion; the discharge or extravasa- tion of certain fluids, indicating the injury of particular bowels or vessels ; the presence of foreign bodies, or of a poison, or irritating matter in the part; loss of substance; the attack of hospital gangrene, &c. AH large or deep wounds are followed by more or less symptomatic fever. According to Professor Thomson, it usually comes on at a period varying from sixteen to thir- ty-six hours after the receipt of the injury; but, as far as my observation extends, the attack is frequently much ear- lier than the time here specified. Its occurrence is indi- WOUNDS. 121 e-ated by a greater warmth of the skin; by an increase in the frequency, and generally also in the strength of the action of the heart and arteries; by anxiety, thirst, and a suppression of the powers of digestion. The symptomatic fever from wounds is generally of the inflammatory cha- racter; and it even sometimes happens that a very high degree of it takes place in debilitated constitutions, and in persons who have lost a considerable quantity of blood. In these latter cases, however, the frequency of the pulse is said to be more remarkable than its strength, and the fever rather to put on the asthenic, than the truly inflam- matory type. It is of great consequence to attend to the character of this fever; for the loss of blood, which may be required and sustained with impunity in one species of fever, may prove highly injurious, if not fatal, in the other.* The danger of wounds is proportioned to their size; the degree of violence done to the fibres in addition to their mere division; the little power which the part has of re- pairing its injuries; its great importance to the constitu- tion; the size of the injured blood-vessels and nerves; and the age and state of the patient's constitution. 1. The removal of a large adipose tumor is often ac- complished without injuring any part of importance, and yet the magnitude of the wound may occasion death. 2. A man cannot bear a large incised, and lacerated wound equally well; because in the latter case, the fibres are not only divided, but stretched, and otherwise injured. I have seen the integuments, covering the anterior surface of the tibia, torn in a straight direction, from the upper head of that bone, nearly to the foot: a rapid mortification of the limb took place, and the man died. Had this been a simple incision, such fatal consequences would probably not have happened, since the wound of amputation, even when a bulky thigh is removed, is not frequently the cause of death. All contused and gun-shot wounds are, for this reason, more perilous, than if they were simple breaches of continuity. 3. Joints seem to possess but little power of repairing their accidental injuries, which often induce a state of ir- remediable disease in the part, or so violent a disturbance of the whole system, that the patient loses his life. I here more especially allude to wounds of the large joints; for the smaller articulations generally bear extensive injuries • See Thomson's Lect. on Inflammation, p. 292. Vol. I. Q 12^ WOl'NDs. as well as most other parts. Some other parts are also pre- vented from readily healing, owing to the continual or fre- quent passage of fluids through them. This is the case with all the ducts and outlets of secreting organs, the in- testinal canal, the arteries, &c. 4. The slightest wound of a part, the functions of which are intimately connected with life,is often fatal; the brain, stomach, &c. 5. When large arteries are injured, the hemorrhage, if not immediately stopped, will destroy life in a few seconds; and, when the main artery and nerve of a part are both di- vided, there is generally a considerable risk of mortifica- tion, in addition to the first danger from the bleeding. 6. Wounds in young, strong, healthy subjects, generally heal more quickly artd favourably, than in persons of ad- vanced age, and impaired constitutions. INCISED WOUNDS. An effusion of blood from the divided vessels, pain aris- ing from the division and exposure of nerves, and a gaping of the wound, or separation of its edges from each other, are the immediate effects of a wound of the skin, or flesh, with a sharp cutting instrument. Anatomy teaches us that almost every part of the body is furnished with a vast number of blood-vessels, which, indeed, exist in such myriads that it is impossible to prick the skin with the point of the finest needle, without open- ing one or more ramifications of vessels containing blood, which fluid instantly oozes out. But this effect always hap- pens in a greater or more remarkable degree when there is an extensive cut in the skin or flesh; and if any of the wounded vessels be above a certain magnitude, the he- morrhage may be profuse, and even immediately fatal. The same experiment which demonstrates the presence of blood-vessels in every situation, namely, pricking any part of the body with a needle, proves also, that filaments of the nerves exist every where, and at every point; for the slightest prick of the skin occasions pain; and pain cannot happen except where there are nerves. The pain of wounds is observed to be. more or less acute, according to the kind of cutting instrument with which they have been inflicted; the extent of the division; and, especially, according as the individual happens or not to be in expec- tation of the receipt of the injury. A patient, on whom WOUND^. 123 an operation is to be performed, turns his whole attention to the effect which the use of the knife will produce upon his feelings, and he suffers a great deal; but if an incision be made when not expected, or when the mind is intent on other things, the agony is more moderate. Thus, a soldier may be wounded in the heat of battle, and not feel the hurt till the bleeding attracts his notice. When the skin, or flesh,is divided with a cutting instru- ment, the edges of the wound separate from each other, and the injury presents a gaping appearance. The instru- ment itself, acting like a wedge, must unavoidably sepa- rate the parts between which it enters; but, if this were the only cause, the gaping would be very inconsiderable. We find, however, that the opposite surfaces of many wounds are drawn away from each other several inches, and the principal causes to which the phenomenon is to be ascribed, are the natural elasticity of the skin, cellular membrane, fasciae, &c.; and power of contraction, inherent in the muscles. The quality of elasticity which belongs to most animal substances, and is inherent in them even after they have been deprived of life, does not prevail in an equal degree in every texture. Hence, the degree of separation, pro- duced by this cause, varies considerably, according to the nature of the wounded parts. The edges of an incision in the skin become widely drawn asunder, because the inte- guments are endued with great elasticity. The cellular membrane, when cut, gapes very little, because it is less elastic. The extremities of a divided artery recede far from each other; the retraction being far greater than what happens in divided veins, which possess a much smaller share of elasticity. The muscles, also, are not remarkably elastic; yet, the sides of these wounds, especially those of the transverse kind, are always considerably separated from each other; but this is not altogether owing to elasticity, but chiefly to a vital power of contraction inherent in mus- cular fibres. The separation of the edges of a wound is also not al- ways in proportion to the elasticity of the parts, but de- pends in some measure upon the degree of tension in which they happen to be at the moment of the injury. A sim- ple experiment proves the truth of this observation: if the skin covering the knee be divided transversely in a dead subject, while the leg is bent upon the thigh, and another similar incision be made in the knee, while the leg is ex- 124 WOUNDS. tended, the separation which happens between the lips of these wounds will be found to be much greater in the first than the second example. The prognosis of incised wounds varies according to the extent and depth of the division, the nature of the in- jured parts, and several circumstances which rank as com- plications. Deep large wounds are more dangerous and difficult to cure, than those which only interest the skin. Wounds, accompanied with injury of large blood-vessels, or nerves, are more or less dangerous, according to the magnitude and importance of those vessels and nerves, and the possibility, or impossibility of obtaining speedy surgical assistance. Simple cut wounds, in which the only indication is to bring the divided parts together, are the most favourable cases of all. On the other hand, compli- cated incised wounds are more or less serious and hazard- ous, according to the particular nature of the complication, whether this be a wounded artery, vein, or nerve of magni- tude and importance; a wounded excretory duct; a wound- ed bowel; a wounded trachea; oesophagus, &c. The com- plications also of bad health, and very advanced age, are other considerations which should influence the prognosis. Generally speaking, the most dangerous examples of in- cised wounds are those which are made about the throat, by persons who attempt to destroy themselves. Here there are so many large blood-vessels, nerves, and other organs of importance, that deep incised wounds too often prove fatal, either immediately, or in a short time. Sometimes the patient opens the carotid artery, and perishes of he- morrhage on the spot, before any assistance can be render- ed. In other instances, he divides some of the principal branches of the external carotid, and after losing a great deal of blood, faints, in which state the hemorrhage may cease for a little while. The fainting, indeed, is often the very thing which saves his life, by checking the effusion of blood until the surgeon arrives, who ties the vessels as soon as they begin to bleed again. Incised wounds of the extremities, when such arteries as the femoral and brachial are injured, may also suddenly destroy the patient by the great quantity of blood sometimes lost before the arrival of surgical assistance. I shall next consider the treatment of incised wounds. In these cases, there is frequently nothing to be reme- died, except the simple breach of continuity, the cut fibres not having been stretched, contused, nor lacerated. When WOUNDS. 125 no artery of importance is divided, and no extraneous bo- dies are lodged in the wound, the duty of the surgeon con- sists in promoting the re-union of the divided surfaces without delay. It often happens, however, that considerable vessels are injured, and then the bleeding demands primary attention. —••>♦»#*«— CHAPTER XIII. MEANS OF STOPPING HEMORRHAGE. In every wound, the bleeding demands the earliest at- tention, because, if loss of blood be not prevented without delay, the patient will frequently die in the course of a few seconds or minutes. Every other consideration may be deferred; but, when large vessels are injured, they must be immediately secured, or else the sudden death of the patient will leave the surgeon no opportunity of exhibiting his skill and usefulness in other matters connected with the treatrrfent. Previously to considering what surgical means are best calculated for stopping hemorrhage, it seems riqht that I should endeavour to give the reader some notion of the nature of the process, by which the bleeding from wound- ed arteries is permanently suppressed. Arteries, as Dr. Jones observes, are supplied not only with small arteries and veins (the vasa vasorum,) but also with absorbents and nerves, and have, in these respects, a similar organization to the other soft parts of the body. This structure makes them susceptible of every change to which living parts are subjected in common, enables them to inflame when injur- ed, and to pour out coagulating lymph, by which the injury is repaired, or the tube is permanently closed.* In short, the coats of arteries inflame, and pass through all the stages of adhesion, suppuration, or gangrene, in the same manner as the skin, a gland, or a muscle.f • Treatise on the Process employed by Nature in suppressing the He- morrhage from Divided and Punctured Arteries; and on the 1st- of the Ligature; concluding with Observations on Secondary II-morrhage, p. 5. 8vo. Lond. 1805. f Hodgson on the Diseases of Arteries and Veins, p. 1. 8vo. Lond. 1815. 126 HEMORRHAGE. Surgeons formerly entertained various theories concern- ing the process, by which the hemorrhage from divided ar- teries was suppressed; but, as none of these seemed alto- gether satisfactory, the late Dr. Jones was led to under- take a series of interesting experiments, the results of which enabled him to give a more correct view of the sub- ject; and, from these investigations, it appears, that when an artery of moderate size is divided, the bleeding is stop- ped in the following manner: An impetuous flow of blood, a sudden and forcible retraction of the artery within its sheath, and a slight contraction of its extremity, are the immediate, and almost simultaneous effects of its division. The natural impulse, however, with which the blood is driven on, in some measure counteracts the retraction, and resists the contraction of the artery. The blood is effused in the cellular substance, between the artery and its sheath, and passing through that canal of the sheath, which had been formed by the retraction of the artery, flows freely outward, or is extravasated in the surrounding cellular mem- brane, in proportion to the open or confined state of the external wound. The retracting artery leaves the internal surface of the sheath uneven, by lacerating, or stretching the cellular fibres which connected them. These fibres en- tangle 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 is completed by the blood gradually adhering, and coagulating around its internal surface, till it com- pletely fills it up from the circumference to the centre. The hemorrhage is checked by the effusion of blood into the surrounding cellular substance, and between the arte- ry and its sheath ; but, particularly, by the diminished ve- locity of the circulation, occasioned by the bleeding, and by the quick manner in which the blood always coagulates, when the action of the vascular system is much dimi- nished. Thus a clot over the mouth of the artery, within its sheath, called by Dr. Jones the external coagulum,r)re&ents the first complete barrier to the effusion of blood. The mouth of the artery being no longer pervious, and having no collateral branch very near it, the blood, just within it, is at rest, coagulates, and forms, in general, 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, which lies near the extremity of the vessel. This coagulum is distinct HEMORRHAGE. 127 from the former, and is named by Dr. Jones the internal coagulum. In the mean time, the cut extremity of the artery in- flames, and the vasa vasorum pour out lymph, which is prevented from escaping by the external coagulum. This lymph fills up the extremity of the artery, is situated be- tween the internal and external coagula of blood, is some- what intermingled with them, or adherent to them, and is firmly united all round to the internal coat of the artery. The permanent suppression of the hemorrhage chiefly de- pends on this coagulum of lymph; but while it is forming r within, the extremity of the artery is further secured by a gradual contraction, which it undergoes, and by an effusion of lymph between its tunics, and in the cellular membrane surrounding it. Thus, these parts become thickened, and so completely incorporated with each other, that one can- not be distinguished from the other; the canal and mouth of the artery becoming obliterated and blended with the surrounding parts. When the wound in the skin is not healed by the first intention, an exudation of coagulating lymph gives a cover- ing to the end of the vessel, and separates it from the cavi- ty of the wound. In the inferior portion of the divided artery, the orifice of the vessel is generally more contracted, and the exter- nal coagulum is much smaller. The extremity of the artery, as far as the first collateral branch, afterwards gradually contracts, till at length its ca- vity is completely obliterated, and its tunics assume a liga- mentous appearance. The external coagulum, which stopped the hemorrhage in the first instance, is absorbed in a few days, and the thickening of the parts, from the extravasation of lymph, gradually diminishes. If the end of the artery be examined, at a still later pe- riod, it will be found to be reduced to a mere filamentous state, as far as its first branch, and the anastomosing branches are considerably enlarged. Another fact, made out by Dr. Jones, is, that, when the division of an artery has happened near a lateral branch, no internal coagulum is formed. When an artery is punctured, or only partially divided, the blood is effused in the cellular substance, between the artery and its sheath, for some distance, both below and above the wounded part. On examination, a short time 128 HEMORRHAGE. after the hemorrhage has stopped, a stratum of coagulated blood is found between the artery and its sheath, extend- ing from a few inches below the wounded part, to two or three inches above it, and is somewhat thicker, or more prominent, just over the wounded part, than elsewhere. In consequence of the space between the artery and sheath becoming filled with blood, and the latter part dis- tended, the relative situations of the punctures in it and the artery are altered, and thus a coagulum of blood be- comes confined by the sheath over the puncture in the ves- sel, and stops the hemorrhage. But this is only a tempo- rary barrier; and the permanent stoppage of the bleeding is effected by reparation, or obliteration. Dr. Jones's experiments also prove, that if an artery be wounded only to a moderate extent, it is capable of re- uniting, and of healing so completely, that, after a certain time, the cicatrization cannot be discovered, either on its internal, or external surface; and that even oblique and transverse wounds (which are attended with more gap'mg than longitudinal ones,) when they do not open the artery to a greater extent than one fourth of its circumference, are also healed, so as to occasion little or no obstruction in the canal of the artery. But, as Petit observed, this can hardly ever happen, except when the aperture in the ves- sel has been of very moderate size.* In larger wounds, the vessel is rendered impervious by the effusion of lymph; and, when the division is still more extensive, the partial- ly divided part of the vessel becomes either torn, or ulce- rated through.f 1. TOURNIQUET. A modern tourniquet, that which is in common use, con- sists of a band and buckle, a pad, and two brass frames, the upper one of which is furnished with two small rollers, and the lower with four, over all of which the band plays, so as to facilitate the action of the screw. When the han- dle of this is turned to the right or left, the band is tight- ened, or relaxed, in the exact degre which the surgeon wishes. A piece of leather, under the lower brass frame, hinders the skin from being hurt at this point by the pres- sure of the edges of the hard metal. The buckle is pre- * Mem. de l'Acad. Royale des Sciences, an. 1735. f Jones, op. cit. chap. i. sect. 3. and chap. ii. HEMORRHAGE. 129 vented from having this effect by its being always fastened over the pad. The band is first buckled round the limb in such a manner, that the pad, which is attached to the band, is placed exactly over the artery. The two brass frames, with their respective rollers, over which the band proceeds, are then made to separate from each other to the requisite distance by turning the screw, and thus the due degree of pressure is produced. The advantages of this instrument are so considerable, that its first invention constitutes a great epoch in the an- nals of surgery. The pressure may be regulated with the utmost exactness, and it operates with most force on the point where the pad is placed, and under which the main artery lies. The instrument does not require.the aid of an assistant to keep it tense; it completely commands the flow of blood into a limb; it may be relaxed, or tightened in a moment; and where there is reason to fear a sudden re- newal of bleeding, it may be left slackly round a limb, and, in case of need, made tense in an instant. Its operation, however, is limited to the limbs, and as the pressure, necessary to impede 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 gangrene. Hence, k is only a temporary expedient for the stoppage of bleeding, general- ly discontinued immediately the surgeon has had time to adopt other means of a more permanent nature. The tourniquet is occasionally applied in a moderate state of tension, with the view of weakening, not suppress- ing, the current of blood in a limb. The common one, how- ever, does not accomplish this object advantageously, be- cause, by retarding the return of blood through the veins, it has the effect of rendering the arteries more charged with blood, consequently, any that are wounded more like- ly to bleed. In cases of anuerisms, where this plan is some- times practised, the compression of the veins does infinite harm, by augmenting the oedema, and painful tension, so frequently attendant on that disease. 2. LIGATURE. The most important of the means which has a permanent effect in the stoppage of bleeding, by producing a closure of the wounded vessels, is the ligature, by which the most alarming bleedings may be restrained. With this, the Vol. I. R 130 HEMORRHAGE. mouths of the divided arteries are tied, and thus, not only an instantaneous stop is put to further hemorrhage, but, long before the ligature becomes loose, the opposite sides of the vessels have generallv grown together, and all dan- ger of the renewal of the bleeding is over. Several of the conclusions, drawn from Dr. Jones's ex- periments upon the subject of hemorrhage, are of the high- est importance, in relation to the practice of surgery, and, were they all of them universally admitted, little doubt would remain about the most advantageous manner of making and applying ligatures. That a ligature, especial- ly a small one, when applied round an artery with a proper degree of tightness, cuts completely through the inner coats of the vessej^ is a fact which is now acknowledged by all the best informed writers on surgery, whatever may be their sentiments about other contested points in regard to the best mode of tying arteries. But whether we should employ such ligatures, as are expressly calculated to pro- duce this effect, and whether we should aim at it, as a be- neficial and useful, not to say an essential object, are ques- tions on which the greatest authorities are yet divided. From a variety of experiments, Dr. Jones was led to infer, that the division of the membranous and muscular coats of a tied artery by the ligature had a principal share in bring- ing on the effusion of coagulating lymph within the vessel, or, in other words, the process of adhesive inflammation, by which the permanent closure of the vessel was effected. He observes, that when a ligature is properly applied, it cuts through the internal and middle coats of the artery, keeps their cut surfaces in contact, and affords them an opportunity of uniting and cicatrizing, as other cut sur- faces do, by the adhesive inflammation. Nay, he extended the doctrine further, by representing the division of the in- ternal coats of the vessel by the ligature, not merely as ad- vantageous, but as absolutely indispensable; for he re- marks, that if the ligature does not completely cut through the internal and middle coats, all round the artery, adhe- sion cannot take place between its internal surfaces, and, therefore, secondary hemorrhage will take place.as soon as the ligature has ulcerated through any part of the artery.* That Dr. Jones erred in describing the division of the inner coats of the vessel as a thing, without which the ves- sel could not be closed by the process of adhesive inflam- * On Hemorrhage, p. 166 and 170. HEMORRHAGE. 131 mation, remains no longer questionable. The assertion, as Mr. Crampton* has observed, rested upon no other foundation, than several experiments, made on the arteries of quadrupeds, in all of which the internal and middle coats were ruptured by the application of the ligature. No com- parative experiments are related in order to show, that this operation of the ligature is essential to the process of union, and that, under these circumstances only, the obli- teration of the artery can take place. Numerous instances are recorded of arteries being obliterated by the pressure of tumors. The subclavian and carotid have been found obliterated by the pressure of an aneurism of the arch of the aorta.f In Mr. Freer's experiments, the pressure of a tourniquet for four days was sufficient to effect the oblite- ration of the radial artery in horses.i. Mr. Hunter observ- ed, that in dogs, the mere exposure of the tibial artery to the air for about an hour, excited such a degree of inflam- mation and thickening of its coats, as completely obstruct- ed the canal.§ All the great arteries, the aorta inclusive, have been found obliterated, in consequence of the effusion of lymph from their internal coat, and this independently of any injury which could produce the rupture of that membrane. The cure of aneurism by compression, (whe- ther mediate or immediate) affords an example of the ob- literation of an artery without any rupture of its internal coats.|| In the course of the interesting experiments undertaken by the late Dr. Jones, he found, that when a ligature is tightly applied round a large tin wounded artery in a quad- ruped, so as to cut through the internal coats, and it is im- mediately afterwards removed, the adhesive inflammation takes place at the part of the vessel, embraced by the liga- ture, and the canal of the artery becomes permanently ob- literated for some extent. This consequence happened, however, with increased certainty, when two or more liga- tures were thus applied near each other, and then taken off.H The promulgation of these observations at first excited hopes that the leaving of a ligature, on arteries, tied for • Medico-Chir. Trans, vol. vii. p. 343. | Hodgson on the Diseases of Arteries and Veins, p. 110. A. Cooper in Med. Chir. Trans, vol. i. p. 12. $ Obs. on Aneurism, p. 14. § On the Blood, &c, |] Crampton in Med. Chir. Trans, vol. vii. p. 345. \ JoncjiwOn Hemorrhage, p. 126, 8tc. 132 HEMORRHAGE. the cure of aneurisms, might be dispensed with; and what Dr. Jones had.himself succeeded in accomplishing, did not fail to convince him still more firmly, that the division of the inner coats of the artery was the main exciting cause of the adhesive inflammation, by which the canal of the vessel was permanently closed; and that the obliteration could not happen unless those coats were cut through by the ligature. But, as Mr. Travers has observed, the result of these experiments neither warranted the conclusion, that the complete division of the internal coat was necessary to union, nor that union was a necessary consequence of it. The history of the broad tape, or riband ligature, proves, that contact without wound will sometimes produce adhe- sion, and the frequent repetition of Jones's experiment has proved, that wound without contact will often fail to pro- duce it. Mr. Dalrymple, of Norwich, repeated the second experiment in Dr Jones's third chapter, not less than se- ven times on horses, and three times on sheep, and in every instance failed in obtaining the same results as Dr. Jones. Not only was no coagulum formed, but, even when the animal had been suffered to live until the thirteenth, fif- teenth, or eighteenth day after the operation, the canal of the artery was not found obliterated. Its calibre was in- deed contracted; but the tube remained in some degree per- vious, and capable of transmitting a lessened column of blood.* The evidence of another eminent writer also coin- cides preciselv with that of Mr. Dalrymple.f Dr. Jones's idea, that the division of the internal coats was essential to the production of the requisite degree of adhesive inflammation for the obliteration of the cavity of the artery, is completely refuted, not only by the facts ad- verted to by the preceding authors, but by a variety of other considerations. A ligature was put round the caro- tid of a dog without being drawn. It lay in contact with the artery, but did not press upon it, nor interrupt the flow of blood through it. The result was an obliteration of that part of the vessel which was irritated by the presence of the ligature. The same experiment was made on the ca- rotid of an ass with a similar consequence.^: Here then we have further proofs, as unequivocal as any of those previously cited from Mr. Crampton's valuable paper, that * Travers in Med. Chir. Trans, vol. iv. p. 442. j- Hodgson on Diseases of Arteries, &c. p. 228. i C. Bell, Surgical Obs. vol. i. p. 261. HEMORRHAGE. 133 the internal coat of an artery will effuse coagulating lymph when any cause of sufficient irritation exists on the outside of the vessel, and that the division of its inner coats by a ligature is by no means essential to the excitement of the adhesive inflammation within it.* As Scarpa remarks, all parts which resemble each other, and especially serous membranes, including the inner coat of the arteries, when kept in close contact in sufficiently vigorous subjects, generally assume with surprising quick- ness the adhesive inflammation in the seat of the compres- sion, and around it, evincing a singular propensity to effuse coagulating lymph, and, though such membranes are in- flamed, they remain free from all ulceration, or breach of continuity. This is daily seen between the lungs and pleura, between the peritoneum and the viscera of the abdomen, and between the tunica vaginalis and the testicle. And, in order to assure ourselves that the same phenomenon also happens betwixt the two opposite sides of an artery, which are sim- ply held in close contact with each other, without any pre- vious ulceration, or rupture of them, we need not have re- course to analogy in what takes place under the same cir- cumstances in other similar parts of the body, since there are numerous instances of the quick union and perfect closure of an artery, by means of the adhesive inflamma- tion, under simple compression alone, practised upon the artery while all its parts remain entire. Duboisf effected this prompt adhesion by means of the serrenoeud of De- sault; Assalini,J by compressing the artery with his for- ceps; and Crampton with a presse-artere, resembling that of Deschamps. To these facts, we are to add numerous others of the closure of the artery, in consequence of pres- sure made on the vessel by a neighbouring tumor, or an aneurismal sac. If the ligature were absolutely preferred to compression, in the treatment of external aneurism, still it would be certain, that by means of pressure, applied above the seat of the disease, several cures have been ac- complished; and if the compressing apparatus does not al- ways produce such good effects, it is often because we have not the opportunity of making the pressure with sufficient * See also Crampton's Experiments with a flat ligature, and piece of me- tal, on the carotids of sheep, in Med. Chir. Trans, vol. vii. p. 346, and other experiments detailed by Scarpa in his Memoria sulla Legatura delle princi- pali Arterie degli Arti, &c. Fol. Pavia, 1817. p. 34. et seq. I Leveille' Nouvelle Doctrine Chir. t. iv. p. 247—280. t Manuale di Chirurgia. 134 HEMORRHAGE. steadiness and force to obliterate the artery. Compression (says Scarpa) generally answers very well when made up- on an exposed artery, behind which there is a point of re- sistance. Formy,* in a wound of the brachial artery, laid bare the vessel, placed a cylinder of linen upon it, and over this some graduated compresses, supported by means of a suitable bandage; and thus he effected the closure of the ar- tery .+ Guattani, exposed the femoral artery as it passes un- der Poupart's ligament, compressed it against the ramus of the os pubis with graduated little bolsters and a band- age, and the vessel was speedily closed. Flajaniyf: in simi- lar cases, found the same method answer. Buzani,§ also succeeded with graduated compresses in healing a wound of the brachial artery, after bleeding; and so did Garneri in two additional examples of the same nature. Scarpa corroborates the purport of these observations by a rela- tion of some experiments, in which the arteries of sheep and other quadrupeds were tied with a simple ligature, and also with a ligature between which and the vessels a roll of waxed linen was placed, in order to prevent the inner coats from being cut through. The main result was, that, in all these cases, the artery closed, but the ulceration ad- vanced more quickly in the instances where the simple ligature was used.|| Four cases are likewise recorded, in which Scarpa's mode of applying the ligature was success- fully practised in operations for aneurism. Some other experiments performed by Mislei, and introduced at the conclusion of Scarpa's memoir, I shall notice in the chap- ter on aneurism, to the treatment of which disease they more particularly refer. The foregoing considerations cannot allow us to hesi- tate a moment about the rejection of Dr. Jones's assertion, that a ligature will never be followed by an efficient de- gree of adhesive inflammation within a tied artery, unless the inner coats of the vessel be divided by the cord. In- stead of this sweeping inference, Dr. Jones should merely have concluded, that such inflammation may take place, after the ligature has had the effect described, and not that it cannot happen under any other circumstances. The de- termination of this question, however, is not at all a deci- * Traite Chir. des Bandes Larges Emplatres, &c. Montpelier, 1652. f De Aneurysmate, Historia 15. * Collezione d'Osservazioni e Riflessioni di Chirurgia, t. ii. p. 47, 8cc. § Opere di Bertrandi. Trattato dell Operaz. t. iii. p. 207. Gli editori. II Memoria sulla Legatura, &c p. 27. 34, &c. HEMORRHAGE. 135 sion of the other point, viz. whether such division of the inner coats of an artery b)^the ligature be useful, or de- trimental, in its effects upon the process, by which the ves- sel is to be obliterated. This is an investigation of great- er difficulty, and one, concerning which very opposite sen- timents prevail. Dr. Jones, who considered such division as the best means of promoting the effusion of coagulating lymph within the vessel, and as the surest and most prompt mode of bringing about the union and closure of the tied part of the arterial canal, gave a decided preference to small ligatures, which always cut through the inner coats of the veesel with the greatest certainty. He thinks, that ligatures should be round, and very firm; and he declares, that there is no danger of their making the external coat of the artery ulcerate, by their tightness, before the internal ones have adhered; for the union of the latter is found to be soon effected. Dr. Jones reprobates broad, flat ligatures, because they cannot be tied smoothly round the artery, which must be- come puckered, and, consequently, have an irregular bruis- ed wound made in its middle and internal coats. By co- vering a considerable part of the external surface of the ar- tery, they may also destroy the very vessels which pass on it in their way to the cut surfaces of the internal and middle coats, and thereby render them incapable of inflam- ing. But, says Dr. Jones, admitting that such a ligature makes a proper wound, and that the wound unites, still it may cover that part of the external coat which is directly over the newly united part, and, consequently, as soon as it has occasioned ulceration through the external coat, it will produce the same effect on the newly united parts, and of course, secondary hemorrhage. A ligature of an irregular form will not cut through the inner coats of the artery equally at every point, which Dr. Jones endeavours to prove ought to be done, with a view of occasioning an effusion of lymph, and adhesion. Dr. Jones has also explained the advantages of applying ligatures in as circular a manner as possible; not higher on one side of the vessel than the other. Any deviation from a circle must be unfavourable to a steady apposition of the cut surfaces of the artery, and be conducive to secondary hemorrhage. Mr. Crampton, however, is far from admitting the utili- ty of cutting through the internal coats of the arterv with 136 HEMORRHAGE. the ligature, and is of opinion, that, in man, the division of these coats not unfrequentljyprevents the obliteration of the artery, and gives.rise to secondary hemorrhage; two assertions which appear to me not to be very well proved. If it be meant to draw a weighty argument from the weak- ening of the artery by this effect of the ligature, and an apprehension of the vessel bursting, or becoming dilated, how can we give such importance to this mode of reason- ing, when such inability of the remaining external coat to resist the impetus of the circulation must be very rare ? Although the two middle coats are divided by the ligature in securing the vessels in the common way after every operation, I have never seen an artery give way, or become dilated from this sort of cause. I have known the ligature slip from not having been skilfully applied; I have known it accidentally pulled off by a jerk of the hand, and hemor- rhage take place. I can even suppose, that an artery may be so forcibly tied as actually to produce a direct lacera- tion.of the external coat; but then the cause would rather be owing to the operator himself, than to any fault of his ligature. An artery may also be in so diseased a state as to give way at once under the application of the ligature; or if it should not burst so immediately, yet from being incapable of the adhesive inflammation, it may afterwards pour out its blood as soon as the ligature has produced ulceration through the external coat. But, in this circum- stance, it is evident, as Scarpa himself allows*, that no mode of tying the vessel will answer. As we are not suf- ficiently acquainted with the actual state of the vessels, the kind of ligatures employed, and some other essential par- ticulars, in the few cases cited by Mr. Crampton, with a view of proving the risk of arteries giving way from their inner coats being cut through by the cord, we cannot pro- nounce whether these were really examples of this injuri- ous operation of the ligature; or whether they might not rather be specimens of some uncommon diseased state of the arteries. For my own part, I cannot suppose any in- stance, in which the brachial artery, after being tied in amputation, would three times form an aneurismal tumor above the ligatures f if it were not in some unusual state • Memoria sulla Legatura delle Principali Arterie, p. 7. f See Warner's Cas.s in Surgeiy, p. 138. Probably the inner coats of the artery were in this case not divided, because the vessel was secured with a needle- and ligature, and of course an intervening portion of flesh included. Mr. Warner himself entitles the case " An Extraordinary Dis-. ease of the Humeral Artery." HEM0RRHA.G11. 137 of disease, because I have seen hundreds of amputations, but have never witnessed such an occurrence. Besides, if this particular case prove any thing, it proves, at all events, that the largish ligatures used in Mr. Warner's time, which ligatures probably never fairly divided the inner coats of a sound artery, could not prevent the vessel in question from giving way. Without extending these criticisms, however, I may safely assert, that the advocates for the utility of cutting through the inner coats of the vessel, and the employment of small fine ligatures, will come off triumphantly, if they only encounter such objections as are founded upon the danger of the artery at once giving way, or forming an aneurismal tumor. It avails little to talk, as Scarpa has done, of the arteries of some individuals being of preternaturally weak texture from birth,* or to urge with Mr. C. Bell, that, if a dead artery be tied too tightly, it will burst at the tied part when distended with anatomi- calf injection. The question can never be decided by such statements; and when we admit with these writers, that an artery with three unbroken coats is physically stronger, than when two of these coats are broken, or torn, we still maintain, that the remaining external coat is strong enough to resist the impetus of the circulation, as far as we can judge from the general result of the practice, in which it is the surgeon's particular aim to cut through the inner coats of arteries in applying the ligature. It matters not what happens in the injection of dead bodies; what hap- pens in aneurismal and diseased arteries before the liga- ture is employed; what may have happened in very unu- sual cases, showing that ligatures are not infallible; it must yet be proved, that the tying of arteries on the prin- ciples recommended by Dr. Jones, is generally less suc- cessful than other plans. Amongst the most distinguished surgeons, who oppose the doctrines and practice recommended by Dr. Jones, and so extensively approved of in this country, is Scarpa, whose valuable observations on many parts of anatomy and sur- gery render him the pride of the modern Italian school. After briefly describing the process of obliteration, accord- ing to Dr. Jones's account, and mentioning a few other things, to which I have already adverted, he argues, that * Mcmoria sulla Legatura dellc Princinali Avterie dogli Am', r> 2i, f Surgical Obs. vol. i. p. 260. Vol. I. S 138 HEMORRHAGE as cutting through the internal coats of an artery must ren- der the vessel weaker than when its coats are left undivid- ed, and we can never estimate the density of such a vessel in the living subject, it is caeteris paribus better to tie the vessel in such a way as will leave all its three coats unin- jured. When the internal coat is ulcerated from internal causes, and the adhesive inflammation does not supervene quickly enough, he says, the blood is invariably effused through the layers of the middle tunic, and extravasated on the outside of it; first in the form of ecchymosis, and afterwards in that of an aneurismal swelling. Now, if this can happen, when only the inner coat is ulcerated, it must still more easily take place, when the middle coat is also divided, and any cause retards the adhesive inflammation. He admits that, even in this second case, if, directly after the division of the two internal coats, the artery is affect- ed with the requisite degree of adhesive inflammation, as fortunately mostly happens, the union and closure of the vessel follow as speedily and favourably as if the two in- ner coats had not been divided. But he declares, that this fortunate issue is not constant, especially in man, in whom the adhesive inflammation is not, as it is in brutes, suffi- ciently quick to produce on the coats of the artery its bene- ficial effects, immediately after the application of a tight ligature. Yet while the adhesive inflammation is thus re- tarded, the ulcerative process occasioned by the pressure of the small ligature, rapidly attacks the external cellular coat of the artery, eats more and more deeply into it, and penetrates into the cavity of the vessel before this has been rendered impervious, and certainly with greater celerity, than if it had to make its way through all the three tunics of which the artery is composed. The slow access of the adhesive inflammation, whether from the general debility of the patient, or from the particular state of the artery itself,is not followed by a proportionate retardation of ul- ceration, which incessantly proceeds till it gives rise to the worst effects. Besides, if in feeble subjects the adhesive inflammation were not materially impeded, the coagulat- ing lymph effused in the cavity of the artery, as well as the coagulum itself, sometimes does not acquire with equal celerity the degree of consistence necessary for firm- ly connecting together the opposite sides of the artery, which are held in accurate contact. These dangers, says Scarpa, are unquestionably avoided by keeping all the three HEMORRHAGE. 139 coats of the tied artery from being injured by the pressure of the ligature.*! * Memoria sulla Legatura delle Principali Arterie, p. 26-28. t J A. highly interesting and valuable paper on tra matic hemorrhage by Professor II. G. Jamc ,on, of Raltimore, is contained in the American Medi- cal Recorder for January 1827. Dr. J. advocates the opinions of Scarpa and Crampton respecting die division of the internal and middle coats of an ar- tery ; he recommendfWlat ligatures of buckskin; which do not cut the coats. The following results were obtained by Dr. J. from a number of experi- ment*, in which ligatures of various kinds were applied to arteries. " 1. Ligatures of four common coarse sewing threads, twisted slightly into a cord, would not cut the inner coats. " 2. Ligatures of two threads applied tightly, not only cut the coats entire- ly around, leaving nothing but the thin outer coat, but by cutting the vasa vasorum, a small portion of blood escaped, and formed a red line, which ap- pcviv.i on removing the ligature. "3. Buckskin ligatures, of common size, drawn through the-nails of the thumb and forefinger, cut the coals more or less. ««4. A flattkh ligature, about two lines in width, not drawn through the nail*, but applied tight, neither cut nor bruised the inner coats. " 5. Ligatures of buckskin of common size, not drawn, applied tightly, did not cut the inner coats. But all kinds of the leather ligatures could be applied, with care, tight enough to bring the sides of the artery into con- tact, without cuttirtg the coats. In every instance, the vessel was much ^"bckered, but still the sides, in all cases, lay pretty well in contact, but "^Riere tied with the cutting ligature, certainly no better than when they dkl not cut. Indeed, we thought there was a preference, in this respect, in favour of the soft animal ligature loosely applied. We have practised these experiments upon the large arteries of human subjects, and find no differ- ence, except that the coats of the human kind do not so readily give under the animal ligature, and with any tolerable prudence in the application, they will not cut the inner coats at all. " We trust, we may now venture to assert, that we havcarrived at the fol- lowing important conclusions : 1. Hunter and Jones were right in advising us to take care of the vasa vasorum. 2. Scarpa, Crampton, Travers, 8tc. were right in objecting to cutting the tissue urteriel. They did not succeed, however, in devising the proper means of securing the intention of obliter- ating vessels without destroying their continuity. 3. Physick, and Sir A. Cooper, by employing a ligature having the property of dissolubility, greatly improved our practice, whatever might have been their kheory. Physick's ligatures, first used in 1814, have done much good. Cooper, by tying, in 1817, the femoral artery of a man aged 80, and healing the wound by the fourth day, shows the superiority of this method over that of Scarpa. " We aim at a combination of the improvements of all these parties ; we say, do not disturb the vessels subsidiary to the vasa vasorum—-do not cut off* the true vasa vasorum, nor strangulate them by your ligature. Tie the artery with a buckskin, ligature very soft, and a little broader than the thick- ness of the skin ; take care not to tie it too tight. Having done this, you may expect that the wound, in many cases, will heal by the first intention, where this fails there will be no suppuration about the vessel, and the wound will very soon close. You may expect a capsule to surround your liga- ture, if you have not disturbed the capillary vessels more than can be avoid- ed. Or the vessel will be surrounded by an abundance of lymph, and the li gature dissolved."—P. F.. \ 140 HEMORRHAGE. But, after all this reasoning, we must return to experi- ence; and if Mr. Crampton and Professor Scarpa have pro- duced cases, exemplifying the possibility of effecting the obliteration of arteries, without a division of the inner coats of the vessels, as I admit has been fully proved, they cannot subvert the fact, acknowledged by all the most ex- perienced surgeons in this metropolis, that since Dr. Jones's principles have been acted upon in practice, and small liga- tures been employed for securing bleeding and aneurismal arteries, cases of secondary hemorrhage have become much less common. Those principles dictate the use of a fine liga- ture, and prohibit all unnecessary disturbance and irrita- tion of the artery ; all needless separation of it from its surrounding connexions; and, in particular, forbid the in- troduction of a larger quantity of extraneous substances into the wound, than the indications positively require. If the increased success, to which I have alluded, be the truth, it is an answer to every argument used by the opponents of Dr. Jones's principles. With respect to the danger of the external coat being ulcerated through more quickly by a ligature, which divides the other two coats, as this oc- currence will enable the surgeon to remove the extraneoufl^ substance sooner, it must be a great advantage, if it be also • a fact, as experience proves, that such division of the in- ner coats expedites the adhesive inflammation, and ensures the closure of the vessel, before the ulceration has pene trated through the external tunic. Dr. Jones refutes the idea of the impulse of the circula- tion making the ligature slip off; a fear which has led to very hurtful practices ; with the view of mechanically fixing the ligature; and he observes, that a candid inquirer into the cause of it will find a much more rational explanation, either in the clumsiness of the ligature, which prevented its lying compactly and securely round the artery; or in its not having been applied tight enough, lest it should cut through the coats of the artery too soon; or in its having that very insecure hold of the vessel, which the deviation from the circular application must necessarily occasion. No other plan of presenting bleeding from large arte- ries is so safe as the ligature, because no other makes such direct pressure on them, nor acts with so little chance of being displaced. In the performance of operations, large arteries are often wounded in situations, where the tourni- quet cannot be applied. The scientific surgeon now knows that he can tie such vessels immediately they are wound- HEMORRHAGE. Ill ed, and then proceed with his incisions, without that con- fusion and danger which would result from the continu- ance of a profuse hemorrhage during the whole time re- quisite for the completion of the operation. Good surgeons always endeavour to tie arteries as se- parately as possible, that is to say, without any nerve, vein, or portion of flesh being included in the noose of the liga- ture. The tying of the flesh should constantly be avoided when possible, because it produces immense pain, and causes a larger part of the wound to remain disunited. Li- gatures, thus awkwardly applied, are likely to become loose, as soon as the substance between them and the ar- teries sloughs ; or they may form a circular furrow in the flesh surrounding the vessels, and remain a tedious time, incapable of being removed. The intervention of any substance, between the ligature and the artery, must also have a greater tendency to prevent the internal coats of the vessel from being cut through; that very event, on which the safety from secondary htmprrhage is found so much to depend. Blood-vessels partake of the same organization as other parts. Hence the healing of a wounded artery can only take place favourably, when that part of the vessel, which is im- mediately contiguous to the ligature, continues to receive a due supply of blood through its vasa vasorum. As these vessels are derived from the surrounding ramifications, it is obvious, that the application of a ligature, to a divided artery, at some distance from where it is encompassed by flesh, must be very disadvantageous and insecure. Thus, although it is quite improper to include much of the ad- jacent flesh with the artery in the ligature, it is highly judicious to make the knot as closely as possible to that part of the vessel which lies undisturbed among its natural connexions. These observations, however, only refer to vessels above a certain size; for others are not sufficient- ly visible to be tied in this manner. The method of tying an artery is as follows ; the extre- mity of the vessel is first to be taken hold of by the sur- geon, with a tenaculum, or pair of artery forceps, which open by their own elasticity, and admit of being kept close- ly shut with a double button, that slides along a slit in each branch of the instrument. The forceps is used only when the vessel is large and obvious. A round firm ligature, and by no means too thick, is then to be put by an assistant, in the form of a noose, round the artery, just below the end 14^ HEMORRHAGE. of the instrument. The same assistant then tightens the noose; and, in order that it may not rise above the mouth of the artery, he draw the ends of the ligature as horizontal- ly as possible, which can be done best with the thumbs. A knot is next made.* Assalini's very ingenious tenacu- lum would be found exceedingly useful in cases where the surgeon has no assistant at hand. See Fig. 1. Plate 1. When the wounded artery is large, one ligature to the orifice nearest the heart frequently will not suffice; for, as soon as this is tied, the blood finds its way, through anas- tomosing branches, into the lower continuation of the ves- sel, the further orifice of which from the heart then begins to bleed. When a large artery is only punctured, and not com- pletely cut through, the vessel is to be first exposed by an incision, and a double ligature then be put under it by means of an aneurism needle. One portion of the ligature is then to be applied above the wound in the artery, the other below it. Tfyus all danger of bleeding, from the blood's passage by the anastomoses into the lower part of the vessel is effectually removed. Sometimes, when the punctured part of the artery can- not be prudently exposed by an incision, the surgeon should cut down to the vessel in a situation nearer the heart, and be content with the application of one ligature.f Since ligatures act as extraneous substances,^ and only one half of each is necessary for withdrawing it when it * See Note G. f In a gun-shot wound, injuring the popliteal artery, I once took up the femoral artery, and the plan answered very effectually ; but the safest ge- neral rule is undoubtedly to expose the wounded part of an artery, and tie it above and below the aperture, from which the blood issues. \ {The introduction of animal ligatures into the practice of surgery is to be considered an invaluable improvement. The plan suggested by Mr. Law- rence ofusingfine ligatures of silk, and cutting offbotli extremities close to the knot, has not been found to answer his expectations. When animal ligatures are employed, both ends should be cut off close to the knot, and the edges of the wound brought together, so as to procure union by the first intention, which will generally be the result, as these ligatures do not act as "extraneous substances," but will speedily be taken up by the ab- sorbents. To Dr. Physick we are indebted for first testing this practice; he employed ligatures of French kid leather; Dr. Hartshorne next employed strips of parchment; Dr. Jameson, in the paper before referred to, recom- mends buckskin; and in the Transactions of the Medico-Chirurgical Society of Edinburgh, vol. ii. for 1826, ligatures made of silk worm gut, are recom- mended by G. Fielding, Esq., of Hull. It is obvious that either of these substances will answer the purpose, either will be absorbed;—\vc have made use of buckskin, and give it the preference.—P. F.J Wat, r. Ho Q. HEMORRHAGE. 14.1 becomes loose, the other half is always to be cut off near the knot. With the view of diminishing still further the quantity of extraneous substance in the wound, the practice of cut- ting off both ends of the ligature close to the knot has been of late years partially adopted. By some practitioners, the method is intended to be applied to all cases in which liga- tures are used, whether the wound admit of being imme- diately closed or not. Others think the practice advan- tageous only when the wound must inevitably suppurate; and they express fears of the inconveniences that might arise from the presence of the little bits of thread, which would be left in the part, if the wound were to be healed over them by the first intention.* The peculiarity in Mr. Lawrence's method, who is an advocate for this practice, even when the wound is to be immediately closed, consists in the use of extremely fine ligatures, made of dentists' silk.f The bits of silk are not absorbed; but generally remain for a time without irritation in the parts, included in minute cysts formed by the adhesive inflammation, or, they afterwards come out by exciting little suppurations on the surface of the cutis; or, when the wound does not directly unite, they come away with the discharge. Ligatures usually separate, even from the largest arteries ever tied, in about a fortnight, and from smaller ones in the course of five or six days. When they continue attach- ed beyond the usual period, it is proper to draw or rathei twist them very gently every time the wound is dressed. so as to accelerate their separation. 3. COMPRESSION. Formerly surgeons used to fill the cavities of wounds with lint, and then make pressure on the bleeding vessels, by applying a tight roller over the part. The moderns understand too well the utility of not allowing any extrane- ous substance to intervene between the opposite surfaces of a recent wound, to persist in this practice, except in a very few instances. They know, that the sides of the wound may be brought into contact, and that compression • Guthrie on Gun-shot Wounds of the Extremities, p. 93. See a'so Cross's Obs. in Lond. Med. Repository, vol. vii. 36:1, and I'.ibsoVs lr. titutes, &c. of Surgery, vol. i. p. 72. ' M dicof'hir. Trans. voV vi'ti. p. 1f '. 144 HEMORRHAGE. may yet be adopted, so as both to restrain particular he- morrhages, and rather promote than retard the union of the wound. When the blood does not issue from any dis- tinct, large vessels, but from numerous small ones, com- pression is preferable to the ligature, the employment of which would render it necessary to tie the whole surface of the wound. In order to make effectual compression in this case, the opposite surfaces of the wound are to be brought into contact; compresses are then to be placed over it, and a roller applied with moderate tightness. If compression can ever be safely practised in bleedings from large arteries, it is when these vessels run in the vici- nity of a bone, against which they can be compressed. Bleedings from the radial and temporal arteries are cases of this kind. Compression is sometimes tried, when the brachial artery has been wounded in phlebotomy. Here it is occasionally tried, in preference to the ligature, be- cause the latter cannot be employed without an operation to expose the artery. It is absurd to adopt compression, in this instance, with an idea that it effects a closure of the wound in the vessel without obliterating the arterial canal; and, consequently, with less chance of mortification from a deficiency of blood in the limb. Frequent dissections have proved, that whenever a large artery has been wound- ed and healed by pressure, the wound is never closed so as to leave the canal of the artery pervious. It is true, that Dr. Jones's experiments, as well as those of Beclard,* tend to show, that an artery, very partially divided, may heal and remain pervious; but this is not to be expected, when compression is employed. When an artery of magnitude has received a small wound, and lies favourably for a trial of pressure, the following plan may be followed: I suppose the brachial artery to be the vessel. A tourniquet is to be applied, so as to command the flow of blood into the vessel. The edges of the external wound are next to be brought into contact. Then a com- press, shaped like a blunt cone, and formed of a series of compresses gradually increasing in size, is to be placed with its apex exactly over the wound in the artery. This graduated compress, as it is termed, is then to be bound on the part with a roller.f * Recherches et Experiences sur les Blessures des Arte res. f See Note II. HEMORRHAGE. 145 After relaxing the tourniquet, if no blood escape, the surgeon should feel the pulse at the wrist, in order to as- certain that the compression employed is not so powerful, as entirely to prevent the circulation. The arm is to be kept perfectly quiet 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. Plenk invented a tourniquet, well calculated to heal wounds of the brachial artery, and represented by Fig. 2, Plate 1. Leather straps are attached to the buttons, a, a, a, a, and are fastened behind the arm with buckles; one above, the other below the elbow. The pad b, is to be placed immediately over a graduated compress, which is to be put directly over the wound in the artery. The ne- cessary degree of pressure may be regulated by the screw c; while the branches of the instrument, d, d, d, d, are at some distance from the limb, and consequently do not in- terrupt the flow of blood, either through the arteries or veins. Compression of large arteries is never commendable, except in such a case as.has been just mentioned, or when the wounded vessel is capable of being firmly compressed against an adjoining bone. The compresses sometimes slip off, or the bandages become slack, so as to give room for fatal hemorrhage. When the plan is employed, therefore, a slack tourniquet should always be left on the limb, ready to be tightened in an instant by a vigilant attendant left for that purpose. In this treatment, the external wound mav heal, while the aperture in the artery remains unclos- ed, and an aneurism be the consequence, particularly if the pressure be not powerful enough; and when it is too great, mortification is liable to happen. 4. AGARIC, Was formerly supposed to possess the virtue of stopping the most violent hemorrhage, without creating irritation. It has, however, no specific property of this kind; and whatever good effects it may seem to have had, are more properly ascribable to the compression adopted in conjunc- tion with it. If it have any virtue at all, this is a mechani- cal one, arising from its soft, spongy texture, which quali- fies it for filling up all inequalities in the wound, and thus closing the vessels. When it is considered that agaric is intended to be applied to the mouth of the bleeding ves- Vol. I. T • 146 HEMORRHAGE. sel: and that, in this plan, the opposite surfaces of the wound cannot be brought into contact, we shall feel inclin- ed to select some other means, not quite so repugnant to the union of the wound. Compression is often tried, be- cause the vessel cannot be tied without an operation in or- der to expose it. But the employment of agaric is war- ranted by no such reason; for its fancied specific virtues require its application to be made directly to the divided artery. Agaric has also the inconvenience of acting as an extraneous substance in the wound, and, like compresses, it is liable to slip off the precise situation which it ought to occupy. When the wounded vessel is large, surgeons should al- ways prefer the ligature to agaric ; and when smaller ves- sels bleed, compression is far preferable to it. These observations on agaric are also applicable to sponge. There are cases, however, in which it is impossi- ble to tie, or compress the bleeding vessel; and improper to employ means which remain to be described. In bleed- ings from the rectum, and from the wound after lithotomy, the expanding quality of sponge pften renders it exceed- ingly useful. The following means do not operate on the principle of pressure. 5. ACTUAL CAUTERY. The application of a heated iron to a bleeding vessel is one of the most ancient modes of suppressing hemorrhage; but, at present, it is almost in general disuse. It operates by producing a slough, which covers and closes the mouth of the artery. In order that it may not injure the cir- cumjacent parts, it is applied through a cannula. There are several formidable objections to its employ- ment: it does not regularly produce a permanent cessation of hemorrhage, as, when the eschar separates prematurely, the bleeding recurs. In many patients, the proposal excites horror; to all, the application is severely painful. The only cases, in which the actual cautery is at all jus- tifiable in modern practice, are hemorrhages situated in the mouth.*f • In Albert's Nosologic Naturelle, torn, i., is related an amputation of the tongue, where the bleeding from three large arteries was instantly and ef- fectually stopped by touching them with the cautery. f J On the removal of fungous tumors from the antrum maxillare, we fre- • > HEMORRHAGE. 147 6. POTENTIAL CAUTERY, OR CAUSTIC. The most common formerly used, was a button of the sulphate of copper, of the size of a pea, rolled up in apiece of linen, and placed on the aperture of the bleeding ves- sel. The operation of strong caustics is similar to that of heated irons. Caustics are even worse than the actual cautery; for their action is more tedious, less effectual, and not confined to the vessel alone. In a case recorded by Pel- letan, inflammation of the dura mater and death were pro- duced by muriate of antimony applied to a bleeding tumor on the head.* 7. styptics, &c. Styptics are alleged to have the property of producing a contraction of the vessels, and, as is sometimes erroneously supposed, a quick coagulation of the blood. Such are cold air, cold water, wine, brandy, tincture of myrrh, spi- rits in general, diluted mineral acids, solutions of alum, sulphate of copper, &c. These substances do, indeed, pos- sess the power of stopping a few hemorrhages from small vessels ; but, they ought never to be trusted, when large arteries are concerned. The method of applying fluid applications of this kind is to dip lint in them, and place it on the bleeding surface. Compression is generally adopted at the same time. That cold air has a styptic effect, we have the most un- equivocal proofs. We frequently tie on the surface of a wound, every artery that betrays a disposition 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 compels us to remove the dressings. The wound is again exposed to the air, and again the bleeding ceases. I have repeatedly seen this happen in the scrotum, after the removal of the testis. The proper conduct in quently see blood poured out by small vessels over nearly the' whole ex- posed surface, in such quantity that the patient would be in danger if means wliv not taken to arrest the hemorrhage. In such cases, therefore, as it would be impossible to use the ligature, we consider that the use of the actual cautery is not only "justifiable," but we know from experience that it is absolutely necessary.—P. E. \ * (linique Chirurgicale, torn. ii. p. 304.' 148 HEMORRHAGE. such cases is not to open the wound unnecessarily; but to apply cold wet linen to the part, and keep up a continual evaporation from its surface, by which means its tempera- ture will be reduced, and the bleeding suppressed. All styptics create great irritation in recent wounds, in which cases, therefore, scientific surgeons never have re- course to them. They are, however, judiciously used to suppress bleedings from many diseased surfaces, where the vessels seem to have lost their natural disposition to contract. When an artery is partly cut through, it generally bleeds more profusely, than when quite divided, because it can neither shrink under the surrounding substance, nor con- tract itself sufficiently to become impervious. Hence origi- nated the advice to divide some wounded arteries com- pletely through. This plan, however, ought seldom to be practised ; for, if the artery is large, a ligature must, after all, be applied both above and below the wound ; and though it may answer when the vessel is of a moderate size, com- pression is safer. Were a large artery to be cut quite through, previously to the application of ligatures to it, its shrinkingamongstthe circumjacent parts would afterwards only increase the difficulty of tying it. Sympathetic inflammatory fever, attended with an in- crease in the velocity of the circulating blood, and an aug- mented action of the heart and arteries, is the consequence of all considerable wounds. Hence, during its predomi- nance, the patient is particularly exposed to the danger of fresh hemorrhage. If the vessels be small, and the patient plethoric, vene- section is sometimes recommended, the loss of venous blood being less prejudicial to the constitution than that of arte- rial. The flow of blood into the wounded limb is to be decreased by placing the part (if possible) in an elevated posture. Sometimes cold applications, sometimes com- pression, may be advantageously tried; while, in other in- stances, a tourniquet, so constructed as neither to stop the circulation in too great a degree, nor hinder the return of blood through the veins, would be exceedingly useful. If, however, the arteries should be above a certain size, and { the hemorrhage still continue, the vessels must be expos- | ed, and tied. Hemorrhages from external injuries seldom require in- ternal means, which, if they were needed, possess but questionable virtue. However, keeping the patient in a HEMORRHAGE. 149 cool situation, not covered with too many cloths; enjoin- ing him to avoid all motion and exertions, and allowing him only a very low diet, are undoubtedly means well cal- culated to lessen the chance of hemorrhage. —-*#©ft«~— CHAPTER XIV. EXTRACTION OF FOREIGN BODIES FROM WOUNDS; UNION BY THE FIRST IN- TENTION, &c. Besides hemorrhage, there is another circumstance which requires attention before the wound is dressed; namely, the removal of all extraneous substances from its surface. This is universally allowed to be an object of very material importance, because, if it be not fulfilled, the wound may be brought together as nicely, as accurate- ly, and as skilfully as possible, and every thing look well at the beginning ; yet, that desirable event,.union by the first intention, will not follow, but, instead of it, a severe degree of pain, considerable swelling of the circumference of the injury, extensive redness, suppuration, large absces- ses, and even the worst consequence, sloughing. All these aggravated effects frequently arise from the irritation of foreign bodies in wounds ; and, as an incised wound can generally be examined, at first with the utmost facility, and properly cleaned, without putting the patient to much pain, the neglect on the part of the surgeon becomes the more blameable. In other deep, narrow, or lacerated wounds, and in many gun-shot injuries, it is often difficult at first to ascertain whether there are extraneous substan- ces in the flesh, or not; or when known to be there, their exact situation cannot always be determined; but, in open incised wounds, no such difficulty and obscurity prevail, and the surgeon who closes them, without having assured himself, that they are perfectly free from all extraneous matter, betrays either supine negligence, or an utter igno- rance of his professional duty. It is true, an incised wound, made with a clean sharp instrument, which has not been broken, can have no foreign bodies in it; but very consid- erable and dangerous cuts are often produced by glass. 150 TREATMENT OP WOUNBS. china, &c, which break at the moment, and leave some of their fragments in the flesh. .Sometimes, also, the weapon, with which the wound is made, is unclean, and sometimes, dirt, gravel, &c. get into the wound, in consequence of the patient falling upon the ground immediately he receives the injury. I shall merely repeat, that, as extraneous bo- dies create serious irritation in every kind of wound in which they happen to be, the surgeon should always direct his attention to their removal as soon as the bleeding is stopped. Mr. Hunter believed that blood, retaining the living principle, and lying on the surface of a wound, was rather useful than otherwise, in promoting the reunion of the parts; and it was his particular opinion that effused blood became hurtful to this process, only after being deprived of the living principle by long exposure, the effect of styp- tics, &c. Yet, this is a doctrine which is by no means sanc- tioned by the best modern surgeons, all of whom are quite convinced, that leaving any blood ttpon the surface of a re- cent wound, when its opposite surfaces are to be brought together, is highly disadvantageous, retarding the cure, and rendering union by the first intention less certain. The presence of blood must have the effect of producing a greater or lesser separation of the opposite surfaces, which strictly ought to touch each other. UNION BY THE FIRST INTENTION. When the surgeon has stopped the bleeding, removed extraneous substances, and properly cleaned the wound, the next indication is to bring the opposite sides of the injury evenly into contact, and keep them quietly and steadily in this position, until they have grown together. Wounds may be healed by two processes, viz. by one, in which pus is produced, and granulations and new skin are formed; and by another, in which, if it perfectly succeed at every point, no suppuration whatsoever takes place. Surgeons have termed this way of healing wounds union by the flrst in- tention, or adhesion, and Mr. Hunter named the process by which it, together with many other analogous effects, is accomplished in the animal body, the adhesive inflammation. The great recommendations of union by the first inten- tion, are, celerity of cure; the hinderance of the pain and inflammation which would arise from the exposure of raw surfaces; freedom from the inconveniences of suppuration: TREATMENT OP WOUNDS. LSI the prevention of the deformity which would result from a large, irregular cicatrix; and the greater permanency and soundness of the cure, as the part is covered by the old, original skin, which is invariably stronger, and less dis- posed to ulceration, than what is new. The strong tendency which divided parts of the animal body have to grow together, when kept a certain time in contact with each other, is an important fact, of which the moderns have taken much more advantage, than the an- cients. In the treatment of ordinary injuries, the latter seem to have availed themselves little, or not at all, of this readiness of raw living surfaces to grow together; and as we may see by referring to Celsus, it was principally in making attempts to repair and improve the appearance of deformed and mutilated parts, that they applied their knowledge of the fact to practice. The moderns, however, (I speak more particularly of our countrymen,) have shown their high sense of the good purposes to which this tendency to adhesion in the animal body may be con- verted, by recommending and practising the immediate closure of every wound, for the keeping of which open there is not some very particular and specific reason. There are even circumstances on record, leaving no doubt of the fact, that it is not quite impossible for parts, entirely de- tached from the rest of the body, to become united again, if quickly replaced. One extraordinary case, generally quot- ed in confirmation of this statement, is that mentioned by Garengeot, where a soldier's nose was bit off, yet on being immediately restored to its natural situation, it acquired there a permanent union.* Two other examples of the re- union of pieces of the nose, which were entirely cut off, are recorded by Fioraventi f, and Blegny i.; and well au- thenticated cases of similar facts in relation to other parts, may be found in different publications.^ The celebrated experiments of Duhamel and Mr. Hunter, furnish also a mass of interesting evidence, completely displaying the possibility of reuniting some parts, which have been re- cently severed from the rest of the body. It was proved • Traite des Operations, t. iii. p. 55. fSccreti Medicinali, 12mo. Venet. 1561. i Zodiacus Medico-Gallicus, Mars, 1680. § Hossu, in Journ. de M6decine, t. xxxiii. Dr. W. Balfour's Obs. on Ad- hesion, with two Cases demonstrative of the Powers of Nature to reunite Parts which have been by Accident totallv separated from the Animal Sv«.. r»-m, 8vo. F.dinb. 1814. 152 TREATMENT OF WOUNDS. by Mr. Hunter, that the testicles of a cock, when intro- duced into the abdomen of a hen, contracted a vascular connexion with the surface of the viscera, and lived ; and that a sound tooth might be transplanted from its socket, and acquire an union in the alveolary process of another person. Lastly, he repeated Duhamel's experiment, he cut off the spurs of a young cock, and found that they might be made to unite to its comb, or that of another cock, and grow even to a larger size than natural, in such situations. The possibility of this species of union shows how strong the disposition of the surfaces of a fresh wound must be to grow together; particularly when it is reflected, that, in the foregoing instances, there can be, on one side, no as- sistance given to the union, as the separated part is hardly able to do more than preserve its own living principle, and (as Hunter expresses himself,) accept of the union.* But, although this evidence is too strong to permit us to doubt the possibility of reuniting parts, which have been completely separated from the animal system, and in which the circulation of the blood has necessarily ceased for a time, it must not be dissembled, that attempts of this na- ture have generally failed. They are very successful, how- ever, when the detached part stilM'etains a partial and slight connexion with the rest of the body, by means of only a few fibres, or a little bit of skin: a circumstance that makes a very material difference. As Dr. Thomsonf has said, many cases are upon record, and many more have been observed, in which parts have been reunited which were completely detached, with the exception of a very small portion of cutis, a portion so small, that it is not easy to conceive, that any effectual circulation could be carried on through it; and he quotes from Arcseus an instance in which the nose, and most of the upper jaw, were so exten- sively separated, as to hang down upon the chin, and yet were afterwards reunited. A remarkable example of the same kind was published by Larrey $, one of whose assist- ants was actually about to cut through the connexion which was left, when he was interrupted by the Baron, who hap- pened to be on the spot. The instances, in which the fin- gers, toes, nose, and ears have been entirely cut off, with * See Hunter on the Blood, &c, p. 208, and Duhamel in Mem. de l'Acad. des Sciences, 1746. \ Lectures on Inflammation, p. 243. * Mem. de Chir. Militaire, t. iv. p. 20. 8vo. Paris, 1817 f TREATMENT OP WOUNDS. 153 the exception of a small bit of skin, and afterwards saved by adhesion, are so generally known, and frequently ex- emplified in practice, that it would be useless prolixity to dwell upon them. The knowledge of the preceding facts cannot but prove useful in relation to surgery: it raises our confidence in the powers of nature, under circumstances in which we should otherwise entirely despair; and, with the precedents before us, we shall be induced to attempt the union of parts, and, sometimes succeed, when the project would appear hopeless and absurd to any one uninformed of what has al- ready happened in other similar cases. In promoting union by the first intention, surgery is merely to officiate as the handmaid of nature. There are only two indications: the first is, to bring the edges of the wound accurately together, and keep them so; the other is, to endeavour to avert violent inflammation, by which the agglutination of the wound would certainly be prevented. The first object is accomplished by a proper position of the wounded part, and by the use of bandages, adhesive plas- ter, and sutures ; the second is fulfilled by a strict observ- ance of the antiphlogistic regimen, and particularly by avoiding every kind of motion and disturbance of the wound. The rest is the work of nature. 1. POSITION OP THE PART. This is to be regulated on the principle of relaxing the wounded integuments and muscles. If the extensor mus- cles are injured, the joints which they move ought to be placed in an extended posture; if the flexor muscles are wounded, the limb is to be bent. When the integuments alone are cut, the same posture which relaxes the muscles situated immediately beneath the wound, also serves in ge- neral to relax the skin. In transverse wounds of muscu- lar fibres, it is astonishing what immense effect a proper posture produces. This is never to be neglected, whatever may be the other means adopted. 2. HANDAGES. Bandages may frequently contribute very essentially to keep the sides of the wounds duly in contact, as is strik- ingly illustrated in cases of harelip, where the opposite edges of the fissure may be brought forward so as to touch, Vor.. I. U 154 TREATMENT OF WOUNDS and be maintained in this position by the simple use of com- presses and a bandage. Such was the mode of treatment actually preferred by M. Louis; and were it not for the greater convenience and certainty of the twisted suture, it is the plan to which surgeons would yet have recourse. The common uniting bandage can only be applied to wounds which take a direction corresponding to the length of the body, or limbs, and which are situated where a band- age can be used with convenience and effect. It consists of a double-headed roller, with a slit between the two heads, large enough to allow one head of the roller to pass through it with facility. The proper dressings having been put on, the surgeon is to take one head of the roller in each hand, and apply the bandage first to that part of the limb which is opposite the wound. One head of the roller is then to be brought round, so as to bring the split precisely over the breach of continuity. The other head is then to be brought round in the opposite direction, and passed through the fissure. The bandage is next to be drawn moderately tight, and its two heads being carried round the limb again, the same artifice is to be repeated. A sufficient number of turns of the roller must be made to cover the whole length of the wound. When the wound is deep, small longitudi- nal compresses are sometimes put under the roller, at a little distance from the edge of the wound. As the uniting bandage can only be made use of for lon- gitudinal wounds, which never have a considerable ten- dency to gape, nothing can be more absurd than the appli- cation of it with immoderate tightness. By this cruel and injudicious practice, many limbs and lives have been lost; for, if the bandage be very tight on its first application, what a dangerous constriction of the limb or part must follow, when the swelling, necessarily arising from the wound, has come on. It is thus, that insufferable pain and gangrenous mischief are frequently induced, when, if the part had been simply dressed, and left unconfined, every thing would have gone on most favourably. It is right to state, however, that modern surgeons are not partial to the uniting bandage, and I have no hesitation in saying, that it is a means which may be advantageously banished from practice. If it be true, that it brings the sides of deep wounds together better than adhesive plaster alone, and that it acts without the irritation arising from the applica- tion of resinous substances to the skin, it still has many in- conveniences: its total concealment of the wound, its lying TREATMENT OP WOUNDS. 155 in irregular folds, so as to create an uneven cicatrix, the difficulty of undoing it, and some other serious objections, might be mentioned. These reasons have rendered its employment much less frequent than in former times, and, I may say, that its use in this country is now superseded by the preference universally and justly given either to a common roller or an eighteen-tailed bandage, in every sort of wound for which the old incarnative bandage, some years ago, used to be recommended. 3. ADHESIVE PLASTER. It is erroneously set down in numerous surgical books, as being only applicable to superficial wounds of the skin. It is true, that it has no direct effect in bringing the edges of a deep, muscular wound together; but, let it be remem- bered, that while it proves effectual in maintaining the edges of the skin in contact, it presents no obstacle to the simultaneous adoption of a proper position, compresses, and bandages, means having more effect on the deeper part of the wound. It is also an error to suppose, that adhe- sive plaster cannot be used in situations where hair grows, or where the application is apt to become moistened. If the part be well shaved, and perfectly dried at first, the plas- ter will not become loose so soon as to prove ineffectual. It is generally applied in strips, between every two of which an interspace is recommended to be left, for the pur- pose of allowing the discharge to escape, in the event of any part of the wound not healing in the ready manner which is desirable. Therefore, to bring the edges of the wound effectually together, and, at the same time, to leave a little room for the exit of the discharge, are the leading objects to which we ought to attend in using adhesive plas- ter. Hence, when the strips are broad, it is not unfrequent to cut out an oval piece of each strip, just where it crosses the wound. Adhesive plaster is of great use, even in those wounds in which it is impossible to bring the edges into contact: by bringing and retaining the edges near each other, the strips lessen the size of the wound, while they keep sur- faces in contact which have a disposition to adhere: and ultimately, when the gradual elongation of the old skin begins to take place, they succeed in bringing the separat- ed edges together.* * See Thomson on Inflammation, p. 29.3 lob TREATMENT OF WOUNDS. A pledget of simple cerate is often applied over the plas- ters: it is frequently preferable to dry lint, which sticks to them and the ligatures, and is more troublesome to remove. 4. SUTURES. Of the numerous sutures used by the old surgeons, only four are now ever employed: viz. the interrupted, the quill, the twisted, and another one, named gastroraphe. The twisted suture will be spoken of in the chapter on the hare- lip, and gastroraphe will be noticed in that on wounds of the abdomen. INTERRUPTED SUTURE. When the bleeding has been suppressed, and all extra- neous substances have been removed, the surgeon is to place the limb in such a posture, as shall enable him to bring the lips of the wound easily into contact. The nee- dle,* armed with a ligature, and having a curvature that forms the segment of a circle, is then to be introduced into the right lip of the wound, at a small distance from its edge, and is to be directed across the bottom of the wound, so as to come through the left lip from within outward. It is now to be cut off, and the ligature tied in a bow. These sutures should always be, at least, an inch from each other. At the same time, strips of adhesive plaster, and a band- age for the support of the part, are usually employed. QUILL SUTURE. Formerly, this means of uniting wounds was often prac- tised, when the muscles were deeply wounded, on the sup- position that it produced a more perfect support of every part of the wound, than could be effected with the preced- ing suture. The same kind of needle is used as for the interrupted suture; but it must be armed with a double ligature. When the double ligatures have been introduc- ed through the lips of the wound, at as many places as its * \ A better plan of making the interrupted suture, and one which gives infinitely less pain to the patient, is to make use of two needles with a sin- gle ligature; both needles should be passed from within outwards, then re- moved, and the ligature tied. This is the more important where it is ne- cessary to introduce several sutures, as in extensive superficial wounds of the neck, &c—P. E. \ TREATMENT OF WOUNDS. 157 length may require, their ends are to be separated, and then tied in a bow over a piece of bougie or quill, placed along each lip of the wound. Dionis first reprobated this suture, which is justly re- jected by the moderns as an artifice of mere ingenuity, and no real utility. An account of its modifications, therefore, would be superfluous. In the present schools of surgery, the use of sutures is less recommended than in former days. By the combined operation of position, adhesive plaster, and a bandage, al- most all wounds are capable of being united as expediti- ously, and well, as they could be, were sutures employed. In the cure of the harelip, and a few wounds of the face, and, perhaps, in the^treatment of large wounds penetrating the abdomen, we mlist admit their utility. In wounds of the lips, the incessant and unavoidable motion of the parts; and, in those of the abdomen, the distention, arising from the viscera, and the danger of their being protruded, are reasons which, in these particular instances, may account for the advantages of sutures. But, in general, the promo- tion of union by the first intention cannot be set forth as a valid argument, in favour of the practice. Inflammation, above a very moderate pitch, always destroys every pros- pect of this nature, and occasions the secretion of pus, in- stead of the exudation of coagulating lymph. Sutures have fallen into disrepute, principally because they tend to in- crease inflammation. The new wounds which they make, their irritation as extraneous bodies, the forcible manner in which they drag the living parts together, and their in- capacity, in general, to accomplish any useful purpose, which position, adhesive plaster, and bandages, cannot effect, are strong motives for reprobating their common application. In fact, it often happens, when sutures are employed, that considerable inflammation of the wound is the consequence, and its swollen edges evince marks of suppuration, unless soon relieved from the irritation of the ligatures. Frequently, in this kind of case, if the surgeon be sagacious enough to cut the ligatures, and remove them in time, suppuration may still be avoided. Extensive ery- sipelatous redness, uncommon pain, and severe nervous symptoms, will often be found to originate from the irrita- tion of sutures. Pibrac's remarks on this subject are highly worthy of consideration: after relating many convincing facts, he concludes with asking, what practice the partisans of su- 15S TREATMENT OP WOUNDS. tures would adopt, were they necessitated, as they fre- quently are, to cut the ligatures, and remove them ? Or, were they to find, as is often the case, that the ligatures had made their way through the lips of the wound, so as to leave them gaping? They would then never think of in- troducing new sutures, but would have recourse to a band- age, in order to unite the wound.* Both this gentleman and M. Louisf urgently recommended the entire discon- tinuance of the practice, and their observations are accom- panied by facts which must have considerable weight. Their arguments, I confess, made a deep impression upon myself; and if I cannot join in the sentiment, that sutures ought to be entirely abandoned, at all events, I believe that they are still a great deal too much used. Professor Thom- son thinks sutures may be generally*omitted, except in superficial wounds, which we wish to heal by the first in- tention, or in wounds where (as in those of the abdomen) it is necessary that the edges should not be allowed to se- parate from each other.:]: But hardly any two surgeons think exactly alike about the cases, in which sutures are truly beneficial or not. Thus, I do not admit that they ought to be used as frequently as the remarks of Dr. Thom- son would warrant; and it seems to me, that the majority of superficial wounds, in which union by the first intention is indicated, so far from being examples in which sutures are necessary, are, of all cases, those which least require them. Were we to admit such as instances of the neces- sity for sutures, the practice would become as common again as ever it was in the less improved periods of surgi- cal knowledge. Such are the principal means for keeping the opposite surfaces of wounds in contact, until union has taken place. The first plasters and dressings should continue on the part at least three or four days, unless any disagreeable symptoms, as excessive pain, hemorrhage, &c. indicate the contrary. The cause of the severity of the pain should al- ways duly be considered, and, if possible, removed : some- times it is owing to the sutures ; sometimes to the immode- rate tightness of the roller; and, occasionally, to extraneous substances yet lodged in the wound. * Sur l'Abus des Sutures, in Mem. de l'Acad. de Chirurgie, torn. iii. 4to. or torn ix. 12mo. f See Memoire sur l'Operation du Bec-de-Lievre, op. cit. torn. xii. p. 118. edit. 12mo. i Lectures on Inflammation, p. 287. TREATMENT OP WOUNDS. 159 When too much inflammation is apprehended, the band- age should never be tight; and wetting it with cold water may be of use. Perfect quietude, and an antiphlogistic regimen, should be observed. The old plan of covering the dressings with thick woollen rollers, caps, and large masses of tow, has now gone very much out of fashion, as being inconsistent with those principles which are recog- nised by every scientific surgeon, as best calculated to avert and lessen inflammation. When the first dressings are removed, the surgeon often finds union by the first intention accomplished only at cer- tain points of the injury; and the connexion even there still requiring further support. On the application of the second dressings, however, it is generally unnecessary to put on as many strips of adhesive plaster as were at first employed, and their number may be gradually lessened at each future dressing. The sutures, if there are any, should also be now withdrawn, as they can do no further good, and their continuance may excite irritation, and do harm. Throughout the rest of the treatment, also, the dressings should be light, simple, and unirritating. I shall conclude this chapter with a few useful rules, which Professor Thomson recommends to be observed in the dressing and examination of wounds. The first is, never to give the patient more pain from our modes of procedure, or methods of dressing, than is absolutely necessary for his present good or future securi- ty. For instance, we ought never to probe a wound, where probing can be of no use; and we should be contented to remain ignorant of things, the knowledge of which would only gratify an idle curiosity. Another good rule is to have all the fresh dressings perfectly ready, before the old ones are removed. A sponge and warm water, adhesive plaster, pledgets, lint, bandages, 8cc. should all be at hand, and not left to be looked for at the very moment when they are wanted. As in many instances the removal of the dressings, and the application of others, take up a considerable time, we ought carefully to reflect what position will be most easy to the patient, and, at the same time, most convenient to the surgeon. When the bandage, adhesive plaster, and other dress- ings, have become hard and dry, and glued together, and to the surrounding skin, by blood, or other discharge from the wound, the surgeon should soften and loosen the ap- 160 TREATMENT OF WOUND*. plications by wetting them a sufficient length of time with warm water, which is to be pressed out of a sponge upon them, a basin being held below the part for the reception of the water as it falls off the dressings. This duty is of much importance in saving the patient from a great deal of agony, which the abrupt removal of the adherent dress- ings would produce. In removing the dressings which are under the bandage, we should be careful that the ligatures are not entangled, and forcibly pulled away, so as to give severe pain, and create a risk of hemorrhage. The strips of adhesive plaster should be removed by tak- ing hold of their ends, each of which is to be drawn to- wards the wound. Were the plasters pulled off in the con- trary direction, the edges of the wound would be liable to be torn asunder again, and the process of reunion at all events disturbed: neither should the plasters be pulled up, as by this proceeding the edges of the wound would be torn from the subjacent parts. In large wounds, only a single strip, or at rnost two, should be off at a time, and the part, from which the plaster has been removed, having been carefully wiped with a sponge and dried, is then to be supported with a fresh strip, before any more strips are taken off. As Dr. Thom- son well observes, it is from inattention to this rule that wounds are daily torn open again at each dressing, merely by the weight of the parts. The sides of the wound, particularly if it be large and deep, should always be supported by an assistant at the time of changing the dressings. When there are several wounds, only one is to be open- ed and dressed at a time, so that all unnecessary exposure of the parts may be avoided.* At each dressing, care must be taken to prevent lodg- ments of matter, by placing the compresses and strips of plaster in the manner best calculated to press upon and obliterate any cavity, in which the pus has a tendency to accumulate. The utmost attention should be paid to cleanliness, eve- ry thing filthy and offensive being removed from the ward as quickly as possible. Above all things, care must be taken not to let the matter touch the bed-clothes. In the military hospitals, the custom of laying a piece of oilskin * See Note I. TREATMENT OF WOUNDS. 161 under suppurating wounded parts, in order to keep the bed clean, is highly praiseworthy; for cleanliness is essential to the general health of the patients, and the favourable pro- gress of wounds. The frequency of dressing must be regulated by the quantity and quality of the discharge ; by the situation of the injury; by the climate and season of the year; by the effects which the renewal of the dressing seems to pro- duce; and by the feelings, and sometimes the wishes, of the patient.* -— ...»ft^ £«'•—- CHAPTER XV. PROCESS BY WHICH THE WOUND IS UNITED. When the opposite sides of an incised wound are main- tained in contact by the foregoing means, they soon be- come permanently connected together. The vessels of the wounded surface cease bleeding, and their extremities be- come impervious to the blood itself, but not to the coagu- lating lymph, which forms the general bond of union be- tween living parts. This uniting medium is the primitive and most simple connexion that takes place between the two sides of a wound. In many cases, where the wound is closed before the hemorrhage has had time to cease, no doubt a coagulum of blood itself constitutes the first bond of union, and wounds must thus be frequently united through the medium of red blood. I have, however, al- ready explained, that the best practical surgeons make the surface of the wound as free from blood as possible, before its opposite sides are brought together, because it is found, that union by the first intention more certainly follows this mode of proceeding. But, the reader is not to understand, that he is to defer bringing the sides of a wound together, until every little oozing of blood is at an end; for the long exposure of the wounded surface would be very injurious, and tend to defeat the grand object in view, direct adhe- sion, without suppuration. * Thomson on Inflammation, p. 294, &r. Vol. I. X 162 PROCESS BY WHICH We have examples of an union, very similar to that by the first intention, in bones which have been fractured ; in tendons which have been ruptured; and even sometimes in muscles which have been wholly or partially torn asun- der, without any division having been produced in the skin which covers such parts. In the sudden and violent divi- sion of these textures, blood is always effused between the divided parts, and into the surrounding cellular membrane. When this extravasated blood is not very considerable in quantity, and when the parts from which it has been effused are not too severely injured, it is observed to be gradually absorbed, in proportion as the process of union advances. If the divided surfaces be examined a few hours after the accident, they will be found to be covered with coagulating lymph. This substance, indeed, appears to be effused very quickly after the injury. Professor Thomson found, that, in animals, a distinct layer of it was effused over their wounds in less than four hours.* But, says he, whatever may be the period at which it is first formed, it is now well ascertained, that, in healthy subjects, when fractured, torn, or ruptured surfaces, to which the external air has not been admitted, are properly covered with this layer of coagulating lymph, and kept in contact, they speedily coa- lesce, and that, by this lymph becoming a living interme- dium, the continuity of the divided part is at length restor- ed. Appearances, precisely similar to such as happen in divisions without communication with the external air, take place in simple incised wounds, the edges of which have been brought together before, or soon after the bleed- ing has ceased. If a wound of this kind be torn open soon after its reunion, the surfaces, which had been united, are seen covered with a substance resembling jelly, which is the coagulating lymph, or fibrin of the blood. By some it is supposed, as I have said, that this lymph is poured out from the smaller vessels which have been cut; but Professor Thomson inclines to the opinion, that it is chief- ly, if not wholly, formed by the secreting action of the ca- pillary vessels of the divided surfaces.f The simple agglutination of the sides of a wound together, is what may be considered as taking place directly they have been brought into contact. The next step, in the process of union by the first intention, is the generation of * On Inflammation, p. 209. fOp. cit. p. 210. THE WOUND I:> UNITCl), 163 vessels in the coagulating lymph, or blood; and this is soon followed by an intercourse between the vessels of the two sides of the wound. The manner in which the new ves- sels arise in the uniting medium, as well as the way in which the inosculation of the divided vessels happens, are at present only matters of conjecture. I have introduced almost as much as is known upon this abstruse subject in the chapter on inflammation. Mr. Hunter once conceived that blood and coagulating lymph, as long as they retained the living principle, possessed the faculty of generating vessels within themselves, quite independently of any ad- joining surfaces ; and in the growth of the chick, there are unquestionably some appearances in favour of this opinion. This doctrine, however, he is said to have renounced pre- viously to his death, and to have adopted the belief, which is now daily gaining ground, that the new vessels are ex- tensions from the old ones. Professor Thomson delivers the following statement; the coagulating lymph, soon after its exudation, becomes penetrated with blood-vessels, which proceed from the divided surfaces, appear to join in the pro- cess of reunion by open extremities, or, in other words, to inosculate with one another. The blood now circulates freely through the new-formed channels of communication established between the vessels, which penetrate the lymph effused upon the surfaces formerly divided; and the ves- sels which shoot into the lymph, often acquire in the course of a few hours a size which renders them capable of being injected. The precise manner, in which the vessels are extended into the coagulating lymph, is still unknown. It has not been positively settled, whether it is the divided vessels which penetrate the lymph. The extremities of the larger branches are closed with the effused lymph, and removed by means of it and their natural elasticity to a distance from each other. Dr. Thomson regards these circumstances as insurmountable bars to their immediate inosculation; and he remarks, that, if it be the closed ves- sels which are prolonged into the lymph, each small artery must obviously have its corresponding vein. But, says he, the inosculation, or direct union of the small blood- vessels from the opposite surfaces of the wound, however difficult to conceive or explain, is a truth undeniably es- tablished.* He then adverts to Duhamel's experiment, which fully proves, that in the reunion of parts which have » iv 212 164 PROCESS BV WHICH been divided, the blood-vessels from the opposite surfaces inosculate directly, and do not merely pass one another. Duhamel broke the legs of six chickens, and, after the bones had reunited, he cut through about one-third of the soft parts, covering the callus, or new bone. When the wound had healed up, he divided another third part, and in the same manner the remaining third part, sparing nei- ther blood-vessel, tendon, nor nerve. Only one of the six chickens survived these cruel operations ; but, upon inject- ing the artery at the upper part of the thigh, the injection penetrated to the lowest part of the leg. " I cannot say (Duhamel remarks) whether the large vessels, filled by the injection, were dilated capillary vessels, or the large vessels of the leg, which had been reunited ; but the experi- ment proves irrefragably the inosculation of the blood- vessels." Later observations than those of Duhamel (says Professor Thomson) have shown, that it is by the small vessels, and not by the larger trunks, that the inosculations are formed, by which the divided parts of a limb are sup- plied with blood; nor does he accede upon this point to the sentiment of Hunter, who conceived that he had cer- tainly succeeded in observing inosculation on the tunica conjunctiva of the eye, the vessels of which are frequently divided by surgeons in cases of ophthalmy. He states, that the two ends of the cut vessel are seen to shrink ; but, after a little while, they are perceived to unite, and the circulation is carried on again.* The celerity, with which the process of union by the first intention is completed, is a circumstance that must excite the admiration of the philosophical surgeon. In the short space of seventy-two hours, the wound, produced by amputation of the thigh, is often securely united through its whole extent, without any suppuration, except just where the ligatures are situated. Incised wounds of a mo- derate size may, in general, be completely healed by this method in forty-eight hours. How different, then, is the surgery of the present day to that of half a century ago, when the bigoted prejudices of our ancestors deterred them from doing, not only what was most salutary, but most simple ! The complicated business of accomplishing digestion, incarnation, and cicatrization, is now reduced to the easy duty of bringing the sides of a clean cut wound • On the Blood, p. 19,1. THE WOUND IS UNITED. 165 into contact, and maintaining them so until they have grown together. As a modern surgical writer has observed," there is no wound, in which we may not try with perfect safety to pro- cure this adhesion; for nothing surely can be more kindly when applied to a wounded surface, than the opposite sur- face of the same wound: it has been but just separated from the opposite surface : it may immediately adhere to it: though it do not adhere, no harm is done; still the wound will suppurate as kindly, as freely, as if it had been dressed with dry lint, or some vulnerary balsam, or acrid ointment. If only a part suppurate, while one-half, per- haps, adheres, then half our business is done: and, in short, this simple way of immediately closing a wound is both natural and safe."* If I were to instance any one circum- stance, in which I think the excellence of English surgery strikingly displayed, I should be inclined to cite our par- tiality to the mode of curing wounds by the first intention. M. Roux,f in his criticisms upon this part of our practice, may convince his readers how sincerely he believes what he says; for he actually fancies we have been, as it were, forced into the custom of healing up wounds as quickly as we can, because, unfortunately, in this country, we have not, as he conceives, a sufficiency of the requisite materials for dressing wounds, which are to heal by suppuration! But, I doubt whether he will be joined by any surgeons on this side of the channel in the belief, that it would be bet- ter to abandon the practice of adhesion altogether, than make it an exclusive method of treatment. He particular- ly mentions the wound after castration as unfit for this plan, because the edges cannot be easily put into a state of co-aptation, unless a considerable piece of the scrotum be cut away, and sutures be used; and also because the closure of the wound is attended with a risk of a collection of blood taking place in its cavity, and nature is nearly as long in effecting a cure, when the sides of the wound have been brougbt together, as when they have not. But if the principle were to be admitted, that the possibility of bleed- ing within a wound is an adequate reason for filling it with rharpie, and not attempting to heal it by the first intention, • Discourses on the Nature and Cure of Wounds, by John Bell, p. 14 edit. 3. j- I'arallele de la Chimrgio Angloisc aver \p Chirurgie Franchise, p. 11" et suiv. 8vn IVi'is. 1815 _ 166 rnoc.L>s by' which we ought to renounce this last beneficial practice in every instance, where the surface of the wound is extensive, and its cavity large, as after amputation, the removal of a breast, the extirpation of tumors, &c. But, even suppos- ing the scrotum should sometimes become filled with co- agulated blood, of which M. Roux is so much afraid, it may then be inquired, which of two patients would be the best circumstanced, one with the scrotum crammed with charpie, or another with the same part distended with co- agulated blood? Which will suffer least pain, have the most moderate suppuration, and get well in the shortest time ? If the answer to these problems be so doubtful, as not to admit of being readily delivered, surely we may be allowed to argue thus: that if, when the evil complained of by M. Roux does really occur, the patient is not decid- edly worse off than when such disaster does not happen, but the particular treatment recommended by that gentle- man is followed, how much better it must be to let the pa- tient at all events have the chance of a considerable portion of the wound uniting; for when this is accomplished, (to use Mr. John Bell's phrase,) half our business is done. But, if any wound require more strongly than others the approximation of its edges, and to be healed, if possible, by adhesion, it seems to me, that it is the incision made in the Hunterian operation for aneurism. Here the wound should be closed to let the artery lie quietly amongst its natural connexions, undisturbed by the contact of any dressings, or other extraneous substances, by which the adhesion of its sides might be prevented, its ulceration induced, and secondary hemorrhage occasioned. But, ex- traordinary as it may appear, this is another example of our practice selected by M. Roux to illustrate our blind predilection for healing wounds by the first intention.* The wonder ceases, however, when we find that he consi- * J Surgeons on this side of the Atlantic will very readily acquiesce in the views of Mr. Cooper on this subject. It is matter of surprise that the sur- geons of France, who have probably done more for the advancement of this branch of the healing art, than those of any other country, should still pertinaciously hold to an opinion, which the most ample experience has de- monstrated to be founded in error. There seems to exist between the sur- geons of France and England a feeling of envy, which manifests itself in the tardiness displayed to adopt the improvements of each other. We, in this country, stand on neutral ground, and are aloof from such feelings, and whilst we freely send our offerings to other climes, we as wdlingly receive and adopt the improvements which come to us from every quarter of the globe.—P. E.} THE WOUND IS UNITED. 167 ders ligatures of reserve (ligatures d'attente) advisable means in operations for aneurism; for they are undoubt- edly awkward things in a wound which ought to be healed as quickTy* as possible, and they put union by the first in- tention out of the question. But in London, where the inutility and dangers of these ligatures of reserve are well understood, a practice, which tends to abolish their use, will be welcomed, as bringing with it another high recom- mendation. CHAPTER XVI. PUNCTURED WOUNDS Are not only dangerous, on account of their frequently extending to a considerable depth, and injuring large blood- vessels, nerves, and viscera of importance, they are also dangerous, inasmuch as they frequently give rise to vio- lent and extensive degrees of inflammation. It is not un- , common to see them followed by formidable collections of matter, especially when the instrument, with which they have been made, has penetrated deeply through an apo- neurosis or fascia. The extension of inflammation along the continuous textures from the original seat of the punc- ture, and the formation of matter under the fasciae, are two of the most remarkable local phenomena, which are parti- cularly liable to arise from punctured wounds.* Stabs, and all other punctures, are not simple divisions of the fibres of the body: they are attended with more or less contusion and laceration. Hence, there is not the same readiness to unite, which we observe in wounds made with sharp cutting instruments; and when the weapon has en- tered deeply through ligamentous expansions, the inflam- mation excited often spreads very extensively, attended with most severe pain in the parts affected, great tension, swelling, and abscesses running under the fascia? to an alarming extent. Violent symptomatic fever, and great agitation of the nervous system, indeed, often follow punc- • Thomson Obs. made in the Military Hospitals in Belgium, p. 29. 8vo. Edinb. 1816. 165 PUNCTURED WOUNDS. tured wounds; effects, which have been attributed to the injury of the tendons, or nerves. This doctrine, however, is now nearly exploded. Surgeons frequently see nerves of considerable size and large tendons wounded, without the occurrence of great constitutional disorder; therefore, it cannot be the mere injury of these parts which is the occasion of all the general indisposition. More is to be feared, I think, from the frequent depth of a stab, or puncture ; the roughness and violence with which the injury has been done; and the many different textures pierced; than from the circumstance of tendons, or nerves, happening to be wounded. Amongst the worst kinds of general indisposition, more frequently following punctured, than other descriptions of wounds, is tetanus; a complica- tion, still oftener seen in warm climates, than our own. Punctured wounds are generally more dangerous and difficult to cure, than cuts and sabre wounds, though much depends upon the nature of the parts injured. WThen im- mense swelling and inflammation follow; large abscesses form; extensive erysipelatous redness comes on; a large artery, or important viscus is wounded, and blood, or other fluid extravasated; the case is undoubtedly of a serious and dangerous nature. The same remark may be made when tetanus, or violent symptomatic fever, and great agitation of the nervous system, complicate the injury. In the treatment of punctured wounds, erroneous sup- positions have commonly led to many serious abuses. The unlimited idea, that the severe consequences o£ most punc- tured wounds are in a great measure owing to the narrow- ness of their orifices, induced numerous surgeons to prac- tise, indiscriminately, deep and extensive incisions, for the purpose of rendering their external communication consi- derably wider. To have constantly in view the conver- sion of such injuries into simple incised wounds, was al- ways a maxim strongly insisted upon, and urged as the reason for such treatment. The doctrine even occasioned the frequent dilatation of punctured wounds by means of tents, a still more absurd and cruel practice. Certainly, if the notion were true, that an important punctured wound, such as the stab of a bayonet, could be actually changed into a wound, partaking of the mild na- ture of an incision, by the mere enlargement of its orifice, the corresponding practice would be highly commendable, however painful. But the fact is otherwise; the rough violence done to the fibres of the body by the generality of PUNCTURED WOUNDS. 169 stabs, is little likely to be suddenly removed by an enlarge- ment of the wound. Nor can the distance, to which a punc- tured wound frequently penetrates, and the number and nature of the parts injured by it, be at all altered by such a proceeding. These, which are the grand causes of the collections of* matter, which often take place in the cases under consideration, must exist, whether the mouth and canal of the wound be enlarged or not. The time, when incisions are proper, is when there are arteries to be se- cured, foreign bodies to be removed, abscesses to be open- ed, or sinuses to be divided; and to make painful incisions, sooner than they can answer any end, is both injudicious and hurtful. Thev are sometimes rendered quite unneces- sary by the union of the wound throughout its whole ex- tent without the feast suppuration. It is true, that making a free incision, in the early stage of these cases, seems a reasonable method of preventing the iormation of sinuses, by preventing the confinement of matter, and, were sinuses an inevitable consequence of all punctured wounds, for which no incisions had been prac- tised at the moment of their occurrence, it would undoubt- ed lv be unpardonable to omit them. To many this may seem a fair reason for enlarging the mouth of a punctured wound. Fair, however, as it may appear, it is only super- ficially plausible, afcd a small degree of reflection soon dis- covers its want of real solidity. Under what circumstances do sinuses form? Do they not form only where there is some cause existing to prevent the healing of an abscess? This cause may either be the indirect way, in which the abscess communicates externally, so that the pus does not readily escape; or it may be the presence of some foreign body, or carious bone; or, lastly, it may be an indisposi- tion of the inner surface of the abscess to form granula- tions, arising from its long duration, but removable by lay- ing the cvst completely open. Thus it becomes manifest, that the occurrence of suppuration in punctured wounds is only followed by sinuses when the surgeon neglects to procure a free issue for the matter after its accumulation, or when he neglects to remove any extraneous bodies. But, as dilating the wound, at first, will only tend to augment the inflammation, and render the suppuration more exten- sive, it ought never to be practised in these cases, except for the direct objects, of giving free exit to matter already collected, and of being able to remove extraneous bodies palpably lodged. I shall once more repeat, that it is an Vol. I. Y 170 PUNCTURED WOUNDS. erroneous idea, to suppose the narrowness of punctured wounds so principal a cause of the bad symptoms, with which they are often attended, that the treatment ought invariably to aim at its removal. Recent punctured wounds have absurdly had the same plan of treatment applied to them as old and callous fistula?. Setons and stimulating injections, which in the latter cases sometimes act beneficially by exciting an inflammation, that is productive of the effusion of coagulating lymph, and of the granulating process, can never prove servicea- ble when the indication is to moderate an inflammation, disposed to rise too high. The counter-opening, which must be formed, in adopting the use of a seton, is also an objection; and though French authors have given us ac- counts of their having drawn setons across patients' chests, in cases of stabs, they would find some difficulty in making the practice seem unattended with harm, much less, pro- ductive of good. The candid and judicious surgical reader, should not always think a plan of treatment right, because the patient gets well; for, there is an essential difference between a cure, promoted by really useful means, and an escape, notwithstanding the employment of hurtful ones. Why, however, should we mention the use of a seton? What good can possibly arise from it? Will it promote the discharge of foreign bodies if any<«re 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, and irritation, of an extrane- ous substance in the wound ? Is it a likely means of di- minishing the immoderate pain, swelling, and extensive suppuration, so often attending punctured wounds? It will undoubtedly prevent the external openings from heal- ing too soon; but cannot this object be effected in a better way? If the surgeon observe 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 parti- cular situation of these injuries. From what has been already stated, the reader must be aware, that I do not follow the bulk of surgical writers in recommending the indiscriminate dilatation of the orifices of punctured wounds; nor the use of the knife, for the pur- pose of preventing mischief only expected and apprehend- ed, but not certain of taking place. Whenever I have at- PUNCTURED WOUNDS. 171 tended bayonet, or other punctured wounds, unattended with any particular complication, I have alwavs observed nearly the same principles as are now so generally approv- ed of in cases of gun-shot wounds. I have abstained from dilating the orifice of the injury, except when it was ne- cessary, either to get at a bleeding artery in the first in- stance, or to give a freer egress to the discharge in a later stage of the case. I have given the preference to mild, simple, unirritating and superficial dressings. I have not placed much faith in the utility of enveloping the parts in a tight bandage; but, after applying the first superficial dressings, have usually covered the limb or part with linen wet with the lotio plumbi acetatis, or cold water. When- ever a roller was used, in the beginning of a case, it was not with the view of making pressure, but of retaining the dressings. The wound having been dressed, I then put in practice all such means as are generally deemed most effi- cient in preventing and diminishing inflammation; such as venesection, the exhibition of aperient saline medicines, low diet, &c. When the pain was severe, opiates were prescribed, and on the access of much inflammation and swelling, it was an invariable rule with me to be sure that the bandage was slack. On the whole, I believe, that the application of superficial dressings and cold washes is the best practice for the first twenty-four hours after the re- ceipt of a punctured wound.* But if, after this period, the pain should increase, and the swelling and tension be- come more and more considerable, the surgeon may then * {Mr. Higginbottom of London, in a communication to Dr. Marshall Hall, published in the London Med. and Phys. Journal, for April 1827, strongly recommends the use of lunar caustic in these cases; we quote his manner of using it.— "In recent punctured wounds, the orifice of the wound must be first ex- amined: if there be any loose portion of skin closing the orifice of the wound, it is to be removed by a pair of sharp-pointed scissors or by a lancet; the puncture, and the surrounding skin, are then to be moistened with a little water; the caustic is to be applied to the former until some pain be expe- rienced, and over the latter lightly, so as not to induce vesication. The caustic is then to be applied to the skin, for an inch round the puncture, and to a greater extent if the swelling exceeds this space. The part is then to be exposed to the air. "These cases are generally adherent from the first application of the caustic, but 1 have sometimes found the eschar to separate from the wound before it has healed, owing to its conical form : it is then only necessary to repeat the application of the caustic slightly, to complete the cure. " At a later period of punctured wounds, inflammation is usually present, the punctured orifice is nearly closed by the swelling, and a little pus has generally formed within. A slight pressure is to be applied to evacuate this i?2 PUNCTURED WOUNDS. remove the linen and bandages, and apply from six to a dozen leeches to the neighbourhood of the wound. He may also substitute for the cold lotions the use of fomenta- tions and emollient poultices, under which is to be laid over the orifice of the wound a small pledget of sperma- ceti cerate, or other simple ointment. The poultices and fomentations are to be renewed twice a day,and the leeches and venesection repeated if necessary. Sometimes, under this treatment, the surgeon is agree- ably surprised to find the consequent inflammation mild, and the wound united by the first intention. More fre- quently, however, in cases of deep stabs, the pain is into- lerable ; and the inflammatory symptoms run so high, as to leave no hope of avoiding suppuration. In this condi- tion, an emollient poultice is the best local application; and, when the matter is formed, its discharge is to be pro- cured, either by dilating the original wound, or by making one or more incisions in other places, as may seem most ad/vantageous. In short, the treatment must then conform to the principles already noticed in the chapter on suppu- ration. —•»»©»<« CHAPTER XVII. CONTUSED AND LACERATED WOUNDS. The instruments, which have the effect of producing what is termed a contusion, are either of an ordinary de- scription, such as a cudgel, a stone, &c; or they consist of balls, bullets, and other metallic bodies which are impelled into the flesh with immense velocity by the explosion of gunpowder. Indeed, a forcible collision of any blunt, ob- tuse, hard body, against parts of the living body, must con- tuse, and often at the same time wound them. Gun-shot fluid; the caustic is then to be applied within the puncture, and upon and a little beyond the surrounding inflamed skin, and the parts are to be exposed to dry. In this manner an adherent eschar is formed, :.nd the inflammation subsides. If there be any vesication, it may be simply left to nature; the fluid is soon absorbed or evaporates." We can offer our testimony in favour of this practice, which we have adopted in several cases.—P. E.} CONTUSED AND LACERATED WOUNDS. 173 wounds, strictly speaking, are only examples of severe contused wounds, though surgeons find it expedient gene- rally to treat them as distinct and peculiar cases: and when it is recollected how many difficult, intricate, and momentous questions, the subject embraces, the necessity of considering it by itself is immediately manifest. The blunt weapons, or obtuse hard substances, which being applied with violence to any part of the living body, bruise, rupture, and otherwise hurt the fibres and vessels, may produce two different species of injury. First, they may more or less forcibly compress and crush the parts, upon which they act, so as to disorder the texture of those organs which are situated under the integuments, without causing, however, any breach of continuity in the skin it- self. This is the case, which is familiarly called a bruise, or contusion, of which one of the worst examples is seen in the effects of cannon-balls, which graze the surface of the body, and crush the muscles and other deep-seated parts, while the skin itself remains unbroken. Secondly, a hard blunt body violently striking against parts, may produce at once a solution of continuity, extending through the skin, and sometimes also through other textures: this kind of accident is what surgeons name a contused "wound. The latter injury more commonly follows, when the sur- face of the contusing weapon is not very broad. The cases, which rank as simple contusions, I shall consider in another chapter. * , The majority of wounds are attended with some degree of contusion. Those which are inflicted with the blunt edge of a sabre, or the obtuse point and wedge-like end of a bayonet, are as much contused as punctured; and hence, like other contused wounds, they do not/ often ad- mit of being united by the first intention. It must be confessed, indeed, that all our endeavours to reunite the sides of a contused wound, however skilfully directed, ge- nerally fail. An agglutination of the parts at most only takes place at the bottom of the wound, in which situation the flesh has suffered less contusion, the violence having spent itself, as it were, upon those parts upon which it first operated. Hence, suppuration of the external portion of the wound is mostly unavoidable. Still, the attempt at re-union ought to be made; for, if only the bottom of the wound heal by the first intention, it is a great advantage gained, more especially, when the surface of a bone has been exposed, and uncovered bv the injurv. In bringing 174 CONTUSED AND LACERATED WOUNDS. the sides of contused wounds nearer together, however, the surgeon is not to attempt to do it with the same close- ness, and accuracy, as in the instance of an incised wound. The injured parts would not bear the pressure, or the means requisite for this purpose ; and it may be laid down, as an established rule, that nothing is more hurtful in cases of contused wounds, than much pressure, either from strips of adhesive plaster, or from rollers. In these cases, su- tures are also totally unjustifiable; and I think that I have seen several examples, in which a rash determination of the surgeon to close large contused wounds with stitches, tight strips of plaster, and bandages, had no inconsidera- ble share in bringing on the rapid and fatal gangrene which carried off the patients. When I say, therefore, that a con- tused wound ought to be closed, and that its opposite sur- faces should be brought nearer together, in order that the chance of some part of the injury uniting by the first in- tention may be taken, I do not mean to recommend drag- ging the parts together by main force, or placing them in a state of constriction. On the contrary, I think, that they ought to be left quite unconfined, the adhesive plaster be- ing used very sparingly, and so put on as rather to hold the loose parts nearer each other, than to press and draw them into contact. Nor should the wound be covered with much plaster, as one or two strips will suffice for the object in view, and a greater number would create irritation, be- sides hindering other better dressings from touching the raw surfaces. Merely a strip or two are to be applied to such points, as seem most advantageous, for lessening the exposed surfaces, and all constriction should be most care- fully avoided. That the practice, here advised, may be followed by a beneficial result, is proved by daily experi- ence ; and theory would lead us to expect such good, when we remember that, by preventing the wound from gaping in the manner it would otherwise do, we not only afford an opportunity for parts of it to reunite, but .at once di- minish an inevitable cause of inflammation and suppura- tion, viz. the continued exposure of a raw surface. Con- tused and lacerated wounds not only differ from incised wounds in the circumstance of being more disposed to suppurate, and slough, and more difficult to heal by the first intention, they differ also in the particularity of not usually bleeding much: sometimes, not even when the largest arteries are lacerated, as must be the case when whole limbs are torn away, in consequence of becoming CONTUSED AND LACERATED WOUNDS. 175 entangled in different kinds of machinery. This indispo- sition to hemorrhage is not altogether a favourable omen, because though the patient runs less chance of bleeding to death in these cases, that in cut wounds, yet the very cir- cumstance of the large vessels not pouring out blood, evinces, that the violence, contusion, stretching, and other injury, done to the parts, in addition to the mere division of them, must have been excessively severe, and that the danger of the subsequent inflammation, suppuration, and sloughing of the parts, is more than a counterbalance to any advantage proceeding from the absence of hemor- rhage. In the records of surgery, no facts are more extraordi- nary, than those which have been published, at different periods, on the subject of whole limbs being torn away, not only without hemorrhage, but without any other fatal effects. The cases of limbs torn off, related by Cheselden, La Motte, Carmichael, Morand, and Gibson*, are some of the most remarkable. All lacerated and contused wounds should be treated according to common antiphlogistic principles. When the injury is extensive, and attended with a great deal of con- tusion, venesection is to be practised, and any moderate oozing of blood from the surface of the wound may be pro- moted by the use of fomentations. With respect to dress- ings, they should always be of a mild unirritating quality. After lessening by a strip or two of adhesive plaster the ex- posed cavity of the wound, when this is large, and the sur- rounding skin loose, or detached from the subjacent parts, the wound may be covered with pledgets of the unguen- tum cetacei, over which should be laid an emollient poul- tice. The first dressings should not be removed for at least 24, or 36 hours. Afterwards, however, the dressings may be changed on'ce, twice, and in bad cases, even thrice a day, for as soon as the sloughs begin to separate and sup- puration commences, the necessity of renewing the dress- ings and poultices more frequently is evident. In severe cases, fomentations may be used at the periods of dressing, as nothing will be found more effectual for the relief of the pain. The employment of leeches also should not be forgotten, as a valuable means of palliating inflammation. Professor Asalinif, of Milan, has particularly recommend- • Institutes of Surgery, vol. i. p. 92. Philadelphia, 1824. f Manualc di Chirurgia, 12mo. Milano, 1812. 176 CONTUSED AND LACERATED WOUNDS. ed the application of cold washes to contused wounds; and I believe the plan is decidedly useful in the first in- stance,* when it is a great object to check the increase of extravasted fluids in the surrounding parts. I think cold applications are also highly proper when contused wounds are disposed to bleed more than usual, and yet, no large vessel presents itself as the source of the hemorrhage. But, in other periods and states of these injuries, I prefer emol- lient dressings. If, in lacerated and contused wounds, the surgeon is less frequently called upon, than in incised wounds, to take measures for stopping bleeding immediately after the ac- cident, he finds greater occasion for attending to another important duty, imposed upon him in his professional at- tendance upon wounded persons in general: I allude to the early removal of all foreign bodies and extraneous substan- ces. Cuts are usually made with clean sharp instruments; but contused and lacerated wounds often occur in a manner which renders them very likely to be complicated with the lodgment of extraneous matter. With regard to lacerated wounds, the same practical re- marks apply to them, which have been offered on the sub- ject of contused wounds; but the prognosis is generally considered more unfavourable, and in warm climates, te- tanus is a frequent consequence. As soon as the surface of a contused or lacerated wound has thrown off its sloughs, suppurated, become clean, and evinced a tendency to form granulations, the poultices are to be discontinued, and simple dressings employed. The quality of these is afterwards to be altered, according to the future appearances of the sore; but, further directions, respecting the management of the case after it has arrived at this stage, will be found in the chapter on ulcers. Some contused and lacerated wounds wo*uld be inevita- bly followed by a rapid mortification of the limb, and the patient run the greatest risk of losing his life, were am- putation not performed immediately after the receipt of the injury. These are generally examples, in which the soft parts are extensively and deeply wounded, and large blood-vessels and nerves also injured. When mortifica- tion attacks patients so circumstanced, it is the gangrene which Larrey has called traumatic, and in which he and some other modern surgeons conceive, that amputation • Sec Note K. CONTUSED AND LACERATED WOUNDS. 177 may often be done with success, though the* mortification has not stopped. The treatment of lacerated and contused wounds, in a gangrenous or sloughing state, must be re- gulated by directions, given in the chapter on mortifi- cation. -—♦•©*<«.•— CHAPTER XVIII. OF GRANULATIONS AND CICATRIZATION. Granulations are formed by an exudation of coagulat- ing lymph from the vessels of the wounded or exposed surface. Into this substance new vessels extend, render- ing it highly vascular. These vessels are described by Sir Astley Cooper as elongations of the vasa vasorum. Ac- cording to Mr. Hunter, they pass from the original parts beneath to the bases of the granulations, and thence to- wards their external surface, in almost parallel lines. In other words, each artery, after having entered the base of the granulation, splits into many ramifications, which ra- diates to its surface. Granulations are also furnished with veins. They must be supplied with nerves and lympha- tics; how tender they frequently are, every one knows; and it is equally well known, that medicines, applied to the surface of ulcers, sometimes find their way into the circu- lation, by means of absorption. According to Sir A. Coo- per, the surfaces of old ulcers more readily absorb, than those of recent ones. He also states, that though granula- tions, springing from parts endued with great sensibility, are extremely sensitive; others, arising from an uninflam- ed bone, have no sensibility whatever, unless they proceed from the cancellated structure. Granulations from tendons and fascia;, are likewise represented as possessing little or no sensibility. Granulations have the same disposition to secrete pus, as the surface from which they are produced. They are very convex, having a great many points, or small emi- nences, so as to appear rough. The smaller these points are, the more healthy the granulations. The colour of healthy granulations is a deep florid red. When of a livid colour, thev are unhealthy: such appearance denoting that Vol. I. " Z 178 GRANULATIONS AND CICATRIZATION. the circulation in them is languid. A depending position produces this livid hue, bv retarding the return of blood: this is the reason, why some sore legs are so backward in healing, when the patients are allowed to stand and walk. Granulations, when healthy, and situated on an exposed, or flat surface, rise nearly to the level of the surrounding skin, and often a little higher; but when they exceed this, and assume a growing disposition, they are unhealthy, be- coming soft and spongy, and losing the power of produc- ing new skin. Healthy granulations are always prone to join with each other, and their vessels soon begin to inosculate: a fact, which, as Sir A. Cooper has justly remarked, in some measure accounts for the efficacy of circular strips of stick- ing plaster, which tend to bring the granulations into close contact with each other. Granulations do not possess the powers of the original parts of the body; and consequently are very subject to mortify, or be absorbed. It is by the foregoing process, that nature fills up the hollows of deep wounds, the edges of which cannot be brought into contact, and it is by the same steps that she succeeds in filling up the cavities of abscesses. The work, however, is not quite reducible to this simplicity. All modern practitioners observe, that as soon as the forma- tion of granulations commences, the diameter of the wound becomes diminished from every two points of its circumfer- ence, even before any new skin appears to be formed. The natural elasticity of the skin, and the contraction of mus- cles, satisfactorily account for the separation of the edges of a wound. But how these edges become approximated, during the granulating process, is not so well understood. It has been said, that it arises from the diminution of the swelling which surrounds the wound. This is by no means a satisfactory explanation, because we know, that the sepa- ration of the edges proceeds from a different cause, and takes place prior to the swelling, and immediately on the occurrence of the wound. Mr. Hunter attributed the be- neficial effect to a contraction of the granulations. He says, " the contraction takes place at every point, but principally from edge to edge, which brings the circumference of the sore towards the centre, so that the sore becomes smaller and smaller, although there is little or no new skin form- ed." This contraction of granulations takes place in a greater degree, and has a greater effect, when there is a GRANULATIONS AND CICATRIZATION. 17f> looseness of the parts, on which they are formed. When they are situated on parts naturally fixed, as the skull, shin, &c. the conti action is impeded. The contraction of granulations is not confined to open wounds; it takes place in the cavities of abscesses, which by this means contract like the urinary bladder, till little or no cavity is left. When the granulations cannot con- tract further, if any cavity be remaining, it is obliterated by the growth of the opposite granulations into each other. Besides the contractile power of the granulations, there is also a similar power in the surrounding edge of the cica- trizing skin. As the granulations contract, the integuments extend over the part deprived of skin; not by being stretched,but as the consequence of what Mr. Hunter terms interstitial growth. t The contraction of granulations is one of the most beau- tiful examples, illustrating the wisdom with which the na- tural principles of the human body have been estsblished. By it the formation of much new skin is rendered unne- cessary; a great advantage, as original parts are much fit- ter for the purposes of life, than those which are new. By it, wounds, which, from neglect, have lost the opportunity of uniting by the adhesive inflammation, and others, which must necessarily heal in a more circuitous manner, are ul- timately brought almost into the same state as if they had been united by the first intention. By this beneficial pro- cess, the cicatrix, compared with the original breadth of the wound, is often made as one to three. After the whole wound is covered with skin, the remains of the granulations beneath it still continue to contract, till hardly any thing more is left than what the new skin stands upon. This is a very small part, in comparison, with the first formed granulations; and, in time, it loses more of its apparent vessels, and becomes white, and like ligament. When a wound begins to heal by the granulating pro- cess, the surrounding old skin, near the granulations, no longer exhibits the glossy redness, about one-fourth or one-half of an inch in breadth, which it previously showed. The angular margin of the skin becomes converted into a roundish, smooth, and white boundary; and the nearer to the cicatrizing edge the whiter it is. This white sub- stance Mr. Hunter suspected to be a beginning cuticle. The new skin is a very different substance, with respect to texture, from the granulations upon which it is formed ISO GRANULATIONS AND CICATRIZATION. It most commonly takes its rise from the adjacent old skin, as if elongated from it; but this is not regularly the case. I remember a workman in a laboratory who was dreadful- ly burnt with ignited spirits over the greater part of his body, in consequence of which he had extensive sores, oc- cupying nearly the whole surface of some of his limbs. When these ulcers had considerably diminished, the pow- er of producing skin seemed to lessen at the edges, but, at the same time, new portions of skin made their appearance at various parts of the ulcers, standing (as Mr. Hunter in- geniously describes) upon the surface of the granulations like little islands. Mr. Hunter was of opinion, that this production of skin, in the centre of sores, never happened the first time of their being sores. In the patient just men- tioned, whom I saw in Mr. Ramsden's private practice, and attended a long while, the contrary fact took place. Sir A. Cooper considers, that the centre of an ulcer has not the power of forming new skin unless some portion or por- tions of the original skin should not have been completely destroyed. How far this observation will explain the fact, which presented itself to my notice, I cannot say; but, it is an original remark, and worthy of future attention. In general, the surrounding skin seems to communicate a disposition to the surfaces of the adjoining granulations to form skin; just as bones give an ossifying disposition to granulations formed upon them. The new-formed cutis is neither so yielding nor so elas- tic as the original. It is also less moveable, and destitute of the furrows observable on the old skin. At first, it is extremely full of vessels; but, afterwards, both it and the subjacent granulations become less vascular, and therefore white. The surrounding old skin is puckered into loose folds, while the new constantly retains a stretched, shining appearance. The production of cuticle, from the new cutis, is a much more easy process, than the generation of skin. The form- ation of skin is chiefly progressive from the surrounding cutis; but the cuticle is frequently formed at once, and equally from every point of the cutis. The rete mucosum is not so readily formed as the cu- ticle; but, at length, it is produced; for, in blacks, a cica- trix, which is at first reddish, after a little while turns even blacker than the original skin. fiUN-SHOT WOUNDS. lfci CHAPTER XIX. GUN-SHOT WOUNDS Are produced by hard, obtuse, generally metallic bo- dies, like cannon balls, bullets, fragments of bomb-shells, he. which being violently propelled by the force of explod- ed gunpowder, are driven into, or even quite through, the injured parts. There are also some exceedingly severe gun-shot injuries, as we shall presently explain, in which the ball contuses and crushes the flesh, and sometimes breaks the bones themselves, while the integuments remain unbroken over all this concealed, and often unsuspected^ mischief. Nothing can be more correct, than Mr. Hunter's observation, that the differences of gun-shot wounds are referrible to three principal causes, viz. the kind of body projected, the velocity of that body, and the nature of the parts injured.* Former surgeons, seeing the terrible mischief frequently arising from gun-shot wounds, entertained a suspicion that the injured parts were either dreadfully burnt by the heat of the projected body, or were irritated by the presence of poison, as well as by mechanical violence. We learn from Pare, that when the king of France was besieging Turin, the besiegers and the besieged mutually believed, that their enemies had poisoned their balls, so cruel and intract- able were the wounds ; but after the taking of the city the soldiers of both parties met, and then they saw that their own clean and unpoisoned balls had made these cruel wounds. The moderns, better acquainted with the laws of projectiles, and the component ingredients of gunpow- der, rightly attribute the ill consequences of gun-shot wounds to the violence, contusion, and laceration, inflicted on the wounded parts. A ball, however great the rapidi- ty of its motion, never acquires in its course any percepti- ble degree of heat; and that there is nothing poisonous in the composition of gunpowder is now universally known. The circumstance of the violence being produced in ge- neral by so obtuse a body as a musket ball, and often done • On the Blood, Inflammation, and Gun-shot Wounds, p. 523. 4to. 182 UUN-SflOT WOUNDS. with immense velocity, is fullv sufficient to account for the usual severe consequences of these injuries. Bullets are the most common bodies shot into the injured parts; but the wound may be produced by cannon balls, pieces of broken shells, and very often on board of ship by splinters of wood. Large bodies of irregular figure, must occasion a greater quantity of mischief than such as are externally smooth, of a round form, and of moderate size. Pieces of clothes are also frequently carried along with the ball into the wound. Gun-shot wounds are always attended with contusion and laceration, by which, most commonly, some of the fibres around the track of the ball are deadened, and must be thrown off in the form of a slough, before the parts can heal. Hence, these cases rarely admit of being united by the adhesive inflammation, but must suppurate ; and, on this same account, they seldom bleed profusely, except when very considerable blood-vessels are torn. Besides the figure and magnitude of the body impelled into the living solids, the velocity with which it moves makes considerable difference. Hence, when a ball has passed with little velocity, (which is sometimes the case at its entrance, but more frequently near its exit), the wound may often be healed by the first intention. At the entrance of the ball, the circumference is usually depress- ed; at its exit, prominent; and, in numerous instances, the adjacent parts have a livid appearance. The opening which the ball makes in entering a limb, is always smaller than that by which it passes out again. On account of the parts, surrounding a gun-shot wound, being often deadened, the nature of the injury cannot al- ways at first be comprehended. A part of some viscus, a large artery, or even a bone, may have been deadened by the violence; but the mischief does not manifest itself before the slough separates.* The detachment of the deadened parts is usually not accomplished till about the sixth, eighth, or tenth day, and sometimes not till about the fifteenth day, after the receipt of the injury; consequently, at these periods, there is the • {Professor Gibson says, that in some cases, large arteries are pushed entirely to one side by the ball, without sustaining injury; and instances the case of Capt. Worth, who, at the battle of Bridgewater, received a wound in the thigh by a grape shot, " which penetrated a little below the groin over the course of the femoral artery and tore up the muscles in » frightful manner, without injuring the vessel."—P. E.J GUN-SHOT WOUNDS. 183 greatest danger of hemorrhage, extravasions of the con- tents of viscera, &c. The knowledge of these circum- stances naturally suggests the propriety of letting the wound be most narrowly watched, at the falling off of the eschars, " for the blood often bursts out in the night, and, in the morning, the patient is found dead, bathed in his blood." *f When a gun-shot wound only injures soft parts of ordi- nary importance, it is termed simple. When at the same time it fractures a bone, wounds a large artery, nerve, or important viscus, it is then called compound. The latter complications must greatly increase the danger of the ac- cident, as any one may readily conceive, who knows the peril attending fractures, conjoined with a wound; the hazard of bleeding, or of mortification, when the main ar- tery of a limb is injured ; and the various consequences of wounds of the viscera, extravasions, &c. The pain of gun-shot wounds is often inconsiderable, so that in many instances the wounded are not even con- scious of having received any injury. If, however, the ball has touched a large nerve, the pain will be severe, and the power of the part lost. Some men will have a limb car- ried off, or shattered to pieces by a cannon ball, without exhibiting the slightest symptoms of mental or corporeal agitation; while a deadly paleness, instant vomiting, pro- fuse perspiration, and universal tremor, will seize another on the receipt of a slight flesh wound.}: The frequent ab- sence of a general agitation of the system for a certain time, after the receipt of bad gun-shot wounds, I had many opportunities of noticing in the late campaigns in Holland and Belgium, where many a brave man was seen with a limb torn completely off, lying without any remarkable perturbation, and as quietly and composedly awaiting sur- gical assistance as if the accident had been only a slight injury. The most dreadful gun-shot wounds, in fact, some- times happen, without bereaving the patient of his senses and presence of mind for a moment. A memorable proof of this truth was seen in a young sailor, who presented himself some years ago at St. Bartholomew's hospital. A * John Bell, Discourses on the Nature and Cure of Wounds, p. 102, edit. 3. f See Notk L. $ Ilennen's Obs. on some Important Points in the Practice of Military Surgery, p. 31. 8vo. Kdinb. 1818. A valuable work, the third edition of which is about to be published. 184 GUN-SHOT WOUNDS. cannon ball had struck him on the shoulder, and, besides severing the limb from the body, had broken away a large portion of the clavicle, and split the scapula into numerous fragments. Yet, even on this severe occasion, there was no syncope, no bleeding of consequence, and the senses were not suspended for an instant. The form, the momentum, and the direction of the shot which is received; the position and the variety of struc- ture, or, in other words, the variety of density, and pow- ers of resistance, in the part receiving it; are the principal causes influencing the course of the ball, in its passage through the substance of the body. Every new resistance, which a shot in motion meets with, operates so as to pro- duce, not only a diminution of its momentum, but, also, a change in its direction. By adverting to the above circum- stances, the strange course which some balls take, running nearly all round the body beneath the skin, may be satis- factorily explained. Their track, when it is thus superficial, is generally indicated by what Mr. Hunter compares to a blush, or, as Dr. Hennen says, by a wheal or dusky line, terminated by a tumor, in which the ball is contained; and sometimes where this mark is absent, a certain emphyse- matous crackling shows the course of the bullet, and leads to its detection. Some very extraordinary instances of the reflection of balls, from one part of the body to another, are recorded by the preceding author. The ball (he ob- serves) is in many instances found very close to its point of entrance, having nearly completed the circuit of the body. In one case, which occurred to a friend of his in the Mediterranean, the ball, which struck about the po- mum Adami, was found lying in the very orifice of its entrance, having gone completely round the neck. This winding course of balls is represented as particularly fre- quent when they strike the ribs or abdominal muscles ; for, says Dr. Hennen, they are turned from the direct line by a very slight resistance indeed, although they will sometimes run along a continued surface like that of a bone, a muscle, or a fascia, to a very extraordinary dis- tance. It is surprising what a variety of parts may be injured by a musket ball, if there be nothing to check its course, and its momentum be very great. Dr. Hennen has seen cases where it traversed almost the whole extent of the body and extremities. In one instance, which oc- curred in a soldier with his arm extended, in the act of climbing up a scaling-ladder, a ball, which entered about GUN-SHOT WOUNDS, 185 rhe centre of the humerus, passed along it over the poste- lior part of the thorax, coursed along the abdominal mus- cles, passed deeply through the glutaei, and presented itself on the forepart of the middle of the opposite thigh. In another case, a ball, which struck the breast, lodged in the scrotum.* It was formerly supposed, that a ball might injure parts of the body in two ways, viz. by actually striking them, and by passing close to them, without touching them at all. This last kind of injury was called a wind-contusion, and supposed to originate from the violent commotion pro- duced in the air by the rapidity of the ball. It consists of a forcible bruising, and even comminution, of the soft and hard parts situated beneath the skin, which itself remains entire. The above mode of explaining how this violence is oc- casioned, is too absurd to need a serious refutation. The slight disturbance of the air is too feeble to account for the degree of violence committed. The air, to which the ball must impart the greatest motion, is that which is di- rectly before it; and yet this does not do the smallest de- gree of violence to the parts surrounding the spot at which the ball enters. Cannon balls often strike limbs, without the neighbouring parts being in the least hurt. Pieces of sol- diers and seamen's hats, feathers, clothes, and even hair, are frequently shot away, without any other mischief. These wind-contusions, as they have been improperly named, are now well known to be caused immediately by the ball itself; and its occasioning a violent contusion, without wounding the skin, or entering the limb, is refer- rible to the sloping direction in which it first strikes the surface, and to its being reflected. Surgeons ought to feel themselves under great obliga- tion to Ambrose Pare, for the more accurate opinions, which he first introduced, concerning wind-contusions. But no man has exposed the absurdity of supposing that life may be extinguished by the "whiff and the wind of a ball" better than Mr. John Bell. "The reason of all these won- derful tales about the wind of a ball (says he) is itself very wonderful. Men often fall in the field of battle, and when the camp-followers come to turn over their bodies in bury- ing the dead, no wound nor mark of injury is seen; and of- ten also men are laid in the military hospitals, dying and * Hennen, op. cit. p. 33. Vol. I A a 180 GUN-SHOT W0UND3. unable to speak, upon whom there is found no kind of wound, nor even the slightest bruise of the skin. Now this apparent difficulty will disappear, when 1 state (says Mr. John Bell) that a limb is often broken while the skin remains unhurt, and a dreadful fracture it is; for when a great bullet strikes fairly it knocks off the limb, but when it strikes obliquely it buffs along the skin, the ball is turn- ed away, and the part struck becomes insensible at the in- stant; there is no feeling of the terrible accident that has happened; the patient is sensible of nothing more than a confused shock; hardly knows where he is struck,and falls down. This fracture is of the worst kind, for it is accom- panied with such a bruising of the parts that they never can be restored; and though the skin is still entire, there is much blood extravasated, the muscles are in an instant rtduced to a gelatinous and pulpy mass, &c. Let a ball hit any of the great cavities thus obliquely, and this pheno- menon appears, the patient is killed without any external wound. He is killed, according to the notion of his fellow- soldiers, by the wind of some great ball. But we know that the ball has actually struck him, that the breast, the belly, or the head, has been hurt. If the chest has been struck, then the ribs have perhaps yielded, and escaped the blow, but the lungs have suffered, and there is often blood extra- vasated in the chest. In the belly there is often a bursting of the liver, or spleen, without any outward wound of the skin; very frequently in the head, though there appears no outward injury, the pericranium is separated from the skull, and there is an effusion of blood upon the brain."* KINDS OF EXTRANEOUS BODIES LODGED IN GUN-SHOT WOUNDS. Extraneous bodies are more frequently met with in gun- shot wounds, than in any others. They are commonly of three sorts: 1. Pieces of clothes, or other substances, which the ball has driven into the flesh: 2. the ball itself: 3. or lastly, loose, splintered portions of bone. They are the cause of many bad symptoms: for they irritate the wound- ed parts so as to excite pain, inflammation, a disposition to hemorrhage, copious, and long-continued suppuration, * See John Bell's Discourses on the Nature and Cure of Wounds 175—177. Also Larrey's Mem. de Chir. Militaire. GUNSHOT WOUNDS LS7 &c, and the more uneven, pointed, and hard they are, the worse are their effects. When there is only one opening, the surgeon has a right to conclude, that the ball is lodged; for I need scarcely lay down as exceptions to this observation, the very rare cases, in which the ball, after making a deep wound, is found in the patient's shirt. In these instances, the foreign body carries a piece of shirt with it into the part, without going through the linen, and when the latter is inadvert- ently drawn out, the ball is also extracted. An officer who wore a silk handkerchief in his breast, had several duplica- tures of it actually carried into the pectoral muscle by the ball, which was afterwards drawn out with the handker- chief.* When there are two apertures, we may infer, that the ball has passed out. However, pieces of the clothes may still be lodged in the wound; for, as they are lighter, and move with less impetus, than the shot itself, they must be more likely to be left behind. In Dr. Hennen's publication, several very curious in- stances may be read, in which the foreign bodies were either of enormous size, or of an uncommon kind. A spent twelve-pound shot is there stated to have been found in the fleshy part of the thigh of an officer, who was killed at the siege of Seringapatam.t In another case, which happened in Belgium, a pantaloon pocket of coarse linen, containing two five-franc pieces and two small cop- per coins, was extracted from the substance of the vastus externus muscle.^: In one still more curious instance, two five-franc pieces, and a Dutch stiver, closely beaten toge- ther, were extracted from the thigh of a soldier, who had no money about him previously to the injury, and who ac- counted for the situation of these coins, by supposing that they had been carried from the pocket of his comrade, who stood before him in the ranks, and who had been killed by the same shot.§ A case is also detailed, in which several fragments of a cranium were taken from a lacerated wound of the thigh; and others, in which pieces of different bones, and even teeth, not belonging to the patients themselves, were found imbedded in their flesh. • Hennen's Military Surgerv, p. J55. f P- 83. y P. 87. ' * P- 8K !e& GUN-SHOT WOUND.-. TREATMENT OE GUN-SHOT WOUNDS. The first thing in the treatment of a gun-shot wound of one of the extremities, is to determine, whether it is more advisable to amputate the wounded limb immediately, or to undertake the cure of the injury. When a bone, especially at a joint, is shattered into nu- merous fragments; when the soft parts are, at the same time, extensively contused and lacerated, with injury of important blood-vessels and nerves; and when at the same time the whole limb is thrown into a cold and insensible condition by the violence of the shock; no resource is so safe as amputation; and delay, under such circumstances, would lead to almost certain death. Larrey says, when a body is projected from a cannon, and strikes a limb, so that the bones are fractured, and the soft parts violently contused, extensively torn and commi- nuted, amputation should be instantly performed. He re- commends the same practice, when a large portion of the soft parts, and the principal vessels of a limb, are carried away by a ball, and the bone fractured. He represents the operation as equally indispensable when a large ball strikes the thick part of a limb, breaks the bone, cuts and tears the muscles, destroys the great nerves, and yet leavesthe prin- cipal artery entire. When a spent or rebounding ball has struck a limb obliquely, without causing a solution of con- tinuity in the skin, while the bones, muscles, tendons, and aponeuroses, are torn, broken, and crushed, Larrey thinks the following conduct proper: the extent of the injury must be ascertained, and if the bones be fractured under the soft parts, and there be ground to suspect, that the great ves- sels are lacerated, amputation should be performed. But, if the vessels and bones have been spared, and the muscles alone have been totally disorganized, he is content with the practice recommended in the Memoirs of the French Academy of Surgery, viz. that of making an incision, and letting out the thick, black, extravasated blood. Larrey then instances fractures of the articular heads of the bones of the knee and ankle by gun-shot, and the extensive denu- dation of a large portion of bone by a ball which has passed through the limb, as demanding immediate amputation. The latter case, however, is not quite so clear; for much- must depend on the situation and quantity of injury inflict- ed. Perhaps the opinion given by another surgeon on this GUN-SHOT WOUNDS. 1&& particular accident is more correct, namely, that where the ball is no larger than one projected from a musket, it is more advisable to wait and be governed by consequences.* I entirely differ,however, from the American surgeon who infers from one example, in which a patient recovered with a stiff joint, after being shot through the knee with a mus- ket-ball, and from a few other rare escapes, that Larrey was wrong in pointing out such injuries as decided exam- ples demanding immediate amputation. On the contrary, all the gun-shot injuries which I noticed abroad, that had been caused by the passage of balls through the knee-joint, fully confirmed the propriety of the general rule of ampu- tating the limb thus injured. With respect to cut wounds of large joints, I allow with Mr. Mann, that they are not always cases positively demanding the immediate perform- ance of the operation. But below some of these violent degrees of injury, in which the necessity of immediate amputation can be readi- ly and positively settled, there are several inferior degrees, in which the soundest judgment is required to form a pru- dent determination. In many of these cases, the scale is so delicately balanced, that an opinion is not to be formed from a consideration of the injury alone. In dubious cases, the patient's constitution, the possibility or impossibility of procuring good accommodation, rest, attendance, and pure air, are matters which ought to have weight. Bilguer published an essay,, in which the practice of am- putation was condemned as an operation hardly ever pro- per.f The arguments, broached in this extraordinary pro- duction, however great their influence might once be, can no longer mislead any practitioner of common sense. In France, the absurdities of Bilguer's work were long ago ably exposed by La Martini ere ;i. and in England by Mr Pott:§ while more recently some judicious criticisms on his statements were drawn up and published by Mr. Guth- rie,|j a gendeman whose evidence is valuable, as beiag founded upon the great opportunities of observation and comparison, of which he availed himself during the war in * Mann's Medical Sketches of the Campaigns of 1812, 1813, 1814, 8tc. p 210. 8vo. Dedham, 1816. \ De Mcmbroruin Amputatione rarissime administranda aut quasi abro- ganda. \ Mem. de l'Acad. de Chir. torn. iv. § Remarks on the Necessity, &c. of Amputation in certain Cases. Pott'- Works, vol. iii. l On •inn-shot Wmmrts of th<» F-st'-rmities. &c r>. 7, &c 8vo. Lond. 1KTS. 190 GUN-SHOT WOUNDs- the Peninsula. Nothing is now better known and establish- ed than that, in many cases of bad gun-shot injuries of the limbs, the patient's only chance of preservation depends upon the performance of amputation. Another question, that was not quite so well settled a few years ago as it is now, is at what time amputation should be done in cases of gun-shot wounds, where such operation is allowed to be indispensable. In 1756, the French Academy of Surgery conferred its approbation on a memoir written by M. Faure, who was an advocate for delaying the operation until the first bad symptoms were at an end. Mr. Hunter was in favour of the same prac- tice. Upon the whole, however, reason, experience, and authority are strongly against delay. The immediate per- formance of the operation is urged by La Martiniere, Le Dran, Ranby, Kirkland, Larrey, Guthrie, Hennen, Thomp- son,* &c. Larrey's valuable works contain the most deci- sive facts in support of this practice; facts, drawn from extensive experience and a comparative trial of both me- thods,! while nothing can be more unequivocal and con- vincing, than the important cases and observations to be found in the practical writings of the other authors, to whom I have referred. It is a doctrine, frequently inculcated in the schools, that a man who has been long habituated to disease, is more likely to bear an operation well, than another man, who is suddenly necessitated to part with his limb for an acci- dental injury. It would be quite unnecessary for me to assert, that there is no truth in this opinion, in relation to some of the operations performed in civil hospitals. What I saw during my apprenticeship, at St. Bartholomew's, left me with an impression, that amputations done immediate- ly after accidental injuries, were generally less successful, than similar operations done for the removal of white swellings, and other chronic diseases. But, then, this has nothing to do with the question before us; for it does not prove any thing at all, with respect to the advantages or disadvantages of immediate amputation in bad accidental injuries, but, merely, that the amputation of a diseased joint * Report of Obs. made in the Military Hospitals in Belgium, with some Remarks upon Amputation, 8vo. Edinb. 1816. f See Relation Historique et Chir. de l'Expedition de l'Armee d'Orient, en Egypte et en Syria; Par D. J. Larrey. Paris, 1803; and Mem. de Chirurgie Militaire, 4 tomes, 8vo. Paris, 1812—1817. GUN-SHOT WOUNDS. 191 generally terminates better than that of a shattered limb. We have still to inquire, whether, if the amputation had been delayed in such cases of badly shattered limbs, where confessedly there was no hope of saving them in the end, the operation would have had more extensive success. The question would then be more to the point; because gun- shot wounds rank as accidents. Now, as far as we can believe the testimony of the most experienced writers, especially that of Mr. Pott, we are bound to conclude, that the operation should be done, in every case of this kind, without the least delay. And, with respect to such gun- shot injuries of the limbs, as are decidedly fit cases for amputation, because no rational chance of saving the part can be entertained, Larrey, Guthrie, Hennen, Hutchison,* and all the latest and most experienced authors on milita- ry surgery, unanimously agree about the necessity either of the immediate, or very early performance of the opera- tion. They further agree about the dangers of delay, and the infinitely greater number of recoveries following the speedy use of the knife. Respecting some little difference of sentiment on the point, viz. whether we should wait till the patient has revived a little from the first effects of the injury, or, (as the expression is,) whether the knife ought to follow the shot as speedily as possible, I believe, this is rather a seeming, than a real difference. No man would amputatewhile a man is lying in a state of depression and syncope, jjerhaps, with hardly any pulse, warmth, or ani- mation. Here we must all coincide with Mr. Guthrie, that it is better to wait a little, and that to let the knife follow the shot would probably destroy the patient upon the ope- rating table. But, should the patient not be thus danger- ously depressed, then neither Mr. Guthrie, nor any other army surgeon, would think of proposing delay. With this understanding, therefore, I conceive the following passage to be judicious and correct: "If a soldier, at the end of two, four, or six hours, after the injury, has recovered from the general constitutional alarm occasioned by the blow, his pulse becomes regular and good, his stomach easy, he is less agitated, his countenance revives, and he begins to feel pain, stiffness, and uneasiness in the part; he will now undergo the operation with the greatest ad- vantage, and, if he bears it well, of which there will be but little doubt, he will recover in the proportion of nine cases • Some Practical Observations in Surgery, 8vo. Lond. 1816 4 S3 (JUN-SHOT WOUNDS. eut of ten in any operation on the upper extremity, or belotc the middle of the thigh, without any of the bad consequences usually mentioned by authors as following such amputa- tions."* For all those injuries, in which amputation must absolutely be done, in order to give the patient the best chances, the practical and common maxim with army sur- geons is, as Dr. Hennen observes, to proceed to the ope- ration with as little delay as possible. While hundreds are waiting for the decision of the surgeon, he will never be at a loss to select individuals, who can safely and ad- vantageously bear to be operated on, as quickly as himself and his assistants can offer their aid: but he will betray a miserable want of science indeed, if, in this crowd of suf- ferers, he indiscriminately amputates the weak, the terrifi- ed, the sinking, and the determined. While he is giving his aid to a few of the latter class, encouragement and a cordial will soon make a change in the state of the weakly, or the terrified.f In all sudden injuries of the limbs, from great external violence, as gun-shot wounds of the extremities truly are, there are generally only two periods, at which amputa- tion can be performed with much prospect of success. The first is immediately after the occurrence of the injury, be- fore inflammation arises, and before a disposition to gan- grene commences in the limb. This period only lasts a few hours; and, when these have elapsed, the dangers of mortification and death must be faced. With^regard to amputating when the limb is universally swollen, and in a state approaching to gangrene, however favourably we may be disposed to think of the practice under circum- stances noticed in the chapter on mortification, and when an earlier and better opportunity has been lost, we cannot then compare the chances of recovery to those, which might have been obtained by an earlier operation. On the contrary, in this late stage of the case, the patient's condi- tion is desperate, whether amputation be done, or not. If, however, these immediate perils should be got over, and the wound be brought into a state of suppuration, the violent inflammation and swelling abate, and, while the patient's strength yet remains adequate, the opportunity of amputating is once more afforded. But if the state of the patient is now not more favourable for an operation * Guthrie on Gun-shot Wounds of the Extremities, p. 24. t Obs. on several important Points in Military Surgery, p. 49. GUN-SHOT WOUND-j. Iii3 than it was directly, or soon after the accident, what has he gain id but a great deal of avoidable pain and suffering? The necessity of the operation was acknowledged; its ge- neral success, when done early, is sufficiently proved; the second opportunity of doing it is frequently lost for ever by the patient's intervening death; and, if it should come, it brings not with it the same promise of recovery as the first did. There arc further reasons for preferring amputation to an attempt to preserve limbs, which have been severely shattered by gun-shot wounds. 1. By means of the operation, the patient gets rid of a dreadful contused wound, which threatens the greatest peril to his very existence, and exchanges it for a simple incised wound. 2. The pain of the operation is not, upon the whole, a greater severity, than the aggregate pain arising from the inflammation^rritation of extraneous bodies, and incisions for their evacuation and that of matter, in cases in which an effort is made to preserve the limb. 3. The loss of the limb ought not to be taken into the scale; for, the surgeon only amputates on the principle of saving the patient's life by that privation. When life is at stake, and it is more likely to be saved by the operation, than both life and the limb together without the operation, it is our duty to amputate. By this maxim, no doubt, a small proportion of limbs, which might be preserved, will be sacrificed, but the patient's life will be more frequently saved. Limbs, which are saved after these dreadful inju- ries, are also very often not more useful than a wooden leg; and the vigour of the constitution is sometimes irre- coverably lost, for a limb, which is rather a burden than a convenience. Perhaps, in the army, surgeons may sometimes be jus- tified in amputating limbs, which it might be proper to endeavour to save, under all the advantages and conve- niences of private practice. The necessity for the opera- tion must evidently be greatly increased, when circum- stances demand the patient's speedy removal from the field of battle to an hospital at a distance. The difficulty of conveyance; the bad accommodation in the military wagons, into which the wounded are crowded: the pain- ful jolting, to which they are there subjected; and the way in which they are exposed to the inclemency of the wea- ther; are all weighty reasons in favour of taking off the Vol. I. Bb 191 GUN-SHOT WOUNDS. shattered limb. When the bones are broken and splin- tered, the sharp spiculse are forced by the motion of the carriage still further into the flesh, and thus cause infinite suffering and vast additional mischief. Frequently, when the operation is put off, the disturbance of the parts in the journey so bruises and lacerates them, that the patient perishes in the most cruel agony, before he arrives at the hospital, which is intended for his reception. As Larrey observes, the dangers of a long residence in an hospital are also much diminished by amputation, which converts a gun-shot wound into one which is capable of being speedily healed, and obviates the causes that pro- duce hospital fever and gangrene. In case the wounded should be left on the field of battle, it is then important that amputation has been performed, because, when it is completed, they may remain several days without being dressed, and the dressings can afterwards be changed with greater facility. * When the upper part of the os humeri is fractured by a musket ball, the necessity for amputating the limb may frequently be obviated by making an incision down the centre of the deltoid muscle, and extracting the splintered head of the bone. The facts recorded by Boucher,* Viga- roux,f and Mr. C- White,f: first exemplified the possibility of saving the whole arm by the excision of the upper por- tion of a diseased or shattered humerus; and the propri- ety of a similar proceeding in some gun-shot fractures of the upper part of that bone, has been well proved in Lar- rey's practice. In Egypt he superseded all occasion for amputating the limb, in no less than ten instances, by ex- tracting without delay the head of the humerus and the fragments of bone; and, in his subsequent campaigns, the propriety of the practice was verified in a much larger number of examples. After the operation, the humerus is to be kept up to the shoulder with a sling and a bandage. In one most remarkable and successful instance, the sca- pulary end of the clavicle, the acromion, and the head of the humerus, were so broken to pieces, by the ball of a four-pounder, that the removal of all these parts was un- avoidable. In some cases, an artificial joint is formed; in others, an anchylosis follows.^ Mr. Mann assures us, * Me*m. de 1'Acad. Royale de Chirurgie, t. v. p. 302, &c. f (Euvres de Chirurgie Pratique. Montpellier, 1812. $ Cases in Surgery, p. 57. § Relation Historique et Chirurgicale de 1'Armee d'Qrient en Egypte et Syria, p. 315.; and Mem. de Chirurgie Militaire. GUN-SHOT WOUNDS. 195 that, in several dreadful lacerated wounds of the shoulder, he also saw the patients recover without amputation, care being taken to remove the splinters of bone. In one case, the superincumbent muscles of the shoul- der, with part of the subjacent, were destroyed, leaving a small portion in the axilla, connected with the principal artery, which received no injury. The acromion process and clavicle were fractured. The head of the humerus was broken, and four inches of the bone forced away by the ball, leaving an inch of its extreme head in the socket. Mr. Mann dee med amputation necessary to save the wound- ed officer's life ; but the proposal was rejected. The frac- tured pieces of bones were removed, and by careful atten- tion to the wound the arm was saved, so as to be of some use. Two other very interesting cases of a similar kind are also recorded, in which many splinters were extracted, pieces of the humerus sawn off, and some of the deadened portions of muscle cut awav. The successful termination of these cases induces Mr. Mann to assert, that such will be the general result when the patient's health is good; and that the limb can be saved, with the small deformity of too sudden a sloping of the shoulder.* In a severe in- jury of the head and neck of the humerus, Mr. Guthrie thinks, that if the splintering extends to the body of the bone, amputation should be performed; if it be confined to the head and neck of the humerus, excision may be practised.! One would suppose, it must generally be bet- ter practice, rather to be content with making a free inci- sion through the deltoid, and extracting all the loose splin- ters of bone, than attempt the formal excision, or sawing off of the whole upper part of it; a proceeding which Mr. Guthrie:}: adduces cases to prove is not always necessary, even where the head of the bone is much shattered. * Medical Sketches of the Campaigns of 1812, 1813, and 1814, &c. pp. 208, 209. f On Gun-shot Wounds of the Extremities, p. 248. I remember an artil- lery-man, at Merxam, near Antwerp, the greater part of whose shoulder was carried away by a 24-pound shot, and all the adjacent parts so broken and lacerated, that the lungs and pericardium were visible. The man, how- ever, recovered without amputation. This case was also seen by the late Mr. Curtis, surgeon of the 1st guards, and by Sir Andrew Halliday, gentle- men then on duty with myself. The latter has given some account of it Sh the Edinb. Med. and Surg. Journ. vol. xi. p. 140. t On Gun-shot Wounds of the Extremities, p. 330, &c I96v GUN-SHOT WOUNDS. THE DILATATION OT" GUN-SHOT WOUNDS, AND THE EXTRAC- TION OF FOREIGN BODIES, CONSIDERED. When amputation was not deemed necessary, the old surgeons used, according to the customary precepts, to en- large the aperture of the wound by an incision Nume- rous advantages were alleged to result from such a dila- tation : it was said to facilitate the extraction of foreign bodies; to occasion a beneficial effusion of blood ; and to promote the escape of fluids extravasated in the surround- ing cellular substance. Dilating the wound by an incision, was also absurdly supposed to convert the fistulous track of a ball into an open incised wound, and, thereby, render its nature more benign, while another good effect, supposed to result from the practice, was the division of unyielding- parts, which confined, and thus aggravated the internal swelling. More modern experience has clearly proved, that the utility of these incisions has been overrated. The know- ledge, that gun-shot wounds are of various descriptions^ ought at once to condemn the unlimited plan of dilating all of them. When the course of the ball lies in soft parts, and has neither touched a bone, nor a considerable blood- vessel, whether the wound have one or two openings, the scheme of dilating it is productive of no good. In gun- shot wounds, the aperture in the skin is at first generally wider than the orifice of punctured wounds and stabs; and by the separation of the sloughs, the diameter of the first class of injuries is rendered still larger, so that not only matter but foreign bodies, often find a ready outlet. Inci- sions also usually soon close again, and the wound becomes, in a few days, in the same condition as if no dilatation had been made. Gun-shot wounds, therefore, are to be dilated, only when there is some plain and beneficial object to be accomplished by it. No doubt, it is right to extract, at first, as many foreign bodies as possible; for, while they continue in the wound, they always exasperate the inflammatory symptoms, and sometimes create agitation of the whole nervous system. By an early extraction of them, profuse suppuration may of- ten be prevented. Yet, let it be remembered, that the search for foreign bodies is frequently attended with great irrita- tion of the wound; and that in numerous instances it is Impossible to find and extract them immediately, as, for GUN-SHOT WOUNDS. 197 instance, when they are deeply, and firmly fixed in parts. When the wound is widened by the separation of sloughs, they generally become loose, and, on both accounts, their extraction may then be more easily performed. After having been deeply lodged, they sometimes spontaneously approach the surface, on the occurrence of suppuration. Lastly, it is to be observed, that foreign bodies, of smooth figure, have often remained, without the least inconve- nience, in parts from which they could not possibly be ex- tracted. Hence, the surgeon acts wisely, who seeks at first to ex- tract only such foreign bodies as are near the external opening, and loose, and removable without much irrita- tion. When, however, they make pressure on an impor- tant part, a large artery, a considerable nerve, or important viscus, so as to create violent and dangerous symptoms from this cause, an incision is warrantable for their remo- val even when deeply lodged. If a large artery bleed, it is to be exposed and tied, as in other wounds. Sometimes when there is reason to expect a fracture of the skull, an incision may be judiciously made to examine the bone; that is to say, if there are symptoms leading to a suspicion that a part of the bone is depressed, and makes dangerous pressure on the brain. In this circumstance, it would not only be advisable to examine the state of the cranium, ui> der the scalp, but even to remove such parts of the bone as are either splintered, or beaten inward. Depressed por- tions of the sternum and ribs may also require incisions.* When the ball lodges in any of the large cavites, inci- sions are mostly improper, because the foreign body can- not be traced, and, therefore, they answer no direct pur- pose. When the ball enters far into the substance of a bone, the dilatation of the wound would also be of no utility. But all that I have said upon this head is insufficient to guide the surgeon in every case. If the dilatation of the wound, for the purpose of extracting foreign bodies, should be less likely to aggravate the inflammation, than the pre- sence of those bodies, then it is highly judicious to put it in practice; but, in every case in which the ball cannot casilv be discovered, one may safely decide to abandon al' painful examinations. Experience shows, that its Lxl-- ■ See Hunter on the Blood, Inflammation, and Gun-sho* Wounds, p. 53% 198 GUN-SHOT WOUNDS. ment does not always give rise to bad symptoms. In some instances, the ball remains on the side of the limb opposite to its entrance, beneath the integuments. If the skin, un- der which the ball is lodged, be contused in such a way, that it will probably slough, it is to be considered as a life- less part, and an opening is to be made into it for the ex- traction of the ball. But, when the ball lies so far from the skin that one can only just feel it, and the skin itself remains uninjured, Mr. Hunter disapproved of making a counter-opening. His experience taught him, that the wound healed much better when the ball was let alone, and that the chief inflammation was not in the vicinity of the foreign body, but about the mouth of the wound. In cases, in which a counter-opening had been made, Mr. Hunter noticed, that the same inflammation sometimes attacked it, which took place at the entrace of the ball. However, notwithstanding this high authority, I had many opportu- nities of seeing, while I was abroad, that the rule here in- culcated was not followed. On the contrary, army sur- geons of the present day always make it a maxim to ex- tract the ball as soon as possible, when situated as above described. " The ball (says a late writer) will frequently have passed nearly through the limb, and be retained only by the elasticity of the common integuments. There we cut upon and extract it at once;" and he then recommends extracting on the spot every extraneous body that we pos- sibly can, either with the forceps alone, or the aid of the bistoury.* Screws, gimblets, and bullet-drawers, ought seldom to be used in extracting bullets. The fingers are commonly the most proper instruments; and, when forceps are judged more convenient, they should not be of a large clumsy construction.! Although one might judiciously omit an incision to ex- tract a smooth round body, like a leaden bullet, one might not always act with equal judgment in doing so, when the * Hennen's Obs. on some important Points in Military Surgery, p. 32. ■\ {The great objection to the bullet forceps of Percy, Chevalier, and others, is, that they are so large as nearly to fill up the whole passage, and the expansion of the blades so as to grasp the ball, is thus in a measure pre- vented. Professor Gibson has, for several years, made use of a very narrow ibrceps, longer and more slender than those contained in the common pocket case, with small and very sharp teeth. He says he has "found them very superior to any others he has tried, particularly in those cases where the ball has not been lodged beyond three or four inches deep."—-P. E.} GUN-SHOT WOUNDS. 199 extraneous body is of an angular figure, and large size, so as to be likely to cause immense irritation. Detached splinters of bone are very irritating; and when their extraction can be accomplished, consistently with the above principles, it ought never to be neglected. In gun-shot wounds, ligamentous bands sometimes com- press the subjacent tumefied parts; but, it is only when they unequivocally do so, or when they confine matter, that the knife should be employed to divide them. DRESSINGS, AND CONSTITUTIONAL TREATMENT. The best general dressings for gun-shot injuries, and the absurdity of several of the former modes of treatment, were accidental discoveries, if we can use that expression, when the genius of a Pare was concerned in making them. " I had heard of nothing (says he) so often as of the poisoned nature of gun-shot wounds, and had read both in De Vigo and in Guy de Chauliac of burning them with burning oils. When the French armies made their way into Piedmont, many of our soldiers were wounded in the smaller garrisons; and I saw the army surgeons using their terrible cauteries, and I also followed the common practice, and dressed the wounded with boiling oils, until all my oils were expended. On the night when this hap- pened, I dressed my wounded soldiers with oil of roses, and turpentine with whites of eggs. I went to bed much oppressed, with the apprehension, that all these poor fel- lows would be found in the morning poisoned and dead, I arose, therefore, betimes, and learnt, to my infinite sur- prise and pleasure, that they had slept well and easy; with- out any pain, or swelling, or redness about the wounds, while those of my soldiers who had been cauterized with hot oils, had great fever and swelling, and excruciating pain." This fortunate accident made Pare afterwards in- variably prefer the milder dressings; a wise resolution, to which he probably owed all his future success. From the degree of contusion, laceration, and sloughing, produced in the generality of gun-shot wounds, no hope of union by the first intention can be entertained. Suppos- ing the degree of injury is not such as to demand the im- mediate performance of amputation, and yet the bones are fractured, and the limb otherwise considerably hurt, the surgeon is first called upon to extract whatever splinters of bone and foreign bodies admit of being taken away 200 GUN-SHOT WOUNDS. without too much irritation. Should any violent hemor- rhage exist, which is not a frequent event in these cases, the bleeding vessel must be secured without delay. The limb is then to be laid on a splint, that has upon it a thick pad, and an eighteen-tailed bandage. The wound is to be dressed with dry lint, or what is always preferable, a pledg- et of common cerate. I think adhesive plaster, which is sometimes recommended as a first dressing for gun-shot wounds, never answers so well as common lint, or pledg- ets of any simple ointment. The tails of the bandage are to be methodically laid down over each other, and these, with some folds of linen, which are to be placed along the limb, may be wet with the liquor plumbi acetatis dilutus, or what is equally good, simple cold water. The practice of keeping the wounded limb, or part, thus enveloped in linen wet with cold lotions, or common water, cannot be too highly commended, as an excellent plan for the first day or two, and one that can always be pursued with ease under any of the circumstances and difficulties which occur in the military service. Even were the wounded simply to have their injuries covered at first with loose wet linen, instead of tight bandages, I believe we should see fewer cases of mortification than actually occur. The wound having been dressed, such other pads t and splints as may be requisite, are then to be put on the member, and secured with straps and tapes. Lastly, the limb is to be put in the most eligible posture, and be kept as quiet as possible. If the patient be young and strong, and should not have lost much blood, he is to be immediately bled, unless the system appears temporarily depressed by the shock of the accident, in which circumstance the surgeon should rather administer cordials. Besides occasional bleedings, accord- ing to circumstances, the application of leeches to the neigh- bourhood of the wound, is extremely beneficial during the inflammatory stage; and, indeed, so are all the means ad- vised for the relief of inflammation. In the course of the first 24 hours, the swelling of the part and the inflammatory fever come on. In a fracture, it will generally be best to persist in the employment of cold lotions, because the linen and bandages can be wet with them without taking off the splints, and disturbing the limb, as must be done if poultices be employed. When, how- ever, suppuration begins, the pledgets and first dressings must be removed; and then the surgeon, if he prefer the GUN-SHOT WOUNDS. 2(T method, may have recourse to emollient poultices, though they are always inconvenient applications under splints. In all other cases, they are undoubtedly the best local re- medies, after the first day or two, during which cold lotions may be used with great advantage. Saline and aperient draughts are to be administered, and, if the pain be severe, opium. Should mortification follow, notwithstanding every effort to counteract it, the surgeon is to take the proper opportunity to amputate, and not wait, as was formerly ad- vised, until an inflammatory reddish circle indicates the commencement of a separation of the living from the dead parts. If the inflammation terminate in suppuration, the quan- tity of matter is, in some measure, proportioned to the con- tusion and other mischief; and, when the case prospers, the inflammatory symptoms abat£, the eschars are thrown off, the quantity of matter gradually diminishes, the cavity of the abscess is filled up with healthy granulations, the broken bones unite, and the patient at last recovers. Unfortunately, in many cases, things do not go on in this desirable way. The pus does not become less copious, and it assumes a sanious, thin, fetid quality. The great- ness of the discharge brings on weakness and hectic symptoms, and the patient falls into a dangerous state. Here the nicest judgment is often required in deciding, whether the attempt to save the limb should be continued, or amputation be done without delay. In the suppurative stage of gun-shot wounds, the same internal medicines and diet, and the same external applica- tions, are indicated, which I have specified in the chapters on suppuration and ulcers. In cases of gun-shot wounds, then, the dressings are to be superficial, and of the mildest description possible; at first some lint and a pledget of white cerate, with cold applications, and afterwards emollient poultices and fo- mentations. What good can introducing lint into the ori- fice of a gun-shot wound produce? Is this practice design- ed to prevent its closure? If it is, the idea is absurd, as gun-shot wounds are little disposed to unite by the adhe- sive inflammation. Fomenting the part, two or three times a day, with a decoction of white poppies, certainly deserves recommendation; for it always diminishes pain, and, con- sequently, must have a good effect on the inflammation. The consolidation of a gun-shot wound is the work of na- ture. The steps, which she takes to effect it, have been Vol.. I. C r ' ^02 GUN-SHOT WOUNDS. noticed in treating of granulations. A suppurating gnu- shot wound is only an abscess, in which there are frequently extraneous bodies. To maintain a ready exit for the pus, and to remove all extraneous matter, which may be loose, and sufficiently near the surface of the body, is all the sur- geon can usefully do. When a limb is torn off by a cannon ball, all the best army-surgeons recommend amputation of the stump, in order to procure an even, smooth incision, instead of an irregular, jagged, and highly dangerous wound. Even Mr. Mann,* hospital-surgeon of the American army, and by no means a zealous advocate for immediate amputation in many cases now considered as urgently requiring such a proceeding, accedes to the proposition, that, when a limb is carried away by a ball, or by the bursting of a grenade or a bomb, the most prompt amputation is necessary, and that the least delay endangers life. As the bone is liable to be split extensively upwards, some even deem it inva- riably necessary to perform amputation, if possible, above the nearest joint. Others object to the practice, on the ground that such wounds are disposed to end favourably without amputation, and that the state of the system does not admit of the operation being done with the best pros- pect of success. But when the operation is not done, an irregular wound of this description requires considerable incisions for the extraction of foreign bodies, for the discharge of matter, and for the purpose of shortening the projecting muscles and tendons; measures, which produce as much, and even more pain and irritation, than amputation, without equal good. If a few cases can be cited, in which patients with shattered stumps survived, with the parts firmly healed,f a much larger number has occurred, in which this reluctance to operate had the most fatal consequences. The surgeon may the more readily make up his mind to amputate, as the loss of a limb is not in question. With respect to amputating above the nearest joint, this must depend in a great measure on the distance of the in- jury from the articulation; no one would think of ampu- tating above the knee, when the injury is near the ankle. • Medical Sketches of the Campaigns of 1812, 1813, 1814, &c. p. 207. 8vo. Dedham, 1816. •J- Some years ago, Mr. Weir, the late Director-General of the army medi- cal department, pointed out to me a soldier, in the York hospital, who from the appearance of his stump, had had his arm as well taken off by a cannon ball as it could have been by the knife. POISONED WOUND:- 2ftS CHAPTER XX. OF POISONED WOUNDS. As poisoned weapons are not made use of by civilized nations, and venomous animals are not numerous in this country, our opportunities of seeing poisoned wounds are but limited. The bites and stings of insects; accidental pricks and cuts, received in dissection; the bites of ad- ders; and those of rabid animals; are the chief cases. Of these, only the two last will be noticed in this volume. BITE OP AN ADDER. The poison of this reptile is lodged in capsules, at the roots of two moveable fangs in its upper jaw, which, when the animal bites, are directed perpendicularly downwards, and the venomous fluid, being then compressed out of the capsules, flows through the grooves of the fangs directly into the bitten part. The effects of the bite on the human subject usually take place with great rapidity. An acute pain, and a burning sensation, are immediately experienced in the part, which soon begins to swell. The pain, heat, swelling, redness, and tension, quickly extend a considerable distance from the punctures, frequently affecting the whole limb, on which livid spots make their appearance. In some cases, the pain is not confined to the limb, or parts in the vicinity of the in- jur}', but affects the viscera and other remote organs. De- jection of spirits; alarming syncope; a frequent, small, concentrated, irregular pulse; difficulty of breathing; cold profuse sweats; confusion of vision, and of the mental facul- ties; vertigo; prostration of strength; headach; nausea and a convulsive vomiting of bilious matter; followed almost always by a general yellowness of the skin, and sometimes by pain about the navel; are the symptoms usually denot- ing the operation of the poison of the viper on the whole constitution. When the case ends fatally, a kind of gan- grenous inflammation of the cellular membrane, the sort of disease lately described under the name of diffuse in- flammation of the cellular substance, and noticed in the chapter on erysipelas, is generally produced in a greater 204 POISONED WOUNDS. or less degree. In this country, the bite of an adder sel- dom proves fatal to man, and, according to Fontana, the danger of the injury is commonly in proportion to the smallness of the animal that receives it. Hence, children suffer more indisposition from the bite, and more frequent- ly die from its consequences, than adult persons, as is proved by certain facts published by M. Paulet.* The same author likewise refutes Fontana's statement, that the bite never kills a grown person, of which event, indeed, some examples have been known in Great Britain. An- other fact, which he explains, is, that of the more perilous effect of the poison on animals already weakened by dis- ease, than on those in a healthy state; in illustration of which observation, he records the case of a horse, which being bitten on the cheek, while in an enfeebled condition, died of the accident in eighteen hours. The activity of the poison is described by all writers as greatest in hot weather, and the effects of the bite are remarked to be ge- nerally more rapid, the nearer the injury is to the heart, and the quicker the circulation of the blood at the time of its reception. The treatment consists of local and constitutional means: by the former, we endeavour to prevent the absorption of the venom; by the latter, we strive to avert the ill effects of absorption, if it should take place, and appease the bad symptoms, when they have come on.f * Obs. sur la Vipere de Fontainebleau, 1805. f {The poisonous snakes of this country, are the rattlesnake and the cop- per-head—the same arrangement exists for projecting the poison, as in the adder. Much has been written in this country upon the treatment of the bites of these reptiles, and many remedies have been proposed. When we take into consideration the fact, that the bites of the above snakes are more or less venomous according to the season o'f the year, (the poison being more active in warm than in cold weather,) we shall be at no loss to account for the supposed success of the numerous remedies, to which the notice of the profession has been so frequently directed. The Indians of this country nave long been known to make use of a plant for the cure ot the bite of the rattlesnake, and it is said with great success. J. G. Stacj, Esq. of Albany, in a communication to the New-York Med. and Phys. Journal, for April 1828, states that it has been discovered to be the uvularia grandiftora, and that it is employed by them in the form of decoc- tion of the roots and leaves internally, the bruised plant being bound to the wound. The treatment of poisoned wounds by the application of cupping glasses, as recommended by Dr. Barry, we conceive to be superior to any plan here- tofore proposed. From his experiments on dogs and rabbits, he found that "the animals bitten by one, two, and sometimes three vipers, when the cup- ping glass was applied for half an hour, suffered none of the effects what- POISONED WOUNDS. 205 The application of a ligature round a limb, above the bite, with the view of impeding the entrance of the virus into the circulation, was a plan, which Fontana, as well as Pan', found particularly useful. The objections to this practice are founded on the inconvenience, and even dan- ever of constitutional poisoning; whilst those that were left to nature were invariably attacked with convulsions, stupor, &c." He says that the action of the venom seems to be concentrated by the cupping glass within its own bounds—" that the vacuum sucks a reddish serum in considerable quanti- ties through the skin of animals in which it is thin, and almost invariably in these cases the poison appeared to have been removed from the wound." The experiments of Dr. Ii. have been repeated by Dr. Caspar Wistar Pennock of Philadelphia, and published in the American Journal of the Med. Sciences, for May 1828, and in his highly valuable essay we find it stated that the results did not coincide with those of Dr. B.; that the symp- toms returned shortly after removing the cupping-glass;—may not this be prevented by excising the bitten part immediately after its removal ? Rea- soning from analogy, Dr. Pennock conceives, that the effect of the cupping- glass is to paralyze those nerves upon which the circulatory action of the absorbents depends, and instances the absence of hemorrhage in cases of extensive lacerated wounds, where limbs are torn from the body, where, by the same agency, the circulation of the blood-vessels may be interrupted. He then proposes the following questions: " have we not good reason to believe that this state of the nerves may be induced by pressure? Whether applied directly by weight, by ligature, or by the exhausted cupping-glass ?'* Another method of treating poisoned wounds has recently been announced^ to the Academy of Sciences, Paris, by M. Antoine Vernicre. From the re- searches of M. Majendie on venous absorption, it has been discovered that absorption is impeded, or even entirely prevented, by producing an artifi- cial state of venous plethora, by injecting tepid water into the veins. From these discoveries M. V. has drawn some fair and logical deductions for the treatment of poisoned wounds—his method of cure "consists in taking ad- vantage of this discovery, establishing a general venous plethora, and then removing the plethora as nearly as possible from that part only wliere the poison has been introduced by opening a vein proceeding from the part. Thus, three grains of the alcoholic extract of nux vomica were thrust into the paw of a dog, and a tight ligature was without delay tied round the limb. Warm water was then very slowly injected into the jugular vein, to as great an extent as the animal could safely bear, and the ligature was removed. Half an hour was then allowed to elapse, which, in ordinary circumstances, would have beer, much more than sufficient to enable the poison to act. The ligature was next replaced, but so as to obstruct the venous circulation only, just as in performing the operation of venesection; the principal vein of the limb was then opened immediately under the ligature, and the blood which flowed out was collected. The blood was then carefully washed away, a little more was allowed to issue, and the ligature was finally remov- ed. None of the symptoms of poisoning with nux vomica ensued, and the slight signs of venous plethora which remained were removed by a bleeding from the jugular vein. The blood which had been withdrawn from the vein of the fore leg, when cautiously injected into the vein of anottier dog, caused violent tetanus and almost instant death." Future experiment must test the value of these suggestions; they should be borne in mind, and opportunity should not be neglected for putting therri in practice.—P. K.J 20t) t POISONED WOUNDS. ger of mortification, likely to result from the long-coit- tinued constriction of the limb. It may also be supposed, that after the removal of the ligature, or tourniquet, the virus would still find its way into the circulation; but, if Fontana's statement be correct, this is not generally the case, and the fact may depend either upon the interruption of absorption produced by the inflammation, or upon some change effected in the virus during its lodgment in the part. One of the most effectual plans for the hinderance of the absorption of the virus, is the excision of the bitten part. I should have more confidence in this treatment, than in attempting to destroy the part with the actual or potential cautery. Fontana's observation, however, that the bad symptoms, when begun, cease after amputation of the part, is at variance with what Russell has stated with regard to the serpents of India. The eau de Luce, (a me- dicine resembling the spiritus ammoniae succinatus) and olive oil, are also celebrated local remedies for the bites of snakes. In order to form a correct judgment of their real efficacy, it must be recollected, first, that the bite of an ad- der rarely proves fatal, and the patient would generally recover with little, or even no assistance at all. Secondly, • that the virus of the animal varies in its quantity and force, according to circumstances, and therefore its effects are sometimes but slight. Thirdly, that both the foregoing applications have repeatedly failed in averting the severity of the symptoms, whatever appearance of efficacy they may- have bad in other examples. In South America, the plant, named mikania guaco,* is regarded quite as a specific for the bites of serpents. The plan is to chew it, and then lay it on the wound, the juice being used also as an inter- nal medicine. An investigation into the real power of guaco by a committee of well-informed professional men, is at present a desideratum. The internal remedies, which have gained repute for their good effects in counteracting the operation of the venom of snakes, are, besides guaco already mentioned, ammonia, eau de Luce, olive oil, and arsenic. Six or eight drops of the liquor ammoniae may be given in a little pep- permint water, or a glass of sherry, every two hours. The dose of eau "de Luce is a teaspoonful, which, if necessary, * Humboldt and Bonpland, Plantes Equinoxiales, t. ii. p. 31. tab. 105.: also Orfila, Traite des Poisons, t. ii. p. 533. ed. 2. POISONED WOUNDS. 207 may be repeated every three or four hours. These two medicines, however, are not considered, in modern days, as deserving the name of antidotes for the bites of snakes, though they may be useful in preventing the syncope, prostration of strength, and mental dejection, apt to occur in such cases. The character of arsenic is supported by much better evidence ; and according to some experiments detailed by Russell, and several cases recorded by Mr. Ire- land, it seems actually to possess very considerable speci- fic power in preventing, and even removing, the ill-conse- quences of the poison of various serpents. The formula used by Mr. Ireland, was 5ij- of the liquor arsenicalis, and ten drops of tincture of opium in ^iss. of peppermint water, to which ^ss. of lemon juice was added just before the medi- cine was taken. The same draught was repeated every half hour for four hours in succession. The inflamed parts were often fomented and rubbed with a liniment, compos- ed of half an ounce of turpentine, the same quantity of ammonia, and an ounce and a half of olive oil. Cathartic clysters were exhibited as soon as the patients began to we purged, and the arsenic was discontinued.* BITE OP A MAD DOG.—HYDROPHOBIA. Of all the poisoned wounds, which happen in this coun- try, the bites of certain rabid animals are the most danger- ous, as they are apt to give rise to one of the most dread- ful and incurable disorders to which human nature is lia- ble. The rabies of certain animals, here alluded to, is de- scribed by writers as either originating spontaneously, or as being communicated to them by the bite of an animal already labouring under it. Whether it ever arises spon- taneously in the human subject, is a doubtful point; the cases adduced as proofs of it, being by no means free from ambiguity. Horses, mules, asses, horned cattle, pigs, and, still more frequently, foxes, wolves, cats, and dogs, are attacked by rabies. Although the infection may be re- ceived, and propagated by other animals, it probably never originates in any except those of the canine race.f The hydrophobic poison, I believe, can only produce its terri- ble effects on the htr.m.n constitution by inoculation, that is to say, the virus, which is blended with the saliva of a :abid animal, must either be introduced into the cutis by * See Med. Chir. Trans, vol. ii. p. 393. ' ^ce Hillary on the Diseases of B:vbadoes, n. '■>!:> 208 POISONED W0UNI». a bite, or be applied to a scratch, cut, or excoriation. As these slight injuries are frequently unnoticed, or forgotten by persons who have been handling infected dogs and cats, and the illness of the animals themselves is also not even suspected, we cannot be surprised that the idea of the dis- ease sometimes having a spontaneous origin in man, should thus receive countenance. In consequence of the virus being mixed with the saliva of the rabid animal, when a person is bitten through a boot, or other thick clothing, the chance of infection is lessened, inasmuch as there is a possibility of the poison having been completely wiped from the teeth in their passage through the leather, or other clothing. Hence, also, bites of the naked face, and of the fingers and hands, unprotected by gloves, are reck- oned particularly dangerous, and alleged to be in general not only more frequently followed by hydrophobia, than bites of other parts covered by the clothing, but to be also sooner followed by it. The human race seems much less susceptible of the in- fection than dogs. Four men and twelve dogs were bit by the same rabid dog; all the dogs died rabid; but the four men escaped, though they used no other means of preven- tion, than such as wc see every day fail. On an average, not more than one person out of sixteen bitten, takes the distemper ;* an important fact to be remembered in judg- ing of the true merit of any preventive methods of treat- ment. From an experiment made by Majendie and Brcschet, it seems that the saliva of a hydrophobic patient is capa- ble of communicating the disorder to dogs by inoculation.f The same thing has been repeatedly tried in England, without any effect. The interval between the infection and the commence- ment of the disease, varies considerably in different in- stances. Out of 131 cases, only three patients took the disease before the eighteenth day; none before the eleventh; from the eighteenth to the thirtieth, seventeen were seized; sixty-three began to be ill from thirty to fifty-nine days after the bite; twenty-three were attacked from two to three months inclusive; nine from three to four months; two at five months; one at five months and eleven clays; one at six months; one at seven months; two at eight * See Hamilton on Hydrophobia, vol. i. p. 31. f Orfila, Trajte des Poisons, t. ii. p. 529. ed. 2. POISONED WOUNDS. 20.9 months; one between eight and nine months; two at nine months; one at eleven months; one at fourteen months; two at eighteen months; and one at nineteen. To cases happening beyond this last interval, Dr. Hamilton attaches no credit.* One case related by Dr. Bardsley, on the other hand, seems not to have commenced till twelve years after the bite.f The most frequent time, for the beginning of the symptoms, is about six or seven weeks after the acci- dent. A dull heavy pain first takes place about the wounded part, the cicatrix of which sometimes becomes red, or even festers, and discharges a thin red ichor. When the bite has been in the hand, the pain shoots up to the shoulder and neck, and not particularly to the axilla. A gloom is diffused over the spirits, accompanied with listlessness and anxiety. The patient becomes timid and distrustful, sleeps unsoundly, and often courts solitude. In a few cases, the distemper begins with a paroxysm of shivering. The night is passed in restlessness; the appetite begins to fail, and some thirst is experienced: now the peculiar symptom, which gives the disease its name, the dread of liquids, is discovered, often accidentally, on the patient attempting to take drink. There are a few cases which cannot, with accuracy, be said to have any melancholy stage; the pain about the wounded part, and the difficulty of swallowing liquids, being preceded by no loss of spirits, nor any kind of men- tal despondency. The patient is not only unable to swallow liquids, he cannot behold them without terror, nor hear them men- tioned without disgust. This fear, however, is not the re- sult of a mental aversion to fluids; but is the consequence of the insufferable sensations which the attempt to swal- low them, or even the sound or sight of them, produces. When the patient attempts to drink, he immediately sobs in a convulsive manner, experiences a dreadful choaking pain, and is seized with general convulsions. Patients have tried to drink with the firmest resolution; but on the liquid approaching their lips, the intolerable disorder ex- cited, baffled the endeavour.:}: If, with great suffering, a • Hamilton, vol. i. p. 113. •\ Mem. of the Literary and Philos. Society of Manchester, vol. iv. par' :. p. 431. ■ Marcet, in Medico-Chirurgical Trans, vol i. p. 138. Voi. I. D d 210 POISONED WOUNDS. little drink is swallowed, it is sometimes immediately vo- mited up again, tinged with bile.* This symptom, hydro- phobia, then, is not a delirious dread, or hallucination of the mind; but a matter of experience, which at first sur- prises the patient himself.f Even shining surfaces, which reflect the light, as water does, are sometimes to hydrophobic persons intolerable. This was not the case, however, with the poor woman, who died in the summer of 1808, in St. Bartholomew's hos- pital; for, she made use of a looking glass, without any inconvenience. But the dread of swallowing liquids, although the most singular symptom, constitutes but a small part of this dis- tressing malady. The mind and body are affected with extreme irritability, and excessive susceptibility to all im- pressions. Hence, the constant watching and inquietude; the impatience and sudden fits of anger from trivial causes ; the distress and the violent paroxysms brought on by such circumstances as the slightest motion of the air, the shut- ting of a door, the buzzing of a fly, &c. Hence, also, the patient's timidity and incessant apprehensions, and the oc- casional fits of delirium and incoherence, from which he quickly recovers. In this disease, the fauces are always oppressed with a large quantity of a thick, tenacious mucus, and, as the pa- tient cannot swallow even his own saliva, he is continually spitting it out. The degree of mental derangement differs greatly in different examples; in some it hardly exceeds great irrita- bility and impatience; in others, it amounts to muttering and incoherent talking, with rational answers to questions; and, in a few, it rises into short fits of the most ungovern- able rage and fury, the patients biting and tearing them- selves, and every thing near them. At length, the muscles of deglutition are more continual- ly affected with excruciating pain, which gradually extends itself to the diaphragm, and abdominal muscles. The con- vulsions become more violent, and the fits of suffering more frequent, the patient's countenance is full of horror, and his eyes look red and furious. Sometimes, the patient, notwithstanding such symptoms, retains his senses to the last. * Mem. of Manchester Society, vol. iv. p. 439. f See Mead on Pojsons, p. 146. edit. 3. POISONED WOUNDS. 211 The duration of life, after the commencement of the symptoms, varies from thirty-six hours to five days, very rarely to six. The difference between rabies canina and tetanus, is not invariably such as to prevent the latter from being mis- taken for the former. Tetanus is mostly occasioned by slight wounds of the fingers, toes, or other tendinous parts. It does not commonly begin till some time has elapsed after the injury, and, perhaps, the wound is healed. It is marked by violent paroxysms of general spasm, which be- gin about the throat and neck, and are accompanied by a difficulty, or inability of swallowing. These spasms are ex- cited by the most trivial causes; for, merely attempting a change of posture, endeavouring to swallow, or even to speak, will sometimes produce a renewal of spasms over the whole body.* Tetanus and rabies canina also mostly end fatally about the fourth day. Some cases must be ex- ceedingly difficult to discriminate. Dr. Bardsley describes an instance, where a slight injury of the finger, with a splin- ter of wood, was followed, in about a week, by spasms of the lips, locked jaw, and paroxysms of general spasm. On the third day, after the attack, the young gentleman could not swallow any watery fluids, nor bear them to be brought near him, without fresh and more violent attacks of spasm being thereby induced. Another similar case arose from the bite of a horse. In both these examples, a recovery took place.f In tetanus, the spasms generally come on sooner after the local injury, than those of rabies canina; the jaw is rigidly locked, and the muscles of the neck and back are particularly affected; the muscles are more unremittingly contracted than in hydrophobia, their action only abating for a time in degree ; there is less fever, less quickness of pulse, and less thirst; and the extreme anxiety and irrita- bility of mind, which accompany rabies canina, do not pre- vail.:}: The name, hydrophobia, has certainly led to much con- fusion, besause it creates an idea, that the most essential and distinguishing symptom of rabies canina, is a dread, or difficulty, of swallowing fluids. The symptom hydro- phobia is far from being peculiar to canine madness: it has • Cullen's First Lines of Physic, vol. iii. Chap, on Tetanus \ Mem. of the Manchester Society, vol. iv. p. 477 I Recs's Cyclopaedia, art. Hydrophobia. 212 POISONED WOUNDS. occurred in typhus fever, tetanus, hysterics, variolous sore throat, inflammation of the stomach", pleurisy, peripneumo- ny, St. Vitus's dance, Sec* Neither is the dread of liquids an inseparable symptom of rabies canina.f As no medicine, hitherto discovered, is capable of infal- libly counteracting the baneful effects of the canine poison, practitioners are strongly called upon to impress on the minds of the patient and his relations, the necessity of do- ing whatever is most likely to prevent the constitution from being affected. As a preventive, surely nothing is more rational, nothing is so forcibly indicated, as the excision of the part bitten immediately after the accident. In all poisoned wounds, the adoption of other steps to prevent the system from be- ing affected, is inferior to the obvious efficacy of this mea- sure, which, the sooner it is practised, the greater must be the chance of success from it. When the operation has been neglected at first, it ought yet to be done; for there- is reason to believe, that it may answer, not only several days, but several weeks after the bite, and, indeed, at any time before the symptoms have actually begun. Were a person to receive a bite close to a largish arte- ry, like the radial, one fatal instance of which fell under my own notice, I am of opinion, that, if the animal from Which the injury was received, were undoubtedly rabid, the part ought still to be cut out, even though the opera- tion might not be practicable without removing a portion of the vessel itself. When the bite extends very deeply, so as to render the complete excision of it impossible, some writers recommend amputation; but it is a practice rarely- adopted, on account of the severity and mutilation attend- ing it. If excision be not practised, the other less certain mea- sures for the prevention of infection, are the application of the actual or potential cautery, particularly caustic potas- sa, quicklime, muriate of antimony, nitrous acid, or the moxa. Bathing the wound with chlorine, or hydro- chloric acid, and keeping it covered with linen wet with this medicine, which is also given internally, is another practice, in favour of which, some cases published by Brugnatelli, deserve attention. The dilatation of the * See Mead on Poisons, p. 147. Sauvage's Nosol. Method. Edinb. Med. Essays, vol. i. p. 222 and 227. Ferriar's Med. Hist, and Kefl. vol. iii. p. 24— 26. Rees's Cyclop, loco citato. f Hildanus, Obs. 88, and Mead on Poisons, loco citato. POISONED WOUNDS. 21' wound, and the application of cupping glasses to it, as well as the plan of keeping up a discharge from it for a consi- derable time, may likewise be mentioned. Various specifics for the prevention of rabies canina have been extolled, though generally without sufficient proof of their real efficacy. No modern practitioner has the least confidence in the pulvis antilyssus of Dr. Mead; the fa- mous Tonquin medicine; or the Ormskirk remedy. Nei- ther does cold bathing, or rather half drowning the patient in the sea, retain as many advocates as it did in former times. With regard to the most powerful articles of the materia medica, I may say, that they have all been repeat- edly tried, and as repeatedly found ineffectual; musk, ammonia, opium, belladonna, stramonium, hyosciamus, arsenic, aether, the nitrate of silver, and mercury in every possible form. That cases may be found in the annals of medicine, in- tended to prove the efficacy of these and other remedies, as preventives, must not be dissembled; but, they are all ©f a questionable and inconclusive description; because,in general, before any preventive remedy is tried, the wound is well washed, or some other means taken to free it from the virus. In this circumstance, the latter measures may be the cause of any benefit really obtained. Hydrophobia also only happens in a small proportion of patients, who are bitten by animals truly rabid, and, be it recollected, that these are frequently not rabid when vulgar report describes them as being so. After the system is affected, the methods of treatment. yet entitled to further trial, seem to me to be, first, the practice of venesection until the pulse can scarcely be felt, as successfully adopted by Schoolbred and Tymon in the East Indies. At the same time, I ought to mention, that, in Europe, such treatment has not hitherto answered the expectations once raised by the reports of its efficacy in Asia. Secondly, the external and internal use of chlorine, or the hvdro-chloric acid. Thirdly, the injection of mor- phine, extract of opium, stramonium, laurel-water, bella- donna, or simply lukewarm water, into the venous system, as suggested and tried by Magendie, Dupuytren, Breschet, Brandreth, and others; though, as yet, only with a partial and temporary relief of the symptoms of some of the cases. Whether this plan of trying the effect of powerful reme- dies, introduced directlv into the veins, instead of mtothe 214 POISONED WOUNDS. stomach, will lead to the discovery of an antidote for hy- drophobia, further experience can alone decide. The bite of a viper has been sometimes tried. Although I strongly recommend perseverance, and would not on any account discourage the boldest experiments in so desperate a case, truth obliges me to say, that, as far as our present know- ledge of their results extends, there is nothing yet establish- ed, that can justify us in lessening our opinion of the high importance of preventing the disease by the early excision of the bitten parts. In Russia, the cauterization of vesicles, discernible under the tongue in an early stage of the case, and the exhibition of a drachm of the powder of genista, three times a day, are said to have prevented and even cured the disease. CHAPTER XXI. CONTUSIONS Are produced by the impulse of a blunt, hard surface, against the body, the skin remaining unlacerated. The consequences are, a diminution of the tone of the injured fibres, and a rupture of an infinite number of small vessels. The bruised muscles are weakened, and cannot be exerted without pain; and the extravasation of blood causes swell- ing, and a black and blue discolouration of the skin, term- ed ecchymosis. Sometimes vessels of considerable size are ruptured, and a copious effusion of blood under the integu- ments is the result. In contusions of the head, we often see the scalp enormously elevated by hemorrhage beneath it, and large collections of blood are frequently found ex- travasated in the cellular substance of almost every situa- tion in the body. Violent contusions not only affect parts, on which the force immediately falls, their effects reach those which are remote from the place directly struck. The second sort of contusion is what the French term a contrl-coup, in which the injury is to be imputed to the effect of a very powerful concussion. The ill-consequences of a bruise are not always propor- CONTUSIONS. 215 tioned to the force applied; but sometimes depend on the nature of the injured part. If the bruise take place on a bone, thinly covered with soft parts, the latter always suf- fer very severely inconsequence of being wounded, at the time of the accident, between two hard bodies. Hence, bruises of the shin so frequently cause sloughing and trou- blesome sores. Slight contusions may be considered as occasioning only a weakness, and a degree of extravasation in the part, which may be rubbed once or twice a day, with the.linim. saponis com p., or be covered with linen moistened with vinegar, cold water, brandy, lime-water, solutions of alum, or of acetate of lead. The bowels should also be opened with a dose or two of salts. When muscles are bruised, they ought to be relaxed and kept perfectly quiet, nothing being more conducive than quietude to the restoration of their proper tone. When the contusion is of a more violent description, and the quantity of extravasation is considerable, bleeding, and other evacuations, together with the use of leeches, are proper. The topical applications should be mildly stimu- lating, and, consequently, such as are calculated to pro- mote the action of the absorbents. Muriate of ammonia, dissolved in equal parts of vinegar and water, or the iiq. ammon. acet. forms an excellent lotion. When the inflam- mation has subsided a little, liniments containing camphor may be used. In cases, in which there is no danger of serious inflam- mation, and the chief indication is to promote the absorp- tion of extravasated fluid, bandages act very beneficially, by the remarkable power which they have, of exciting the action of the lymphatics. It is best, however, not to em ploy them too early. It is surprising, what large collections of blood will sometimes take place about the shoulder, and under the scalp, in consequence of bruises. Many surgeons would be induced to puncture such swellings, and let out the ex- travasated fluid. Without condemning every instance of this practice, I have no hesitation in pronouncing it to be in general hurtful. In ordinary cases, under the use of discutient lotions, and aperient medicines, the blood is rapidly absorbed. But, when an opening is made, the ad- mission of the air to such blood as cannot be pressed out, makes it putrefy; febrile symptoms arise ; the part is often attacked with an erysipelatous redness; and extensive ab- 216 CONTUSIONS. scesses, sloughing, and death, have been the too frequent consequences.* Should the distention, however, threaten to bring on sloughing, every one must coincide in the propriety of dis- charging the blood by an incision. I have seen many ca- ses, in which the whole scalp was prodigiously raised and distended by blood, effused in consequence of a blow; but, generally, in about a week, the swelling entirely disappear- ed, with the aid of bleeding, purging, and the lotion of vinegar and muriate of ammonia. From the observations and cases, published by Pelletan, it appears, indeed, that a puncture may sometimes be ad- vantageously made in collections of extravasated blood; but, only after discutient means have had a fair trial, and the tumor has existed a considerable time.f The putrid decomposition of extravasated blood, great local irritation, an erysipelatous affection and sloughing of the part, severe febrile symptoms, and death, sometimes take place, in consequence of the inflammation arising from the violence of the contusion ; for, when the parts unavoid- ably slough, or suppurate, from the degree of injury inflict- ed, the sloughs and matter become blended with the ef- fused blood, and, in this circumstance, the latter fluid in- evitably putrefies.:}: Here an external opening should be promptly made, and even this will not avail, unless the contents be completely discharged. It matters not, whe- ther the external opening, in a collection of extravasated blood, be made by accident or design : putrefaction of such portion of this fluid, as cannot be discharged, and the se- vere effects already hinted at, are the consequence. Besides cases, in proof of the foregoing statements, Pel- letan has related others, tending to show, that, when the whole of the extravasated blood can be completely dis- charged, and the sides of the cavity can be so effectually compressed together as to exclude the air, the making of an incision may sometimes prevent bad symptoms, instead of inducing^ them. It is acknowledged, however, that, if an opening is made, and the blood cannot be entirely eva- cuated, nor the cavity obliterated by compression, such * Several cases, illustrative of the evils arising from an external opening, arc detailed by Pelletan, in his Clinique Chirurgicale, torn. ii. Mem. sur lea Epanchemens de Sang, p. 161, &c. j See Clinique Chirurgicale, torn. ii. p. 130,131. Cases 10 and 11 i Vide Pelletan in the Memoir above referred to, p. 139, &c. § Vide Pelletan in the Memoir above referred to, p. 192—211. CONTUSIONS. 217 practice leads to a putrefaction of the part of the blood left behind, and does much harm. I must leave it to the ex- perienced surgeon to decide, whether it is generally in our power to discharge, thus completely, every particle of ex- travasated blood, especially in recent cases, where that fluid is not contained in one cavity, but is widely diffused in the interstices of the cellular membrane. In cases, where extravasated blood putrefies, and the whole cannot be discharged, Pelletan* suggests, whether it may not be proper to counteract the process, by intro- ducing into the cavity alcoholized or acid injections, &c. I can conceive, indeed, that, by chemical means, we might stop the putrefactive process in the effused blood ; but, the irritation of these injections, on the living and highly in- flamed parts around, no doubt, would do more mischief than the putrid blood itself. Amongst the examples of contusion, in which the utility of making an incision for the discharge of extravasated blood appears to be decidedly acknowledged, I may men- tion those, which are improperly called wind-contusions, the nature of which is pointed out in the chapter on gun- shot wounds. CHAPTER XXII. ULCERS. By some surgical writers, an ulcer is defined to be a so* lution of continuity in the solid parts of the body, accom- panied with the discharge of a purulent fluid. According to this definition, the term ulcer is synonymous with the words sore, suppurating wound, and open abscess. By others, the word is restricted entirely to those solutions of conti- nuity, from which an ichorous, sanious, or vitiated matter is discharged, attended with a loss of substance in the part. Although Professor Thomson thinks more favourably of this definition than of the former, I cannot help expressing a decided preference to the first, for the very reasons which • Vide Pelletan in the Memoir above referred to, p. 237. Vol.. I. E e ■J 18 ULCERS. this judicious surgeon has himself suggested.* If we ob- ject to calling suppurating wounds, and such abscesses as have burst, ulcers, as long as they discharge healthy pus, what particular reason is there for approving of their re- ceiving this name only when the matter from them hap- pens to be of a bad quality ? The healthy or unhealthy state of the discharge from a sore or abscess is an acci- dental circumstance, depending upon the favourable or unfavourable condition of the parts to admit of the pro- cess, by which they are to be healed. If the preceding capricious method of defining an ulcer were to be sanc- tioned, every ulcer would cease to be so called as soon as the discharge from it presented the appearances of healthy pus; nor could there ever be any such ulcer as that, which has usually been described under the name of the simple healthy ulcer. It seems to me, that, in a general sense, we may consider sores or ulcers of every description, as chasms or breaches more or less gradually formed in the substance of the body, by a process, well known by the name of ulceration, in which the absorbents of the part re- move the old particles back into the system more quickly, than the new ones are laid down by the secerning arteries. Ulceration does not invariably spread by that kind of de- struction of the parts, where no remnants of the destroyed portions are left. Sometimes portions of organs, about to be destroyed, are observed to slough, and mortification is then partly concerned in extending the destructive pro- cess. Such cases are less frequent, however, than other instances, in which we know that a considerable extent of parts has been destroyed, without any remains of them being perceptible. Surgeons have endeavoured to disco- ver the physiological reason of this curious fact; and an explanation is offered, which supposes that nutrition ceases in the ulcerating parts, while the destructive function of the lymphatic system, absorption, still proceeds.! Some- times, however, the destruction of parts, the actual loss of substance, is only apparent; as, when a sore is the conse- quence of a simple incised wound, that has not united by the first intention, and continued for a greater or lesser time unhealed. Here we have sometimes the appearance of a cavity, from the retraction of the parts; but none of the flesh has been in reality removed, either by the acci- * Lectures on Inflammation, p. 426. f Delpecb, Precis des Maladies reputes Chirurgicales, t. iii. p. 594. ULCEUS. 2iy dent itself, or by any subsequent action of the absorbent vessels. An ulcer, resulting from such a cause, is differ- ent, therefore, in respect to the process by which it is form- ed, from another sore, in which a chasm is truly produced in the part by ulceration. Also, when an ulcer is the conse- quence of mortification, and the separation of the sloughs, the process by which the loss of substance is occasioned, is very different from what happens in other cases, in which any chasm that may exist, has been wrought by the activi- ty of the lymphatic vessels. However, even in the instance of sores resulting from mortification, the latter vessels are somewhat concerned, inasmuch as it is by them that the uniting medium between the sloughs and living flesh is removed, and the dead parts loosened, so as to admit of separation. With regard to open abscesses, which have become what are customarily named sores, I think there can be no doubt of their being strictly entitled to this name, because here it is the process of ulceration, which always thins the superincumbent skin, and produces in fact the opening by which the matter is discharged. When the abscess has been opened with a knife, however, before the ulcerative process has commenced for the establishment of a spontaneous aperture, the case is then not essentially different from any other sore arising from an incised wound, in which some particular causes impede direct union, and create a necessity for the more circuitous manner of heal- ing, by means of the granulating process. The truth is, in all the foregoing cases, whether sores, suppurating wounds, open abscesses, or large raw cavities left by the separation of sloughs, the parts can be healed only by one and the same process,—the formation of granulations; and the principal differences between them are derived from the consideration, that, in suppurating wounds and ab- scesses, there is not always essentially a loss of substance, which must, of course, attend every other sore, which is the consequence either of ulceration or sloughing. If the pre- ceding view of things be allowed, and suppurating wounds, especially those of a certain standing, be considered as ul- cers, then, of course, I see reasons for not agreeing with Dr. Thomson, that the words "attended with loss of sub- stance" will increase the correctness of the definition, any more than Callisen's expression does, " solutio continui in partibus organicis lente exorta," &c* The accuracy or • Systema Ohirurgise Hodierns, vol. i. p. 379. 220 ULCERS. inaccuracy, however, will depend upon the rejection, or not, of the suppurating surfaces of old wounds from the cases regarded as ulcers. Were the term ulcer entirely restricted to the effects of the process of ulceration, then, of course, loss of substance, and the gradual manner in which the solution of continuity has been produced, would be essentials in the definition. The usual causes of ulcers may be said to be abscesses, which have burst, or been opened; wounds which have not healed by adhesion, but continued a certain length of time suppurating and indisposed to heal with facility and readi- ness; various surgical operations in which the knife has been employed; the separation of mortified parts; differ- ent kinds and forms of external irritation; and internal constitutional diseases, many of which are of a specific na- ture, as scrofula, lues venerea, the scurvy, &c. The division of ulcers into constitutional and local, true and natural as it is, is to be received with an understand- ing, that many sores, which at first depend entirely upon internal causes, and are in the beginning of a specific na- ture, are often changed so much in their nature before ci- catrization is completed, that, in their latter stage, they are strictly only local ulcers; while many other sores, which are at their commencement only of a local nature, quite unconnected with internal causes, afterwards change with any change or affection of the general system, and become, in every sense of the expression, constitutional ulcers. The prognosis generally depends, first, upon the nature .of the cause, and the facility or difficulty of" its removal; secondly, upon the kind of parts attacked, whether of great importance or not in the animal economy; and thirdly, upon the patient's age, constitution, and mode of life. The steps which nature takes in the healing of sores, I have endeavoured to describe in the chapters on wounds. With respect to the art of surgery, it is its province to re- move and diminish the causes from which an ulcer has originated; to prescribe a proper regimen, quietude, ad- vantageous posture, and the best dressings. It is only in compound and constitutional ulcers, that any necessity com- monly arises for internal medicines. This term of com" pound is applied to sores, in which the cure is retarded by any complication not existing in what is understood by a simple or healthy ulcer; and such complication may be either internal or external. Of the former we have a spe- cimen in a scorbutic ulcer; of the latter, in a sore which ULCERS. 221 is prevented from healing by hurtful and improper appli- cations. Ulcers present themselves in very various forms, but I think it sufficient, in this elementary book, to consider five kinds : viz. the healthy, the irritable, the indolent, the vari- cose, and the specific. 1. SIMPLE, OR HEALTHY, ULCERS Secrete white thick pus, which does not adhere to the surface, and their granulations are small, and florid, with rather pointed tops. As soon as the granulations have risen to the level of the surrounding skin, those next the old skin become smooth, and covered with a thin semi-trans- parent film, which afterwards becomes opaque, and forms cuticle. An ulcer, answering this description, is in a healing state, and the surgeon can only be useful by keeping the surrounding skin clean, applying soft scraped lint to absorb the redundant quantity of matter, and covering this sim- ple dressing with a pledget of any unirritating ointment, with a view of preventing evaporation from the surface of the sore, a thing which would lead to the formation of a scab, and often change the favourable condition of the ulcer. A roller will frequently promote the cure, as it not only- serves to retain the dressings, and as a kind of defence to the sore, but also to support the muscles and skin, which are frequently loose and flabby, from the want of the natu- ral exercise of the limb. I shall presently have occasion to speak of Mr. Bayn- ton's plan of dressing old ulcers of the leg, with long cir- cular strips of adhesive plaster. This method is now not confined to old ulcers, but often adopted with the greatest advantage in cases of simple healthy ulcers upon the lower extremities. 2. IRRITABLE ULCERS. Irritable ulcers cannot always be known by their appear- ance, though, in many instances, they can be so discrimi- nated. A sore will invariably partake very much of the nature of the constitution, and when this is known to be irritable, the local complaint will often be so. A surgeon, however, is frequently quite unaware of this quality of an £22 ULCERS. ulcer under his care, until, perhaps, at the end of a little time, not finding the sore heal sufficiently quick, he ven- tures to applv some stimulating application, or to roll the bandage round the limb more tightly, than at the previous visits. The next day, he is mortified to find, that his pa- tient has passed a miserable night, and that several dis- coloured sloughy parts have formed on the surface, and also at the circumference of the sore. At other parts, the granulations have been' rapidly absorbed, and whatever matter lies on the surface of the ulcer, is diminished in quantity, and of a blackish, fetid quality. When the excel- lent plan of treating many ulcers, recommended by Mr. Baynton, was first introduced, I saw much mischief result from its being indiscriminately applied by dressers to this kind of ulcer. Some appearances at once deno*te the irritable nature of an ulcer. When the margin of the surrounding skin is jagged, and terminates in a sharp undermined edge ; when the bottom of the ulcer is made up of concavities of differ- ent sizes; when there is no distinct appearance of granu- lations, but only of a whitish spongy substance, covered with a thin ichorous discharge; when touching the surface causes pain, and frequently hemorrhage, the sore may be set down as of an irritable description. Irritable sores are particularly often situated over the lower end of the fibula, the anterior surface of the tibia, and ligament of the patella. The applications to irritable ulcers should be of the se- dative kind. The steam of warm water acts very benefi- cially on them. A warm decoction of poppy-heads, ap- plied every morning and evening as a fomentation, by means of flannels, is highly useful. The extract of hem- lock, or opium, dissolved in hot water, makes a good fo- menting liquor. Emollient poultices may be employed as the continued application, and that made of linseed is the best. It is frequently found serviceable to lay immediately over the surface of the sore, under the poultice, lint dipped in a so- lution of opium, (^iss. to fcj. of water). When the weight of the poultice seems to have a bad effect, the lint wet with the above lotion may be covered with a pledget of simple ointment. The carrot poultice, particularly when made by boiling the vegetable, and beating it into a pulp, deserves to be ULCERS. 22?, noticed as a remedy, which agrees with many irritable sores. Powdered carbon and cream have also obtained repute for their good effects. It is of great use in these cases, to have a choice of remedies ; for those which agree at first generally lose their virtue after being used a certain time, and it becomes ne- cessary to have recourse to others. Thus six or seven different applications may all have a period at which they are productive of benefit. The pressure of bandages is al- ways pernicious.* 3. INDOLENT ULCERS. The appearances of indolent ulcers are the very reverse of those characterizing irritable sores. The edges of the sur- rounding skin are thick, prominent, smooth and rounded. The granulations are smooth and glossy, the pus is imper- fectly formed, and blended with flakes of coagulating lymph, which adheres so firmly to the surface of the ulcer, that it can hardly be wiped away. The bottom of the sore forms almost a level, and its general aspect gives the idea of a portion of the skin, and parts underneath, having been for some time removed, and the exposed surface not having commenced any new action to fill up the cavity.f This is the most genuine indolent ulcer. In other cases, the appearances bear some resemblance to those of that opposite kind of sore, the irritable ulcer. Indolent ulcers form the majority of those which are to be seen in the large hospitals of this metropolis. Their granulations are endued with a weak living principle, and are very apt to be suddenly absorbed without any assign- able cause. When poultices are improperly applied a long time to indolent ulcers, the chasms will be filled up with large, loose, pale, glossy granulations, which would never ac- quire the power of forming a durable cicatrix, if the same relaxing treatment were to be continued. These weak un- healthy granulations, when stimulated by topical applica- * {When the sensibility of the nicer has diminished, a weak solution of nitrate of silver, we have found very beneficial; Professor Gibson says it is one of the best applications that can be employed. He also enjoins the ne cessity of an elevated position of the limb, and perfect rest.—P. E.\ \ Home's Practical 0b9. on th disappear spontaneously, and (except in a few instances in which they have been made to slough and ulcerate by caus- tic and stimulating applications, a plan on every account to be reprobated) all attempts to disperse them invariably prove ineffectual. Every kind of fleshy tumor, every enlargement of an original part of the body, can only be the effect of some change in the action in the vessels. Whatever matter is deposited in the interstices of a gland, or any other part, must be placed there by those secerning arteries, which, in the healthy state, secrete exactly a sufficient quantity of new particles to supply the old as fast as they are removed by the absorbents. Thus the action of the secerning arte- ries, and that of the lymphatics, ought to be equal; and whenever more matter is deposited by the blood-vessels, than is taken away by the absorbents, a tumor forms in the disordered part. It is possible to conceive, however,. that when original parts are enlarged, the morbid change may be owing to an imperfect absorption, and not to any wrong action of the blood vessels. But in cases of tumors, which are quite distinct, and which constituted no original part of the body, the formation of the disease is probably always the result of a morbid state of the surrounding arteries. The process by which sarcomatous tumors, and indo- lent indurations and thickenings, are formed, is sometimes referred to chronic inflammation; but, whether this doctrine be correct, or not, little or nothing is known about the causes of the growth of the generality of fleshy tumors. In fact, we know not what the particular circumstances are, which invariably precede and give rise to whatever change it may be in the action of the blood-vessels, or that of the 240 SARCOMA lymphatics, which leads to the formation of a fatty, or fleshy tumor. We know not what it is that causes the secern- ing arteries to deposit too much, or the absorbents to re- move too little. Neither do we understand, why, in one case, the swelling should consist of fat; in a second, of a fleshy substance; in a third, of medullary matter, &c. un- less we be content with the explanation, that the cause de- pends upon diathesis, predisposition, &c. which is leaving things, in reality, unexplained. It is usually supposed, that coagulating lymph is the first kind of matter, which is thrown out from the vessels, in the early stage of sarcomatous tumors; and that it after- vfirds becomes vascular itself, and is converted by the ac- tum of its own vessels into the various kinds of morbid structure already mentioned. In proportion as a tumor increases in size, it compresses the surrounding cellular substance, which is converted into a kind of membranous capsule. However, in sarcomatous cases, the cyst is ge- nerally thin; and, sometimes, there is even no cyst what- ever. The growth of indolent tumors does not disturb the Constitution; they form in an insidious manner, without in- creased heat, and generally without any uneasiness in the part; and most of them are disposed to become gradually larger and larger. Surgeons are not only ignorant of the particular causes of the growth of various fatty, fleshy tumors, they also know of no effectual means, by which the progress of the disease can be stopped, and the patient freed from the in- conveniences of continually bearing about with him a mass of redundant matter, which in a chronic state is both a de- formity and an oppression; in an inflamed or ulcerated state, is a source of severe pain and even of dangerous mis- chief; and in certain malignant forms, the frequent occa- sion of death, preceded by unusual sufferings. It has been conjectured that topical bleeding and cold applications would check the growth of sarcomatous tumors; but ex- perience teaches us to place no dependence upon the plan. Attempts have also been made to promote the absorption of the new formed substance by means of mercurial fric- tions, blisters, electricity, and stimulatingdiscutient appli- cations. These methods, however, are not recommended by many examples of success; and they are attended with some risk of irritating the tumor, without lessening it, in which case the disease sometimes changes from an indo- .-..VUCUMA. 241 lent quiet form to an irritable state, in which it inflames, enlarges, ulcerates, emits fungi, and assumes a character as intractable and dangerous as that of cancer itself. I believe, thatthconly kind of swelling, which does not pre- sent these risks, is the common adipose one: at least, I have never seen it change into a malignant disease. When local stimulating applications succeed, it is usually by their in- flaming the whole swelling, and causing it to ulcerate and slough. This, however, when it answers, is on the whole a more severe method than extirpation with the knife, and often induces alarming constitutional illness, to which the patient sometimes falls a victim. I remember a man, who had a considerable sarcomatous tumor, extending from the angle of the jaw over the side of the neck; the late Mr. Ramsden, by means of stimulants and escharotics, succeed- ed in making it ulcerate ; but the disease now put on so aggravated an appearance, with incessant darting pain, fever, delirium, &c. that the patient did not live beyond three or four days from the period when the tumor began to ulcerate and slough. For the reasons which have been explained, the practice of trying to disperse indolent sarcomatous tumors, is not deserving of praise. The removal of the disease by the knife is the best measure, and the sooner it is done the better; for a common adipose tumor, now about the size of an apple, and capable of being extirpated with the utmost safety, may, in the course of a few years, become so large as to weigh from fifteen to twenty or thirty pounds; and the magnitude of the wound, necessarily made in cutting out so large a mass, may prove highly dangerous and even fatal. Besides, sarcomatous tumors, when removed in an early stage, are less apt to, leave the surface of the wound com- plicated with any impediments to a radical cure. When the tumor is known, at the time of the opera- tion, to be either a mammary, a tuberculated, or medullary sarcoma, care should be taken to make a free removal of the surrounding substance. The operation is performed in the same way as that of removing a diseased breast, to the chapter on which sub- ject the reader is referred. Vor. I. Hh 242 CANCER. CHAPTER XXVI. OF CANCER. In the present imperfect state of our knowledge of can- cer, the greatest difficulty, in determining many of the most important questions concerning it, undoubtedly arises from one term embracing numerous forms of disease. While some authors confine the name of cancer to one kind of case, as, for instance, to a disease capable of con- taminating other parts, either by direct communication, or through the medium of the absorbents, and when it ap- proaches the skin, producing in it small tumors of its own nature,* others have no scruple in calling nearly every in- duration a scirrhus, and every intractable ulcer a cancer. Nay, a splendid modern work has appeared, in which are minutely described the symptoms and characters of six different species of cancer, to each of which a particular name is assigned-! When different authors, therefore, are speaking of cancers, they are not always speaking of the same disease, and it is by this fact, that the discordant statements about the effects of remedies, and the possibili- ty of a cure, are to be reconciled. The cases adduced by Sir E. Home, support the opinion, that cancer is at first entirely a local disease ; a doctrine, however, about which the best authorities still disagree. They also tend to prove, that cancer is not a disease which immediately takes place in a healthy part; but is a dis- temper, for the production of which the part must have undergone some previous morbid change. Thus, pimples, small tumors, or warts, upon the nose, cheek, or prepuce, remain for ten, fifteen, twenty, or thirty years, without producing the smallest inconvenience ; but, at the age of sixty or seventy, upon being cut in shaving, bruised, or otherwise injured, change into cancers. The same doc- trine is also corroborated by the many indolent tumors of the breast, which remain quiet for years; but, on being irritated by accidental violence, become cancerous. * Home's Obs. on Cancer, p. 146. 8vo. Lond. 1805. | See Nosologic Naturelle, ou les Maladies du Corps Humain distribute par Families, par J. L. Alibert. torn. i. p. 540, &c. fol. Paris, 1817. C \NCf.R. 24f> Cancer is said to prevail in particular families, and is still regarded by some of the latest writers as an heredita- ry complaint.* We are not to undestand, however, that this is so much the case, that because a mother has the disease, her children must necessarily be afflicted with it. Cancer is rather a disease of old, than of young persons. Exceptions undoubtedly occur. Sir E. Home mentions an instance of cancer in the breast of a young lady aged fifteen. The true cancerous structure, however, is seldom seen under the age of twenty-five or thirty.t What used to be regarded as cancer of the eye, and is frequent in children, clearly appears from the observations of Mr. Wardrop to be, in reality, fungus haematodes of that organ. Cancer scroti, however, sometimes, but not commonly, presents itself in young lads. Cancer is most prone to attack the female breast and the uterus. It seldom affects the breasts of the male sex, though I have seen one example that was supposed to be such; and also another case, which, though it resembled cancer externally, had not internally the carcinomatous structure; but, if possible, was a worse affliction, be- ing complicated with a general disease of the glands, in the course of the abdominal aorta, which were immensely enlarged, and changed into a greenish substance, much like turtle. Cancer often invades the testes, lower lip, penis, and tongue, the skin, and other parts of a glandular struc- ture. Though women are less frequently afflicted with cancerous lips, they are, on the whole, much more subject to cancer than men: a fact, accounted for by the change of the constitution at the cessation of mentruation, a change, found materially to promote its commencement, and by the uterus and mamma being the parts on which the distemper is most disposed to make its attack. In women, accustomed to menstruate in large quantity, the uterus is frequently attacked when that evacuation ceases. In unmarried females, and those who have not had chil- dren, the breasts often become the seat of the disease, about the same critical period. However, as Sir A. Coo- per has remarked, pregnancy and suckling do not always * Pearson's Principles of Surgery, ed. 2. p. 225. Alibert professes the same opinion, and mentions a lady who died of cancer of the uterus, whose mother and grandmother had both perished of the same disease. See Nosologic Naturelle, &c. t. i. p. 556.; also Bayle in Diet, des Sciences Med t. hi. p- 677. Sir A. Cooper, in Lectures, vol. ii. p. 187. f Wardrop on Fungus Hsematodes, p. 189. 244 CANCER. prevent the complaint, of which he knew one woman die, who had been pregnant seventeen times, and had ten liv- ing children.* The disease is more malignant in some situations, than others. When it commences in the skin, its progress is said to be generally slower than when it begins in the mammary gland, and its effects on the health less rapid. Relapses are more common after the extirpation of a can- cerous breast, than after that of a carcinomatous lip, or a scirrhous testicle. It is even said, that a part of a scirrhous tonsil may be left behind; and yet the circumstance will not hinder the patient from receiving material relief, since cancerous ulceration is, in this instance, not disposed to break out with ungovernable malignity, as usually happens when a portion of other cancerous tumors is left. I be- lieve, however, that most indurations of the tonsil are not really scirrhous, but scrofulous. According to M. Roux, the skin, cellular substance, mu- cous membranes, glandular secreting organs, and, perhaps, lymphatic glands, are the only parts capable of being pri- marily affected with cancer;}:}: and though it is its nature to extend to a great many structures, this is consecutively and by propagation. Thus it never begins in muscles, serous membranes, tendons, cartilages, &c. Mucous membranes are more frequently the primary seat of cancer, than the skin. To this place must be re- ferred such cancers of the eye as begin on the conjunctiva, cancers of the nasal cavities, tongue, oesophagus, stomach, bladder, uterus, penis, and rectum. Cancer of glandular secreting organs is alleged by M. Roux to be more circumscribed than in any other struc- ture, and this maybe the case in the testis; but, in the mammary gland, the scirrhous structure, which will be presently described, soon branches out into the surround- ing part of the breast, so that the limits of the disease can- not be so readily comprehended, as the mere feel of indu- ration might lead us to suppose. According to M.Roux, cancer never first commences in the lachrymal gland, but extends to it from the eye; and the salivary glands are also never affected but secondarily. The breast and testi- cle, he says, are the only glands exposed to the primary * Lectures, vol. ii. p. 186. f Memoire renfermant quelques Vues Gcne'rales sur le Cancer, in (Euvres Chir. de Desault par Bichat, t. iii. * See Note N. CANCER. 245 attack of the distemper. In the two last organs, the dis- ease is more constantly, than in mucous membranes, pre- ceded by the state called scirrhus. M. Roux believes, with Mr. Pearson, that cancer of the lymphatic glands is, perhaps, always a secondary affection. Mr. Wardrop, however, has seen two primary cancerous affections in lymphatic glands; similar cases have been met with by Mr. Abernethy;* and Klein once extirpated a very large original scirrhus of a lymphatic gland, situat- ed upon the serratus major anticus, to which it adhered so intimately, that it was necessary to cut away a portion of the muscle with the swelling, f In general, whenever the skin is near the focus of the distemper, it'is in it that the first vestiges of the extension of the disease are manifested. The organization of the skin may already have suffered, and the surface of the tu- mor be ulcerated, while the whole swelling may still be moveable, and the disease not have extended itself at all to the muscles, or other subjacent parts. When cancer affects organs covered with a serous mem- brane, the latter part is affected only in an advanced period of the disease. Thus scirrhus of the pylorus exists a good while, without the peritoneum being diseased. Cancerous affections of the testicle prevail a long time without the tunica vaginalis becoming affected. The blood-vessels seem to withstand the ravages of all kinds of ulceration longer than other organs; a fact exem- plified in cancer,!, as well as other cases; for, though the fungous growth, produced in the imperfect attempt at ci- catrization, frequently bleeds profusely from the slightest causes, hemorrhage is not often occasioned by the exten- sion of the ulceration, not even when it denudes a consi- derable artery. In a cancerous affection of long duration, the lymphatic glands, with which the diseased part communicates, usually swell. The same thing sometimes happens in the very commencement of the disease, while the part is only in the state of scirrhus. In cases of scirrhous breast, the axillary glands enlarge; but, it is remarked, that if the dis- ease be on the sternal side of the nipple, the gland, just above the clavicle at the lower part of the neck, is harden- • See Wardrop on Fungus Hxmatodes, p. 188. f Chirurgische Bemerkungen^p. 262. *• Diet, des Sciences Med. t. in. p. 549. 246 CANCER. ed, as the disease is then extended by the absorbents, through the intercostal muscles, to the internal mammary absorbent vessels and glands.* In the majority of cancerous diseases, the skin has a yel- lowish or lead-coloured tinge, and is dry and scaly. In advanced cases, the bones are frequently deprived of a good deal of their organized part; the calcareous matter predominates in them; and they become so brittle, that they break from the patient's merely turning in bed; a fact, of which there are many well-authenticated examples on record. Some patients soon fall victims to the disease; while others lead a long life of misery and suffering. A few in- dividuals, in whom the distemper becomes almost stationa- ry, suffer little more than the anxiety and disgust insepa- rable from it. The younger the patient is, in whom a truly cancerous disease occurs, the more rapid are generally its advances. When a scirrhous breast occurs in very old persons, it does not generally shorten life, or rather it is more correct to say, that they often live several years with it, and finally die of some other complaint.f The progress of the disease may be accelerated by an unhealthy resi- dence, mode of living, painful emotions of the mind, wrong treatment, &c. " Mental trouble," says a distinguished surgeon, " has the worst effects upon scirrhi: in consequence of this, I have seen a small indolent scirrhus, of twelve years' standing, enlarged to the size of an apple in three weeks, attended with intolerable shooting pains, and, in seven weeks, become an open cancer.":t. Hence, when once an operation is decided upon, he recommends it to be per- formed as soon as possible, as the fear of it is likely to produce, in a very short time, the worst consequences. Many writers refer all the phenomena of a cancerous diathesis to a virus, which they suppose to be formed in the seat of the disease, and thence conveyed by absorption over the whole system; a doctrine, rejected by M. Roux on the following grounds:—the lymphatic glands are often affected, while the disease is only in the state of scirrhus, and before any matter is formed. Such glands are some- times not affected for years after the existence of the dis- * Sir A. Cooper's Lectures, vol. ii. p. 178. f Sir A. Cooper's Lectures, vol. ii. p. 185. t Chr. Klein. Chirurgische Bemerkungen, p. 259. 12mo. Stuttgart, 1801. I ANLER. 247 ease; a circumstance that seems inconsistent with the no- tion of an active poison. We possess no proofs, that can- cerous matter is infectious, when applied to a sound person or capable of producing a disease similar to that by which it was formed.* MM. Biett, Lenoble, P'ayet, and Alibert, inoculated themselves with the ichorous matter which exuded from a horrible fungous cancer of the breast; but without any ill consequences.! Some surgeons have not thought it always necessary to remove, with a scirrhous breast, the axillary glands, when they are diseased,} and, no doubt, the swelling of such glands may sometimes be the mere effect of irritation or sympathy. I may observe, however, that this cannot be the case, when those parts exhibit, as they frequently do after their removal, the same scirrhous texture as the breast itself. M. Roux also argues, that if the symptoms of a cancerous diathesis depended upon the impression of a cancerous virus on our organs, it would matter little whether the poison originated in this or in that part, and cancers of the uterus and breast would not be sooner fatal than those of the skin. Some women, reduced to the last stage of weakness, have been perma- nently cured by the removal of cancerous breasts. If a cancerous virus existed in the constitution, M. Roux inquires, why does not cancer of other parts always follow the removal of those already diseased? Why do seconda- ry operations frequently succeed? Why does the appli- cation of caustic to a livid fungous part of the wound after the operation, sometimes completely prevent the threatened recurrence of the distemper ?§ Experience, I believe, will justify the explanation, given by M.Roux, of the cause of many relapses; namely, that the parts, in the vicinity of the cancerous affection, were, at the time of the operation, in a state of disorganization, though undisco- • Pearson's Principles of Surgery, edit. 2. p. 259. f Alibert. Nosologic, Naturelle, &c. p. 558. t " Once (says an excellent surgeon) I was obliged by a profuse bleedin*- to leave the operation unfinished, and not remove some very indurated axif- iary glands; but, during the treatment, they disappeared, a circumstance which their hardness did not allow me to entertain the least expectation of." ( hirurgische Bemerkungen, von Chr. Klein, p. 263, 12roo. Stuttgart, 1801. I have lately heard of several instances, in which hardened glands in the axilla, left after the removal of diseased breasts, have subsided and given no trouble. I am far from meaning to say, however, that these glands should never be removed; on the contrary, I have seen the true scirrhous texture as strongly marked in them, after their removal, as in the mammary gland itself, whatever might be the mode in which it was extended to them. {. P. J. Roux, in CEuvres Chir. de P. J. Desault, par X. Bichat. torn. hi. 248 CANCER. verable by the most attentive eye. The circumstances. revealed in the dissection of a scirrhus, also strengthen this explanation. But this mode of accounting for relapses should be qualified, as nothing is more certain, than that cancer often breaks out again in distant parts, and that its origin, though often excited by local irritation, must always be joined with some peculiarity of constitution, without which no kind of irritation will produce the complaint. Thus, when the diathesis prevails, the extension of the disease along the lymphatics, and to their glands, may be the consequence of simple irritation from sympathy, or from another kind of irritation, connected with the quality of something that is absorbed in the diseased part. This doctrine is quite independent of all theory about a specific cancerous virus, or its universal diffusion in the system. OP SCIRRHUS, OR CANCER, PREVIOUSLY TO ULCERATION. I have always considered scirrhus as a diseased hard- ness, in which there is a propensity to cancerous ulcera- tion, and a greater backwardness to recede, than exists in any other kind of diseased hardness, although the skin may occasionally not break during life, and a few scirrhous in- durations may have been lessened. The puckering of the skin, the dull leaden colour of the integuments, the knotted and uneven feel of the disease, the occasional darting pains in the part, its fixed attach- ment to the skin above, and muscles beneath,* and in the breast, the retracted state of the nipple, generally accom- panied with declining health, and a peculiar sallow com- plexion, form so striking an assemblage of symptoms, that, when they are all present, there cannot be the smallest doubt, that the tumor is a true scirrhus. But, the diagnosis is frequently more obscure. In some cases, scirrhus is moveable, and not fixed to the subjacent parts; and the disease may be indolent, without much pain, or without discolouration of the skin. In the female breast, the part first affected may be very small, and feel like a loose pea under the skin; in other instances, it may be more extensive and deeply situated. Neither is the swelling always irregular and craggy. * In advanced cases of cancer in the breast, the disease is frequently not only adherent to the pectoralis major, and intercostal muscles, but even tr- the ribs. See Howard's Pract. Obs. p. 18. •* CANCER. 249 The pain of a scirrhous breast, which generally extends to the nearest shoulder, and often to the nerves of the arm, is commonly most severe a little before the period of the menses, by which evacuation it is lessened again.* A scirrhous induration rarely happens in patients under thirty, and seldom acquires the magnitude, which the ge- nerality of other tumors are disposed to attain, when their growth is not interrupted. Other tumors, especial- ly when they have not been inflamed, are commonly more moveable than scirrhi. If we except fungus hsematodes, other tumors do not involve every kind of structure, skin, muscle, cellular sub- stance, &c; and the integuments seldom become affected before the distention, produced by their size, is very con- siderable. In scirrhous cases, the skin soon becomes con- taminated, discoloured, and puckered; and, in the breast, an early symptom is a retraction of the nipple; owing to the lactiferous tubes being drawn out of their course by the swelling.f Some few tumors may be harder and heavier, than a few scirrhi; but, the reverse is commonly the case. In a scir- rhus of the breast, the part affected is generally hard, heavy, and connected with the mammary gland; and, when moved, the whole gland moves along with it4 The nip- ple, besides being retracted, is also frequently inflamed and excoriated The cellular membrane also becomes hardened, and little tubercles form in the absorbent ves- sels under the integuments.§ In parts which have become scirrhous, the structure isually consists of a very firm, light brown substance, in- tersected by membranous or ligamentous septa, which run in various directions. The membranous septa are more numerous, and of greater thickness in some cases, than others. A cartilaginous substance is occasionally mixed with this structure. The whole structure sometimes re- sembles a piece of common cartilage, softened by macera- tion. Sometimes cysts, containing a serous fluid, are form- ed in scirrhi, particularly those of the testicle and breast; but they are also frequently absent. A substance, pos- sessing the common characters of scirrhus, has been known * Sir A. Cooper's Lectures, vol. ii. p. 177- f Ibid. p. 178. ♦ Obs. on Cancer by Sir E. Home, p. 156. f> Sir A. Cooper's Lectures, vol. ii. p. 17>( Vol. I. I i 250 CANCER. *• to be converted into a kind of bony matter* When a section of a scirrhus is made in an early stage, the centre is found more compact, harder to the feel, and of a more uniform texture, than the rest of the tumor, and is nearly of the consistence of cartilage. This middle part is not larger than a silver penny; and from this are seen white ligamentous bands, passing to the circumference of the disease, in every direction,, like rays. In the interstices, between these bands, the substance is different, and it is less compact away from the centre. Transverse ligament- ous bands, of a fainter appearance, are likewise percepti- ble, forming a sort of net-work, in the meshes of which the new-formed substance is enclosed. When the disease is further advanced, the whole mass has a more uniform structure; no central point can be distinguished; the external edge is more defined; and the ligamentous bands are more visible, running with great irregularity. When the disease has proceeded to cancerous suppura- tion, which, however, does not invariably precede the for- mation of an outward sore, a small irregular cavity i > found, filled with a bloody fluid, and having ulcerated, jag- ged, and spongy sides. Beyond these there is a radiated appearance of ligamentous bands; but the tumor near the circumference is more compact, and consists of distinct portions, each of which has a centre, surrounded by liga- mentous bands, in concentric circles. In some instances, there is no appearance of suppura- tion, or ulceration, in the centre of a scirrhus; but a cyst is found filled with a transparent fluid, and having a fun- gus projecting into the cavity.f The most characteristic mark of a scirrhus is this inter- section of its structure with white ligamentous bands. It is to be regretted, that the existence of such texture can- not be detected till the disease has been removed. Every surgeon should be well apprized, that these membranous septa frequently extend a good way into the surrounding fat; for, the circumstance dictates, in the strongest man- ner, the necessity of removing a considerable portion of the substance at the circumference of every scirrhous swelling. * Dr. Baillie in a letter inserted in Adams's work on the Cancerous Breast. ■f Sir E. Home, p. 157—159. Also Baillie's Morbid Anatomy; Aberne- thy's Surgical Works, vol. ii.; and Meckel'sHandbuch der PiithoL Anato- mie,Bd. ?. Abth. 2. p. 338. CANci:a. 2j1 Sometimes cysts, of moderate, or very minute sizes, containing a transparent fluid, and supposed by Dr. Adams to be hydatids, are found in the substance of scirrhi; but such cysts are not so frequently attendant on the complaint as to form any essential part of its character.* Cancer may also arise under conditions, in which there cannot possi- bly be any hydatids concerned; for example, when a wart is torn off, and a cancerous sore is the result, the ulcer is only situated at the base of the excrescence, where there is never any hydatid. Himlyf and Mr. John Burnsi. have never been able to detect in cancerous parts any thing like hydatids; and Meckel^ makes nearly the same declara- tion. The dilatation of the superficial veins around scirrhous swellings, is not peculiar to them; but attends many other tumors. OF CANCER IN TIIE STATE OF ULCERATION. The time when a scirrhus ulcerates is very uncertain; sometimes a long time, even many years, elapse before this change occurs; and sometimes it never happens at all, the patient dying with the complaint still in the form of scir- rhus. However, the diseased skin, covering a carcinoma- tous tumor, generally ulcerates before the swelling is very large. A large chasm is then produced in its substance, partly by sloughing, and partly by ulceration. A copious discharge of very fetid, sanious matter, follows. The ulcer becomes irregular in its figure, and unequal on its surface. The edges are thick, and indurated, and often have a ser- rated appearance, being sometimes retorted, at other times inverted. The ulcer sometimes spreads with rapidity' to a great extent, and the fungous mass, generally soon form- ed, is the source of frequent hemorrhages, which, joined with the irritation of the disease, reduce the patient to the lowest state of debility. Granulations are generally form- ed on the ulcerated surface, when the ravages of the dis- order seem to undergo a temporary stop; but this appa- rent attempt at reparation only ends in the formation of an inveterate fungous substance. The surface of the sore feels • Home, p. 160. j Dissert, on Inflammation, vol. ii. p. 445. 8vo. Glasgow, 1800. ; Journ. der Prahtischen Heilkunde, 1809. st. 12. s. 126. ^ Handbif-h d*r Pathologi?chen Ar:Vomi<\. Bd. 2- Abth. 2. p. 355. t.vNC'EK. hard, like the original tumor, and is remarkably insensible of pressure. In some places, the granulations rise up con- siderably; while, in others, scarcely any at all are produced; but they always differ from common healthy granulations in their hardness, their insensibility, and their secretion, which is generally a bloody serum.* Generally, while the skin remains free from ulceration, though the health may be seriously disturbed, and severe attacks of pain be occasionally felt, the patient is not dan- gerously reduced; but no sooner does ulceration take place, than an immediate deterioration of the health is noticed. However, this sudden change does not constantly happen, much depending on the quickness or slowness of the dis- ease, its situation, magnitude, &c. However, sooner or later, in every case, after ulceration has taken place, the countenance changes for the worse; debility, loss of appe- tite, acough, with tightness of the chest, and difficulty of breathing, come on: the bowels are sometimes constipated; sometimes relaxed; and very distressing sickness and vo- miting affect many patients, who at length sink into extreme emaciation and weakness.f The time when the lymphatic glands become affected, is subject to great variety. Carcinoma of the breast is most apt to contaminate the axillary glands, several of which be- coming diseased, the function of absorption cannot be duly carried on in the arm, so that, in bad cases, the hand, fore- arm, and, in time, the whole of the limb, up to the shoul- der, are swelled with an incurable kind of cedema. Occa- sionally, the lymphatic glands towards the clavicle are the only ones affected; and in a few instances, those towards the sternum are alone diseased. In advanced cases, the disease mostly extends to the pectoral muscle. Instances are also recorded in which the cancerous disease of the breast extended to the pleura and lungs.:): The pressure of a diseased lymphatic gland on one of the axillary nerves, * Sir A. Cooper's Lectures, vol. ii. p. 179. f Howard, p. 25. \ Hist, d'une Bisection des Cotes et de la Pleiire lue a l'Acad. Itoyale des Sciences de l'Institut de France le 27 Avril, 1818, par le Chev. Itiche- rand: in Nouv. Journ. de Mcdccine, Chirurgie, et Pharmacie, par Beclard, Chomel, &c. torn. ii. Mai, 1818. See also the account of a case which was in the Hotel-Dieu at Marseilles, where " not only the whole breast was de- stroyed, but also the axillary glands, the surrounding cellular substance, the pectoral muscles, and some portions of the ribs; so that when the patient died, the pleura costalis, much thickened, formed the bottom of the ulcer in several places." See Diet, des Sciences Med. t. iii. p. 548. CANCER. 253 nay cause excruciating agony. A fever has been known to occasion a mortification of a cancerous breast, and, had the sphacelus embraced all the contaminated parts, and the patient been less reduced, it seems probable that a cure might have followed.* The celebrated Mademoiselle Con- tat is said to have been suffocated by the tumefaction of the cellular substance about the throat, in consequence of an enormous cancer of her breast.f TREATMENT OF SCIRRHUS AND ULCERATED CANCER. The treatment of scirrhus embraces two objects; first, the dispersion of the tumor, or induration, by means of in- ternal and external medicines, diet, &c; secondly, the ex- tirpation of the diseased parts with caustic, or the knife. With respect to the dispersion of any truly cancerous tumor, that is to say, one in which the really scirrhous tex- ture exists, I am decidedly of opinion, that it is a thing which is never accomplished ; and that if the benefit to be derived from an operation be put out of consideration, such disease is incurable, and for the most part fatal. The cases, form- ing an exception to this general truth, are said to be three. 1. Not only true scirrhi, but even ulcerated cancers, have been known to be so extremely slow in their progress, that they have lasted an immense number of years, without having apparently contributed to the abbreviation of life. 2. Mortification, which is one of the occasional fatal termi- nations of cancer, may sometimes, though very rarely, prove a means of cure. The whole of the tumor has been known to separate by the effects of gangrene, and the ulcer thus produced speedily heal up, like one of of a simple na- ture.]: 3. Another event, still more rare, is the actual cica- trization of an ulcerated cancer, while the subjacent scir- rhous mass has not been destroyed, either by gangrene or any surgical operation.^ But I may observe, that if such change were to take place, the patient could not be con- sidered out of all danger, because the remaining scirrhus * For cases proving the foregoing statements. See Obs. on Cancer by Sir F.. Home, pages 55. 59. 64. 76. 86. 91. j- Alibert Nosologic Naturelle, ou les Maladies du Corps Ilumain distil buces par Families, p. 543. fol. Paris, 1817. f See Bulletin des Sciences Medic, par la Socielc Med. d'Emul. Cahier deDec. 1810, et Sept. 1811. § Diet, des Sciences Med. t. hi. p. 555, and Obs. de M. Nicod in Bulletin de la lacultt, S.c. No. I ann. 1810 254 OANCER. might ulcerate again, or even prove fatal, without being converted into an open cancer. Dr. A. Monro, senior, appears to me to have shown more discrimination than many of his cotemporaries, when he gave it as his opinion, that the resolution of a cancer was a very rare occurrence; but that, as he had seen two swellings of this nature, or at least what he supposed to be such, cured, he would not take upon himself absolutely to deny its possibility*. Certainly it would be unphilosophi- cal to assert, that the resolution of a cancer is utterly im- possible; but if a single well-authenticated example of it, amongst several thousands of cases, cannot be found, at all events, such a termination may be regarded as not in the natural course of things, and we should act, just as if it were altogether impossible.| When the hardness is so situated as to be easily remov- ed with the knife, no delay should be occasioned by at- tempting to disperse a swelling of this nature, because an early operation affords the best chance of effectual extirpa- tion. The means, employed in the endeavours to disperse a true scirrhus, are tedious in their operation, often injure the health, and when of an irritating nature, and incau- tiously applied, convert the tumor into a cancer. The ope- ration can be prudently postponed, and discutient reme- dies tried, only when doubts exist of the disease being a true scirrhus, with the peculiar texture already described. There are various diseases of the breast, which some- what resemble cancer; and besides encysted tumors, and different sarcomatous swellings, mentioned in a former chapter, surgeons frequently meet with other affections, which may be mistaken not only for an indolent scirrhus, but even for the painful form of this complaint, and ulcer- ated cancer itself. If the true nature of such cases be not ascertained, we may suppose, when we are treating only a simple chronic inflammation, or some other benign form of disease, that we are treating a really cancerous complaint, and ascribe to the virtues of the medicines a cure, which would frequently be produced by nature alone. These mistakes have had as much influence, as credulity and quackery have had, in conferring a temporary reputation upon specifics for cancer. Were these milder diseases also not discriminated, we should be continually giving • Edinb. Med. Essays, vol. v. art. 32. j Diet, des Sciences Med. t. iii. p. 556. CANCEK. Xf55 unnecessary alarm by pronouncing them to be scirrhi, and even perform needless operations. Some of these exam- ples, however, though free from malignancy, cannot be cured without the knife. 1. In young women under thirty, one breast is often ra- ther larger and more tender than the other, especially about the period of the menses.* When, in such persons, this evacuation is by any cause considerably checked, or sup- pressed, one or more indurations may form in one or both breasts. This case is described by Sir A. Cooper, under the name of the irritable tumor of the breast, on account of its great tenderness and painful nature. The uneasiness extends to the shoulder and axilla, and frequently down the limb to the fingers. When the pain is most severe, vomiting is produced. The skin over the part retains its natural co- lour. The same experienced surgeon states, that the dis- ease is frequently attended with profuse, or scanty men- struation, and often with fluor albus. Its causes he refer? to irritability of constitution, and a wrong state of the ute- rine secretion. A blow sometimes operates as the excit- ing cause. A The treatment consists in applying to the part the ex- tract of belladonna; opium mixed with ceratumcetacei; the extractum conii or fresh hemlock in a poultice; a plaster of soap serate ; a piece of hare-skin, or oiled silk. When the pain is very urgent, and the breast unusually full, leech- es are useful. The internal medicines are directed to the restoration of the proper state of the uterine secretion; and those preferred by Sir A. Cooper, are calomel and opium joined with mild aperients; the mistura myrrhae cum ferro; the ferrum ammoniatum ; rhubarb and soda with columba, and conium joined with rhubarb.f 2. Sir Astley Cooper also gives an account of what he calls simple chronic tumor of the breast; a case resembling the indolent form of pancreatic sarcoma, described by Mr. Abernethy. It occurs in young patients of healthy appear- ance ; grows very slowly, is at first superficial, extremely moveable, has the feel of a conglomerate tumor, and does not affect the absorbent glands. It cannot be cured with- out an operation; but it is quite free from malignancy4 3. After acute inflammation of the breast, a deep-seated. uneven hardness, often remains, which, when irritated b) • Sre Notk «> F.prture1--. voT ii. p. ?1P. Vn'. r\t. v 211 256 CANCER. any accidental cause, becomes painful, of a livid red co- lour, and so like an occult cancer, as frequently to be mis- taken for it. These are the kinds of cancer, which are al- leged to have been cured by bleeding, the repeated appli- cation of leeches, emollient and narcotic applications, low regimen, &c. One of the principal characters by which the previous cases may be detected, is, that they are all of them more or less painful on being handled; while a true scirrhus is not so, not even at the period when the lancinating pain has begun in it, provided it be un- complicated with an attack of inflammation.* 4. The hydatid tumor of the breast, described by Sir A. Cooper, and so named from its containing cysts of the na- ture of hydatids, is at first unattended with pain, and is not so hard, nor so distinctly circumscribed as scirrhus. The skin over the part is not discoloured, and the health is un- affected, even when the swelling has attained a great size. In time, a part of it presents a manifest fluctuation. The tumor is pendulous, and the whole breast very moveable, though the disease may be bulky. The case is painful, only when the cysts are inflamed. The absorbents are never diseased. When a cyst ulcerates, or is opened, se- rum, blended with mucus, or a little matter, is discharged ; and the aperture then heals ; but the tumor returns. This form of disease occurs at all ages after twenty; but more frequently in old subjects. It appears to correspond to the cystic sarcoma described by Mr. Abernethy, except that it is not at all malignant, and never returns after removal, which is the only mode of cure. However, when the cyst is single, a puncture, and exciting the adhesive inflamma- tion so as to obliterate the cavity, will sometimes produce a cure.f 5. The breasts are subject to swellings of a scrofulous nature, which at first bear a resemblance to indolent scir- rhi, and afterwards to ulcerated cancer. They are said particularly to occur between the age of puberty and the thirty-sixth year, and in women, who, though not evident- ly scrofulous, have thick lips, broad flat noses, &C. M. Bayle has often seen them cured by tonics, the extract of conium, the alkalies, and other antiscrofulous medicines, after the disease had continued more than a year." When the swelling was painful, emollient poultices were applied. * Diet, des Sciences Med. t. iii. p. 558. f See Sir A. Cooper's Lectures, vol. ii. p. 163, ?.c CANCER. 257 raid sometimes camphorated liniment. The tincture of iodine internally, and ung. hydriodatis potassae externally, might here also be tried with advantage. The ulcers, ori- ginating from these swellings, sometimes present thicken- ed everted edges ; their circumference is of a lead-colour- ed, or reddish hue; the veins seem dilated, and fungous granulations are produced. In short, they are the strong- est likenesses of ulcerated cancer. The age and constitu- tion of the patient; an attentive inquiry into the nature of the pain, discharge, &c, will throw some light upon the diagnosis, and all other doubts will soon be dispelled by the good effects of anti-scrofulous remedies. 6. Swellings often form in the breast, very soon after delivery, in consequence of a milk abscess, or inflamma- tion : but though hard and firm, are commonly nothing more than chronic inflammations, arising in individuals, whose constitutions are somewhat influenced by the state of the secretion of milk. They may generally be success- fully treated by exhibiting the compound decoction of sar- saparilla, and employing resolvent remedies. The following medicines have been most recommended in cases of cancer. 1. Hemlock, or conium maculatum, was highly praised by Storck.* Two grains of the extract were given at night and in the morning, and the doses were sometimes gra- dually increased to as much as a dram and a half or two drams in the day. The very circumstance of all Storck's cases being represented as cures, might alone have raised suspicions as to the accuracy of his accounts, had not his high reputation operated as a pledge of the truth of his assertions. Subsequent experience has proved, however, that he erred, as a great many other eminent men have done, in consequence of his having confounded with can- cer, diseases of another nature. He saw cases get well, which he supposed to be cancerous, and he ascribed every thing to the medicine. De Haen declares, that out of 120 cancerous patients, who tried conium, not a single one was cured ; and of eight women with cancers of the uterus, to whom he administered hemlock on Storck's plan, not one obtained a recovery. Fothergill, Akenside, and Kirkland, in England; and Bierken, in Sweden, reaped no better success from the exhibition of conium. Most of these writers, however, acknowledge its usefulness in resolving • T.ibellusdc Cicuta, Yimlob. 1"«"'0. Vor .1 Kl> 2oS CANCER. scrofulous, and some other indurations. Such was alsg the opinion of Cullen.* Lastly, Dr. Alibert, tried Storck's plan on more than 100 women afflicted with ulcers of the uterus, and other cancerpus diseases, without finding the least benefit result from it.f Whether conium ever ren- ders the progress of these cases slower and less painful, is a point, on which different opinions are entertained. 2. Small doses of the extract of belladonna have been found sometimes to lessen the pain of cancerous diseases ;f, but all idea of its being capable of curing them is univer- sally renounced. The same report may be made respecting aconitum, the aqua laurocerasi, and stramonium.^ 3. Acetite of copper is the principal ingredient in the remede de Gerbet, and Gerbicr's pills, two famous nos- trums in France, for cancerous swellings and ulcers. Im- partial investigations have proved, however, that it pro- duces no good effects in such cases; but, that some in- stances of noli me tangere (lupus) got well while the pa- tients were taking it. 4. Arsenic was proposed as a certain cure for cancers, by M. Lefebure de St. Udefond.;) His preparation was white arsenic, or acid of arsenic, of which four grains were dissolved in a pint of distilled water. Of this solution, the patient took at first every morning one table-spoonful, in an equal quantity of milk, sweetened with syrup. At the end of a week, if no unpleasant effects arose, a second dose was given every evening, and, after a fortnight, three doses were taken every 24 hours. When the first bottle had been exhausted, another was prepared with six grains of the arsenic, and the third bottle, which was the strongest ever used, contained eight grains. The ulcer was also bathed, and v.'ashed with a liquid composed of eight grains of arsenic, in a pint of distilled water, and afterwards cover- ed with a poultice made of carrots, which had been boiled in a similar solution, to which the acetite of lead, lauda- num, and the extractum conii were added in various pro- portions. This author assures us, that he had by these means cured thirty confirmed cancers, in the course of * Materia Med. part ii. chap. 6. f Diet, des Sciences Med. t. hi. p. 662. Nouv, Elem. de Therap. t. i. p. 425. Nosologic Naturelle, &c. t. i. p. 558. + Sir A. Cooper's Lectures, vol. ii. p. 193. § R. Ext. Stramonii, gr. £. Camph. gr. ij. M. ft. pil. bisterve die su- tnenda. The formula directed by Sir A. Cooper. H Remede eprouv6 pour guirir radicalement le Cancer, &c. 8vo. 1775. CANCER. 259 fifty years' experience. Justamond's reports were also highly favourable to. arsenic, as a remedy for cancer.* On the other hand, Acrel in Sweden, Metzer in Prussia, B. Bell in Scotland, Pearson in England,! and Dcsgranges, of Lyons, found arsenic inadequate to the cure of cancer, while its deleterious effects in many instances made itr- discontinuance necessary. No reliance is now put on it, as a remedy for really cancerous diseases, though the tes- timonies in favour of its good effects in lupus, and other inveterate ulcerations of the skin and lips, are strong and respectable.^ 5. Preparations of iron have been recommended by Mr. Carmichael of Dublin.§ He employed the carbonate, the oxyphosphate, and suboxyphosphate of this metal, in doses of from 30 to 60 grains in the da)% aloes being given to ob- viate costiveness. He also used the carbonate as a topical application. Five cancerous ulcers of the face are reported to have been thus cured. It would have been more satis- factory, had these cases not been reputed cancers of the face, diseases which are in reality generally, if not always, very different from specimens of the true scirrhous, or car- cinomatous structure. We know that many of these af- fections are only instances of lupus, or noli me tangere, and that, in their worst forms, they will often yield to the ^external and internal use of arsenic, conium, stramonium, and other alterative plans, such as the compound decoction of sarsaparilla, with Plummer's pills, &c. 6. Preparations of mercury have been so often tried and found ineffectual and even hurtful,|| that little need be said about them. Mercurial frictions, we well know, are amongst the best means for dispersing most indolent swellings, which admit of resolution. They also produce a change in the sys- tem, which, like any other alterative, will frequently make obstinate and troublesome sores heal. These effects are the foundation of the notion, that some really cancerous affec- tions have been cured by mercury. 7. Muriate of barytcs was proposed by Dr. Crawford; of his three cases, however, only one is allowed to have been • An Account of the Methods pursued in the Treatment of Cancerous and Scirrhous Disorders, &c. 8vo. Lond. 1780. | Principles of Surgery, p. 277. edit. 2. i See Klein's Chirurgische Bemerkungcn, p. 264. § Kssavs on the Effects of Carbonate and other Preparations of Iron upon Cancer, 2d edit. Dublin, 1809. I Pearson's Principles, p. 277. edit. 2 260 *A:.CER cancerous: it was a cancer of the penis, which, notwith- standing some temporary appearance of improvement from the medicine, ultimately proved fatal. The other cases are considered by MM. Bayle and Cayol to have been in reali- ty scrofulous'. Pinel and Alibert also confirm the inefficacy of the muriate of barytes in cancer.* 8. Repeated bleeding has been highly recommended, as a means of curing cancer, in particular, by Valsalvaf and Fearon}. The latter applied leeches every two or three days, unless the bites caused too much irritation, and he used also the cold lotion of the acetite of lead. In cancer- ous affections of the uterus, and internal organs, he prac- tised venesection, and, he assures us, that repeated bleed- ings always have the effect of lessening the pain in the lat- ter stages of disease, when opium and hemlock give no relief. Of the utility of general and topical bleeding, when true cancerous diseases are complicated with common acute or chronic inflammation, no doubt can be ascertained; but experience will not warrant the conclusion, that they have the power of curing either true scirrhus or cancer. All the alleged cures have in truth been cases of another na- ture. According to an experienced surgeon, tumors aris- ing from cold yield most readily to the repeated use of leeches, while those which are more indolent, and con- nected with a languid constitution, give way to hemlock or mercury.§ 9. Living altogether on milk, or on a regimen just suffi- cient to support life, as first proposed by Pouteau,|| has been found to retard the malady. A strict vegetable diet, the avoidance of fermented liquors, and the use of nothing but distilled water in every thing which is taken as drink, have also been recommended.^} But although some favourable reports have been made of the effects of such treatment, its power of completing a cure is not much credited, and, I * Diet, des Sciences Med. t. iii. p. 665; Nouv. Elem. de Therap. t. i. p. 498. Nosologic Naturelle, p. 558. •j- De Sed. et Causis, Morb. Epist. 39. art. 35. $ Treatise on Cancers, with an Account of a New and Successful Method of Operating, &c. 8vo. Lond. 1786. This novelty consisted in the plan of bringing the sides of the wound together, and healing it by the first inten- tion. The principles which Alanson applied to amputation, Fearon extend- ed to operations for cancer. § Sir E. Home on Cancer, p. 154. • || ffiuvres Posthumes, torn. i. ^ See Lambe's Reports on the effects of a peculiar Regimen on Scirrhous Tumors, &c. Abernethy's Surgical Works, vol. ii. Classification of Tu- mor?, p. 93. cANv.KR. 261 observe, that Sir A. Cooper in his lectures is by no means an advocate for it. 10. With respect to opium, its utility is limited to alle- viating the pain and misery of cancerous diseases, and pro- curing rest. 11. Various mineral waters, blisters, and issues* are mentioned by writers; but all idea of their power to cure cancerous diseases is now universally renounced. I next proceed to the consideration of topical remedies. 1. Arsenic put on cancerous ulcers acts as a caustic, and destroys the parts. In a few days, all the ulcerated sur- face is converted into an eschar, on the separation of which the remaining sore sometimes heals. But, in other exam- ples, the application brings on dangerous symptoms, colic, shivering, vomiting, syncope, &c. and even death. Fernel tells us of a woman who had a cancer of her breast, to which a mixture of arsenic and corrosive sublimate (oxy- muriate of mercury) was applied: she died in six days, with symptoms indicating that she had been poisoned. With a view of preventing such disasters, arsenic has therefore been generally mix^d with other less deleterious ingredients, such as dragon's blood, cinnabar, &c. These compositions are moistened, and made into arsenical pastes. Modern surgeons seldom venture to apply arsenic to true carcinomatous ulcers, because its irritation is sure to do infinite harm, unless the whole of the diseased parts admit of being destroyed by it, which rarely happens. If the parts are to be extirpated, the knife is the surest, safest, quickest, and least painful means. If, however, arsenic is not to be advised as a topical application for true cancers, it deserves trial in cases of lupus or noli me tangere, and other reputed cancerous ulcerations of the skin, lips, and other parts of the face. 2. Caustic potassa, the nitrous and sulphuric acids, the nitrate of silver, even the actual cautery itself, can only cure cancer on the principle of a complete destruction of the diseased parts; a plan which is always uncertain of accom- plishment, and if not completed, must dangerously aggra- vate the disease. I have seen several patients die in the course of four or five days, in consequence of the violent indisposition brought on by the application of caustics to cancers and other anomalous diseases. 3. The liquor plumbi acetatis alone, or mixed with * Flajani, Collczione d'Osservazioni e Riflessioni di Chirurgia, t. i. p. 275. *6*2 CANCER. laudanum, spirit of wine, and camphor, is a common ap- plication. The late Mr. Ramsden often used it for indo- lent swellings of the breast; but, the cases which I saw successfully treated by him in this way, were certainly not real scirrhi. Sir E. Home adds his testimony, however, in confirmation of the application sometimes actually dispers- ing tumors which resemble scirrhi.* The employment of the diluted liq. plumbi acetatis, and leeches, by Mr. Fearon, has been already noticed. 4. Opium, cicuta, belladonna, and other narcotics, have been extensively tried as topical applications, in the form of plasters or laudanum, to scirrhi; and of laudanum, lo- tions, fomentations, and poultices to ulcers. With the ex- ception of laudanum for sores, these narcotics are, perhaps, nearly as safe as any dressings which can be used, because they are not likely to create irritation. 5. The carrot poultice is one of the safest dressings for cancerous sores, and has long been in frequent use in Eng- land. However, the idea of its being able to cure such dis- eases, is not retained by any honest or judicious surgeon. 6. Preparations of irons haife been praised as topical ap- plications; viz. a solution of the sulphate of iron, rj to tfej of water, or covering the surface of the sore with a paste made of arseniate, or carbonate of ironf moistened with water. It is far from being proved, however, that these applications have answered, except for phagedenic ulcers, cases of lupus, &c4 * On Cancer, p. 154. f Carmichael, Essay on the Effects of the Carbonate and other Prepara- tions of Iron on Cancer, &c. 8vo. Dublin, 1809. edit. 2. $ Jin the Revue Medicale for 1826, M. Graefe, Jr. of Berlin, states that "a female setat 50, was admitted into the hospital, for cutaneous cancer, ex- tending from the upper part of the left mamma as far as the nipple. The ordinary means proving inefficient, an unguent was prescribed, consisting of rose ointment }$\j, hydriodate of potash ^j. The appearance of the ulcer speedily improved, and the callosity of the margin diminished. When cica- trization commenced, the proportion of the hydriodate was doubled, and in nine weeks the patient was cured." We have met with a case of supposed cancerous ulceration of the right mamma of long standing, which readily yielded to the external application of hydriodate of potash, in the form of ointment, together with its internal exhibition. We may be permitted to express strong doubts if this remedy will ever prove of service, in a case of genuine cancer. There are so many diseases of the mamma liable to be con- founded with cancer, that we can easily conceive how it has happened that so many remedies have been recommended as specifics for that disease. An interesting and valuable practical paper on the subject, by Joseph Parrish, M. D. will be found in the North American Med. and Surg. Journal, for April 1828.—P. E. j CANCER. 2Go 7. Amongst a great variety of topical remedies which ;"iave been suggested, but not found effectual, I shall only mention the following: the fresh bruised plant of the house- leek; the juice of the berries of the phytolacca americana, or the extract; a mixture of ^ss of the juice of digitalis in tbj of water; the gastric juice of animals ; fermenting poul- tices; olive oil; various discutient plasters; electricity. 8. The long-continued application of cold running spring water.* 9. Whatever doubts may be entertained about the pru- dence of venturing to try several of the local remedies to which I have adverted, all surgeons now seem to agree about the propriety of retaining a scirrhus in an equal tem- perature, and as much as possible defended from accidental violence. With these views, it is usual tq advise patients to keep the swelling covered with a piece of swan's-down, or rabbit's-skin, soap plaster, oiled silk, or belladonna plaster. 10. Methodical pressure was a few years ago strongly recommended. The only essential part of this plan is the compression of the cancerous tumor, gently at first, and with a force gradually increased, till at last it is augment- ed to a very great degree. If the cancer be open, the ca- vities are filled up with finely levigated chalk, and all the surface thickly covered with hair-powder, over which long straps of plaster are put, so as to cover the whole surface of the tumor. Compresses are then laid on, and the whole firmly bound down with a long roller; or over the first straps are laid a second set, bracing the parts more firmly than the first; next a plate of lead; and lastly a roller car- ried round the chest. With respect to the merits of the plan, it appears from investigations made at the Middlesex Hospital, that the specific action of cancer is not subdued by pressure, and that it accelerates the coming on of the last fatal symptoms. "It frequently gave so much pain, that the patients could not, after repeated trials, endure it, under any modification whatever; and often it appeared to hasten the fatal event." We learn," that in the scirrhous tu- mors, the disease advanced, rendering extirpation necessa- ry in two instances; in six others, the disease passed into ulceration, assuming the usual malignant appearances, and terminating in death."f * Alibert, Nosologic Naturelle, &c. t. i. p. 563 !- Surreal Obs. by C. Bell. vol. i. p. 4—11. 264 CANCER. In truly carcinomatous affections, the removal of the whole of the diseased parts with a knife, when they admit of being thus entirely cut away, is the measure by which the patient is sometimes fortunate enough to be perma- nently relieved. Many delicate and difficult considerations occur, however, in this part of practice. In most cases, the whole of a cancerous breast can be completely removed; the operation is neither difficult nor dangerous in itself; the wound resembles any other simple wound; and it ge- nerally heals up very well. But, unfortunately, in a cer- tain proportion of cases, the disease, sooner or later, recurs in the same or some other part of the body, and, as some writers urge, generally in a much more violent form than before the operation. But it cannot be doubted that some writers, who have been led by this fact to reprobate the operation altogether, have carried their mistrust in the resources of surgery too far; and De Houppeville himself, who condemns the ope- ration, seems to have succeeded by this means in curing four women who were afflicted with occult or ulcerated cancers; and many similar cures are upon record, in some of which the patients remained perfectly free from the dis- ease, at periods exceeding twenty and thirty years after the operation.* If, however, we suppose (as I think wc are bound to do,) that amongst these and other histories of the same nature, some of the tumors extirpated were not really cancerous, we cannot reasonably extend this opinion to the whole of the cases in question; and the num- ber to be regarded as true scirrhi, is still large enough to show the impropriety of an absolute rejection of the operation. The accuracy of the three following propositions seems unquestionable. 1. After the extirpation of a scirrhous tumor, whether the disease be indolent or painful, or small or recent, there is no certainty that the disease will not re- cur. 2. Neither is it certain that the disease will return, even when it has made considerable progress. 3. The more recent the disease is, the less the chances are of relapse. As soon, therefore, as a tumor is considered to be a real * Vacher, Diss, surle Cancer des Mamelles, p. 119—174, 12mo. Besan- con, 1740; Mem. de PAcad. Royale de Chirurgie, t. iii. p. 25—40; Sabatier Mcdecinc Opt ratoire, t ii. p. 335. edit. 1. Unzcr, Gazette Salutaire, Mars, 1791. Hill's Cases in Surgery, 8vo. Edinb. 1772. CANCER. 26S scirrhus, the earlier the operation is performed the better. We know of no other plan which holds out as good a pros- pect of relief, and though not exempt from the possibility of failure, it frequently succeeds. It is also declared by high authority, that when the patients undergo an altera- tive course of medicine, as soon as they have recovered from the operation, relapses are less frequent, than in for- mer days.* When, however, the patient has several cancerous affec- tions, a case which is unusual, or is of very advanced age, which generally renders the disease indolent, the knife should not be employed, the operation should not be done. When the extent and situation of the disease are such as to render the removal of the whole of the morbid parts im- practicable, the operation, of course, must not be attempt- ed. The partial extirpation of a true scirrhus, whether by caustic or the knife, is sure to convert the distemper into a malignant ulcerated cancer, and hasten the patient's death. Hi nee, in no operation is the aim at quickness more dan- gerous, and the maxim of "sat cito, si sat bene" should ne- ver be out of the surgeon's mind. Above all things, a free removal of the skin,covering and adjoining a scirrhus, and of the surrounding fat, is highly advisable. Sometimes, however, notwithstanding all possible pre- cautions to cut away every particle of the disease, the wound, instead of healing up, changes into a cancerous ulcer. Eve- ry prudent surgeon, therefore, should ensure his own re- putation by making a guarded prognosis. When the axillary glands are diseased, the surgeon is to remove them, as soon as he has taken away the scirrhus of the breast. A fact, however, to which I have already adverted, merits attention; viz. cases have occurred, in which the axillary glands, though very much enlarged and indurated, were not in a scirrhous state; but merely inflamed from irritation.f In such examples, Louis, Desault, Klein,f. Assalini, and Soemmering^ have successfully extirpated cancerous breasts, without removing the axillary glands. As, however, it is scarcely possible to know beforehand, whether the glands are simply inflamed, or truly cancerous, * Sir A. Cooper's Lectures, vol. ii. p. 198. | Vacher, op. cit. p. 134—171; Zinn, in Comment. Societ. Gotting. t. i $ Chir. Bemerkungen. § De Mofb. Vasorum Absorbentium Vol. I. L 1 s 266 CANCER. we should undoubtedly make it an invariable rule to take away all such as are swelled and hardened. After the re- moval of a cluster of diseased glands from the axilla, a swelling of the arm has been known to ensue, and cause the patient's death.* According to Sir A. Cooper, if se- veral glands in the axilla be enlarged, their removal will not prevent the return of the disease, because there are others beyond the reach of the knife.f Camper believed, that a sure sign of the incurability of a cancerous breast, consisted in a shooting pain between the second and third ribs, at the place where the mammary vessels quit the cavity of the chest. He was persuaded, that, when such pains commenced, the cancerous distem- per had extended to the lymphatic glands underneath the sternum, which have a communication with both breasts by means of absorbent vessels, and, therefore, he deemed the operation too late. In opening women who had had a breast removed, and some of whom lived till the wound was quite healed, Camper found the glands under the ster- num changed into cancerous excrescences, which had al- ready made their way through the intercostal muscles, and formed a projection beneath the integuments. No man would be justified, I think, in imitating Richerand, who ventured in one case even to cut away a part of the ribs and pleura costalis itself. The poor patient was tre- bly remarkable : first, on account of the extraordinary rava- ges of the disease; secondly, because his case was an in- stance of a cancerous breast in a male subject; and, third- ly, becanse he was himself a surgeon, capable of judging of the dangerous nature of the operation to be done upon him. Richerand, in his haste to communicate the history of this formidable excision to the Royal Institute of France, was rather too sanguine in his description of the success which was likely to follow the proceeding; for hardly a month more had elapsed, when tidings arrived of the pa- tient's decease. In ulcerated cancers, the chances of a cure are less than in cases of scirrhus. However, when the patient is not too far reduced, and the whole of the diseased parts can be taken away, the operation will sometimes answer. Some high authorities may be cited in justification of the opera- tion, even when there is little or no reason to expect the avoid- * Sir E. Home on Cancer, p. 62. f Lectures, vol. ii. p. 200. CANCER. 267 ttiice of a relapse. Thus, Monro says, when an ulcerated cancer is reducing the patient so rapidly that he is likely to be carried off in a very short time by it, we should ope- rate as the only means of prolonging the patient's days.* And Mr. Abernethy remarks, that the ulceration and self- destroying process of cancer are so horrible, that it may be stated, as an argument for the operation, that a patient gets rid of a quantity of disease upon easier terms by hav- ing it removed by the knife, than by suffering it to proceed in its natural course. When the scar or surface of the wound, after the operation, becomes indurated and cancer- ous, the patient suffers much less pain, and there is much less fetor in the disease thus formed, so that the patient's sufferings are on the whole much diminished!; a remark which perfectly coincides with the experience of a judi- cious foreign practitioner.!. Nothing can be a stronger proof of the propriety of ope- rating even upon many ulcerated cancers, than the unex- pected radical cures which have been frequently known to follow operations, undertaken merely with the view of lessening the patient's sufferings, and extending life for a short period. Thus, Le Cat operated and cured an enor- mous ulcer, which had rendered one rib carious, and de- stroyed several of the axillary glands.$ Foubert success- fully removed both breasts; one of which was scirrhous; the other, deeply ulcerated.|| Another question is, whether we ought to operate more than once upon cases in which a relapse unfortunately hap- pens, supposing the form of the tumor, and its relation to the adjacent parts, should not constitute an impediment to the practice ? A relapse is itself undoubtedly one of the most valid arguments against operating, because as the disease has already returned, and we are ignorant of its causes, it may return again. Should the relapse happen, however, in the situation which it previously occupied, the case is not so discouraging as when it attacks other parts; because, in the first instance, the return of the complaint may possibly be owing to some undiscovered portion of the disease being left behind; while, in the second, no * Edinb. Med. Essays, vol. v. art. 32. f Abernethy on Tumors, in Surgical works, vol. ii. p. 186. * Klein, Chirurgische Bemerkungen, p. 261. 12mo. Stuttgart, 1801. § Journ. de Med. 1761, t. iv. p. 258. || Mem. de l'Acad. de Chir. t. iii. p. 25. 26S i ANCER. doubt is left about a constitutional tendency to the distem- per. Sabatier repeated operations for cancer, in two remarka- ble instances: a woman underwent one operation, which was very severe, owing to the largeness of the tumor. She enjoyed good health for ten years, but having then a relapse, she was operated upon again, and continued well at the end of five more years. The same surgeon operat- ed three times upon an officer's breast, whose health was afterwards very good.* M. Lacombe operated four dif- ferent times upon a woman's breast, who, at the end of five years after the last extirpation, was enjoying perfect health.f With the view of preventing relapses, Mr. Abernethy strongly urges the propriety of endeavouring, after the ope- ration, to quiet the nervous system, and keep the diges- tive organs in as healthy a state as possible ; and he re- commends a mere vegetable diet, with as much milk, broth, and eggs, as is just sufficient to hinder the patient from los- ing strength.! Other surgeons, like Klein, Flajani, &c. have confidence in issues, which they recommend to be kept open a long time.§ Abroad, an idea also prevails, that relapses are less frequent, when the wound is not healed by the first inten- tion, but allowed to suppurate.|| As, however, this was the old practice in England, and it had not attractions enough to preserve its ground amongst us, I see no reason for re- storing a method certainly attended with numerous disad- vantages. Sir A. Cooper recommends a course of altera- tive medicines. * Sabatier, Med. Opertoire, t. ii. p. 335. f Propositions sur le Cancer, Paris, 1805. i Abernethy on Tumors, p. 93, in Surgical Works, vol. ii. § Chir. Bemerkungen, p. 264. Collezione d'Osservazioni, &c. di Oh" rurgia, t. i. p. 207, &c. II Flajani, Op. cit. t. i. p. 278. FUNGUS H-EMATODES. 269 CHAPTER XXVII. FUNGUS ILEMATODES. We are indebted to Mr. John Burns,* of Glasgow, for the first distinct account of this formidable disease, which he called spongoid inflammation; and the additional parti- culars of the subject, subsequently published by Hey, Freer, Wardrop, Langstaff, and others, have afforded a good deal of information respecting the history of the dis- temper, which is usually regarded as of the same nature as the medullary sarcoma, described by Mr. Abernethy. It commences with a small colourless tumor, which is soft, when not covered by an aponeurosis, but firm when situat- ed beneath it. When the disease occupies merely the adipose, or cellular membrane, upon the surface of the muscles, the tumor is not usually painful in its beginning; nor does it impede the motion of the muscles on which it is seated. But when deeply seated in the limbs, it causes pain and weakness of the part affected. Also, when it oc- curs in the mamma, its growth is attended with consider- able pain.f , For a considerable time, the tumor is smooth and even, but afterwards projects irregularly at one or more points, and here the skin becomes thinner, and of a livid red co- lour. The swelling has a considerable degree of elastici- ty, yielding to pressure, and rising up again immediately this is taken off. The sensation of a fluctuation often seems to be so mani- fest, that the mistaken surgeon plunges a lancet into the tumor, with the intention of discharging the fluid supposed to be present4 An error of this kind is generally a se- rious one, as a painful bleeding fungus, which rapidly ac- quires a very large size, shoots out of the opening, and by the irritation and loss of blood which it occasions, soon destroys the patient. But in the natural course of the dis- * Dissertations on Inflammation, vol. ii. f Hey's Pract. Obs. in Surgery p. 290, 291. edit. 2. % See Wardrop on Fungus Hxmatodes, p. 126. M'Kechnie's Case of fungus Hxmatodes, in Edinb. Med. and Surg. Journal, vol. vii. p. 168. Earle in Med. Chir. Trans, vol. iii. p. 60. ■2 70 FUNGUS HJSMATODE:*. ease, openings are at length formed in the projecting parts of the swelling, and a thin bloody matter is discharged. Almost immediately after the formation of these aper- tures, a small fungus protrudes, which rapidly increases both in breadth and height, and frequently bleeds profuse- ly. The discharge is thin, and exceedingly fetid. The integuments round the ulceration are red and tender. The neighbouring glands swell, and assume the spongy morbid structure of the original tumor. If the patient still sur- vives, similar tumors frequently make their appearance in other situations, and hectical symptoms, and repeated he- morrhages, put a period to life. On examining the affected parts after death, or amputa- tion, the tumor itself is found to consist of a soft sub- stance, somewhat like the brain; membranous partitions intersect it, and there are cells, or abscesses, in various places. The tumor frequently dives between the muscles down to the bones, and is not invariably contained in an entire cyst. The adjoining muscles are of a pale colour, and lose their fibrous appearance, becoming more like liver than muscles. The bones near the tumor are always carious. The disease sometimes appears to be brought on by exter- nal violence; but frequently the cause is quite unknown. Fungus haematodes has now been observed in numerous situations and organs, viz. the eyeball, the superior and inferior extremities, the testicle, liver, spleen, kidney, lungs, uterus, ovarium, mamma, thyroid gland, neck, and fauces. No remedy seems to have the least power in checking this formidable disease ; all escharotics, even undiluted oil of vitriol, are incapable of destroying the fungous growths as fast as they are regenerated. Nothing seems to offer a prospect of preserving life, except the early and total re- moval of the disease with a knife ; and, of course, this is not always practicable, on account of the situation of the tumor. When it can be done, no part of the surface sur- rounding the tumor should be left, as the disease would certainly recur. Here, however, it is incumbent on me to state the me- lancholy truth, that, excepting an instance or two where the eyeball appears to have been removed with the pro- mise of lasting success,* almost every attempt to extirpate * See Hey's Practical Observations, p. 290. edit. 2. Wardrop on Fun- gus Haematodes, p. 8.; and a Case by Wishart, in Edinb. Med. Journ. 1'CNGUS H.EMAT0DES. 271 the disease by simply cutting away the morbid part has failed, the fungus re-appearing with increased malignity. The only cures with which I am acquainted, are a few which were accomplished by amputation of the limb, and are related by Mr. Hey. But, as the observations of the same gentleman prove, even amputation does not always have the desired effect; for, if the distemper has extended itself in the slightest degree to any part of the stump, a relapse appears to be certain. It is much against the general success of all attempts to extirpate fungus haematodes, that the distemper is fre- quently not confined to one part or organ. Thus, when the disease has appeared on the lower extremity, tumors of the same nature have been observed, after death, situat- ed in the lymphatic glands, along the course of the iliac vessels and abdominal aorta; and when the eyeball has been the seat of the disease, various little spots or tumors, resembling in structure the medullary, or cream-like con- sistence of fungus haematodes in general, have been ob- served between the^ cranium and dura mater, and be- tween the tunica arachnoides and pia mater. On the whole, I am inclined to think with a modern author, that fungus haematodes is either originally a contitutional disease, or very soon becomes so.* Although fungus haematodes has generally been con- founded with cancer, it is a widely different disorder. In- stead of being hard and unyielding, like a scirrhous tumor, it is generally soft and elastic. Instead of being intersect- ed by the same kind of ligamentous fibres or bands, which exist in a scirrhus, fungus haematodes consists of a soft pulpy matter, which mixes readily with water, and is hard- ened by acids, or by being boiled in water. VVhen the skin, or external covering, of fungus hsematodes gives way, in- stead of the morbid growth being destroyed by ulceration, as in cancer, a quick-growing fungus arises from it, and the tumor seems to increase with even greater rapidity. This fungus, instead of having a firm texture, like that which sometimes arises from a cancerous ulcer, is a dark red or purple mass, of an irregular shape, and of a soft texture, is easily torn, and bleeds profusely when slightly injured. A primary cancer seems to be confined to few organs and few textures; and while, in some of these, fungus haema- todes in its primary state has not been seen, it has beende- ♦ C. Bell, Surg. Obs. vol. i. p. 410. 272 FUNGUS HiEMATODES. tected in other parts, where no true scirrhous structure has ever been met with, as, for instance, the liver, spleen, kidney, and lungs. While cancer also is rather a disease of advanced life; most patients attacked by fungus haema- todes are young.* Fungus haematodes of the eye, will be described in the second part of this volume. CHAPTER XXVIII. OF SYPHILIS; OR, THE VENEREAL DISEASE. The venereal disease is generally believed to arise from a specific, morbid poison, which, when applied to the hu- man body, produces effects, either on the part to which it is immediately applied, or on various parts of the system, in consequence of absorption. The effects, produced on the part, to which the poison is directly applied, are called primary symptoms; while those happening in consequence of the virus being absorb- ed into the circulation, are termed secondary. When the primary symptom is a sore, it is denominated a chancre; and when the absorbed matter, in its course towards the circulation, makes the absorbent vessels or glands inflame and suppurate, the latter complaint is named a bubo, which likewise generally ranks as a primary symp- tom, because the virus, which produces it, is only on its way into the circulation, and the swelling is not in reality an effect of the poison, after its arrival in the sanguiferous system. According to several authors, amongst whom is Mr. Hunter, the primary symptom may also be a discharge of venereal matterTrom the urethra, or from the surface of the nymphae, clitoris, meatus urinarius, &c. in women, well known by the name of a clap or gonorrhoea. The earliest or first order of secondary symptoms gene- rally consists of ulcers in the throat or skin, or of spots on the surface of the body. The second order comprehends * See Wardrop on Fungus Hxmatodes, chap. xii. syphilis. 27;"! either swellings of the bones, periosteum, and tendons, called nodes, or else mere pains in these parts. In the opinion of Mr. Hunter, gonorrhoea and chancre arise from the application of the same specific virus. The difference of the effect he explains by the application being made, in the first instance, to a secreting surface; and, in the second, to one that does not secrete; but, this belief in the identity of the infections, which produce these very different diseases, may now be said to be rapidly declining. According to Mr. Hunter, the application of venereal matter commonly gives rise to inflammation, followed by a discharge from secreting surfaces, and by ulceration in other parts. It is acknowledged, however, that inflamma- tion is not invariably produced by it. Although the matter of primary venereal complaints,viz. of chancre, bubo, and according to Hunter, of gonorrhoea also, contains the venereal poison, and can communicate the disease to others, the matter of all secondary venereal complaints does not contain the specific virus, nor, of course, possess the property of being able to impart the distemper to others. Neither is the blood, nor any of the secretions of a venereal patient, possessed of such quality. After the venereal virus has been conveyed into the cir- culation by the absorbents, Mr. Hunter inferred, that it did not long continue there, but was soon ejected, together with some of the excretions. Previous to its expulsion, however, it contaminates certain parts of the body, and gives them a disposition to the disease. Mr. Hunter's chief reason for supposing, that the virus does not remain long in the circulation, is, that when the parts, first affect- ed with secondary symptoms, have been cured, before the disease is eradicated from such parts, as are generally af- fected with secondary symptoms at a later period, the first parts which have been cured, never again become diseased from the same stock of infection, as, in all probability, they would do, if the virus continued mixed with the circulat- ing fluids. The reasons why the virus, after being absorbed, is sometimes expelled again, without leaving, in any parts whatsoever, a disposition to the disease, or in other words, any contamination, are not very well solved, by the Hun- terian theories. Neither do they explain to us, why the number of parts; to which the disposition is communicated, by the absorption of the virus into the system, should vary so considerably, as we find happens in different examples. Vor.. I. M m 27<1 svwni.i>. Mr. Hunter, indeed, assigns to mercury the power of pre- venting the formation of the disposition: but, then, he re- presents the presence of the virus in the constitution as being so transient, and the disposition to the disease as being produced so nearly about the same time in whatever parts are contaminated, that, in a multitude of cases, the supposition, that mercury has been given to prevent the disposition in all or some parts, is altogether inconsistent with the foregoing principles. But, though Mr. Hunter believed,that the disposition was formed nearly about the same time in such parts as happen to be contaminated; yet, his doctrines teach us, that they fall into a state of palpable disease, or (to use his own lan- guage) they afterwards take on the diseased action at dif- ferent periods, some showing much sooner, than others, the local effects of the disease. This remarkable circum- stance in the history of syphilis, Mr. Hunter ascribes, part- ly to the different susceptibility of action in different or- gans, and partly to the effect of external circumstances, having no relation to the poison or the constitution. Of these external circumstances, one of the principal is cold, which accelerates the local effects caused by the pas- sage of the virus through the system. The change from disposition to action appears also to be hastened by proxi- mity to the surface of the body, and by any great disturb- ance in the habit from scrofula, gout, rheumatism, and, more especially, fever. It was likewise one of Mr. Hunter's tenets, that the change from disposition to action, never happened while the constitution was under mercurial irritation. He inculcates, that, when the disposition has taken place, the action may be suspended by mercury; but the disposi- tion will remain, and the action show itself at some period after the mercurial irritation has ceased. But, although mercury cannot destroy a disposition already formed, it may hinder the disposition from being formed at all, or, in other words, prevent contamination. When the action has begun in one order of parts, it may be cured, and will not return in the part, or that order of parts, from the same stock of infection. But the diseased action may take place in another order of parts, if that other order has been contaminated; and, in this order, it must be treated as in the former. When the diseased action has taken place, and been cured in the part first affected, in the throat SiTIiTi.Is. 27-> and fauces, the skin and the bones, or periosteum, the pa- tient may be regarded as free from the disease. The usual time of the skin, or throat, taking on the dis- eased action, is, on a medium, six weeks alter the sub- sidence of the mercurial irritation, by which the first symp- toms were cured, and in the bones, about twice that time; but, these intervals, between the primary and secondary symptoms, are subject to much variety. Whatever doubtful appearances may arise in the skin, throat, or bones, during the mercurial irritation under which chancres or buboes are giving way, they are not regarded by Mr. Hunter as venereal; and even if such secondary symptoms occur, after the mercurial irritation has ceased, but earlier than the usual periods above specified, they are not to be considered as unequivocally syphilitic. If no secondary symptoms appear in three months after the mer- curial irritation has ceased, and the constitution has not, in the mean time, been occupied by any other disease, we have, for the most part, no reason to apprehend any com- plaints in the skin or throat from that stock of infection.* That there are some glaring inconsistencies in Mr. Hun- ter's precepts, with regard to the venereal disease, I think no man of candour will deny. One of the most striking incongruities is the theory, that mercury cannot cure the disposition, and yet, by way of security, the recommenda- tion of its continuance, for a certain time, after all palpable symptoms have been cured. Throughout Mr. Hunter's writings, we are taught, that it is the invariable character of all really venereal com- plaints to become progressively worse, and never undergo any amendment, unless mercury, the specific remedy, be exhibited. Thus, chancres on the penis, and ulcers in the throat, are described as constantly growing worse* with- out the aid of mercury. In the third edition of this pub- lication, which was printed in 1813, I expressed doubts concerning the veracity of this doctrine. I remarked, that, if a sore put on a healing appearance, without the aid of mercury, we were directed to infer, that the complaint was not venereal. I noticed the advice, which was formerly very common, in doubtful cases, to defer the employment of mercury, for the purpose of judging of the nature of the disease by the foregoing criterion. I then commented on • See Hunter's Treatise on the Venereal Disease, and Adams on Morbid Poison«, edit. 2. p. 159, !'>•.> 216 ::VP11ILI:> the fact, that primary venereal symptoms will sometimes yield to several medicines besides mercury? I called the reader's attention to the mass of evidence in favour of the nitrous and muriatic acids, the oxymuriate of potassa, &c. being in a certain degree anti-venereal. I did not assert, that these remedies could be depended upon as much as mercury; but only that they possessed considerable power over syphilis, and would sometimes make chancres, vene- real ulcers in the throat, he. give way. By reference to the writings of Mr. Pearson, I showed his clear admission, that guaiacum and sarsaparilla were capable of alleviating symptoms derived from the venereal virus, though not of eradicating the disease,* Also his statement, that even bark would sometimes have a salutary effect on incipient buboes, ulcers of the tonsils, and gangrenous sores, from a venereal cause, was particularly remarked, as well as his description of the almost complete reduction of venereal buboes by this medicine.f I called the attention of the profession to Mr. Pearson's observation, that the carbo- nate of ammonia would sometimes relieve pains of the limbs, and remove a venereal eruption.\ I adverted to his confession, that he had given the muriate of barytes, with great advantage, when he could not determine positively whether the case was venereal or not.§ I was struck with his remark, that elixir of vitriol would sometimes stop the progress of venereal ulcers, and make venereal eruptions fade and almost disappear, though he represented the be- nefit as not permanent. I pointed out his evidence, in confirmation of the fact, that the nitric and vitriolic acids had removed both the primary and secondary symptoms of syphilis; and, in some instances, without the former having recurred, or the latter appeared at the usual time, when the cure was imperfect. The declaration of Mr. Pearson and several of his friends, however, that they had never seen a permanent cure accomplished by these acids, where secondary symptoms were present, was not omitted; nor his own decided opinion, that the efficacv of such re- medies in curing primary symptoms, was not sufficiently frequent to make them eligible medicines.|| I concluded, that if so many remedies are alleged to * Observations on the Effects of various Articles in the Cure of Lues Venerea, edit. 2. p. 12—25. f Lib. cit. p. 61. _ tP.Ol. § p. 106. H Obs. on the Effects of various Articles in the Cure of Lues Venerea, edit. 2. p. 236, 237. SYPHILID. 277 possess a certain anti-venereal quality, we must receive with doubt a doctrine, that all venereal affections constant- ly become progressively worse, and never undergo the least amendment, nor put on a healing appearance, with- out the aid of mercury. I remarked, that if an incipient venereal bubo could sometimes be reduced by bark, as Mr. Pearson affirmed ; or if guaiacum, sarsaparilla, meze- reon, walnuts, and opium, had often removed some of the primary and secondary symptoms of lues venerea, as the same gentleman confessed; we were justified in suspect- ing, that it is by no means the invariable character of syphi- litic complaints to proceed, in every instance, from bad to worse, even though no medicines at all be exhibited. I add- ed, that whether this suspicion were correct or not, the in- ference to be drawn from Mr. Pearson's observations, at all events, appeared to be, that venereal sores, &c. would often become better, and even heal without mercury. Since the period when the forgoing reflections were made, the great question, whether syphilis is curable with- out mercury, has been completely settled, chiefly by the meritorious labours of the surgeons of the British army. The results of their experiments and inquiries furnish the most unequivocal proof, not only that syphilis may be cured without mercury, but even without the aid of any medicines whatsoever. As far as I can judge, no other inference ought ever to have been drawn from all the evi- dence which may be brought to bear upon this point, from a review of circumstances connected with the history of the venereal disease ; and this, whether we adopt the vul- gar opinion, that true syphilis has only been known in Eu- rope subsequently to the year 1493, or the belief, to which I am myself inclined, that it is a disorder which has pre- vailed from the earliest antiquity. In order to avoid, however, as much as possible, the latter controverted point' we shall confine ourselves to periods in which the exist- ence of syphilis in Europe has been generally acknow- ledged* A great many practitioners, both in the six- teenth and seventeenth centuries, combated the venereal disease with considerable success, without the aid of mer- cury. Fallopius, Palmarius, Abercromby,f and several There is so much difficulty in reconciling many of the phenomena and old theories respecting the venereal disease, that 1 am not at all surprised 'o find its very existence disputed in a modern anonymous publication, •' Sur la Non-existence de la Maladie Vfnerienne." Paris, 1811. - The work of this author, which was obligingly pointed out to me bv Mr. Dunn, of Scarborough, is remarkable on account of its title : "Tuta a'c 278 SYPHILIS. others, who might be cited, furnish proofs of the fact; their principal remedies have been guaiacum, sarsaparilla, and antimonials, with occasional venesection, and purging. Had it been the invariable character of the venereal dis- ease to become regularly worse without mercury, no pa- tients could ever have recovered, before the use of that mineral, in the treatment of the distemper, had been in- troduced into Europe*; a supposition, contradicted by abundant evidence. Nor is it here necessary to avail our- selves of the arguments, which might be deduced from the cessation of the ravages of the particular distemper which broke out in the French army at the siege of Naples in 1494; because I do not see how we are authorized by the descriptions extant to regard that disorder in any other point of view, than as a contagious malignant fever, or pestilence, spreading with such celerity as to destroy a large army; an event totally irreconcilable with the well- established facts, that true syphilitic complaints are for the most part chronic, the primary sores only communicable by contact, and the secondary not in any way infectious. Better evidence on the point before as seems to mc to be furnished by a review of the practice of the old surgeons, to whom I have already adverted ; for, as they cured vene- real complaints without mercury, at periods when syphilis unquestionably prevailed, it never can be argued, that none of their cases, so treated with success, could have been of that nature; a conjecture, which, though it must naturally arise out of the Hunterian theories, appears, in the present state of our knowledge, to be erroneous. An opinion is sometimes entertained, that the venereal disease is modified by climate, and that it can be cured in warm countries, by means which would completely fail in colder parts of the world. The facility of curing the vene- real disease in the West Indies, the Brazils, &c. with sar- saparilla, guaiacum, and other vegetable productions, is a fact, which has long been familiarly known. YVithout the acknowledgment of such efficacy in these remedies, or in the powers of the constitution, the advocates for the Ame- Efficnx Luis Veneres sxpe absque Mercurio, ac semper absque salivatione mercuriali Curaivlae Methodus;" Authore Davide Abercromby, M. 1). 12mo Londini, 1684. * In China, where the venereal disease is said to have existed 2000 verm, mercury lias been employed for its cure from time immemori.d. See the reports of Toureau, and other .lesnits, as detaih'd in Vstnic'^ works. SYPHILIS. ^~U rican origin of syphilis, and the believers in the incurability of the disorder without mercury, would be totally unable to explain how it happened, that the population of'the new- continent was not annihilated by syphilitic ravages long before the visit of Columbus. In Portugal, the use of mercury, in the treatment of the venereal disease, is nearlv abandoned ; the disorder proving there very mild, arid be- ing curable for the most part by msre topical treatment, or wearing itself out without the use of any adequate mer- curial remedy. During a superintendence of the Portu- guese hospitals for upwards of two years, Dr. Fergusson observed, that the common practice of the surgeons of that country was to cure all cases by simple topical applica- tions ; and the return of the patients to hospital with se- condary symptoms, after being thus treated, was far from being an universal, or even a frequent occurrence.* It is curious to learn, however, with respect to the British sol- diers in Portugal, that the disease*in them was often pe- culiarly severe, a circumstance ascribed either to the dif- ference of their constitutions from those of the natives, or to the treatment pursued by our surgeons being less bene- ficial, than what was adopted by the Portuguese. This striking diversity in the progress and consequences of the disorder cannot, I think, be rationally imputed to any mo- dification of the virus itself by climate, but rather to a mo- dification of the constitution by that cause, habits of life &c; because, if we adopt the first of these opinions, viz' that the thing is to be explained by a change of the virus itself, why should the disease, when contracted from the same sources of infection, have been followed only by mild effects in the Portuguese, and by a severe train of conse- quences in the British ? But, should I be mistaken in sup- posing, that the constitutions of the natives rendered them less susceptible, than our troops were, of the ill-effects of the disease, then I see no other mode of accounting for the difference, than by concluding, that the simple treatment, followed in the Portuguese hospitals, was attended with more benefit, than the long and injudicious courses ot mercury, which, in conformity to the then existing doc- trines, were probably adopted in our own establishments, with little discrimination between real syphilis, and other resembling complaints, to which I shall presently advert. Nor is it only in the warmer parts of Europe and Ameri- • See Med. Chir. Trans, vol. iv J so aYPHILi:-. ca, that syphilis is readily subdued without mercury: the same truth is proclaimed in Asia, as may be learned b\ referring to Dr. Scott's observations on the anti-venereal virtues of the nitro-muriatic acid *, and of baths impreg- nated with it. To me this gentleman's statements appear more important in relation to the point before us, than as connected with the question of the real efficacy of the parti- cular mode of treatment, which it is the object of his essay to recommend; because, as syphilitic diseases are now known to be capable of a spontaneous cure, it becomes doubtful, what share of benefit ought to be ascribed to the acid, es- pecially to its external use in the form of baths. The curability of every kind of ulcer, by common means, is well known at Paris, where Cullerier annually demon- strates this fact to his pupils ; but, after the ulcers are heal- ed, each patient is put upon a mercurial course, in order to prevent secondary symptoms.j Several of the German surgeons, who were in our service during the late war, were always extremely reluctant to prescribe mercury for the cure both of syphilis and resembling complaints; and yet the success, obtained in their hospitals without mercu- ry, was at least equal to what resulted from the opposite treatment in those of other corps.:}: But no facts have had greater weight, than those of Mr. Rose,§ in regulating the judgment of modern surgeons, on the question of the curability of syphilis without mercury. The importance of this question (says he) is obvious, not so much in reference to the treatment of syphilis under common circumstances; for, the strikingly good effects of mercury will probably not render it advisable in general to give up the use of that remedy, but from the change which it will produce in our views of the diagnosis of that disease. The distinction, which has engaged such a share of attention of late years, and which is evidently so im- portant, between syphilis and syphiloid diseases, has been * Ibid. vol. viii. p. 173, &c. f Guthrie in Med. Chir. Trans, vol. viii. p. 552. $ This seems at first contradictory to the general admission, that mercury, though not absolutely necessary, often expedites the cure of true syphilitic diseases. In order to reconcile these statements, we should recollect, that mercury frequently retards the cure of other complaints, not truly syphili- tic, which are more frequent than the former, in a proportion beyond com- putation. § See Observations on the Treatment of Syphilis, with an Account of several Cases of that Disease, in which a Cure was effected without the use of Mercury: in Med. Chir. Trans, vol. viii. p. 349, &r. SYPHILIS. made to depend so much upon the former admitting of no cure, except by mercury, that, if this principle should be found to be erroneous, the difficulties which have attend- ed it, will, in a great measure, be explained. Mr. Rose then adverts to the occasional trials which have been made of sarsaparilla, carbonate of ammonia, opium, and different acids, in the treatment of the venereal disease, and to the success of some of these remedies, as attested by men of veracity and ample experience. He notices the fact, of mercury either not being used at all in several parts of Europe, or being used in a manner which we should con- sider totally inadequate to the cure of the disease. He allows, that many of the cases which happened in Portugal, as mentioned by Dr. Fergusson, would not be regarded by cautious practitioners as truly syphilitic, because, in describing the effects of the disease on the British soldiers, this gentleman states, that, while the constitution was strong- ly under the influence of mercury, the patients became affect- ed with secondary symptoms, in a proportion that could not have been expected. Mr. Rose then speaks of the con- clusion, drawn by Mr. Carmichael from Dr. Fergusson's description, viz. that the disease, which prevailed in Por- tugal, was a phagedenic, or sloughing ulcer, different from the true syphilitic chancre, and for which mercury is nei- ther necessary nor serviceable; an inference he considers refuted by the impossibility of supposing, that a country, then overrun by every description of foreigners, could escape the introduction of syphilis. He had tried the non- mercurial treatment in the hospital of the Coldstream Re- giment of Guards, for a year and three-quarters, and had certainly succeeded, without mercury, in curing all the ulcers on the parts of generation, which he had met with in that period, with the constitutional symptoms to which they gave rise. Though some of these cases might not have been truly syphilitic, it is impossible to suppose that others were not so. A considerable number of them presented the commonly received characters of a primary venereal sore, as loss of substance, indisposition to granulate, and an indurated margin and base. They were also seen and considered as well-marked cases of true chancre by Mr. Brodie, Mr. Bacot, Mr. Worrell, &c. The battalion of the Coldstream, in which they occurred, consisted of upwards of a thousand men, who, being stationed in this metropolis, and often associating with the lower orders of prostitutes, were particularly exposed to the risk of infection, and Vot . I N n -.£>- sYPHILIs. might have been expected, in a much shorter period, t« furnish many examples of the venereal disease. In the treatment, all ideas of specific remedies were en- tirely laid aside. The patients were usually confined to their beds, and such local applications employed, as the appearances of the sores seemed to indicate. Aperient medicines, antimony, bark, sulphuric acid, and occasionally sarsaparilla, were administered. The observations of Mr. Guthrie, Professor Thomson, Dr. Hennen, and indeed the united reports of all our army surgeons, from different parts of these kingdoms, and France, also fully proved the curability of the primary and secondary effects of syphilis without mercury, and, generally speaking, of all sores, whether truly syphilitic, or only of a resembling nature, "provided sufficient time be granted, the constitution be good, the patient regular in his mode of living, and atten- tion be paid to cleanliness and simple dressings, and to keep the patient in a state of quietude.'1* From the preceding facts and view of the subject, many curious and important considerations naturally arise. In the first place, they oblige us to renounce all the most im- portant doctrines advanced by Mr. Hunter, and adopted in almost every school, in relation to the history, progress, and cure of the venereal disease. They compel us to be- lieve, either that true syphilis has totally changed, in the course of the last twenty or thirty years, or that most of the Huntcrian theories about it were always false, and founded upon mistaken notions. At the present day, it will be extremely difficult to come to a positive decision, with regard either to the altered nature, Of diminished frequency of syphilis; more especially, when we recollect two facts; first, that ever since the epoch of the supposed introduction of this disease from America, there have al- ways been practitioners, who successfully treated every form of venereal complaints without mercury ; and second- ly, the absolute impossibility of our asserting, that if expe- riments had been formerly made, similar to those which have now been undertaken on a public-spirited, impartial, and extensive scale, the same results and inferences would not have followed. The facts, recently established, lead also to other highly.interesting questions, concerning the frequency and nature of the secondary symptoms, which occur when no mercury has been employed. * Guthrie, Med. Chir. Trans, vol. viii. p. 556. SYPHILIS. 2oi' Upon an average, according to .Mr. Rose, one out of every three of the sores, thus treated, was followed by some form or other of constitutional affection, which was in most in- stances mild, and sometimes so slight, that it would have escaped notice, if it had not been carefully sought for. The constitutional symptoms were evidently not such as could be regarded as venereal, if we give credit to the commonly received ideas on the subject. Caries of the bones, and some of the least equivocal symptoms, did not occur. In no instance was there that uniform progress, with unrelent- ing fury, from one order of symptoms and parts affected to another, which used to be considered as an essential characteristic of true svphilis.* Great diversity, however, prevails in the statements, re- lative to the frequency of secondary symptoms, where no mercury has been used. While Mr. Rose represents the proportion, observed by himself, to be as great as one out of every three cases, only six cases of secondary symptoms were remarked in the York Hospital,in nearly 100 patients, who had been treated without mercury. It is allowed, how- ever, that the real proportion might have been somewhat larger; and, according to some other returns, collected by Mr. Guthrie, the proportion would appear to be about one- tenth.f It is mentioned by Dr. Hennen, that eruptions were much more common in patients treated without mercury, than in others treated with it; but the breakings out did not end in ulcerations, as they frequently did when that mineral had been used.f: The observations, drawn from the returns of certain military hospitals, and published by Mr. Guthrie, also tend to prove, that mercury lessens the frequency of secondary symptoms; for it appears, that out of 521 cases, treated with mercury in one district, only ten cases of secondary symptoms happened.^ As to the general mildness and curability, without mer- cury, of these secondary symptoms, which takes place in cases where that mineral has not been employed, the re- ports of nearly all the gentlemen, who have entered into this investigation, completely agree. They also concur about the rarity of an affection of the bones. The further the subject before us is investigated, the • See Med. Chir. Trans, vol. viii. p. 422. f Ibid. p. 559—561. i Edinb. Med. and Surg. Journ. No. 54. p. 20? ft Op. et. vol. citat. p. 569 284 SYPHILID more reason we find to join Hunter, Carmichael,* and others, in the belief, that what has been generally consider- ed as syphilis, is not one disease, but several, and that " other diseases may not only resemble the venereal, in ap- pearance, but in the mode of contamination; proving them- selves to be poisonous, by affecting the parts of contact; and from thence producing, not only immediate consequences similar to buboes, but remote consequences, similar to the lues venerea." If any gentleman is entitled to superior praise for in- dustry and talent in the investigation of the distinctions, between syphilis and the diseases generally confounded with it, this high compliment, I think, is unquestionably due to Mr. Carmichael. He confines the term syphilis to that disease, in which the chancre, or primary ulcer on the genitals, has a hardened edge and base; in which the blotch- es are scaly, as described by Willan, with the excavated ul- cer of the tonsils, noticed by Hunter; or when affections of the bones are complained of, those patients alone are truly syphilitic, who have nocturnal pains in the shafts of the long bones, or decided nodes, or enlargement of the bone. All other cases, though many of their characters may resemble those of syphilis, are not to be considered as syphilitic; but as they proceed from sexual intercourse, he adopts the term venereal for them.f In considering the primary and se- condary symptoms of the disease, I shall notice some of v the principal opinions advanced by Mr. Carmichael, to which the greatest attention is certainly due. One of the most im- portant propositions,to which his observations lead,is,"the constant association of a distinct and peculiar train of con- stitutional ailments, with corresponding primary symptoms, demonstrating that the regularity, which marks the cha- racter of all morbid poisons, also has a place in venereal diseases." OF TRUE CHANCRES, AND OTHER PRIMARY SORES. Chancres signify sores which result from the application of true syphilitic matter to a part of the body; and, con- * See his inquiry into the probability of the spontaneous origin of some diseases, which bear a resemblance to the constitutional symptoms of Syphi- lis, in his " Essay on the Venereal Diseases, which have been confounded with Syphilis." 4to. Lond. 1814. ■j- See an Essay on the Venereal Diseases, which have been confounded with Syphilis. 4to. Lond. 1814. SYPHILIS. 285 >equently, they are generally situated on the genitals. A true chancre, according to Mr. Hunter, is somewhat of a circular form, excavated, without granulations, with mat- ter adhering to the surface, and with a.thickened edge and base. This hardness, or thickening, is very circumscribed; not diffusing itself gradually and imperceptibly into the surrounding parts, but terminating rather abruptly. When the disease occurs on the prepuce, or framum, the effects of the inflammation are more extensive. When the sore is on the glans penis, it sometimes causes profuse bleeding. In women, chancres are usually situated on the labia, or nymphae, and, very rarely, in the vagina. The discharge from a chancre contains the true syphilitic poison, and, of course, is capable of imparting the disease by contact or inoculation. Mr. Carmichael also adopts Mr. Hunter's definition of chancre, and points out, that it is the solidity, firmness, and abrupt termination of the surrounding induration, which chiefly distinguish it from other ulcers. The induration, he says, is less marked, when a chancre is situated on the body of the penis, but then the sore is of a dark livid co- lour, which, if mercury be not resorted to, " is alternated every third or fourth day, with that of a light brown, or tawny, sufficiently distinguishing it from the dark slough- ing ulcer, with which it might be confounded." Thechan- crous ulcer, at the same time, extends its dimensions slowly, and, " as it advances, the surrounding induration obviously increases." Phymosis and inflammation are also " less frequently attendants upon chancre, than upon those ulcers which are destitute of its characteristic marks." The se- condary symptoms, represented by Mr. Carmichael, as fol- lowing the absorption of the virus of a true syphilitic chan- cre, or bubo, are, first, an eruption of scaly blotches, pre- senting either the character of lepra, or psoriasis, unattend- ed with any obvious degree of fever; secondly, excavated ulcers of the tonsils; thirdly, pains in the joints, tibiae, cranium, &c.; fourthly, nodes. He proposes also for vene- real diseases, a new nomenclature, founded on the charac- ters of the eruptions, which he thinks afford the most cer- tain criterion, and he names the true chancre and its conse- quences the scaly venereal disease.* * See Obs. on the Svmptoms and Specific Distinctions of Venereal Dis- eases, p. 202, &c. 8voi Dublin, 1818. Also, Essay on Venereal Diseases, edit. 2. p. 304, &c. 8vo. Lond. 1825. ■2S6 SYPHILIS. Mr. Carmichael divides the primary diseases which have been confounded with syphilis, into two classes ; the first comprehends, 1. A superficial ulcer, without induration, but with elevated edges. 2. A similar ulcer, destitute not only of induration, but of elevated edges. 3. An excoria- tion of the glans penis, and internal surface of the prepuce. 4. Gonorrhoea virulenta. From the first of these four dis- eases, he has been seldom able to trace any constitutional symptoms. The constitutional symptoms of the other three he describes as precisely alike. In the second class, Mr. Carmichael comprises the two remaining species of pseudo-syphilitic disorders, viz. the phagedenic ulcer, and the sloughing ulcer. In the year 1814, he calculated, that the number of patients with these ulcers, who sought admission into the hospital under his charge, exceeded those with true syphilitic chancre in the proportion of five to one. What the proportion may be at the present time I know not; but it must be wonderfully changed, if the very curious assertion, subsequently made by this author, be correct, viz. that, in the considerable space of time which had elapsed since he published his first essay, he had met with only three cases of true syphili- tic chancre in all his extensive practice, public and private.* How we are to reconcile this account with Dr. Hennen's statement, that, on an average, twenty out of every 105 are Hunterian chancres, is difficult to say, unless we suppose the latter gentleman is more easy in admitting cases as chancres than Mr. Carmichael, who rejects all ulcers from this class, which do not possess "the callous edge and base, terminating abruptly under the skin, and feeling nearly as hard as a piece of cartilage." Let us now consider more particularly the primary dis- eases, which Mr. Carmichael has described as being liable to be confounded with syphilis, excluding from present at- tention, however, the subject of gonorrhoea. The first class of these diseases are :— 1. The superficial ulcer, without induration, but with ele- vated edges, presents a reddish brown surface. It is not excavated, but is either on a level with the surrounding skin, or considerably raised above it, though sometimes the elevated edges give an appearance of excavation. At its commencement, it appears in the form of a small pus- * Obs. on the Svmptoms and Specific Distinctions of Venereal Diseases. p. 14. SYPHILIS. 287 tule, attended with itching. It sometimes bears a strong resemblance to the phagedenic ulcer, from which, however, it may be distinguished by its raised and well-defined margin, the abence of the irregular and corroded surface, and of the pain of that ulcer. It may be known from a chancre, by having no callous edge and base. It occurs on the external surface of the prepuce, body of the penis, and scrotum ; and sometimes a circle of small ulcers of this kind, forms upon the orifice of the prepuce, producing an obstinate phymosis, which remains after the sores are healed, and requires the use of the knife. Mr. Carmichael has seldom traced this sore to its constitutional symptoms, but, in the appendix to his essay, he details two cases, in both of which the eruption was pustular, and aftervvards spread into ulcers, covered at first with thin crusts. In short, the ulcer with elevated edges, without induration, according to Mr. Carmichael, is liable to be followed by buboes with undermined edges ; an eruption of pustules, generally phlyzaceous, preceded by fever, and terminating in ulcers covered with thin crusts, healing from their margins, and, when the disease is on the wane, the eruption desquamates into scaly red blotches. On the fauces, ul- cers occur in different places, with a white aphthous ap- pearance; and sometimes pains in the joints and nodes. To this ulcer, and its consequences, Mr. Carmichael ap- plies the name ;of Pustidar Venereal Disease, from the cha- racter of the eruption.* 2. The simple ulcer, without induration, elevated edges, or phagedena, has neither the indurated base, which attends the true syphilitic chancre, nor the elevated edges which surround the primary ulcer of the pustular venereal dis- ease; nor the surface of the primary phagedenic ulcer. It begins on the prepuce, or body of the penis, as a small pustule; then forms a thin crust, which soon falls off,leav- ing an excavated, round, or oval sore. In the second week, this fills up, and afterwards rises above the skin, present- ing a smooth surface, of a healthy colour, but without granulations, and with somewhat of a fungous appearance. It most frequentlv occurs on the glans and internal surface of the prepuce, when it generally excites phymosis ; but is sometimes on the outside of the prepuce, on the body of • Op. cit. &.c, p. (V2; Lond. Med. Journ. for 1S15; and IN-.;V on Yr« ]V; cases, edit. .-' p. M-'i. Svo. Lond. 1825 -00 .iYIIIILt- the penis, or on the scrotum ; and, in women, it takes place on the labia, perineum, and fossa of the nates. 3. Excoriation of the glans penis, and internal surface of the prepuce, attended with purulent discharge, is usually ac- companied with gonorrhoea, and produces phymosis. The corona glandis is the part most affected; but, when the prepuce can be retracted, the excoriation is found to be in patches only, with intervening spots of sound cuticle. Mr. Carmichael's observations lead him to believe, that the constitutional symptoms, which are apt to follow the small ulcer without induration, or elevated edges, and the patches, excoriation of the glans and prepuce, and, even in some rare examples gonorrhoea virulenta, are the same, and*therefore, that all these diseases have their source in the same venereal poison. The constitutional symptoms consist of more or less fever, which ushers in a papular eruption, and soreness of the fauces, attended with diffi- culty of swallowing, severe pains in the head and larger joints, iritis, and sometimes inflammatory swellings over the superficial bones, which many would call nodes.* The whole of these cases, taken collectively, he names the Pa- pular Venereal Disease.^ The second class of primary diseases, which have been confounded with syphilis, consists of two species; viz. the phagedenic ulcer, and the sloughing ulcer. 1. The phagedenic ulcer is described by Mr. Carmichael, as a corroding sore, without granulations, or surrounding induration, spreading with great rapidity, and having its destructive process increased, instead of being checked, like chancre, by mercury. It more frequently attacks the glans, which it sometimes totally destroys, and occasion- ally, notwithstanding " every anodyne and lenient applica- tion, the ulceration will gradually proceed, until the en- tire penis is destroyed."- The ulceration, by destroying the coats of an artery, may produce such profuse hemor- rhages as can only be stopped by ligatures, but, in this case, its progress is arrested. One of its remarkable characteristics is the frequent return of ulceration, after the part has healed, to the very same spot which was first affected. The constitutional symptoms are, an eruption of * Essay, &c. p. 82. See his Obs. on the Symptoms and Specific Dis- tinctions of Ven. Diseases, p. 205., and his Essay, &c. edit. 2. 1825. + Carmichael's Obs. on the Symptoms and Specific Distinctions of Ven. Diseases, p. 209. SYPHILIS. 25b tubercles, or spots of a pustular tendency, or both inter- mixed, preceded by fever, and terminating in ulcers cover- ed with thick crusts, which often assume a conical form, healing from their centre, and extending with a phagede- nic margin.* The affection of the throat is " a white slimy- looking ulceration, which occupies almost the whole of the back of the pharynx in view; and may be followed by ca- jies, exfoliation of the spongy bones, tenderness of the ossa nasi, and a foul discharge from the nostrils. The velum and uvula are occasionally destroyed, so that on looking into the mouth of a person in this lamentable state, there appears one vast continuous ulcerated cavity, covered with white viscid matter, and extending from the palate to the lower part of the pharynx. At the same time that the patient is thus affected, the larger joints, and sometimes the smaller, also become red, swelled, and ex- quisitely painful, and nodes suddenly appear, which can- not be distinguished by their aspect from those of syphi- lis. According to Mr. Carmichael, the ulcer with elevated edges not unfrequently exhibits the apparently corroded surface, which characterizes the phagedenic ulcer, and its secondary symptoms also have a very close resemblance to those of the latter sore.f 2. The sloughing ulcer at first resembles a small black spot, which produces so little uneasiness, that it remains unnoticed for several days ; it soon, however, increases, and, when the slough separates, the sore is not clean and granulating, as after simple mortification, but a corroding phagedenic ulcer appears, which becomes painful, assumes a bluish cast, and is soon covered again with a fresh slough. It proceeds in this manner, alternately sloughing and ulcerating, until the whole of the external organs of ■ generation, and sometimes the bladder also, are involved, and, even if the progress of the disease be checked, the orifice of the urethra is so contracted, that great difficulty in voiding the urine is experienced. The sloughing ulcer is said to produce the same kind of secondary symptoms as are connected with the phagedenic sore, and the whole of these affections Mr. Carmichael distinguishes by the name of the Phagedenic Venereal Disease. Such is the arrangement proposed by Mr. Carmichael, • Carmichael's Obs. on the Symptoms and Specific Distinctions of Ven. Diseases. f Op. cit. p. 59. Vol. I. Oo 290 SYPHILIS. in which, however, many surgeons do not coincide; I mean with respect to the regularity and peculiarities of the secondary symptoms, and of the eruption in particular, represented by that gentleman as appertaining to each pri- mary disease.* Indeed, he carries this doctrine so far as to say, that, with the exception of some anomalous cases presently to be noticed, every primary affection has its cor- responding eruption, so that we may foretell by the former what the latter will be; or, if we have only the opportuni- ty of seeing the eruption, we may judge what the primary ulcer has been. That many difficulties still oppose the complete reception of these doctrines, is a truth, which candour obliges me to state. Various observations pub- lished by Dr. Hennen and others, prove, that primary sores, of a determinate character, frequently communicate ulcers of a very different description, and sometimes more than one kind of sore, to the same* infected person. Cer- tain cases, detailed by Mr. Evans, show, that various sores may be the result of a connexion with common prostitutes, in whom no complaint at all can be detected; such ulcers probably arising from the mere irritation of the natural se- cretions of the parts. There must, also, be some hesita- tion in the adoption of the sentiment respecting a particu- lar virus having the power of producing a primary phage- denic sore, because this character of an ulcer rarely exists from the commencement, and when it occurs, may fre- quently be referred to disordered health, bad treatment, neglect, and other circumstances. Also, since a phagede- nic sore is generally attended with great pain, its frequen- cy is much greater, than could be accounted for by the supposition of patients in this state being likely to have connexion with women. Mr. Carmichael, however, with his usual candour and devotion to truth, wishes his facts to be considered independently of all theory about the plu- rality of poisons ; and, certainly, the frequent association of particular primary complaints with secondary ones of determinate characters, is a point first established by him, and promising a great deal of additional light to this ob- scure subject. * "As we have seen true syphilis accompanied by eruptions not scaly, so we have seen the primary symptoms of pseudo-syphilis described in the first class of our author's arrangement, followed both by pustular and tuber- cular eruptions; and that the same infection will also produce eniptions of a-different character in different individuals, has been ascertained," &c. See Lond. Med. Repository, vol. iv. p. 323. SYPHILIS. 291 With respect to the treatment of the true syphilitic chan- cre, the fact of even this kind of sore being generally ca- pable of cure without mercury, though often in a less ex- peditious manner, must be admitted, the proofs of it being most unequivocal. The determination of this point, how- ever, is far from amounting to any thing like a decision, that mercury ought not to be employed in the cure. On the contrary, all those gentlemen who have so ably inves- tigated the point, candidly own, that mercury generally expedites the recovery. Thus, Mr. Guthrie tells us, that ulcers, possessing the true characters of chancre, required in general a longer period than other sores for their cure, "that is, from six, eight, to ten, twenty, and even in one case, twenty-six weeks, healing up and ulcerating again on a hardened base;" and he afterwards expresses his con- viction, that almost all these protracted cases would have been cured in one-half, or even one-third, of the time, if a moderate course of mercury had been resorted to, when common applications were found to fail.* If some other statements laid before the public by another gentleman were correct, however, the effect of mercury in accelerat- ing the cure of chancres would be less striking; because it is said, "the general period (required for the healing) was four weeks, and this whether the sores possessed the IIun- terian characteristics or not."| It is admitted, however, by the same author, that the cure of some other protracted cases would probably have been hastened by the use of mercury. The fact of the possibility of curing true chan- cres without mercury, is then, by no means, to be confound- ed with the question of the propriety of the practice. It is of vast importance, however, as it demonstrates the error of inferring, that a sore cannot be venereal because it is heal- ed without mercury, and exposes the equally false and still more dangerous notion, that large quantities of this mine- ral are necessary for the cure of a chancre. It teaches us, that, in unfavourable states of the health, we may await, its improvement with safety, before we have recourse to the medicine. In short, it instructs us, that mercury, though useful, is not so absolutely necessary in the treatment, as to claim the name of a specific for any primary syphilitic ulcers. Hence it ought to be prescribed in moderation, • Med. Chir. Trans, vol. viii. p. 558, 559. | Hriinm, in Kdinb. M'-d. and Surg. Journ. No. 54. p. 207 29s2 MPHILI9. and rather in alterative doses, than in such quantities as are calculated to excite profuse salivation. Whether the united experience of surgeons in general ultimately confirm, or not, Mr. Carmichael's belief in the existence of different venereal poisons, and in the uniformi- ty of the secondary symptoms arising from each of them, still, I think, one truth will remain unshaken; viz. that true syphilitic chancres are often influenced in their pro- gress by constitutional causes. In irritable weak habits. even after the original character and appearance of the sores have been changed by mercury, we often find, that the ulceration will continue to spread, or sloughs to be formed. Too often, under such circumstances, the foul appearance of the ulcerated surface leads the unwary prac- titioner to increase the quantity of mercury; the system then becomes more and more disordered and debilitated; and the local disease grows worse with the declension of the health, until either the patient dies, or is absolutely too weak to employ the destructive medicine any longer. To the foregoing statement, Mr. Carmichael himself also assents; admitting, that neglect, local irritation, and exces- sive constitutional irritability, will cause a venereal ulcer, as they will any other, to become phagedenic, however mild originally in its nature. It must, therefore, he ob- serves, be in the highest degree useful to attend to the progress of an ulcer, and if possible ascertain, whether it was of the phagedenic species from its commencement, or not; and, if not, it is not to be classed with that venereal dis- ease, which may be termed phagedenic* Whenever chancres, which originally presented the true syphilitic character, afterwards alter, and rapidly extend themselves by a phagedenic, or sloughing process, there is always great reason to believe, that the alteration is owing to an unfavourable state of the constitution, irritation ot the diseased part, or general bad treatment. In such cases, mercury should be omitted, without delay; bark, sarsa- parilla, guaiacum,and the nitrous or sulphuric acid prescrib- ed, with absolute rest, plenty of good fresh air, &c. As far as my observations extend, one of the best dressings in these cases is a solution of the extract of opium, in the proportion of 3iss to ffej of water, which may be applied * Obs. on the Symptoms, &c. of Ven. Diseases, &c. p. 61. The existence of a primary phagedenic ulcer, originating from a specific poison, independ ent of constitutional causes, is not universally admitted. SYPHILIS. 293 by means of lint, laid under a simple pledget. Thus the state of the constitution will be amended; and, as this hap- pens, the morbid appearances of the sore, which depended on general weakness and irritability, will disappear; and then, if necessary, (which I believe will rarely be the case,) mercury may be given in moderate quantity again. As every surgeon knows, a true syphilitic chancre, while small, may be cured by removal with the knife, or destruc- tion with caustic, and, if none of the virus has been absorb- ed, the patient will remain free from secondary symptoms. As, however, there is always an uncertainty, whether ab- sorption has taken place or not, the plan has never been very commonly adopted, because if mercury is to be given at all events, with the view of preventing secondary symp- toms, no good is gained, as the sore will heal very well with- out it. Astringent lotions, containing the sulphate of cop- per, or that of zinc, and any common simple ointment, are the best general applications for chancres. The dressings must vary, however, according to the state of the sore; and, in the healing stage, when the granulations are high, the use of the nitrate of silver, or of the unguentum resina with 5j of the pulv. hydrargyri nitrico-oxydi to each ounce of it, will materially expedite cicatrization. With regard to the treatment of primary complaints, liable to be confounded with true chancre, my limits oblige me to be very brief. The superficial ulcer, without induration, but with elevat- ed edges, may be cured by dressing it with washes, either of oxymuriate of mercury and lime-water, in the propor- tion of a grain to an ounce; or of the submuriate and lime-water, in the proportion of ten grains to an ounce ; or of the compound spirit of lavender alone, or diluted with one or two parts of water. Together with these applica- tions, Mr. Carmichael orders decoctions of sarsaparilla, and small d»ses of antimony, either separately, or in con- junction. " Primary ulcers, with elevated edges, (says he), are often extremely obstinate under the use of mercury. I have frequently seen that medicine exhibited in full do- ses, which maintained a str|fcg mercurial action in the system for several months, without inducing them to heal." He assures us, also, that stimulating and caustic applications do no good, and if the ulcer be irritable, make it extend. " In fact, our principal care should be to keep the patient at perfect rest; and this observance, with gen- tle astringent applications, or mild ointraent9, seems to be 2Ui SYPHlLIs. all that is requisite," the above medicines being prescrib- ed rather to satisfy the patient, than as essential.* The simple primary ulcer, without either induration or elevated edges, requires the same treatment as the former case, except when it appears on the external surface of the prepuce, body of the penis, or on the scrotum, resembling a fungus, or soft wart; in which case, the wash should consist of two or three grains of the oxymuriate of mer- cury to an ounce of water. The third example " excoriation of glans penis, and in- ternal surface of the prepuce, attended with purulent dis- charge" may also be cured by simple means, resembling those recommended for the two preceding cases. As, however, it is often joined with gonorrhoea and phymosis, the chapters on those subjects may be consulted. Mr. Carmichael is strongly adverse to the plan of giv- ing mercury in cases of phagedenic chancres, which he represents as being invariably rendered worse and more in- tractable by that mineral. With respect both to this and the sloughing sore, u the treatment which succeeded best, was the use of means calculated to lessen inflammation and pain, including general blood-letting, antimonials, purga- tives, clcuta, and opium. The local applications were warm fomentations, and bread poultices, frequently with the addition of opium. In every instance, low diet, and the recumbent position, were strictly enjoined." Mr. Car- michael also found nothing more effectual in stopping the progress of these destructive ulcers, than " the division of any band of integument, which connected two portions of the ulcer together," such division being merely an antici- pation of the destruction of this bridle by ulceration. He also commends the removal of any jagged part of the edges of the ulcer, or of the adjoining surface, which may have a livid colour, and be ready to fall into ulceration; measures, which he thinks owe their utility chiefly to tho bleeding excited by the use of the knife.f OF SYPHILITIC AND OTHER BUBOES. While no venereal matter has been taken up from the sur- face of a chancre by the absorbent vessels, the disease is * See Obs. on the Symptoms and Specific Distinctions of Ven. Diseases, p. 47. + Op. cit. p. 64, 65. SYPHILIS. 295 entirely local. The matter, in its passage through the in- guinal glands, frequently occasions an inflammation and enlargement of them, followed by suppuration and ulcera- tion. The secondary affection is named a venereal bubo. The syphilitic poison (it is also not unfrequently supposed) may sometimes lodge on the sound skin, be absorbed with- out the occurrence of any ulceration at all, and a bubo be the consequence. However, true syphilitic buboes are commonly preceded by a chancre; and it is a remark made by Mr. Hunter, that they more frequently follow sores on the prepuce, than those on the glands. The absorbent glands in the groin are subject to en- largements, which are altogether unconnected with vene- real causes, and require to be discriminated from true ve- nereal buboes. Mr. Hunter was of opinion, that commonly only one gland is affected by the absorption of true syphi- litic matter; and, if this be the case, we have one criterion, by which a true venereal bubo may be known from other swellings. The syphilitic poison also affects the glands nearest the seat of absorption, and never those, which are situated in the course of the iliac vessels, and higher up. The syphilitic bubo commonly begins with a sense of pain, soon followed by a small hard tumor, which increases, like every other inflammation that has a tendency to sup- purate. If not checked, it advances to suppuration and ulceration, the progress of the matter to the skin being quick. Some few syphilitic buboes, however, are slow in their progress, and Mr. Hunter suspected, that the inflammato- ry process is then retarded by mercury, or a scrofulous tendency. According to Mr. Carmichael, the distinguishing cha- racteristics of a syphilitic bubo, are more difficult to assign, than those of chancre; but, he conceives, that the aching pains, which attend it, the callous feel of its bottom, and its dark, foul, tawny appearance, may assist in forming a diagnosis. I perfectly agree with thrs valuable writer, respecting the propriety of not ordering mercury for bu- boes which have been preceded by chancres. Buboes not of a syphilitic nature are generally preceded, and attended with a slight fever, or, as Mr. Hunter says, the common symptoms of a cold, and the swellings are usually indolent and slow in their progress; but when quicker than common, they are more diffused than syphi- litic buboes, and often affect at once several glands. In 296 aYPHILIS. general, they do not suppurate, but continue stationary; and, when they do suppurate, it is slowly, and often in more glands than one. The matter comes slowly to the skin, unattended with much pain, and the integuments are of a dark purple colour. If the swelling be only in one gland, be very slow in its progress, and give but little or no pain, it is probably scrofulous. The same observations, which have been delivered, re- specting the falsity of the doctrine, that true syphilitic chancres do not admit of cure without mercury, are equal- ly applicable to the buboes, which originate from such primary sores. Thus, in a great many of the cases, which were treated in the hospitals of the Guards without mer- cury, the absorbent glands of the groin were affected, and often suppurated. "The abscesses were in general allow- ed to burst of themselves, and almost all of them healed readily." Two cases, however, are mentioned, which proved more troublesome; one was that of a sloughing or phagedenic bubo; the other an instance in which the diffi- culty arose from the number of absorbent glands which became affected.* In numerous other cases of primary sores, treated without mercury, as referred to by another late writer, we are informed, not only that buboes occur- red on the average with less frequency, than in other in- stances, where mercury had been used, but also, that these swellings were not so often followed by suppuration; a circumstance ascribed to the antiphlogistic means which were employed. Mr. Hunter, who had the same implicit faith in the necessity of mercury in the cure of syphilitic buboes, which influenced all his opinions relative to the true venereal disease, conceived, that in attempting to ef- fect the dispersion of a syphilitic bubo, it was an object of high importance always to make as much mercury as pos- sible pass through the swelling, by rubbing the unguent. hydrarg. on surfaces, from which the absorbents tended to the seat of the local disease. The same plan he deemed equally commendable when a bubo of this nature was in a suppurated state; for,both in this and the preceding stage of the swelling, the medicine, says he, thus applied, cannot pass into the common circulation without going through the diseased parts, whose cure it must promote in its pas- sage through them, while it also prevents the matter, which » Rose, in Med. Chir. Trans, vol. viii. p. 379. Guthrie, Op. et. vol. cit. p. 558. SYPHILIS. 297 has already passed, and is still continuing to pass, into the constitution, from acting there, so that the bubo is cured, and the constitution preserved. According to the Hunterian precepts, then, the thigh, leg, or part of the abdomen on the same side as the bubo, are the places on which the frictions should be made. Mercury, however, was never intended to do more, than cure the specific quality of the inflammation. When the common inflammation rises very high, bleeding, purging, and fomentations,are requisite auxiliary means; and if the bubo be conjoined with erysipelatous inflammation, Mr. Hunter recommended bark; if with scrofulous, hemlock, and poultices made with sea-water. True syphilitic buboes ought seldom to be opened. When it is thought proper to open them, the skin should be allowed to become as thin as possible; for the abscess will heal better in consequence of this rule being observed. How long the mercurial fric- tions are to be continued, and in what quantity the oint- ment is to.be rubbed in, are questions to which different replies would be made by the believers in the Hunterian tenets, and by what may be called the mercurial reformers, who, while they generally inculcate the possibility of cur- ing all forms of syphilis without mercury, acknowledge the superior efficacy of this mineral in accelerating the cure of some of them, and rendering secondary symptoms less frequent, which advantages they think may also be best obtained by prescribing mercury in small alterative quan- tities. While surgeons were swayed by the belief, that no syphilitic disease could be cured without mercury, the com- mon plan, when a bubo healed very slowly, was to discon- tinue this mineral after the constitution had been kept a certain time (perhaps five or six weeks) strongly under its influence. But when the bubo had rapidly healed, mercury was given for a fortnight or three weeks afterwards. It was universally admitted, however, that there were many instances, in which it was quite unnecessary to continue mercury until a bubo had entirely healed. Sometimes the sores produced by buboes assume an ill- conditioned appearance, even when they are losing, or are quite deprived of their original syphilitic character. We are not, therefore, always to set down the backwardness of a bubo to heal, as a mark of the presence, or continuance of its first nature. The disorder, produced in the system by a course of mercury, is frequently the cause of syphili- tic buboes being gradually converted into phagedenic ul- Vol. I. Pp 296 SYPHILID cers, or such as will not cicatrize. In scrofulous constitu- tions, the irritation of venereal matter, in its passage through an absorbent gland, frequently gives rise to a scrofulous enlargement of the groin, and this disease cannot be made to heal by the influence of mercury; on the contrary, if the system should have already suffered much from a mercu- rial course, perseverance in this treatment will change the usual indolence of a scrofulous abscess, or ulcer, into a foul, fast-spreading, ill-conditioned, local disease. In these eases, bark, sea-bathing, pure air, and the internal and ex- ternal use of hemlock, are serviceable. With regard to such buboes as belong to what Mr. Car- michael terms the papular venereal disease, and arise from primary ulcers, which he distinguishes by the negative characters of having neither callosity, raised edges, nor phagedenic surface, his experience has not taught him, that mercurial frictions will discuss these swellings. On the contrary, the trials, which he has made of this medicine, incline him to believe, that it tends to increase the inflam- mation and chance of suppuration; and, that when in a state of suppuration, they will heal better if the patient be not subjected to a strong mercurial irritation. He observes, that buboes of this nature are often remarkably hard and indolent, without any tendency to subside or suppurate. In such cases, he says, the greatest-advantage may be de- rived from the repeated application of blisters to the in- durated bubo, which soon bring about either the disper- sion, or suppuration of the tumor.* The buboes, which arise from the primary ulcer with elevated edges, are alleged to resemble the original sore in their tendency to form projecting, or undermined edges, particularly, when much mercury is employed; and, says Mr. Carmichael, if these edges are not removed by art, the disease may remain for months, and perhaps years, without healing. He prefers the knife for their removal, as caustic is too slow in its effect; and by this plan he has got many cases well in five or six weeks, which would have resisted any other mode of practice as many months. Full courses of mercury always increase their tendency to bur~ row, and not unfrequently produce dreadful mischief; the integuments even up to the navel being undermined or de- stroyed. He met with eight or ten ulcers, situated either • Observations on the Symptoms and Specific Distinctions of Venereal Diseases, p. 21 SYPHILIS. 29b on the groins, pubes, or scrotum and fossa of the nates, or on all these parts at once in the same individual, and re- sembling in their raised edges and obstinate nature the primary ulcer of this description. He describes them as creeping on slowly, with margins both raised and under- mined ; and expresses doubts, whether they should be con- sidered as primary, or secondary ulcers, though he inclines to the former opinion, as they were never accompanied with any other symptoms indicating a general affection of the system. In all the cases, the patients had used large quantities of mercury, and one might therefore regard such ulcers as mercurial, if they were ever observed to arise from the exhibition of mercury for any diseases which were not venereal. Under every mode of treatment, they are obstinate; and, according to Mr. Carmichael, caustic and irritating applications are always injurious. The patient, he says, often recovers under the use of sarsaparilla, coun- try air, and sea-bathing. One very tedious case yielded to Fowler's solution of arsenic, and pressure on the dis- eased parts with straps spread with equal parts of soap and strengthening plaster.* SECONDARY SYMPTOMS. Mr. Hunter describes the first order of parts which be- come diseased, in consequence of the diffusion of the virus through the system, as consisting of the skin, tonsils, nose, throat, inside of the mouth, and sometimes the tongue. The second order of parts, or those which are affected in the latter stage of lues venerea, comprehend the perioste- um, fasciae, and bones. This description can only relate to true syphilis, and indeed, of the accuracy of the latter part of the account, doubts must be entertained, if it be esta- blished that nodes hardly ever happen in syphilis, unless mercury be employed. At first, the skin of every part of the body is generally mottled with discolourations, many of which disappearf; while others continue and increase. In other examples, distinct blotches occur, which are sometimes not observed till the scurfs are forming. In certain cases, the eruptions • Obs. on the Symptoms, &c. of Ven. Diseases, p. 56. f Though such is the observation of Mr. Hunter, I have known eminent surgeons immediately pronounce an eruption not to be venereal, if any part of it died away, without the interference of mercury 300 SYPHILIS. come out in the form of small distinct inflammations, con- taining matter, and resembling pimples; but not so pyra- midical,nor so red at the base. A copper-coloured, dry, inelastic cuticle, forms. This is thrown off, and a new scurf of the same kind is regene- rated. These appearances spread to the breadth of a six- pence ; but seldom more extensively, at least for a consi- derable time. Every succeeding scurf becomes thicker and thicker, till at last it becomes a common scab, and matter forms in the cutis underneath, so that, at last, the blotch becomes a true ulcer, which usually spreads, although slowly. According to Mr. Carmichael, when absorption of the syphilitic virus into the system takes place, ulceration of the throat is the earliest indication of the general disease ; but " the eruption in the skin is usually considered the first of the constitutional symptoms; and this, when truly syphilitic, is scaly; a circumstance, by which it may be distinguished from the eruptions of the pseudosyphilitic diseases, which are either papular, pustular, or tubercu- lar."* He describes the eruption as always consisting of scaly blotches, presenting either the character of lepra, or that of psoriasis, and unattended with any obvious degree of fever. He represents this as the eruption which follows the absorption of the virus of a true chancre. From a simple primary ulcer, patchy excoriation attended with discharge, or gonorrhoea virulenta, the eruption is pa- pularf, preceded by fever, and ending in desquamation. From the ulcer with elevated edges, without induration, the eruption is of pustules, in general phlyzacious, preced- ed by fever, and terminating in ulcers, covered with thin crusts, that heal from their margins, and when the disease is on the wane, the eruption desquamates into scaly red blotches; while the eruption, consequent to a primary phagedenic ulcer, consists of tubercles, or spots of a pus- tular tendency, or both intermixed, preceded by fever, and terminating in ulcers, covered with thick crusts, which of- ten assume a conical form, healing from their centre, and * Essay on the Venereal Diseases, which have been confounded with Syphilis, &c. p. 39. f In Mr. Rose's investigations, "it appears, that most of the papular erup- tions followed ulcers which were not very deep, and which healed without difficulty." However, he could not discover any uniform character in the sores, by which these papular eruptions were preceded. See Med. Chir. Trans, vol. viii. p. 399. aYPHILIS. 301 extending with a phagedenic margin. In the decline of the disease, this eruption also desquamates into scaly red blotches*. Very able'men, however, dissent from the in- ference, that no eruption is to be regarded as syphilitic, which is not scaly. They assert, that a primary sore on the genitals, having none of the characters of a true chan- cre, will produce constitutional symptoms, attended with copper-coloured eruptions, resembling those of syphilis, but curable without mercury; and that while these erup- tions are sometimes even scalyf, true syphilitic eruptions sometimes assume the pustular formf.. But, before we pronounce Mr. Carmichael wrong, I think we should fol- low exactly the line of discrimination which he has recom- mended ; for, in particular stages of the disease, we find, that he himself represents certain eruptions as becoming scaly, which he does not regard as syphilitic. We should consider, as he expressly directs, whether the eruption is scaly from the first, or not; whether it is preceded with fever; whether the affection of the throat differs from what is usually considered syphilitic; and what is the nature of the pains of the limbs ? If we compare all these symptoms, as described by Dr. Bateman§, with the criteria of syphi- lis, particularly insisted on by Mr. Carmichael, we shall immediately perceive, that the latter gentleman would not have hesitated a moment about excluding such cases from the class of true syphilitic eruptions. VENEREAL SORE THROAT. In the throat, tonsils, and inside of the mouth, lues ve- nerea generally makes its appearance as an ulcer, without much previous swelling. Common inflammation of the tonsils often suppurates in the centre, so as to form an abscess, which bursts by a small opening; but this com- plaint never looks like an ulcer, which begins on the sur- face, like the true venereal sore; it is always attended with too much inflammation, pain, and swelling, to be venereal, * See Synopsis in Carmichael's Obs. on the Symptoms and Specific Dis- tinctions of Venereal Diseases, &c. 8vo. Dublin, 1818. ■J- See Batcman's Hist, of a Tubercular Eruption of Syphilitic Appearance, but curable without mercury, in Med. Chir. Trans, vol. v. p. 225. + See Lond. Med. Repository, vol. iv. p. 316. § Med. Chir. Trans, vol. v. p. 226, 227. Mr. Rose has repeatedly seen the scaly blotch in cases where mercuiy had been freely employed for the primary sores, and where he considered the virus as eradicated, disappear 'inder the use of sarsaparilla. See Med. Chir. Trans, vol. viii. p. 421. 302 SYPHILIS. and immediately the little abscess bursts, the swelling sub- sides. The complaint is also generally attended with fe- brile symptoms. Another disease is an indolent enlargement of the ton- sils, which is peculiar to persons disposed* to scrofula. Portions of thick mucus, or perhaps coagulating lymph, lie upon the surface of the tonsils, and are frequently mis- taken for sloughs or ulcers. When doubts exist, they may be cleared away by removing the thickened mucus with a probe. An ulcerous excoriation of the tonsils is another disease, liable to be mistaken for a venereal ulcer of these parts. This sometimes becomes very broad and foul, having a regular margin; but never extending deeply into the sub- stance of the parts, like the venereal ulcer. If the obser- vations of Mr. Carmichael be correct, excoriation of the fauces is mostly a consequence of the simple primary ul- cer, patchy excoriation of the prepuce, or gonorrhoea viru- lenta, being the cases which he represents as giving origin to the class of symptoms, which he distinguishes by the name of the papular venereal disease. When the primary ulcer, with elevated edges, but without induration, is followed by sore throat, Mr. Carmichael finds, that the ulcers affect differ- ent parts of the fauces, and are in general of a white aph- thous appearance. This is the sore throat, which he de- scribes, as accompanying what he names the pustular vene- real disease. In the phagedenic venereal disease of the same author, the ulcers of the throat also affect different parts of the fauces, and particularly the back of the pharynx, frequently occupying the whole of the fauces, and some- times extending to the nares and larynx. The affection of the throat is " a white slimy-looking ulceration." The velum and uvula are occasionally destroyed, u so that in looking into the mouth of a person in this lamentable state, there appears one vast continuous ulcerated cavity, cover- ed with white viscid matter, and extending from the palate to the lower part of the pharynx." The true venereal ulcer is represented by Hunter as a fair loss of substance, part being, as it were, dug out of the body of the tonsil. It has a defined edge, and is com- monly very foul, having thick white matter adhering to it, like a slough, which cannot be washed away. This excavated ulcer of the tonsils, however, is not at present universally regarded as a symptom peculiar to syphilis. Mr. Rose has repeatedly seen such a throat cured SYPHILIS. 303 by sarsaparilla.* Mr. Carmichael, in acknowledging the correctness of Mr. Rose's observation, tells us, that since the publication of the Essay, he has often noticed the ex- cavated ulcer of the tonsils, " either attending the primary phagedenic ulcer, or the train of constitutional symptoms arising from it."f NODES. The swellings of the periosteum, tendons, and bones, arising from syphilis, are so called. Their progress is ex- tremely slow, and attended with little pain. In some cases, however, the pain is considerable, particularly in the night- time. They continue a long time before matter forms, and then suppuration is very imperfect. Sudden swellings of the periosteum, without nocturnal pains, are not venereal. Syphilitic nodes are described by Mr. Carmichael as indolent, slowly-increasing swellings, attended with little pain and inflammation, until in an ad- vanced state. On the contrary, the nodes of diseases, lia- ble to be mistaken for syphilis, seem in the first instance to affect the periosteum and soft parts covering the bone, and not the bone itself, as swelling and redness of the in- teguments are seen from the very commencement. These swellings arise suddenly, increase with rapidity, and fre- quently disappear without mercury, as quickly as they arose. In short, they are of a much more inflammatory character, than syphilitic nodes.!: A very curious fact appears now to be established, viz. that nodes, corresponding to the description of those of syphilis, very rarely occur, except in patients who have nsed mercury for the cure of other venereal symptoms. The evidence derived from the late extensive investiga- tions in military hospitals, all tends to the confirmation of this interesting point, of which the explanation is difficult, without supposing that mercury itself has the power of causing nodes; a conjecture refuted by the fact, that ex- cept in syphilis, or its resembling diseases, we rarely or never see such an effect on the bones produced by mercu- ry, however long and freely it may have been employed. The superficial bones are most liable to syphilitic nodes; • Med. Chir. Trans, vol. viii. p. 421. \ Olis. on the Symptoms, &c. of Venereal Diseases, &c. p. 17. $ Kshav on the Disrases which have been confounded with Syphilis, &c p. 45. ■304. SYPHILIS. for instance, the front surface of the tibia, the bones of the cranium, the triangular part of the ulna below the olecra- non, &c. TREATMENT OF SECONDARY SYMPTOMS. The important fact, of late so unequivocally developed, that both the primary and secondary symptoms of syphilis may generally be cured without the aid of mercury, must of course be followed by an absolute rejection of the claim of that medicine to the character of being the specific for this disease; or the only remedy by which it can be cured.* This position I hold to be incontestable, without the other distinct and different questions, concerning the utility of mercury in syphilis, and the propriety of renouncing its exhibition, being at all involved in the statement. That mercury generally expedites the cure, both of the primary and secondary symptoms of syphilis, or the scaly venereal disease, is another truth amply confirmed. Yet, we are not to forget, that, in some states of the constitution, even when true syphilitic affections are present, or when ulcers, which were originally of this nature, have assumed the phagedenic, or sloughing form, mercury is of all medi- cines the most unfit medicine to be prescribed, as instead of promoting the cure, it increases, in a most dangerous * {Dr. Thomas Harris, of the U. S. Navy, an able advocate of the non- mercurial treatment of syphilis, has published the results of his experience in the first number of the North American Med. and Surg. Journal. In one hundred and sixty-four cases of syphilis, (excepting three, in which altera- tive doses of mercury were prescribed) the treatment consisted of bleeding, purging, warm bath once a week, and the decoction of the woods. Poultices and cooling lotions—a wash of calomel and lime-water, a strong solution of blue vitriol, and the nitrate of silver, were the local applications. Seconda- ry symptoms followed in two cases, and were cured by nitric acid and the decoction of the woods. Twenty-three cases of secondary symptoms were cured by this means, after they had been treated with mercury by other physicians. Upon the whole, we conceive that this mode of treatment is rapidly gaining ground both in Europe and in this country, and we consider that the profession is under great obligations to Dr. Harris for his active and efficient endeavours to introduce the practice. In this place, we may call attention to a communication in the American Medical Recorder, for April 1828, by Thomas Y. Simons, M. D. of Charles- ton, S. C. in which one of our indigenous plants, the stillingia sylvatica, or queen's delight, is recommended as "one of the most powerful and Valua- ble vegetable alteratives which we know of; and forms an admirable substi- tute for mercury, when that medicine would be inadmissible—such for in- stance, as secondary syphilis more particularly." Dr. S. also gives a highly interesting case of enlargement and extensive disease of the bony structure, produced by syphilitic taint, in which it proved highly efficacious.—P. E. | SYPHILID 3ud manner, both the bad state of the health, and the ravages of the local disease. In making also a due discrimination, between the uses and abuses of mercury, we should ever be mindful of the undisputed facts, that mercury generally benefits not only the ordinary forms of syphilis, but a great many other diseases, both of a somewhat resembling, or totally different description; that a vast number of these disorders, whether cured under the use of mercury, sarsa- parilla, guaiacum, antimonials, the mineral acids, the nitro- muriatic baths, sea-bathing, or change of air, would in the end get well of themselves, or by the powers of nature, if the constitution could last long enough; that the efficacy of such means therefore is mostly limited to the abbrevia- tion of these complaints; and that with respect to mercu- ry, or any other potent remedy, if it be not administered in such quantities as dangerously to impair the health, it will not usually hinder any sores, or other complaints, from get- ting well, which are disposed to undergo a spontaneous cure. We shall admit as the common belief, then, that mercu- ry, though not essential to the cure of all those forms of disease, which are regarded as truly syphilitic, generally abridges their duration, and that on account of this impor- tant degree of utility, its exhibition in moderation is right and advantageous. It may be conveyed into the system, either externally by the skin, or internally by the mouth. In particular con- stitutions, mercury employed in one way seems to have no effect on the constitution or disease, and then it must be tried in the other. In the same manner, when one pre- paration of the medicine proves ineffectual, another should be tried, as the change is frequently followed by beneficial effects on the disease. Sometimes the bowels can hardly bear mercury, and, in this circumstance, it is to be given in the mildest form possible, conjoined with other remedies for diminishing its bad effects on the viscera. In general, the external employment of mercury is the most advantageous and convenient. In giving mercury, the first attention should be to the quantity, and its visible effects at a given time;* for when * {The following case will give a correct idea of the method of treating syphilis, by Dr. S. A. Cartw right of Natchez, as recommended in the Am Med. Rec. vol. viii. for 1825. «' In 1S23, a female -.ipplicd to me who had had the lues venerea for up Vol.. I. Qq 306 SYPHILIS. those effects have attained a certain pitch, they are not to be increased, but only kept up, while the decline of the disease is watched. The visible effects of mercury are of two kinds; the one on the constitution, the other on parts capable of secre- tion. In the first, it appears to produce universal irrita- bility, a quick pulse, ike. Salivation, or an extraordinary secretion of saliva, attended with soreness of the gums and mouth, forms the second description of effects. The latter affection is the criterion, by which practitioners have generally calculated the influence which mercury has over the whole constitution; but, from the facts already ex- plained, it is a criterion, which should be no longer adopt- ed, as the cure of syphilitic affections may generally be ac- wards of two years, and had been several times salivated without having been effectually cured. The per-chloride or oxymuriate of mercury, the blue pill and ointment, were the preparations of mercury which had been used. She had two cutaneous ulcers, several bones of the nose had exfo- liated, and a ragged ulcer occupied a considerable portion of the soft pa- late. 1 gave her a box of pills, each of which contained scr. ss. of calomel and 2 grs. of rhubarb, with directions to take two of the pills every third or fourth night at bed time—if they operated more than twice, and the stools were not green or black, to take a little laudanum or paregoric—if green or dark, to let the evacuations continue until their appearance be- came changed. If the pills did not operate in 12 or 16 hours, to assist them by a teaspoonful or two of Epsom salts, or some mild purgative. So soon as the least soreness in the gums or teeth was felt, to quit taking them, un- til it had entirely ceased; after which, cautiously to begin again—in the mean time, to drink plentifully of sassafras tea. The patient pursued the above directions for six or eight weeks, at the end of which time, the ulcers had entirely healed, and the disease had disappeared. Her catame- nia, before interrupted, were re-established—her sallow complexion be- came ruddy, and her general health good." About the same time that this method was recommended by Dr. C. in this country, Mr. Boyle, of London, published his views on the subject, which were precisely similar to those of Dr. Cartwright. We have treated several cases of syphilis upon this plan since Dr. C's. communication, and have been well pleased with the results. We should not omit to mention, whilst on the subject of the administra- tion of mercury in syphilis, the new views of Professor Dzondi of Halle. He gives the corrosive sublimate in form of pills; the following is his pre- scription—R. Hydrarg. Sub. Corros. grs. xii. Solve in aq. dist. q. s. adde Micac panis albi et Sacchari albi, aa q. s. ut ft. pil. No. ccxi.—These are to be taken every other day, commencing with four to be taken at once, immediately after dinner; the number to be increased at each time of taking, by adding two, so that by this increase, the patient at the last days of the treatment takes 30, or a grain and a half of sublimate at a dose. If pain is produced, laudanum should be administered. The whole cure, according to Prof. D. " lasts twenty seven days." Every form of sy- philis, says Prof. D. "may be radically cured by this trer.tment; all, even to the oldest and most inveterate." See American Journal of the Medical Sciences, No. 1.—P. E.} SYPHILIS. 307 complished without subjecting the patient to all the dis- tress and impairment of health attendant on salivation. But, if it be deemed proper in some cases to resort to this test, the mercury should always be introduced into the system gradually, beginning with small quantities, which may afterwards be increased. At first, one scruple, or halt a drachm of mercurial ointment, may be rubbed in every night: and if the mouth in a moderate time should not be affected, the quantity must be gradually increased to one drachm or more. When mercury is given internally, and salivation is aimed at, there are three preparations commonly prefer- red in syphilitic cases; the pil. hydrarg. which maybe gi- ven in the dose of gr. x. every night, either with or with- out opium, as circumstances may indicate; the oxydum rubrum in the dose of gr. i. with or without opium; and lastly, a solution of the oxymuriate of mercury, (subli- mate.) One-sixth of a grain dissolved in brandy, or any aromatic water, or made up into a pill, and given twice a day, is the usual dose. VVrhen it is intended, however, only to put the patient on an alterative course, the doses need not be so large, nor frequent; and the submuriate is very commonly preferred. With respect to the preparation of mercury, in unequi- vocal cases of syphilis, the most simple are reckoned the best, not only in consequence of their acting with least vio- lence on the system, but also because they prove most ef- ficacious in the cure of the disease. Hence, frictions with the ointment, and the exhibition of the pil. hydrarg. are the most common plans. It is incumbent on me to mention fumigation, another mode of introducing mercury into the constitution through the skin. It is one of the most ancient forms of adminis- tering this medicine, and was much praised in France by M. Lalonette. Mr. Abernethy, who published a descrip- tion of its advantages, recommends a powder for the pur- pose, made by agitating the submuriate of mercury in wa- ter, mixed with the liquor ammoniae carbonatis. The pa- tient is placed in a machine, not unlike a sedan-chair, but having an opening at the top, out of which he can conve- niently put his head. A heated iron is placed at the bot- tom of it, and when the powder is thrown on the hot surface of the iron, it sublimes, and is deposited on the surface of the patient's body. The patient afterwards puts on his flannel waistcoat and drawers. No doubt, it would be SOS SYPHILIS. quite sufficient to fumigate the inside of the clothes, and then let them be put on with care. Besides mercurial fumigations applied to the whole sur- face of the body, with the view of affecting the constitu- tion, some practitioners place considerable reliance in the efficacy of topical fumigations with the hydrargyri sul- phuretum rubrum for improving the appearance, and in- ducing a healing disposition in certain primary as well as secondary syphilitic ulcers, which are backward in yield- ing to the ordinary employment of mercury. In the shops may be procured an apparatus, consisting of a stand, an iron heater on which the mercurial powder is thrown, and a tube for conducting the smoke to the part affected. With respect to the principle on which mercury acts, the Hunterians suppose, that it cures syphilis, not by any chemical operation, but by exciting, in the constitution and parts affected, a particular action, which overcomes and removes that of syphilitic disease. At the commencement of this chapter, some of the lead- ing Hunterian principles, on which the treatment of the venereal disease is to be regulated, have been already mentioned. According to Dr. Adams, whenever we have cured a patient of the first local symptoms, we may assure him, that as long as he keeps out of the way of mischief, he is free from all danger of a relapse in those parts which have been cured; but we cannot pretend to inform him, whether the disease will yet appear in his throat, skin, or bones. This uncertainty must remain for a few months, after the chancre or bubo has been cured.* So when the disease has reappeared in the skin or throat, and been cured, we cannot say, whether it will afterwards show it- self in the bones, though we know that it will not again do so in the skin or throat. But when the primary com- plaints, and the secondary in the skin, throat, and bones, have all appeared, and been cured, we may regard the pa- tient as free from the danger of future symptoms from the same stock of infection. As I have already related, the Hunterians explain most of the preceding circumstan- ces, by supposing mercury to have no power of curing the disposition to the disease, but only the action or the palpa- ble and perceptible forms of the distemper; and, by laying it down as a law of this disease, that the same order of • Observations on Morb'd Poison, p. 163,164, edit. 2; and the Comment, ■y.\ Hunter's Treatise on the Venereal Disease. SYPHILIS. 30& parts can never be affected more than once from the same stock of infection. With respect to svphilitic nodes, mercury is frequently incapable of removing the whole of the swelling: in such cases, blisters applied over the tumor, and kept open with the savin cerate, are highly beneficial.* In the treatment of the constitutional symptoms, describ- ed by Mr. Carmichael as proceeding from the simple pri- mary ulcer, patchy excoriation attended with discharge, or gonorrhoea virulenta, this gentleman has recourse to blood- letting when the fever is considerable, the pulse full and strong, and the tongue furred, with severe pains of the joints. He then opens the bowels and the skin by antimo- nials, and u when the febrile symptoms are reduced," throws in the simple or compound decoctions of sarsaparilla with antimonials, occasionally giving " the mercurial salts in al- terative doses," when the disease is completely on the de- cline. When iritis, however, is a consequence of these pri- mary affections, he recommends the free use of mercury, until the inflammation is subdued. When there are phagedenic symptoms,! Mr. Carmi- chael's practice is first to subdue the febrile excitement by blood-letting, daily repeated until the pain and fever have abated; and he prescribes antimonials in nauseating doses, and opium; at the same time applying to the sores warm fomentations, with poultices of bread and water, or bread and a solution of opium; and confining the patient to bed, with the penis supported in the most easy and convenient * {In the American Medical Recorder, vol. iv. 1820, Samuel jToIhoun, M. D. of Philadelphia, published an account of several cases of nodes which were effectually cured by the use of Fowler's solution of arsenic, in doses of 10 drops three times a day. Since this communication, the practice has become very general in this country, and is often found to succeed where other remedies have failed—we have used it with much success in these cases.—P. E.} | jTlie chloride of lime has been used with advantage, in cases of phage- dena gangrenosa. A girl was admitted into St. Bartholomew's Hospital, with a sore on the left labium, which included a great part of the perineum, and was covered with a dark-brown slough. The discharge was fetid—the cel- lular texture was puffy—and there was excessive pain. Under the ordinary treatment, little benefit resulted. The chloride was now tried, and by the next day there was less irritability, and the ulcer had lost its sloughy cha- racter. An opium lotion was now applied, with salines internally, which had a decidedly bad effect upon the sore. The chloride of lime was re- sumed, and from that time the girl did well. Dr. Cazenavc, of Cadillac, (.Archives Generates') has successfully employed the chlorurets of lime and »oda in syphilitic ulcers; and internally, in several obstinate cases which had resisted the usual means.—l' K. \ 310 SYPHILIS. manner. Cicuta in large doses, and decoction of sarsaparilla, are afterwards given, " when the primary ulcer is accom- panied with constitutional symptoms;" but when there are only constitutional symptoms, he prescribes "the decoc- tion of the woods alone, or conjoined with antimony, or compound powder of ipecacuanha, or muriate of mercury." During the co-existence of the fever and tubercular erup- tion, or spots of a pustular tendency, Mr. Carmichael is an advocate for blood-letting; and, besides the general means recommended in his Essay, sometimes employs arseniate of kali, nitrous acid, and nitro-muriatic baths. For phage- denic ulcers in the throat, he praises the same general treat- ment, with the application of oxymel aeruginis, a strong so- lution of muriate of mercury, or nitrate of silver, or fumi- gations with the sulphuret of mercury. Should these re- medies fail, u mercury may be used largely with advan- tage in checking the progress of the ulceration, even though it should exasperate the general disease." This mineral, he observes, increases the ravages of the disease in all its stages but the last. For ulceration and caries, the same plans are also recommended, and the pains in the joints and nodes are to be treated like those resulting from the primary ulcer with elevated edges.* For the secondary symptoms, proceeding from the ulcer with elevated edges, without induration, and characterized by a pustular eruption, Mr. Carmichael advises blood-let- ting during the febrile state, followed by antimonials, sar- saparilla, guaiacum, tar-ointment, baths of sulphurated kali, or nitro-muriatic baths. Mercury, he says, is decidedly pernicious, until the pustules terminate in scaly blotches, instead of forming ulcers ; and then mercurials, in altera- tive doses, conjoined with sarsaparilla and guaiacum, may occasionally be employed with benefit. The same gene- ral treatment is recommended for the white aphthous sore throat, often attendant on this form of disease, with com- mon detergent or mercurial gargles; oxymel aeruginis, and fumigations of the sores with the sulphuret of mercury. For the pains in the joints, Mr. Carmichael praises the same constitutional treatment, together with leeches, fo- mentations, bread and water poultices, blisters, and oint- ment of tartarized antimony. But mercury, he says, should be particularly avoided while inflammation of the knee ex- ists. As for the nodes, resulting from the primary ulcer * Obs. on the Symptoms, &c. of Ven. Diseases. SYPHILIS. 311 with elevated edges, he recommends the same general and local means, and sometimes a division of the periosteum. When the preceding means prove insufficient, and the dis- ease is on the decline, he allows that a mercurial course may be of advantage. The same writer has treated of "anomalous disorders resembling the phagedenic disease, yet not of venereal ori- gin." He adverts to Mr. Abernethy's doctrines, respect- ing the connexion between disorders of the digestive or- gans and the production of local diseases, admitting, with the latter gentleman, that the surest method of curing these complaints is by improving the digestion and health in ge- neral. If, however, there should be an extensive and ra- pidly spreading ulcer of the throat, he thinks the treatment should be more active, and precisely such as he has recom- mended for those ulcers of the throat which attend the phagedenic disease, to which he has seen these spontane- ous ulcers bear so strong a resemblance that it was impos- sible for the eye to discover the difference. In most of the instances which he has seen, the eruption also pos- sessed a strong resemblance to the large tubercular erup- tion, which he describes as often following the primary phagedenic ulcer; and extending into ulcers, with irregular, jagged, undermined edges, and generally best cured with nitrous acid, or sometimes with small doses of blue pillr or of the muriate of mercury, joined with sarsaparilla. Mr.. Carmichael recommends the same general treatment for spontaneous nodes, with leeches and blisters; and if these means fail, he divides the periosteum, which, he says, ic lisually found much thickened.* CHAPTER XXIX. ANEURISM. An aneurism is generally a pulsating tumor, arising from a dilated, ruptured, or wounded artery, and filled with blood, which, in the early stage, is in a fluid, and at a later period, in a more or less coagulated state. It origi- nates either from an alteration of structure and consequent • See Note P. 312 ANEURISM. dilatation of the several coats of a part of an artery, or from a dilatation of the external tunic alone, the inner coats hav- ing previously given way in consequence of disease or vi- olence.* These forms of the complaint constitute the ca- ses which, I think, ought still to be called true aneurisms^ in which the sac is really a dilated part of the artery itself. When all the coats of an artery are wounded, ruptured, or perforated by ulceration, the tumor is called a false aneu- rism. Here the blood is either extensively injected into the cellular membrane, the case being named accordingly a diffused false aneurism; or it is collected in one mass, which is bounded by a kind of cyst, soon formed around it by the adhesive inflammation : this is the circumscribed false aneurism. An aneurismal swelling, which arises directly from a wound or breach extending through all the coats of the ar- tery, is sometimes known by the appellation of a primitive false aneurism; while other cases, which either began with a destruction of the inner coats, and terminated in the giv- ing way of the external coat, or which began with dilata- tion, and ended in a rupture of all the tunics, are termed secondary false aneurisms.] If a direct communication be formed between a large ar- tery and its accompanying vein, as sometimes happens in venesection, when the lancet transfixes the vein and opens the subjacent artery, the wound in the skin may heal up, while the opening between tlfe vein and artery may con- tinue permanent, the arterial blood gushing into the for- mer vessel at each pulsation of the heart, and producing in a very short time a remarkable varicose swelling, ac- companied with peculiar symptoms. Such is the nature of the varicose aneurism, or aneurismal varix. Lastly, the aneurism by anastomosis,], is totally different from any of • Some writers mention a wound of the outer coats of an artery, and the dilatation of the inner tunic. Arnaud calls th s case hernia urteriee. In 1804, Dubois demonstrated to the Ecole de Medecine at Paris, two specimens of ^- the aneurysmu herniosum, which were found in the thoracic and abdominal aorta of the dead subject, and of course, could not have arisen from any par- tial wound. It was imagined, that these cases had arisen from the destruction of the external and middle coats by ulceration; and as such a disease is perhaps never seen in other arteries, its occurrence in the aorta is referred to its lining being more elastic than that of smaller arteries. See Diet, des Sciences Med. t. ii. p. 112. •f Dr. Aug. Frid. Ayrer iiber die Pulsadergeschwulste, p. 19. Gbttingen, 1800. Also, C. D. Kahln de Aneurysmate Externo, p. 4. 4to. Jena?, 1816. \ See John Bell's Principles of Surgery, vol. ii. p. 456. A..EUR1SM. 313 the preceding forms of disease, as it proceeds from a mor- bid growth, or dilatation of the arterial ramifications, by which a highly vascular substance is produced, which has a singular propensity to increase to a great and dangerous extent, and which, when cut or broken, bleeds with incre- dible obstinacy. According to the observations of Scarpa, aneurism, in whatever part of the body it is formed, and from whatever cause it arises, is never occasioned by the dilatation, but by the rupture, or ulceration of the internal and muscular coats of the artery, and, consequently, these coats have not the smallest share in the formation of the aneurismal sac, which, he observes, is undoubtedly composed of the cellular sheath, which the artery receives in common with the parts contiguous to it.* He completely disapproves of the division of aneurisms into true and false, as totally incorrect, not admitting, even as an exception, the case which I have mentioned, as ac- companied with a dilatation of the external coat alone, and a rupture or ulceration of the middle and inner tunics. At first, the reason of Scarpa's sentiment upon this lat- ter point seems obscure, until he takes an opportunity of explaining, that he does not agree with the generality of anatomists in considering the covering of an artery as one of its proper coats, but merely as an adventitious sheath, or cellular investment, which the artery receives in com- mon with the parts in the vicinity of which it runs.f But, here the question seems, not about the state of what is call- ed the sheath of the artery in a certain form of aneurism, but about the condition of its external or elastic coats, in the same disease. As Dr. lones remarks, the external tunic derives from the particular arrangement of its component fibres a cha- racteristic appearance, which distinguishes it from cellular membrane, and entitles it to be ranked as di proper coat of an artery. Having described its whiteness, density, great elasticity, &c, he then notices the sheaths, in which the arteries are contained while in their natural situations, and to which they are connected by means of fine cellular mem- brane.J Hence, when Scarpa specifies the invariable ul- * See Trans!, by Wishart, p. 113. f On the Anatomy, Pathology, 8tc. of Aneurism, transl. by Wishart, p. 69. t On the Process employed by Nature in suppressing the Hemorrhage tV'un divided and punctured Arterie", &c. -*<)■ L<>n!. 1805, p. 3. Vol. 1. llr 314 ANEURISM. ceration or rupture of the muscular and internal coats, in proof of the impossibility of a true aneurism, he is passing over that form of true aneurism in which the external coat of the vessel is dilated. The attention of several eminent surgeons has been of late particularly directed to the question before us,—whe- ther any aneurisms really consist of a dilatation of the arte- rial coats, without a rupture or ulceration of all the three coats together, or of the two internal coa*s by themselves. The results of these investigations are quite adverse to the side which Scarpa has espoused; and the doctiine of true aneurisms, or aneurisms by dilatation, is still most respect- ably, and, I believe, successfully defended.* "My own observations (says Mr. Hodgson) will not allow me to co- incide with Scarpa, in defining aneurism to be constantly produced by the destruction of the coats of an artery. On the contrary, the inspection of innumerable preparations of this disease, contained in the principal museums of this metropolis, and the more minute examination by dissec- tion of various specimens of diseased arteries, and of aneurisms in the different stages of their formation, have produced a conviction in my mind, that, although in most aneurismal sacs, especially in those which have arrived at a considerable size, the coats of the vessel have given way, yet, in a great proportion of aneurisms, the disease com- menced in a partial dilatation of the coats of the artery." We are not to suppose, however, that Scarpa means to ex- clude a preternatural dilatation from the catalogue of dis- eases to which the arteries are liable; on the contrary, in several parts of his writings, he speaks of a yielding of the arterial coats with a weakening of a part, or of the whole circumference of the artery. But, such morbid dilatation he always considers as a disease totally distinct and differ- ent in many particulars from aneurism.f The root of an * Ueber die Pulsadergeschwiilste von A. Scarpa; Zurich, 1808, mit An- merk und Zusatzen von Christ. Fr. Ilarles, p. 299, &c. Hodgson's Treatise on the Diseases of Arteries and Veins, Sic. 8vo. Lond. 1815, p. 59, &.c. Krevsig, Ueber die Krankheiten des Herzens, theil ii. abth. 1. Berlin, 1815, p. 381, &c. Spangenberg, in Horn's Archiv. fur Med. Eifahrung, 1815, heft. 2. j Memoria sulla Legatura delle Principali Arterie degli Arti, con una Ap- pendice all' opera sull' Aneurisma, p. 87, &.c. fol. Pavia, 1817. Here I find Scarpa admits the occurrence of dilatation at a part of the circumference of the artery,—a point which, as appears'from the quotation 1 next cite, he positively denies in the first part of his work. " Sometimes (suys an accu- rate writer) the dilatation is partial, and occupies only one side of the ves- sel." Hodgson on Diseases of Arteries, &.C. p. 47. ANEURISM. 31."J aneurism of the aorta, says Scarpa, in whatever point of this artery it appears,never includes the whole circumfer- ence of the tube of the artery, but constantly occupies and involves only the one or the other side of the artery, from which side the aneurismal sac rises and enlarges in the form of an appendix or tuberosity, more or less large and extended, according to the circumstances of the place, or of the period of the disease; while, on the contrary, the dilatation of the arterv, occurs constantl)' in the whole circumference of the tube, and therefore differs essentially from aneurism.* The dilatation of an arterv, he says, is not an affection, properlv speaking, organic, as the blood is always contained within the cavity of the vessel; in the track of the expanded artery, no masses nor layers ofgru- mous blood are ever found, as in aneurism; the dilatation never forms a tumor of considerable bulk; and, as long as the continuity of the proper coats of the artery remains 'uninterrupted, the circulation of the blood is not percepti- bly changed.f There can be no doubt, I think, respecting the reality of the differences between aneurism and the dilatation of an artery, and that circumstances appear fully to warrant a distinction. Yet, I cannot omit this oppor- tunity of condemning all attempts to generalize too much,— a desire which often leads men of the most distinguished talents into error. Thus, Scarpa not only contradicts him- self, with respect to the question, whether dilatation always includes the whole periphery of the artery or not; but, he falls into another inconsistency, for we find him, in one place, asserting that by dilatation a swelling of large size can never be formed, yet, afterwards, himself adduces a morbid dilatation of the arch of the aorta, where the tumor .was six inches in length and five in breadth.:}: The case is mentioned to prove the inaccuracy of the common con- jecture, that coagulated blood is only found in large dila- tations of the arteries, and not in smaller tumors of this nature. In the considerable swelling, here specified, there was not the least vestige of the lamellated coagulum, which is constantly found in aneurism. * In the appendix, p. 92, published 1817, Scarpa speaks of dilatations on the arch of the aorta, which were not larger than half a bean, and which, of course, could not affect the whole circumference of the vessel. These, however, are said to have had the other distinguishing characters of dilata- tion. f See Scarpa's Treatise on Aneurism, transl. by Wishart, p. 56, 57 \ Mem. sulla Legatura, &c. p. 90. Slt> ANEURISM. In aneurism, the blood passes into a cavity, which is, as it were, out of the track of the circulation ; there its course is retarded; and there it invariably deposits lamellated co- agula, and sometimes in such quantity as entirely to fill the cyst. If, says Scarpa, any breaches of continuity hap- pen in the inner surface of a morbid dilatation, it is only within the cavities of such solutions of continuity and roughnesses that coagula are deposited,* and all the rest of the inner surface of the disease is entirely free from them. These solutions of continuity and inequalities on the inside of a dilated artery, Scarpa very justly regards rather as the beginning of another disease, totally differ- ent from dilatation, viz. of aneurism formed consecutively to this latter affection. Mr. Hodgson, who has given a very correct account of the changes in a dilated artery, observes that smaller sacs or pouches often grow from the sides of the great cyst, and are lined with a calcareous crusty and that, in other instances, the dilated coats ap- pear to have given way at some point, and an aneurism is thus, as it were, ingrafted upon the dilated artery.f Besides these distinguishing characters of the two dis- eases, modern pathologists advert to others, not less wor- thy of notice. When the morbid dilatation of an artery is partial, or confined to one side of the vessel, resembling a thimble in shape, the opening through which the blood passes into the cyst is as large as the fundus of the cyst it- self. And, when the dilatation occupies the whole circum- ference of the arterial tube, the tumor, thus produced, con- stantly has a cylindrical or oval shape; and if it be so situat- ed as to admit of being compressed, it readily yields to the pressure, and almost disappears; while in the dead sub- ject it seems much smaller than in the living. But aneu- rism, says Scarpa, presents entirely a different aspect. Whether preceded by a dilatation of the proper coats of the artery or not, its origin is always on one side of the ves- sel. Its neck, or that part, through which the blood must pass in order to get into its cavity, is more narrow than the rest of the aneurismal pouch. The swelling has an irregular shape, yields under pressure with difficulty, and is nearly of the same size both in the living and the dead subject. Lastly, while the preternatural dilatation of * See case in A. Burns on Diseases of the Heart, p. 206. f Hodgson, op. cit. p. 46, also p. 72, &c. ANEURI-SM. 317 an artery is increasing in size, the proper coats of the vessel grow thinner and thinner; but in proportion as an aneurism gets larger, the thickness of its sac is aug- mented.* When such cases are situated in the chest or abdomen, they cannot, of course, be distinguished from each other by the symptoms; but, fortunately, the means for palliating the two diseases, and retarding their sad consequences, are the same. The event of the two cases, however, may dif- fer very much; for, as Scarpa remarks, if the case be an in- ternal aneurism, some very slight hope may be indulged, that a radical cure will be effected by nature or art; which hope, however, can never be entertained in any instance of morbid dilatation. Experience proves, says he, that the spontaneous cure of an internal aneurism may happen, when- ever the impetus of the circulation is lessened, and the la- mellated coagula -completely fill up the aneurismal sac. When this is accomplished, nature finishes the rest of the cure, just as she does when the main artery of a limb is tied; with this difference, that in an internal aneurism, the co- agulum shuts up the burst side of the artery, without inter- cepting the course of the blood through the vessel; while, in an external aneurism, the coagulum plugs up the sac and tube of the artery both together. This fortunate combination of things cannot be hoped for in cases of dilatation, because however diminished the force of the circulation may be, coagulated blood is never deposited in a pouch, that con- sists of a preternatural expansion of the proper coats of an artery .f Whether aneurism begin with dilatation or not, in the end there is almost constantly a rupture or ulceration of all the coats of the artery. In most instances, the aneurism is formed by a destruction of the internal and middle coats of the vessel, and the expansion of the external coat into a sac, which at last giving way, the sheath of the artery and the surrounding parts form the boundary of the tumor. On the other hand, the sac which is formed by the dilatation of all the coats of an artery, as it advances in size, contracts firm adhesions to the parts which are in its immediate vi- cinity; so that when the dilated coats give way, the effu- sion of blood is restrained by these adhesions, or rather by the timely effects of new adhesive inflammation, and, as • Scarpa in Memoria sulla Legatura delle Principal! Arterie, &c. p. 93. f Scarpa, op. cit. p. 94—98. 318 ANEURISM. Mr. Hodgson observes, the sac then continues to be formed in the same manner as when an aneurism is in the first in- stance produced by destruction of the coats of the vessel. Sometimes, however, the sac bursts so suddenly, that the adhesive inflammation .has not time enough to circum- scribe the hemorrhage, and a diffused extravasation fol- lows.* A pulsating tumor, near a large artery, is always a suf- ficient reason for suspecting the disease to be aneurism; but, as other swellings, and even abscesses in the vicinity of an important artery, sometimes have a throbbing motion communicated to them by the neighbouring vessel, no po- sitive judgment should be formed, until other circumstan- ces of the case have been duly considered. I once saw a large abscess, at the side of the lumbar vertebrae, in a blue- coat boy, where the tumor pulsated with as much force as any aneurism which I have ever examined. An abscess, that occurred in a case of fractured sternum, had as regu- lar a contraction and dilatation as the heart itself or the aorta could be supposed to have. Upon pressure, the tu- mor receded; upon a removal of the pressure it immedi- ately resumed its former size. At length it burst; dis- charged a considerable quantity of matter; and the patient recovered.f In a case of glandular tumor, situated over the carotid artery, Sir A. Cooper readily distinguished the nature of the disease by the line of pulsation, caused by the artery, as the lateral parts of the swelling had no pulsation. He observes, that, when a tumor lies over an artery, and derives pulsation from it, the case may be discriminated from aneurism by raising the swelling from the vessel, by which means the tumor is deprived of its pulsation. In a doubtful case of aneurism in the groin, Mr. Brodie found all ambiguity cease on applying the stethoscope.i. In or- der to discriminate certain pulsating tumors from aneu- risms, writers direct us to recollect, that, in the first cases, the alternate rise and fall of the swelling amount to a real change of situation; while in an aneurism the motion pro- ceeds from an alternate dilatation and contraction of the tumor at every point of it.§v I confess, however, that the recollection of this fact has not seemed to me to facilitate * See Hodgson on Diseases of Arteries, p. 71. f Warner's Cases in Surgery, 8vo. Lond. 1784, edit. 4. p. 155 t Lectures, &c. vol. ii. p. 46. § Diet, des Sciences Med. t. ii. p. 91. A5EUR1SM. 319 the diagnosis in actual practice; for it is often equally dif- ficult to pronounce, whether what we see is a displacement of the swelling, or only an expansion of it. In cases of diffused false aneurism, the pulsation is ge- nerally indistinct, and often quite imperceptible. Warner relates an instructive example of this total absence of pul- sation. The case was a large diffused false aneurism. The thigh was enlarged to a very great size. The tumor was uniform, and extended from the inside of the knee to within a small space of the groin. The integuments were every where of their natural colour. The inside of the thigh was soft, and presented a kind of fluctuation ; but not the least pulsation could be distinguished, either here, or at any other point. The tumor, at its superior, poste- rior, and lateral parts, was of a stony hardness. It was judged advisable to make an incision into its most promi- nent part, when a stream of florid blood immediately gush- ed out, and evinced the true nature of the disease. As surgeons knew less then than now, how aneurisms ought to be treated, the limb of the patient was immediately amputat- ed. The diffused nature of this aneurism, and the large quantity of coagulated blood within it, which had acquired the texture and appearance of brown macerated leather, are circumstances fully accounting for the absence of pul- sation.* Pelletan tells us of a case, where an axillary aneurism, that had no pulsatory motion, was opened from an idea that it was a collection of matter ; but as the puncture was small, immediate death was prevented, by the appli- cation of sticking plaster.f I once saw a large popliteal aneurism, which extended a good way towards the front of the limb, had a very solid feel, and not the slightest pul- sation. The case was considered by many other surgeons, as well as myself, to be some kind of fleshy tumor, so in- volving the knee-joint as to admit of no other mode of ex- tirpation but amputation of the limb. Previously to the operation, however, an abscess lancet was deeply plunged into the tumor, without giving issue to any fluid.:): This was an instance, in which the absence of pulsation had been caused by the cavity of the aneurism being nearly filled with coagulated blood; and if we had not formed a * Warner's Cases in Surgery, p. 159; in which work are recorded ti a other instances of aneurism without pulsation. •j- Clinique Chirurgicale, t. ii. p. 84. t Luvivnee in Mcdico-Ch'.v. Trans. v;>!. viii. p. 497 320 ANEUHIsM. wrong judgment of the nature of the disease, but left the case to itself, the popliteal artery might soon have become impervious, and a spontaneous cure followed. A true aneurism, in an external situation, generally pre- sents itself in the form of a small pulsating tumor, which subsides under pressure, and immediately re-appears when the pressure is taken off It also subsides, or at least be- comes more flaccid, when the portion of the artery between it and the heart is compressed ; but immediately resumes its usual fulness and pulsation when such compression is discontinued. In other tumors, which derive a pulsatory motion from their lying over a large artery, pressure made on the vessel completely stops their alternate elevation and depression, but they remain as tense and prominent as ever, which is not the case with aneurism. True aneu- rism, in its commencement, is generally little painful; and the integuments are of their natural colour. The pulsa- tions are strong, especially while the tumor is small, and none of the coats of the vessel are yet ruptured, because, in this stage, the blood in the sac is all fluid, and no la- mellated coaguia are deposited upon its inner surface. The greater strength of the pulsation in true aneurisms also de- pends very much upon the ample and direct communica- tion between the sac and the direct channel of the blood. In a more advanced stage, as Sir Astley Cooper has ex- plained, the tumor is larger and more solid, and the sac cannot be completely emptied. A part of the blood in it has coagulated, and its parietes have become much thicken- ed. The size of the swelling, and its pressure on the sur- rounding parts, now create pain, and obstruct the circula- tion. The pulsation, however, though not so strong as at first, is yet distinct. In a still further advanced stage, the size and solidity of the aneurism are more increased; the pulsation is very indistinct, and only to be felt at that part of the tumor which is opposite to the orifice in the arterv. The sac is now almost filled with lamellated coaguia, and contains but a small quantity of fluid blood.* With respect to the diffused false aneurism, it generally presents but a feeble and indistinct degree of pulsation, and this only near the situation of the aperture in the ar- tery. In consequence also of the extensive injection of the cellular membrane, with blood, the case is at the same time attended with more discolouration, than any other \ * Sir A. Cooper's Lectures, vol. ii. p. 25. ANEURISM. 321 form of aneurism, unattended with inflammation. The history of the disease ; its cause ; its sudden formation, &c, also serve to throw light on the diagnosis. Nor is the diagnosis of what is named the secondary false aneurism difficult; for, when a case, which has been for some time attended with the symptoms of true aneu- rism, and restricted to a certain form, suddenly undergoes an alteration of shape, and an increase of size, either be- coming more protuberant at one or more points, or more extensively diffused, (in the latter case, with a material decrease or loss of pulsation,) we have great reason to suspect, that a secondarv false aneurism has been formed by the bursting of the original aneurismal sac. By the pressure of large aneurisms an absorption is caus- ed of all the surrounding textures, whether bone, cartilage, muscle, &c. It is curious, however, to remark with re- spect to the bones, that however they may suffer in this way in case of popliteal aneurism, their condition rarely gives any trouble after the aneurism itself has been cured. This kind of caries is also peculiar in never being accom- panied with suppuration : it is a simple absorption of bone. From the increasing size of an aneurism, it produces in time severe suffering by compressing large nerves, and even pushing them quite out of their natural situation. In internal aneurisms, in particular, a variety of evils may arise, as difficulty of deglutition from the pressure on the oesophagus; complaints of the urinary organs from pres- sure on the bladder; vomiting from pressure on the sto- mach; difficulty of respiration from pressure on the lungs, or diaphragm; or, suffocation from pressure on the trachea. Large external aneurisms also generally produce, besides great pain, a serious impediment to the passage of fluids through the lymphatics and veins of the limb, which some- times becomes enormously enlarged by an cedematous ef- fusion. When an external aneurism is about to burst, the event may be foreseen by a part of the tumor becoming particu- larly tense, raised into a conical prominence, something like the pointing of an abscess, and presenting a thin soft feel, and a dark purple colour. On the apex of this projecting part, the cuticle separates, and a small slough forms, which generally spreads till it is of about the size of a sixpence or shilling; and at length being loosened, or detached with the adjoining coagulum, is followed either by one copious and sudden gush of blood, that destroys life in a few in- Vol. I S s •rza ANEURISM. stants, as I saw happen in a case of subclavian aneurism, or by repeated hemorrhages, by which the patient is more gradually exhausted. I have seen two or three cases, in which this mode of rupture was exemplified, and its cor- rectness is confirmed by the corresponding reports of some of the best writers on aneurism.* According to Mr. Hodg- son, when an aneurism bursts into a cavity which is lined by a mucous membrane, like the oesophagus, intestines, bladder, &c. the breach is also produced in the same way; but when the sac projects into a cavity lined by a serous membrane, as the pleura, the peritoneum, and the pericar- dium, these membranes, after being rendered extremely thin, give way by laceration. With respect to the causes of aneurism,-there can be no doubt, that, with the exception of those cases which pro- ceed from wounds, the generality of instances are preced- ed either by a steatomatous thickening, with ulceration of the in.ernal coats of the artery, or by calcareous deposi- tion between the middle and internal coats, attended with loss of elasticity in the affected part of the vessel, and a disposition to crack or give way. The blood then comes into contact with the external elastic coat, which is raised into an aneurismal swelling. At length, more or less of this coat is removed by absorption, or bursts, and the blood then receives a covering from the arterial sheath. As the disease advances,it presses upon,and causes the absorption of all the surrounding parts, and is more or less diffused or circumscribed, according as it may happen or not to be confined or bounded by an entire cyst, formed by the ad- hesive inflammation, the remains of the original sac, or any ligamentous expansion. In works of the greatest accuracy, we find accounts of aneurisms which arose from violent efforts, forcible pres- sure on arteries, the reiterated bruising of parts, the force employed in reducing a dislocated humerus, the violence of falls, fractures, wounds,f &c. With the exception of cases, however, in which arteries are wounded with a sharp instrument, the point of a fracture, &c, together with other soft parts, aneurism seldom proceeds from external vio- lence, unless the coats of the vessel be already in an un- sound state. Mr. Hodgson never met with the laceration * Pelletan, Clinique Chir. t. ii. p. 91. Hodgson on Diseases of Arteries and Veins, p. 85. Sir A. Cooper's Lectures, vol. ii. p. 26. f See Pelletan's Clinique Chir. t. i. and n. ANEURISM. 323 of the coats of an artery which had not undergone some pre- vious morbid alteration, nor does he think it probable, that any exertion, which did not lacerate the surrounding parts, could be sufficient to rupture the coats of a healthy vessel. He also ascertained by repeated experiments, the inaccu- racy of Richerand's statement,* that the inner coats of the healthy popliteal arterv may be ruptured by violent exten- sions of the leg, since the laceration never happens, unless the extension be made in such a degree as to break the ligaments of the knec-joint.f As aneurism occurs more frequently in the large than the small arteries, it is evident, that the impetus of the blood must frequently have a considerable share in its ori- gin. True aneurisms, as Monro thought, take place as often in the aorta, particularly its arch, as in all the other arteries together. Aneurisms also frequently occur in the ham, and wherever the arteries run unsurrounded by mus- cles, and are most exposed to external violence. Patients frequentlv have several aneurisms at the same time. I have seen patients, who either had more aneurisms than one at the same time, or who had had other aneuris- mal tumors before those which I had the opportunity of observing. Sir A. Cooper has seen seven in one person.!. But, the most remarkable example of a multiplicity of aneurisms is mentioned by Pelletan, who counted in one subject sixty-three, from the size of a filbert, to half that ©fa hen's egg.§ The experiments of Mr. John Hunter, and Sir E. Home, decidedly prove, that a mere local weakness of a part of an artery, otherwise healthy, will not occasion the formation of aneurism. Even dissecting off the outer coats of an artery will not cause it.|j Nor is the sudden laceration of the internal and middle eoats of a sound artery ever the cause of -aneurism : this fact is completely proved by the experiments of Dr. Jones, as well as by what happens in the practice of surgery, where small ligatures are now so commonly employed, and sometimes have even been taken off intmediately after be- ing applied, so as to leave the cut part of the internal coats exposed to the impetus of the circulating blood. This point, I think, is well deserving attention, because the op- * Nosographie Chir. t. iv. p. 78. f Hodgson, P- 64- , I .ectures, vol. ii. p. 37. 4 Clinique Chir. torn. ii. p. 1 1 Se.- Trans, of a Societv for Med. and Chir. Knowledge, wl. i. p. 114. 324 ANEURISM. ponents of Dr. Jones's doctrines have laid some stress on the danger either of aneurismal dilatations, or the too speedy ulceration of the artery, from the effect of a small ligature in dividing the inner coat of the vessel. As when the ligature is left on the artery, a coagulum forms within it, and fluid blood no longer comes into contact with the solution of continuity, some surgeons may be inclined to impute the prevention of the dilatation of the external coat to this occurrence; but the thing cannot be entirely owing to such cause, because we find, that when the liga- ture is taken off immediately after its application, and the current of blood is allowed to proceed as it did previous- ly, no aneurism is the consequence. We must, therefore, conclude, that the formation of aneurism, except where all the coats of an artery are pierced, or cut, must generally be preceded by a morbid change in them ; a fact, fully con- firmed by what is disclosed to us in dissection. DIFFERENT PROCESSES BY WHICH ANEURISMS ARE CURED. Although it is the common course of aneurisms, when they are left to themselves, to increase in size, and at length to burst and destroy the patients by hemorrhage, sometimes things happen otherwise, and, in consequence of certain changes taking place, a spontaneous cure is the result. There are four modes, in which this desirable event may be produced. 1. Sometimes the whole aneu- rismal swelling suddenly inflames and sphacelates: in this state, if the inflammation extend its effects to a sufficient depth, the sac in the vicinity of the artery, and a portion of the canal of this vessel itself, may become complete- Iv blocked up with coagulating lymph, so that no more blood can get into the tumor, the pulsation of which is suppressed. In cases of this description, the mortified parts, together with the mass of congealed and sometimes putrid blood in the sac, are cast off, and if the patient's constitution hold out, the ulcer, left by the detachment of the sloughs, heals up, and the cure is completed. When, however, the inflammation and sloughing are confined to the skin and superficial portion of the sac, the patient bleeds to death on the separation of the dead part. 2. The se- cond process, by which the spontaneous cure of an aneu- rism may be produced, is the increase of the lamellated coaguia in such a degree within the aneurismal sac, as completely to fill it, in which case the blood also coagu- ANEURISM. 325 fates in the adjoining portion of the artery, which becomes impervious for a certain extent above and below the com- munication which it had with the vessel. Similar changes happen when the cure is accomplished by pressure. 3. Scarpa and all the best modern surgical writers, until late- ly, supposed, that no aneurism could be cured, unless the sac and an adjoining part of the artery were thus obliterat- ed : the facts, however, collected by Mr. Hodgson,* leave no doubt, that when an aneurism of the aorta undergoes a cure, the sac alone may be filled up with coaguia, while the vessel itself remains pervious. 4. The last manner, in which spontaneous cure may be brought about, is by the pressure of the aneurismal sac itself upon the artery. In one instance on record, this fortunate pressure of the sac followed four days after the change of a popliteal aneurism from a circumscribed to a diffused state.f As it is from the increase of coagulated blood within the tumor, that the patient, generally speaking, has the best chance of a spontaneous cure, it must of course always be a desideratum to prevent the sac from becoming very large, which would lessen the probability of its cavity be- coming entirely filled up with lamellated coaguia. Some- times, however, even when the tumor is of vast size, cer- tain changes happen, by which the mouth of the sac is blocked up, the swelling loses its pulsation, and a cure en- sues. But the best plan is always to resist as much as pos- sible the increase of the tumor; and since its enlargement and ultimate rupture are caused by the force of the circu- lation, one grand principle, whenever we aim at promoting a spontaneous cure, must necessarily consist in lessening the impetus of the circulation. TREATMENT OF ANEURISMS. In aneurisms of the aorta, debilitating remedies, absti- nence, a milk diet, occasional bleedings, the exhibition of digitalis, and the avoidance of all exertion, have been the means commonly recommended, rather with an expecta- tion of retarding the disease, than of effecting a cure. The facts, however, which modern experience has adduced in favour of the efficacy of a treatment first proposed by Val- salva, are certainly such as to justify a confident belief, * Treatise on the Diseases of Arteries, &c. p. 117. c! seq. ^ Sir A. Cooper's Lectures vol. ii. p. 47 V 326 ANEURISM. that many internal aneurisms, even though large and much advanced, are capable of palliation, reduction, and cure. The cases, published by Pelletan, furnish the most con- vincing evidence, that vast aneurisms of the aorta, so large as to project through the absorbed part of the ribs and sternum, may sometimes be reduced and cured by Valsal- va's method. Together with repeated bleeding, strict quietude, and a very spare diet, Valsalva recommended ice, or compresses wet with a cold lotion of vinegar and water, to be applied to the swelling. By such treatment, Pelletan effected the cure of a subclavian aneurism.* In aneurisms of the aorta, bleeding so as to induce fainting, is extremely dangerous :f the blood, therefore, should be taken away slowly, and in little quantities at a time. The principle, on which external aneurisms are usually cured, consists in preventing the entrance of fresh blood into the aneurismal sac; for when this is accomplished,the blood, already contained in the sac, is gradually absorbed, the sac itself contracts, the whole tumor diminishes, and by degrees, the power of using the limb is restored. The stoppage of the influx of blood into the sac, may sometimes be fulfilled by the skilful application of pressure, particu- larly while the aneurism is small, and its contents can be made to recede. But, although it may be generally proper to try pressure in the early stage of the disease, it cannot be said that the practice is attended with considerable suc- cess. I should suppose, indeed, that it does not answer in more than one case out of thirty; and a certain propor- tion of the successful instances on record are, no doubt, rather examples of a spontaneous cure. On the whole, I am of opinion, that there is no inducement to make a long trial of pressure in any case of aneurism, and that wheiv the disease is already large, and increasing with rapidity, it is better njot to waste time upon the experiment. There can be little doubt, however, that pressure would more fre- quently cure the disease, if it could be made to operate ef- fectually upon a given point of the artery, before this ves- sel reaches the aneurismal sac. The plan has many times been attempted, and ingenious compressing instruments devised; butyunfortunately, the large nerve, which usually accompanies every artery of importance, must also be com- pressed, and the agony which the patient experiences is so • See Clinique Chirurgicale, par P. J. Pelletan, torn. i. Mem. sur le? Aneurismes Internes. Paris, 1810. ] Hodgson, p. 151. ANEURISM. 327 great as to compel the surgeon to relinquish the project. Another common cause of failure proceeds from the arte- ry not admitting of being efficiently compressed against a firm surface underneath it: consequently, the circulation through the vessel still goes on, and the adhesive inflam- mation of its inner coat is not excited. Another plan of applying pressure consists in bandaging, with as much equality as possible, the whole limb inclusive of the swell- ing. Such is the method to which Genga,* Thedent, and Scarpa:}:, give the preference. Here it seems as if the aim were rather to lessen the impetus of the circulation in the member generally, and promote the coagulation of the blood in the sac, than at once to stop the main flow of this fluid into the cavity of the aneurism; as is done either when the artery is compressed, or tied, above the aneurismal swell*- ing. Whenever pressure is tried, the experiment should be conjoined with a low regimen, venesection, the exhibi- tion of digitalis, and the application of ice, or cold lotions, to the tumor. In this branch of surgery, however, it is high- ly necessary never to be unmindful of the dangerous con- sequences of immoderate and long-continued pressure; a subject on which I have offered several cautions in the chapter on mortification. POPLITEAL ANEURISM. The surgical methods of cure are only two, viz. com- pression, and the ligature.* As Scarpa has observed, com- pression is not a mode in which much confidence can be » Anatomia Chirurgica, p. 219. ■j- Bemerk. und Krfahrung, 1. Th. Berl. 1778. * Treatise on the Anatomy, Pathology, &c. of Aneurism, transl. by Wish- art, p. 204. 231. 337, &c. * fin the paper to which we alluded at page 139, by Dr. Jameson, of Bal- timore, there is a detail of a number of experiments which he performed on inferior animals. Having laid bare a vessel of large size, a common suture needle was passed through the artery, armed with a tapering ligature, the largest end of which was about three lines in width, and its thickness that of pretty thick buckskin. It was cautiously drawn through nearly to the largest end; both ends were then cut oft" about three lines from the vessel. No blood escaped. The wound was then dressed, and in the course of a few weeks the animal killed. On dissection, it was found that the ligature was reduced to a pulpy state, (sufficient time not having been allowed for its absorption;) the coats of the artery were thickened, and its caliber so nearly obliterated, that little, if any, circulation remained. We have repeated these experiments (alone, and in conjunction with Mr. II. S. Levert, an intelligent student of medicine from Alabama,) on the oa- 32b ANEURISM. placed, except when the rupture of the artery is owing rather to an external cause, than to disease and ulceration of the arterial coats; when the two opposite parietes of the lacerated artery in the ham admit of being pressed against the inferior and posterior surface of the thigh-bone; and when the degree of pressure, which can be employed, is sufficient to excite deeply in the proper coats of the popli- teal artery the adhesive inflammation, by which the artery is finally converted into an impervious ligamentous sub- stance. The combination of these three circumstances is a rare occurrence. For, if we suppose what is seldom the case, that the coats of the artery have not been too much diseased, previously to their giving way, to admit of in- flaming and adhering together, there are yet many other difficulties, which prevent the surgeon from applying to the artery that exact and steady degree of pressure, rotid and the aorta of sheep, and in every instance where the experiment was properly performed, we have found a similar result. But, it may be asked, what benefit is likely to accrue to surgery in cases of aneurism, by passing a seionof buckskin through the affected artery, instead of tying it, even if it be found to answer in the human body? We would refer to the regular gradations of improvement which have taken place in the treatment of aneurism. The bold operation of Sir Astley Cooper, of passing a ligature around the aorta will hardly warrant a repetition—here, nearly the whole column of blood which is destined for the supply of the lower extremities, it suddenly cut off—nature is not afforded sufficient time to make an effort to restore the circulation—can we suppose that the anastomoses of the epi- gastric with the internal mammary, the inferior with the superior mesente- ric; the lumbar, the circumflexa illii, and a few minor branches, when sud- denly called upon could convey a column of blood which required the com- bined efforts of the aorta, the primitive, and the external and the internal iliacs. We are not unmindful of the remark make by the celebrated Scarpa, that "the whole body may be regarded as an anastomosis of vessels, a vas- cular circle." Morbid anatomy has pointed out a path, and we confidently believe flie day is not far distant, when abdominal aneurism will be nearly as tractable in the hands of the skilful and scientific surgeon, as those of the humeral or femoral arteries. Several cases have recently been recorded, where the aorta has been found obliterated. In these cases, the closure of the vessel was the result of disease, and it must have been effected slowly and gradual- ly,- nature was enabled to accommodate herself to the changes which were taking place; the anastomosing branches were permitted gradually to en- large, whilst the caliber of the aorta continued to diminish, until it was finally closed. Present us a mean by which this operation of nature can be imitated—by which we can gradually obliterate the aorta, and thus al- low time for the enlargement of the anastomosing branches, and the difficul- ties which present themselves will disappear. A hope may be held out from the facts which have been developed by Dr. Jameson, and their further in- vestigation is certainly a subject worthy the attention of the profession.— P. E.} ANEURISM. 329 which is requisite for the complete and radical cure of the aneurism in the ham. The compressing force on the aneu- rismal sac must press down and remove from the artery the concentric coagulated lavers of blood, so that the pres- sure may fall precisely on that portion of the vessel im- mediately above its rupture. This, says Scarpa, cannot take place except in a case of very recent popliteal aneu- rism, of small size, where the coagulated blood can be made to descend below the place which we wish to compress. Besides this, it is necessary that the compression should not injure the great sciatic nerve, especially its large tibial branch. This is very difficult to avoid, because the nerve runs on the back of the aneurismal sac, and is superficially situated, immediately below the integuments and aponeu- rosis of the ham. Strong pressure on the nerve, also, ren- ders this mode of cure insupportable. Nor can the plan answer, if the breach in the artery be too high up where the femoral artery passes through the tendon of the triceps, or too low down, under the heads of the great muscles of the calf of the leg, where the vessel divides into tibial arte- ries. In both these situations, pressure cannot be made to operate effectually in holding the parietes of the artery at the necessary point in close contact. Were the pressure powerful enough to force the artery against the posterior surface of the tibia, when the rent in the artery is low down, the obstruction of the inferior articular and tibial arteries, and gangrene of the leg, would be the inevitable consequences. Such considerations induced Scarpa to lay down the fol- lowing practical rules : compression is not advisable when the popliteal aneurism is spontaneous, or not depending upon a wound, or violent stretching of the artery; when the aneurism is of long standing, and of large size; when it occasions acute pain and sympathetic fever; when it produces considerable swelling of the leg and foot, with a diminution of their heat; and when the sac is situated too high or too low in the ham. On the contrary, a trial of compression is proper, when the popliteal aneurism is ve- ry small, recent, and produced by a violent stretching of the artery ; when it is indolent, soft, and yields to the pres- sure of the hand; when it is situated exactly in the middle of the cavity of the ham; and when it is not accompanied by swelling, or numbness of the leg and foot. But, how- ever favourable circumstances may seem to a trial of pres- Voi.. T. Tt • 330 ANKUEI^M. sure, if it be found to excite severe pain, or swelling and torpor of the leg, it should be immediately given up.* The operation for the popliteal aneurism consists in sup- pressing, by means of the ligature, the course of the blood through the popliteal artery, so that the current of blood, which passed by this artery, is conveyed to the leg and foot by the different channels of the lateral anastomosing vessels. The effect, in respect to the primary indication which the surgeon proposes to accomplish, is the same, says Scarpa, whether the artery be tied in the ham, a little above the breach in the vessel; whether the ligature be ap- plied on the inner side of the thigh, or in the middle or at the top of the thigh; that is to say, we intercept the flow of blood through the popliteal artery into the aneurismal sac; and successively obtain the obliteration and conver- sion of the diseased artery into an impervious ligament- ous cord.f We are indebted to Mr. John Hunterf: for the greatest improvement ever made in the mode of operating for aneurism, and, more especially, the popliteal aneurism. He saw that much of the ill success of the old method arose from the severe practice of laying open the swelling, and tying the artery in the ham; a situation where it was least likely to admit of the adhesive inflammation, by which the vessel was to be obliterated. He was led, therefore, to try the infinitely better plan of taking up the femoral arte- ry above the middle of the thigh, or at some distance from the point where the vessel perforates the tendon of the tri- ceps muscle, and of then leaving the tumor to be lessened by absorption, instead of laying it open. In short, the operation, as practised by the best modern surgeons, con- sists in making an incision about two inches and a half in length through the skin and fascia of the thigh, precisely over the course of the artery in its descent within the in- ner edge of the sartorius muscle. Scarpa recomuKiuls us, however, to make the incision in the upper third o' ine thigh, or a little higher than the situation which Mr. Hun- ter selected, and his reasons for this alteration appear ju- dicious. First, we thus avoid the necessity of removing the sartorius from its position, or of turning it back, for the purpose of getting at the artery. I have frequently • Scarpa, transl. by Wishart, p. 227—231. f Op. cit. p. 235. * See Trans, of a Society for the Improvement of Med. and Chir. Know- ledge, vol. i. art. 9. • ANEURISM. JJ1 seen the best operators, even professed anatomists, embar- rassed by the sartorius being immediately in their way, when they had cut through the integuments and fascia. Secondly, the artery is more superficial a little higher up, than in the place usually chosen. And, thirdly, as being further from the disease, it is more likely to be sound, and in an advantageous state for the effects of the ligature. It is a point of considerable importance in operations for aneurism to avoid all contusion, disturbance, and unne- cessary handling of the part of the artery which we are about to tie; for thus we lessen the chance of the vessel inflaming too violently, and ulcerating, so as to give rise to secondary hemorrhage, which is the chief danger to which the patient is exposed. The organization of the blood-vessels being similar to that of other soft parts, they must be subject, like these other structures, to inflamma- tion, ulceration, and sloughing. They are themselves vas- cular, and derive their nourishment from vessels (the vasa vasorum) transmitted to them from the parts which are immediately around them. Hence the advantage of sepa- rating the part of the artery which we are about to tie, as little as possible from its surrounding connexions. In other words, the ligature should always be applied round an artery, as near as possible to the place in which the vessel lies amongst its natural attachments. P'or many valuable observations in support of this principle, now universally approved, the profession are indebted to Mr. Abernethy.* In particular, we should keep this principle constantly in view in our next proceedings. We have divided the skin and fascia, and can feel the artery beating under our fingers. The next object is to divide the cellular mem- brane, till we can see the sheath of the vessel. We are now not to separate the artery to such an extent from the surrounding parts, as will allow us to put our finger under it, a practice which is a serious infringement of the prin- ciple above recommended, and on no account necessary, but we should cautiously make a slight puncture or scratch on each side of the undisturbed, undisplaced artery, and then pass a ligature with an eye-probe, or aneurism-needle, under the vessel, observing not to include the femoral vein, and accompanying branches of the anterior crural nerve. The ligature is next to be firmly tied, one end of •.Surgical Works, vol. > 332 ANEURISM- the ligature being afterwards cut off close to the knot, and the other left hanging out of the wound, the edges of which are to be immediately brought together with adhesive plaster. If the operator prefer, however, to tie the artery with a ligature composed of fine dentist's silk, he may then cut off both ends of it, close to the knot, and endeavour to heal the wound by the first intention. This method I have seen followed'bv Mr. Lawrence; and, in another case, in which Mr. Carwardine, of Thaxted, operated, and the practice was tried, the whole wound healed by the first intention, not a particle of pus was formed, and the cicatrix continu- ed sound.* There have been several variations made in the opera- tion by different surgeons. Thus Scarpa still prefers avoid- ing to use the ligature in such manner as to divide the in- ner coats of the vessel, and, in order to prevent this effect, imitates Pare, Heister, and Platner, by interposing between the artery and the ligature a small cylinder of waxed linen. His advice on this point, however, has produced few or no converts to it in this country, where the principles esta- blished by Dr. Jones universally prevail. Since the prac- tice of tying arteries with small ligatures came into vogue, and surgeons have taken care not to separate the artery too much from its natural connexions, and not to irritate it with the presence of any extraneous substances, in ad- dition to a single small ligature, the frequency of seconda- ry hemorrhage has been surprisingly lessened, and opera- tions fcr aneurism attended with the most brilliant success. In the chapter on hemorrhage, I have adverted to some of the arguments which Scarpa has employed in defence of his precept, that, in tying the artery, we should avoid ap- plying the ligature so as to cut through the inner coats of the vessel, and, therefore, should interpose between it and the noose a roll of linen. In the appendix to his great work on aneurism, he has also introduced an account of some experiments made by Professor Mislei, with a view of ascertaining whether ulceration of an artery is produced more quickly by the noose of a small ligature, or by the noose of a somewhat larger one, with the interposition of a roll of linen between it and the vessel. The tenor of these investigations is to prove, that the simple noose of a fine ligature produces ulceration of the external coat too * Med. Chir. Tcans. vol. viii. p. 492, ANEURISM. 333 rapidly, and creates a danger of secondary hemorrhage. Mislei details a case, in which he first tied the carotid of an old emaciated diseased mare, with a single ligature : but four-and-twenty hours afterwards hemorrhage took place. He exposed the artery therefore without delay, and appli- ed a simple circular ligature above the aperture in the ves- sel, and below it a ligature with the interposition of a cy- linder of linen. Thirty-nine hours afterwards, the simple circular noose was removed, and at the end of eighty-seven hours, the other ligature, with the roll of linen, was gently taken away. Twelve days after the removal of the first, the animal perished of hemorrhage from the superior angle of the wound.* This case is considered by Mislei as a complete proof of the superiority of the method of inter- posing a cylinder of linen between the artery and the liga- ture. When we carefully read over the particulars, how- ever, we see that the animal, which was the subject of experiment, was in a very unfavourable state for the in- vestigation, being very aged and diseased, with the artery in an ossified condition, highly unpropitious to the access of the requisite healthy kind of adhesive inflammation for the obliteration of the vessel in the situation of the liga- ture. There was also a good deal of handling, disturbance, and irritation of the vessel, in the different proceedings which were adopted; a cause quite adequate to account for the secondary hemorrhage. I do not, however, attempt to explain why the bleeding happened to come from the part of the artery which had been tied with a simple circular ligature, and not from the other part, which was tied by the interposition of a roll of linen. One part might have been more exposed and irritated, and more detached, than the other, from its natural connexions. At all events, no positive conclusion is to be drawn from one experiment^ and that too neither performed on the artery of a human subject, nor on the sound artery of a healthy animal. On the continent, one or more ligatures of reserve are sometimes put loosely round the artery, above the first ligature with which the vessel is tied. These ligatures of reserve are meant to be tightened, in the event of secondary hemorrhage. But, when it is considered how much the arte- ry must be detached from its surrounding connexions by any supernumerary ligatures, and how likely these extraneous • See Scarpa's Memoria sulla Legatura delle Principali Arterie degli Arti, con una Appendice all' Opera sull' Aneurisma, p. 75. Pavia, 1817. '334 ANEURISM. bodies are themselves to cause irritation of the wound, ul- ceration of the artery, and secondary hemorrhage, the dan- ger of this practice is a very good reason for its rejection. Not one judicious surgeon in this country now remains an advocate for ligatures of reserve. (Etius, Celsus,* Tenon, and others, mention the plan of tying the artery with two ligatures, and cutting through the intervening portion of the vessel; a practice, which was revived about the same period by Mr. Abernethy, and Professor Maunoir, of Geneva. The former thought this method would leave the artery, as nearly as possible, in the same state in which it is on the surface of a stump; and that secondary hemorrhage from the femoral artery would then not be more frequent after an operation for a popliteal aneurism, than after amputation.f But, as Mr, Hodgson observes, an artery tied in two places, and divid- ed in the interspace, cannot be regarded as placed exactly in the same condition as an artery tied in amputation. In the latter case, the retraction of the vessel corresponds with that of the surrounding parts, which are divided at the same instant, and, therefore, its relative connexions stand as before the operation. But, in the operation for aneurism, the retraction of the artery takes place without being attended with a corresponding retraction of its con- nexions. How far the retraction of the artery is beneficial or injurious, is by no means evident; and if it be supposed useful on the principle of hindering any tension of the ar- tery, this fancied good may be obtained by simply laying the limb in a bent position.^: If, then, this method has no particular recommendation, its present decline cannot but be right on the principle of lessening the quantity of ex- traneous substance in the wound. In fact, few good ope- rators now prefer two ligatures to one. The only circum- stance, in which this practice is decidedly advantageous, is where the artery has been too extensively separated from its natural connexions; for then one ligature may be ap- plied at the upper end of such detached portion of the ves- sel, and the other at the lower; so that they will both lie closely to the points at which the artery begins to be sur- rounded by its natural connexions again. Having already declared myself to be no admirer of the * Lib. v. cap. 26. f See Abernethy's Surgical Works, vol. i. p. 227, &c. i On Diseases of Arteries, p. 222. ANEURISM. 33;; practice of compressing the artery between a cylinder of linen and the ligature, I can entertain no favourable opi- nions of any other analogous modes of operating, as exe- cuted with the presse-artere of Deschamps, the serre-noeud of Desault, or the instrument proposed by Mr. Crampton. Nor do I hesitate to deliver the same judgment, respect- ing the plans of compressing the artery between two me- tallic surfaces, as we see exemplified in the use of the pin- cers of Baron Percy, and Assalini's compressor, repre- sented by Fig. 3. Plate 1. In the chapter on hemorrhage I have noticed the expec- tations which were once raised by the interesting experi- ments of Dr. Jones, that, if a smallish ligature were tight- ly applied round an artery, the cord might be immediately afterwards removed, and still the tube of the artery be- come impervious. Had this hope been realized by later investigations, the surgeon would then have had no extra- neous substance in the wound, which would have had a better chance of healing by the first intention, while the risk of secondary hemorrhage from ulceration of the ves- sel, induced by the ligature, would have been entirely re- moved; but, unfortunately, the momentary application of a ligature is not found to be always, or even generally, fol- lowed by an obliteration of the tied part of the vessel. Mr. Travers* conceived, that if the ligature were appli- ed a certain time, and then removed, it might simplify the practice employed by surgeons for obliterating the largev arteries ; but, further observation has led him to renounce the plan. Sir A. Cooper in one case tied the femoral ar- tery very firmly, and loosened the ligature after thirty hours; but, in half a minute, the aneurism began to pul- sate as strongly as ever again. The ligature was, there- fore, tightened for forty-two hours longer, and the pulsa- tion did not return. Thirteen days afterwards, hemorrhage occurred ; but it was stopped by the tourniquet, and a cure followed. In a case of radial aneurism, this method failed in hindering the return of pulsation when the ligature wa- loosened at the end of twenty-four hours, and the common operation was judged advisable.f Scarpa, however, con- tinues an advocate for the removal of the ligature, as soon as the closure of the arterv is sufficiently advanced to ob- viate all chance of its becoming pervious again, and it is • See Med. Chir. 1'rans. vol. iv. p. 435, &c.; also vol. vi. p. 632—^ 1\ fct ■*- I tctuiv-i, vol. ii. p. 5^ 336 ANEURISM. strong enough to resist the impetus of the blood. He re- presents this period to be on the third or fourth day after the operation, when he recommends us to remove the li- gature altogether, and not wait for its spontaneous detach- ment, as its longer continuance, he conceives, is of no further use, and may sometimes cause ulceration at the principal point of adhesion between the sides of the arte- ry.* Although I fully agree, that a sufficiently firm clo- sure of the vessel must generally have taken place long before the time when a ligature is spontaneously detached, yet, I apprehend, that if the momentary application of the cord will not suffice, we shall never derive any solid ad- vantage from not awaiting its natural separation. If the ligature could be taken away directly after its first appli- cation, then we should be able to close the wound, and attempt to heal it by the first intention, and this with in- creased chances of success, inasmuch as the case would not be complicated with the presence of any extraneous substance. But, unless the thing can be done in the first instance, we must, in order to be enabled to cut off the ligature, lose all the advantage of the chance of union by the first intention.f In attempting to remove the ligature, there must also be some danger of tearing the recent ad- hesion, and thus producing hemorrhage. When the weather is very cold, or the temperature of the limb sinks after the operation, flannel should be appli- ed. Pressure on the heel is to be prevented, as it is apt to produce a gangrenous spot on it; and perfect rest is to be observed, both while the ligature remains, and for three or four days after its separation, so that the wound may have the best chance of healing by the first intention, and all risk of the newlv-closed artery bursting may be avoid- ed.} OF FEMORAL ANEURISMS SITUATED HIGH UP THE LIMB. Not many years ago, cases of this description were deemed incurable by any surgical operation, and, perhaps, until the present time, the same opinion might have pre- * See Memoria sulla Legatura delle Principal'! Arterie, &c. p. 51, &c. Sic. Pavia, 1817. f See Quarterly Journal of Foreign Medicine and Surgery, vol. i. p. 29 Lond. 1818. t See Sir A. Cooper's Lectures, vol. ii. p. 58, 59. ANEURISM. 337 vailed, had not Mr. Abernethy* exemplified the possibili- ty, not only of successfully tying the femoral artery above the giving off of the profunda, but even the external iliac artery itself higher than Poupart's ligament, and, as it were, within the abdomen. When we hear from a register of cases, in which this bold and judicious proceeding has been adopted, that out of twenty-two, fifteen were cured,f we must dispel all fear about the limb being left without other adequate channels for the continuance of the circulation. Indeed, the numerous instances, in which the external iliac artery has now been tied, fully warrant the conclusion, that the limb is not in more danger of mortifying after the liga- ture of this vessel, than after that of the femoral artery be- low the profunda; and the several opportunities, which I have had of seeing the external iliac tied, have left not a doubt in my own mind, that the success of the operation would have been still greater, had it been done in some cases at an earlier period, before the tumor had become very large, and the health materially impaired by long confinement. No doctrine, I think, is more pernicious than that, which inculcates delay for the unnecessary ob- ject of giving the anastomoses time to enlarge; for these are always ready to do their office, if they be not prevent- ed by the effects of the distention and pressure of an enor- mous tumor. The truth of these remarks, was strikingly displayed in the ever-memorable case of inguinal aneu- rism, in which the human aorta was tied: for, notwith- standing the ligature of this vessel above its bifurcation, the blood found its way with ease into the limb, which was not on the same side of the body as the disease; but, on this side, the same desirable circumstances seem to have been impeded by the obstruction produced by the pressure and effects of the tumor.} In order to take up the external iliac artery, the integuments are to be divided in the direction which this vessel naturally takes in its de- scent to pass out of the pelvis. In an adult, the incision of the integuments is to begin half an inch below the supe- rior spinous process of the ilium, and an inch and a half from the same process towards the linea alba. From the point here specified, the wound is to be caried down nearly as low as the femoral arch, but not lower, in order to avoid * Surgical Works, vol. i. p. 227, &c. f Hodgson on the Diseases of Arteries, 8cc. p. 417. t Surgical Essays, by A. Cooper and 11. Travers, p. 114, &c Vol. I. Uti 336 ANEURISM. injuring the spermatic cord and epigastric artery. The apo- neurosis of the external oblique muscle, at the bottom of the wound, is to be divided to the same extent. The point of the finger is then to be introduced into the lower angle of the incision, and, under its guidance, the layers of the in- ternal oblique and transverse muscles are to be cautiously divided, particular care being taken not to hurt the subja- cent peritoneum, which serious accident may be avoided by pressing this membrane a little back with the finger, where it first makes its appearance under the divided apo- neurosis of the transverse muscle. The finger will now be in immediate contact with the external iliac artery in the vicinity of the lower angle of the wound, and a little above the origin of the epigastric, at the exact point at which the former vessel rises from the side of the pelvis, to pass over the horizontal ramus of the os pubis,* where it makes another turn to descend under the femoral arch to get to the bend of the thigh. At that point, after the vein has been separated from the artery by means of the end of a director, a single ligature is to be passed with an eye-probe, or aneurism needle, under the artery, and firmly tied. It is observed, that the situation of the latter vessel over the vein, at the point above described, is a circum- stance materially facilitating the application of the liga- ture.f In general, however, surgeons tie the external iliac artery rather higher than the point here specified, and the vein then lies on the inner side of it.} ANEURISM AT THE BEND OF THE ARM. In operating on aneurisms of the brachial artery, former surgeons always deemed it necessary to tie the vessel both above and below the swelling. They thought that one liga- ture, above it, would not be sufficient, by reason of the * Haller, Fasc. Anat. Arterise Pelvis, Tab. 1, 2. z. b., and Scarpa in Me- moria sulla Legatura delle Principali Arterie, &c. p. 116. ■j- Scarpa, p. 117. i \The operation of tying the common iliac artery for the cure of aneu- rism, has been first successfully performed in this country. In 1812, Dr. Gibson, the distinguished Professor of Surgery in the University of Penn- sylvania, first demonstrated the practicability of this operation in a case of wound of the vessel. An account of Dr. G.'s operation is published in the third volume of the Am. Med. Recorder, in which he suggests its applica- tion to the cure of aneurism. In 1827, Professor Mott, of New-York, first performed it with that view, and was completely successful. Dr. M.'s case is published in the Am. Journal of the Med. Sciences, No. 1.—P. E. £ ANEURISM. 339 freedom with which the blood would get into the sac, through the inosculations between the collateral and re- current arteries. Scarpa has explained, however, that one ligature, above the tumor, is quite enough. An incision is to be made along the inner edge of the biceps muscle, the sheath of the artery opened, and the vessel, after being separated from the median nerve, and two accompanying veins, tied with due firmness. When aneurism of the brachial artery is diffused, and attended with violent pain and inflammation, Scarpa* pre- fers the old operation of opening the tumor, taking out the coagulated blood, and tying the artery with two ligatures, one above, the other below, the opening of the vessel. The same practice is said to be necessary when the aneurism h very large.f AXILLARY ANEURISMS. The sufficiency of the anastomosing vessels for the trans- mission of the blood, when a large arterial trunk is tied, appears now to have been exemplified in every situation, where the performance of such an operation is at all prac- ticable. Not only may the external iliac artery be tied, without the circulation in the lower extremity being cut off, the subclavian artery may also be secured at the point where it first emerges from the chest, and yet the arm re- ceive an adequate supply of blood.} In several operations, where the artery was tied through an incision below the clavicle, a large portion of the great pectoral muscle was divided; indeed in the case of a wound where it is necessary to apply a ligature both above and below the aperture in the vessel, such proceeding must sometimes be indispensable for the purpose of ascertaining the exact point of injury. But, in an aneurism not extend- ing too far inward, the following less severe method is practicable, though more difficult of execution. An incision two inches and a half long is to be made through the integuments, a little below the clavicle, and * Anatomy, Pathology, and Surgical Treatment of Aneurism, transl. by Wishart, p. 356. | Sir A. Cooper's Lectures, vol. ii. p. 80. i fTlie practicability of passing a ligature even around the arteria innomi- nata, with every probability of success, has, we conceive, been amply de- monstrated by the operations, first of the distinguished Professor Mott, of New-York, and subsequently, of Graefe, of Berlin.—P. K } 340 ANEURISM. immediately over the hollow between the deltoid and pec- toral muscles. The axillary vein here lies in front of the artery, and as a wound of it would probably be fatal, the utmost caution must be observed in the dissection. Care must also be taken not to mistake one of the cervical nerves for the artery. With an eye-probe, a ligature is to be put under the vessel, as soon as it is distinctly ascertained to be such, and the vein and any adjacent nerve should be care- fully excluded. Scarpa describes the method of operating below the cla- vicle as follows : the patient being seated with the shoulder somewhat depressed, an assistant standing behind is to hold him firmly in this position. The operator is to com- mence the incision in the integuments an inch from the sternal extremity of the clavicle, and to extend it along the lower edge of this bone tpwards the acromion, as far as the hollow between the pectoral and deltoid muscles. To the same extent he is then to detach the pectoral muscle from the clavicle, and reflect it a little, when the pectoralis minor will be found presenting itself, which, proceeding from the coracoid process, will be seen intersecting the lower, or external angle of the wound. The surgeon is now to insinuate the end of his finger between the point of the coracoid process, and the lower edge of the clavicle, where he will feel the exposed subclavian artery, surrounded b\ a part of the brachial plexus of nerves, and the subclavian vein in front of it. The arterv having been separated from these parts, is next to be tied.* When the aneurismal tumor extends far inwards towards the sternum, the only place where the subclavian artery can be taken up, is just where it emerges from the chest, from behind the anterior scalenus muscle, and the object must be effected by cutting above the clavicle.} On a dead subject, having no large aneurismal swelling, such an * Memoria sulla Legatura delle Principali Arterie, &c. p. 126. Pavia, 1817. A similar method of finding the subclavian artery was also described in Mr. C Bell's Operative Surgery, vol. ii. p. 370. edit. 1. f {It will be recollected that tlie subclavian artery gives off all its princi- pal branches, viz. the vertebral, internal mammary, inferior thyroid, &.c. be- fore it passes under the scalenus anticus muscles, that is, on the tracheal side—so that a ligature placed around the vessel before these branches are given off, might render the success of the operation doubtful, as the anas- tomoses are so complete. In cases, therefore, where the aneurismal tumor extends so far as to prevent the possibility of passing a ligature around the artery on the humeral side of the scalenus, in order to obviate the difficul- ties, and prevent the dangers attendant on the operation of the ligature oi« ANEURISM. 311 operation is much easier than on a living person, whose clavicle is sometimes pushed up by a vast tumor, so as to render the distance, between the artery and the wound in the skin, considerable.* However, in some cases, no diffi- culty of this kind was experienced; a fact, perhaps, to be imputed, either to the particular position and figure of the tumor; a natural difference in the distance between the cla- vicle and first rib in different individuals; and some vari- ation made in the size and height of the wound, and parts cut, by different operators.} The common plan consists in making an incision about two inches and a half, or three inches in length, along the upper edge of the clavicle, be- ginning it a little above the clavicular portion of the sterno- cleido-mastoideus. The fibres of the platysma myoides are next to be carefully divided to the same extent, when several veins will generally present themselves,and, if they cannot be pushed aside, and should bleed much on being divided, ought to be tied at once, so that the blood may not obscure the rest of the requisite proceedings. The cervical fascia having been cautiously divided, the knife is to be laid aside; the cellular membrane and glands of the neck separated with the finger, or end of a director, and the eminence felt for at the junction of the bone with the car- tilaginous part of the first rib, the point, where the vessel will be found coming out from behind the anterior scale- nus muscle. The ligature is then to be conveyed under the tracheal side, Dupuytren of Paris, has proposed dividing the fibres of the scalenus anticus down to the artery, and there tying it. We do not know if this suggestion has been acted upon, but we consider it highly im- portant. We can hardly conceive that it would be possible to pass a ligature around the left subclavian artery before it passes under the scalenus muscle, without wounding the thoracic duct—at all events, the course of the duct should be borne in mind.—V. E.j * See Note Q. ■j- In the first attempt which I saw made to take up the subclavian artery, it was very deep, and the surgeon tied one of the cervical nerves instead of it. In the next case which fell under my observation, the operation took up nearly an hour, on account of the difficulty of getting the ligature round the artery. Dr. Post, of New-York, whose case is the first instance of recovery after the operation of tying the artery by cutting above the clavicle, found it necessary to use an instrument calculated to facilitate the conveyance of the ligature round the vessel. See Med. Chir. Trans, vol. ix. p. 188. In one case, Sir A. Cooper was even prevented by this difficulty from com- pleting the operation. See Lond. Med. Review, vol. ii. p. 300. On the other hand, Mr. T. Blizard, and some other surgeons in their particular ex- amples, had no difficulty hi applying the ligature with a common aneurism needle. Ileiljson, Op. cit. p. 598. 342 ANEURISM. it with the aid of one of the needles hereafter described. Care must be taken not to mistake one of the cervical nerves for the artery, the pulsation of which communicates a cor- responding motion to any of these nerves in its vicinity. Most of them, however, lie rather behind it, and more to- wards the shoulder. This operation has now been done with complete suc- cess by Dr. Post, of New York, Mr. Liston, of Edinburgh, Dupuytren, and several other surgeons. The judgment that I formed from the observation of the first instance, in which this operation was ever finished, was, that, in all probability, a complete cure would have taken place, had the attempt been made earlier, before the tumor began to slough, and before the health was materially impaired; and had the operation itself been shortened and facilitated by the assistance of the needles represented in Mr. Ramsden's publication. These instruments undoubtedly resemble, in principle, Desault's spring aneurism needle, which consisted of a silver sheath, one end of which was straight, and the other curved in a semi-circular way. This sheath enclosed an elastic wire, one end of which projected a little beyond the bent end of the sheath, and had a transverse eye in it, for the reception of the ligature. The instrument being in- troduced under the artery, the sheath was kept fixed, while the elastic wire was pushed through it, till the transverse eye had ascended sufficiently to let the surgeon take hold of the ligature. This being disengaged from the instru- ment, the latter was withdrawn.* The needle, invented by Mr. Watts, appears to me rather an improvement on Desault's, inasmuch as it is made to let loose the eye and ligature together, as soon as they are conveyed far enough round the artery; a contrivance which overcomes the dif- ficulty of extricating the ligature. See Fig. 4, Plate l.f The most ingenious contrivance, however, for passing a ligature under a deeply-seated artery, where the wound is narrow, is the needle made by Mr. Weiss, at the sugges- * See OZuvres Chirurgicales de Desault par Bichat, torn. ii. p. 560, 561. ■j- {After the ligature has been passed around the artery, much difficulty is sometimes experienced, in consequence of the depth of the wound, to close the knot completely, without disturbing the vessel frpm its connexions. A very ingenious instrument, which by holding the first knot firm, will en- able the surgeon to tie a second with facility, has been invented by Dr. Alexander Hosack, of New-York, and is here represented, reduced one ANEURISM. 343 tion of Mr. Kirby, of Dublin. The following is a repre- sentation of it, reduced to one half of its proper size.* f half. Fig. 1, is a perspective view of the complete instrument. Fig. 2, is the lower extremity, (attached by a screw) showing two grooves, into which each end of the ligature is placed, and then pressed upon.—P. E.} * It consists of three parts; the porte-aiguille, the disengaging forceps, and the needle. The needle, fig. 3, is short, flat, and elastic, with a wide eye, a, and a thick point, b, that also has an eye in it to be laid hold of with the forceps. The porte-aiguille, 1, is hollow from c to e for the reception of the needle, and has a slit in it from e to d, so that the extremity a of the needle, when it is in the case, is in the middle of the slit e d, and the eye can be threaded. Another essential part of the porte-aiguille is the trans- verse fulcrum at/, on which the notch g turns. The length of the forceps, 2, must be exactly such, that when the notch is on the fulcrum, the spring at the end, h, is correctly applied to the point b of the needle in its case. When the instrument is to be prepared for use, the end of the needle, marked a, is to be put into the hole, marked c, at the end of the porte- aiguille, and pushed quite home. One end of the ligature is then to be put through the slit at d, from the outside of the needle, and the same end again from the inside through the eye of the needle, and the slit at e. The needle thus threaded, is to be introduced under the artery; and now the disengag- ing forceps, marked 2, is to be placed with its notch g on the screw, when by pressing on the rough part of the handle of the forceps, marked i, the surgeon will make the point h catch hold of the eye b of the needle, to which the ligature is attached. Then, by taking hold of the part of the handle of the forceps, marked k, and pressing it downwards, he will draw out the spring, and the ligature with it. The best mode of clearing the liga- ture from the spring, is to cut the former away at both ends from the instru- ment. See Kdinb. Med. Journ. No. 76. ■j- {The aneurismal needle and forceps invented many years since by Prof. Physick, is generally employed in this country for this purpose. But the 344 ANEURISM. CAROTID ANEURISM. That the carotid artery might become gradually oblite- rated, without any dangerous effect on the brain, and that most ingenious, and decidedly the best contrivance for passing a ligature around a deep-seated artery, has recently been presented to the profession by Professor Gibson. "It consists of a silver cannula, fixed in a wooden handle, surrounded, (near the part-where the cannula joins the handle,) with a silver collar, through which a steel stilet, made of a narrow watch-spring, the length of the instrument, passes, and immediately afterwards enters an opening just below the collar, in order to traverse the whole cavity of the cannula and emerge at its point. The extremity of the stilet is covered with a flattened silver cap moderately blunt, whilst its other or upper extremity, passing upwards, from the collar above mentioned, lays parallel with the handle, arid has an eye near its end for holding a ligature. A small screw, for the purpose of fixing the stilet while the surgeon is in the act of passing the instrument beneath the artery, works through the silver collar, and may be used or not, as the surgeon pleases." The following cut represents the form of the instrument, reduced to one- half its proper size. It will be seen that there is a groove in the extremity of the handle, along which the ligature should be carried, and then twisted around the handle. An additional stilet, with a sharp point, intended for deep-seated arteries, which may be divided, as the internal pudic, &c. may accompany the instrument.— Fig. 1, is a perspective view of the cannula with its stilet. Fig. 2, a side view. 1. The handle. 2. Silver cannula. 3. The stilet, formed of watch- spring, having an eye at the upper end, through which is passed a ligature; the lower end having a silver head, which is made to fit accurately to the end of the cannula. A better view is afforded by the needle being pushed out some distance. 4. The screw to retain the stilet. In conversation lately with Dr. G , he stated that he conceived the screw might be dispensed with, as by having a groove in the handle as mentioned, the ligature will be suffi- cient to retain the stilet in its place. The great advantage of this instrument over those in common use, is, that "the ligature being held by the upper f ANEURISM 345 an aneurism of it might undergo a spontaneous cure, was long since proved by the case related by Petit.* But, be- sides this kind of obliteration by a process of nature, mo- dern experience has evinced, that the carotid artery may be tied with a ligature, and thus rendered suddenly im- pervious, without any pernicious consequences on the brain. Hebenstreit mentions a case, where the external carotid was wounded in the extirpation of a tumor; and the patient would quickly have fallen a victim to the he- morrhage, had not the surgeon instantly tied the trunk of the artery. The patient lived many yearsf afterwards. After the battle of Waterloo, I assisted my friend Mr. Collier in taking up the carotid, for the purpose of sup- pressing a violent hemorrhage from a wound made with u lance, and extending from the angle of the jaw into the mouth. This operation had the most successful result. Aneurism by anastomosis, situated in the orbit, antrum, and on other parts of the head, have been cured by the application of a ligature to the common carotid. The cases, recorded by Mr. Travers, Mr. Dalrymple, and Pro- fessor Pattison, of Baltimore, illustrating the success of this practice, are highly deserving of the notice of the pro- fession. In a few instances, the carotid has been tied, for the purpose of lessening the hemorrhage, during the re- moval of large complicated swellings from the neck and side of the head. The operation is performed by making an incision through the integuments of the neck, beginning just above the up- per part of the sternum, and ascending for two inches, or a little more, by the side of the inner edge of the sterno- cleido-mastoideus. A wound of this length will be quite long enough to expose the sterno-hyoideus and sterno- thyroideus muscles.£ The patient's chin being now turn- ed towards the diseased side, in order to relax the sterno- instead of the lower end of the stilet, the surgeon can draw the stilet along with the ligature, at once, through the cannula and under the vessel—where- as, in other instruments, the ligature being passed through the lower end of the stilet, must, after having been carried below the artery, be in part re- tracted again before the surgeon can tie it" A description of this instrument accompanie.s an account of a case in which Prof. G. experienced consider* ble difficulty in passing a ligature around the subclavian artery, with the in- strument in common use, and published in the Am. Journ. of the Med. St.. ences, No. III. 1828.—P. E.} " Acad. H. des Sciences de Paris, an. 1765. | See his trans, of B. Bell's Surgery, vol v i Scarpa, sull' Aneurism tav. 5 9R. Vol.. I. X x old ANEURISM. cleido-mastoideus, while the sterno-hyoideus, and sterno- thyroideus are gently pressed towards the trachea, the large internal jugular vein presents itself. This vessel, on account of its magnitude, and its alternate expansion and subsidence with each inspiration and expiration, might sometimes retard the operation, were it not pushed to- wards the outside of the neck. Immediately under the in- ternal jugular vein, the common carotid appears. The operator is then cautiously to make a small opening, about a quarter of an inch long, in the sheath of the cellular mem- brane, which includes the artery. He now separates this vessel from the par vagum, and introduces a ligature un- der it with an eye-probe, or aneurism-needle. Sometimes two ligatures have been used, and the vessel divided be- tween them ; but, I believe, little doubt is now entertained about the preference, which should be given to the employ- ment of only one, excepting for a wound of the carotid, where two would be indispensable, or where a long por- tion of the vessel has been detached from its natural con- nexions.* •—»>»«©»«..— CHAPTER XXX. FRACTURES.! Fractures are of two principal kinds, namely simple and compound. A simple fracture is unattended with any * The cure of a carotid aneurism, by tying the artery above the swelling, when the ligature could not be applied below it, has been accomplished by Mr. Wardrop. See Med. Chir. Trans, vol. xiii. f {There are some injuries of the bones in children, the results of externai violence, to which the attention of surgeons has been very slightly directed. The only regular account of them of which we have any knowledge, was published by Dr. J. R. Barton, of Philadelphia, in the American Medical Recorder, for January 1821. The first to which we shall allude, is a simple bending of the bones,—an injury which requires the same treatment as frac- tures, although unattended with their two most prominent symptoms, viz. crepitus and displacement of fragments. We subjoin the following from Dr. B.'s account of it. "There occasionally happens, perhaps more fre- quently than we are aware of, this intermediate kind of injury, between a simple contusion of the soft parts and a complete fracture of the bone. Not unfrequently young children are brought to us labouring under an injury of the fore-arm, which after a very superficial examination, or perhaps from the FRACTURE*. 347 external wound, caused by the protrusion of the end of the broken bone : a compound fracture is always accompanied with a wound of this description. unnatural shape of the arm alone, we pronounce to be a fracture, and treat the limb accordingly; but we do not invariably err upon this the safer side; on»the contrary, since we are unable to produce crepitus in some cases, or feel the asperities c f a fracture, we are apt to consider the bone to be unin- jured, and attribute this deformity to tumefaction from simple contusion of the soft parts. Applications therefore are made with a view of discussing this swelling; but we find, perhaps when our mistalce is irremediable, that this deformity depended upon an injury of the bone. If we examine such a case more attentively, and inquire minutely into the symptoms, we shall find the arm painful, and deformed by a curvature, and the child deprived of its use; yet there is no derangement of fragments, nor can any crepitus be perceived, though there is motion at the part. If the radius and ulna be held at their extremities, and an attempt made to bend it further, the curva- ture will be increased in proportion to the exertion used. If sufficient force be employed in the opposite direction, the deformity will disappear, and the limb will resume its natural shape; but an attempt to produce the prominence on the other side, by continuing the pressure, would subject the arm to fracture. If the limb be again liberated, the curvature will to a certain ex- tent return." "The symptoms then of pain and loss of power in a limb, its preternatural curve, which may be increased or diminished optionally, and the disposition in the bones u hen straightened to return to their flexed po- sition, unattended by crepitus, or that circumscribed piojt ction which a dis- placed fragment of bone would produce, are my reasons for considering the injury as a bending of the bones." This.kind of injury has been very slightly noticed by Boyer, Underwood, and others. There is another injury, detailed by Dr. B., to which the bones of chil- dren further advanced in age are liable—it is a partial or incomplete fracture of a single bone or both. "The subjects of these cases are generally under the age often years; and the causes which produce them are such as give rise to the common kind of fracture. The usual symptoms also of a broken bone occur, with the exception of crepitus and derangement of fragments. The patient is deprived of the use of the arm; it is painful and deformed; but in- stead of a curvature as in the preceding cases, there is an angle formed opposite the place of fracture. The projection of bone can be increased in one direction only, and attempts to remove it by straightening the limb, frequently produce a complete division of the bone into two portions, ac- companied by a noise which in some instances may be distinctly heard, after which the crepitation may immediately be felt as in any other common case of fracture. The pain, loss of power in the limb, and angular deformity, with motion just at the injured part, are my reasons for considering the bone fractured; and the impossibility of producing crepitus in the first instance, and the facility with which it may be effected after the case is reduced to the state of a simple complete fracture, which occasionally happens in at- tempts to straighten the limb, are sufficient reasons for supposing that the bone was not completely separated into two fragments originally. The symptoms are, indeed, so unequivocal as to leave no doubt, as to the nature of the case." "The mode of treatment in these cases is such as is adopted in common fractures; but it would be advisable to avoid if possible separat- ing the bones into two fragments; since in the former situation, there would be necessity for little more than lateral pressure, which if gradually increas- ed would in time remove all deformity. Notwithstanding, however, the greatest caution, the division is apt to become complete, and additional de- formity ensue from the hones losing what little support was left." ';!;• FRACTURES. A fracture is often named complicated, when the bone is broken in more places than one, or is joined with disloca- tion, the injury ol some considerable blood-vessel or nerve, a gun-shot wound, &c.; and when the bone is crushed, or broken into many small pieces, the fracture is termed comminuted. The expressions longitudinal, transverse, and oblique fractures, signifying their direction, with respect to the axis of the bone, are also frequent in the language of surgery. The long cylindrical bones are more frequently broken than the short, or flat ones ; a fact, explained by their shape, • their uses, their situation, and the many powerful muscles attached to them. It is generally stated in surgical books, that the muscles are always concerned in the production of fractures ; but this is far from being the case. We know, that they sometimes act with such force, that they break the patella, and even the humerus, without the co-opera- tion of any external violence whatsoever. We know, that when a person is falling, their effort to save him is often We have met with several cases of bending of the bones of the fore-arm in children, and were indebted to Dr. B. for a Knowledge of the nature of the injury. Plate 2, together w/ifh Dr. B.'s explanation, will be found to convey a cor- rect idea of these injuries. " Fig. 1.—Is intended to represent the arm of a boy near four years of age, who had fallen upon it from the fourth rail of a fence. The force was not so violent as to produce a fracture of the bones, but sufficiently so to derange \ he texture of them, and to occasion the deformity as delineated in the plate. " This case happened in the child of a labouring man by the name of Iianse, (residing at the corner of Vine and Juniper streets,) and afforded me an op- portunity of exhibiting it to one of my colleagues, Mr. B. H. Coates, and to Mr. De Graflenreidt,* students of medicine; and in the presence of them and others of placing a sheet of paper against the arm, and tracing accurate- ly an outline of it with a pencil, before the deformity was removed. From this again was carefully taken the outline in the present plate. "The several cases of this nature might have been drawn out individually, and inserted at length; but it was not deemed necessary, since it would be a mere repetition of the annexed described symptoms. "Fig. 2.—Is not intended to represent any particular case, but is introduc- ed merely to illustrate, by comparison with figure 1, the different kind of deformity: the first occurring where the hones of the arm have been bent; and the second where they are supposed to be partially divided by fracture. "Fig- 3.—Drawn from the bones of the fore-arm now in my possession, where the experiment was tried by applying considerable force to the limb after death. The radius is partially divided by fracture, and the ulna simply bent. " Fig. 4.—An os humeri subjected to the same experiment, also in my pos- session."—P. E.} » Now Drs. Coates and De Graffenreiit. Plate H. ?Op !!?%§ &<,. :i J',,,. / FRACTURES. 349 -urprisingly powerful, and may contribute, with the blow, or shock, to the production of the fracture. But, when a bone is broken by a direct blow, the muscles have no more share in causing the breach of continuity in the bone, than they ever have in occasioning a fracture of the cranium. In the advanced stages of cancer, particular constitutions, and old age, the bones are sometimes so brittle, that they are broken by very moderate degrees of external force, or even the ordinary exertion of the muscles, independent- ly of all violence. The symptoms of fractures are exceedingly diversi- fied, according to the bones which are broken; and, though many writers set down loss of motion in the injured limb, deformity, swelling, tension, pain, &c. as forming the ge- neral diagnosis, it is easily comprehensible by any one ac- quainted with the structure of the body, that numerous fractures cannot prevent the motion of the part, nor pro- duce any visible deformity. Thus, there may be a fracture, and yet, from the entangling -of the fragments, or from a sound bone serving as a support to the broken one, no distortion can be perceived. Many cases are recorded, in which the patients, under these circumstances, were even capable of walking about, for some time after the acci- dent.* Every surgeon also knows, that though at first there may be pain in the situation of a fracture, no swell- ing and tension, excepting what may happen to arise from extravasation of blood, can take place till inflammation has had time to produce them. More or less deformity, pain, swelling, and inability to move or use the limb, are also symptoms which may at- tend dislocations, and various diseases, so that they are never unequivocal proofs of the existence of a fracture. When, therefore, a limb is broken, and the event is not manifest from the distortion of the part, it is proper to trace with the finger the outlines of the suspected bone, and, wherever any unusual pain occurs, or any unnatural irregularity appears, to try whether a grating, or crepitus, can be felt, on endeavouring to make one end of the bone rub against the other. When the os humeri, or os femoris, is the subject of injury, a crepitus is generally felt almost as soon as the limb is touched, and in the case of a broken thigh, there is mostly a considerable shortening of the ex- tremity, caused by the action of such muscles as draw the ' See Gibson's Institutes, vol. i. p. 372, and Dorsey 's Elements, vol. i. p. 11'; 350 PRACTITRES. leg and knee towards the pelvis. But, when there are two bones, as in the leg and fore-arm, and only one is broken, the other continues to prevent the limb from being short- ened and thrown out of its natural shape, so that a crepitus can only be felt by a proper examination with the fingers. As I am aware, that considerable harm and great unneces- sary pain, have frequently been occasioned by the custom of feeling for a crepitus, and moving the limb about in all directions in order to produce it, let me observe, that the plan is only justifiable when the nature of the case cannot be sufficiently understood without it. A fracture is a case necessarily attended with considerable injury of the soft parts, and always followed by more or less inflammation, and its usual consequences, heat, tension, swelling, &c; all unnecessary rough handling of the part, therefore, must be, above all things, contrary to the principles of good surgery. The displacement, or derangement of a fractured bone, may be either angular, longitudinal, transverse, or in the direction of its circumference, and very frequently more or less in all these directions together. The causes of the displacement always depend, either upon the force by which the accident was produced, upon the action of mus- cles, upon the weight of the body, or that of the limb it- self* The muscles of a broken limb are often affected with spasms, which put the patient to great pain, and when the thigh-bone, humerus, or both bones of the leg or fore-arm are broken, sometimes occasion, during their violence, very considerable distortion of the member. The prognosis depends very much upon the injury done at the same time to the soft parts; the patient's age and constitution; the direction of the fracture; and the parti- cular bone broken. Oblique fractures of the long bones are more difficult to cure without deformity, than trans- verse ones. Compound, complicated, and comminuted fractures are the most dangerous. A fracture near, or affecting a large joint, frequently ends badly; but injuries of the patella, olecranon, and small joints, mostly have a favourable termination. A fracture of the* neck of the thigh-bone, within the capsular ligament, perhaps, does not admit of a perfect cure, a bony union never taking place. Fractures of the patella, olecranon, condyles of the os hu- * Gibson's Institutes, vol. i. p. 373. FRACTURES. 351 meri, and coronoid process of the ulna, also generally unite by means of a ligamentous substance.* The steps of nature, in the union of broken bones, are very similar to those which she pursues in the union of wounds of the soft parts. The vessels on the surfaces of the fracture, and those of the periosteum, and soft parts directly adjoining the injury of the bone, first effuse co- agulating lymph. This gradually becomes vascular, and as its vessels acquire the power of depositing earthy mat- ter, it is ultimately converted into new bone, termed cal- lus, which becomes the bond of union. In order that the first connecting substance may speedi- ly become organized, and adapted to the formation of callus, nothing is so favourable as perfect quietude. Hence, the chief surgical indication, after the ends of a fracture are replaced, is to keep them perfectly motionless : nature completes the rest. The accomplishment of a complete bony union, however, requires that each end of the frac- ture should be duly supplied with blood; and hence the reason may be understood why fractures of the neck of the thigh bone entirely within the capsular ligament, and some other cases, do not generally unite by bone. In the example here specified, the only channel for blood to the upper fragment, must be the small vessels of the ligamen- tum teres. The observations of Sir A. Coopert likewise tend to prove, that if the end of a fracture be kept much asunder, or with such an interspace as occurs when the protruded end of the tibia is sawn off, and the fibula is whole, no bony union follows. Different bones require different lengths of time to be firmly united; the ribs and clavicle unite as soon as any; in general the os brachii is tolerably firm in five weeks ; but, the bones of the leg and the os femoris seldom become perfectly strong in less than six. These calculations, however, refer to adults; for, in children, fractures are cured with much greater ex- pedition; and, it is always found, that the quickness of union in all persons, is in proportion to'the vascularity of the bone or bones concerned, the skill of the treatment, and the sound state of the constitution. The three principal indications in the treatment are, to reduce the ends of the bone if displaced, to retain them in this position, and to administer such diet and medicines ' see A. Cooper on Dislocations, &r. p. 11 ~., edii\ -1 - On '^locations, p. 116. .552 FRACTURES. as the future symptoms arid state of the patient may re- quire. In the language of surgery, the first indication is ac- complished by extension, counter-extension, relaxation of the muscles, and coaptation, or the adjustment of the frag- ments. The relaxation of such muscles, as have the power of displacing the ends of a fractured bone, always materially facilitates the reduction. The choice of an advantageous position, indeed, is the first thing in all cases, in which the extremities of the fracture are not in even contact. The muscles are the chief powers which cause the displace- ment, by drawing that end of the bone which is most moveable, out of its due position, in regard to that which is most fixed. Hence, in the extremities, the lower ends of fractures are those which are truly displaced, being drawn upward, or to one side, by the action of certain muscles, which have their origin and insertions both above and below the situation of the breach of continuity. The muscles, therefore, which displace the lower ends of such fractures, are the principal powers which must be counter- acted. In oblique fractures, it is much more difficult to keep the ends of the bones in a proper state of coaptation, because two oblique surfaces make no mechanical resist- ance to that effect, (viz. the retraction of the lower por- tion of the broken bone,) which the strong muscles have a continual tendency to produce. But the relaxation of muscles, possessing the greatest influence over a fracture, is not only to be observed while the surgeon is setting the broken bone; it is to be strictly adopted throughout the whole of the treatment, at least, until the two ends of the bone have become firmly united. Were this plan not rigorously followed, the fracture would soon be displaced again by muscular action. The principle, from which the utility of relaxing mus- cles in these cases arises, is the fact, that every muscle can only contract to a certain degree of shortness: and that in proportion as its origin and insertion are approximated, the disposition to spasmodic action diminishes. The reflecting student may inquire, what particular posi- tion will relax every muscle connected with, a broken bone ? The same position, which relaxes the flexors, seems to have quite an opposite effect on the extensors. The answer is, that no posture will completely relax every set of muscles in every instance; and in this circumstance, the joints must FRACTURES. 353 be placed in the middle state, between perfect flexion and perfect extension, as in this manner, though complete re- laxation is not effected, most of the muscles will not be in a state of tension. When, however, every muscle, havino- the power to displace a fracture, can be relaxed, the others, which have no power over the progress of the case, may be neglected, and the posture determined accordingly. Thus, in common fractures of the leg, where we cannot perfectly relax every muscle capable of disturbing the frac- ture, we place the knee-joint in the mid-state, between per- fect flexion and extension: but in a fracture of the patella, where we can relax every muscle capable of resisting the object of the surgeon, we regulate the posture, without any regard to other muscles, which have no influence over the fracture. In cases of broken thighs, where the impossibility of re- laxing every muscle that has the power of disturbing the fracture is strongly exemplified, it was the practice of Mr. Pott to select also a half-bent position of the hip and knee- joints, in which state he conceived that less trouble was experienced from the action of the muscles. It does not require, however, a powerful mass of muscular fibres to displace the fracture.. Hence, though the half-bent pos- ture may relax such muscles as have the greatest force, yet, if we leave a certain set of muscles unrelaxed, which, by their action, can draw the ends of the broken bone into a wrong position, I am afraid, posture alone is not the great object, to which every other consideration should be sa- crificed. I am also the more persuaded of the truth of this remark, from knowing, that no position, no approximation of the origin and insertion of a muscle, can altogether pre- vent those violent, involuntary spasms, which take place in cases of fractures. We must then turn our minds to the improvement of our mechanical means for holding the ends of the broken bone steadily and evenly together. In the case of a broken thigh, it is quite impossible to employ the bent position, as advised by Pott, which relaxes the most powerful and troublesome muscles, and, at the same time, use the best kinds of apparatus for keeping the ends of the fracture in a proper state of coaptation, and free from mo- tion. In this accident, the whole limb ought to be kept motionless by mechanical means; for, if the knee be left unconfined, and the leg subject to frequent motion, as is actually the case in Pott's mode of treatment, how are we to expect that the fracture can remain undisturbed andun- Vor. I Y y 354 FRACTURES: displaced? However, when position of the limb, and re- laxation of the most powerful muscles, can be made to con- cur with the best mechanical apparatus for securing the ends of a broken bone from being displaced, these are the principles by which we should be governed. Hence, in the case of a broken thigh, the position of the limb on the double-inclined plane, with the patient lying on his back, and his leg and foot properly fixed on the machine, is great- ly superior to Pott's method of treatment. The positions for particular fractures, will be noticed in the second part of this work. Having placed the ends of the fracture as evenly toge- ther as the case will allow, the next object is to keep them securely and quietly in this state, until they have become firmly united. In certain constitutions, almost all the muscles of the in- jured limb are continually acting in a violent, involuntary, and spasmodic manner, so that neither position, nor me- chanical means, are effectual in preventing displacement of the fracture. Patients, in this state, if young and ro- bust, should be bled, and be kept under the influence of opium. The mehanical contrivances, employed to give that de- gree of support to the limb, which the breach of continuity in the bone or bones has taken away, consist of instruments called splints, with which a kind of steady, unyielding case, is formed for the limb. Splints ought to be made of strong materials, and of a sufficient length to reach beyond the two joints nearest the fracture, and they ought to be adapted in shape to the contour of the limb. They are generally se- cured with straps or tapes. However, as the hardness of splints would give pain, if they were firmly applied to the limb, without the interven- tion of soft materials, it is customary to place a piece of the emplastrum saponis immediately over a simple fracture, and to apply, what is termed an eighteen-tailed bandage, between which latter and the splints are also interposed pads filled with tow, or any other soft substances. Addi- tional soft compresses are also generally put at every point where the pressure of the splints is likely to give pain. When there is much swelling, surgeons generally apply, for the first few days, cold water, with a little spirit of wine in it; the liquor ammon. acet., or the lotio liq. plumbi acetatis, instead of a plaster, and the linen, employed for this purpose, may be kept sufficiently wet, (without taking FRACTURES. 355 off the splints) by squeezing the water or lotion out of a sponge into the interspaces between them. All violent extension for the reduction of fractures, is quite abandoned by the moderns. In general, when the muscles are relaxed in a scientific manner, the ends of the bone may be put into a state of coaptation with the great- est ease, and very little extension and counter-extension is necessary. Many fractures, indeed, are not in the least displaced. Common fractures of the arm and fore-arm, in healthy subjects, are firmly united in about a month ; while those of the thigh and leg require about six or seven weeks. When the union does not take place, after a reasonable length of time, the surgeon should endeavour to ascertain the cause. This may sometimes be imputed, either to the ends of the fracture not being in apposition; to the part having been moved and disturbed too much ; to the advanc- ed age of the patient; or to a general languor, or some idiosyncrasy of the constitution. In the first and second of these cases, the bone should be set again, and kept quite motionless. When the patient is very old, the use of splints is to be continued longer than in other cases, and tonic medicines may be prescrib- ed. When several months elapse, without any union of the fracture, and there is reason to apprehend the formation of an artificial joint, surgical writers join Celsus in recom- mending the ends of the broken part to be firmly rubbed against each other, with the view of making them inflame and grow together. On the same principle, some surgeons have allowed their patients, with broken legs, or thighs, confined in splints, to get up and walk about. As soon as the necessary irritation is produced, the limb is to be kept motionless a sufficient length of time.* If such plans fail, it has been proposed to cut down to the broken part, and rasp or saw off the ends of the bone, and then treat the case, like a recent compound fracture. The latter operation was first devised, and practised with success, by Mr. C. White, of Manchester, in an example, in which the humerus could not be united by ordinary methods; and scraping the fracture was successfully per- formed by the same gentleman, for the cure of an old frac- ture of the tibia.f • SeejWhite's Cases in Surgerv, p. 75. t See Cases, pp. 69—79. • sob" FRACTURES. I hav e seen the operation of sawing off the ends ot v. fractured humerus practised without success, in St. Bar- tholomew's Hospital. After one operation of this kind, done in France, the patient died on the sixth day.* On the other hand, Mr. White's cases are highly favour- able to the practice. Mr. Rowlands, of Chester, and other surgeons, have likewise found the operation answer. The latter gentleman performed it on the thigh-bone, by cutting down to the fracture between the rectus and vas- tus externus muscles, and placing a strong plate of tin under the ends of the bone, when the saw was used. It was found necessary to make a transverse incision through a great part of the vastus, in order to facilitate the removal of the lower end of the fractured part; but, though Mr. Row- lands succeeded in his objects, the case was attended with such difficulties, that he expresses himself to be undecided concerning the propriety of advising the operation to be undertaken by others.f Dr. Physick's practice consists in making the ends of the bone inflame and suppurate by the introduction of a seton through the fracture, and then applying splints. He thus succeeded in consolidating a disunited humerus. This plan, which is considered milder and safer than turning out the ends of the fracture, and sawing them off, has been followed in London, with various degrees of success, by Mr. Brodie, Mr. C. Bell, Mr. Wardrop, &c4 * Iticherand's Nosographie Chir. t. hi. p. 39. edit. 2. | See Medico-Chir. Trans, vol. ii. p. 47. t {The method of treating artificial joint by means of pressure, as first suggested by a distinguished surgeon of London, Mr. Amesbury, has ac- quired many advocates. We select the following case from the London Med. and Phys. Journal, for July 1827, as illustrating the success of this practice in the hands of Mr.Brodie, after a failure of the seton. "J. M'Ewen, aet. twenty-four, broke his right arm and left leg, in November 1825. He was taken to a hospital and treated in the usual way. The fracture of the leg did well, but no union took place in the arm. In August 1826, he went to Panton Square, where Mr. Wardrop passed a seton, which was withdrawn at the end of a week. After a time the patient was discharged, and reported as cured in the Lancet. In Nov. 1826, he entered St. George's, the broken ends of the bone appearing to be united by ligament, riding one over the other, and admitting of extensive motion. Mr. Brodie now determined on applying pressure, on the principle suggested by Mr. Amesbury. The fore- arm being semi-bent, a wooden splint adapted to its figure, and reaching from the axilla to the fingers, was applied on the inside. On the outside of the arm, a straight splint was placed, extending from the shoulder to the outer condyle, and both splints were then secured by bandages. Over all there was a tourniquet, the band of which embraced the fracture, whilst the degree of pressure thus made on the broken bone was easily regulated by FRACTURES. 357 COMPOUND FRACTURES. A compound fracture is accompanied with a wound of the integuments, caused by a protrusion of the end of the broken bone. When the wound is large and lacerated, when the bone or bones are extensively splintered, or shattered, and when the neighbouring muscles are severely injured, the case must be considered as extremely dangerous. A limb, in this condition, submitted to the inspection of the discerning and scientific practitioner, presents to him one of those urgent cases, in which he sees at once the necessity for immediate amputation. The accident is an analogous injury to a bad gun-shot wound of the limb, with fracture, and the observations which have been made respecting the frequent danger of delaying the amputation of limbs, shattered by gun-shot violence, are in every respect applicable to these very bad compound fractures, occasion- ed by other causes. So great and considerable an injury, inflicted upon parts endued with life and sensibility, capable of inflammation, suppuration, and gangrene, cannot be expected to take place, without being followed by the most severe effects, both upon the limb itself and the constitution. Supposing, however, the bone to be less badly broken, and the soft parts not quite so much bruised, wounded, and torn, and no large artery lacerated, the case is then of a very differ- ent description; and resorting to amputation, without an endeavour to save the limb, would be rash and unjustifia- ble. Instead of this, the fracture is to be immediately the screw, which was on the outside of the arm. The splint on the inside being broader than the limb, and only slightly concave, the principal vessels vere defended from pressure, and whatever was the force employed, the circulation was but little interrupted. In six weeks, the motion of the frac- tured bones was much diminished, and at the end of three months none wa» perceptible. On the 31st May, the man left the hospital, the bones being firmly consolidated, and the arm as useful as before the accident." In the Am. Journal of the Med. Sciences, for August 1828, there is an inter- esting communication on the subject, from Dr. T. H. Wright, of Baltimore, .n which three successful cases, by this mode of procedure, are detailed. We have employed the apparatus of Mr. Amesbury, in three cases of un- united fracture of the tibia and fibula, with the most complete success__ anion of the bones having been effected in every instance in the space of six weeks. The practice of applying caustic to the extremities of the bones, has also been successful in the hands of several surgeons, but we consider that the method by means of properly regulated pressure, is decidedly supe- rior to this, the seton, or excision, and should always be preferred.—P. E. J 358 FRACTURES*. placed as nearly in its natural situation as circumstances will allow, and the wounded integuments brought nicely into contact by means of adhesive plaster, in order that the chances of union by the first intention may be taken. Under favourable circumstances of constitution, and pro- per antiphlogistic treatment, the subsequent local inflam- mation will not be too extensive and high, to prevent the much desired object of a quick and complete closure of the external wound by adhesion, and when this is the case, the sympathetic fever is always moderate in proportion. In all cases of compound fractures, in which an attempt is to be made to save the limb, the primary object to be aimed at, is to lessen the danger of the accident, by con- verting the injury, as speedily as possible, from the state of a compound into that of a simple fracture, by uniting the wound of the integuments. Sometimes the plan suc- ceeds, and a very important step is gained. In some in- stances, only a partial union follows; while, in others, where the contusion and laceration of the soft parts are more severe, the attempt fails altogether. When the local violence is followed by higher inflam- mation, when the wound does not unite by the first inten- tion, and suppuration is the consequence, a considerable degree of sympathetic fever generally follows, and great powers of constitution are necessary to bear all the irrita- tion consequent to the injury, and the long and copious discharge. Sometimes, in this state, the constitution, im- paired and weakened by the local disease, is attacked by hectic symptoms; fresh irritation occurs about the frac- ture ; large suppurations take place under the fascia, and require to be opened; and the patient is at length brought to the lowest condition of weakness, from which nothing can extricate him, but the removal of the limb, the result of which operation is also uncertain. At other times, the patient's constitution holding out, the suppuration is soon accompanied with the formation of granulations, and cica- trization follows. Let us consider a third case, in which the violence done to the limb has been more severe, so as to be followed by a speedy mortification of the whole extremity, and death of the patient. Here, perhaps, had the limb been sacrific- ed, and amputation performed immediately after the re- ceipt of the accident, the patient's life might have been preserved. But, as soon as the rapid symptoms of gan- grene have made their appearance, amputation is general- r r.ACTUI.L;. 2,oB ly too iatc ; and though it may be a question, whether we ought not in some of these cases yet to amputate, on the principles explained in the chapter on mortification, the inferior chance of recovery, which the patient now has, is proved by manifold experience. Hence, the absolute ne- cessity of determining primd facie the propriety or impro- priety of attempting to preserve a limb with a compound fracture. In cases of compound fractures, there are two points of time when the surgeon has it best in his power to decide, whether it is most advisable to try to preserve the limb, or to sacrifice it for the sake of the patient's life. The one is immediately after the occurrence of the acci- dent, and before an inflammatory and gangrenous tenden- cy in the limb has had time to form. The other is after the subsidence of the first inflammatory symptoms, conse- quent to the injury, when the constitution seems incapable of bearing any longer the great irritation and immense dis- charge from the wound, and when hectic fever is more likely to close the patient's existence, if a further perse- verance in an attempt to save the limb be made, than that the object in view should be accomplished. The treatment of a compound is similar to that of a simple fracture, only a more rigorous attention to quie- tude, diet, and the administration of proper medicines, is necessary. The posture of the limb must generally be regulated by the same considerations as in the case of a simple fracture; the fracture, if displaced, must be re- duced as speedily as possible; the limb must be laid upon a splint, long enough to hinder all motions of the two nearest joints, and having upon it a pad of tow or other oft materials, and an eighteen-tailed bandage. The wound must then be gently closed, so as to give it an opportunity t)f uniting by the first intention. When the wound sup- purates, such dressings must be used as circumstances re- quire, care being taken, that, at each application of them, the fracture be disturbed as little as possible. Exfoliations arc common in these cases, and attention will be required to the extrication of every piece of bone as soon as it is loose. Though in the early stage of compound fractures one might generally be induced to have recourse to phleboto- my, as one of the best means for preventing inflammation, it is found in London to be ultimately prejudicial, weak- ling the constitution too much, and incapacitating the pa- ticnt to bear the long and copious discharge of matter 360 FRACTURE!:. which often ensues. It is also a commonly received opi- nion, that compound fractures go on so much better in the country than in this large metropolis, and patients bear so much better the rigorous employment of antiphlogistic measures, that it is right to attempt the preservation of numerous limbs out of town, which in London would re- quire amputation. In all bad fractures of the lower extremity, it is a mat- ter of great importance to place the patient upon a bed constructed on the principles of that invented by Mr. Earle, by which means any posture of the whole body or limb, deemed advantageous, may be conveniently main- tained, and, what is of equal consequence, the bowels emp- tied, without the least disturbance of the fracture. -—•»»©©©«"— CHAPTER XXXI. DISLOCATIONS. When the head, or articular surface of a bone is thrown out of its proper place, with respect to the corresponding articular cavity, or surface of another bone, in or upon which it is naturally situated, the accident is termed a dis- location, or luxation. Dislocations are divided, like fractures, into two princi- pal kinds; viz. simple and compound: simple, when there is no external wound penetrating the capsular ligament, and communicating with the cavity of the joint; com- pound, when the injury is attended with a wound of this description. Dislocations have also been divided into an- cient and recent; complete and incomplete; primitive and consecutive.* Such joints as admit of extensive and various motions, are generally the most liable to dislocations ; for instance, the shoulder, which is dislocated more frequently than any other joint. In those of the ginglymoid kind, which * {Another species has recently been described by Dupuytren of Paris, which, as it occurs at birth, he calls congenital. It will be found more par- ticularly described, in a note under the head of dislocation of the thigh.— P. E.} DISLOCATIONS. 361 move only in two directions, luxations happen much less frequently, and for the most part, are incomplete ; that is to say, the articular surfaces, though displaced, are not wholly separated, owing to their great breadth, their mu- tually corresponding eminences and depressions, and the number and strength of the ligaments by which they are bound together. If we put out of consideration partial dislocations of the astragalus from the os naviculare, we scarcely ever meet with incomplete luxations, except in ginglymoid joints, like the ankle, the knee, and the elbow. Thus, a case is related by Sir Astley Cooper, in which the end of the tibia rested in part upon the astragalus, but a larger portion of it on the os naviculare.* The distinctions primitive and consecutive, much adopt- ed by Desault, are highly necessary in considering the na- ture of dislocations; for, the practitioner should under- stand well, that after the head of a bone has slipped out of the articular cavity, its situation may be materially al- tered by the action of the muscles. When it remains in the place into which it was originally forced, the luxation is called primitive; consecutive when it has been drawn by the muscles out of the situation, into which it was first thrown. The diagnostic marks of dislocations chiefly consist of circumstances, arising from the functions of the affected joint being interrupted; and the lodgment of the head of the bone in an unnatural situation, and among parts which it compresses and renders painful. Hence, there is a di- minution or loss of motion in the joint; the limb or part is either shortened, lengthened, or distorted to one side, according to the kind of dislocation; its axis is changed; the shape of the joint is altered; the natural prominences of bone either disappear or become less conspicuous, as the trochanter at the hip; or the reverse may occur, as in dislocations of the shoulder, where the acromion projects more than usual.f In many cases, the head of the bone may be plainly felt in its new situation, and the nature of the accident readily detected by rotating the limb, as the head of the bone then also rotates.:): The pressure of the head of the bone on the surrounding parts causes great pain, which is immensely increased when the surgeon * On Dislocations, &c. p. 17. ed. 4. f Surgical Essays, part i. p. 4. 8vo. London, 1818 $ See Sir A. Cooper on Dislocations, p. 5. ed. 4. Vol. L Z z 36^ DISLOCATION'S. moves the limb in order to examine the case, extreme agony, and an obstinate and even incurable paralysis be- ing induced, when a large nerve is thus compressed and injured. Nay, the pressure of the head of a dislocated bone upon important organs may endanger life; and Sir A. Cooper has recorded one instance, where such danger arose from the pressure of the sternal end of the clavicle upon the oesophagus. In thin subjects, before inflamma- tion and swelling have had time to come on, the head of the dislocated bone may sometimes be distinctly felt, form- ing a preternatural tumor or projection, while, in the situ- ation of the articular cavity, there is an unusual depres- sion, or want of fulness. A considerable degree of mobi- lity sometimes continues for a short time. A man dislo- cated the head of the thigh-bone upon the obturator fora- men ; the thigh could at first be moved about with free- dom; but, in less than three hours, the head of the bone became firmly fixed it its new situation by the contraction of the muscles.* A good deal of swelling generally follows a dislocation, and this sometimes very quickly, especially, when the vio- lence has been considerable, and blood is extravasated. However, in simple dislocations, which have been reduced, the ensuing inflammation rarely ends in suppuration; though two fatal instances of it, after the reduction of a dislocated hip, are mentioned by Sir A. Cooper. Dislocations may be accompanied with fracture: in those of the ankle, the fibula is mostly broken; at the hip, the acetabulum may be fractured; and in the elbow, the coronoid process of the ulna sometimes suffers. Luxations are mostly produced by external violence, by which such ligaments are torn as naturally keep the dislo- cated heads of the bones from being thrown into the par- ticular directions in which, in the various cases, they are found to be situated. Even tendons, in the vicinity of the joints, are frequently lacerated. According to Sir A. Coo- per, the capsular ligament is torn to a great extent trans- versely ; in the hip, the ligamentum teres is ruptured; but, in the shoulder, he never found the tendon of the biceps broken. He describes the tendons which cover the liga- ments, as being also torn, particularly the tendon of the subscapularis muscle, when the head of the humerus is thrown into the axilla. Some of the muscles are much * Op. cit. p. 3. 1U5.L0CATI0N5. %s shortened, while others are upon the stretch, as is the case with the psoas and iliacus internus in dislocations of the thigh-bone downwards. A considerable laceration of muscles now and then occurs, as of the pectineus and ad- ductor brevis, in the latter kind of luxation.* In the ginglymoid articulations, external violence alone commonly produces luxations, which are frequently in- complete. But, in the orbicular joints, the action of the muscles has a share in occasioning the accident, which i-» almost always complete. A dislocation of the lower jaw is caused entirely by the action of the muscles, and rarely by mechanical force. The predisposing causes of dislocations are either natu- ral, or accidental. The natural are; the joint admitting of great latitude of motion; the small extent of surfaces, by which the bones touch each other; the laxityf and small number of the ligaments uniting them; the shallowness of the articular cavity, &c. The accidental predisposing caus- es are, paralysis of such muscles as tend to strengthen the joint; a looseness of the ligaments from disease ; and the circumstance of the bone having been dislocated on one or more previous occasions ; a state, that has a remarkable ef- fect in facilitating the displacement in luxations of the shoulder, patella, lower jaw, and thumb. Boyer mentions a case, where the deltoid muscle being paralytic, the mere weight of the arm dislocated the humerus from the sca- pula ; and the same writer adverts to a woman, who could not yawn even moderately, without her jaw being luxated, in consequence of a looseness of the ligaments.:): If mus- cles are kept extended for a long time, and their tone is destroyed, or if from a paralytic affection, they lose their action, the bone to which they are attached may be easily dislocated, and as easily replaced.§ Dislocations are less frequent in very young and elderly persons, than in those of middle age; because, in old subjects, the ends of the bones are so softened, that the force applied often breaks them; and, in children, the bones more commonly break, * A. Cooper in Surgical Essays, pp. 5 and 6; also on Dislocations, &c. p. 7, ed. 4. + A young girl brought up to tumbling, who went to consult Sir A. Coo- per, used to have the patella laid flat upon the side of the external condyle of the femur, by the action of the rectus muscle, in consequence of the lax state of the ligaments. t See Boyer's Lectures on the Bones, by Richerand, transl by Farrcll,No! ii. pp. 38, 39. § A. Cooper's Surgical Essays, p. 10 ^64 DISLOCATION. or the epiphyses give way.* I have attended, however, several cases of dislocation in young children ; and an in- stance last year (1825) in one of Dr. Good's grand-daugh- ters, whose ulna was dislocated backward at the elbow. though she could not be more than six years of age. In luxations, the degree of danger is very much altered by the case being simple or compound. Simple disloca- tions, when recent, may commonly be reduced with facili- ty, and cannot generally be reckoned dangerous. On the other hand, compound dislocations of large joints, like compound fractures, .are frequently attended with consi- derable danger; and the same nicety of judgment is requi- site in determining whether amputation ought to be imme- diately performed, or an effort made to preserve the limb, as in these latter cases. Hence, most of the remarks, de- livered on this point with respect to compound fractures, are here quite applicable. The degree of violence and laceration done to the soft parts, the great or little chance of healing the wound by the first intention, the patient's state of health, and his youth or advanced age, are circum- stances, by which the judgment should be guided in this difficult part of surgery. In the country, it is said, many cases recover, which in large cities would require ampu- tation. Dislocations of orbicular, are reckoned less dangerous, than those of ginglymoid joints. In the former, the action of the muscles has a great share in producing the accijJent, and the soft parts are generally less injured. But, even in joints of the same kind, the extent of the evil is mea- sured by the largeness of the articular surfaces, and the number and strength of the muscles and ligaments. Hence, luxations of the elbow and wrist are generally less hazar- dous than those of the knee and ankle, the production of which requires the operation of greater violence. Though luxations of orbicular joints are generally not so dangerous as those of ginglymoid articulations, they are more difficult to reduce, because the muscles, resisting the aim of the surgeon, are more numerous and powerful. The indications, in the treatment of dislocations, are, to reduce the displaced articular surfaces as speedily as pos- sible, and to support the joint with bandages, or splints, until the lacerated ligaments, tendons, &c. have had an opportunity of uniting: proper means being taken to sub- "■ See A. Cooper, on Dislocations, p. 19. DISLOCATIONS. 365 due inflammation, and to prevent as much as possible the incurable stiffness that would arise from an exclusive re* gard to the second indication. In some joints, the form of the bone may produce an impediment to the reduction: thus when the socket is sur- rounded by a ridge, as the acetabulum is, the head of the bone is stopped by it, and requires to be lifted over it. When the head of a bone is larger than its cervix, as is the case with the upper head of the radius, some trouble is ex- perienced.* The chief difficulty, however, in the reduction of dislo- cations, arises from the resistance which the muscles make, and which increases in proportion to the length of time the bone remains unreduced. In some cases, this seems to depend in a great measure upon the permanent short- ening of the muscles, which will not readily admit of be- ing extended again to their usual length. When a bone is dislocated, the muscles draw it as far from the joint as the surrounding parts will allow, and by their contraction fix it there. The business of the surgeon is to counteract this resistance. If extension be made immediately after the accident, the resistance of the muscles is easily over- come ; but, if the operation be deferred only a few days, the utmost difficulty is experienced. That the action of the muscles forms the principal impediment to reduction, *is proved, first, by the facility of putting the bone into its right place in cases where the muscles are paralytic; se- condly, by the same facility which occurs when the patient happens to be debilitated by intoxication, or faintness. Thus, Sir A. Cooper mentions a case of injury of the jeju- num, and dislocation of the hip, where the muscles scarce- ly made any opposition to the reduction. Another fact, proving the power of the muscles in making resistance, is the ease, with which a luxation may often be reduced when the surgeon suddenly makes the attempt when the patient's mind is directed to another subject, and the muscles are therefore unprepared for resistance. These facts furnish useful suggestions in practice, teach- ing us not only how to avail ourselves of any accidental swooning, or syncope, to replace the bones, but also how to adopt means for the express purpose of inducing faint- ness, great momentary debility, and universal muscular relaxation. These means are bleeding from a large orifice, * A. Cooper, on Di^rat'ions he. p. 20 36ti DISLOCATIONS. nauseating doses of tartarised antimony*, the warm bath, opium, &c. with the aid of which dislocations may be re- duced at a later period, than could otherwise be accom- plished.! In strong, athletic subjects, the utility of such practice is daily seen; and if there remained any doubt about it, the manner in which it has been lately recommended by Sir A. Cooper ought to produce conviction. In fact, the cases published by him, completely prove, that when this method is neglected, the most powerful mechanical means sometimes fail. One excellent principle in the employ- ment of mechanical force is to begin with it gently, conti- nue it unremittingly, and increase it very gradually. The propriety of attending to this principle depends upon the fact, that the muscles are more certainly overcome by long- continued, gradual extension, than by short, interrupted, numerously repeated exertions of great sudden violence. When the muscles are opposed in this last injudicious man- ner, it requires an immense time to fatigue them effectually, and the sudden violence is more likely to tear the flesh, than reduce the bone. In reducing dislocations, counter-extension is to be made; that is to say, the bone, with which the luxated one is naturally articulated, is to be fixed, and kept back while the extension is practised. The necessity of fixing the sca- pula and clavicle in dislocations of the humerus, and the pelvis in luxations at the hip, is too obvious to require any comment. In making counter-extension, however, one essential caution is requisite; viz. never to make pressure exactly on the articular cavity, or any point between it and the head of the bone, as thus a great obstacle to the re- duction would be created. The extending force may be made either with towels, sheets, &c. put round the limb, and pulled by a sufficient number of assistants, or with what is better, multiplied pulleys, which, indeed, in cases of difficulty, are indispensa- ble. The French (as I think) rightly prefer applying the extending force as far as they can from the luxated head of the bone; but, in this country, the plan of apply- ing the towels, pulleys, &c. to the lower end of the dislo- cated bone itself is mostly practised. In luxations of the hip, Sir A. Cooper applies the extension just above the condyles of the femur; in dislocations of the shoulder, how- ever, he makes extension at the wrist, placing the heel in the axilla, and drawing the limb in a line with the side ol * A. Cooper, Surgical Essays, p. 22. f A. Cooper on Dislocations, p. ?(j DISLOCATIONS. 3G7 die body; in which position, the pectoral and latissmus dorsi muscles are relaxed.* In the reduction, it is always necessary to consider what muscles have the power of opposing the attempt, and if possible, they should be relaxed when the exten- sion is made. The return of the head of the bone into its right place, is indicated by a snap heard at the instant of its slipping into the socket; by the restoration of the proper shape of the joint; and by that of its original motion. The position in which the limb ought to be placed, and kept quiet, until the ligaments have united, must generally be determined on the same principles as in cases of frac- tures; and sometimes by a knowledge of those positions, in which the part can never be luxated. Thus, the hip can never be dislocated, while the knees are confined toge- ther; nor the jaw, while the mouth is shut; hence, the use- fulness of bandages, which maintain these positions. In general, however, the reduced bone may be more easily kept in its proper situation, than a bone that is fractured. Some trouble, however, is occasionally experienced, when the bone has been repeatedly out of its place, and the mus- cles are paralytic, or the ligaments preternaturally loose. The modes of reducing particular luxations will be no- ticed in the second part of this work. In compound dislocations, it is a most important point to obtain a prompt union of the wound, as the injury is thus at once converted into a simple case. Therefore, as soon as the bones are reduced, the lips of the wound are to be accurately brought together with sticking plaster, and the joint kept perfectly quiet in splints. In compound dislocations of the ankle, it appears to me generally bad practice to saw off the protruded end of the bone. Mr. Gooch was inclined to think favourably of the plan, when the head of the bone had been long exposed to the air.f But no surgeons, of the present day, ever delay the reduction until the bone has been materially affected by exposure. An eminent surgeon in London, who some- times follows the practice, assigns as a reason for it, the avoidance of tetanus; but this ground cannot be sufficient, because, though the method was never adopted in St. Bar- tholomew's Hospital, during the many years that I attended ' Surgical Essays, vol. i. p. 25; also on Dislocations, &c. p. 28. ed. 4. (• Ca^es in Surgery, p. 103. edit. 1 Mb DISLOCATIONS. it, tetanus was a very rare occurrence there after compound dislocations. It is admitted, however, that if the disloca- tion can be easily reduced without the use of the saw; if the end of the bone be not so obliquely broken, that it will not remain firmly on the astragalus; if it be not shattered, and the patient so irritable, that the muscles are thrown into violent spasms by the attempts at reduction; the bones ought to be at once returned into their places.* The late Mr. Hey also sometimes sawed off the end of the bone; but, the only instance of the practice published by him, is strongly against it, the patient, after the cure, being able to walk but slowly and weakly, with his toes turned out- wards.! This gentleman's use of sutures is also to be con- demned. Old luxations can hardly ever be reduced; for, not only the muscles become permanently shortened, and the arti- cular cavity more or less obliterated, but the head of the dislocated bone acquires adhesions to the parts in its new situation, and is sometimes confined by a new bony socket, which must be broken, ere it could change its situation again.:}: Sir A. Cooper considers all attempts to reduce the shoulder, after it has been out three months, imprudent, on account of the injury likely to result from the force employed. The endeavour to reduce the hip, he does not recommend after eight weeks. These rules, however, he does not apply to persons of relaxed fibre, or advanced age.y Though dislocations are commonly occasioned by exter- nal force, they are, now and then, the consequence of dis- ease in the joints. Every surgeon knows, that a luxation of the thigh-bone is often caused, in disease of the hip, by the destruction of the acetabulum, and articular ligaments. Sometimes the ligaments become greatly relaxed, after an accumulation of synovia in the joints. When the knee- joint has been distended with such fluid, the patella is sometimes dislocated by the common efforts of the mus- cles in walking, as soon as the redundant secretion is ab- sorbed.|| We do not often see a dislocation take place in white swellings of the knee; but it may occur. Mr. Law- * Sir A. Cooper, on Dislocations, p. 281. ed. 4. f Pract. Observations in Surgery, jp. 375. edit. 2. * {Some observations on this subject will be found in a note under the head of particular dislocations.—P. E.} § Surgical Essays, vol. i. p. 21, and Treatise, &c. p. 30. II See Sir A. Cooper, in Surgical Essays, p. 9. DISLOCATIONS. 3r>y rence informed me of a child, whose bones of the leg were drawn considerably upwards towards the tuberosity of the ischium, in consequence of disease in the knee; and since this observation was communicated to me, I have met with two or three examples of the same kind. In the museum of St. Thomas's Hospital, is a preparation, in which a knee is dislocated in consequence of the destruction of the liga* ments by ulceration: the bones of the leg are anchylosed at right angles with the femur, and turned directly for- wards.* I once saw, with the above gentleman and Mr. Lang- staff, a person afflicted with a diseased knee, whose leg could be bent to a very great extent towards each side, and this even when the limb was brought completely for- ward. The pressure of the dislocated head of a bone sometimes gives rise to oedema and paralysis of the limb. Desault met with several dislocations of the shoulder, in which a palsy of the arm was occasioned by injury of the axillary plexus of nerves. Some of these paralytic affections prov- ed incurable; others yielded to the application of the moxa above the clavicle, or to the employment of strong ammo- niacal liniments.f * Op. cit. p. 11. r See OZuvres Chir. de Desault; torn. i. p. 356—357. PVU OF THE FIRST PAR'I VOL I. 3 A THE FIRST LINES OF THE PRACTICE OF SURGERY. PART II. PARTICULAR SURGICAL SUBJECTS. CHAPTER I. INJURIES OF THE HEAD, May be divided into superficial injuries; fractures of the cranium; pressure on the brain from extravasation; pres- sure on the brain from matter; concussion; phrenitis; the operation of trepanning.* * {Under this division, we think might very properly be added, fractures of the cranium, with a loss of a portion of the substance of the brain. It is a well known fact, that injuries of this kind are not necessarily fatal, and that under a properly regulated treatment, patients have recovered without ex- periencing more inconvenience than from a simple fracture. The fact is so well established by the experience of several army surgeons, that, without entering into details, we shall merely refer to two cases, reported by Pro- fessor Sewall, of Washington City, and published in the third number of the Am. Journ. of the Med. Sciences. In one case, a man aetat 50, received a blow on the right side of the head with a sharp spade. On examination, Prof. S. found a deep wound, which had divided the integuments, the tem- poral muscle, penetrating the cavity of the cranium, and extending horizon- tally from an inch above the external angular process, through the parietal bone, forming a fissure of three inches in length. The lower portion of bone was considerably depressed, and the edges separated about half an inch. The dura mater was divided for an inch in extent, and the brain penetrated some way into its medullary portion, which was easily distinguished from its cortical part The patient was much exhausted from the loss of blood, and 312 INJUR1L> 01 TUL HJSA1' SUPERFICIAL INJUHIES. Contusions of the scalp, sometimes occasion abscesses under the aponeurosis of the occipito-frontalis muscle. The matter ought to be discharged as soon as its presence is ascertained; and, if possible, the opening should be made in a depending situation. The same kind of violence may produce an extravasation of blood beneath the same aponeurosis, attended with a tumor, which communicates to the fingers a sensation so like that of a fracture, with depression of the cranium, as may be easily mistaken. The effused blood, however, is soon absorbed, when mild pur- gatives, and the lotion of vinegar and muriate of ammonia, are duly employed. Cuts of the integuments of the head, without injury of the skull, are simple wounds, unattended with any pecu- liarity, and generally admitting of direct union. Many contused and lacerated wounds of the scalp may also be united. The flaps, angles, and detached portions of these wounds, provided they are connected with the rest of the scalp at some point or other, ought never to be removed though not insensible, he had lost his reason, and appeared not to know how he came by the injury. "Suitable dressings were applied, and he was conveyed home, about one mile distant, and placed in bed with his head and shoulders considerably elevated. From the great loss of blood, his pulse was feeble, and his ex- tremities cold. Warmth was applied to the limbs, he soon became sensible, and complained of severe pain in the head, and vertigo The most rigid antiphlogistic course was enjoined, and the patient placed under the imme- diate care of an intelligent student, who was directed to bleed and to purge in proportion to the reaction of the system, a'.id with a freedom that should prevent any bad effects from subsequent inflammation. He was bled and purged daily for a considerable time, the circulation equalized by warmth applied to the extremities, and by gentle diaphoretic remedies given inter- nally. " During the process of suppuration, the brain protruded and sloughed away, and subsequently portions were removed by a spatula. "A few days after the accident, a second wound was discovered, which. penetrated the integuments and the frontal near the median line, and about one inch from the coronal suture. This wound was apparently made by a small spear-pointed instrument, and was so large as to admit a probe to pass through the skull. "For about ten days after the accident, the patient complained of con- stant and sometimes of severe pain in the head; and on one occasion was affected with a slight spasm of the muscles of the face, neck, and extremi- ties. The wound healed, and in six weeks the patient was quite well. He has since followed his occupation, that of scavenger, and has not manifested any deviation in the functions, either of body or mind, from their ordinary healthy condition."-~P. E} INJURIES OF THE HEAD. .173 so as to cause an unnecessary exposure of the cranium, on the contrary, they ought to be carefully laid down, and, when not too severely contused, they will be found to live and unite to the surrounding parts. No wounds are more liable to be followed by erysipelas than those of the head; a circumstance explained by Petit, Desault, and Bichat, by the supposition, that they often disorder the hfepatic functions, and thus produce a state of the constitution favourable to its occurrence. It is on the same principle, that these celebrated men, as well as Baron Larrey,* account for the frequency of abscesses in the li- vers of persons who die after injuries of the head; a thing which Richerand refers to the liver itself generally having Buffered a concussion or mechanical injury at the same time as the brain.f But, whatever may be the cause, the j.icts remain incontestible, that the head is particularly' liable to erysipelas from wounds, and that disorder of the liver, and even abscesses in this organ, are occasional complications of injuries of the head. When a tumor is removed from the scalp, however skilfully the operation be done, a severe attack of erysipelas, sometimes ending fatally, will sometimes follow. Erysipelas, in cases of wounds of the scalp, has been erroneously imputed to an injury of the aponeurosis of the occipito-frontalis muscle and pericranium; and extensive incisions, down to the skull, have been advised, for the purpose of removing the supposed tension of that tendi- nous expansion. It would be presumption to say, that there never is a case which may be thus benefited: but, I am of opinion, that the practice has been too extensively recom- mended, the affection being mostly on the outside of the fascia. The best treatment, as far as I have observed, con- sists in prescribing small doses of tartarized antimony, the blue pill, mild purgatives, and a low regimen. FRACTURES OF THE CRANIUM. When the breach of continuity in the bone is very fine, it is termed a.flssure; when wide and open, it is named a fracture. When it happens at some distance from the spot on which the external violence has immediately operated, it is denominated a counter-fissure. The skull, at the frac- * Mem. de Chir. Militaire. t. iv. p. 213. - No-ographie Chir t. ii. p. 245. edit 4. lPl^ J74 INJURIES OF THE HEAD. tured part, either continues on a level with the rest of the cranium, or it is depressed. The inner table is sometimes broken, while the external one remains entire. Fractures of the cranium are in themselves by no means dangerous; that is to say, the simple breach of continuity in the bone, were it unaccompanied with other mischief, would rarely give rise to any serious complaints. In fact, fractures of the skull often get well without ^any bad symp- toms whatever. The alarming symptoms, which frequent- ly originate, are occasioned, either by the bone being beat- en inward, so as to press upon or even wound the brainy or by the sharp irregular edges of the fracture irritating the dura mater, and making it inflame and suppurate; or else by mischief done \o the parts within the cranium by the same force which broke the bone itself. A fracture of the cranium, without depression, is not only itself unproductive of any dangerous effects, it is also unattended with any particular symptoms.* Its existence can only be ascertained by the eye or the touch, and there- fore its diagnosis is not easy, unless it be exposed. How- ever, a surgeon need not be solicitous to find out an unde- pressed fracture; nor is he warranted in making an use- less incision merely to see the crack; for, if symptoms de- mand the application of the trephine, he is to apply it to the bone, whether it be fractured or not; and if they do not require the operation, the fracture itself can never be a reason for the practice. Bleedings from the nose, mouth, and ears, are no signs of a fracture of the cranium. The only inference from them is, that the force applied to the head has been vio- lent; and even this conclusion is not a certain one; for, some persons have hemorrhages of this sort from very slight causes. Vertigo, paralysis, vomiting, loss of sense, &c. so often attending these cases, denote injury of the brain, and not a fracture of the skull. Though a mere breach in the skull itself is not a source of danger, yet, considered as a symptom, it is of the high- est importance; for, it shows that considerable violence has been applied; and, consequently, that the brain may * In Klein's Chirurgische Bemerkungen, p. 161, we find a remarkable proof of the truth of this observation : a man's skull was so badly broken, that after death, the left half of it could, with very little trouble, have been separated from the right; yet after the patient had recovered from the first stunning, which lasted an hour, he remained four-and-twenty hours abso- lutely without any bad symptom. INJURIES OF THE HEAD. 375 have been injured. The effects on the parts within the skull, however, are not caused by the fracture, but by the same force which produced the breach of continuity in the bone. Although the internal mischief is mostly situated be- neath the place where the external violence has operated with most force, that is, beneath the fracture, yet it not unfrequently lies in a remote part. The same violence which breaks the cranium, may occasion a concussion of the brain, extravasation of blood in, or upon it, and a sub- sequent inflammation of it. Even fractures, with considerable depression, are some- times unattended with urgent symptoms; and, in this cir- cumstance, the trephine is quite unnecessary; for, the only- sound reason which can ever be given for its use, is the removal of such pressure from the brain as gives rise to existing symptoms of a dangerous tendency. But whenever these symptoms do accompany a depress- ed fracture, the sooner the bone is elevated the better. Sometimes the inner table is depressed, so as to wound the dura mater and brain, and cause perilous symptoms, while the outer table is not even broken, nor thrown out of its natural level. On the 19th of June, 1815, I trephined a soldier for such an injury, which he had received at Wa- terloo. He was lying quite, senseless, with stertorous re- spiration, dilated pupils, &c. On dividing the scalp, he be- trayed no signs of sensation; but no sooner had the de- pressed portion of bone been removed, than he raised him- self up, looked round, and began to answer every question put to him. The only treatment, which a fracture of the skull neces- sarily requires, consists in taking measures to prevent in- flammation of the brain, which is sometimes caused by the mechanical irritation of the fracture, but, in most instances, by the same violence which broke the bone itself. If we could ascertain, that the inequalities or pressure of the fracture caused the bad symptoms, we should be warrant- ed in removing the fractured part with a trephine; but all that we can rationally do in common cases, is to apply cold washes to the part, bleed the patient freely and re- peatedly from the temporal artery and arm, and prescribe antimonials, saline purgative medicines, and a low diet. The antiphlogistic regimen should be continued at least :; month; for it is by no means uncommon for inflammation and abscesses of the brain to follow injuries of the head, j/6 INJURIES OP THE HEAD. a very considerable time after the patients have had rea- son to Suppose themselves in perfect safety.* PRESSURE ON THE BRAIN FROM EXTRAVASATION. External violence, applied to the head, frequently occa- sions a rupture of the spinous, or some other artery of the dura mater; and a large quantity of blood is effused on the surface of this membrane. In many instances, the blood is extravasated between the dura and pia mater, or in the very substance, or cavities of the brain. Extravasations between the dura mater and any part of the base of the skull, are mostly fatal.f When the blood lies between the dura mater and tunica arachnoides, or in the convolutions of the brain, it is in general widely diffused; but, when it is situated in the ventricles, or substance of the brain, it is always circumscribed.f. In cases of extravasation, the patient is usually stunned by a blow, from which state he sometimes soon recovers; while, in other instances, he remains stupid and senseless. When he regains his senses soon after the first effects of the violence have subsided, and afterwards gradually re- lapses into a drowsy condition, and then into a state which I am about to describe, considerable light is thrown upon the case by there having been an interval of sense. That the following symptoms cannot arise from the concussion, is proved by the patient having recovered his senses, which he at first lost by being stunned; that the symptoms can- not be imputed to a depression of any part of the skull, is clear, because the patient would have continued senseless from the first; that the same symptoms cannot be attribu- ted to matter beneath the skull, is certain, because the time would not have been sufficient for the formation of matter, * Some very interesting cases, illustrating thisfact, are contained in Klein's Chirurgische Bemerkungen, 12mo. Stutgart, 1801, p. 113, &c. In some of these examples, the patients remained well and sensible more than a month, and were then seized with fever, shivering, convulsions, paralysis. &c. which soon destroyed them. What is curious, it was sometimes found, that though the symptoms began thus late, and perhaps proved fatal in two or three days, a large portion of the brain and its membranes was inundated with matter; abscesses formed in its substance; parts of it destroyed ? its membranes considerably thickened; and even the cranium broken. We must here suppose, either that such disease was going on for a time, with- out producing any particular bad symptoms, or that its progress w^s mos' rapid after it had once begun. f OZuvres de Desr.ult par Bichat, torn. ii. p. 24 i Op. cit. p. 25. INJURIES OF THE HEAD. ->77 ;md there have been no symptoms of inflammation of the dura jnater. Here any reflecting man must know, that hemorrhage within the skull has taken place, and that, in proportion as the quantity of effused blood increased after the accident, it induced the bad symptoms under which the patient labours. Unfortunately, much obscurity is frequently occasioned by the effects of extravasation taking place before those of concussion subside, in which case, no interval of sense oc- curs, and we know not whether to ascribe the general in- sensibility to the former or the latter cause. But the worst cases of all are those, in which concussion and ex- travasation are co-existent. When the quantity of blood is at first small, drowsiness and head-ach may be the only symptoms. When, how- ever, the pressure on the brain increases with the increas- ing extravasation, the patient is gradually deprived of all sensibility. His eyes remain half open; his pupils are dilated; the iris does not move, even when a candle is brought near the eye; there is no sickness, which would betray sensibility in the stomach and (esophagus ; the pulse is generally slow; the feces and urine pass involuntarily; and respiration is carried on with difficulty, and with a stertorous noise. These symptoms indicate, with tolerable certainty, both extravasation and dangerous pressure on the brain; but the surgeon has few or no means of judging with precision where the effused blood is situated, nor of course where he should perforate the cranium with the trephine. He neither knows whether the blood lies immediately under the skull, upon the outer surface of the dura mater; be- tween the dura mater and tunica arachnoides; in the con- volutions; in the ventricles; or deeply in the substance of the brain. Supposing it to lie upon the dura mater, he knows not the exact point of its situation. The common rule, in these cases, is to apply the tre- phine to the place where any traces of external violence appear, the extravasation being often situated under that part of the skull which received the blow. Should an ap- pearance of contusion be manifest on the scalp, after the head has been shaved and carefully examined; should the scalp be wounded; or lastly, should there be a visible fracture of the cranium; the perforation is to be made in the situation of these injuries The practitioner, how Vor. I. 3 B 378 INJURIES OF THE HEAD. ever, has often the mortification to find, that the extrava- sation is not under the part of the skull, which has been perforated. In this dilemma, if the dura mater should ap- pear prominent at the opening, as if blood were under it, some surgeons advise a puncture to be cautiously made in it. This practice might indeed sometimes let out a small quantity of serum; but as blood, in this situation, is al- ways widely diffused, an effectual discharge of it is im- practicable. As for extravasations more deeply situated, the uncertainty of their exact place must generally prohi- bit a prudent surgeon from meddling with them. Paralysis is a symptom of pressure of the brain; when it affects one side of the body more than the other, and one pupil seems more dilated than its fellow, the extrava- sation is mostly on that side on which there is least para- lysis, and least dilatation of the pupil. Sometimes, how- ever, though the paralysis affects only parts of one side of the body, the extravasation is diffused, and not restrict- ed to the opposite side of the brain. When blood lay on the dura mater, Mr. Abernethy found, that the bone above it would not bleed when scrap- ed : a remark well deserving recollection. Desault, in the enumeration of his reasons for renounc- ing the trephine, notices the possibility of extravasation happening without any dangerous symptoms. Here, how- ever, no surgeon would trephine, because the bad symp- toms are the only true reason for the operation; nor with- out them would the extravasation be even suspected. With regard to the uncertainty of the diagnosis, I believe De- sault was incorrect in denying the possibility of distin- guishing the difference between the symptoms of extrava- sation and those of concussion, phrenitis, &C. Such dis- crimination has certainly been made with considerable success by Mr. Abernethy ;* and some of the symptoms, characteristic of the several cases, as related in this publi- cation, will not be likely to be confounded.! It is princi- * Surgical Works, vol. ii. ■j- Klein relates a case which furnishes a useful caution : a little girl, five years old, fell out of a carriage, pitched upon her head, and the hinder wheel passed over her right side. She got up directly afterwards, with a considerable wound of the forepart of the scalp, five inches in length. In the course of a day or two, she became feverish, talked incoherently, vomit- ed several times, and was exceedingly thirsty. Notwithstanding anti- phlogistic remedies, the symptoms soon became worse; the child being in a state of stupor, and of a deadly pale colour, with twitchings of the face. INJURIES OF THE HEAD. 3**9 pally in mixed cases, as when a man is labouring under the effects of concussion and compression together and perhaps inflammation, that obscurity and uncertainty will be experienced. PRESSURE ON THE BRAIN FROM MATTER. When a great deal of matter collects on the surface of the dura mater, it finally produces symptoms of pressure on the brain; but, previously to their occurrence, the pa- tient must have betrayed signs of an inflamed dura ma- ter, while, in the situation immediately over the matter beneath the cranium, the symptoms of pressure from this cause must have been preceded by a puffy, circumscribed, indolent tumor of the scalp, and a spontaneous separation of the pericranium. If a wound be immediately over the part of the cranium covering the suppuration of the dura mater, the edges lose their Vermillion hue, and become pale and flabby; instead of healthy pus, a thin gleet is dis- charged, and the pericranium is loosened from the skull, for some extent from the edges of the sore. This case demands the immediate application of the trephine, in order to let out the matter confined beneath the bone. Antiphlogistic treatment, copious bleedings, saline purgatives, antimonials, quietude, and low diet, are here strongly indicated.* stertorous and difficult respiration, a tremulous pulse, which could not be counted, involuntary discharge of the feces; frequent convulsions; inability to swallow, 8cc. The wound of the scalp had united very well at the edges, but the flaps were hollow, and from the cavity an unhealthy matter yet issued. Klein was required to apply the trephine, but he thought the symptoms not clear enough, and therefore waited. The child died, and on examination of the body, the cranium and its contents were perfectly sound; but in the chest, the right lung was found violently inflamed, and filled with blood; and a quantity of bloody serum in the cavity of the pleu- ra. The posterior part of this membrane was exceedingly inflamed ; a great quantity of blood extravasated between it and the intercostal muscles, and to the surgeon's astonishment, the five first ribs fractured. Chirurgis- che Bemerkungen, p. 141. * Besides the kinds of pressure here specified, as requiring the trephine, there is another case particularly insisted upon by I.arrey: I allude to the lodgment of a ball or bullet between the fragments of a fractured skull, 01 to the entrance of the same within the cranium, near some part of which i; continues lodged. This author records one surprising case, in which he tppanned the os frontis, and removed an iron ball, that weighed seven French ounces, off the anterior and right lobe of the brain: the patient com- pletely recovered, ^ec Mem. de Chir. Militaire, t. iv. p. 18"!—1H5 $80 INJURIES OF THE HEAD. CONCUSSION. Its first effect essentially consists in a sort of contusion, or general irritation of the brain, occasioned by the shock which every part of this organ receives. The nature of such shock is readily conceived, when we recollect the way in which contusing bodies act upon the cranium. When the skull is struck, it changes its shape ; it becomes flatten- ed in the direction of the violence, and widened in the op- posite direction, as happens in the same circumstance to every round elastic body. Hence, the brain suffers an nniversal shaking and compression, and having been con- tused and irritated, an increased determination of blood to it has always a tendency to follow. The truth of this doctrine is proved by experience, which teaches us, first, that, in the majority of cases, inflammation of the brain succeeds concussion; secondly, that the best method of preventing the secondary effect, is to excite an artificial ir- ritation, which counteracts the effects of that to which the brain has been subjected.* Concussion may happen in very different degrees. How many varieties exist between that slight stunning, the sud- den effect of an inconsiderable blow, and that complete disorganization, which, at the instant of the injury, anni- hilates at once all power of motion and every spark of life ! When the concussion is slight, a transient stunning, a little pain in the head, acceleration of the pulse, vertigo and sickness are sometimes immediately experienced; but, none of these complamts last long, especially if evacuation be used.f In certain instances, however, the dura mater inflames after slight blows on the head, and this at a peri- od when sometimes there is not the least apprehension of danger.:): If the violence has been great, the patient is di- rectly stunned and thrown into a state of total insensibili- ty; his extremities become cold, his pulse is weak, slow, and intermitting; his respiration hardly perceptible; and his power of motion abolished. This is what Mr. Aber- nethy considers as the first stage of concussion. In pro- portion as the stupefaction, arising directly from the inju- ry, goes off, (supposing the violence not to exceed a cer- * ffiuvres de Desault, torn. ii. p. 57, 58. f Pott's Chirurg. Works, by Earle, vol. i. p. 4®, edit. 1808. i For illustrations of this important truth, 1 would particularly refer to the writings of Pott and Klein. INJURIES OF THE HEAD. 3S1 lain degree, for then no signs of returning sensation fol- low,) Vickness, increased frequency of the pulse and respi- ration, more or less motion, and other symptoms, take place, followed by marks of inflammation of the brain. The tendency to phrenitis, in fact, always increases as the first effects of concussion subside. If the patient's eyelids be now opened, he will shut them again in a peevish man- ner ; the pupil is contracted, and though the patient is re- gardless of slight impressions, he is not by any means in- sensible. As the case advances, the patient gets no sleep at all; hss a wild look; an eye much like that of a person who has long watched through apprehension and anxiety ; talks much and very inconsistently; has a hard labouring pulse; if not restrained he will get out of bed, and act with a kind of frantic absurdity; and, in general, he appears much hurt by a strong light. As the signs of delirium increase, the pulse becomes small, frequent, and even ra- pid. The inflammation under the skull may now produce suppuration, or a copious effusion of serum, and the fore- going afflictions may be followed by those depending on the pressure of the secreted fluid. Death is the unavoidable consequence of violent concus- sion ; such is then the extent of the disorder, that every means is incapable of re-establishing the functions of the brain. But when the injury, which this organ has received, is less considerable, its functions may be gradually restor- ed in a more or less perfect state. Frequently the patient is for ever afterwards affected by the accident. Imbecility, loss of memory, and a marked change in the character, are sometimes the permanent consequences. In certain in- stances, the patient's memory remains weakened, and he can only recollect things which have very recently attracted his attention. Desault used to cite a curious case, in which the patient could at first only remember circumstances with which the mind had been lately impressed ; but af- terwards, he could recollect nothing, except what had hap- pened in his childhood. Mention is also made of a luna- tic, who was so fortunate as to recover his reason, in con- sequence of an accidental concussion of the brain.* The treatment, of which I entertain the highest opinion, consists in taking away blood freely and repeatedly from the temporal artery and arm, giving tartarized antimony, administering saline purgatives, and aperient clysters, and " (Fuvrcs de Desault, torn. ii. pp. 59—61. 382 INJURIES OF THE HEAD. ordering a low diet. In the first stage of concussion, in- deed, when all the functions of life are at the lowest ebb, such measures are not indicated ;* and stimulants (espe- cially external ones) may be allowable; but, when the se- cond stage arrives, which is invariably joined with a ten- dency to inflammation of the brain and its membranes, the antiphlogistic treatment affords the best chance of preserva- tion. Counter-irritation should also be excited on the outside of the head, by means of a large blister. Leeches will often be useful, and linen, wet with a cold lotion, may be laid on the temples, and any part of the head not co- vered with the blister. Copious bleeding has not been universally approved of as a means of relieving concussion. In a few cases, Desault bled once ; but he never carried the bleeding so far as to open a vein a thirdf time. He preferred a stimulating plan of treatment, and especially that of keeping up a coun- ter-irritation on the whole scalp, and giving antimonials. Others, not content with external stimulants, have had recourse to the internal exhibition of opium, brandy, wine, liq. ammoniae, and aether. This practice, I think, arose from the two stages of concussion not having been formerly discriminated. PHRENITIS. When, in consequence of external violence, the sub- stance of the brain inflames, the case is attended with hardness, frequency, and strength of the pulse; slow full respirations; broken sleep; redness of the tongue ; anima- tion of the countenance ; excessive sensibility of the retina to the impression of the light; a full, red, and inflamed ap- pearance of the eyes; an acute throbbing pain in the head; general heat of the body; disturbance of the intellectual faculties; and, after a time, vertigo, loss of sense, delirium, coma, and convulsions. But, when the membranes of the brain are principally affected, the pulse is contracted, fre- quent, and small; the fever characterized by a dull pain in the head; dryness and burning heat of the skin ; vomit- ing; clammy furred tongue; high-coloured urine ; deliri- • Mr. Hey, among others, thinks a copious bleeding injurious "during the diminished state of the vis vitx, which immediately succeeds the inju- ry." He has seen great benefit arise from the warm semicupium, and blis- tering the head after topical bleeding. Pract. Obs. in Surg. p. 486. edit. 2. f Op. cit. p. 64. INJURIES OF THE HEAD. iibo tiro; loss of sense, &c. In most examples, however,*the brain and its membranes are more or less inflamed toge- ther, and hence, in general, the symptoms do not precisely correspond to either of these descriptions. Inflammation of the brain, and its membranes, is a case that generally requires a very free use of the lancet, and the operation is to be repeated, according to the patient's strength, and the state of the symptoms. There is an ad- vantage in taking blood from the temporal artery; or, in conjunction with venesection, blood may be drawn from the temples by leeches, or cupping glasses. The skin ought to be kept moist with antimonials, which should be given in nauseating doses, so as to have the effect of suddenly lessening the impetus of the circulation. Counter-irrita- tion should be excited on the scalp with blisters, or, at first, the head may be covered with linen wet with ice-cold water, or an evaporating lotion. Laxative glysters, saline purgatives, a very low diet, and a quiet, rather dark roorn, sre also proper. • THE OPERATION OF TREPHINING Consists in removing a portion of the skull, and is usu- ally done in order to raise a part of the bone producing dangerous pressure on the brain; to discharge collections of matter, or blood, which have the same effect; or to ex- tract a ball, or other foreign body lodged under the skull.* * J A most interesting and valuable paper on injuries of the head, by the distinguished professor of anatomy and surgery in Transylvania, B. W. Dud- ley, M. D., will be found in the first number of the Transylvanta Journal of Medicine. Prof. D. is an advocate for the use of the trephine in cases of epilepsy resulting from injury of the head; several cases of this kind are detailed in the paper alluded to, and as the subject is one of considerable importance, we shall select a case as illustrative of his practice.—"In the spring of 1825, W. T. a young gentleman twenty-one years of age, in com- pany with his mother, came to this place from South Carolina; and from the mother was received the following history of her son's case.— " When five years of age, he received a severe blow accidentally on the superior and middle portion of the left parietal bone. Being at school, he was able to go home on foot without giving any particular manifestations calculated to excite alarm. On the ninth day he became suddenly apoplec- tic, and paralysis of one side ensued. " The paralytic affection gradually disappeared, so as to leave him in the enjoyment of his faculties, as well corporeal as intellectual, at the expira- tion of two months; but from that period he became the subject of severe pain in his head, and especially about the seat of the injury he had previ- ously sustained. From this time his constitution became exceedingly deli- cate and excitable, with disinclination for exercise, and liability to faintness 38-1 INJUKIES OF THE HEAD. Every part of the cranium cannot be trephined with equal safety. However, the mere presence of a suture after the slightest exertions: finally,about his fourteenth year, nine years after the reception of the injury, he became the subject of epileptic con- vulsions. These had ever since continued to recur at irregular intervals of two, three, or four weeks, varying with the occasional causes which for a time invited or retarded their appearance. He had been but a short time the subject of epilepsy, until a most manifest improvement in his constitu- tion took place. His personal appearance and constitutional vigour being much changed for the better, his former excitable habit, with his liability to faint after very slight exertion, now left him. But these flattering symptoms were soon followed by a perceptible injury of his intellect, insomuch that it became useless to confine him longer to his studies in school. "After receiving this history of the situation of the patient from the mo- ther, upon turning to himself with a view to additional information, I ob- served a stammer in every attempt at enunciation ; while his memory had become so entirely treacherous, that he could no longer recite with any de- gree of accuracy, an event which had transpired within two days, his recol- lection being good, however, in relation to circumstances of his childhood. For most particulars in relation to his daily history, even in reference to-the operation of a dose of medicine, it wai necessary to consult his mother. "A cicatrix on the side of the scalp, pointed oirt the seat of the original injury. Under all these discouraging circumstances, after a few days pre- paration, the operation was resorted to on the 10th of May 1825, to relieve him of an injury, the consequences of which had been accumulating upon him for sixteen years. A small depression of bone appearing manifest, cor- responding with the original site of the injury, indicated the point upon Which to apply the trephine. The crown of the instrument was made to embrace the depressed bone, which when removed, presented a process projecting from its inner surface about one inch in length, of the size of a small quill at its base, the extremity tipped with soft cartilage. This snicu- lum of bone had penetrated the dura mater, and communicated with a large preternatural sinus, from whence issued a stream of blood as thick as a man's little ringer, which continued to flow from the instant the bone was remov- ed, until from the quantity lost, it was judged proper to check it by means of pressure. "The dura mater was diseased, presenting a dark blue appearance over a space nearly as large as the opening in the cranium made by the trephine; while the sinus beneath appeared to be, from an examination made by the little finger, more than an inch in depth, and of equal width. The disposi- tion to haemorrhage was checked in a few minutes by means of pressure with the thumb, and being now satisfied that the trephine was not further neces- sary, it was proposed to cleanse and dress the wound. Before the dressings were applied, an alarming convulsion came on, during the continuance of which, a stream of blood issued through the opening in the dura mater, that projected three or four feet. A second and third convulsion ensued, with like discharges of blood from the opening of the dura mater, before the pa- tient could be placed in bed. For six or eight hours after the operation, he remained in an insensible state, and then his natural feelings and reason returned. " It was now supposed, whatever might be the termination of the case, the cause originally productive of the disease was removed. From bloody water, the discharge from the wound changed in the course of twelve hours to a colourless serum, and for three days and nights in suscession, it was so copious as to make it necessary to change towels, pillows, bolsters and INJURIES OF THE HEAD, 3 3 "J ought not to deter the surgeon from making the perfora- tion in any place which seems advantageous. I believe, also, that the fears, respecting wounds of the longitudinal sinus, have been vastly exaggerated, and that if the situa- tion of a depressed fracture, or extravasation, demanded the removal of a piece of the skull directly over this ves- sel, the operation would be justifiable. The longitudinal sinus has often been wounded by spiculae of the cranium, in cases of fractures; and it has been purposely punctured with a lancet, in order to bleed the patient; yet, the he- morrhage was never known to be troublesome, after a lit- tle bit of lint had been applied.* But, though I feel warranted in making this statement concerning the longitudinal sinus, I am not acquainted with any facts, showing that hemorrhage from the lateral sinuses would not be likely to prove more serious. These latter are much larger, and as they occupy the deep trans- verse furrows, in the middle of the inner surface of the os occipitis, a trephine applied over them would inevitably wound them. Authors generally interdict the application of the tre- phine to the anterior inferior angle of the parietal bone, on account of the trunk of the spinous artery of the dura mater being situated in a groove on the inner surface of that part of the skull. For my own part, I should never sheets, two or three times during the day. Those young gentlemen who assisted in dressing and attending to the case, insisted that the entire amount of serum discharged,could not be less than two gallons. On the morning of the fourth day, the dressings were dry, and in some few hours after, suppuration became manifest. The wound was now dressed with adhesive plaster, which was renewed daily for about thirty days, when it was healed. '•The patient had no convulsion after the day on which the operation was performed; a manifest improvement in his memory became perceptible in a few days to all around him. His stammer, which appeared to proceed from an indistinct recollection of tilings, very suddenly vanished; his eye, which had been half closed, heavy, and inanimate, was now sprightly and intelli- gent. In ten days he left his room, and at the end of six weeks, he returned home in the enjoyment of perfect health; travelling a distance of five hun- dred miles in the month of July, in ten or twelve days. A few months after this young gentleman returned home, I was informed that by excess in eat- ing and drinking, together with severe exercise in dancing, a slight epilep- tic attack was produced. He is, however, as I have been very lately inform- ed, through a letter received from an individual affected as he formerly was, now in the enjoyment of uninterrupted health." In addition to the testimony of Prof. D., we have the experience of M: Cliuc in favour of the application of the trephine in similar cases.—P. E.J • Cases in Surgery, by J. Warner, p. 8. edit. 4; Marchetti, Obs. 4. Sharp's Operat. p. 144. edit. 5; Pott's Chirurg. Works, vol. i. p. 156—159. r-dit. b\ Karle. 1808. Vol.. I. 3 C 386' INJURIES OF IHB HEAD. be afraid of trephining here ; for, if the above vessel were wounded, a little dossil of lint, introduced into the open- ing, would immediately stop the bleeding. It is a maxim to avoid trephining any part from which a complete circle of bone cannot be sawn, without hurting the dura mater. The inequalities on some parts of the inner table of the skull, make attention to this rule neces- sary. Thus, the centre of the forehead is rather an incon- venient part for the trephine, because, when the spine of the os frontis is prominent, it could not be sawn, without the dura mater being wounded by the teeth of the saw. Should the surgeon apply the trephine to this place, he must be careful not to saw too deeply; and complete the separation of the circle of bone with the elevator, in- stead of making any dangerous attempt to saw entirely through the projecting spine. Surgical writers caution us not to trephine over the frontal sinuses, and, not without reason; for, if the perfo- ration be continued in the direction in which it begins, the inner table will be sawn entirely through, on one side of the circle, before the other is at all divided. However, the outer table may be first removed with a large trephine, and the inner table then perforated with a smaller one, placed evenly and perpendicularly on the posterior surface of the sinus.* The trephine cannot be applied lower down on the fore- head than half an inch above the superciliary ridge of the os frontis, without risk of injuring the orbit. If requisite, the trephine may be applied to the squamous portion of the temporal bone; for, wounds of the temporal muscles are not at present so much dreaded as they were by our ancestors. The unevenness of the os occipitis ; the course of the longitudinal and lateral sinuses; and the way in which a part of this bone is covered by muscles; have made surgeons fearful of applying the trephine to it. How- ever, there are two small spaces on each side of the groove for the longitudinal sinus, where a trephine may be safely applied.f The operation may even be done below the transverse ridge, near the foramen magnum, the muscles attached to that part of the bone being no valid objection, as a division of them is not dangerous, while unrelieved pressure on the cerebellum would certainly be fatal.:}: ' C. Bell's Operative Surgery, vol. i. p. 439. | See Warner's Cases, p. 18. edit. 4. - Med.-Chir. Trans. voV ii. r>, 10}. INJURIES OP THE HEAD. 3$7 When the bone is already sufficiently exposed by a wound, the operation may commence at once; but other- wise, it is first requisite to make room for the application of the trephine, by making an incision of a crucial form, or shaped like the letters T or V. None of the scalp should ever be removed, as it is quite unnecessary, and might afterwards occasion serious deformity. The incision should be made directly down to the bone; but, in cases of large fractures, attended with great sepa- ration of the broken edges, or with loose pieces, the dan? ger of pressing too hard with the knife is obvious. Mr. Pott informs us, that a suture, or the impression of a vessel on the surface of the bone, may be discriminated from a fracture or fissure, by the undctached state of the pericranium. This membrane is always found loose and detached from the track of a fracture; besides which, the edges of'a fracture constantly seem rough to the probe or finger. The natural situation of the sutures is also a source of. information to a surgeon not deficient in anato- mical knowledge. It would be dangerous to apply the trephine to depress- ed portions of the skull. The perforation is always to be made on that side of the fracture, where the elevator can be most conveniently introduced beneath the depressed bone for the purpose of raising it. In cases of extravasa- tion, the perforation ought to be made at the place, where there are traces of violence done to the scalp.. When the scalp has been divided, and loose splinters of the cranium are found under it, they ought to be taken away with the forceps or finger; for, they can only be re- garded as extraneous bodies, the continuance of which may be productive of dangerous irritation. The depressed pieces of the skull, causing the bad symptoms, are some- times completely detached from the rest of the cranium, and may be taken away in the same manner. In every instance of fracture with depression, unattend- ed with any motives for supposing that part of the pres- sure on the brain arises from extravasation, provided such depressed fracture can be raised with a pair of forceps, or an elevator, without applying the trephine, the latter ope- ration may be dispensed with. It is customary to scrape the pericranium from the part of the bone on which the crown of the trephine is to be 3SS INJURIES OF THE HEAD. placed; but, if this instrument cut well, no such proceeding is necessary.* In order to fix the centre-pin of the trephine, surgeons make a small hole in the external table of the skull with an instrument named a perforator. The crown of the trephine is to be alternately turned in one direction, and then in the other, by the pronation and supination of the surgeon's hand. As soon as the teeth of the instrument have made a circular groove, sufficiently deep for fixing the trephine, the centre-pin is to be removed, lest it should injure the dura mater, before the internal table of the cranium is per- forated. At first, the operation may proceed with brisk- ness, as the surgeon cannot possibly do mischief; and, every now and then, the trephine is to be taken out of the circu- lar groove, in order that the bone dust may be brushed from the teeth of the instrument. When the sawing is more advanced, the surgeon must proceed with greater caution, and frequently examine with the point of a quill, whether any part of the circle- is nearly, or completely sawn through. When this is the case, the pressure of the instrument is to be inclined to the parts which are not sufficiently perforated. It is always better to use a little force in raising the circle of bone with the ele- vator, than to run any risk of injuring the dura mater and brain, by sawing too deeply. In a few cases, the surgeon clearly perceives the entrance of the saw into the diploe, by the sensation which the instru- ment communicates to his fingers, in consequence of en- tering a soft substance, immediately after having divided the hard texture of the outer table, and by the blood which then appears in the circular groove, and on the teeth of the saw. The operator, however, is not warranted in sawing too boldly until a criterion of this sort takes place; for, in many skulls, and in different parts of the same skull, the diploe is very thin, and, in old persons, it is sometimes quite obliterated. * |In order to avoid the mischief which sometimes results from the prac- tice of rasping the pericranium, and from the teeth of the saw when applied in the manner mentioned, Professor Gibson has suggested a simple and ingenious contrivance. For some years past, he has employed a trephine with a small moveable lancet attached to its outer surface, the extremity of which can be made to project about the sixteenth part of an inch beyond the teeth of tlie instrument; the object of this is to cut the pericranium smoothly instead of tearing it. When this is accomplished, the surgeon may retract the lancet and proceed to saw the bone. The advantages gained by" this proceeding, are too obvious to need illustration.—P. E.f flat* a. 4 INJURIES oy THE HEAD. 3S9 When the surgeon knows with certainty that he has ar- rived at the diploe, the rest of the sawing should be ac- complished with slowness and circumspection. After hav- ing removed the circle of bone, if the lower edges of the perforation next the dura mater are splintered, they may be made smooth by means of an instrument, called a lenticular. When the whole track of the depression cannot be raised, or all the blood or matter cannot be discharged, by making one perforation, the trephine must be applied again; and indeed as often as the circumstances of each particular case demand. Sawing out large portions of the skull, however, should always be avoided, if possible, because it may be itself the source of bad and even fatal conse- quences; but it is certainly less dangerous, than not com- pletely effecting the object of the operation, viz. the remo- val of the pressure from the surface of the brain. Pain is here no objection; for the majority of patients, on whom it ought to be practised, are in an insensible condition. When the operation is finished, the scalp is to be laid down in its natural position, and dressed very lightly with a pledget of any simple unirritating ointment. The importance of preserving every part of the cranium, which the safety of the patient does not compel us to re- move, is a truth with which I am forciblv impressed. No; can it be disputed, that the trephine is often an objection- able instrument, since the piece of bone sawn out must al- ways be of one figure, whatever be the form of the fracture, and the quantity of bone removed must frequently be great- er than the case requires.* Hence the late Mr. Hey sel- dom used the trephine, or trepan, but saws resembling those delineated in the annexed plate.f With the convex one, the bone may be sawn in a curvilineal direction. There are undoubtedly numerous cases, in which it is unnecessa- ry to remove a whole circle of the cranium for the purpose of raising a depression; for instance, if the fracture were shaped like the letter V, and beaten inward, by making a division across its base, the depressed portion might easily be taken away. * See Hey's Practic:-! Obv in ^tircr''"-, n. 7. ed:^ 2: 1 l'Ve JIL 390 ENCEPHALOCELEt CHAPTER 11. OF ENCEPHALOCELE; FUNGUS, OR HERNIA CEREBRI. When a portion of the brain, together with its mem- branes, protrudes through a preternatural opening in the cranium, the disease receives the above appellations. There are several varieties of this affection. One case sometimes occurs in young children before the ossification of the cranium is completed, and then the tu- mor is covered by the common integuments of the head. In one example of this kind, the falciform process of the dura mater was contained in the swelling.* This species of encephalocele usually appears as a soft, smooth, round tumor, which has a pulsation corresponding to that of the arteries. It yields and disappears under compression, is generally unattended with any change in the colour of the skin, is formed in the situation of the fontanellae and sutures, and its circumscription depends on the extent of the deficiency of bone.f The proper treat- ment is to keep up a moderate pressure on the swelling. Ferrand successfully employed for this purpose a compress, containing a piece of sheet-lead, and fastened to the child's cap exactly over the tumor. The degree of pressure was increased or diminished, as occasion required, by tighten- ing or slackening the cap. Another species of encephalocele is rather to be regard- ed as a malformation, being the consequence of a con- genital deficiency of an extensive portion both of the cra- nium and scalp. In such cases, the infant is generally still-born, or dies soon after birth. A remarkable example of this disease was published by Dr. Burrows. The scalp, the os frontis, the parietal, and a great part of the occipital bones, were wanting. The cerebrum, which projected through the deficiency, was of a mulberry colour, and the tumor was adherent at its neck to the edge of the integu- ments. This child lived till the sixth day after its birth; it had no power of voluntary motion, and all the secretions * Corvinus de Hernia Cerebri, in Haller. Disp. Chirurg. t. ii. p. 333, | Ferrand, Mem. de l'Acad. de Chirurg. torn, v. ENCEPHALOCELE. 391 were stopped.* In one case, where there was a deficiency of the skull at birth, the plexus choroides was found in the contents of the tumor under the scalp; and, in another in- stance, the cerebellum.f The foregoing kinds of encephalocele are rare compared with others, which sometimes follow the destruction of a part of the skull by disease,!, or the operation of trephining. In the latter case, the tumor generally arises a few days after the perforation of the cranium. It protrudes through an ulcerated opening of the dura mater, and very soon at- tains the magnitude of a pigeon's or hen's egg, the pia mater covering it seeming inflamed. As it enlarges, frequent hemorrhages occur, and its surface is commonly darkened with coagulated blood. In a few cases, it is not attended with loss of the mental faculties, though, in most instances, we find that coma, insensibility, and other marks of pressure on the brain, accompany the disease. According to Mr. Abernethy, this singular case pro- ceeds from an injury done to a part of the brain at some distance from its surface, which injury produces a diseas- ed state of the vessels, similar to what occurs in apoplexy. The morbid state increasing, one or more vessels give way, and an effusion of blood in the substance of the brain follows. This occurrence, if the skull were entire, would probably occasion apoplexy; but when there is a deficien- cy of bone, allowing the brain to expand, this viscus and its membranes protrude through the aperture. The dura mater soon ulcerates, and the tumor rapidly increases, in proportion as the internal hemorrhage goes on. At last, the pia mater, and stratum of the brain, covering the effus- ed blood, give way, and the blood oozes out and coagulates.^ In the cases recorded by Mr. Stanley, however, the pro- trusion consisted both of the cortical and medullary sub- stance of the brain, and the effused blood is described, as merely lying upon the surface, and not extending thence to any other place, in which it had been originally effused.ji That all cases do not correspond with Mr. Abernethy's description is certain. Thus we have on record the ac- count of a man who, without having any previous disease * Med. Chir. Trans, vol. ii. p. 52. f See Uichter's Anfangsgr. der Wundarzn. b. ii. p. 198. edit. ". \ Richter's Chir. Biblioth. 2 B. 1 St. Seite 159. ^ Surgical Works, vol. ii. p. 51. I See Medico-Chir. Trans, vol. viii. p. 12, &c SS2 ENCEPHALOCELE. or accident, became afflicted with a pulsatory swelling, which originated from the substance of the anterior part of the left lobe of the brain, protruded through the os fron- tis, was as large as an orange, and on dissection was found to resemble the medullary matter of the cerebrum in ap- pearance, and to be covered by an elongation of the dura mater.* Mr. C. Bell represents the hernia cerebri as a true or- ganized vascular growth from the substance of the brain, and not as a mere protrusion. He has seen the disease arise after an exfoliation of the two tables of the skull, when no blow had happened to cause any rupture of blood- vessels within the brain; and he states, that the removal of bone, and the ulceration of the dura mater, always pre- cede the growth of the fungus .f The proper line of surgical conduct in such cases as fol- low trephining, is hardly yet determined. Mr. Hill suc- cessfully pared off the tumor with a knife in several in- stances}: ; and patients have been known to tear off the whole tumor, without any particular ill consequences.^ In the case recorded by Mr. Pring, the removal of the pro- truded mass, and the employment of pressure, were fol- lowed by the recovery of the patient.|| The French sur- geons also recommend either cutting the tumor away, or repressing its growth by applying turpentine to it, and gen- tle pressure.^ In one instance lately published, the whole tumor, which equalled a small orange in size, "was slic- ed off with a scalpel," without any particular pain being excited. A profuse hemorrhage took place from the ex- posed surface of the brain, "the blood being thrown with great force, and to a considerable distance, from numerous vessels, which were attempted to be secured, but ineffec- tually, by ligatures. After a short time, however, the bleeding ceased." On examination of the part which had been cut off, its exterior was found to consist merely of a layer of coagulated blood, the rest of the mass was brain, possessing a natural appearance, the distinction between the cortical and medullary matter being readily seen, with the convolutions and pia mater descending between them. * Med. Trans, art. 18. ■j- Operative Surgery, vol. i. p. 428. t Cases in Surgery, p. 91, 92. § Mem. de l'Acad. de Chir. torn. i. Mem. par M. du Quesnav, obs. 10., | Edinb. Med. and Surg. Journ. vol. ix. ^Richerand Nosogr. Chirurg. torn. ii. p. 289. ed> Z\. ENCEPHALOCELE. 393 During the remainder of the day, on which the operation* had been performed, " the boy, on the whole, was more tranquil. For the next two days, he remained much in the same state; but, on the third, he became worse ; was completely insensible ; had strabismus, and a remarkable quickness of the pulse. On the following morning he di- ed."* On the whole, the results of various cases on record ap- pear to sanction the application of pressure, which, in cases where the tumor is already large, must be preceded by a removal of the protruding mass with a scalpel. Con- sidering the state of the brain, I should also be generally- inclined to combine with such treatment copious bleeding. In one interesting case, where the whole swelling had been removed down to a level with the skull, the cut surface of the brain bled freely from numerous vessels of large size. Firm pressure was then made. The disposition to protrusion after a few days ceased. The protruded matter, which had hitherto resembled healthy brain, now put on another appearance. The exposed cerebral substance lost its na- tural colour; acquired a light yellow appearance ; was split into several portions; and a fetid odour exhaled from it. Its substance daily became softer, and the whole gradually wasted away. As the dead and putrid brain was detach- ed, fresh granulations rose up to fill the vacancy, evidently produced from the exposed substance of the brain. During these changes, which occupied several days, the boy's health was good. At each dressing of the wound, mode- rate pressure was still made. By this means, the granu- lations, filling the space before occupied by the protruded brain, became daily more flattened, and at length brought down to the level of the skull, when their cicatrization commenced, and proceeded with such rapidity, that, in a few days, the whole wound was perfectly healed, and the boy in every respect well.f Unfortunately these are generally complicated cases, the brain being deeply and extensively diseased. Thus, in the examination of one case, after death, it was found, " that all that part of the dura mater, adjacent to the ul- cerated aperture, through which the brain had protruded, • Stanley, in M<-d. Chir. Trans, vol. viii. p. 15. The pressure, which was endured without ill effects in the examples related by this gentleman, i% truly surprising. f Stanley in Med. Chir. Trans, vol. viii. p. 20—22. Vol. I. 3D W4 ENCEPHALOCELE was black, sloughy, and much thickened. The exposed surface of the brain, from which the portion had been cut off, exhibited a softened and broken down texture; a state of disorganization, which extended deeply into its sub- stance. About an ounce of fetid and dark-coloured fluid was found between the dura mater and arachnoid mem- brane, several small effusions were met with both between the membranes and in the substance of the brain. The arachnoid coat was thickened and opaque over each hemi- sphere," Sec* ?-■•*•►*© ^9 w***'*^ CHAPTER III. FUNGOUS TUMORS OF THE DURA MATER. Fungous tumors sometimes grow from the external sur« face of the dura mater, and, after destroying the super- incumbent portion of the cranium, make their appearance in the form of an external swelling under the scalp. They are generally preceded by a blow, or fall on the head, and occur at the part to which the violence was applied. As the fungus grows larger, its pressure against the skull, and particularly its pulsatory motion, derived from that of the brain, occasion a slow and gradual absorption of the bone, just in the same way as an aneurismal tumor destroys any part of a bone against which it happens to press. The portion of the cranium immediately over the swelling being absorbed, the fungous excrescence meets with less resistance; it quickly protrudes through the opening in the skull; forms a prominent tumor under the scalp; and enlarges with increased rapidity. The severe pains in the head, which precede the external appearance of the disease, become still more violent as soon as the fungus protrudes through the opening in the bone, and is irritated by the sharp inequalities of its edge. The swell- ing has a manifest pulsation, corresponding to that of the arteries, and when compressed, it either returns entirely within the cranium, or is considerably lessened. The pain then subsides, the tumor being no longer irritated by the * Stanley in Med.-Chir. Trans, vol. viii. p, 16. TUMORS OF THE DURA MATi.Il. J95 irregular circumference of the opening in the skull. If the size of the fungus be large, no relief can be thus ob- tained ; for, when an endeavour is made to reduce the tu- mor, all the alarming symptoms of pressure on the brain are immediately excited. Fungous tumors' of the dura mater constitute a very dangerous form of disease, and mostly prove fatal. Before fungus of this description has made its way through the cranium, and projected under the scalp, so that its nature and existence can be ascertained, the prac- titioner has no opportunity of attacking the disease with any effectual means. The ordinary treatment of the se- vere pain occurring in certain parts of the head, after blows or falls on the cranium, and before the fungus protrudes, has consisted of bleeding and evacuations. But when the disease has manifested itself in the form of an outward swelling, the nature of which is recognised from previous circumstances, as well as from the pain which attends it, and subsides on its reduction, and its pulsatory motion; the head should be shaved, a crucial incision made in the scalp covering the fungus, the angles dissected up, and the whole of the tumor, and the margin of the opening through which it protrudes, fairly exposed. But as it is impossible to get at the entire root of the fungus, while it is closely embraced by the cranium, it becomes necessary to saw away the surrounding bone. This object has gene- rally been accomplished very inconveniently with the tre- pan or trephine, which, while it cuts away more of the cranium than is requisite, cannot effect the removal of every part of the bony circumference, and the surgeon is obliged to break away the pieces betwixt the perforations. The best instruments for cutting away the surrounding part of the cranium, are Mr. Hey's saws. The root of the fungus being thus exposed, the next bu- siness is to cut the swelling away, which is most effectually done by carefully dissecting out the part of the dura mater with which it is connected. The excision of fungous tumors of the dura mater is far better practice, than applying ligatures or caustic to them, i'.'U *Vu(:.Ni» OF THE PACE CHAPTER IV. WOUNDS OF THE FACE. As any disfigurement of the face is peculiarly conspicu- ous, it is always a great point to prevent the formation of ugly scars upon it. Hence, it is an invariable maxim to endeavour to heal its wounds by the first intention. As cuts, confined to the soft parts of the face cannot be deep, adhesive plaster is generally sufficient to keep them closed; but, when the wound is situated in one of the lips, the part is so incessantly in motion, that surgeons find it advantageous to maintain the sides of the division in con- tact by means of the twisted suture. When the edges of the wound are much contused and lacerated, they should be pared off, to increase the chance of union, and lessen the future scar. Sabre-strokes, directed obliquely downward against the face, often produce a wound attended with a flap, which should be immediately laid down in its proper situation again. When the flap is large and muscular, a suture may be applied at one or two points. Sabre-wounds sometimes break and splinter the bones oi the face. The fracture, however, seldom extends far, be- cause most of these bones are soft and spongy. Notwith- standing this complication, the soft parts frequently admit of being evenly united, particularly if care be taken to ex- tract all the splinters, and put the surfaces of the division of the bones accurately together. Unless the fragments be quite detached, they should never be taken away, but be replaced as well as circumstances will permit. Their re- moval is not an easy matter; it occasions an unpleasant disfigurement; and experience proves, that all divisions of these bones heal with great readiness.* A very terrible sabre-wound of the face is recorded by Dr. Hennen. The weapon struck an officer nearly across the eyes, one of which it destroyed; it then divided the parts downwards and backwards, to such an extent, that the pharynx could be seen.f Yet the injury healed very * Anfangsgr. der Wundarzn. band. i. p. 24-f. edit. 3. f Obs. on Military Surgery, p. 370; also, Larrey, Mem. deChir. Militaire, t. iv. p. 20. WOUNDS OP THE PACE. 397 favourably, as indeed do the generality of wounds of the face, owing to its great vascularity. In some horrid cases, where the lower jaw is torn away by a cannon-shot, life is , preserved; but, in general, the patient sinks under the ac- cumulated tortures of his situation. " It is still, however, our duty to try every expedient; and, after the ragged parts and splinters of bone are removed, the vessels within reach « secured, and the suppurating process fairly established, we may endeavour to assist nature, faithfully following any effort she may make to fill up the chasm, but without al- lowing ourselves to count upon a showy or complete cure."* Dr. Hennen saw one dreadful case recovering, in which nearly one-half of the face had been carried away by a round-shot at Waterloo. Larrey has recorded a similar case;t and I witnessed in Holland a recovery of the same nature. It was the case of a soldier wounded at Bergen- op-Zoom, in 1814. All the lower jaw, and a large part of the upper, were in this instance completely torn away: there was very little hemorrhage, and no vessels required ligature. In injuries of this description, the usefulness of an. elastic catheter for the conveyance of food and medicines down the oesophagus, is often very great. Wounds of the lower part of the forehead or eyebrow, are sometimes followed by the disorder named ptosis, in which the upper eyelid hangs down; but they more com- monly give rise to an opposite complaint, called lagoph-* thalmos, in which, from the contraction of the cicatrix, the skin is drawn up, and the eyelid cannot cover the eye. Wounds of the eyebrow are sometimes followed by amaurosis, a case generally very difficult of cure. Wounds of the eyelids scarcely admit of an effectual ap- plication of adhesive plaster, and are generally brought to- gether with a suture. Cuts of the ear usually heal very favourably. A suture may be advantageous; but it need only be passed through the skin, and not through the cartilage. Ravaton has re- corded a case, in which the ear united again, though nearly separated from the head; and it is important in every simi- lar instance to make the attempt, since the loss of the ex- ternal ear would create an imperfection of hearing. When a part of the nose is divided, but not entirely de- tached, it is the duty of the surgeon to replace it as expe- ditiously as possible, and retain it in its situation with ' Op. cit. p. 373. t Mem. de Chir. Mil. r. iii. p. 32«. 398 WOUNDS OP THE FACE. strips of adhesive plaster, and, if necessary, a suture. Putting out of the question Garengeot's extraordinary case, to which I have elsewhere adverted, we have many facts on record, showing not only that most incised wounds of the nose admit of union, but also, that contused ones, at- tended with an almost complete detachment of the part, may often be united.* As the parotid duct passes beneath the integuments of the cheek over the masseter muscle, it is much exposed to wounds, which, if not properly treated, end in what art- termed salivary fistula?. ——»Hfi> Q fr4v«*- CHAPTER V. SALIVARY FISTULA. A salivary fistula is an opening on the cheek, from which the saliva escapes, more especially when the patient is eating or talking, and it flows out so profusely as to wet the patient's clothes. During a meal, two ounces of it have been known to escape in the short space of a quarter of an hour. The great loss every day of a fluid so serviceable in digestion, produces loss of appetite, indigestion, weak- ness, and emaciation; and the constant dribbling of the sa- liva over the adjacent parts, is at least a vexatious annoy- ance. A wound, an ulcer, or gangrene extending either to the parotid gland or duct, is the cause pf the disorder. When the first part is interested, the fistulous opening is close to the ear; when the duct itself is concerned, the aperture is on the cheek. Sometimes calculous concretions are formed in the parotid duct, like those frequently met with in the salivary ducts under the tongue. In general, they do not cause much inconvenience before they are large, when they occasion an abscess, which either bursts on the cheek, or is opened; and, if the nature of the case should not have been previously suspected, it now becomes evident, from the quantity of saliva discharged from the aperture; the * Richter's Chir. Bibliothek, 6 B., seite 538. Larrey, Mem. de Chir. Mill »©© 9«>«— CHAPTER VII. CANCEROUS DISEASES OF THE LIP. What is usually called a cancer of the lip, is met with in various forms; sometimes it has the appearance of an ulcerated, wart-like, excrescence, which occasionally be- comes as large as an apple; sometimes it is seen in the form of a very destructive ulcer, which consumes the sur- days, only wetting his mouth with cold water; at the expiration of this time, the threads were removed, and the parts found perfectly united. On the tenth day, the patient returned home, his voice materially improved.__P CANCEROUS DISEASES OP THE LIP. 405 rounding substance of the lip: and, in other examples, the disease resembles a hard lump, which at length ulcerates. The disease in its infancy is often a mere pimple, which gradually becomes malignant. Cancers of the lip are more frequent in men, than wo- men, and generally occur in the lower spheres of life. The upper lip is seldom affected. Every obstinate hardness and ill-conditioned ulcer on iiie lips, is not to be regarded as truly cancerous: many cases yield to the remedies mentioned in the chapter on cancer. Keeping the constitution under the influence of either mercury, cicuta, stramonium, or opium, maybe tri- ed ; but, I believe, generally speaking, that arsenical me- dicines are the most successful. Many ill-looking, and very obstinate ulcers of the lips, depend on the projection of a sharp rough tooth, the extraction of which is necessa- ry in the treatment. Whenever the disease is of an unyielding and truly can- cerous nature, the sooner it is extirpated the better ; and, as the action of caustic cannot be regulated with so much precision as the extent of a wound can be, the knife should be employed. The operation should be done as for the hare-lip; that is to say, the wound is to be of a shape that will allow its edges to be evenly united. Every portion of the morbid part must also be most carefully removed, lest the disease return. When the affection is extensive, the surgeon is frequently necessitated to remove even the whole of the lip, a great disdvantage, as the patient's saliva can then only be prevented from continually running over his chin, by some artificial mechanical contrivance ; the deformity is very great ;* and swallowing, and the pronunciation of words, imperfect. Many surgeons consider the operation unadvisable, when the glands under the jaw are enlarged. * Jin such cases, Messieurs Dupuytren and Richerand remove the whole lip by an incision of a semilunar form, the bleeding vessels are secured by li gatures, and the wound, dressed with charpie, is left to heal by granulation In this way, says Richerand, little deformity ensues, as the granulations shoot up in such a manner as to cover the teeth, and as it were, a new lip is pro- duced—P. E.} 406* DISEASES OF THE ANTBUMv CHAPTER VIII. DISEASES OF THE ANTRUM. The diagnosis of inflammation and suppuration in tins cavity, is at first not very clear. A darting pain is felt in the side of the face, extending from the teeth to the orbit, and unattended with any external swelling. The pain and tenderness do not affect the integuments, 'which may be handled without inconvenience to the patient. The state Of the disorder is not attended with much fever, and is usuahy regarded as a tooth-ach. In some instances, matter flows into the nose ; and, its being discharged from one of the nostrils, excites a suspi- cion of the nature of the case. But many patients do not distinguish the pus from the usual mucous evacuation ; and frequently, in consequence of the communication between the nose and antrum being closed, there is no purulent discharge whatever. The disease, when further advanced, becomes more ob- vious. The whole antrum now expands, and its parietes are rendered thinner by absorption. The expansion of the bone towards the nose may produce a complete obstruction of the nostril, or its swelling above may raise the floor of the orbit, and push the eye out of its situation. But the greatest degree of expansion commonly takes place to- wards the surface of the body; for, all collections of matter have a natural tendency to burst in this direction. At length, the abscess makes its way through the bony parietes of the antrum, and continues to be discharged through ulcerated openings. In some instances, the mat- ter finds a passage into the mouth, through one of the sockets for the teeth. Although the diagnosis is generally rendered sufficiently plain by the foregoing train of symptoms, yet writers mention a few exceptions, in which the fistulous external aperture, being situated very remotely from the seat of the disease, as, for instance, behind the ear, no suspicion of the case being an abscess of the antrum would be excited, were it not for the swelling of the cheek, &c. The most common cause of suppuration in the antrum DISEASES OF THE ANTRUM. 407 is a caries of one or more of the upper grinding teeth. The general causes, however, capable of exciting local inflam- mation in any situation, may here have the same effect. An obstruction of the opening through which the mucus flows from the antrum into the nose, may create such an accumu- lation of this secretion as shall occasion suppuration. The indications in the cure are chiefly two, viz. to pro- cure an outlet for the matter as speedily as possible; and to check the suppuration, and promote the separation of any exfoliations which are taking place. When there is a carious tooth below the antrum, its ex- traction is proper; for thus not only a source of great irri- tation is removed, but frequently a depending opening is at once made into the antrum. When the fang of the tooth does not extend quite into this cavity, the perforation must be completed with a sharp gimlet, or perforator. When alt the teeth are sound, the third or fourth grinder is to be selected. The pain and swelling, following the operation, are to be lessened by fomentations; and zinc injections into the sinus may be usefully employed. Cases present themselves, in which fleshy or bony fungi, or detached portions of dead bone, are situated in the an- trum, and in which it is requisite to make a larger opening into this cavity, than can be obtained at its lower part. In- stances also occur, in which the patients have lost tht: grinding teeth, and the sockets are quite obliterated, so that a perforation from below can hardly be effected. In such cases, practitioners have usually followed the method recommended by Bordenave and Lamorier, and which consists in perforating the malar process of the up- per maxillary bone with a small trephine. Another plan was proposed by Desault. After detaching the inside of the cheek from the bone, and exposing the surface of the latter, he drilled a hole into the sinus with a perforator, at the lower part of the fossa canina. The aperture was then- enlarged to the requisite extent with the blunt perforator; the corresponding part of the gum was cut away, and a dossil of lint was placed in the opening. For a few days the cheek was covered with an emollient poultice, and, af- ter the removal of the dressings, the cure was completed by the use of gargles and injections. The perforation was kept open a sufficient time, by occasionally introducing the little finger into it. The detachment of dead portions of bone is altogether the'work of nature: and the only way, in which the sur- 40b DISJtAS^S OF THE ANTRUM. geon can be useful, is to extract, through proper incisions, all exfoliations as soon as they are known to be loose. The worst diseases, to which the antrum is liable, are fungous and other tumors growing in its cavity, and pro- ducing first an enlargement, and then a destruction of its bony parietes. They frequently produce a complete impedi- ment to .the passage of the tears from the eye into the nose; render the eyeball itself motionless, and amaurotic; and ultimately push it entirely out of its socket. The neigh- bouring teeth also gradually drop out. A sanious fetid matter is discharged from the nostril, the puncta lachry- malia, and even the orbit. The excrescence makes its way through the palate and alveolary processes into the mouth, and, by expanding the bones, completely obstructs the nos- tril. At last, the swelling protrudes through the cheek, as- sumes a frightful aspect, and, after attaining this degree, soon proves fatal, the patient dying in a comatose state. On dissection, the greater part of the upper maxillary bone is found destroyed, while the fungous mass occupies not only the antrum, but the whole nostril. The caries sometimes extends to the os ethmoides and orbitar pro- cess of the os frontis, a good deal of the anterior lobe of the brain being also destroyed. Numerous are the unfor- tunate cases of this description on record,* and, in some of them, the want of spirit and judgment in the practition- ers consulted in an early stage of the disease, is but too ap- parent. The proper treatment is to trephine the antrum as soon as the existence of the disease is known; and to make such a free opening into the cavity, that every atom of the fun- gus can be conveniently cut out. It is an unfortunate truth, however, that this terrible disease is seldom attacked in the bold and judicious manner advised and practised by the great Desault, who saw more danger in tampering with the case, than in the most decisive measures. The main object, which this surgeon always had in view, was to remove an adequate portion of bone, so as to allow the distemper to be effectually destroyed at its root. His practice consisted in drilling a hole in the antrum with the perforator, and then cutting away the anterior bony pari- etes of this sinus Avith a strong falciform knife, construct- ed for the purpose; and, if with this instrument he could * See Flajani's Collezione d'Osservazioni a Riflessioni di Chirurgia, torn. i. p. 95, where three such cases are mentioned. Plateir.\ ife :: DISEA"LS w~ jiie ant:u:m. 40^ not remove bone enough, he scrupled not to effect his de- sign by means of a gouge and mallet. Rather than suffer the disease to remain unextirpated, he sometimes broke away part of the alveolary process with the corresponding teeth. As much of the fungus as could be cut away was then removed, and the surface from which it grew, was af- terwards carefully cauterized. In these cases, Mr. Liston's cutting forceps would be of considerable service, and ob- viate all necessity for those rough instruments the gouge and mallet.* -wt^ ^ 9**"" CHAPTER IX. FISTULA LACHRYMALIS* Whenever the tears cannot pass freely through the na- sal duct into the nose, the lachrymal sac becomes distend- ed, so as to form a preternatural tumor, situated just on one side of the root of the nose, below the internal angle of the eye. The contents of the sac, however, are not merely the tears, but also the mucus which the inner mem- brane of the tarsus and the sac itself naturally secrete. In consequence of this state, the tears cannot freely enter the puncta lachrymalia; and, every now and then, a drop of them falls from the corner of the eye down the cheek. On compressing the space between the eye and the nose, the tumor is for a time diminished, in consequence of its contents regurgitating through the puncta lachrymalia; • {For operations of this kind, Professor Gibson has had constructed a number of curved and angular scalpels, of unusual strength and thickness- We have seen him employ these instruments in several cases, and are ot opinion that they are preferable to, and will supersede the use of the "mal- k-t and chisel," in the generality of cases in which this formidable operatto-: is called for.—P. K-J • Lachrymal parts of the eye. Plate IV. fig. 1. a. b. The lachrymal sac. c. The tendon of the orbicularis palpebrarum muscle. d. Punctum lachrymale superius. e. Punctum lachrymale inferius. f. Caruncula lach'rynudis. 'g. Portion of the orbicular muscle refl-.-cfd hum \h>: su^.r- o: tn.» lachrvmal sac. Vox.. I. ' "< J: 410 FISTULA LACHRYMALIS. and also, in some measure, (when the obstruction in the nasal duct is slight,) by reason of their passing down into the nose. This is the first stage of the disease, absurdly named the fistula lachrymalis. The second stage is,when ulceration has formed in the lachrymal sac an external opening, which is prevented from healing by the contents of the sac continually oozing through it. This state sometimes induces a carious affec- tion of the os unguis, and thus the disease is rendered more complicated. In most instances, the neighbouring eye is more tender than in the healthy state, and, in some, it is always more or less inflamed. Scarpa asserts, that the chief part of the yellow viscid matter, which accumulates in the lachrymal sac, is secreted by the lining of the eyelids, and by the little glands of Meibomius, and that the altered quality of this secretion has a principal share in the cause of the disease. On the other hand, Mr. Travers considers this doctrine as hypo- thetical, for various reasons, and, amongst others, because, if it were founded on fact, it would be present in every severe lippitudo, or ophthalmia with purulent discharge, which is not the case.* TREATMENT. When the tears occasionally trickle over the cheek, in consequence of relaxation of the lachrymal points and canals, after inflammation of the eye, the disease is named by Schmidt and Beer, stillicidium lachrymarum, which is easy of cure, the infirmity often ceasing of itself at the ap- proach of warm, dry weather; and when surgical aid is re- quired, it readily yields to astringent collyria. These are to be dropped out of a quill several times a day into the eye, the patient lying down upon his back at the time, and for some minutes afterwards, in order that the operation of the remedy may not be immediately stopped.f When the case depends upon the mere obstruction of the puncta, the introduction of a small silver probe, through them into the sac, once or oftener, as may be required, is alleged to be capable of effecting a cure; but a complete obliteration of * Synopsis of the Dieases of the Eye, p. 360. f Lehre von den Augenkrankeite. , 2 • r B. p. 4!\ FISTLLA LACHRVMALIS. 411 these orifices is incurable.* With regard to the epiphora, which depends upon an augmented secretion of tears, and originates from iritability of the eye and its appendages, remaining after ophthalmy, Beer describes the complaint as generally so easy of cure, that it will subside if the pa- tient merely keep himself in a pure, dry, and if possible, warm air; and moderately exercise his eye, especially upon varying objects, &c. But, in unhealthy, irritable sub- jects, when the disorder is more obstinate, he enjoins, with the preceding plan, attention to diet, and the use of astringent collyria, the most effectual of which, he says, is composed of a solution of nitrate of silver, with a pro- portion of the acetate of lead and thebaic tincture. He also recommends the eyelids to be rubbed with the 6piri- tus aromaticus, or a mixture of eau de Cologne and tinc- ture of opium.f The first stage of the fistula lachrymalis, sometimes named in this country epiphora, and by Scarpa called the purulent palpebral discharge, may frequently be cured by- very simple means. I shall not enter into the question, whether the morbid state of the Meibomian glands, and of the internal membrane of the eyelids, is the cause, or only an effect, of the obstruction in the ductus nasalis. I think the discussion of this point quite superfluous; for, whether it be one or the other, it is proper to follow the same practice, namely, to make such applications to the inside of the eyelids, as have a tendency to improve the quality of the secretion from them, and to endeavour to restore the free passage of the tears into the nose. While the lachrymal sac is entire, that is, while the dis- ease is not in an advanced state, the most judicious plan is to inject warm water, at least once every day, into the lachrymal sac, through the lower punctum lachrymale, by means of Anel's syringe, with the view of mechanically washing away any thickened mucus, or other matter, ob- structing the nasal duct. If there be marks of inflammation in the situation of the sac, leeches may be applied. At the same time, the patient should employ a colly- rium, composed of five grains of the sulphate of zinc dis- solved in four ounces of aq. ros.; or he should introduce upon the point of a blunt probe, every morning and even- ing, between the eyelids and eyeball, a small quantity of the ung. hydrarg. nitrat. mitius. • Travers's Synopsis, p. 366. f Op. cit. p. 45. 412 FISTULA LACHRYMALIS. Perseverance in this treatment, for two or three weeks, will often effect a complete cure. When it does not, and there is no ulcerated opening already, the sac should be punctured, and the duct simply examined with a fine probe: if the probe pass without resistance into the nose, the case (as Mr. Travers correctly remarks) requires no further ope- rative treatment; the integument recovers its healthy con- dition under an emollient application, the discharge gra- dually diminishes, and the wound heals. If, on the other hand, upon examination with the probe, resistance is offer- ed to its passage into the nose, a better opportunity will not be had to overcome such resistance. This should there- fore be accomplished, and the wound afterwards suffered to heal, without further disturbance.* I consider, that the mild, unirritating treatment, here adopted by Mr. Travers, in preference to that of keeping an extraneous substance in the duct for several weeks, in every respect judicious. However, when the passage of the probe is so firmly re- sisted, that a good deal of force is necessary to get it down into the nose, some measure is afterwards indispen- sable to prevent the newly-opened duct from closing again. For this purpose, Mr. Travers introduces a small silver probe, from either of the puncta lachrymalia down the nasal duct into the nostril. Many recent cases, in which the structure is not very firm, he says, are completely cured by the passage of the instrument three or four times, at intervals of one or two days. When the case is not cured by this method, he introduces a style through the punctum into the nose, and leaves it in the duct twen- ty-four hours. A day, or two, are suffered to elapse, be- fore the style is introduced again, which is done through the other punctum. On the intervening days, tepid water is injected with Anel's syringe. Whenever the water flows into the throat in a full stream, the further use of the probe is unnecessary; but, if the tears and mucus should not readily pass into the nose, astringent lotions may be injected, and the vapour of vinegar, or of diluted nitric acid, inhaled up the nostril.f The silver style, employed by the late Mr. Ware, (Plate 4. figs. 2. and 3.) has a flat head, like that of a nail, only placed obliquely, in order that when it is situated in the duct, the top may lie in close contact with the skin covering the sac. For an adult, it should be about an inch and a quarter, or an inch and • Synopsis, &c. p. 364. f Op. cit. p. 375. VISTULA LACIIRYMALIS. 413 three-eighths in length. A small puncture is made in the sac, when there is no external opening, or this is unfavour- ably situated. A small prt)be is now introduced down the lachrymal sac and nasal*duct into the nose. The passage is then kept from closing by putting the style into it, and leaving it there. It is to be withdrawn and cleaned twice a week, and warm water injected through the external opening down into the nose. At the end of six weeks, the style may in general be left off, and the aperture healed.* Surgery, I consider to have been truly improved by Mr. Travers's observations on the former officiousness with styles, the keeping of which in the nasal duct for several weeks, can, indeed, be rarely proper.f The occasional pas- sage of a small probe is certainly better practice; but, for fear of doing permanent injury to the lachrymal puncta and canals, I should prefer introducing the instrument through a small puncture in the skin and sac. When the os unguis is carious, it may sometimes be pro- per to make a larger opening into the sac, in order to re- move any tedious exfoliations. But, now that the practice of cramming the sac with tents, escharotics, &c. has given place to the mild methods above explained, disease of the bone is found to be a rare occurrence. The perforation of the os unguis, for a new passage into the nose, I think with Mr. Travers,f: can hardly ever be so judicious a plan, as that of restoring the natural channel, or of forming one as nearly as possible in the same direction. * {M. Dupuytren, of Paris, instead of the style, inserts into the lachrymal canal a metallic tube, over which the integuments are to be healed. Mr. I) states as the result of his experience, that this operation is successful in nine- teen cases out'of twenty. The instruments employed in the operation are a straight bistoury, a can nula of silver, gold, or platina, and a parte-canule, to which the cannula is af- fixed for being more conveniently inserted in the lachrymal canal. The length of thr cannula is one inch; its upper opening measure one-tenth of an inch; the tube gradually tapers from its upper to its lower opening, the diameter of which measures one-twentieth of an inch; the lower opening ib placed obliquely, and the upper opening is surrounded by a small rim, to prevent its sinking too low into the duct.—P. E } + J Dr. Physick iuiputes the occasional failures with the straight stile ot Mr. Ware, to a distorted state of the ductus ad nasum, the lower extremity of which operates like a valve in preventing the passage of the tears. To remedy this, he introduces a small bougie, made with fine cambric linen, i.uo the canal, and allows it to remain until it has acquired the precise form of this duct, and from this, as a model, he has constructed a block-tin stile, * hich is worn like that of Mr. Ware. He has thus succeeded in a few weeks, after the straight stile hasbfen unavailingly worn for a year or more,—P. E.J t Synopsis, &.c. p. ."572, 414 DISEASES OF THE ETELips CHAPTER X. DISEASES OF THE EYELIDS. INFLAMMATION OP THE LINING AND MARGINS OK THE EYELIDS. In this section, are comprised the cases, to which the terms catarrhal inflammation of the eyelids, psorophthalmia, and lippitudo, are applied ; the two latter, however, only to certain stages of the disease. According to Mr. Law- rence, catarrhal inflammation of the eyelids begins with soreness, smarting, burning, and dryness of their margins, which become red, swelled, and painful. The palpebral conjunctiva is at the same time red, and perhaps villous. As the motions of the eye create great uneasiness, with a sense of stiffness or dryness, the eyelids in an acute attack are kept shut and quiet. Reading and writing, particular- ly before the fire, bring on pain. A mucous discharge soon takes place from the inflamed membrane, and the pain is then succeeded by itching, (psorophthalmia.) The Meibo- mian glands participate in the affection, which begins on the ciliary margin of the eyelids. They no longer pour out the mild unctuous matter, which usually softens the edges of the eyelid, but their secretion is suspended, so that, in the morning, these edges are rendered adherent by the increased conjunctival discharge, which has become incrusted by the evaporation of its watery part during the night. Thus the eyelids are often so firmly agglutinated together, as to require long bathing with warm water be- fore they can be parted. When the Meibomian secretion is renewed, its viscidity is increased, and consequently it assists in gluing the lids together, while its diffusion over the cornea affects its polish, impairs vision, and leads the patient to ask for something to clear it. Hence frequent attempts to clear the cornea by moving the eyelids; and hence, when vision becomes worse in the evening exacer- bation of the symptoms, rings, haloes, and irides are seen round the candle, or its flame splits into stars. At the same time, the uneasiness, smarting, or itching, the stiffness, red- ness, and mucous secretion, are increased. The ciliary mar- gins become raw. The eyelids, particularly towards their DISEASES OP THE EYELIDS. 415 angles, and the lower eyelid more especially, are irritated by the nature of the discharge, excoriated, and even ulcerated. This, which is the chronic form of the complaint, and call- ed lippitudo, often lasts for many weeks, months, or years; recurring on the application of slight causes, whether ex- ternal or internal; often originating insensibly, and ad- vancing slowly, without any marked acute stage ; leading to thickening of the eyelids, especially of the mucous lin- ing of the lower one, and consequent ectropium of that lid, and loss of the cilia. The causes of this disorder are referred by Mr. Law- rence to atmospherical influence, exposure of the eyes to cold and wet weather; residence in close smoky apartments; and employment of the eye by candlelight, &c. The ope- ration of these causes, he says, is increased by neglect of cleanliness, indulgence in fermented liquors, and inatten- tion to the state of the bowels. In the acute, or incipient stage, Mr. Lawrence recom- mends the application of leeches to the eyelids, tepid lo- tions, mild ointments, and active aperients, and afterwards alteratives and gentle purgatives. The taking of blood from the temples by cupping may sometimes be necessary, and the repetition of leeches is frequently so. Blisters may afterwards be used. The organ must be rested, and the exciting causes removed. In the chronic stage, Mc. Lawrence employs astringents and stimulants, and free scarification of the inside of the eyelid. The vinum opix and metallic salts in solution may be used; but the unguen- tum hydrargyri nitrati, or the red precipitate ointment, weakened with an equal quantity or two thirds of ung. eetacei, is preferred. It i9 to be applied with a camel- hair pencil to excoriated edges of the eyelids, which should be previously freed from all incrustations, after they have been duly softened with tepid water. The disease is sometimes rendered obstinate by compli- cation with a scrophulous constitution, in which circum- stance, alterative medicine, the warm bath, the flesh brush, regular exercise, warm clothing, and blisters kept open be- hind the ears, may be tried. GRANULAR CONJUNCTIVA, Is mostly an effect of severe purulent ophthalmy, and con- sists of a rough, hard, granulated state of the lining of the eyelid, attended with a thin or puriform discharge; a van- 416 DISEASES 01' T1IL LVELID^. cose affection of the vessels of the sclerotic conjunctiva; a nebulous appearance of the cornea; a sensation as if sand were lodged under the eyelids; great tenderness of the organ, and inability to bear the light; and an 'incessant epiphora. In recent cases, the cure may be obtained by applying • leeches to the vicinity of the eye, and putting on the dis- eased part of the lining of the eyelid, once or twice a day, with a camel-hair pencil, a little of the ung. hydrarg. nitrat. When this application fails, the sulphate of copper, or nitrate of silver, may be applied; and for this purpose, as Mr. Welbank has rightly observed, the eyelids should al- ways be completely everted, as there is sometimes at the angle, where the conjunctiva passes from the globe to the lid, a semilunar fringed fold, not unlike a cock's comb,* which might otherwise not be discovered. After the use of caustics, the part must always be well washed with te- pid water, before being returned into its natural position. When the granular productions are hard, callous, and pen- dulous, some writers prefer excision to caustic. CONCRETIONS OF THE EYELIDS, Are of two kinds; one, termed symblepharon, in which the lining of one or both eyelids adheres to the eyeball; the other named ankyloblepharon, in which the two eye- lids adhere at their edges. The two states frequently ex- ist together. The last form of the complaint is sometimes, though rarely, an original malformation. It is most frequently produced after birth by violent ophthalmies, burns, &c. When the edges of the eyelids have grown together, the oreternatural connexion is to be divided with a bistoury, care being taken not to wound the eyeball. The cut sur- faces are then to be kept asunder by the interposition of lint dipped in sweet oil, or by supporting the upper eyelid with a strip of court plaster, until they have healed. When the edges of the eyelids have grown together, from the outer to the inner canthus of the eye, it is of no use to separate them, if the cornea be known to be perfectly opaque. It is only when the adhesions between the eyelids and eyeball are loose, limited to a small extent, and not • See Frick on Diseases of the Eye, p. 240, note. DISEASES OF THE EYELIDS. 417 situated over the cornea, that it is very practicable to do good by an operation. ECTROPIUM. • A turning out of the eyelids is so named. The lower one is most frequently affected, its edge falling downwards and forwards away from the eyeball, which is no longer duly covered and protected.* The exposure of the lower portion of the eye, and of the conjunctiva of the eyelid, produces in these parts a species of chronic inflammation, attended with constant pain, and redness, and thickening of the membrane, which is at length converted into a hard callous substance, lying just under the globe. As the flow of tears towards the inner angle, and through the puncta lachrymalia, is obstructed, they fall over the cheek, which is sometimes excoriated. One of the most common causes of this disorder is a contraction of the integuments of the eyelid, or neighbour- ing part of the face, after the cicatrization of burns, ul- cers, and wounds. In this case, dividing the contracted skin will not give permanent relief, as the new granulations will be absorb- ed, and the usual contraction again follow cicatrization. The difficulty of curing this form of ectropium led Sir W. Adams to cut out a triangular portion of the tarsus, and then unite the divided parts with a suture, by which means the deformity and all its inconveniences were materially lessened. Another plan, which I should generally prefer to this, is the removal of a considerable portion of the thickened lining of the eyelid, with a convex bistoury, and a pair of dissecting forceps. Afterwards, in proportion as the wound heals, the eyelid, with the aid of a compress and bandage, returns to its natural position. Care must be take,n not to cut the puncta lachrymalia. The eyelid is drawn inward again by the same principle which caused its eversion, viz. the contraction of the cicatrix.f Another species of ectropium, mostly met with in old persons, and arising from relaxation and swelling of the conjunctiva, and a fungous thickened state of the lining of the eyelid, if not in a bad degree, maybe cured by turn- ing the eyelid completely out, and rubbing the argentum nitratum along its fungous surface, until a slough is pro- • Plate 4, fig. 4. t Plate 4, fig. 5. Vol. I. 3 G 'US DISEASES OF THE EYELIDS. duced. The eyelid must be everted until the caustic has been washed off the slough, and the part smeared with oil. Applications, calculated to remove the relaxed state of the conjunctiva, and a compress and bandage for the sup- port of the eyelid, will complete the cure. A slight, recent ectropium, caused by purulent ophthalmy, will generally yield to mild astringents. When the lining of the eyelid i6 quite hard and callous, its excision should be preferred. TRICHIASIS, Is of two descriptions; in the first, there is no defect of the eyelid, and the whole grievance depends entirely on the wrong direction in which the eyelashes grow; in the other, the defect lies altogether in the eyelid itself, the margin of which turns towards the eye, so that the cilia rub against the front of this organ, and produce consider- able inconvenience. The latter case, which is by far the most common, is termed entropium. When the upper eyelid is inverted in the slightest de- gree, a distressing irritation of the eye is occasioned; but when a large portion of the lid is inverted, the case be- comes truly afflicting. The friction of the cilia against the eye is incessant, and from the continual suffering, the pa- tient's health and strength decline. The cornea ulcerates and becomes opaque, and the sight is ultimately destroyed. Nor is this the end of the patient's misery, unless the cornea become thickened and indurated in an extraordina- ry degree, assuming a white appearance, like that of a ma- cerated ligament, in which case, the patient finds ease in the insensibility of this new-formed substance. The appearance of the disease, in its inveterate form, is truly disagreeable. The discharge, the copious flow of tears, the excoriation of the cheek, the opacity of the cor- nea, the villous, granular, or fungous conjunctiva, com- pose altogether a disgusting sight. The patient carries his head obliquely, and attempts, in the most awkward man- ner, to direct the pupil towards the objects which he wants to see; indeed, when the upper eyelid is inverted, the patient, in order to avoid turning up the eye, distorts his head, and seems as if he had a wry-neck.* The usual cause of the distorted position of the cilia is * See Saunders's Treatise on some Pract. Points relating to Diseases of 'the Eye, &c. pp. 45—48, DISEASES OF THE EYELIDS. 419 cicatrices near the edges of the eyelids, after strumous ophthalmy, inveterate and neglected cases of psorophthal- mia, &c. In consequence of inflammation or ulceration, the hairs fall off, and when they grow again, they shoot in a wrong direction. Trichiasis, if not relieved, generally destroys the sight, for the friction and pressure of the hairs against the eye occasion severe pain, constant in- flammation, and, at length, ulcers, and complete opacities of the cornea. The cure of the first description of trichiasis consists in plucking out the inverted hairs, and preventing their re- production in the same direction, by smearing the whole inner half of the margin of the. eyelid, by means of a ca- mel-hair brush, with the liq. ammon.; or a solution of the argentum nitratum ; or else by removing a piece of the skin, containing the roots of the inverted cilia, as proposed by Mr. Saunders. The second kind of case, called entropium, is the most frequent. In the upper eyelid, the defect may be owing to a relaxed state of the levator muscle, or integuments of the part, in which circumstance, it may sometimes be cur- ed by supporting the eyelid, for a certain time, with stick- ing plaster; but if this plan fails, a cure may generally be accomplished by cutting away a fold of the integuments near the edge of the tarsus. This should be done exactly in the middle of the inverted part, and the best instru- ments for the purpose are a pair of curved scissors, and the forceps invented by Bartisch. The wound is then to be closed with sticking plaster, compresses, and a band- age.* In proportion as the contraction of the cicatrix fol- lows, the tarsus is restored to its right position. Another ingenious treatment is that of producing a con- traction of the skin of the eyelid, by means of strong sul- phuric acid,f which is to be applied by means of a piece of smooth solid wood to the centre of the affected part of the lid, and rubbed along on an oval space, a little longer than the extent of the inversion of the hairs, and from three to six lines in width, according to the inveteracy of the disease. After the acid has been applied about ten * See Scarpa's Osservaz., &c. sulle Principali Malattie degli Occhi, pp. 76—78. edit. 8vo. ?• {Dr. Darrach, one of the surgeons of the Pennsylvania Eye and Ear In- ution, has cured entropium by pure nitric acid, applied with a camel's hair brush, near the roots of the evcta«!i«s See American Med. Recorder vol. vii. p. -I-' —P. E.J ■120 DISEASES OF THE EYELIDs. seconds, the part is to be dried. In general, three or four applications in this manner will bring the hairs into their natural position.* More difficult cases, however, are met with, arising from an alteration in the shape of the cartilage of the eyelid. For these the common plans will not suffice. In one exam- ple of this kind, Dr. Crampton effected a cure by making- two perpendicular incisions in the broad margin of the tar- sus, at the sides of the inverted hairs, and then making a transverse cut through the lining of the eyelid, from the ex- tremity of one of the first wounds to that of the other. The inverted portion of cartilage, within the incisions, was then put into its right position, and retained so with sticking plaster.f In very bad cases, in which Mr. Saunders conceived the vicious shape of the tarsus made the restoration of its na- tural position totally impracticable, he performed its exci- sion; but the operation, which is severe and apt to leave disfigurement, is not in general considered so eligible as that suggested by Crampton. Other plans of relieving entropium have been proposed; but the preceding seem to be those which deserve notice in an elementary work. If an inversion of the lower eyelid were to proceed from the orbital edge of the tarsus being pushed out by an en- cysted tumor, or by a chronic thickening of the conjuncti- va, the removal of the tumor, or thickened membrane, and the use of a compress to keep the orbital edge of the tarsus inwards, would effect a cure. PTOSIS. This disease consists in an inability of properly raising the upper eyelid. Three varieties are noticed: the first de- pends on a preternatural elongation of the skin of the up- per eyelid; the second, on weakness or total paralysis of the levator muscle; and the third, on a spasmodic contrac- tion of the orbicularis palpebrarum. The first example is the most frequent, and is cured by the removal of the redundant integuments of the eyelid. The second species is principally met with in old per- sons, in whom the cure is often impracticable. It is some- * See Guthrie's Operative Surgery of the Eye, p. 30. f Essay on Entropeon, p. 55. DISEASES OF THE EYELIDS. 121 times symptomatic of hydrocephalus, and apoplexy, inju- ries of the head, chlorosis, worms, &c, while in other ex- amples it is entirely a local defect. The chief means of cure are, bathing the eyelid and fore- head with cold water; the shower bath; friction with cam- phorated mercurial ointment, or liniments, strengthened with the tincture of cantharides ;* electricity; an issue be- tween the mastoid process and angle of the jaw; the exhi- bition of bark and other tonics. But, in every instance, the cure will depend upon the possibility of removing the ori- ginal disease, of which the paralysis of the evelid is an ef- fect. Ptosis from a spasmodic affection of the orbicularis mus- cle is the least frequent, is never continual, but makes its attacks at certain or uncertain periods, and its duration va- ries in different cases. The spasmodic ptosis is sometimes an effect of epilepsy, hysteria, worms, &c, in which cases the treatment should be directed to the original complaint. As a general obser- vation, it may be said, that the affection of the eyelid re- quires aperient medicines, antispasmodics, blisters behind the ears, and bathing the eye with a warm decoction of poppy-heads. HORDEOLUM, OR STYE, Is always situated at the edge of the eyelids. It is a verv small circumscribed tumor, about the size of a barleycorn. An inflamed stye is extremely red and painful; and is ven. similar, in every respect, to a small boil. The cure of an inflamed stye demands the external em- ployment of emollient applications; for the tumor always suppurates, and the more this is promoted, the sooner is the patient freed from inconvenience. Even when the stye has already suppurated, emollients are the best appli- cations, until the hardness has subsided. When the sup- puration has terminated, a weak solution of the acetate of lead may be used to disperse the remaining redness and swelling. The indurated stye, as it is called, occasions a good deal * J Dr. Darrach has also remedied this affecti»n by the pure nitric acid ap- plied in the course of the wrinkles on the upper eyelid. Its effect was to contract, very gradually, the skin, and thus raise the lid without the puck- ering consequent on the operation by the actual cautery, of the welt left, bv the mode of incision.—P. E \ 122 DISEASES OF THE EYELID^ of inconvenience, by frequently inflaming and becoming painful, hindering the motion of the eyelids, and prevent- ing the free enjoyment of sight. The best mode of curing this disease, is to touch the little induration with the ar- gentum nitratum, until it is destroyed. ENCYSTED TUMORS OF THE EYELIDS. These are most frequently situated immediately under the skin, but sometimes they lie so deeply, that they can be taken out more easily from the inside, than the outside of the part. They seldom become very large, and are more commonly observed on the upper than the lower eyelid. When they have attained a certain size, they hinder the ele- vation of the eyelid, and occasion ptosis. They can only be safely extirpated with a cutting instrument. Scarpa is an advocate for removing the generality of them, by making the incision through the lining of the eye- lid, which practice is decidedly right when the tumor is deep-seated within the eyelid, or beneath the orbicularis and levator muscles. Care must be taken not to cut the tendon of the trochlearis. However, if the tumor be on the outside of the cartilage of the eyelid, the wound should generally be made through the integuments. —w«®6«...— CHAPTER XI. OPHTHALMY, OR INFLAMMATION OF THE EYE* Of all the disorders of the eye, inflammation is the most frequent; and there are few diseases of this organ, with which it is not sometimes connected, either as cause or ef- fect. It has only been of late years, however, that its va- rious forms have been well discriminated; for ophthalmy was a term applied to all inflammations of the eye, whe- ther the. eyelids, the conjunctiva, the sclerotica, the iris, or the retina, were the Structure chiefly concerned; and al- * For some valuable observations in this chapter, I am indebted to Mv. Lawrence's Lectures. OPHTHALMY. 123 though the epithets mild and severe, dry and humid, external and internal, were frequently used, the more valuable dis- tinctions deducible from the structure principally affected in different examples, and the characteristic symptoms of each variety, were altogether overlooked. As my friend Mr. Lawrence has observed in his excellent lectures, in- flammation of the eye generally commences in one struc- ture, to which it is at first restricted, and beyond which, if it be rightly treated, it does not usually extend. But, if it be neglected, or wrongly treated, it soon exceeds its original limits, and, perhaps, ultimately invades the whole organ. Inflammation of the whole eyeball, or common inflamma- tion, seated both in its external and internal structures, when fully developed, is characterized by very considerable pain, increased external redness, more or less swelling of the whole organ, an augmented secretion from the lachrymal gland, and redness and swelling of the upper eyelid. The pain is not confined to the forepart of the eye, but is deep- seated, and extends to the eyebrow, cheek, temple, and back of the head. In the commencement, the redness is inconsi- derable, and chiefly in the vessels of the sclerotic'coat; but the conjunctiva very quickly participates in the inflam- mation, and the distention of its vessels produces the bright scarlet colour, which conceals the fainter pink tint of the sclerotica. The conjunctiva then begins to swell, and a deposition of coagulating lymph (not blood, as is commonly stated) takes place, not only in the texture of the membrane, but in the loose cellular tissue which unites it to the sclerotica: this very red, circular projection, of the conjunctiva round the cornea, giving the latter mem- brane a sunk appearance, and even sometimes partly con- cealing it, has long been known under the name of che- mosis. Light is very offensive; so that the pupil contracts to exclude it; and the eyelids are spasmodically closed. As all motion of the organ gives pain, the patient keeps it as much as possible at rest. In the beginning, the organ is rather stiff and dry, but this state goes off, and is suc- ceeded by a copious lachrymal discharge, which is much increased if the eye be exposed to the light, or any exter- nal irritation. In a more advanced stage, various changes of structure are observable. The colour of the iris is altered, its bril- liancy disappears, and its usual motions in different de- grees of light are interrupted. The pupil diminishes, and ) 424 OPHTHALMY. loses its clear black colour. The cornea becomes more or less opaque, and vision is lost, sometimes from this cause, and the closure of the pupil; sometimes from injury of the retina, as when sight is destroyed, though the cornea and pupil do not completely obstruct the light; and, frequently, from all these circumstances together. Although the internal parts of the eye, generally, cannot be seen to be inflamed, no doubt can be entertained of the fact, when it is considered that the eyeball is actually increased in size, the structure of the iris changed, and the sensibility of the retina lost. The thickened eyelids protrude ; ectropium of the low- er one takes place; and a portion of the front of the eye projects, like a piece of red flesh. < So violent an affection of a vascular and sensible organ, situated in the immediate vicinity of the brain, necessari- ly produces a great deal of constitutional sympathy, or in- flammatory fever. If the case be not checked, the pain becomes throbbing, rigors occur, and suppuration of the eyeball takes place, the cornea assuming first a dull white, and then a yellow •colour; No relief is experienced until the cornea bursts, and the collected matter is voided, with which the vitre- ous humour, and crystalline lens usually escape. The eye then shrinks into the orbit, its original form being com- pletely destroyed. When the disease does not proceed quite so far, the patient escapes with opacity of the cor- nea, and a closed pupil, vision being either lost, or seri- ously impaired, but the natural figure of the organ continu- ing. Even in the most favourable terminations, when the cornea is clear and the pupil open, the retina has ge- nerally suffered so much, that vision remains more or less imperfect. No hope can be entertained of preventing change of structure in the organ, and consequent loss of sight, unless the case be actively treated in its early stage. When chemosis is formed, the cornea cloudy, the colour of the iris changed, and the pupil contracted, the patient is likely to lose his sight.* Inflammation of the external proper coats of the eye varies considerably in degree, from a slight affection of the con- junctiva, to acute inflammation of it, with chemosis, and similar inflammation of the sclerotica and cornea. In sim- * See Lawrence's Lectures on diseases of the Eye. OPHTHALMY. 425 pie inflammation of the conjunctiva, there is little pain or inconvenience, and no danger to the organ; but, the firmer textures of the sclerotica yield to distention, only slowly and painfully, and their vessels do not easily recover, so that inflammation is more difficultly subdued; while the implication of the cornea, and the ready transition of in- flammation to the iris, expose the organ to serious dan- ger. Inflammation of the external proper tunics of the eye is attended with outward redness, pain, intolerance of light, increased lachrymal discharge, and more or less febrile disturbance. The external redness begins on the front of the globe, immediately round the cornea, where it forms a red zone, to which numerous vessels tend over the scle- rotica from the back of the eyeball. In inflammation of the conjunctiva, the redness begins at the circumference of the organ, its anterior part being comparatively free from it, and the sclerotica retaining its natural white appearance. The discharge is also of a. muiuus nature. The character of the red tint differs remarkably in the two cases. The vessels distended in sclerotic inflammation, being seen through the conjunctiva, have a dark-red rose or lively car- mine appearance,* which forms a striking contrast to the bright scarlet tint of the vessels distended in conjunctival inflammation. The vessels of the sclerotica always follow the motion of the eye, a circumstance peculiarly character- istic; those of the conjunctiva, on the other hand, are ca- pable of being moved without any motion of the eyeball itself.f The conjunctiva soon participates in the affection; the cornea looks dull; it is not actually opaque, but its polish is impaired. A stiffness and dryness of the eye, with a sort of burning or aching pain, tension, and pressure; or an uneasiness, similar to what would be produced by sand or gravel in the eye, is felt; and as the disorder in- creases, the pain grows more severe, and extends to the back of the head, and nearest temple. Intolerance of light is a strongly marked symptom of inflammation of the scle- rotica ; and forms another striking contrast between this affection and conjunctival inflammation; for, in the latter, the patient generally opens his eye freely, and experiences no pain from the access of light. In violent cases of inflammation of the outer proper coats * Frick on Diseases of the Eye. New edition, p. 59. Lond. 1826. f It. Welbank, Op. cit. p. 14 Vol. I. 3 H 426 OPniHALMT. of the eye, chemosis takes place, and the cornea loses its bright polished appearance, and turns greyish. The eyelids are also affected, their conjunctival lining becoming red and inflamed. Although the eye feels dry and stiff at the commencement of the case, the lachrymal secretion is soon restored, and even augmented, so that whenever the eye is opened, there is a copious flow of irritating tears. When the disorder becomes still worse, the cornea first turns greyish, and, on the occurrence of chemosis, white, cloudy, and, lastly, yellow, as if pus were deposited in its texture. The yellow substance, however, is not fluid; nei- ther does it make its way to the surface like pus; but the cornea ulcerates, and the deposited matter is removed by ulceration. A similar deposition may take place in-the anterior chamber, producing what is termed hypopium. When the cornea is affected in this manner generally, the ulceration commonly extends into the anterior chamber at several points; the aqueous humour escapes, and the iris comes in contact with the inflamed and ulcerated cornea, and is often protruded in one or more places. When the inflammation subsides, the cornea is left opaque, the iris ad- herent to it, the anterior chamber is abolished, and vision irrecoverably destroyed. If matter be deposited only at one point of the cornea, ulceration may be stopped by active treatment, the cornea nearly regain its natural appearance, and vision be restored entirely, or with little defect. The degree of danger will depend on the state of the cornea; when this is not affected, or but slightly, there is no danger. If there be chemosis, and the cornea be grey, or white, or if a yellow deposition has taken place in its texture, followed by ulceration, ckc. sight will be more or less impaired. Causes of inflammation of the eye.—Wounds, and other kinds of external violence ; the irritation of extraneous sub- stances lodged under the eyelids; immoderate exertion of the organ, particularly in viewing minute shining objects, and in hard study by candlelight; exposure of the eye to a glare of light reflected from the sea, or a snowy, sandy, or chalky country; the sudden impression of a flash of light- ning ; and certain states of the atmosphere. Mechanical and chemical injuries of the eye necessarily produce more or less inflammation in all individuals; but atmospherical influence, a redundance of light, and great exertion of the organ, will not excite the complaint in every person. Be- sides these latter exciting causes, therefore, some predis- OPHTHALMY. 427 posing state of the part or constitution must exist, without which the eye will not be inflamed by them. In the list of predisposing circumstances, writers mention fulness of habit, or plethora; a disordered state of the digestive or- gans ; intemperance, producing an increased circulation, and an augmented distribution of blood to the head and eyes; the cessation of habitual discharges; sedentary occu- pations; and costiveness. Treatment.—The fir A duty is to remove, if possible, the cause of the inflammation of the eye, as may be accom- plished when extraneous substances are in contact with the organ. The eye should first be examined in a good light, and, if nothing be discovered on it, the lower eyelid should be depressed, and the inferior portion of the globe brought into view by the patient's looking upward. If no particle of extraneous matter can be detected in this way, the patient should turn the eyeball downward, and the upper eyelid be raised, so that the upper portion of the globe may be seen. In most cases, the extraneous body lodges in the concavity of the upper eyelid, which is then to be everted. The eyelashes are first to be taken hold of, and the eyelid drawn downwards, and while steady pressure is made against its upper part, its ciliary margin is to be carried upwards and backwards. When small particles of metal stick in the cornea, tbey should be removed with the point of a cataract needle. In bad cases, the eye must re- main perfectly at rest in a darkened room; and even in slight ones, reading, writing, &c. should be discontinued, though the eye need not be kept in the dark, or covered up. As soon as the patient can bear a moderate light, without inconvenience, it is an excellent rule to remove all coverings from the eye, except a green shade, and ad- mit every day into his chamber a brighter light; so that he may be habituated, as quickly as possible, to the open day-light; for nothing has a greater tendency to prolong an irritable, weak state of the organ, than keeping it long in a dark situation, and unexposed to the air. Bleeding is the chief means of subduing the above- described forms of ophthalmic inflammation. The blood should be taken from the arm, and, in severe cases, the quantity taken away should be sufficient to induce faint- ness when the disorder will receive an immediate and de- cided check. This practice is necessary in inflammations affecting the whole eyeball, in those which attack the ex- 42S OPHTHALMY. ternal proper tunics of both eyes, or are violent in the same tunics of only one of them. The next most efficacious method of taking away blood, Mr. Lawrence finds to be cupping, either on the back of the neck or temple; which he deems more certain and convenient, than opening the temporal artery or jugular vein. To the latter situation, however, he gives the pre- ference, because some branches of the temporal artery are commonly wounded, from which an adequate quantity can always be readily obtained. In severe cases, the repetition of venesection is sometimes necessary, but cupping still more frequently. Leeches are useful, and may be put either on the eyelids, the temple, eyebrow, or just below the inner commissure. On the eyelids, however, they of- ten produce a kind of ecchymosis, on which account, some practitioners apply them to other parts near the eye. Sca- rifying the conjunctiva, a plan formerly in common use, is condemned by Mr. Lawrence in every instance of ac- tive inflammation, as more likely to do harm than good; a sentiment in which I fully coincide. In addition to bleeding, every other part of the anti- phlogistic system will be requisite, as low diet, and purg- ing with calomel, combined with rhubarb, extract of colo- cynth, or jalap, or followed by infusion of senna, salts, and manna. Saline medicine, with antimony, or nitre, is af- terwards to be given to promote perspiration, and keep the bowels regular. After evacuations, blisters may be applied to the back of the neck, or behind the ear; but, when the inflamma- tion is active, not nearer to the affected organ; a valuable remark, particularly insisted upon by my friend Dr. Vetch. With respect to topical applications in acute ophthalmy, their efficacy is certainly inferior to that of bleeding, and the rest of the foregoing measures; but, it is customary to employ them. I am of opinion, however, with my friend Mr. Lawrence, that a poultice is an inconvenient applica- tion to the eye, and, perhaps, generally more hurtful by its pressure and its total exclusion of the light and air, than truly useful. In the very acute stage of ophthalmy, there- fore, a tepid collyrium, composed of about five grains of the sulphate of zinc, or acetate of lead, dissolved in four or six ounces of rose-water, may be used in an eye-cup; and, if the case be very severe, and attended with vio- lent head-ach, a strong decoction of poppy-heads may be employed as a fomentation. In proportion as the irrita- OPHTHALMY. 429 bihty of the eye diminishes, the warmth of the collyrium should be gradually lessened, until it can be borne quite cold. When the acute form of the complaint has complete- ly subsided, thef cure may often be accelerated by intro- ducing between the eye and eyelids, once or twice a day, two or three drops of the vinous tincture of opium. The premature employment of this application, however, while great tenderness of the organ and aversion to light exist, is never advantageous; nor is it in any circumstances su- periorly useful to other stimulating fluids of the same de- gree of strength. With the view of relieving severe acute ophthalmy, and preventing opacity of the cornea, when the case is attend- ed with a sense of distention in the eye, and cloudiness of the cornea, Mr. Wardrop sometimes makes a small punc- ture in the anterior chamber, and lets out the aqueous hu- mour; a proceeding which he also recommends when there is the smallest quantity of pus in the same chamber, attended with inflammation. Various opinions are enter- tained of the usefulness of this practice ; but it is certain- ly one that is not at present very commonly followed. Neither is the treatment with nauseating and purgative doses of tartarized antimony much adopted, a plan so highly commended by Scarpa. When, in severe cases, a yellow substance is effused in the anterior chamber, the quick exhibition of mercury, as well as the continuance of antiphlogistic remedies, is urgently necessary. When inflammation of the proper coats of the eye h■<[<■• attained its chronic stage, or, according to Mr. Lawrence's view of the subject, when its degree has lessened, the question is, whether an attempt should be made to restore the tone of the organ by astringent applications, tonic me- dicines, liniments to the eyelids and eyebrow, and the va- pour of the spiritus ammon. comp. to the eye itself, assist- ed with a strengthening diet, good air, and gentle exer- cise; or whether the continued use of cupping and leech- t-s, and the insertion of a seton in the temple, with a re- gimen and medicines adapted to the particular state of the constitution, will answer best ? This is a point, on which high authorities differ. Inflammation of the conjunctiva presents itself either in a mild or severe form: the first case is named by Beer, ca- tarrhal ophthalmy; the second comprises all the varieties of purulent ophthalmy, as it is customarily called in this country. Catarrhal ophthalmy generally commences with 430 OPHTHALMY. stiffness and smarting, or a sensation as if sand had got into the eye, some uneasiness on exposure to light, a wa- tery state of the eye, and external redness. When fully developed, it is characterized by redness? increased mu- cous, not lachrymal, discharge, inconsiderable pain, and no intolerance of light. The redness is superficial, and of a bright scarlet colour, forming a striking contrast to the rose or pink tint which belongs to the inflammation seated in the sclerotica. The distended vessels are quite superfi- cial, and of a scarlet colour. They may be readily pushed aside by moving the eyelids. The redness is generally in patches, the membrane having a mottled appearance ; but, in the fullest development of this affection, the whole sur- face becomes of a bright red. The redness begins at the circumference of the globe, and gradually advances to- wards the cornea; but at first it is confined to the palpe- bral conjunctiva, or to the angle of reflection. In severe cases, little ecchymoses are sometimes seen in the conjunc- tiva, denoting the activity of the inflammation ; and some- times small vesicles, containing a serous fluid, are form- ed, usually near the margin of the cornea. Catarrhal ophthalmy produces much swelling of the con- junctiva, yet nothing like chemosis, the only approach to which is a loose serous effusion, raising the mucous mem- brane from the sclerotica. When the lachrymal discharge, observed in the very commencement, stops, its place is supplied by increased secretion of mucus, which is at first thin, but becomes thicker as the inflamed conjunctiva goes through certain stages, assuming a whitish or yellowish appearance, and even resembling pus. Its quantity depends on the degree and extent of the inflammation: it may be just sufficient to collect in small quantity at the corners of the eye; a whitish streak may be seen on the inside of the lower eyelid at the angle of reflection; there may be enough to form more or less copious incrustations about the cilia, and agglutinate the edges of the lids at night; or it may con- stitute a profuse discharge, hardly distinguishable from that of mild purulent ophthalmy. In every marked case of catarrhal inflammation of the eye, the eyelids are always more or less affected. Whenever the attack is severe, other mucous membranes suffer; hence,pain and sense of weight about the frontal sinuses and antrum; disordered stomach, foul tongue, chills, heat, head-ach, &c. According to Mr. Lawrence's further correct descrip- OPHTHALMY. A3'. tion, this species of ophthalmy is distinguished from com- mon inflammation of the external tunics by its catarrhal origin ; the diurnai remission, and nocturnal exacerbation of the symptoms; the absence of pain and intolerance of light, even when there is great general redness; the bright red tint of the membrane and of the distended vessels; and the mucous discharge. From purulent ophthalmy, it is dis- tinguished by its much milder character, and by its not be- ing contagious; if the latter always be so, which, in Mr. Lawrence's opinion, and that of the generality of foreign surgeons, has not yet been proved. In general, catarrhal ophthalmy readily yields to proper treatment, and is therefore free from danger. If the in- flammation be violent, neglected, or badly treated, it may extend to the sclerotica and cornea, causing ulceration and opacity of the latter, and thus seriously injuring the organ. Sometimes it is restricted to the eyelids. The origin of the complaint is mostly referred to atmo- spheric causes. Exposure to drafts of air and cold winds, especially in damp, foggy weather, often gives rise to it. Length of exposure, without exercise, is said to favour the action of the cause: hence, soldiers on watch, or in camp, very often suffer. Great changes in the atmosphere from heat to cold, within a short period, bring on catarrhal affec- tions. These vicissitudes are most common in hot climates, where the burning heat of the day is succeeded by a chilly night air, often combined with heavy dews, to which sol- diers are frequently exposed by the nature of their duty. A contaminated state of the atmosphere, produced by the hydrosulphuret of ammonia generated in privies, or by the continuance of numerous individuals in one room or build- ing, is a common cause of catarrhal ophthalmy, and ac- counts for its frequency in barracks, schools, and other crowded institutions. Like other diseases of mucous mem- branes, it often prevails epidemically in towns, or certain districts; no doubt, in consequence of particular, but un- known, changes in the constitution of the atmosphere. Sometimes it prevails at the same time with an epidemic influenza; and it is alleged, as a remarkable circumstance, that all those persons who are attacked with ophthalmy escape the influenza.* In catarrhal ophthalmy, mild antiphlogistic treatment will suffice, and it is not necessary to reduce the patient very • Frick on the Diseases of the Eye, p. Cft 432 OPHTHALMY. much, as in some other cases of inflammation of the eye. Venesection may in general be dispensed with, unless the patient be young and of full habit, and the inflammation in both eyes, and severe. In ordinary cases, cupping and leeches will be sufficient. The bowels should be freely opened. If the tongue be foul, an emetic may follow the loss of blood. Saline and sudorific medicines may then be given, and the warm bath, or pediluvium, used at night.* But, in very slight cases, nothing more is necessary, after evacuations, than a dry, cool atmosphere, a low regimen, and the frequent application of cold spring-water, or any weak astringent lotion, to the eye. Mr. Lawrence, I ob- serve, gives the preference to warm water, or poppy fo- mentations. When little febrile excitement is present, Mr. Welbank recommends the early use of astringent collyria, to prevent the formation of vesicles; and mentions one composed of a grain of the extract of belladonna, two or three grains of sulphate of copper, and four ounces of wa- ter, as very useful.f In a later stage, when the secretion is thick, and resembles pus, the collyrium may contain la- pis divinus, nitrate of silver, alum, or Bates's camphorated lotion. The latter and the vinous tincture of opium were much used by the late Mr. Ware; but though they answer very well, they are not superior to other stimulants of equal strength. To prevent the agglutination of the eyelids in the night, their edges may be smeared at bed-time with a little sper- maceti cerate, or any other simple ointment. After the inflammation has been lessened by the fore- going means, blisters may be employed, if necessary, which will not often be the case. The eye need not be covered, unless a strong light should be offensive, when a common green shade may be used. Purulent ophthalmy is a violent form of inflammation of the conjunctiva, beginning in the linings of the eyelids, and extending to the mucous surface of the eyeball. When severe, and uncontrolled by due treatment, it soon attacks the cornea, which it either completely spoils, or so changes in structure, that vision is either destroyed, or seriously injured. The whole texture of the membrane swells and becomes thicker; its vascular tissue is developed; and its • Lawrence's Lectures. f Note, Op. cit. p. 27. OPHTHALMY. 433 surface acquires an intense bright-red. The mucous sur- face is rendered villous, pulpy, and granular, like the vil- lous surface of the foetal stomach, and from the secreting surface, thus produced, the puriform discharge flows. The changes in the cornea are sloughing, ulceration, and inter- stitial deposition, causing opacity. The sloughing and ul- ceration often expose the anterior chamber, causing pro- lapsus of the iris, and may, by letting out the humours, destroy both the function and form of the eye. (Law- rence.) In the progress of the disease, the swelling of the con- junctiva sometimes increases in such a degree, that the upper eyelid cannot be raised, and projects so far, as en- tirely to cover the lower eyelid. The outside of the upper one becomes red and swelled, and even the cheeks and face. The disease, from its commencement, is attended with pain, which gradually increases, and is sometimes periodi- cal, coming on generally at night. A little before the pu- riform discharge is established, a spontaneous bleeding frequently occurs from the eyelids, and is always followed by some mitigation of the symptoms. Occasionally, the conjunctiva, round the cornea, becomes so red and swell- ed, that it seems like a thick ridge of flesh encircling the latter membrane, which seems sunk in the eye, frequently little more than its centre being visible. If the matter be allowed to lie some time upon the cornea, it may acquire a thick consistence, and so resemble membrane that the inexperienced surgeon may suppose the cornea has sup- purated.* Respecting the causes of purulent ophthalmy, I am not aware, that any very useful remarks can be offered in ad- dition to those delivered on the causes of catarrhal oph- thalmy. The circumstances, giving rise to the form of it which occurs in infants, are not exactly determined, though a multitude of conjectures may be found in books. The purulent ophthalmy of adults, including the Egyptian oph- thalmy, is sometimes imputed to the effects of vivid light and heat reflected from a sandy soil; and to exposure to cold, damp, nocturnal air, after the eye has been unduly stimulated and weakened in the day. With few excep- tions, the belief of army surgeons, as well as of the gene- rality of practitioners in England, is, that purulent oph- • Sec Frick on Diseases of the Eye, pp. 40—42 Vol. I. 3 I 434 OPHTHALMY. thalmy is infectious; that is to say, capable of being com- municated by the application of the discharge to a health) eye. One form of purulent ophthalmy is supposed to arise either from the suppression of a gonorrhoea, or the inadvertent application of the discharge from the urethra to the eyes; a case, which I shall dismiss from this work. until satisfactory proofs of its reality have been given. Even the believers in its existence represent it as very rare, which could not be, if the causes were such as are con- jectured. In the army, the treatment of purulent ophthalmy has generally commenced with taking away sixty or seven- ty ounces of blood from the arm, followed by purga- tives, and nauseating doses of tartarized antimony. In private practice, where the generality of patients would not bear the sudden loss of so much blood without great injury of their health, about sixteen ounces may be drawn from the arm by a free orifice, and cupping or leeches employed on the temple. For young children, leeches are the most proper. When the disease has been neglected, the patient debi- litated, and the discharge profuse, bark is generally pre- scribed; and its extract, or the sulphate of quinine, will be found the most convenient for children. If the cornea be threatened with sloughing, bark is stated to be frequent- ly capable of preventing the evil. The eye must be washed, every three or four hours, with any weak astringent lotion, injected under the eye- lids with a syringe. A drachm of Bates's camphorated lotion in two ounces of water; a weak solution of the sul- phate of zinc, common alum, or sulphate of copper, will answer the purpose. Blisters are also to be applied behind the ears, or on the nape of the neck. Afterwards, the lo- cal applications may be strengthened; even the undiluted liquor, plumbi acetatis, tincture of opium, and oil of tur- pentine, have been used with benefit.* To prevent the eyelids from adhering together in the night, their edges may be smeared with spermaceti cerate. * |The best application that can be employed in these cases, is a solution of the nitrate of silver, in the proportion of two grains to an ounce of water. Of this, one or two drops should be dropped in the eye, twice or thrice a day. When the inflammatory symptoms have abated, the strength may be doubled. We have made use of this application in the different forms of ophthalmy, and have derived more benefit from it, than from any other we have ever employed.—P. E. \ OPHTHALMY. 43;> Scrophulous inflammation of the conjunctiva, like every other form of scrophula, attacks children more frequently than adults. In its simplest form, it is almost peculiar to children, stationary, marked by a very slight redness of the sclerotic conjunctiva, and the utmost intolerance of light.* By the late Mr. Saunders, pustles of the conjunc- tiva, aggregated at the margin of the cornea, or appearing separately, or successively at any part of its surface, were deemed a specific character of strumous ophthalmy,f with which the usual marks of a scrofulous constitution were more or less connected. These small pustules are apt to burst, and change into ulcers. The eyelids, particularly the upper, are much swelled and reddened, and generally- half closed, on account of the pain always resulting from exposure of the eye to light. The cheeks are irritated by the constant dribbling of the tears over them, and the pa- tient is incessantly rubbing his eye. The pain, caused by the light, renders it difficult to obtain a sight of the affect- ed eye, especially in children. The surgeon should sit down, put the child's head between his knees, and, placing his right forefinger over the orbit, gently raise the skin of the upper eyelid with its point, while the lower one is de- pressed with the forefinger of the other hand.i: Although great pain is excited in the eye by light, the disorder at all other periods, is remarkable for being attended with scarcely any pain. When the eye is carefully examined, a diffused and unequal redness is seen, the vessels running in distinct.fasciculi towards the cornea, at the circumfer- ence of which most of them terminate. However, a few reach even to its centre; and each fasciculus ends in one of the minute pustules already described. In a more ad- vanced stage, the vessels of the conjunctiva pass over the margin of the cornea to its very centre, and the latter mem- brane itself becomes of a reddish-brown colour, thicken- ed, and much altered in texture. The iris and pupil are thus concealed, and vision seriously interrupted. The causes of strumous ophthalmy were referred by Mr. Saunders to bad air, improper food, and cold. Mr. Travers regards the disease as intimately connected with a disor-" dered state of the secreting surfaces of the alimentary ca- nal and skin.§ Probably, whatever would bring on catar- • Travers's Synopsis, &c. p. 92. | On Diseases of the Eye, p. 99. \ Frick on Diseases of the Eye, with notes, by It. \\ elbank, p. o< \ Synopsis, p. 93. 436 OPHTHALMY. rhal inflammation of the eyes in a healthy person, would produce this variety in a scrophulous constitution. In the treatment of strumous ophthalmy, rigorous antiphlogistic measures are never necessary. The secretions of the ali- mentary canal and skin, however, should be restored, for which purpose Dr. Frick recommends the liquor, ammon. acet., combined with vinum antimonii, to which may be added a small quantity of syrup of poppies, when it is to be given to children. The pulv. ipecacuanhae comp., and calomel with opium, are also described as fit medicines. The eye should be protected from the light with a green shade, or by darkening the room. The intolerance of light would only be aggravated by bandages; but a blister, kept open on the nape of the neck, diminishes it with great effect. If the cornea be opaque, calomel, or the blue pill, or the oxymuriate of mercury, with opium, should be giv- en so as slightly to affect the system.* The state of the general health, and that of the eye which is dependent on it, may sometimes be improved by bark, joined with the tinct. guaiaci ammon. (Scarpa). In every instance, a pure air, cleanliness, and a light nutritious diet, are of essential service. The sea-air, and the regular use of a flesh-brush, often do much good.f When ulcers are present, a solution of nitrate of silver, (two grains to an ounce of distilled water) may be injected on them. (Saunders.) When the disease is accompanied with violent contractions of the or- bicular muscle, fumigations of laudanum in boiling water %will afford great relief. For the prevention of a relapse, an issue, kept open in the nape of the neck,^ or arm, is one of the most effectual plans. CHAPTER XII. IRITIS. Although this subject might have been classed with other inflammations of the eye, and treated of in the pre- • Travers's Synopsis, p. 259. f {In this form of ophthalmia, iodine has been found a very valuable reme dy—P. E.} * Welbank, in his edit, of Dr. Frick's Work, p. 35. IRITIS. 437 ceding chapter, I think its importance well entitles it to separate consideration. Next to the conjunctiva, the iris is that texture of the eye, which is most frequently affect- ed with inflammation. The iris often becomes inflamed, in consequence of sur- gical or accidental wounds of the eyeball; it may indeed arise from various external causes; or it may originate from some peculiar diathesis of the whole system. Thus one species of iritis, having a very distinct character, is produced by the venereal disease, especially that form of it, which is described by Mr. Carmichael under the name of the papular venereal disease. Sometimes inflammation extends to the iris from other textures of the eye. The iris constitutes the principal seat of inflammation in the distinct kind of ophthalmy, frequently met with in gouty constitutions. In rheumatic ophthalmy, the inflammation, though never originating in the iris, frequently extends to it. Scarcely any disease to which the eye is subject, has a more immediate or rapid tendency to destroy vision, than inflammation of the iris. In idiophatic iritis, (as Professor Schmidt observes,) besides the common symptoms of oph- thalmia, certain changes happen at the very commence- ment, indicating the seat of inflammation. The pupil ap- pears contracted, the motions of the iris are less free, its brilliancy fades, and the pupil loses its natural bright black colour. The iris becomes thickened and puckered, with its inner margin tujmed towards the crystalline lens. The change of colour nappens first in the lesser circle of the iris, which becomes of a darker hue ; and afterwards in the greater circle, which turns green, if it had been greyish or blue ; and reddish, if it had been brown or black. The redness accompanying these changes is by no means con- siderable, and is at first confined to the sclerotic coat, in which a number of very minute rose-red vessels are seen running in straight lines towards the cornea. In the words of Mr. Saunders, the vascularity of the sclerotica is very great, whilst that of the conjunctiva remains much as usu- al, the plexus of vessels lying within the latter tunic. The inosculations of these vessels are numerous, and form a rose-coloured zone at the conjunction of the sclerotica and cornea. Here the vessels disappear, not being continued over the transparent cornea, as in a case of simple ophthal- my, but penetrating the sclerotica, in order to pass to the inflamed iris. The red zone, here mentioned, has been 438 iiutis. deemed a certain mark of iritis ; but, this is a mistake, since it also presents itself in strumous ophthalmy. The irritation caused by the light is distressing, and the patient is much incommoded by any pressure on the globe of the eye, or by the rapid or sudden motions of this organ. Consider- able uneasiness is felt over the eyebrow, and acute lanci- nating pains shoot through the orbit towards the brain. The pupil loses its circular form, becomes somewhat irre- gular, and presents a greyish appearance. Examined with a magnifying glass, this appearance is found to be produc- ed by a substance very like a cobweb occupying the pu- pil, and which can soon afterwards be distinguished, even without the aid of the glass, to be a delicate flake of coagu- lable lymph. Into this, says Professor Schmidt, the pro- cesses or dentations of the irregular pupillary margin of the iris seem to shoot, and it is afterwards found that ad- hesions are apt to be established at these points. Owing to these adhesions, the patient, whose vision has been all along indistinct, is now able to see only one side or part of an object. While these changes are taking place in the posterior chamber, others equally remarkable are occur- ring in the anterior. The iris projects more and more towards the cornea; a small orange-coloured tubercle now forms upon its surface, gradually enlarges, and is full of a purulent fluid. At length it bursts, and discharges its con- tents into the anterior chamber, so as to produce the case termed hypopium. If more than one tubercle be present, the whole anterior chamber may be filled with pus, and the iris be completely hidden. W According to Mr. Travers, when the inflammation com- mences in the iris, and is not propagated to it secondarily, the conjunctiva is less reddened, and consequently the vas- cular zone is plainer.* When iritis is not subdued by ef- ficient treatment, the consequences may be a more or less complete closure of the pupil, with opacity of the capsule of the lens; adhesion of the iris to the cornea, with more or less opacity of the latter; and even an amaurotic affection of the retina. Schmidt, Beer, and many English surgeons believe, that the iris is subject to an inflammation, which is as characteristic of the presence of syphilis in the con- stitution, as any other secondary symptom. As, however, this iritis frequently comes on in persons while they are actually under the influence of mercury, or after they have * Synopsis, p. 133. IRITIS. 439 used it profusely for papular eruptions, pains in the large joints, and other anomalous diseases, often confounded with syphilis, it is sometimes regarded, (and as I conceive justly) not as an effect of true syphilis, but rather as a pseu- do-syphilitic affection. A pale redness all round the cor- nea is the first symptom perceived in the syphilitic iritis: this is at first seated in the sclerotic coat alone, but the conjunctiva very soon shares in it, and afterwards becomes the redder of the two. However few the vessels may be elsewhere, there is always a broad zone of them all round the cornea. The redness has a peculiar tint, being brown- ish, something like the colour of cinnamon.* From this zone, the vessels have a disposition to extend under the edge of the cornea. The whole of this last membrane now becomes uniformly hazy, losing its clearness, without being in any place actually untransparent. The pupil becomes contracted, and the iris limited in its motions, as in com- mon iritis, but the pupil, instead of preserving its natural situation, is removed in a direction upwards and inwards towards the root of the nose, and is irregular. The iris also loses its natural colour, and projects forwards. An aggravation in the symptoms always takes place towards evening, the intolerance of light, and painful sensibility of the whole eye increasing, and a gush of tears following every change of light and temperature. At length a regu- lar nightly pain begins, which is extremely severe, and strictly limited to that part of the cranium which is imme- diately over the eyebrow. It usually comes on between six and seven in the evening, gradually increases, reaches its utmost height about midnight, and then diminishes till about four or five in the morning, when it ceases. After every such attack of pain, the pupil is found more contract- ed drawn farther upwards and inwards, the iris being at the same time more altered both in colour and form, the quantity of lymph increased, and consequently vision more impeded. , . Peculiar appearances then take place in the iris, for ei- ther on its pupillary, or ciliary margin, or on both, there arise one or more reddish-brown tubercles, which have a spongy look. Their growth is pivtty rapid. Lardy-look- » Tin- conjunctiva and sclerotica "have a brick-dust or dusky red, instead of a bright scuru-t hue, and the lymph is compact und brown, .3 for this temporary suffering, by the comfort experienced, a few minutes after the operation. This sudden production of ease is imputed by Scarpa to the destruction of the irritable surface of the ulcer, and to the eschar, which shields the part affected from the contact of neighbouring surfaces; but the relief only lasts until the slough is detached. On the recurrence of burning pain at the ulcerated part, and of restraint in moving the eye and eyelids, the surgeon, without delay, is to renew the ap- plication of the argentum nitratum. The same benefit de- rived from the previous operation, will be experienced again. In this manner, the caustic is to be used as often as may be necessary. At every separation of the eschar, the diseased sensibility of the eye, and the extent and depth of the ulcer, will be found more and more diminished. The sore also loses its ash-colour, and assumes a pink hue; a certain mark of its disposition to heal. We must now abandon the use of caustic, and employ merely an astrin- gent collyrium. Towards the end of the case, if relaxation of the conjunctiva should continue, the ung. hydrarg. nitrat. may be applied. It is proper to remark, however, that very good surgeons object to this free use of caustic, and begin with tepid as- tringents, which, if the sore should not heal with them, are to be followed by a slight application of the caustic, or that of a solution of four or six grains of it in an ounce of distilled water. Slight excoriations of the cornea do not require caustic; for them, the zinc collyrium, with due attention to the re- moval of their cause, will be quite sufficient. Also to sores produced by mechanical or chemical injuries of the cornea, caustic should not at first be applied, as they would increase the irritation and inflammation of the eye, and do serious mischief. On the contrary, soothing applications, and an- tiphlogistic remedies, are best. Sometimes an ulcer of the cornea assumes the form of a fungous excrescence, which seems to derive its support from a plexus of blood-vessels in the conjunctiva. The proper treatment of this case consists in cutting away the fungus, and extending the incision far enough on the con- junctiva to remove, with the excrescence, the net-work of vessels, by which it was supplied with blood. The blood is to be allowed to flow freely, and the cure completed by oc- casionally touching the part with caustic. When ulcers of the cornea have a sloughing tendency. ■154 DISEASES OF THE CORNEA. and the constitution is much debilitated, bark and the mine- ral acids are indicated. Staphyloma signifies that disease of the eye in which the cornea loses its natural transparency, rises above its proper level, and even projects between the eyelids, in the form of a whitish, pearl-coloured, or bluish tumor, attended, when the whole cornea is affected, with loss of sight. To this grievance are added, in bad cases, all the evils which necessarily result from the protuberance of the cornea. The inability of closing the eyelids; the exposure of the eyeball to the air, and extraneous matter suspended in it; and the friction of the eyelashes against the tumor; render the eye painful and inflamed; while the constant dribbling of tears is apt to make the cheek and lower eyelid inflame and ulcerate. Even the sound eye itself is sympatheti- cally affected with tenderness, pain, and sometimes actual inflammation. The opacity being incurable, the only business of the surgeon is to prevent the inconveniences, produced by the projection of the cornea. In recent cases, when these do not prevail, it is best not to interfere with it, as the disease will often remain stationary during life. In inveterate cases, the prominent part of the cornea must be cut off by passing a cataract-knife completely across it. The flap is to be turned up with a pair of forceps, and the incision rendered completely circular with the knife, or scissors. The aqueous humour, crystalline lens, and some of the vitreous humour, usually escape, and the eye is so dimi- nished, that the eyelids can cover it-again. The dressings, and subsequent treatment, are the same as those employed after the extraction of the cataract. In particular, a strictly antiphlogistic plan will at first be necessary. CHAPTER XVI. PTERYGIUM AND ENCANTHIS. Pterygium means a preternatural, reddish, ash-colour- ed, triangular, little membrane, growing from the internal angle of the eye, about the caruncula lachrymalis, and ex- tending towards, or over the cornea, to the great impair- pterygium. 455 ment of vision. Although it generally proceeds from the inner canthus, it occasionally arises from the outer one, and, in some instances, from the superior and inferior he- misphere of the eye. It is invariably of a triangular shape, with its base towards the white of the eye, and its apex to- wards the cornea, at a greater or lesser distance from the axis of sight. In a few uncommon cases, two* or three pterygia, of various sizes, are met with in the same eye; and their points may even coalesce on the centre of the cornea, so as completely to hinder vision. The common pterygium, is said by Scarpa to consist of a thickening of the layer of the conjunctiva spread over the cornea; yet be it remembered, that the greater part of the disease, is not at all on the cornea, and that some specimens of the pterigium crassum have a deeper origin than any part of the conjunctiva. A peculiar feature of the membranous pterygium is the facility with which it may be taken hold of with a pair of forceps, and raised in a fold over the cornea, when it ex- tends thus far upon the eye. Sometimes a pterygium as- sumes a malignant cancerous nature, and then it has a bright red colour, like sealing-wax, easily bleeds when touched, is firmly adherent to the cornea, and occasions lancinating pains, which extend over the whole eye and temple. Scarpa recommends this case to be treated on the palliative plan ; but it might be proper to attempt the total excision of the disease : and certainly this measure would be necessary, if it could not be checked by other means. The ordinary membranous pterygium is not attended with pain, and has no tendency to become malignant. Frequently it does not increase so as to interrupt vision at all, in which case, its removal is scarcely a matter of necessity. The cure is performed by lifting up the pterygium with forceps, and accurately cutting it away from the surface of the cornea, with a pair of curved scissors. As one part of it is the delicate layer of the conjunctiva, forming the na- tural covering of the cornea, a cicatrix, and a degree of dimness, necessarily remain after the operation. The opa- city, however, is always of much less extent, than the pterygium. • Plate 6, fig. 2. Two pterygia, of different sizes, on the same eye. A, the larger one, next the nose; B, the smaller one, next the temple. The straight and semicircular lines on the pterygium, A, denote the double di - rection which ought to be given to the incision, in extirpating the malady. 456 PTERYGIUM. The detachment need only extend as far as the com- mencement of the sclerotica, and then the separation is to be completed by a semilunar transverse incision,* en- croaching not more than one line on the conjunctiva. The subsequent part of the treatment chiefly consists in pre- venting inflammation. An incipient Encanthis, is a small, soft, red, and some- times livid excrescence, growing from the caruncula la- chrymalis, and neighbouring semilunar fold of the con- junctiva. In the inveterate state, its magnitude is consider- able, and its roots extend beyond the caruncula lachry- malis, along the lining of one or both eyelids. The com- plaint excites chronic ophthalmy, prevents the complete closure of the eye, and by compressing and displacing the puncta lachrymalia, obstructs the free passage of tears into the nose. The surface of the excrescence is at first gra- nulated like a mulberry; but, after the tumor has become large, only a part of its outside has the above appear- ance, while the rest seems like a smooth, whitish, ash-co- loured substance. As of pterygium, so there is a malignant species of en- canthis, denoted by its dull red colour, bleeding tendency, lancinating pain, excessive hardness, and very fetid dis- charge. The same practical observations apply to this case, as to the cancerous pterygium. The cure is accomplished by raising the tumor from its base, and lifting up the elongation, extending along the in- side of the eyelids with a pair of forceps, and detaching them with a sharp bistoury. No more of the caruncula lachrymalis is to be remov- ed, than is absolutely essential to the success of the ope- ration, in order that an irremediable weeping of the eye may be avoided. CHAPTER XVII. DROPSY OF THE EYE. When the secerning extremities of the arteries, and the minute mouths of the absorbent vessels of the eye, do • See the shape of the incision, Plate 6, fig. 2. DROPSY OP THE EYE. 457 not act in their naturally reciprocal manner, the organ may become distended with fluid, attended at first with great weakness, and afterwards with total loss of sight. Authors describe one case as proceeding from a morbid increase of the aqueous humour, and another as resulting from an augmentation of the vitreous, combined perhaps with a diseased alteration of the alveolary membrane, by which this humour is produced. The eye assumes an oval shape, terminating in a point on the cornea, and, as the organ en- larges in all dimensions, it projects from the orbit, so as to cause great deformity, and prevent the closure of the eyelids. The disease is sometimes preceded by an obstinate in- ternal ophthalmy. In other instances, it is preceded by no inconveniences, except an uneasy sensation of tumefaction and tension in the orbit, a difficulty of moving the eyeball, and a considerable impairment of sight. When the eye has assumed an oval figure, and the anterior chamber has become preternaturally capacious, the iris is situated more backward than natural, and tremulates on the slightest motion of the eyeball. The pupil remains dilated in every degree of light, and while the crystalline is sometimes dis- coloured in the earliest stage of the disease, sometimes it does not become opaque, before the disease is far ad- vanced. In the last stage of it, when the eye projects from the orbit, and does not admit of being covered by the eyelids, the same grievances originate as in bad cases of staphylo- ma. Violent inflammation, ulceration, and total destruc- tion of the eye may follow, with caries of the orbit, and even a fatal termination. No correct knowledge of the causes of dropsy of the eye has yet been obtained, in addi- tion to the facts, that a slow inflammation of the interior of the eye sometimes precedes it, and that it may be join- ed with a general dropsical affection of the system. The prognosis is always unfavourable, as far as the restoration of sight is in question. The increase of the disease, how- ever, may possibly be prevented, and, at all events, unless a general varicose state of the organ, and a tendency to carcinoma exist, the several grievances, produced by the magnitude and exposure of the eye, may be obviated. When a dropsical habit attends the complaint, calomel and he.nlock, or calomel joined with digitalis, stimulating and mercurial liniments rubbed on the eyebrow, a course of mercury, electricity, and a blister or issue near the dis. Vol. I. 3 M 45S DROPSY OF THE EYE. eased organ, may be tried. In other cases, cupping and blistering the temple, or nape of the neck, with various al- terative medicines," may be directed. Astringent collyna are generally condemned as hurtful, and tepid emollient applications preferred. When the large size of the organ brings on the same kind of distressing complaints, as usually attend large pro- trusions of the front of the eye in staphyloma, the same treatment should be adopted as in the latter case. A portion of the centre of the cornea, about as broad as a pea, is to be cut off, and as much of the humours then pressed out as will permit the eyelids to be brought over the eye. A pledget and bandage are to be the only appli- cations, until inflammation has taken place, which is usual- ly about the third or fifth day, when antiphlogistic means and emollients may be useful. When a fungus grows out of the internal part of the eye, after the operation, and its return and increase cannot be prevented by caustic, the preservation of the patient's life will render the extirpation of the whole of the diseased organ absolutely indispensable. CHAPTER XVIII. CANCER AND EXTIRPATION OF THE EYE. Cancer of the eye mostly begins in the conjunctiva, and seems analogous to carcinoma of other mucous membranes, being at first like it of a comparatively mild character, though afterwards assuming a malignant and fatal nature. In its commencement it is generally restricted to the con- junctiva, which becomes swelled, thickened, and prominent between the eyelids, so as even to hide the cornea. In a more advanced stage, the eyelids, and the lachrymal gland and caruncle, are frequently involved, and sometimes all the neighbouring part of the cheek. The peculiar charac- ter of the ulceration, the fetid quality of the discharge, the acute lancinating pains, and the cartilaginous hardness of the fungus, sufficiently prove the very serious and incura- ble nature of the disease. Other forms of disease in the eye have also been classed extirpation of the eye. 459 with cancer, especially a case in which the eyeball becomes irregular and knobby, and swells to the size of an apple; the sight is gradually lost; the blood-vessels in die white of the eye enlarge; and the whole extern.il and internal structure of the organ is so altered, that the part resembles a piece of flesh, and no vestiges of its original organization remain. The fungous growths, which sometimes proceed from the interior of the organ after operations for the relief of staphyloma and dropsy of the eye, have likewise a cha- racter so malignant, as to be set down as cancerous. Until lately, fungus haematodes of the eye was always confounded with cancer. Scarpa is perfectly correct in representing true cancer of the eye as less destructive than fungus haematodes; first, because it makes its earliest appearance on the exterior parts of the eye, so that whatever relates to the origin and formation of the disease is open to observation; and, se- condly, because the cancerous fungus of the eye is very frequently not actually malignant at first, but becomes so in process of time, or from improper treatment, in conse- quence of which it assumes the real character of scirrhus, and afterwards of phagedenic cancer, during which inter- val the art of surgery may be resorted to with effect. Ac- cording to the same writer, we have no pathognomonic symptoms, excepting one, indicative of the exact period when the sarcoma of the eye changes from a benign fun- gus to carcinoma. The exquisite sensibility, darting pains, rapidity of growth, colour, and ichorous discharge, are by no means a sufficient criterion, and, says Scarpa, the only symptom, if not entirely pathognomonic, at all events less uncertain than any other, is the almost cartilaginous hard- ness of the malignant ulcerated fungus, which induration is not met with in the benign fungus, and never fails to pre- cede the formation of cancer.* Under particular circumstances, it becomes indispensa- bly necessary to remove the eyeball; as, for instance, when the organ protrudes from the orbit, cannot be reduc- ed, and the disease creates both great irritation and disfi- gurement. The operation is also requisite for certain cases of ulcerated staphyloma, and for every form of disease in which the coats and humours of the eye are so altered, as not to admit of being restored to a natural state, and in which the distemper, if unextirpated, would be likely to • Scarpa on the Eyes, p. 511—511 Transl. by Briggs, edit. 2. 160 EXTIRPATION OP THE EVE. end fatally, either by extending its ravages to the orbit and brain, or by keeping up such pain and irritation as must ultimately destroy life. Cancer and fungus haematodes of the eye, however, are the two diseases for which the operation is most common- ly required. What is usually called a cancer of the eye does not seem to be nearly so malignant as carcinoma of the breast; for, if the distemper be confined to the globe and the eyelids, cellular substance, and bones of the orbit continue unaf- fected, the operation generally produces a radical cure; a fact, strongly dictating an early recourse to that effectual means in surgery, the knife. In the operation, there are two important circumstances, to which attention must be paid. The first is to remove every particle of the disease. The second is to avoid pierc- ing or injuring the orbit. In order to be able to separate the eyelids far enough from each other, for the easy removal of an eye that is much»tfhlarged, it is sometimes recommended, in the first instance, to make an incision through them at their exter- nal commissure. The patient should lie down on a table of convenient height, with his face exposed to a good light. The generality of surgical writers advise the opera- tor, before he begins the dissection, to introduce a strong ligature through the anterior portion of the diseased or- •gan, by which means the part may be drawn out, or to either side, as the convenience of the surgeon may dictate, while he is making the necessary incisions. Hooks have also been recommended for the same purpose. The best instrument for the operation is a common scal- pel. When the diseased part is very large, a knife, slightly bent laterally, may be used on the temporal side of the or- bit for dividing the parts deeply situated in it. The upper eyelid having been raised by an assistant, and the lower one depressed by the surgeon himself, the conjunctiva, connecting the eye with the two eyelids, is first to be di- vided. As when the eyeball is enlarged, it mostly falls towards the cheek, so that an incision between the diseased part and the lower eyelid cannot easily be made, Richter re- commends first separating the globe from the upper eyelid; then dividing the superior and lateral attachments of the eye ; and, lastly, its connexions with the lower eyelid. This mode of operating is said to be the more easy because EXTIRPATION OP THE EYE. 461 the globe of the eye can always be more readily inclined downwards, so as to make room above, than pushed up- wards, for the purpose of making room below. Scarpa, after dividing the external commissure of the eyelids, if the tumor be very large, perforates the conjunc- tiva at the external angle, and from thence, keeping the knife close to the upper plane of the orbit, as far as the caruncula lachrymalis inclusively, cuts through the eleva- tor muscle of the upper eyelid, the tendon of the greater oblique muscle, and the superciliary nerve. The diseased eyeball being then raised, and the lower eyeball depress- ed, the incision is next continued along the inferior seg- ment of the orbit, from the external towards the internal angle; by doing which, the knife will penetrate between the eyeball and this muscle, as would happen in cutting in the opposite direction. The eye, freed from these attach- ments, and from that formed by the nasal branch of the ophthalmic nerve, will fall on the external side of the or- bit, and give the surgeon room on the internal side as far as the bottom of that cavity, where he is to divide with one stroke of the scissors the origin of the muscles of the eye and the optic nerve. He is then gently to bring his finger round to the external side of the orbit, and push its contents a little towards himself, while, with a second stroke of the scissors, he divides all the parts which enter the orbit through the sphaeno-orbital fissure. As soon as the eye has been completely detached, all the inside of the orbit should be very carefully examined, and whatever indurated parts are found, should now be diligently removed. In particular, the surgeon should in- troduce his finger along the inner side of the orbit, where he will feel the greater oblique muscle, which he must dissect away by means of a tenaculum and the scissors. When the eyelids are affected, they should always be removed, to prevent a recurrence of the disease. As the lachrymal gland is now useless, and particularly apt to be the source of inveterate fungous diseases, if left, it is always to be taken away, whether apparently healthy or not. . The bleeding may be repressed by means ot a piece ol fine sponge, introduced into the orbit, and a light compress laid over the evelids. Mr. Tracers removes the sponge on the day after the operation, and applies a soft poultice in- cluded in a muslin bag, instead of the compress. The practice of cramming the orbit with lint, he justly repro- 4bJ EXTIRPATION OF THE EYE. bates.* Sometimes a compress, wet with cold water, or the lotio plumbi superacetatis, and put over the eyelids, is the only dressing judged necessary. When the patient suffers violent pain after the opera- tion, an anodyne should be given. The inflammatory symptoms and fever rarely demand any other means, than a low diet, and aperient saline medicines. Although the operation mostly succeeds when the dis- ease is true cancer, and limited to the eyeball, the same success cannot be expected when the case is fungus hsema- todes. Sometimes, the granulations formed in the orbit are flab- by and indolent, in which circumstance, a mild astringent should be applied; as, for instance, lapis calaminaris, pul- vis myrrhae, alumen ustum, &c. If they acquire a fungous appearance, they should be destroyed with caustic. The records of surgery inform us, that, in some cases, the cure has appeared perfect for half a year, or more, and then a fungous excrescence has arisen and proved fatal.f Some- times, a few days or weeks after the operation, head-aches, vomiting, convulsions, &c. come on, and end fatally. Con- vulsions, after the operation, were suspected in one case to be owing to the pressure of the lint in the orbit on the op- tic nerve; and hence,the late Mr. Ware renounced the plan of introducing dressings within the eyelids.:}: Cases present themselves, in which fungous diseases are ho confined to a particular portion of the front of the eye, that the removal of the whole organ is unnecessary. CHAPTER XIX. FUNGUS HAEMATODES OF THE EYE. The best informed surgeons scarcely know what forms of disease should alone be called cancer of the eye. We here meet with no distempers, which exhibit the peculiar scirrhous structure, that is so generally allowed to be cha- * Synopsis, &c. p. 308. f Mohrenheim, Beobachtungen, band. ii. ♦ Trans, of Med. Society of London, vol. i. p. 152. FUNGUS HJEMATODES OF THE EYE. I'»^ racteristic of carcinomatous disease; yet, this organ is fre- quently attacked with certain diseases, which in point of malignity, and incurability, are not less dreadful than the cancer of other parts of the body, and have usually gone under the same appellation. Fungus haematodes of the eye was one of these cases; but, instead of being allied to can- cer, it has a very different and peculiar character, corres- ponding to that of thfi same disorder in other structures, some of which are never the seat of true carcinoma. The second and twelfth chapters of Mr. Wardrop's publi- cation,* appear to me highly valuable; the one, as containing a clear description of fungus haematodes of the eye, a case which previously had not been distinctly explained; the other, as furnishing us with an excellent comparative view of this disease and cancer. In fungus haematodes of the eye, the pupil is dilated, has a dark amber, or greenish hue, instead of its natural deep black colour, the iris is motionless, and the sight seriously impaired, or even quite lost from the first. One of the earliest symptoms, however, is a white shining substance in the posterior part of the eye, visible through the pupil in some particular positions of the head; but not in all; an appearance, compared to that of burnished iron. As the disease advances, this deviation from the natural appear- ance of the pupil is discovered to be produced by a solid substance, which is formed at the bottom of the eye, and gradually approaches the cornea. At length, the excres- cence occupies the whole interior of the eye behind the iris, and appears through the pupil to be of an amber or brown colour. In this stage of the disease, Mr. Wardrop has known two cases, which were mistaken for cataracts, and, in one of them, an experienced surgeon actually at- tempted couching. In a case of cataract, however, the opacity lies immediately behind the pupil; in the fungus haematodes, it is deeply situated in the posterior part of the eye. In the cataract, also, the pupil generally retains the power of dilating and contracting in different degrees of light; but, in fungus haematodes, the pupil never varies its size, and is usually dilated. When the disease advances still further, the form ot the eyeball begins to alter, acquiring an irregular knobby ap- pearance; and at the same time, the sclerodc coat loses its natural pearl-white colour, and becomes ot a dark blue, or • see Obs. on Fungus Haematodes, or Soft Cancer, 1809. 464 FUNGUS HJEMAT0DE3 OP THE EYE. livid colour. The tumor, by its continue d growth, finally occupies the whole anterior chamber; and, in some cases, a quantity of purulent matter collects between the diseased mass and the cornea. At last, the cornea ulcerates, and the tumor protrudes, or else it makes its way through the sclerotic coat, so as to be covered by the conjunctiva. The protruded fungus is generally rapid in its growth, often attains a large size, is of a dark red, or purple colour, has an irregular surface, and is frequently covered with coagulated blood. It bleeds profusely from the slightest causes, and its most prominent parts occasionally slough. Frequently,the absorbent glands,about the parotid gland, and lower jaw, become affected, sometimes attaining an enormous size. On dissection, the retina is mostly found annihilated, the diseased mass extending forwards from the entrance of the optic nerve. Sometimes the tumor pushes before it the choroid coat, and ultimately occasions its total absorption; while, in other instances, this membrane remains in its na- tural situation, having no apparent connexion with the dis- ease. The morbid growth itself has a medullary appear- ance ; its consistence and colour, however, being subject to some variety. According to Scarpa, the optic nerve and retina are always the structures first attacked. Sometimes the optic nerve becomes thicker and harder than natural, assumes a brownish ash-colour, and loses its natural tubu- lar appearance. Sometimes, it is converted into a tumor, of the figure and size of an olive, the disorganized sub- stance of which exactly resembles that of the fungus, which fills the orbit, and projects beyond the eyelids. In other instances, the nerve is split into one or more pieces, the morbid growth filling up the intervening spaces, and sur- rounding the different portions of the nerve. It is noticed by Mr. Wardrop, that when the optic nerve is diseased, the alteration in its structure generally extends to its junc- tion with the opposite nerve, and often further, the thala- mus being converted into an irregular, soft pulpy mass, more or less blended with blood. Sometimes, the dura mater and pericranium exhibit dark red-coloured spots; and on other occasions, the tunica arachnoides and pia mater are studded with numerous white spots, which, on being cut into, are found to be small bags, or abscesses containing a white viscid fluid like cream. Children are more subject than adults to fungus haema- FUNGUS HAEMATODES OP THE EYE. 4G5 Codes of the eye ; for out of twenty-four cases, with which Mr. Wardrop was acquainted, twenty were in children un- der twelve years of age. On the other hand, true cancer of the eye mostly afflicts persons advanced in years. Children generally lose the sight of the affected eye, be- fore the disease is at all noticed by the parents. In many cases, however, the appearance of the diseased substance at the bottom of the eye, is preceded by a blow, and inflam- mation of the organ. But when no external violence is concerned, the first perceptible symptom is merely a little fulness of the vessels of the white of the eye. Sometimes, the iris is full of vessels, its colour changes, and the pupil is considerably dilated and motionless. The child sel- dom complains of much pain; but sometimes appears lan- guid and feverish. In adults, the disease generally begins without any ap- parent cause ; though, sometimes, it is preceded by a blow. As in children, it commences with a slight redness of the conjunctiva, and an impairment of vision. These symp- toms increase slowly, and at length are followed by head- aches, which often become exceedingly agonizing, espe- cially during the night, and continue with violence, until the eye bursts, and the humours are discharged. In most cases, only one eye is affected with the disease; but exceptions are recorded. As surgeons are utterly unacquainted with any internal or external medicines, which have the power of checking or curing fungus hsematodes of the eye; and as it is the nature of the disease to extend its ravages till the patient is destroyed, the only chance of preservation depends up- on the early extirpation of the affected eye, care being also taken to remove every part in the orbit having any ap- pearance of participating in the distemper. Hitherto, how- ever, with few exceptions, the operation has not prevented the return of the disease, and a fatal termination. When the constitutional nature of the complaint, its extension along the optic nerve, and its usual affection of several or- gans are considered, this result seems almost a necessary consequence, the great chances of which should at all events be contemplated in any prognosis that may be given. Vol. I. SN 106 AMAUROSIS. CHAPTER XX. AMAUROSIS, Or, Gutta Serena, is the name given to a weakness, or total loss of sight, arising from disease, whether affecting the structure, or function of the retina, the organ, usually considered as the medium, by which the impressions, re- ceived from the rays of light that enter thus far into the eye, are communicated to the sensorium, so as to consti- tute vision. One of the best divisions of amaurosis, there- fore, is into organic and functional*; and when the class, to which any particular case belongs, can be recognised in practice, the information is highly important, with re- ference both to the prognosis and treatment; for organic disease of the retina, of the optic nerve and thalamus, or of the parts of the brain immediately connected with them by function, are absolutely incurable; whereas, a possi- bility of cure attends many examples of functional amauro- sis, unaccompanied with organic disease of the parts con- stituting the immediate seat of vision, and arising from a kind of sympathy between these parts and others, which are the seat of some kind of irritation, or disease. The truth of this proposition is as evident as the fact, that, if the diminution or suspension of vision depend upon the sympathy of the eye with the morbid condition of another organ, and the latter admit of being effectually cured, be- fore; any unfavourable change has taken place in the retina and optic nerve, from too long an .interruption of their function, the power of vision may generally be restored. This remark proves also the usefulness of other divisions of amaurosis into recent and inveterate, incomplete and com- plete, &c. the chances of benefit being much influenced by the differences to which these epithets refer. Unfortunate- ly, a great deal of the ill success in the treatment of amau- rosis depends upon the connexion of the disease with more causes than one ; for, the case may be both organic and functional at the same time; and, in addition to the existing disease of some part, which perhaps had a princi- pal share in causing, at first, the functional, and afterwards • See Travers's Synopsis, &c. p. 139. AMAUROSIS. 167 the organic affection of the retina, there may now be a general derangement of the health, that would leave but little or no hope of recovery, even if the organic nature of the amaurosis did not exist. Such cases might, with much propriety, be named complicated. Amaurosis is mostly attended with dilatation of the pu- pil; and a motionless state, or diminished activity of the iris, while the natural black colour of the pupil, and gene- ral transparency of the humours, in cases not resulting from severe ophthalmic inflammation, are but little changed. Sometimes, however, even in the complete and most irre- mediable forms of the disease, the pupil is of its natural size, and the iris capable of motion. In particular instan- ces, the diameter of the pupil is considerably lessened. Although the transparency of the humours is unaffected, a skilful examiner will generally perceive behind the iris, a change in their appearance, the pupil rarely exhibiting the clear, shining blackness, which is seen in a healthy eye. On the contrary, it has a dull, glassy, or horny look, and sometimes a greenish tinge. Occasionally, indeed, it has a whitish opaque appearance, that may cause the complaint to be mistaken for an incipient cataract. These alterations in the natural colour of the pupil are generally ascribed to a thickened opaque state of the retina, producing a reflec- tion of the rays of light from it, and Scarpa regards this symptom as one of a very unfavourable character. In ad- dition to this dull glassy look of the pupil, the aperture seldom retains its perfectly circular form, the lesser circle of the iris becoming irregular or angular. The pupil is also more or less displaced, being almost always drawn upwards and inwards. Sometimes, in organic amaurosis, a white or greenish-yellow spot may be discerned in the fundus of the eye, a little on one side of the axis of vision; but it is occasionally observed in persons who complain little or not at all of their sight. Mr. Travers suspects that it may depend upon a deficiency in the secretion of the choroid pigment, an adhesion between the choroid and re- tina, and discolouration of the latter.* With respect to the impairment of vision, it sometimes amounts to absolute and complete blindness; but, in gene- ral, the patient can distinguish light from darkness, and even perceive bright colours and large objects. The dimi- nution or loss of sight, when not instantaneously produced, * Svnopsis, &c. p. 148. 468 AMAUROSIS. as it sometimes is by lightning, apoplexy, or mechanical injury, is always preceded by a defective state of the eye, before which numerous small substanceslike insects (muscse volitantes), pieces of cobweb, &c, seem to fly about in the air, especially when the patient looks at a white surface. This symptom is worthy of recollection, as one of the cri- teria between incipient amaurosis and the early stage of cataract, which last is attended with a simple dimness or cloudiness of vision. In the beginning of amaurosis, the patient in reading misses whole words or lines, which he cannot make out, unless the position of his eye and head be changed for the purpose. Frequently, all objects ap- pear to be surrounded with a tremulous zone of various colours, or the eye is often disturbed by false luminous appearances, even when it is shut, and in a room perfectly dark. Other not unfrequent symptoms of early and im- perfect amaurosis are double vision, from an alteration in the axis of sight; the appearance of objects in a distorted shape, or with a colour that does not really belong to them; an obliquity of sight; a degree of strabismus; and severe pain in the orbit, eyebrow, or other part of the head. All cases of amaurosis may be referred to two classes; one, attended with a diminution in the irritability of the whole eye, the patient constantly preferring a strong light; the other, characterized by great tenderness and irritability of the organ, and aversion to a vivid light. The latter state seems to imply the continuance of a degree of inflam- mation within the eye, to which the first affection of the retina itself may often be imputed. As Mr. Travers has remarked, the history, and concomi- tant appearances, or morbid states associated with amau- rosis, will commonly indicate whether it be functional or organic. Thus, he observes, diseased changes in the situa- tion, or texture of the eyeball, or in the brain, a hemiplegia, or partial paralysis, with other signs of apoplectic, or other pressure on the brain; an acute, deep-seated inflamma- tion of the eye; a fulness of the superficial vessels of the conjunctiva; a bluish grey tint of the sclerotica; a degree of bulging on one or more sides of the eyeball; or a loss of its sphericity, point out the amaurosis as organic. On the other hand, he has known functional amaurosis pro- duced by a wound of the scalp, caries of the skull, disease of the antrum, and abscesses about the face, the eye being in all these cases sound, and the orbit untouched by the neighbouring disease. Functional amaurosis may also de- AMAUROSIS. 469 pend upon immoderate exertion of the eye; disorder in the functions of the stomach, liver, and uterus; sudden and alarming depletion; the suppression of habitual secretions: difficult dentition; worms in the bowels; and the deleteri- ous effects of certain substances upon the organ, or the sys- tem. Amongst other predisposing causes are also enu- merated sedentary occupations, producing a torpid state of the liver and bowels, and combined with much exertion of the eye upon minute, or shining objects, while the head is in a depending position; the use of optical glasses; ob- stinate amenorrhoea; or constipation of the bowels, with de- termination of blood to the head in a full habit.* With regard to the prognosis, when amaurosis is com- plete, and been of some continuance, no mode of treatment can be expected to restore vision. Complete, inveterate amaurosis, with organic injury of the substance constitut- ing the immediate organ of siglut, may, indeed, be set down as a disease absolutely incurable. Amaurosis is ge- nerally incurable, when it has existed several years in per- sons of advanced age, whose sight has been weak from their youth; when it has come on slowly at first, with a morbid increase of sensibility in the immediate organ of sight, then with a gradual diminution of sensation in this organ, to the state of utter blindness; when the pupil is either motionless, and has lost its circular shape, with- out being much dilated, or when this aperture is dilated in such a degree, that the iris seems as if it were wanting, and its margin is irregular and fringed; when the bottom of the eye, independently of any opacity of the lens, pre- sents an unusual paleness, like that of horn, or else a green- ish hue ; when the case is attended with universal head- ache, and a constant sense of tension in the eyeball; when it has been preceded by a violent, protracted excitement of the whole nervous system, followed by general debility and languor; when it is connected with epilepsy; when it is the consequence of severe internal ophthalmy; when, be- sides being of long standing, it has originated from con- cussions of the head, blows on the eyeball, or injuries of the supra-orbitary nerve, or from the entrance of foreign bodies into the eveball; exostoses on the forehead, sides of the nose, or os" maxillare; or when it is conjoined with a manifest change in the figure and dimensions of the eye- ball. The distorted appearance of objects in ajj early * See Travers's Synopsis, pp. 142—116. 470 AMAUROSIS. stage of the disease, was regarded by Beer as an unfa- vourable omen, because indicating, in his opinion, disease of the brain. Incomplete recent amaurosis is mostly curable when not produced by any causes capable of permanently injuring the organic texture of the optic nerve and retina, and when the immediate organ of sight retains some sensibili- ty to light. Recent and sudden cases, in which the pupil is not excessively dilated, and its disk is regular, while the bottom of the eye is of a deep black colour; cases not accompanied by any acute and continual pain in the head and eyebrow, nor by any sense of constriction in the eye- ball ; cases which originate from violent emotions of the mind; disorder of the stomach; plethora; suppression of habitual evacuations ; great loss of blood ; nervous debi- lity, of not an inveterate nature in young subjects, are all, generally speaking, curable- Amaurosis is also mostly re- mediable when it is periodical, or comes on during con- vulsions, the efforts of difficult parturition, and towards the termination of acute, or intermittent fevers. When the eye is equally free from marks of organic change, as Mr. Travers has justly observed, the slow and the steadily progressive amaurosis is more difficult of cure, than either the sudden,or the rapidly advancing form • of the disease.* Rules for the treatment of amaurosis cannot be of much value, unless founded on a correct view of the causes of the disease, or drawn from successful experience. A great deal of the common difficulty in the cure, I believe, is owing to our ignorance of the causes, to their frequently be- ing various, complicated, and incapable of removal, or, if removable, their effects on the eye cannot be dispersed with them. From what has been previously stated, it must be clear, that this is most likely to be the case, when the disease has existed a long time, and come on in a slow, and gradual manner. When functional amaurosis depends upon disorder of the primae viae, habitual costiveness, and an increased flow of blood to the head and eyes, purgatives are found in this country to answer better, than the free employment of tartarized antimony, in emetic and nauseating doses, so highly praised by Richter and Scarpa. Mr. Travers em- ploys the blue pill, with gentle, saline purgatives, and • Synopsis, &c. p. 298. AMAUROSIS. 171 tonics. In most of these cases, he observes, we should first aim at the regulation of the visceral functions, and then employ tonics. The blue pill with colocynth, rhu- barb, or aloes, and the combination of soda with rhubarb and columba, he recommends for the first purpose ; the mineral acids, bark, and steel, for the second.* When amaurosis is recent and sudden, and signs of an obscure inflammation are present, Mr. Travers has re- course to mercury, introduced into the system gently, and just sufficiently to make the mouth sore. Dr. Frick has seen much advantage from mercury, or calomel, in cases of incipient amaurosis, attended with deep-seated, and es- pecially an intermittent pain in the head, or orbit.f In cases, accompanied with plethora, great determina- tion of blood to the head and eyes, or chronic, deep-seat- ed, ophthalmic inflammation, venesection, cupping on the temple, and the occasional use of leeches, are necessary. Besides topical bleeding, the only local remedies, which now possess much confidence in amaurotic diseases, are blisters, issues, and the moxa. Any of them may be applied to the nape of the neck, or the blisters may be put over the eyebrow, or on the temple, and either repeated or kept open. Many of the varieties of functional amaurosis present clear indications: thus, when the disorder isK connected with worms, the suppression of habitual evacuations, or immoderate exertion of the eye on minute or shining ob- jects; the first requisite steps to any melioration of the sight must be the removal of these particular causes. Also, when a general bad state of the health and mental de- spondency are joined with the impairment of vision, these states must, if possible, be obviated by due means; pro- per medicines and diet; regular exercise in an open car- siage, or on horseback, in a dry salubrious air; change of scene, and the pleasures of society. * Synopsis of the Diseases of the Eye, p. 304. f On Diseases of the Eye, ed. by Welbank, p. 153. 472 CATARACT. CHAPTER XXI. CATARACT Is the term applied to every kind of opacity in the eye, situated between the vitreous humour and iris, and causing more or less impediment to vision, by hindering the rays of light from duly reaching the retina. The opacity may be in the crystalline lens, or its capsule, or in the posterior chamber between the capsule of the lens and the back sur- face of the iris, frequently named the uvea. When it af- fects the lens or its capsule, it is called a true cataract; but when it consists of opaque matter, deposited in front of these parts, it receives the name of a. false cataract. Cata- racts are also divided into idiopathic, or such as arise from internal, but generally unknown causes, and into accidental, which originate from external violence, or active inflamma- tion. The idiopathic generally affects both eyes; the acci- dental is more frequently confined to the organ that has been injured.* The idiopathic disease is usually formed with remarka- ble slowness, and at first may easily be mistaken for amau- rosis. In cases of cataract, all objects seem to the patients obscured by a thin mist; and the diminution of vision is exactly in proportion to the opacity manifest behind the pupil. The opacity is first noticed in the centre; seldom, towards the edge of the pupil. Hence, the clear view of such objects as are directly in front of the eye is prevent- ed, while others, laterally situated, may yet be seen with tolerable distinctness. Hence, also, the eye-sight is better in the shade, where the pupil is dilated, than in a strong light, where the iris expands over the transparent circum- ference of the cataract. As the opacity augments, a black ring is observable round the pupil; and ascribed by Beer to the shadow of the iris upon the lens. To a patient with cataract, the flame of a candle appears surrounded by a whitish circle, which enlarges as he retires from the light; but when the opacity is far advanced, the flame cannot be discerned, and the patient can then merely judge of the distance of its light from the eye. A cataract, in its early * Guthrie's Operative Surgery of the Eye, p. 190. CATARACT. 47J stage, does not impair the motions of the iris; and the eye- sight receives assistance from convex glasses. In amaurosis, the cloudiness in the eye lies far behind the pupil, and has a concave, greenish, or reddish appear- ance. The diminution of sight is not at all in a ratio to the degree of this deep-seated loss of transparency; the pupil is generally dilated and angular; the activity of the iris lessened, or destroyed; and the brightness of the cor- nea somewhat changed. The increase and diminution of the eyesight does not depend, as in cataracts, upon the quantity of light, or the consequent greater or less dilata- tion of the pupil; but, on a variety of circumstances, aug- menting or lessening the sensibility of the retina. Thus, agreeable emotions of the mind, a hearty meal, or a glass or two of wine, will cause a temporary improvement of the sight; while long-fasting, mental anxiety, and every debi- litating cause, will have the contrary effect. The flame of a candle, and the zone around it, instead of being white, as in cataract, exhibit the various colours of a rainbow. Glasses afford the patient no assistance, and lateral objects are generally as indistinct as those situated directly before the eye. (Beer.) Idiopathic cataracts affect persons of all ages; but most frequently such as are advanced in years, though the num- ber of young subjects with the disease is considerable, and infants are occasionally born with it. Females are some- times supposed to be more numerously afflicted than males. Cataracts are not found to prevail with increased frequen- cy in any determinate kind of constitution; neither has pre- vious disease any influence on its formation, unless it should have attacked the part, or the eye generally, by particular and direct sympathy. Scrophula and syphilis are never concerned in the production of a cataract, except when they extend their effects from other parts of the eye to the lens or its capsule, in which case, the disease is not properly idiopathic* Various examples are recorded in proof of the prevalence and frequency of cataracts in particular families, and of an hereditary predisposition to them; but, as facts of this kind are not very common, and the disease is extremely so, we may conclude with Mr. Guthrie, that, at all events, a family tendency to cataracts is far less fre- quent, than an hereditary predisposition to consumption, gout, or scrophula. • Sec Guthrie's Operative ^urgerv of the Eve, p. 191 Vol. I 3 O 471 CATARACT. The consistence of cataracts is a matter of some import- ance, particularly, because a method of operating adapted to a soft, or fluid lens, may not be well calculated for one that is firm and hard. A pearl yellow, or brown colour of the lens, may be considered as indicating a hard cataract; while a white, milky, or striated appearance, rather denote a soft cataract. But, as Mr. Guthrie has observed, the milky colour of a cataract is by no means a certain test of its fluidity; many cataracts, perfectly white, and supposed to be soft, having been found after extraction to be hard; and, on the contrary, pearl-coloured ones soft. The size of cataracts is a better criterion of their consistence than their colour is; for the smaller the lens is, and the darker its colour, the more solid its substance generally is; while the larger, and more protuberant it is against the iris, the greater is the probability of its being soft.* Writers treat of the hard; caseous, gelatinous, or soft; the fluid, or milky ; and the capsular, or membranous, cata- racts. When a cataract is hard, it mostly presents one of the colours above specified; the interspace between it and the pupil is considerable; the patient distinctly perceives the light, and can even plainly discern in the shade, were the pupil not too much contracted, large objects, or bright co- lours. In the dilated state of the pupil, the black circle around the lens is very manifest; and, as the opaque body does not project against the iris, the motions of the pupil are free and prompt, and the front surface of the cataract is flat, without the least degree of convexity. Cataracts, which occur at an advanced period of life, without previ- ous disease of the eye, are frequently of this description; and it is remarked by Beer, that they may exist many years, without an extension of the opacity to the capsule. In the caseous, gelatinous, or soft cataract, the lens is thicker and larger than natural, and hence the motions of the iris are considerably obstructed by it. Vision is near- ly, or completely prevented ; nor is there any improvement of it when the pupil is dilated in the shade, or by the ef- fect of belladonna. The lens is said to have a spotted or flocculent appearance, and no black circle is perceptible around it. According to Richter, the milky or fluidcataract is most- ly of a white colour, with irregular spots and streaks upon ._-----m--------------------------.___________________ * Guthrie, op. cit. p. 208. CATARACT. 475 it, the-shape and situation of which are sometimes changed by sudden motions of the eyes, or when the eyelids are rubbed over them. The lower half of the pupil is often more opaque than the upper. The altered lens is large, and the opacity close behind the pupil, which is itself ge- nerally dilated. The cataract, by projecting forwards, ob- structs the motions of the iris, which are therefore slower and less perfect than they ought to be; while the size and thickness of the cataract render the patient so blind, that he sometimes cannot distinguish the light without difficul- ty, and his power of vision is not materially improved in the shade, or by the application of belladonna : this is par- ticularly the case when the iris is habitually dilated. In the capsular, or membranous cataract, either the ante- rior, or posterior capsule of the lens may be affected. In the latter case, sight is completely prevented, and but little improved by dilatation of the pupil in the shade, or with belladonna. The opacity seldom begins in the centre of the pupil, but generally at its margin, in the form of small shining spots, or stripes; and it never exists long without the lens becoming affected. If the opacity be restricted to the front capsule, the cataract will have a convex appear- ance, and seem close to, or even in contact with, the iris, so as to interfere with its movements. When the posterior capsule is opaque, the cataract seems deep in the eye, and its surface concave. As this species of cataract is frequent- ly the result of inflammation, extended to the capsule from neighbouring parts, this membrane is often adherent not only to the lens, but also to the hyaloid membrane.* A cataract is termed simple, when accompanied with no other disease of the eye likely to impair its functions, or with no complaint of the general system: complicated, when joined with some other morbid change in the eye, or a constitutional disorder, or particular diathesis, like the disposition to gout, rheumatism, erysipelas, &c. One not unfrequent complication is an adhesion of the iris to the front capsule of the lens; the effect of previous inflammation, and indicated by an angular deformity of the pupil, the loss of mobility in the attached portion ot the iris, and the visible state of the adhesion when the pu- pil is dilated with belladonna. Cataracts may be complicated by a diseased state ot the vitreous humour, exemplified either in the opaque change • See Beer's I.ehre, and Frick on Diseases of the Eye, p. 161 476 CATARACT. of its fluid part, or of the hyaloid membrane, termed glau- coma, or else in the total disorganization of it, and the de- struction of its cellular texture, called synchysis. A very unfavourable complication of cataract is amau- rosis, the existence of which, however, must not be posi- tively inferred from the state of the dilated pupil, and mo- tionless, or sluggishly moving iris, because these effects may be caused altogether by the protrusion of a large lens against the iris, as frequently happens in cases of soft and fluid cataracts. But, if these states of the pupil and iris be joined with the patient's complete inability to discern the light, amaurosis certainly exists. Cases very difficult of discrimination sometimes arise, especially when the af- fection of the retina has commenced subsequently to the cataract, and is incomplete. The only other complications, which need here be men- tioned, are general impairment of the eye by frequent at- tacks of previous inflammation; its actual presence; lip- pitudo; cirsophthalmia, or a general varicose state of the vessels of the eye ; hydrophthalmia, or a dropsical enlarge- ment of the organ; opacity of the cornea; staphyloma; and incipient fungus haematodes. A favourable prognosis very much depends upon the cataract being free from every complication, both in the eye itself, and the constitution. The best chance of suc- cessful treatment attends cases which, besides being un- connected with any of the circumstances or states above specified, have not been accompanied with repeated attacks of severe and distressing headach, or pains in the eye and eyebrow; nor been preceded, at any period of the patient's life, by epilepsy, or convulsions, the renewal of which may be brought on again by the operation, long after their seemingly permanent cure. In hypochondriacal and hys- terical patients, an operation is more apt to fail, than in a healthv individual. The pupil should have its regular cir- cular shape, the iris a power of motion in the varying de- grees of light, and the patient be able to discern the light distinctly, and, in shady places, where the pupil expands, even bright colours. It is still a question in surgery, whether in cases of sin- gle cataract, the other eye remaining sound, an operation be advisable. The authorities, and reasoning, which might be adduced in support of the propriety of it, would lead me to recommend at all events a further investigation into the question; that is to say, a fair trial of the operation CATARACT. 477 in a sufficient number of cases to justify a positive con- clusion respecting its utility or disadvantages; because a few occasional failures do not settle the point. That the plan has answered in many cases, is fully proved by the re- cords of surgery. At the same time, I am ready to admit, that if confusion of vision were to happen only in a very moderate proportion of examples, for instance, in ten out of every hundred operations upon single cataracts, the rest being successful, the practice would hardly seem warrant- able, because unless the risk were still considerably small- er, the surgeon would not be justified in exposing to any disturbance the useful degree of vision which the patient enjoys from the possession of one healthy eye. On the other hand, it is to be remembered, that the continuance of a cataract in one eye, has been set down by very expe- rienced men, not only as a cause likely to induce a cataract in the other, but an amaurotic state of the retina in the eye already affected, in consequence of the long suspension of its functions. The question, therefore, involves several important considerations, which should be correctly weigh- ed against each other. When both eyes have cataracts in them, and the case has no unfavourable circumstances in it, it is not unfre- quent to operate upon both at the same time ; but, as Mr R. Welbank has observed, the saving of a little confine- ment, the only reason for this method, does not counter- balance the disadvantages arising from the risk of greater inflammation in the eyes, and the danger of an attack of spasm.* Various internal medicines, and local applications,have been tried for the purpose of dispersing opacities of the lens, or its capsule; but none of them retain the confi- dence of experienced men. In a few rare cases, patients have regained their vision, and the pupil has resumed Its usual transparency, without any operation ; a change, that has sometimes proceeded from the accidental displace- ment of the lens from the axis of sight, of which Boyer has recorded an instance.f Spurious cataracts, or those formed in front of the lens by deposits of lymph, blood, &c. may be occasionally dispersed ; but true cataracts, or those occupying the lens, or its capsule, scarcely ever dis- appear, without an operation for their removal. • Frick on Diseases of the Eye, p. 17u, note. f Traite des Mai. Chir. t. v. p. 509. 478 CATARACT. In former times, a great deal of preparatory treatment for the operation, was generally adopted; but, unless the patient be unhealthy, little more is requisite, than a tem- perate regimen for a few days, and due regulation of the state of the bowels. Timid patients may take a few drops of laudanum a little before the time fixed for the opera- tion : and if much fulness of habit exist, venesection may be advantageous a day or two previously. At the present time, three principal methods of operat- ing for the removal of cataracts are practised; namely, extraction; couching, or depression; and the breaking of the opaque lens and capsule into fragments, which are after- wards absorbed. However, the latter method is mostly de- scribed under the head of couching, of which it has al- ways been regarded as a modification. Extraction of the cataract is performed by making an in- cision through the lower segment df the cornea, dividing the capsule, and gently promoting the escape of the opaque body through the wound. The knife for the incision in the cornea, should gradually increase in thickness from its point to its hilt, so that the aqueous humour may not be discharged before the section is completed, and the iris be exposed to injury by falling forwards under the edge of the instrument. Its shape should be such as will permit the incision in the cornea to be finished by one stroke, or movement, and, consequently, its greatest breadth should be at least equal to half of the diameter of the cornea. The broadest part should not be too far from the point, be- cause the nose would then be pricked before the perfect division of the lower part of the cornea had been effected. One of the best knives is that employed by Beer, and re- presented in plate 3, fig. 3. As Mr. Guthrie has observed, the position of the pa- tient must necessarily depend upon the surgeon's capa- bility of using both hands with equal dexterity; for, if he can employ only the right, the common position, and or- dinary method, are not at all applicable to cases, in which the right eye is to be operated upon.* If he be an ambi- dexter, he will operate on the left eye with his right hand and on the right with his left? if not, it will be prudent for him to place himself behind the patient, and divide the upper segment of the cornea in the manner which will presently be noticed. When the surgeon can use both * Operative Surgery of the Eye, p. 294. CATARACT. 179 hands with sufficient skill, and even when he cannot, if the left eye be the subject of operation, the patient is to sit on a stool, the height of which is exactly such as puts his head on a level with the operator's breast. Hence, the usefulness of a seat contrived on the principle of a music stool, that admits of being raised or lowered by simply turning a screw, by which means, the most convenient height for the patient's head can be readily arranged. The light, to which the eye is exposed, should not be too strong, because it would render the pupil too contracted; and, in order to make the eye as steady as possible, the other should always be covered with a small compress, or handkerchief. An assistant is to keep the upper eyelid raised with his fore and middle fingers, and at the same time support the patient's head upon his breast. The operator should be seated rather higher than the patient, and rest his right foot,on a stool, in order that his knee may be high enough to serve as a point of support for his elbow. The knife is to be held like a writing pen, and the little finger of the hand that holds it, is to rest steadily on the outside of the cheek. With his left fore and middle fingers, he depresses the lower eyelid, and at the same time lets them make a gentle projection against the eyeball, so as to prevent its motion inwards, away from the knife. When the eye is perfectly quiet, and its position such, that the whole of the cornea is distinctly in view, and es- pecially its inner and inferior segments, the operator is to plunge the knife into this tunic, a little above its transverse diameter, and about half or three-fourths of a line from the margin of the sclerotica. In this first proceeding, it is of great importance to direct the point of the knife obliquely towards the cornea, as if to penetrate the iris. Not unfre- quently, the knife is directed in a line parallel to the iris, and hence it happens, especially in elderly persons, where the cornea is much thickened, and the anterior chamber considerably lessened, that the blade is carried for some distance between the laminae of the cornea, and consequent- ly the opening is too small, so that the pressure, and other manoeuvres, afterwards necessary to get the lens out of the eye, often do great violence to the iris, occasion profuse loss of the vitreous humour, and become the cause of a sub- sequent closure of the pupil. The arrival of the point of the knife in the anterior chamber, is indicated by its bright appearance, the part of the" blade buried in the cornea he- 480 CATARACT. ing always obscured.* The cornea having been completely pierced, the knife is now to be conveyed cautiously and steadily across the anterior chamber, in a parallel direction to the iris, until its point has passed out of the cornea at a point as nearly as possible corresponding in height and distance from the sclerotica, to that at which it entered. The surgeon should now stop, until the spasmodic action of the muscles of the eye has ceased, which will be in a few moments, when, all pressure on the organ having been removed, the incision of the cornea is to be finished by pushing the knife steadily in the same direction, until its edge descends through the lower portion of that mem- brane, when the eyelids may be allowed to cover the eye again, until the continuance of the operation is resumed. In making the incision of the cornea, care must be taken not to let the point of the knife wound the caruncula la- chrymalis, and nose, or its edge cut the iris, when this falls forwards. The first parts are avoided by inclining th£ han- dle towards the temple ; and the iris may be made to recede from its dangerous situation, by gently rubbing the cornea with the left fore-finger. One of the most essential things in the operation, is to make the section in the cornea sufficiently large for the ready escape of the lens; for, when this is not the case, the force requisite to bring the cataract through the wound, seriously injures the iris, and is apt to excite violent in- flammation of it; too often terminating in a closure of the pupil. Hence, if the wound, made with the knife, should not have due extent, it must be enlarged with Daviel's scissors. The next business to that of making a fit incision in the cornea, is the division of the front capsule of the lens, which should be accomplished with a small steel couching-nee- dle, and not with gold instruments, the bluntness of which renders them ill calculated for the purpose. Some operat- ors make a crucial division of the capsule; while others endeavour to cut it into very minute portions, by repeated strokes of the instrument in various directions. This is done in order that the fragments may escape with the lens, and the risk of a secondary cataract be thereby lessened. In this stage of the operation, a skilful operator always avoids lifting up the flap of the cornea too freely, or dis- placing the lens, an occurrence that increases the chance * Frick on Diseases of the Eye, pp. 185—186. CATARA< 1 4tl of a protrusion of the vitreous humour before the cataract is extracted, the difficulty of doing which is then seriously increased by the sinking of the lens further into the eye- ball.* When the iris contracts so considerably as to pre- vent the safe division of the capsule, the light must be diminished. After this division has been duly accom- plished, the lens in general soon escapes through the pupil by the action of the eye itself. If this should not happen in a very short time, the expulsion of the lens is to be pro- ^ moted by gentle pressure. When its passage forward is still delayed, it is probably retained by an adhesion to the posterior capsule, which is also adherent to membrana hy- aloidea. This occurrence, which is not generally attended with an adhesion of the lens to the anterior capsule, is mostly a consequence of previous inflammation. In this emergency, the surgeon is to press upon the lower part of the eye, until the inferior portion of the lens presents itself, when the curette is to be gently insinuated behind it, and its separation completed. When any fragments of the opaque lens yet continue in the pupil, they are also to be taken away with the curette. Frequently, however, the pupil may be freed from them by gently rubbing the upper eyelid with the fore-finger, after the eye is shut. A fine I pair of eye-forceps, constructed with a small hook, is usual- ly employed for the removal of any pieces of opaque cap- sule. When extraction is to be performed on the right eye, and the surgeon cannot operate with his left hand, he may i follow Mr. Guthrie's plan; the upper eyelid is to be raised |, by the operator, who is to stand behind the patient, and at | the same time keep the head steady, either on a low chair, table, or bed. The knife, with its edge directed towards k the eyebrow, is to be introduced below the horizontal dia- l meter of the cornea, which is to be divided upwards. Great > care must be taken not to wound the upper eyelid, nor let it descend and engage itself behind the flap of the cornea.f After each method of extracting cataracts, the utmost . attention should be paid to placing the flap of the cornea in regular contact with the part with which it was naturally joined, so that its union may follow without any opacity, or uneven cicatrix. Both eyes should then be covered with light compresses, retained by a bandage round the forehead. • See Frick on Diseases of the Eye, p. 190. Travers's Synopsis, p. 326. ■j- See Guthrie's Operative Surgery of the Eye, p. 320. Vol. I. 3 P 4 3d CATARACT. The patient should be kept in bed, with his head mode- rately raised; a very low regimen prescribed; and the cham- ber darkened. If pain arise in the eye soon after the opera- tion, venesection should be practised, or leeches applied to the temple. In general, the wound of the cornea is com- pletely united in two or three days; but, unless there be reason to suppose that the flap has become displaced, or that the iris has insinuated itself between the edges of the incision, the eye should not be examined before the fifth or sixth day, when the compresses and bandage may be if taken off, and a green eye-shade applied instead of them. Instead of giving purgatives directly after the operation, it is better that the bowels should be opened previously, so that all bodily disturbance may be avoided for at least a day or two. The best cases for extraction are those in which the cataract is hard, the eye prominent, the anterior chamber large, the pupil not contracted, the fissure between the eye- lids ample, the diameter of the cornea not diminutive, the cataract free from adhesion to the iris, and from va- rious other local and constitutional complications already detailed. Couching is a term that has been applied to various ope- rations, performed for the cure of cataracts, with a needle, and has not been restricted to depression, properly s.o named, but extended to the several methods of disturbing, cut- ting, breaking, and lacerating the cataract, whether it be removed from its natural situation or not. In fact, some kinds of cataracts do not admit of being at once displaced, and pushed out of the axis of vision; but experience proves, that the disturbance, apd breaking of them with the needle, frequently lead to their absorption. The surgeon may em- ploy either a slender spear-pointed needle, like that of Beer,* Scarpa's delicate one with a curved extremity, sharp point, arid two cutting edges,f or Hey's fine, round, couch- ing-needle, terminating in a sharp minute edge of a semi- lunar shape-i. When the aim is merely to disturb and break the opaque lens, or gently lacerate the front cap- sule, so that the aqueous humour may have access to the cataract, Saunders's very fine needle^ will answer the purpose. • Plate 7, fig. 2. f Plate 7, fig. 3. The part between the handle and the dotted li; be advantageously deducted from its length. * Plate 7, fig. 4. § Plate 7, fig. 5 and 6, sy.i/. ^mu».■■■-**"*** (ft- Heisituiers double hook fone/'s a AU*. // /.titemf view of one of its bruiifht &* CATARACT. 4S3 The pupil having been dilated with belladonna, the pa- tient and surgeon are to be seated in the same manner as in the operation of extraction. An assistant is to support the head on his breast, and keep up the upper eyelid with the fore and middle fingers of his right hand; while the surgeon depresses the lower eyelid with those of his left hand. If the curved needle be preferred, it is to be held with its convexity forward, its point backward, and its han- dle parallel to the temple. The patient having turned his eye towards his nose, the opportunity is to be taken of in- troducing the needle boldly through the conjunctiva and proper coats of the eye into the vitreous humour, about a line and a half from the margin of the cornea, and a little below its transverse diameter. This place is selected in order that the ciliary processes and long ciliary artery and nerves may not be injured. The first direction of the nee- dle should be towards the centre of the vitreous humour; but, directly after its point has passed through the coats of the eye, the needle may be guided to the upper part of the lens, which, in the first instance, is to be depressed a little downward with the flat convex surface of the instru- ment. Thus a space is made between the cataract and ciliary processes, for the safe conveyance of the needle into the posterior chamber, in front of the lens and its capsule. In this step of the operation, care must always be taken to keep the marked side of the handle forwards, so that the point may be turned away from the iris. The needle will now be visible in the pupil, and its point is to be push- ed transversely as far as the inner edge of the lens. The handle is now to be inclined forwards, by which means the point will be directed through the capsule into the sub- stance of the lens, and, on moving the needle downward and backward, the former will be lacerated, and carried with the latter deeply into the vitreous humour. The laceration of the anterior capsule is deemed of con- siderable importance, because the absorption of the opaque lens is thereby promoted, and a secondary membranous cataract frequently prevented. When the cataract is fluid, its contents flow out as soon as the capsule is pierced, often rendering the whole ot the aqueous humour so turbid, that the iris and needle are completely hidden. The surgeon should not be discon- certed by this event, but endeavour, as tar as he safely can, to lacerate the capsule, and leave the opaque matter in the 484 CATARACT. chambers of the eye to be absorbed, which will often be the case in a few days. When the cataract is soft, and will not admit of depres- sion, the surgeon should freely break and cut it into frag- ments, taking care not to spare the capsule, and pushing as much of the opaque matter as he conveniently can, for- ward into the anterior chamber, where absorption is car- ried on more vigorously than behind the pupil. When the case is a secondary membranous cataract, the surgeon is to turn the point of the needle cautiously to- wards the pupil, and pierce the opaque capsule, which is to be broken, as far as it is practicable, at every point of its circumference, and the fragments either left in their situation, or pushed through the pupil into the anterior chamber. When the capsule is adherent to the iris, the attachment may often be broken by skilful and delicate movements of the needle, the cutting edges of which may here be found useful. If the operator prefer a straight needle, he may also imitate Scarpa, and depress the cataract a little in the first instance, so as to make room between the lens and the ciliary processes for the passage of the needle in front of the opaque body. The generality of surgeons carry the needle directly across the posterior chamber, between the iris and the cataract, until its point is beyond the nasal edge of the pupil, with one flat surface towards the lens, the other towards the iris. They then place one of its flat surfaces on the upper part of the lens, which is depressed more or less deeply backward and outward. That it should not be forcibly propelled too far backward, so as to injure and press upon a part of the retina essential to vision, I think must be as manifest as the contrary fault of not car- rying the depression far enough, which must leave a risk of the return of the lens to its former situation, or of a dangerous degree of iritis from its lodgment against the uvea. Reclination, a term, of which so much is now heard in surgery, consists in turning the opaque lens, so that its anterior surface may be upwards, and its posterior surface downwards, in which position its depression is effected. The dilatation of the pupil, by means of belladonna is a very useful preparatory step in this operation. The needle may be introduced, either at the place usually preferred in the ordinary mode of depression, or through the cornea and pupil, a method distinguished by the name of kerato- CATARACT. 4S5 nyxis, which is of two kinds. The first is that of Conradi, Beer, and Saunders, for destroying a central portion of the capsule, equal to the size of the pupil, with or without a yery gentle opening of the texture of the lens. The second is that of Buchhorn, Langenbeck, Walther, and Reisinger, in which the whole of the lens is broken, the capsule de- stroyed, and the pieces brought into the anterior chamber. For details of the plans of performing these operations, I must refer to Mr. Guthrie's work.* After their comple- tion, the eye must be covered as after extraction, means taken to prevent inflammation, and the pupil kept dilated with belladonna, until all risk of the iris contracting adhe- sions is past. With respect to the choice of a method of operating, I have already specified the circumstances favourable for extraction. When there is reason to believe the cataract hard, but the case is attended with some condition prohi- biting extraction, depression should be preferred. Soft cataracts are most calculated for plans, in which the main object is to divide and break them into fragments, which, when conveniently practicable, are to be pushed forwards into the anterior chamber, where they are more quickly absorbed, than behind the iris. Membranous, or capsular cataracts, are manifestly not adapted for depres- sion; neither are they well suited for extraction, except where the capsule presents itself in an opaque state, direct- ly after the lens has been extracted, in which case, it should be taken out with a pair of eye forceps. In all other cir- cumstances, membranous opacities are most advantageous- ly removed by means of the needle, with which they are to be lacerated, broken, and displaced from the axis of vision.f • Operative Surgery of the Eye, p. 333. f {An interesting and valuable paper on this subject, by Arthur Jacob, M. D., of Dublin, is published in the fourth volume of the Dublin Hospital Keports and Communications, for 1827. Dr. J. is decidedly in favour of the method of operating through the cornea, and expresses his conviction, (the result of extensive experience,) that it is not necessary to cut up the lens, and deposit the portions thus divided in the anterior chamber,- he consi- ders it all sufficient to make a free opening in the capsule of the lens, punc- ture or divide the lens, and then leave it to the action of the aqueous hu- mour, which will have free and ready access to it. With precisely similar views, at the suggestion, and from the experience of Dr. Physick, we were induced to perform a similar operation, in a case of congenital cataract now under care. There now remains as the result of our operation, opacity of the capsule only, (the lens being absorbed,) which we anticipate will speedi- ly be removed by another operation. For making the opening into tho cornea, all the needles now in use are 486 CATARACT. Congenital cataracts are mostly capsular, and attended with a complete, or partial absorption of the lens. Hence, extremely imperfect: with a view of obviating the difficulties attendant on them, says Dr. J., "1 determined to try a fine sewing needle curved at the point, and after about forty operations, I do not feel in the least inclined to repent of my choice. It rarely, if ever, leaves even the slightest mark in the cornea. I could produce examples where it has been three times in- troduced, and where not the slightest speck can be detected ; and I have introduced it through the very centre of the cornea without any bad conse- quence. When fairly introduced into the eye, it is capable of accomplishing any object to be attained by a needle. The capsule can be opened to any extent: a soft or friable lens can be actually broken up into a pulp, by push- ing the curved extremity of the needle into its centre, and revolving the handle between the fingers: large fragments can be taken up on the point of the needle from the anterior chamber, and forced back out of the way of the iris, or if sufficiently soft, may be divided by pressing them against the back of the cornea with the convexity of the needle; a method which I have repeatedly adopted with advantage. When the lens has been displaced from the capsule, in consequence of the needle sticking in it in attempting to open its texture, 1 have, without removing the needle, placed the lens in the anterior chamber, and then extracted it; and in other cases have forced it back into the vitreous humour, out of the reach of the iris. From the fineness of its point, and the ease with which it can be turned and twisted in every direction, it enables the surgeon to deal most effectually with an opake capsule; he may pick it with the point from any attachment it may have formed to the iris, or if it hangs flaccid, he may entangle and detach it by pulling or twisting. In certain cases, the pupil is found nearly closed, and adhering to a small cataract of nearly cartilaginous hardness; in these 1 have introduced the needle, and with the point picked up the adhesions between die margin of the pupil and this hard mass, which 1 have then placed in the anterior chamber, and removed through an opening in the cornea, with a pair of forceps. " There is one difficulty attending the use of the round needle; it re- quires very considerable force to pass it through the cornea; so much in- deed as frequently to embarrass those who use it for the first time. I can, however, safely assert, that very little practice enables the surgeon to sur- mount this difficulty. It is only necessary that he should be aware of the degree of force required, that force he is perfectly safe in employing. The greatest advantage in the use of the needle results from the very circum- stance which causes the difficulty in its introduction, it is from its conical form firmly wedged in the cornea, prevents the aqueous humour from escaping, and in consequence of being thus fixed, gives the surgeon a pow- er of holding the eye, that defies every effort on the part of an unruly patient, unless he actually pluck out the instrument with his hand. " The size of the needle is known in the shops as number seven, being the forty-fourth part of an inch in diameter, about one-half the size of the finest Saunders's needle which is made. The point can be turned to the requisite curve by means of a pair of cutting forceps, or the ward of a small key ; of course without heat, which would destroy the temper. It must not, however, be expected that all needles are so soft as to be bent thus cold : there may not be ten in a hundred of this temper, but when once turned they retain the curve without any danger of bending or breaking, and cer- tainly possess a degree of strength and temper never observed in needles separately forged and finished by the best cutlers. They should always be tried before use by passing them repeatedly through thick calves-skin lea- CATARACT. 487 and also on account of the unsteadiness of children, the pro- per operation is that of dividing and breaking them with a sharp-edged needle. The late Mr. Saunders was accus- tomed to operate at any time between the ages of eighteen months and four years ; but Dr. Farre considers that of two years the best period. The upper eyelid was kept up with Pellier's elevator; and the child laid on a table, parallel to a window, from which the eye, about to be operated upon, was farthest. Four assistants, and when the child was stout, five, were required to confine it. The pupil was dilated with belladonna, previously to the operation, and ther. After they have received the requisite curve, the point should be cut flat on each side, on a fine hone, and carefully examined with a magnifying glass to ascertain that it is perfect. The extent to which the point should be curved may be left to the choice of the surgeon, reminding him that the greater the curve the more effectual the needle will be when introduced, but the difficulty of introducing it through the cornea will also be greater. I therefore recommend those who use it for the first time to choose one slightly curved. After the point has been turned, the needle, held in the jaws of a pair of pliers or a vice, is to be run down into a cedar handle, without cement, leaving only half an inch of blade, which I have found to answer every purpose. If the blade be left longer, it will yield and spring when opposed to a resistance. The handle should be about a fifth of an inch in diameter, and four inches long. I use the handles made for camel- hair pencils, and find that a metallic ferule, which increases the weight, is unnecessary and objectionable. A needle thus constructed, and preserved free from rust, w'U retain its poinr^for a great length of time : I have used the same one a dozen times without sharpening." Dr. J. next proceeds to describe the steps of the operation; he is not particular at what point of the cornea he passes the needle—when it is brought into an advantageous position, he suddenly strikes it in, as near the circumference as possible. When its point is once fastened in the cor- nea, the surgeon has complete command over the eyes; no action of the muscles, says Dr. J., can disengage it, and an elevator or ophthalmostat is therefore altogether useless. The needle should be introduced with the point down, and the convexi- ty up, observing that the flat is kept to the iris, otherwise it is liable to be injured. Should its point pass through the iris, it may easily be extricated by gently drawing it back, without removing it from the eye. The needle being fairly introduced, the surgeon turns the point directly back, gently tears open the capsule, picking and scratching the surface of the lc-ns with a rotatory or drilling motion of the instrument; not with tlie lever or cutting movement of Saunders's or Adams's needle. If the lens be soft and friable, the fragments fall like snow into the anterior chamber, and the surgeon may push the needle deep into its structure ; and twirl the point round so as to mash it into a pulp; if it be hard, however, and the surgeon attempts to deal with it thus, the needle becomes fixed in its tough structure; it is borne from its capsule, dragged against the iris, and must either be extracted or pushed back into the vitreous humour. In hard lenticular cataract, there- fore, the capsule should be opened, and the centre of the lens cautiously scratched with the point of the needle, so as to be exposed to the action of the aqueous humour, by which it will be softened and fitted for breaking up on a future occasion.—P. E \ 4*8 CATARACT. kept so afterwards, until all danger of the iris becoming adherent to any portion of the capsule, was past. Mr. Saunders had two modes of operating; one corresponding to what is now called keratonyxis, that is, the needle was introduced through the cornea and pupil. The other me- thod consisted of the division and laceration of the opaque membrane with the needle, introduced in the manner usual- ly followed in couching, namely behind the iris. The an- terior operation was ultimately preferred, because it in- flicted slighter injury on the eye, did not disturb the ciliary processes and vitreous humour, and produced less inflam- mation, than the other method. One peculiarity in most of Mr. Saunders's operations, was that of opening and destroying chiefly the central portion of the capsule, and, if the lens was present, gently opening its texture, without displacing it. This plan mostly requires several repeti- tions of the operation, which are the strongest objections to it. Modern operators, I believe, find a freer disturb- ance of the cataract, and the displacement of the fragments from the pupil, on the whole, better practice. However, one fact in favour of Mr. Saunders's method, is very strong, namely, out of sixty cases operated upon by him, fifty-two were successful. Among the arguments, mentioned in favour of operating early, two in particular merit attention. First, when the patient has no perception of external objects, the muscles acquire so inveterate a habit of rolling the eye, that, for a very long time after the pupil has been cleared by an ope- ration, no voluntary effort can control this irregular motion, nor direct the eye to objects, with sufficient precision,for the purpose of distinct and useful vision. Secondly, the retina, when not exercised for along while, is apt to lose a degree of its sensibility.* * See a Treatise on some Practical Points relating to the Diseases of the Eye, by the late J. C. Saunders; to which is added, His Method of Curing the Congenital Cataract, by J. R. Farre, M. D. 1811. Of this work, there have now been several editions. NOTES BY A. H. STEVENS, M. D. ONE OF THE SURGEONS OF THE NEW-YORK HOSPITAL. Note A. Page 6. There exists in some inflammations a phenomenon which seems to favour the idea of error loci: for instance, when a part, naturally white, and in which the eye can discover no red vessel, becomes inflamed, it assumes a red co- lour, more or less deep, which might be attributed to the passage of red blood into the lymphatic vessels. But in all parts, even those that are the whitest, the blood circulates, and its globules preserve the red colour, which is essential to them. Now, since the sanguineous vessels of these parts are extremely delicate, and receive, so to express it, only single globules, they do not show a red colour; in the same manner, a drop of coloured liquor, in a transparent capillary tube, or a plate of coloured glass, extremely thin, ap- pears white. But, if several globules of blood united, enter, successively, a vessel, through which they do not thus pass in the natural state, they will show, through the thin transparent walls of this vessel, their red colour, in a man- ner precisely similar to several united drops of coloured liquor in a transpa- rent tube. In this way the sclerotica, the skin, and, in general, all parts of the body which are naturally white, become red by inflammation. There is no need of recurring to error loci in order to explain this phenomenon, which is, beside, disproved, as we have seen, by anatomical experiments.— Boyer's Surgery, vol. i. pp. 5 and 6. Note B. Page 54. The utility of blisters, applied in strips overthe sound parts immediately next those which are gangrenous, a remedy for which we are indebted to Dr. Physick, is too universally known and acknowledged in this country, to require more than a passing notice. The pyro-ligneous acid, the use of which was first suggested to me by my friend, Dr. S. W. Moore, of this city, promises to be a very valuable topical application; not only in cases of mortification, but in sloughing, and all other fetid ulcers. The method I have adopted, is, to cover the surface of the ulcer or slough with lint, or soft linen rags, and to wet them frequently with the acid. With many ulcers it agrees better than the nitric acid, or yest Vol. I. 3 Q 490 NOTES. poultice, and is altogether superior to either in its powerful antiseptic quali- ties. The most intolerable fetor is removed by it. No one who knows how essential it is in cases of mortification and of phagedenic ulcers, to keep the^ stomach of the patient in good order, but will think highly of a remedy of such powers. I have not had an opportunity of testing its efficacy in remov- ing the fetor of patients, in low fevers, when applied to the skin by means of a sponge, or otherwise; but I venture to hope, that it will be found high- ly useful in such cases. Note C. Page 76. These directions for the constitutional treatment of erysipelas, are not at all applicable to the disease as it appears in this countiy. There are few severe cases, in which, at least, one large bleeding is not proper, and, indeed, indispensable. In many cases, venesection requires to be repeated several times, and the whole of'the antiphlogistic regimen strictly enforced. Note D. Page 80. Several cases have been published in the Medical and Physical Journal, published by Dr. Chapman, by Dr. Dean, intended to illustrate the use of mercurial ointment as a topical application in erysipelas. Dr. Chapman mentions, that Dr. Physick has applied it with great advantage. Other cases, illustrating its utility, may be seen in the Medical Recorder, of Phila- delphia, and the Medical Repository, of New-York. Note E. Page 90. I believe it is not common to meet with cases of carbuncle in which the chylopoietic organs are not disordered. Such a case has not occurred to me; and effectually cleansing the prima? viae is a primary and indispensable object in every case. Note F. Page 91. Doctor Physick has revived the ancient practice of cauterizing carbuncles* of the success of which he speaks in high terms. See Philadelphia Medical and Physical Journal. I have no experience of this practice, but I cannot agree with Mr. S. Cooper in advising the use of emollient poultices. It is contrary to the ad- vise and practice of the best surgeons, both in Europe and America; who, with few exceptions, agree in the propriety of using stimulating applications. Yest is highly recommended by Dr. Hosack, and is pretty generally em- ployed in New-York. Mr. A. Cooper recommends spirits of turpentine, diluted with two parts of olive oil. After opening the carbuncle, I common- ly direct it to be smeared over with warm spirits of turpentine, and apply a yest poultice. It is often necessary to support the constitution with ammo- nia and opium, and a generous diet. I have known Fowler's solution admi- NOTES. 491 nistered with great advantage, in this, and other species of mortification aris- ing from constitutional debility. Mr. A. Cooper observes, in his lectures, that he never knew an instance of recovery from carbuncle situated on the head; the patients generally dy- ing comatose on the third or fourth day. Note G. Page 142. After applying a ligatnre to the subclavian artery above the clavicle, in a peculiar case, preparatory to amputating at the shoulder joint, I found the blood flowing from the divided end of the axillary artery, in the course of the operation, and it became necessary to apply a ligature to that also. This was owing, as afterwards appeared, to the first knot having loosened itself before the second was applied. The surgeon's knot is not liable to this accident, and should be preferred, I think, on that account. Note H. Page 144. Annexed is a representation of a tourniquet, invented by Dr. Moore, of Massachusetts, and particularly described in the New-England Journal, ap- plied so as to compress the anterior tibial artery. Besides answering all the purposes of a common tourniquet, when applied without the splint, it may thus be made to compress very effectually a single artery. • Note I. Page 160. Where a person ha9 received several wounds, it will, in general, be found most advantageous to begin by dressing those which are least painful, so that he may be left undisturbed immediately after the most painful operation. 492 NOTES. Note K. Page 176. . In recommending cold washes as useful in contusions, and around the edges of lacerated wounds where the skin is not broken, Mr. Cooper does not mean, I presume, to advise them to be applied immediately after the accident. Until the chilliness and first nervous symptoms pass off, and are succeeded by increased zeal and fulness of the pulse, they can be of no uti- lity, but are rather calculated to do harm, by increasing the severity of the cold stage. Note L. Page 183. * If we may trust to the statements of Mr. C. Bell, the danger of secondary ^hemorrhage, after gun-shot wounds, is greatly exaggerated, if not entirely groundless. • " In the first place, I positively deny that, because a gun-shot wound bleeds, there must, therefore, be a great artery wounded : for I have seen wounds of the thigh, of the axilla, and arm, by musket balls, where much blood flowed, and yet there was no secondary hemorrhage, and no great artery wounded, as the event of the cases showed. " It would be great presumption in me to contradict the opinion of Mr. Hunter, upon a subject of this nature; yet, as I have felt alarms in conse- quence of what he says, and others think they have confirmed, and have found my fears groundless, 1 think it necessary to state, that, while I would still take the precaution recommended in regard to the secondary hemor- rhagy from gun-shot wounds, yet I do not think there is that occasion for trembling anxiety, which I, at first, conceived there was. On a late occa- sion, when I went among the wounded from Corunna, I had two purpose* in view: first, to satisfy myself on several points of which I had just know- ledge sufficient to make me doubt the received opinion. The other was, that I might have striking instances of acknowledged facts, for the purpose of teaching; and, among other accidents, I thought we should have seconda- ry hemorrhagy. I hope it will not be irrelevant if I state, from my notes, the opinion as it grew. " «It is singular that, among all the hundred wounds of balls in these wards, with slough hanging from the wounds, there is no instance of he- morrhagy.' In succeeding mornings I find the same expression in my notes. •Now the slough is just coining out of these wounds, in cases, too, where I should imagine the artery must have been touched; yet, in bringing the men ashore, there has been no bleeding. I see a man wounded in the sar- torius, very near the femoral artery.' " * 1 found no instances of secondary hemorrhagy. I began to think it was equally incorrect to say, that every artery touched with a ball must slough and bleed, as it is to say, that every bone touched by a ball must exfoliate.' "This case is, in no respect, different from the secondary hemorrhagy after amputation, when there is a sloughing stump."—Operative SureeriL. vol. ii. p. 423—425. s * NOTES. 493 Note M. Page 233. I have been greatly embarrassed in removing encysted tumors about the orbits of the eye, after the common method of dissecting the sac out whole. The following observations of Mr. A. Cooper, appear to me altogether just. " The common mode adopted for their [encysted tumors] removal is, to dissect them out whole; but the best manner of doing it is to make an inci- sion into them, and then, by pressing the sides of the skin together, the cysts may be easily everted and removed. If it be attempted to be extract- ed whole, the dissection is most tedious, and, before it is completed, the cyst is either cut or burst; so many incisions and so much pain may be readi- ly prevented by opening it freely by one incision; and raising its edge be- tween the forceps, dissect it from its adhesion to the surrounding cellular membrane. When a swelling of this kind, in the scalp, is to be removed, the surgeon makes an incijion from one side of the tumor to the other, di- rectly through its"centre; and its contents, which are solid in this situation, are directly discharged in form similar to the tumor; then a tenaculum is put into the cyst to raise it, and it becomes most easily separated. In half a minute the operation may be accomplished, and with scarcely any pain. The hair is then braided together from each edge-of the wound, and the edges are thus approximated, being clotted together by means of blood. Pressure upon the little vessels, which are divided in this simple opreration, will be sufficient to stop the bleeding. " The swelling of this description which takes place at the outer canthus, is the most difficult of these encysted tumors to remove; it passes within the orbit, and often adheres to its periosteum, and the inner part of the cyst is, with great difficulty, reached. The operation of removing it is always very tedious and painful. " The removal of encysted tumors is not entirely unattended with danger. I have seen three instances of severe erysipelatous inflammation succeed the operation of removing those swellings upon the head, and I believe it is owing to the occipito frontalis being wounded when they are attempted to be dissected out whole. It is well known, that in cases of injury of the head, when this tendon is contused and inflamed, the inflammation often extends over the head and face. Trifling as the aperture appears which is occasioned by this operation, care must be taken for a few days after it, when the swelling is seated on the head. " A lady had an encysted tumor removed from the scalp. Three days afterwards she weiit into a cold bath; soon after she left the bath, she was seized with a rigour and severe pain in the head; an erysipelatous inflamma- tion succeeded upon the head and face; and, notwithstanding she had promptly the most able medical assistance in Dr. Bailhe, she fell a victim to this inflammation."—Surgical Essays, part 2d. Note N. Page 244. Rover contends, that encysted tumors never become cancerous. Many wens are enclosed in a particular cyst, or sac, situated immediately below the skin. Others have so much cyst, and are contained m cells of trreater or less size. Hence the distinction of tumors into encysted and not encysted The matter contained in encysted tumors, " is sometimes limpid and serous, forming an hydropic encysted tumor; sometimes it is lactescent 494 ^o*iss. or sanguineous; but most commonly the matter is yellow, viscid, and of the consistence of honey, or of a greyish white colour, and gramous. The former is called meliceris, the latter atheroma."—Bayer's Surgery, vol. ii. p. 345. Meliceris and atheroma are always less dangerous than steatoma, because they never grow so large, and never terminate in cancer.—Ojoms. Cit. vol. ii. p. 348. Note O. Page 255. Young women are very frequently subject to an irritable swelling of the breast. It occurs most commonly between the ages of 17 and 25. A slight swelling of the lobes of the breast often occurs at this period of life. This sort of swelling of the mamma has no circumscribed basis. It seems to be' rather an irritable inflammation of the glandular substance of the breast, than a distinct swelling. It is somewhat hard, and is characterized by its excessive tenderness. When it is touched with the finger, the patient shrinks back and complains of being hurt. Eventhe pressure of the clothes is painful. The breast often remains in this state for months, and even for years. The pain excited by pressing upon it, continues all day, and extends down the cutaneous nerve of the arm, and is altogether disproportioned to the apparent disease existing in the part. This affection seems to be connected with diseased uterine functions. The menstruation is sometimes scanty, and at other times profuse. It at- tacks, most frequently, pale and delicate females, of irritable habits and strong passions. It never terminates in cancer. The application of leeches is very useful. Sir Astley Cooper recommends a course of bark and soda, with small doses of calomel and cicuta, taken the same day; the first late, the latter early; and as a local application, oiled silk, rubbing the breasts with an ointment of camphor gi, spermaceti 2ji. Pregnancy cures this complaint. I have seen an operation performed twice on a breast affected with this disease, which returned as soon as the suppurative process, consequent to them, had ceased. Note P. Page 311. The foregoing chapter will be read with great interest by those who have considered mercury necessary in all sores on the genital organs; but, while the practice is so unsettled as it is at present, I cannot think, that any pru- dent practitioner will deem himself justified in treating chancre and its con- sequences without mercury. The statements of the British army surgeons are indeed imposing, and I find it difficult to reconcile them to my indivi- dual experience, without supposing that the venereal disease is, at presenjt, different in this country from what it has been in Great Britain, within the last ten years. I have studied the subject with care, and my opportunities of observation have not been very limited, and I freely declare, that I have met with few cases of chancre, (1 speak of what Mr. Hunter defines to be such) which would heal without the use of mercury, or, which having yielded, were not followed by secondary symptoms. The proportion of chancre to other sores, on the genitals, I have found about as one to three; and of erup- tions, about one-half that I have met with have been of the scab kind, with a depression in the centre, and these have uniformly required the use of mercury. Sarsaparilla and guaiacum would partially relieve them; and other eruptions would get well under the use of these articles. NOTKV 495 Tliis subject is too extensive for a full discussion in this place; but it ap- peared to me, to require this slight notice. Note Q. Page 341. The annexed plnte is the representation of an osteo-sarcomatous tumor of* the humerus. It commenced, without any known cause, below the insertion of the deltoid muscle, abdut six months before the sketch of it was taken. It was not much painful until it had attained considerable size, when the health of the patient began to be impaired, his appetite failing, and his • nights being passed without sleep. By the advice of an eminent surgeon, to whom he applied when the tumor was smaller than a hen's e^, it was blistered repeatedly, without benefit. It had an obscure feeling of fluctua- tion, especially in the most prominent points, which induced an ignorant practitioner to puncture it. Only blood and bloody serum were discharged. As I had foretold, that such would be the consequence, if opened, he im- * mediately resolved to take the advice previously given him, and enter the Hospital in order to submit to the removal of his arm at the shoulder joint. The integuments were not much discoloured, but tense and somewhat red. The humeral artery was very much enlarged, and beat with unusual force. After consulting with my colleagues, Drs. Post, Mott, and Cheesemun, the patient was brought into the theatre of the Hospital on the 15th of June 1821, the day of his admission, and compression was made on the subcla- vian, as it passed over the first rib. I found it required so much force to arrest the pulsation of the axillary artery, that I could not feel safe in divid- ing that vessel, and the numerous enlarged branches about the axilla, with- out previously securing more effectually the subclavian artery, either by subjecting it to direct pressure, or by tying it. By pressing upon the e\ ternal veins of the neck, so as to distend them, I found the external jugular giving off* a branch nearly as large as itself, running from the side of the neck towards the upper aeromial end of the clavicle. Drawing down the skin of the neck, especially that over the sternal end of the clavicle, I cut through the integuments, platysina-myoides, and the fascia of the neck, along the middle of this bone, from the external edge of the external jugular vein to the inner edge of the large vein of which I have spoken. Thus, when the integuments retracted, the course of the wound was along the middle of the clavicle, inclining outwards and a little downwards. A small vessel was cut and tied. By depressing the shoulder, the edge of the anterior scalemus was brought into view. I hesitated a moment, whether I should now have the subclavian artery compressed by the finger of an assistant dur- ing the amputation, or should place a ligature around it. The latter was determined upon. By the aid of Colis's curved spatulas, the sides of the incision were drawn asunder, and the omo-hyoides drawn inwards, and I cautiously removed some cellular and adipose substance in the triangular space, and exposed fairly the axillary plexus. I felt now the artery very distinctly under the upper nerve, and, cautiously dividing some dense cel- lular membrane over it, I there secured it by passing from above down- wards a blunt needle, with the ingenious instruments of Drs. Parish, Hew- son, and Hartshorne. The vessel was embraced in two single knots of a double silk ligature. The arm was then removed after the manner recom- mended by Sharp, the diseased state ofthe integuments rendering that plan must expedient. .Although one of the assistants had announced the cessa- tion of* pulsation in the radial artery, the axillary artery gave out blood when it was divided, so that it was necessary to secure it as well as- some smaller vessels, owing, as 1 conclude, to the first knot on the subclavian having loosened itself, before the second was applied. 49G NOTES. The wound was long in healing; the ligature on the subclavian did not come away until the sixtieth day; and even at the expiration of three months after the operation, the man in the mean time having suffered much pain, there was a small fistulous sore in the axilla. After four or five months of comparative comfort, I perceive with regret a return of ulceration, a fungus shooting out, attended with hardness around the shoulder, especially near the pectoralis major. DISSECTION. The first incision, in amputating the arm, confirmed the apprehension en- tertained of the malignant character of the case. The knife encountered spicule of bone, and accidental pressure of the hand squeezed out a brown gelatinous matter. The humerus was found entirely separated about the middle. The cartilage, at its head, was healthy, and in other respects en- tirely corresponding to the description of the malignant exostosis of A. Coo- per; and the osteo-sarcoma of Boyer, Gibson, and others. The separation of the humerus, which had not been suspected, fully accounted for the eau-. trion with which the patient had moved, always supporting it with a sling and with the other hand, and not being able to endure the pain of having it raised from the side. Such are the important particulars of an operation, undertaken with more reluctance than any I have ever performed, and sup- ported witli more fortitude than any I have ever witnessed.* Note R. Page 401. If the child is able to suck, I believe the operation ought never to be per- formed, until about the age of two years, or until all the teeth are formed. Children not only die frequently after an operation, performed in the early months, but the cure is always more or less imperfect, and often the opera- tion requires to be repeated. I have found the interrupted suture more con- venient than any other means of keeping the divided surfaces in contact. If one of the coronary arteries bleed, introduce the needle, first (a straight needle with a triangular point is most convenient,) on that side where the bleeding occurs, and bring its point out close to, or, if possible, through the mouth of thetbleeding vessel. This effectually stops the hemorrhagy- * A most interesting case of aneurism of the right subclavian, in which Doctor Mott tied the arteria innomiuata, may be sten in the New-York Hospital Register, No. 2. The patient Jived to the 26th day. END OF VOLUME I. * NLM041394785