A
SYSTEM
OF
SURGERY.
EXTRACTED FROM THE WORKS OF
BENJAMIN BELL, OF EDINBURGH:
BY NICHOLAS B. WATERS, M.D.
FELLOW OF THE COLLEGE OF PHYICIANS OF PHILADELPHIA.
AND ONE OF THE PHYSICIANS AND SURGEONS
TO THE PHILADELPHIA DISPENSARY.
ILLUSTRATED WITH NOTES AND COPPERPLATES.
PHILADELPHIA
PRINTED BY T. DOBSON, AT THE STONE-HOUSE
No. 41, SOUTH SECOND-STREET.
M,DCC,XCI.

No. 21.
District of Pennsylvania, to wit:
BE it remembered, that on the nineteenth day of August, in the
sixteenth year of the Independence of the United States of America, Tho-
mas Dobson, of the said district, hath deposited in this office the title of
a Book, the right whereof he claims, as proprietor, in the words follow-
ing, to wit:
" A System of Surgery, extracted from the Works of Benjamin Bell,
" of Edinburgh : by Nicholas B Waters, M. D. Fellow of the college
" of Physicians of Philadelphia, and one of the Physicians and Surge-
" ons to the Philadelphia Dispensary.—Illustrated with Notes and Cop-
" perplates." In conformity to the act of the Congress of the United
States, intitutled, " An act for the encouragement of learning by se-
curing the copies of Maps, Charts, add Books, to the Authors and Pro-
prietors of such copies, during the times therein mentioned."
SAMUEL CALDWELL, Clerk
of the District of Pennsylvania.

PREFACE.
SURGERY teaches us the knowledge of all those
diseases which require manual operations for their
removal; their causes; and the methods of preventing
and of curing them.
For some years past it has been a subject of regret with
the medical part of the public, and particularly among
students, that we have had no work on this important
branch of medicine, which gives a view of the present
state of the art, in a moderate compass: Mr. Bell's sys-
tem, although a most valuable production, being extend-
ed to so great a length, as to be not only expensive, but
exceedingly inconvenient.
To supply this defect, I have repeatedly heard a wish
expressed, by some of the most eminent of the profession,
that a selection of the more essential parts of Mr. Bell's
treatise were made ; in which, however, nothing useful,
immediately relating to Surgery, should be omitted.
Although well aware that I might not execute a work of
this kind in such a way as to obtain the approbation of the
critical reader, yet the belief, however mistaken, that it
might be done by any person tolerably acquainted with the
subject, if not in the best manner with respect to lan-
guage, at least in such a manner as to be highly useful;
the late Dr. Jones, formerly professor of surgery in King's
College, New-York, cheerfully engaging to look over the
manuscript, and add occasional observations*, furnished
by his own experience; Dr. William Shipped, professor
of anatomy and surgery, also obligingly promising to de-
vote
* These will be readily distinguished from such as I have given
myself, which consist chiefly in extracts from different authors of
merit. 

vi CONTENTS.
CHAP. XIV.
Of the Stone,  166
CHAP. XV.
Of Incontinence of Urine, 187
CHAP. XVI.
Of a Suppression of Urine, 189
CHAP. XVII.
Of Obstructions in the Urethra, 192
CHAP. XVIII.
Of the Fistula in the Perinæum, 198
CHAP. XIX.
Of the Hermorrhois or Piles, 202
CHAP. XX.
Of Condylomata, and other similar Excrescences
about the Anus, 204
CHAP. XXI.
Of a Prolapsus Ani, 206
CHAP. XXII.
Of an Imperforated Anus, 207
CHAP. XXIII.
Of the Fistula in Ano, 209
CHAP. XXIV.
Of the Paracentesis of the Abdomen, 215
CHAP. XXV.
Of the Paracentesis of the Thorax, 219
CHAP. XXVI.
Of Bronchotomy, 228
CHAP. XXVII.
Of Oesophagotomy, 230
CHAP. XXVIII.
Of the Amputation of Cancerous Mammæ, 233

CONTENTS. vii
CHAP. XXIX.
Of Affections of the Brain from external Vio-
lence, 235
CHAP. XXX.
Of Diseases of the Eyes, 257
CHAP. XXXI.
Of Diseases of the Nose and Fauces, 304
CHAP. XXXII.
Of Diseases of the Lips, 318
CHAP. XXXIII.
Of Diseases of the Mouth, 324
CHAP. XXXIV.
Of Diseases of the Ears, and Operations practi-
sed upon them, 354
CHAP. XXXV.
Of the Wry-Neck, 360
CHAP. XXXVI.
Of Diseases of the Nipples, 361
CHAP. XXXVII.
Of Issues, 362
CHAP. XXXVIII.
Of the Inoculation of the Small-Pox, 364
CHAP. XXXIX.
Of Wounds, 365
CHAP. XL.
Of Burns, 417
CHAP. XLI.
Of Tumors, 420
CHAP. XLII;
Of Fractures, 464
CHAP.

viii CONTENTS.
CHAP. XLIII
Of Luxations, 594
CHAP. XLIV.
Of Distorted Limbs, 521
CHAP. XLV.
Of Distortions of the Spine, 524
CHAP. XLVI
Of Amputation, 527
CHAP. XLVII
Of removing the Ends of Bones, in Diseases of
the Joints, 554
CHAP. XLVIII.
Of preventing or diminishing Pain in Chirurgi-
cal Operations, 557
CHAP. XLXIX.
Of Midwifery, 558
CHAP. L.
Of opening Dead Bodies, 563
CHAP. LI.
Of Embalming, 565
CHAP. LII
Of Bandages, 567

A
SYSTEM of SURGERY.
CHAP. I.
On Inflammation and its Consequences.
SECTION I.
Of the Symptoms, Terminations, and Causes of Inflammation.
EVERY organized part of the body is liable to in-
flammation; but as the treatment of this affection,
when seated in the internal parts, belongs to the province
of medicine; we propose in this place, merely to consider
the complaint, with its consequences, as it is most frequent-
ly observed to occur externally. And as the greater part
of the phenomena which in general attend it, will be
understood from the consideration of Phlegmon, we
shall confine our observations more particularly to that
species of the disease.
Phlegmon is a circumscribed tumor, attended with
heat, redness, tension, and a throbbing pain; and, if exten-
sive, with fever.
When these symptoms are removed, and leave the part
unaltered in its structure, the disease is said to terminate by
resolution.
If however, in a short time all the symptoms are aug-
mented, and the tumor becomes soft, somewhat prominent
A in

[ 2 ]
in the middle, or towards the most depending part, ac-
quires a clear, shining appearance, and becomes less pain-
ful ; the different symptoms of fever then abate, and upon
pressure a fluctuation is perceived; the inflammation is
then said to end in suppuration.
But if all the symptoms, general as well as topical, ex-
cept the swelling, continue to increase, there will be reason
to apprehend that gangrene will soon take place.
Gangrene, or mortification, is first indicated by a
change of colour in the part affected, from a bright red to
a livid or leaden cast, while small vehicles, containing a thin
acrid serum, are dispersed over its surface—the pain abates
and the pulse sinks—but continues frequent—the tumor at
last loses its tenseness—turns black and flaccid—and the
part is entirely deprived of its vital properties.
These are the most common terminations of inflamma-
tion ; but sometimes, though very rarely, it ends in schir-
rus.
The general exciting, causes of inflammation, are what-
ever tend to produce irritation and pain. They are either
external or internal. The external causes are, wounds of
all kinds; bruises; burns, whether by the actual or po-
tential cautery; corrosive and stimulating applications, as
strong acids, cantharides, and rubefacients; ligatures, and
tumors that act as ligatures; violent exercise of a particu-
lar part; and cold partially applied. The internal causes
are morbid matters of various kinds; as those of syphilis,
small-pox, measles, scrophula, and fevers.
Those circumstances which seem to give a predisposition
to inflammation are, a full plethoric habit of body, indu-
ced by a very nourishing diet, or by want of exercise; or
perhaps by a combination of both—Inflammation occurs
also more frequently in young than in old people, and in
men than in women.
The proximate cause of inflammation seems to consist in
an increased action of the arteries of the part; and when
the 

[ 3 ]
the disease does not originate from the application of irri-
tating substances, this, as well as the increased action of
the heart when it occurs, seems to be supported by a spasm
or constriction of the extreme vessels, either of the parti-
cular part or of the general system. See Cullen's Pract.
Physic. vol. I.
In almost every case of external inflammation, the prog-
nostic may be favourable. For if resolution, which is the
easiest and most desirable mode of termination, is not ef-
fected, suppuration will most readily be the consequence;
and the danger attending that, if the constitution is other-
wise healthy, is seldom great:—When, however, the dis-
ease is extensive, and the symptoms very violent, there is
much danger to be feared; for, independent of the risk from
the fever itself, if the symptoms continue high for any
length of time, without shewing a tendency to resolution
or suppuration, gangrene will pretty certainly follow; and
in what manner that may terminate is always uncertain.
SECT. II.
Of the Treatment of Inflammation by Resolution.
In the cure of phlegmon, the first indication in general
is to promote resolution. There are, however, some cases
in which this is not to be attempted. Thus inflammato-
ry swellings, that succeed to fevers, and other internal dis-
orders, should always be brought to suppurate as early as
possible; as it is generally supposed, that nature by these
points out an outlet for some superabundancy of fluids;
and that it might be attended with danger to give her any
interruption. And in phlegmons occuring in scrophula,
we should trust entirely to the operations of nature; for
if they are repelled, bad consequences might ensue; and if
brought to suppuration they produce sores very trouble-
some to heal. In

[ 4 ]
In cases of incipient phlegmon, where the general sys-
tem is not affected, topical remedies merely, with a pro-
per attention to regimen, will often accomplish a resolution.
But when the effects of the disease are in any considerable
degree extended to the whole system, it becomes necessary
at the same time to pay attention to these.
The first circumstance to be attended to in every case,
is the removal of all exciting causes that continue to ope-
rate. Of applications to the part, those of a sedative nature
are chiefly to be depended on; and next to these, emol-
lients. Of the former may be considered the preparations
of lead dissolved in vinegar, and the vegetable acid. Of
the latter, all the bland expressed oils, alone, or joined
with wax, in form of a soft ointment.
With respect to sedative applications, it is not meant
to recommend the whole class in external inflammation.
Thus opium, one of the most powerful sedatives, when
applied externally, always produces some degree of irri-
tation ; and although it perhaps may have been very use-
ful in some species of inflammation ; yet it will probably
never become of general use in such diseases.
Warm emollient fomentations too, although more
powerful, as sedatives, in removing tension and pain, than
any other remedy; yet from experience, I am well con-
vinced they always tend to produce suppuration ; and
when this is not occasioned, they leave such a relaxation
in the parts, as renders the complete removal of the dis-
ease exceedingly tedious.
Similar objections may be made to most sedative ap-
plications. They do not, however, operate against the use
of the preparations of lead; which we may affirm, from
the experience of a great many practitioners, to be by far
the most serviceable remedies as discutients, that have yet
come into general use. They have been said to produce
deleterious effects in some instances; but these have been
very

[ 5 ]
very rare; and I have known the greater part of the sur-
face of the body to be covered with them for weeks, with-
out any bad consequences being occasioned by them.
Saccharum saturni, or the sugar of lead, as being
the preparation whose strength can be most exactly
ascertained, should be preferred to any of the o-
thers. It is most conveniently applied in the form of a
watery solution; for the preparation of which the follow-
ing proportions in general answer very well: R. Sacch.
Saturn. ℥ss solve in aceti ℥iv. and adde aq. fontis distillat.
℔ij. The addition of vinegar renders the solution more
complete.
Mr Goulard's vegeto-mineral water is preferred by
some to this preparation: it is made by adding two tea
spoonfuls of the Extractum Saturni to a quart of water,
and four tea spoonfuls of brandy. The quantity of
extract or brandy to be diminished or increased accord-
ing to the nature of the disease, or sensibility of the part.
Cataplasms made of these preparations and crumb of
bread, should be constantly applied, as cold as the patient
can bear them without uneasiness, and be renewed whene-
ver they become hard. When the inflamed part is not ve-
ry tender, or lies deep, the vegetable acid instead of the lead
answers very well; and an alternate use of this and the lead
has, in some instances, appeared to be more serviceable than
a continuance of either separately. If, however, the sen-
sibility of the part does not admit of poultices, doubled
pieces of soft linen, moistened with the saturnine solution,
should be substituted to them.
Emollients tend greatly to remove inflammation: but as
they are less efficacious than the preparations of lead, and
always blunt the action of these, they should never
be employed except the tension, irritation, and pain are
very considerable: when any of the mild expressed oils
may be gently rubbed over the inflamed parts two or three
times a-day. Topical

[ 6 ]
Topical bleeding should always be employed when
the inflammation is extensive: and the blood should be
drawn from a part as near as possible to the disease.
Rest should be enjoined—and the use of animal food, and
of spirituous and fermented liquors, strictly forbid.
And,
When a considerable degree of fever comes on, it will
be proper to order general bleeding, gentle laxatives, and
cooling diaphoretics. We should then procure ease to the
patient by the exhibition of opium in large doses.
By these means, in the course of a few days, resolution
of the tumor will generally begin to take place. The
same plan should then be pursued, but with caution ; be-
cause, if suppuration should at last be produced, its pro-
gress will be rendered flow and uncertain by debilitating
the system, and the patient will not be capable of support-
ing the consequent discharge, should it be considerable.
Although we may generally determine, in the course
of three or four days, whether the disease will end in
resolution or not; yet it must be observed, that inflam-
mations in tough membranous parts, often continue a
considerable time without shewing any tendency to ter-
mination : In such cases, we should never be deterred from
a perseverance in the use of resolvents, unless the symptoms
of suppuration commence, gangrene is threatened, or an
incurable obstruction is feared; when suppuration should
always be encouraged as much as possible.
SECT. III.
Of Suppuration.
Suppuration is that process by which the con-
tents of tumors and ulcers are converted into a whitish,
thick, 

[ 7 ]
thick, opaque, and somewhat fœtid matter, termed Pus.
This, by many, has been supposed to be effected entirely
by a natural exertion of the system ; but experience teach-
es us, that art is capable, in all cases, of giving consider-
able assistance.
With respect to the formation of pus, various opini-
ons have been entertained. By some, pus has been be-
lieved to consist in a dissolution of the blood-vessels, nerves,
and other solids, in the fluids of inflamed parts. Others,
have supposed it to be formed in the blood; and that
it is from thence secreted into abscesses, wounds, and
ulcers. But the most probable opinion is, that pus is
produced by a certain degree of fermentation upon the
serous part of the blood, after its separation into the ca-
vities of ulcers and abcesses ; and this, in consequence of
the natural heat of the part, or of heat artificially appli-
ed. And it is further rendered probable by experiment,
that as the serum is deposited more or less free from fat,
red globules, &c. it will yield a pus more or less pure or
vitiated. Vide Cullen and Pringle.
When suppuration is to be promoted, all the means of
producing resolution must be laid aside. But as a certain
degree of inflammation is found necessary for the forma-
tion of pus, it will be improper to let the inflammatory
state subside suddenly. The diet of the patient should there-
fore be regulated by the circumstances of phlogistic diathe-
sis, or of debility which seem to prevail; and, such applica-
tions should be made to the inflamed parts as tend to pre-
serve in them a proper degree of heat. This last is a cir-
cumstance of the utmost importance—And the experi-
ments of Mr Gaber and myself on serum out of the body,
and of myself on inflammatory tumors in the body, have
made it evident to me, that the greater the heat is, to a
certain extent, the sooner suppuration will take place.
From hence it probably happens, that swellings near the
heart suppurate in much less time than those more distant 
from 

[ 8 ]
from it; and the want of a due degree of heat, perhaps,
prevents the greater part of soft swellings from coming to
suppuration; which then form atheromata, steatomata,
and melicerides.
Warm fomentations and cataplasms are the means
generally used for the application of heat to phleg-
mons; and when they are frequently renewed, they
answer the purpose very effectually. But if they are not
applied more than once or twice a-day, it is probable
they do more injury than good. For as soon as the heat
they at first possessed is dissipated, the moisture they sup-
port, with the consequent evaporation, must always ren-
der the part colder than if it had been merely wrapped up
in flannels.
In order to receive advantage from these remedies, the
parts affected should be well fomented with flannels,
pressed out of some emollient decoction, and applied, as
warm as the patient can bear them, continued half an
hour at once, and renewed four or five times a-day. Im-
mediately after the fomentation, a large emollient poultice
should be applied warm, and renewed every two or three
hours. Bread and milk, with a little butter or oil, in
common, forms the most eligible poultice.
When there is a defect of inflammation in the tumor,
roasted onions, garlic, &c. may be added to the poulti-
ces ; but strained galbanum, or some other of the warm
gums, dissolved in the yolk of an egg, or a small portion
of cantharides, are much more elegant and efficacious
additions. Plasters of the warm gums are useful, and
become necessary substitutes to the poultices, if the patient
cannot be confined within doors.
Dry cupping, e.i. cupping without scarification, upon,
or as near as possible to the affected part, in cases where
inflammation is defective, is also eminently serviceable.
2 These 

[ 9 ]
These applications should be continued, until suppura-
tion takes place; which seldom fails to be the case, in
a longer or shorter time, according to the circumstan-
ces of the disease—The formation of matter is indicated by
a remission of all the symptoms. The throbbing pain
goes off, and a more dull and constant pain succeeds;
the tumor becomes pointed at some particular part, gene-
rally near the middle, where, if the matter is not contained
in a cyst, or very deep-seated, a whitish-yellow appear-
ance is observed; and a fluctuation of fluid is plainly per-
ceived upon pressure. In addition to these local symptoms,
whenever a large collection of pus is formed, frequent
shiverings almost constantly occur.
In the treatment of collections of mattter or abscesses,
it is a general rule never to open them, until a tho-
rough suppuration has taken place ; for if it is done be-
fore, they never heal kindly. An exception to this rule
occurs in the treatment of critical abscesses that are pro-
duced in malignant fevers, and in the plague—These
should be opened as soon as it can be ascertained that
there is a deposition of fluid. And collections of matter
on the joints, or over the cavities of the breast or belly,
especially if they run deep, ought to be discharged as
soon as any fluctuation can be perceived. Because, when
the resistance on every side is equal, they may as readily
pour out their contents internally as externally : and the
consequence of a large abscess, bursting into either of the
large cavities, is commonly fatal.
Abscesses have usually been opened either by Caustic or
Incision. With respect to the caustic, it is not attended
with any superior advantage to a simple incision: It gives
much more pain; it is more slow in its effects; and it is
impossible always to confine its operation to those parts
which were alone intended to be affected. On account 
B of 

[ 10 ]
of these inconveniences, incision with a lancet or scalpel, is
very generally preferred to it.
When the swellings are not very large, they are com-
monly opened by an incision, extending two-thirds of their
length, and terminating at their lower extremity : but
abscesses of considerable extent should be laid open their
whole length. It has been advised by some, to take away
a part of the teguments, when they are very much stretch-
ed; but this can very seldom be necessary or proper—-
never indeed, unless the parts are completely dead.
The inconveniences of opening abcesses with the knife,
arise from the suddenness of the discharge of their con-
tents, and the admission of air to the ulcerated surface.
The first occasions faintings, and other disagreeable symp-
toms, and the latter often induces an astonishing change
in the discharge, from a well digested pus to a thin sanies ;
and that sometimes within so short a space as forty-eight
hours ; and afterwards, if the tumor has been very large,
a hectic fever, which either proves fatal in a short time,
or terminates in confirmed phthisis. It seems probable that
the air produces these effects by its irritation; by stimu-
lating the Vessels to a greater absorption, and by rendering
the matter to be taken up more putrid.
None of these bad consequences of incision and caustic,
follow the use of the seton. It therefore, with propriety,
claims a preference to both of them, When the seton is
employed in opening abcesses, there is little or no surface
of the sore exposed to the air; a gradual discharge is occa-
sioned ; it is attended with very little pain and inflamma-
tion ; produces a very small cicatrix ; and generally com-
pletes a cure in half the time necessary to accomplish it
when incision or caustic are used.
The seton is to be formed as follows :—-An opening
sufficiently large for the cord, being made with a lancet
in the superior part of the abscess, a director, slightly
curved, and having an eye at one end, threaded with
a 

[ 11 ]
a cord of candle-wick cotton, or of soft silk, pro-
portioned in thickness to the size of the tumor, is then to
be introduced, and its point to be pushed downwards
until it is felt externally, exactly opposite to the most de-
pending part of the swelling. The director being kept
firm by an assistant, an incision is to be made with a scal-
pel upon its lower end, somewhat larger* than the open-
ing first made. The director is now to be withdrawn
downwards, with so much of the cord as will leave two
or three inches of it hanging out of the lower orifice.
In about twenty-four hours after the introduction of the
cord, and daily afterwards, so much of it should be drawn
downwards as will admit of all that part of it be-
ing cut off which had been lodged in the abscess. In order
to make the cord pass easily, the part to be used should
always be rubbed with some emollient ointment.
By this method of cure, the gradual discharge produced,
admits a gradual contraction of the sides of the cavity, and
the slight inflammation supported on their surfaces, by the
irritation of the cord, induces a firm and speedy union of
them. As the discharge diminishes, the seton should be
lessened by degrees, by withdrawing a thread of the cot-
ton once in two or three days. At length, when little more
matter is produced than may be supposed to arise from
the irritation of the cord, it may be altogether taken out;
and a gentle pressure should then be made on the parts by
a roller, until the completion of the cure†.
Every
* This will hinder an inconvenient transuding of matter above. B.
† Several objections may be offered to Mr. Bell's method of opening
abscesses with the seton: In the first place, it does not appear to be an easy
matter to pass a seton in the mode he directs, through a large or deep
abscess, or that it should answer the purpose he proposes by it.
In the large deep abscesses frequently formed in the breasts of fat women,
such small openings do not discharge the matter contained sufficiently to
prevent new and troublesome sinusses; and many women are too timid
to 

[ 12 ]
Every thing that has been said respecting the cure of
abscesses from recent inflammation, applies with equal pro-
priety, to all tumors which contain a purulent matter, or
a fluid not much thicker than pus.
SECT. IV.
Of Mortification.
A complete mortification, or the last stage of gangrene*,
is known by the diseased part becoming black, by its losing
all pain and sensation, and by its emitting a considerable
fetor.-—A softness, and entire dissolution of the different
parts of the organ affected, also in common take place.
There is a species of gangrene called the dry, in which
the parts continue hard and connected a considerable time
although entirely mortified. This seems to be produced
from an obstructed flow of blood to the parts, by the pres-
sure of tumors, ligatures, &c.; and is. never a consequence
of inflammation. With respect to the disease termed the
white gangrene, and in which the parts preserve nearly the
natural colour, it is very doubtful whether it can with
propriety be considered as a gangrene-—We mean, in this
place, to confine our remarks more particularly to that
species which succeeds inflammation. They are, however,
in general, applicable to all the varieties.
Erysipelas† is the species of inflammation most apt to
terminate
to permit of one opening, instead of two which must be made by the se-
ton-—nor does fresh good air appear to be so injurious to wounds as Mr.
Bell seems to think. Upon the whole, further experience seems necessary
before this new mode can be generally prefered to that in common prac-
tice.
* See what has been already said on gangrene.
† See sect. on inflammatory tumors. 

[ 13 ]
terminate in gangrene; and when joined with phlegmon,
as it frequently is, it gives that the same tendency.
In some instances, mortification comes on almost before
an inflammation is completely formed. This occurs most
frequently in carbuncles. In these, there is seldom any
evident swelling; and the parts often become gangrenous
in the course of twenty-four hours. The rapid progress
usually made in these cases renders them extremely dan-
gerous, when very extensive, or seated on any of the large
blood vessels or nerves. If this is not the case, the patient
frequently recovers, with the loss of the affected part.
Carbuncles commonly appear without any evident exter-
nal cause; and probably depend, in general, on a scorbutic
or putrescent state of the fluids. They are usually a symptom
in pestilential diseases; but sometimes, although very rarely,
they happen as idiopathic affections.
Gangrene seems to be produced from a putrid fermen-
tation in blood effused by the violent action of the vessels
in an inflamed part; and to be propagated, by the assimila-
tory power of the gangrenous ferment.
The separation of the diseased part is occasioned by an
inflammation, and succeeding suppuration, of some irritable
part to which the mortification is extended ; and the ge-
neral symptoms are readily accounted for from the debili-
ty induced by the putrescent state of the fluids. See
Cullen, Pr. Ph. vol. I.
We should never make a positive prognostic in the be-
ginning of gangrene; for patients are sometimes carried off
suddenly, without previously appearing in any imminent
danger. When, however, the disease originates from ex-
ternal inflammation, is not deep or extensive, and has be-
come stationary, the prognosis may generally be much more
favourable than when it is produced from an internal cause,
is considerable in extent, and continues to increase. For,
in 

[ 14 ]
in this case, there is always the greatest danger to be fear-
ed; and, even in any considerable mortification from an
external cause, the patient cannot be pronounced free from
danger until the entire separation of the gangrened parts.
As there have been many instances in which death has
suddenly ensued after the cessation of the progress of the
disease, and before any general putrescency has appeared,
we conclude that the fatal termination is then produced,
not from absorption of the putrid matter, as may be with
probability supposed in long continued cases, but from the
deleterious effects of the gangrened part on the nervous
system.
In the treatment of gangrene, whenever the general
symptoms of inflammation continue to a considerable de-
gree, it will be proper to order blood letting, laxatives, and
acidulated cooling drinks. But evacuations, and particularly
blood letting, should be used with the greatest caution ; and
never to a greater degree than seems absolutely necessary
for moderating the violence of the symptoms.
When, however, as is most frequently the case if the
the disease has made any considerable progress, the patient
is much debilitated, the indication is, to give the system suf-
ficient vigour to free itself from the mortified parts*.
This is accomplished by a generous diet, and a liberal use
of tonic cordials, and particularly of good wine. When
very great debility and languor occur, volatile alkali, con-
fectio cardiaca, &c. may be given with advantage. But
of all the tonic remedies of mortification, the † common
Peruvian
*Mr. Pott describes a species of mortification incident to the toes
and feet, in which opium is a very effectual remedy, and nothing else is
of any material benefit. B.
† Besides the advantages derived from the internal use of the bark, we
may, from the experience of many practitioners in this city, with confi-
dence recommend it as one of the most powerful external applications in
this formidable disease. 

[ 15 ]
Peruvian bark* is the most efficacious. It should be gi-
ven as soon as the symptoms of inflammation are abated,
and in as large quantities as the stomach will bear—As a
great irritability of this organ is very commonly a conse-
quence of gangrene, it will be best to exhibit the bark, ve-
ry finely powdered, in combination with some of the spi-
rituous waters. The vitriolic acid may also be given
with advantage; and may be mixed with the patients
common drink.
These are the internal remedies that can be with most
certainty depended on.
There has been a great variety of external applications
recommended; particularly all the warm gums and
balsams, ardent spirits, and even alcohol; and to admit
of a nearer application of them to the sound parts, deep
scarifications through the diseased, and into the heal-
thy parts, have constantly been advised. But it is proba-
ble that these stimulating substances, by exciting too
strong irritation, do more harm than good. And the in-
cisions also may do material injury, not only by wound-
ing blood vessels, nerves, tendons, &c. but also, by ad-
mitting a free entrance of the putrescent fluids into the
sound parts. For these reasons, and because I have never
known them productive of good effects, I have long been
of opinion that they might be entirely laid aside.—Mr
Pott concurs with me in sentiment.-—It will, however, be
proper to remove a portion of the mortified parts, when
the disease is extensive ; in order to lessen the fœtor, and
contribute to render the healthy parts capable of throwing
off the remainder : but the scarifications should never ex-
tend to the parts unaffected by the complaint.
Theriaca
* The red bark, from many experiments, appears evidently much in-
ferior to the common bark. B. 

[ 16 ]
Theriaca has long been, and is now with some, a ve-
ry common application ; but I never saw any evident good
effects from its use.
All the advantages to be derived from the common ap-
plications in gangrene, are generally obtained with more
ease and certainty, from gently stimulating embrocations.
A weak solution of crude sal ammoniac in vinegar and wa-
ter answers exceedingly well—a drachm of the salt to two
ounces of vinegar and six of water, form a mixture of a
proper strength in common cases ; but the degree of sti-
mulus may be easily increased or diminished according to
circumstances, by using a larger or smaller proportion of
the salt.
When a slight inflammation commences on the verge
of the living parts, we may generally with certainty ex-
pect a separation of those mortified : but after suppura-
tion is perceived, this, without doubt, will very soon follow.
When the separation is accomplished, the wound is to be
treated as a simple purulent ulcer ; while at the same
time, proper attention is to be paid to the general state of
the system.
It sometimes happens, that mortifications destroy so
much of the soft parts in the extremities, that amputation
becomes absolutely necessary. In these cases, the opera-
tion should never be performed until we are satisfied that
the progress of the disease has entirely ceased. When
this is determined, the limb should be removed as soon as
possible. See chap. on Amputation.
I
CHAP. 

[ 17 ]
CHAP. II.
On the Theory and Treatment of Ulcers.
SECT. I.
Observations on Ulcers in general.
AN ulcer, is commonly defined a solution of continui-
ty in any of the softer parts of the body, discharg-
ing either pus, sanies, or any other vitiated matter. But
it must be evident, that every caries attended with loss of
substance might with propriety be termed an ulcer: how-
ever, to avoid making distinctions which are not absolutely
necessary, we shall consider caries as an accidental symp-
tom of ulcers, and treat of it under the general denomina-
tion of carious ulcers.
Ulcers have received various appellations, derived from
their appearances, causes, and other circumstances; but
we shall make such distinctions only as appear to be of
real use in directing the proper treatment.
Ulcers may be divided into two general classes. In
the first may be comprehended all those that are entirely
local, and do not depend upon any disorder of the system
at large. In the second class all are included that are the
consequence of, or that are connected with, any disease of
the constitution. The utility of such a classification must
be evident from the difference of treatment necessary in ac-
complishing the cure of the species arranged under each
division. Those of the first class requiring none but to-
pical remedies; while in the latter, medicines that affect
the whole system are also absolutely necessary.
C T

[ 18 ]
The topical ulcers are, 1. The simple purulent ulcer. 2.
The simple vitiated ulcer. 3. The fungous ulcer. 4. The
sinuous ulcer. 5. The callous ulcer. 6. The carious ulcer.
7. The cancerous, and 8. The cutaneous ulcer.
The ulcers connected with an affection of the whole
system, are, 1. The venereal ulcer. 2. The scorbutic, and
3. The scrophulous ulcer.
The general causes of ulcers, are, 1. Occasional or ex-
citing. 2. Predisposing; or, 3. A combination of both
these.
Under the first head may be ranked wounds in general—
bruises ending in suppuration—burns—and inflammation
which terminates in gangrene or suppuration.
The second division includes all systematical affections
attended with topical determinations; such as fevers that
terminate in abscesses—lues, scrophula—and scurvy. And,
In the third, are comprehended the sores produced by a
concurrence of the causes above enumerated. Thus a
slight wound, in a habit contaminated by the abovemen-
tioned diseases, will occasion a troublesome sore, which,
in a healthy constitution would have healed without diffi-
culty.
The prognosis in ulcers must depend, 1. Upon their
causes. 2. Their situation; and, 3. On the time of life and
habit of body of the patient.
The occasional cause must evidently have a very consi-
derable influence on the nature of the complaint, e.g. An 
ulcer produced by a wound inflicted with a sharp instru- 
ment, will, every other circumstance being alike, heal
much more easily, than one consequent to a bruise, or a 
wound from a ragged instrument. Punctured wounds 
are likewise more difficult of cure than such as have large 
openings; this seems to originate, 1. From the want of a
free exit to the matter; which, in consequence, causes it
to form sinusses between the integuments and muscles, &c.
and 

[ 19 ]
and, 2. To the pain and inflammation which so particularly
occur in wounds of this kind.
2dly. The situation, whether with regard to the na-
ture and organization of the parts affected, or their being
seated on the trunk or extremities. Thus it has been
long known that ulcers in the fleshy parts give less pain,
afford a better-conditioned discharge, and heal much more
readily than those situated on tendons, glands, the perioste-
um or bones. And experience has taught us, that sores
on the head and trunk heal much more easily than those
on the extremities, and particularly when the lower extre-
mities are affected.
This difference seems to arise principally from the de-
pending situation of the latter ; for the fluids in the veins
and lymphatics having here to proceed in a direction con-
trary to their own gravity, and receiving but little aid from
the action of the heart; whenever any of the parts lose
their tone, or are deranged by accident, swellings, and
especially of the serous kind, must be produced. And
when these swellings arise in the vicinity of ulcers, by oc-
casioning too great an afflux of matter to the sore, they
at length vitiate the discharge, and thus protract the cure.
The situation of ulcers with respect to the neighbour-
hood of large blood vessels and nerves, or any of the larger
joints or cavities, from the risk of the matter penetrating
to them, must also considerably influence the prognosis.
And, lastly, The age and constitution of the patient must
be taken into consideration. Thus, in young healthy peo-
ple, ulcers will heal much more kindly than in the old and
infirm.
With respect to the treatment of ulcers, the first circum-
stance to be determined is the propriety of attempting a cure
or not. In recent sores there is no room for doubt; but
when ulcers have been of long continuance, or appear to
have had any effect, either in carrying off or preventing
diseases 

[ 20 ]
diseases to which the system has formerly been subject, it
has always been considered as dangerous to heal them;
and instances have often happened of the fatal effects of
the sudden stoppage of long continued and large dischar-
ges. From experience, however, we may now affirm,
that the cure of any ulcer may be attempted, provided a
discharge of matter, equal in quantity to that produced by
the ulcer, be kept up by any other means. This discharge
is most conveniently furnished by an issue.
An issue being introduced, and made to discharge nearly,
as much as the ulcer, the cure of the latter may then safe-
ly be carried on; and if the sore has not been of very long
standing, the size of the issue may be gradually lessened, till
it contains only a single pea; and it will then give but lit-
tle trouble. But when the ulcer has been of long dura-
tion, and particularly if it has apparently prevented any
dangerous disease, the issue should be continued of the,
same size for life. Its situation may be determined by the
conveniency of the patient.
This circumstance obviates one objection that has been
made to the practice, viz. that an issue is as troublesome and
disagreeable in its management as an ulcer ; for the situa-
tion of ulcers, independent of the nature of the discharge
they occasion, and of the bad effects of absorption of the
matter on the system at large, often renders them exceed-
ingly inconvenient, and sometimes dangerous.
It has been also objected to ; the substitution of a dis-
charge by issue to that by ulcers, that the matter produced
is not similar; that issues constantly afford a bland pus,
while the discharge from ulcers is often very acrid, and
thus may free the system from a matter highly pernicious
to it. But that the effects of all these drains on the body
at large, arise more from the quantity than the quality of
the discharge, is clearly evidenced by the following, as
well as a variety of other circumstances, viz. that the same
bad 

[ 21 ]
bad effects are produced from the stoppage of a discharge
from issues, as from the healing of the worst species of
ulcers.
And it is very clear from many facts, that the variety of
matter afforded by ulcers originates, except in some cases
in which a great degree of putrescency prevails, and the
blood runs off in form of a thin ichor, from the degree of
inflammation or peculiar conformation of the vessels in an ul-
cerated part; from the heat supported; and from the
remora of the fluids for a longer or shorter time in the ca-
vity of the sore. Thus it cannot be proved, by any analysis
of the blood, that the acrid matter which is sometimes dis-
charged, previously existed in it; and by varying the
degree of external heat, the applications to the sore, and
the interval of the dressings, we can vary the nature and
appearance of the discharge.
SECT. II.
On the simple Purulent Ulcer.
The simple purulent ulcer, is entirely a topical affection,
is attended by an inconsiderable degree of pain and inflam-
mation, and affords a discharge of mild pus. The granu-
lations which arise in it are of a firm, red, healthy appear-
ance, and if no accident occurs, in general, the cure goes on
regularly until a cicatrix is produced.
This ulcer is first treated of, because it is the most sim-
ple that is produced, both in its symptoms and method of
cure. And, as it is to the state of such a sore that every
other species must be reduced, before a cure can be ob-
tained, we shall be particularly minute in our observations
with respect to it; and, when treating of the other varieties 
of

[ 22 ]
of ulcers, we shall occasionally refer to what is here ad-
vanced, in order to avoid repetition.
The causes of purulent ulcers, are, all wounds that do
not unite without the formation of matter—burns, whe-
ther produced by fire, aquafortis, scalding liquids, &c;
bruises; and every external accident that terminates in
suppuration, with an opening as a consequence of it.
The prognosis may generally be favourable; and more
or less so as there is a less or greater loss of substance—fa-
vourable or unfavourable situation of the sore, and good
or bad habit of body of the patient.
Before proceeding to a particular investigation of the
means to be employed in the cure of the simple ulcer, it
will be proper to make a few observations on the manner
in which nature, as well as art, operate to accomplish the
healing of sores in general.
In the progress of ulcers to a cure, there is generally a
growth of new parts, termed from its appearance granu-
lations, that tends to diminish any vacancy produced. This
substance is formed in larger or smaller quantity, as the pati-
ent is young or old, healthy or otherwise; and to so con-
siderable a degree in young plethoric people, as often to
rise above the level of the neighbouring integuments.
When the loss of parts is thus as far as possible suppli-
ed, the cure is then perfected by the formation of a cicatrix,
either by a natural exsiccation, forming a kind of cuticle
or scarfskin, or by the application of astringents. Granu-
lations seem to consist, in every case, merely in an extension
of the small blood vessels that have been divided, with a
considerable proportion of inorganic cellular substance,
probably secreted from these vessels, and which serves to
connect and support them; for it does not appear that or-
ganical parts are ever reproduced.
But although granulations contribute very much to les-
sen vacancies occasioned by loss of substance in ulcers, and
particularly

[ 23 ]
particularly in young people; yet this effect, in all cases,
is evidently chiefly produced by a diminution of the parts
that remain. And cures, even of large ulcers are often
obtained, especially in old people, without any evident
growth of parts whatever.
This part of nature's process, is to be remarked even in
the smallest sores ; but is much more evident in the larger,
and more particularly in those induced by amputation of
the thigh. In ulcers produced by amputation, there is
never any considerable formation of new parts; and the
cure advances only in proportion to the contraction of the
skin caused by the decrease of the parts which it sur-
rounds—This wasting takes place in every part but the
bones; and is fully evidenced by dissection: for this
teaches us, that even the largest as well as the smaller
vessels, are entirely obliterated to a certain extent, and
appear only as cords : the fibres of the muscles are greatly
diminished, and there is often hardly any trace of cellular
substance.
From what has just been said, it must be plain, that
compression, by the laced flocking and bandages, produce
beneficial effects in ulcers ; not only by preventing æde-
matous and other swellings in their vicinity, but by con-
tributing to the diminution of the adjoining parts.
I have constantly found more benefit to arise from
compression, than from any other remedy; and as the laced
flocking is not always well made, and is difficultly appli-
ed, I prefer the roller to produce it. The rollers should
be made of thin flannel, and ought to be about two and a
half inches wide.—If the member is œdematous, they
should be applied from its extremity to a little above the
diseased part; but if there is no œdematous swelling, they
should extend only from two or three inches below to as
much above the sore.
In the application of the bandages, they should always
be so managed as to support the skin, and bring the edges
of

[ 24 ]
of the sore as near together as possible: for, as new skin
is never re-produced, or even an elongation of the old,
all those parts which remain uncovered by it, will have
nothing for their future protection, but a thin scarf skin.
It is to be observed, however, that compression is ne-
ver to be employed while any considerable degree of in-
flammation remains in wounds ; as soon, however, as this
has a good deal subsided, it will contribute exceedingly to
expedite a cure by aproximating the sides of the sore, and
at length producing their coalescence.
The production of granulations in sores, is an opera-
tion of the system itself; and all the assistance art can af-
ford, consists in removing the obstructions which nature
meets with in her progress. These obstructions may be
reduced to two general heads, those of an internal nature,
and those which operate as external or local causes.
Of the former kind are, every general disorder to which
the constitution is liable; as we find, from experience,
that a healthy state of the body only is capable of pro-
ducing proper granulations. Thus the cure of ulcers
that occur in syphilis, scrophula and scurvy, can never be
properly effected, unless the general effection be first cor-
rected.
A low emaciated state of body, also, either from a very
poor diet, or from immoderate evacuations, is very preju-
dicial to the growth of new parts. In general, the pati-
ent should be suffered to live so as that he may be kept in
a situation at least not much more reduced than that of
his common health. But as a variety of treatment in this
respect must be necessary in different cases, the proper
diet must be directed by the judgement of the surgeon.
The local obstruction to the granulation of ulcers, may
be reduced to those that act mechanically, and those of a
corrosive nature. As inflammation and pain contribute
much to prevent the healing of sores, every thing, which 
2 by

[ 25 ]
by irritating, tends to excite them should be avoided—
All stimulant extraneous bodies should be taken away,
and the dressings should be mild and simple, and changed
but seldom.
The corrosive substances that impede the cure of ulcers
are chiefly the vitiated discharges from them. These are
sometimes so acrid, as not only to prevent the rising of
granulations, but even to corrode the neighbouring parts.
They should be corrected, and if possible, by the means
hereafter to be pointed out, converted into pus.
When the vacancies in sores are properly filled up, the
remaining part of the cure consists in the formation of a
cicatrix. This is frequently, in a great measure, a work
of nature; but it may often be considerably expedi-
ted by the application of mild styptic powders and washes.
These, by corrugating the ends of the vessels, and ex-
siccating the cellular substance in which they are envelo-
ped, tend very much to form that delicate covering term-
ed cicatrix; which though at first very thin, by subsequent
depositions of inorganic substance, commonly acquires at
length no inconsiderable degree of strength and firmness.
The indications of cure in the simple purulent ulcer are,
1. To diminish, as much as possible, any vacancy the ulcer
may have occasioned: and, 2. To promote the formation
of a cicatrix. For the accomplishment of the first, it is
necessary, as before explained, not only to have new gra-
nulations formed, but also to produce a decrease of the
parts contiguous to the sore.
In order to effect a production of new parts, we must
avoid the application of every thing that may occasion pain
or irritation, as the Warm gums, balsams, and spirituous tinc-
tures, which have been so indiscriminately used in all sores,
remove all corrosive matters, and make use of mild,
bland unguents as dressings. The following is one of
the most useful of this class—℞. of wax, ℥iv. spermaceti, 
D ℥iii

[ 26 ]
℥iii. oil ℔j. Goulard's cerate is also a very good mild
application. It is thus made: Take 4oz. of refined wax,
and ℔j. of oil; keep them over a slow fire, until the wax
is melted, stirring them gently. Having previously mix-
ed ℥iv. of extract of lead with ℔vj. of water, add it gra-
dually to the wax and oil, now cooled. Let them be
well incorporated together with a wooden spatula; always
taking care to let the quantity of water first put in, be
entirely absorbed before any more is added. This oint-
ment, as well as every other, should be made in small
quantity at a time, as it is of consequence to have them
free from rancidity.
The frequency of dressing ulcers must principally de-
pend on the quantity of matter discharged; but in general
they should be dressed once in twenty-four hours. The
ointment should be spread on pledgits of lint, and should
be applied immediately after the removal of the preceding
dressings, in order to prevent the bad effects which often
follow exposure of the sore for any time to the air. Some
surgeons have advised the renewal of the applications to
sores but once in five or six days. By this method, how-
ever, and particularly in hospitals, the air must necessarily
be rendered impure.
Ointments have been supposed by some to render the
granulations lax and flabby; but this I have never been
able to perceive. Such effects are, indeed, produced by a
long continued use of emollient fomentations and poul-
tices—Lint applied immediately to sores, except the dis-
charge is very great, gives too much irritation, and indeed
always acts more or less as an escharotic.
The next circumstance requiring attention in this part
of the cure, is to preserve the matter discharged in a pro-
per purulent state. This, in the simple purulent ulcer, is
chiefly produced by the preservation of a proper degree of
heat—Whilst any inflammation remains, this is best ef-
fected

[ 27 ]
fected by warm emollient poultices, renewed every three
hours; but as soon as the inflammatory symptoms have aba-
ted, they should be laid aside. The same purpose may then
be better answered by applying over the dressings thick
quilted coverings of wool, cotton, or any such substances
as retain heat most effectually.
The other most material part of the first indication in
the cure of ulcers is to be answered by compression. This
is to be employed in the circumstances, and in the man-
ner mentioned when we treated of ulcers in general.
When the loss of substance in ulcers is fully supplied, the
second indication is to be attended to, viz. the formation of
a cicatrix.
This is frequently affected by nature alone; but, in many
instances, it is a matter of considerable difficulty. The
emollient ointments must be now laid aside, and the sore
should be dressed with some styptic drying ointment, as the
unguent album prepared with ceruss, and washed once
or twice a-day with lime-water or ardent spirits. These
will often succeed.
On some occasions, cicatrization is prevented by the gra-
nulations rising above the surface of the neighbouring
parts. It is then necessary to have recourse to astringent, or
even escharotic applications. One of the best of the mild
escharotics is blue vitriol; if this is not sufficiently strong,
nothing weaker than the common caustic stone will be ef-
fectual ; and, in slight cases of this kind, lint and a pretty
tight bandage will frequently produce a cicatrix.
When every previous part of the cure has gone on
very well, it often happens, that the granulations con-
tinue raw, and show no tendency to heal for some time;
in these cases, when the means we have recommended do
not accomplish the cure, compresses wet with ardent spi-
rits, being applied under the roller, will often answer;
or

[ 28 ]
or these may be. alternated with tincture of myrrh, or a so-
lution of blue vitriol in water.
Besides local applications, there are some general cir-
cumstances very necessary to be attended to in the treat-
ment of ulcers.
Rest of body, and particularly of the part affected, is
very requisite: and, in all sores on the lower extremities, not-
withstanding what has lately been said to the contrary, I am
fully convinced by long experience, that a more perma-
nent and speedy cure will be effected, if the patient can
keep the limb in a horizontal posture generally, than if he
is permitted to take much exercise.
The diet should be so regulated, that the patient may
be kept in his usual habit of body. All excesses in eat-
ing, as well as drinking, should be carefully avoided.
Internal medicines appear to be entirely unnecessary for
the cure of the simple purulent ulcer, except when the
discharge is uncommonly large and thin ; in which case
the peruvian bark is often a very useful remedy.
SECT. III.
Of the Simple vitiated Ulcer.
The vitiated ulcer differs only from the simple puru-
lent sore in the nature of the discharge.
The matter afforded, is either, 1. A thin, limpid,
sometimes greenish discharge, termed sanies. 2. A some-
what red-coloured, thin, and generally very acrid matter,
termed ichor; or, 3. A more viscid, glutinous kind of
fluid, called sordes. This last, is also frequently of a
brownish red appearance, somewhat resembling the
grounds of coffee, or grumous blood mixed with water.
They are all more fœtid than pus, and none of them free
from

[ 29 ]
from acrimony -What has been termed ichor, is often so
corrosive as to destroy large quantities of the neighbour-
ing parts. In consequence of the nature of the discharge,
the granulations waste away, and have a dark brown or
black appearance. The pain is often considerable, and
is proportioned to the acrimony of the matter.
The causes of this ulcer are the same as those produ-
cing the purulent ulcer ; and that species easily degene-
rates into this from neglect or improper treatment; and
particularly when the tendinous parts are the seat of the
disease.
The prognosis in the vitiated ulcer, may be favourable
when the complaint is not extensive or local, has not been
of long duration, and occurs in young, healthy subjects ;
but, in opposite circumstances, it should always be very
doubtful.
The quality of the discharge in ulcers has been above
shewn to depend chiefly on the different degrees of inflam-
mation in the part; and this is further confirmed by the na-
ture of the remedies that are most effectual in relieving
these disorders, which are principally of that kind which
remove pain and irritation. Thus warm emollient cata-
plasms and fomentations often give great ease, and meli-
orate the discharge within twenty-four hours: these
should be used as formerly recommended to promote sup-
puration, and the dressings applied immediately to the
sore should be mild, like those advised in the simple puru-
lent ulcer, while too great a degree of inflammation con-
tinues. When the pain is very considerable, opiates
should be given, and repeated according to circum-
stances.
The diet must be regulated by the habit of body; if
weak, it should be nutritious ; if full, the regimen should
be low. In the former case, the peruvian bark is a very
effica-

[ 30 ]
efficacious remedy, and should be given in doses of ℥j.
six or eight times a-day.
When the abovementioned circumstances are attended
to, and the part affected is kept at rest in a proper pos-
ture, the sore is commonly sooner or later reduced to
the state of the simple purulent ulcer ; and then requires
the same method of treatment.
I have never seen any evident good effects produced by
the exhibition of nitre; although I have frequently given
it in large doses for a considerable length of time *.
SECT. IV.
Of the Fungous Ulcer.
By fungus, or as it is sometimes termed hypersarcosis,
is meant such preternatural risings in sores as are common-
ly more soft and spongy than healthy granulations.
These, in some instances, arrive at a very considerable size;
and now and then acquire very great degrees of hardness.
The pain attending them is seldom considerable; and the
discharge afforded varies according to the species of sore
they happen to be connected with while they are recent;
but after some continuance, this, as well as other circum-
stances become so changed, as to form very different
sores from those which originally existed.
These excrescences are often owing to the neglect of
repressing the granulations when they shew a disposition
to advance beyond the surface of the found parts. They
are also produced in various sores that are not healed at
bottom, before granulations are suffered to proceed any
length.
* It has, however, in a few instances, been attended with very happy
effects in the cure of old habitual ulcers of the leg. 

[ 31 ]
length. These instead of cicatrizing when they are on a
level with the sound parts, continue to advance until the
cause is removed.
 With respect to the cure of fungi, when it is found that
they are produced merely by an over-growth of parts, if
they are not of any considerable breadth, and especially if
they are not very high, we should have recourse to escha-
rotics.—By many, we are directed to use the actual caute-
ry, and by others the scalpel; but few patients will sub-
mit to either of these, and particularly as the disorder may
just as effectually, though not quite so expeditiously, be re-
moved by means more gentle.
Of all the caustic preparations, the lunar caustic is the
best for this purpose. It acts more quickly, and does not
give more pain than the milder sorts ; it never fails to pro-
duce the proper effect as many others do ; and it is not so
apt to run, and to spread over the neighbouring parts, as
some of the other caustics.
The caustics should be liquefied, and then applied by a
small brush or pencil, daily or every other day—A strong
solution of verdigrease, sal ammoniac, blue or white vitriol,
will also commonly prove effectual. But solutions of sil-
ver or mercury in nitrous acid form the most powerful
applications of this kind. In making the last we must ob-
serve, that one ounce of strong spirits of nitre will dissolve
no more than about six drachms of quicksilver. These
caustics should never be applied to an extensive surface at
once. After their use the part should be covered with
lint, as ointments lessen their activity.
When the base of the excrescence is narrow and its
height considerable, it should be removed by a ligature ap-
plied at its root, and tightened daily. If, however, toge-
ther with great height, the tumor has a broad base, this me-
thod will not succeed; and the following must be put in
practice.
A 

[ 32 ]
A strong straight needle fixed in a handle, with an eye
near the point, being pushed through the tumor at its base,
and two strong waxed threads being introduced at its eye,
it is to be again drawn back, leaving the threads with their
ends hanging out at each side of the swelling. A firm liga-
ture is then to be formed round each half of the swelling by
the threads, and tightened from time to time.
The fungus being by either of these methods removed,
the sore is then to be treated as a simple purulent ulcer.
The other species of fungous excrescence which proceeds
from the granulations not being raised on a good founda-
tion, is generally easily distinguished from the preceding
species : It rises with greater rapidity, and is not so firm
as healthy granulations.
As soon as the cause is discovered, any confined matter
beneath should have vent given to it by a proper open-
ing; after which, by taking care that the sore fills up from
the bottom, the cure will go on easily in the common way.
There is seldom then occasion for escharotics, as the fungus
commonly wastes away of itself.
SECT. V.
On the Sinuous Ulcer.
By sinuous ulcer is meant a species of sore communi-
cating with one or more openings or cavities, which are
commonly seated in the cellular membrane, between the
interstices of muscles, or between the muscles and integu-
ments. By long continuance, or by the use of astringent
applications, a sinus often becomes hard and callous in
its internal surface; and in such a state, from its supposed
resemblance to a pipe, it is termed a fistula.
I The 

[ 33 ]
The most frequent cause of sinuses, is the want of a
free discharge of matter formed in ulcers and abscesses;
which, falling to the most depending situation of the part,
if it does not there find a ready passage by an opening
made to it, readily insinuates itself into the cellular
membrane, and proceeds gradually onward until it finds
a vent. Very tight bandages, applied immediately over
a sore, and not made to act on the parts above and below
for some distance, are also a frequent cause.
In healthy constitutions, when there is easy access
to the sinus, a favourable prognosis may generally be
made ; but when the disease has been of very long conti-
nuance, and particularly if the sinuses open into any of
the joints, or are beyond the reach of an operation, a cure
is difficult, and doubtful.
The intention of cure, in every case of sinus, is to pro-
duce a coalescence of its sides, so as to destroy any vacui-
ty that may have been occasioned.
To effect this, it is necessary first to make a depending
orifice for a free exit to the matter; and then, by a gentle
irritation, to induce on the internal surface of the
sore, a slight degree of inflammation, and consequent ad-
hesion of the sides of the sinus. Both these intentions
are answered by the introduction of a seton, from the o-
rifice in the ulcer along the course of the sinus to its
other extremity, where an opening should be made in the
manner we formerly directed in abscesses. The treatment
is then to be similar to that of abscesses in which a seton is
used. Vide chap. I. sect. iii. A cord should be intro-
duced into every sinus.
This method is entirely free from danger, and is admissi-
ble in almost every case that can occur. It is particularly pro-
per in sinuses in the perinæum: for the cicatrix formed there
E after 

[ 34 ]
after the opening a large sinus by the knife, is often more
inconvenient and painful than the original disease.
The sinuses being by this means filled up, the ulcers
with which they have been connected, are then to be
treated by the method adapted to the species to which
they belong.
By many writers, ancient as well as modern, we are di-
rected, in recent sinuses, to use healing injections ; and
when their sides have become callous, escharotic injec-
tions and powders have been recommended. None of
these, however, produce any permanent good effects ;
and often convert simple sinuses into the callous. Others
advise to lay open the different sinuses, and cut out the
whole of the callosities. This will often effect a cure;
but the pain, and often the danger attending it, must
induce a preference of the mode above recommended.
When, however, incision is preferred, unless all the
parts are evidently callous; in which case extirpation
may be necessary, mere division of the parts forming
the sinus should alone be used. The free vent thus gi-
ven to the matter, and the suppuration supervening, will
frequently remove very considerable callosities.
SECT. VI.
On the Callous Ulcer.
An ulcer is said to be callous when its edges, instead
of contracting and diminishing the size of the sore, keep
at a distance, turn ragged, and at last, by acquiring a
preternatural degree of thickness, often rise considerably
above the level of the neighbouring parts—the discharge
afforded 

[ 35 ]
afforded by it, is commonly a thin vitiated matter. Vari-
cose veins also occur as a symptom, and particularly when
the disease is seated in the lower extremities ; hence the
name of varicose ulcer, which this species has acquired,
from a supposition that it was produced from matter sup-
plied by these veins, which frequently have the appearance
of opeing into the sore. The varices seem to originate
chiefly from an obstructed return of blood, by the pres-
sure of the callous parts on the vessels.
The causes of callosities in ulcers may be all reduced to
neglect and mismanagement. When, from these circum-
ces, the small vessels of the edges of ulcers are prevented
from proceeding in a proper direction, are forced to push
upwards, and even sometimes backwards, they, by the
pressure of bandages, will necessarily acquire at length
a morbid hardness or callosity.
In the cure of this disease, the causes originally produ-
cing it are first to be removed; and the callosities may
then be taken away.
Recent cases are often cured merely by the repeated
application of warm emollient cataplasms—and also by
gum-plasters; but when the parts have acquired much
hardness, the only remedies are the caustic, or scalpel.
And as the first is equally certain with the other, it should,
as the easiest method, be always employed. For the
reasons formerly given, the lunar caustic should here
likewise be preferred. The solution of silver or of mer-
cury in nitrous acid, may be also used to advantage. Ei-
ther of these should be applied to the callous edges every
two days, while the cataplasms are still continued as
long as any degree of foulness remains in the sore.
For the cure of the varices, it is not only necessary to
remove their primary cause, the callosity, but like-
wise to restore the tone of the vessels weakened by their
distention,

[ 36 ]
distension, by the application of the laced stocking, or a
roller*.
A considerable swelling of the adjacent parts very com-
monly occurs; when this does not go off after the hard-
ness is removed, the use of a flannel bandage will usually
prove effectual in dissipating it.
SECT. VII.
On the carious Ulcer.
By the term carious ulcer we understand that species of
the disorder only which is connected with a local affection
of a bone : whether the disease of the bone may have been
always confined to the part, or exists after a general dia-
thesis which originally gave rise to it has been removed. †
When a bone is at first laid bare, it is impossible to de-
termine whether it will become carious; as in a great ma-
ny instances this does not follow even a removal of part of
it. A cure should, however, never be attempted until this
can be ascertained.
If at the end of the fourth day after the denudation of a
bone, it retains its natural appearance, we may conclude,
with tolerable certainty, that a caries will not succeed. For
when this is to happen, it generally begins in three days or
four at farthest. The bone begins to lose its natural heal-
thy appearance, turns first of a pale white, and then of a
pale yellow, It sometimes remains in this state for some
days,
* The growth of varices may be retarded by the use of the roller or
laced stocking judiciously applied; but I never was able to cure old exten-;
sive varices by these or any other means.
† Caries appears evidently from its symptoms, causes, and method of
cure, to be a disease exactly of the same nature with a sphacelus or gan-
grene of the soft parts. B. 

[ 37 ]
days, and by degrees gets a more deep tallow-like appear-
ance. It continues thus for a longer or shorter time, ac-
cording to the degree of violence with which the injury
has been done; and afterwards goes through the differ-
ent stages of brown and black, until it has acquired a black
of the deepest dye.
The discharge from ulcers of this kind, is generally thin;
and of a most disagreeable fœtor, which always be-
comes more considerable as the disorder advances; at
last it acquires a blackish hue, and often a considerable de-
gree of acrimony. As the several degrees of blackness
go on, small holes appear in the bone, and increase
so as at length to render it quite spongy. The carious
part then generally becomes loose, and when pressed, a
large quantity of a fattish, intolerably fœtid matter is forced
out. This taints the whole discharge; and the smell of
it is so very peculiar, as to afford one of the most charac-
teristic marks of caries.
The granulations in this ulcer are soft and flabby, spring
up in clusters, and have a dark brown, together with some-
what of a glassy appearance. They usually advance very
fast, and if not carefully attended to, will be apt to form
large and troublesome excrescences.
All the phenomena abovementioned, occur in greater or
less degree, whether one lamina, or the whole substance of
a bone is affected.
When the bone has not been bared, it is often a matter
of considerable difficulty to discover a caries. If we are
able to introduce a probe, and by that means find a rough-
ness on the surface of the bone, we may, with certainty, con-
clude it to be carious. And when it impossible to reach the
diseased part with an instrument, we may commonly as-
certain the existence of a latent caries, by the appearance
of the sore and the nature of the discharge.
The 

[ 38 ]
The causes of caries may be, in general, whatever de-
stroys the circulation in the whole or any part of a bone:
as wounds which affect either the periosteum or bones;
violent contusions and inflammations of the periosteum,
terminating in abscess or gangrene ; the acrid matter of ul-
cers penetrating to, and destroying the periosteum; and
the improper application of sharp acrid spirits and pow-
ders to bones merely laid bare.
It is to be remarked, that definition of the periosteum,
or even the removal of part of a bone is not always follow-
ed by caries; and this is seldomer a consequence of such in-
jury to the cranium than to any other part of the body;
probably from the greater number of blood-vessels distri-
buted to that part.
The prognosis in caries must depend principally on the
following circumstances: The situation of the diseased parts;
the nature of the affected bones ; the nature and degree of
the cause ; the size of the caries; the age and habit of the
patient.
Thus a caries in any of the bones of the skull, ribs, or
vertebræ, from their situation near the vital organs, must
be attended with more risk than when it affects the bones
of the extremities. And a caries near a joint from the
danger of this becoming diseased, is always more to be
feared than when it is confined to the middle of the bone.
The texture of a bone should have also considerable influ-
ence in the prognosis ; exfoliations being much more te-
dious in the hard and compact, than in the more soft and
vascular bones, as well as the nature of the cause: Thus a
wound with a sharp instrument, does not generally produce
so deep or extensive a caries as that which commonly suc-
ceeds to violent contusions. The cure is likewise produced
in a longer or shorter time as the caries is extensive or
not.
And, lastly, the habit and age of the patient must have
considerable 

[ 39 ]
considerable weight in making a prognosis. For the cure
of caries generally proceeds so slowly, that few can support
the discharge it produces, if they have not previously been
perfectly healthy.
The healing of an ulcer, attended with caries should ne-
ver be attempted, until the diseased bone is removed. For
if the soft parts above should be united, an abscess would
be produced by the irritation of the bone beneath, and
force them open.
In a healthy state of the body, the separation of the cari-
ous bone is produced, as in gangrene, by the intervention of
a slight degree of inflammation excited on the extremity of
the sound parts—Suppuration follows, and this, together
with the rising of granulations, soon detach the dead from
the living parts. If we suffer ourselves to be directed by
this process of nature, we may often accomplish in a few
weeks what would otherwise require many more months
to effect. The principal indication of cure therefore, it
is evident, should be, by repeated and judicious applica-
tions to excite such a degree of inflammation, in the adjoin-
ing sound parts of the bone, as may be requisite for the
separation of those mortified.
If the bone is not bared, it should be exposed to view
either by laying open the soft parts or removing some of
them. The safest and easiest mode of exciting the neces-
sary inflammation, is by making a number of small perfo-
rations in the diseased part, with the pin or perforator of a
trepan fixed in its handle, to such a depth as to give a lit-
tle pain, every third or fourth day. When the caries is very
deep and extensive, it will shorten the process to use the
small head of a trepan.—As soon as any part of the
bone becomes loose at the edges, its separation will
be much hastened, by daily insinuating below them
the end of a spatula or levator, so as to press them up-
wards 

[ 40 ]
wards. During the separation of the bone, in order to
obviate the fœtor, the sores should be washed with a decoc-
tion of bark, of walnut leaves, camphor dissolved in
spirits, or lime-water. The latter I would advise to be al-
ways used, as it not only corrects the fœtor, but likewise
dissolves the cohesion of the bony matter. Pledgits of lint
dipped in these should be laid on the bone, while the rest of
the sore is dressed in the ordinary way.
After the separation of the caries, the ulcer is to be
treated as a simple purulent sore.
When a very large portion, or the whole circumfer-
ence of a bone is carious, the shortest process is to take out
all the diseased parts by the head of a trepan, or a straight
or circular spring-saw. This may be done in all cases
where the disease is confined to the middle of a bone,
except, perhaps, when the thigh bone is affected. There
are many instances of the regeneration of whole bones;
hence we should never despair of a cure where the part
diseased can with safety be removed. When the thigh
bone is extensively affected, or when the ends of the larger
bones forming joints, are carious, amputation is almost the
only remedy to be depended on. See chap, on Amputa-
tion.
During the treatment of caries, the same attention is re-
quisite to the patient's habit of body, diet, and regimen in
general, as we have recommended in other species of sores.
The bark is almost the only remedy that should be
used internally; but when the soft parts become very
painful and inflamed, slight scarification, or bleeding
with leeches, should be employed, and opiates should be
given freely.
I SECT. 

[ 41 ]
SECT. VIII.
On the cancerous Ulcer*.
Cancers have generally been divided into the occult and
open. By the former are meant such hard schirrous swel-
lings as are attended with frequent shooting pains, and
which generally terminate at length in the latter. By the
open, or ulcerated cancer, we understand that species of
sore, which commonly succeeds to hard swellings of the
glands, although in some instances, it occurs without any
previous hardness. The edges of this ulcer are hard, rag-
F ged,
* The following observations on Cancers, are the result of the expe-
rience of Mr Berchien, a Swedish surgeon of eminence; and who, in
consequence of having purchased Mr Guy's remedy for twenty years,
had a very great number of patients with cancerous complaints under his
care from all the northern parts of Europe. They were published in the
Swedish language by Mr Berchien, and by him sent to Dr Adam Kuhn,
the present professor of the practice of physic in the university of this
place, who has favoured me with a transition of them.
There are three species of cancers : the cancer genuinus, fungosus, and
serophulosus. The cancer genuinus, or genuine cancer, is the most common.
It usually appears first in the form of a very small, hard, and moveable
tumor or schirrus : this is usually smooth and round ; but in some in-
stances, it feels like a small tendon or firing. After some increase of size,
it often retains its smoothness; but in other cases, it becomes rough.
and angular, assumes the form of a cone, an almond, &c. It often
continues of the same size for a number of years; but it also frequently
continues constantly to increase in magnitude from its first appearance.
The tumor is at first moveable, but after it has made some progress, it
becomes attached to the adjacent parts. When it advances near to the 
surface, it becomes Very perceptible to the eye, and the skin contracts a
wrinkled appearance.
A pain, in some instances, is felt before any evident tumor, particularly
in the cord-like cancer. In other cases, there is no pain until the tumor
appears; and in others, again, which is most frequently the case, the
pain 

[ 42 ]
ged, and unequal, very painful and reversed in different
directions. The surface of the sore is commonly very
unequal. The discharge is for the most part a thin fœ-
tid ichor; and is often so acrid as to excoriate and even
destroy the neighbouring parts, and by this means it some-
times produces considerable hemorrhagies. There is a
considerable sense of heat over the whole ulcerated sur-
face, which is the most tormenting symptom of the disease,
and violent, shooting, lancinating pains.
These are the most frequent symptoms of cancer, but
they
pain does not come on, until the tumor has acquired a considerable size 
but after the pain begins, the swelling constantly increases in magnitude.
Sometimes a momentary shooting pain only is felt during the menstrual
flux, or upon changes of weather; but in other cases it is continual.
Not long before the cancer becomes ulcerated, the skin changes to a
red colour, and is painful to the touch ; it soon after becomes chapped,
and a thin sanies issues from the fissures. The edges of the sore soon be-
come hard and uneven, and are reflected in various directions. There is
never a good pus afforded, but the discharge is a thin sanies or ichor,
which often destroys the contiguous parts.
This species of cancer attacks various parts of the body ; but particu-
larly the lips, nose, and breast.
The cancer fungosus chiefly occurs in fat women of a lax habit of body
and who have large breasts. It begins like the genuinus, with a small
moveable hard tumor; but it is more spongy, elastic, like a cluster of
small tumors, and not so hard. Its progress is astonishingly rapid: in
some instances, it has grown from the size of a nutmeg, to the bigness
of a man's head, in the course of eight or ten months: Little blue or
reddish spots, often appear over the surface of the tumor ; which, when
opened, discharge blood, or a bloody serum.
When the cancer ulcerate, it discharges such quantities of a bloody
scrous matter, often all at once, that no dressings can keep it dry. From
one or more of the openings, arise large spongy lobe-like excrescences,
which sometimes have a resemblance to sheep's liver, and at other time,
have the form of the head of a cauliflower; and are hard and
cartilaginous to the touch. These often spread over the whole breast,
and are, in some instances, strangulated at their base by the skin.
This species effects not only the breast, but also the neck, shoul-
ders, arms, and legs.
The 

[ 43 ]
they are often so varied, that it is not always easy to distin-
guish the disease. When however, two, three, or more
of these concur, we may always be pretty certain of the
ulcer being cancerous.
We may be assisted in the diagnosis by the situation of
the sores: thus they generally affect glands, or parts in
which glands are numerous. Hence a far greater num-
ber occur in the lips and in the breasts of women than
in every other part of the body.
Various circumstances have been assigned for the pro-
duction
The cancer scrophulosus begins sometimes like the two other species
with a single schirrus ; but in most instances, there are several near each
other, and which often seem connected : These are not so hard as in
the genuinus, and give little or no pain until they become open sores,
and even then but little. In the advanced stages, the breast appears co-
vered with reddish blue spots, and is flat and hard. The integuments
and substance of the breast being drawn in, so as to produce a furrow in
the middle, and firmly fixed to the muscles and ribs. This attachment
often occasions a considerable impediment to respiration. The subcuta-
neous lymphatic glands become hardened in every part of the breast,
and particularly those towards the axilla.
There are many openings formed ; some of these often dry up in a little
time, and get a thick white scab : others continue open—some of them
discharge pus, others a thin foetid black ichor. The edges of the ulcers
are frequently red and fungous ; and the discharge often penetrates at
length to the ribs and sternum, and even into the thorax.
In this species, there are usually indurated lymphatic glands in various
parts of the body, and other marks of scrophula ; and it evidently de-
pends on a general affection.
Tumors in the breast from milk, have been accused of terminating in
cancer; but there is no good evidence of this ; and where it has appa-
rently been the case, I have no doubt that there has, at the same time,
been a schirrus in the breast, which has become cancerous from the ir-
ritation produced by the milky tumor.
The general exciting causes of cancers, are passions of the mind, parti-
cularly grief or terror, and external violence. In the cancer genu-
inus and fungosus, these operate locally by producing, probably, an
obstruction in the lymphatic vessels, and a consequent schirrus from
a gradual accumulation of lymph, and absorption of its thinner parts; but
on the cancer scrophulosus there is a general disease connected with the
topical 

[ 44 ]
duction of cancers; and at least an equal number of re-
medies have been proposed for the cure of them ; but our
little success in the treatment of the disease shows clearly,
that the ideas adopted, and the remedies offered, have
been more founded on theory, than on observation and
practice.
It
topical affection. From hence it is evident, that the cure of the latter can
only be effected by conjoining the general remedies of scrophula with
proper applications to the cancerous part; whilst the genuine and fun-
gous cancers may be effectually removed by timely, topical remedies a-
lone. The scrophulous cancer may sometimes be cured by an early and
judicious use of mercury, general and topical, and by hemlock ; but both
of these are injurious in the other species; for the cure of which, we can,
with safety, only depend on early extirpation, or Guy's powder.——
As a confirmation of the accuracy of this interesting account of can-
cers, I am happy to give the testimony of Dr Jones, of this city, whose
long experience has afforded him an ample opportunity of ascertaining
its agreement with the phenomena, nature, and proper method of treat-
ing these dreadful diseases.
The Doctor thus expresses his opinion on the subject:—Mr Berchien's
observations on cancers, appear to be the result of accurate observa-
tion, and great experience; from which alone any genuine improvement
can be made in the cure of diseases.
His distinction of cancers into the three general species of genui-
nus, fungosus, and scrophulosus, is well founded, and merits the se-
rious attention of all those who wish to treat this terrible disease with
propriety. The two first may be radically cured by extirpation with the
knife or caustic, as they appear to be local diseases: but the cancer
scrophulosus requires the aid of internal medicine, to correct the vitiated
habit; though very few instances occur of perfect cure.
The cancer fungosus appears to be more liable to relapse than the ge-
nuinus ; and instances have been known, where the cancer fungosus has
broke out after it appeared to be perfectly cured by Guy's powder, and
remained found above ten years.
The same species of cancer has been frequently closed by the use of
arsenic ; but has often broke out again, and at last baffled all remedies.
Similar consequences have attended a quack nostrum, which has been
much boasted of in this city for two years past.
From these instances, it appears to be a melancholy truth, that there
are cancerous ulcers which baffle all the remedies hitherto discover-
ed. 

[ 45 ]
It however appears evident to me, that cancer is ge-
nerally a local affection, not originally connected with any
constitutional complaint; and that a general cancerous
taint, seldom, or perhaps never occurs, but in consequence
of the cancerous virus being absorbed into the system from
some local affection. This opinion is more particularly
rendered probable, by the success of extirpation in curing
cancers. From a statement of Mr Hill, surgeon in
Dumfries, it appears that of eighty-eight cancers he had
extirpated before the year 1768, in 1770 there were
two of the patients not cured: in nine they had broke
out again : one was threatened with a relapse; and about
forty remained alive and sound. From these and many
other authenticated facts, we think ourselves warranted
in drawing the abovementioned conclusion. The ill suc-
cess of some surgeons, and particularly of hospital prac-
titioners, may more justly be attributed to the inveteracy
of the cases in which they have been usually consulted, than
to any thing really incurable in the nature of the disease.
Cancers succeed to external accidents : to tumors of the
breasts in nurses and lying-in women mismanaged ; to fe-
vers and other internal disorders, of which they seem to
be the terminations : and they happen to women about
the time of the cessation of the menses.
All these circumstances probably operate in bringing on
Cancer, by first inducing a preternatural determination of
fluids to the part, which necessarily distend and obstruct
its vessels : from the small degree of irritability in these, the
part affected being usually glandular, an indolent tumor or
schirrus is thus gradually produced by the accumulation of
fluid : this, at length, either from increase of bulk or from
external violence is excited to inflammation ; which, at a
longer or shorter period, finally terminates in the forma-
tion of the cancerous virus.
This explanation will perhaps be admitted as agreeable
at

[ 46 ]
at least to probability, if we consider that glandular parts,
which are almost always, if not in every case, the seat of
cancer, never afford a good discharge: and, from the
analogy of many other sores which often produce a mat-
ter nearly as acrid as the cancerous virus, we may certain-
ly be allowed to infer, that some peculiar affection of
these parts may induce the formation of a matter as acrid
as that of cancers : and when the virus is thus formed, it
may in time be absorbed, and produce a general cance-
rous diathesis.
There is no remedy to be depended on in cancers but ex-
tirpation ; and it should be had recourse to immediately on
the discovery of the disease. With respect to the parti-
cular modes of performing this operation, we must refer
to what will be said hereafter; and shall only observe in
this place, 1. That caustics, on account of the irritation
and inflammation they produce, should never be preferred
to the scalpel. 2. Wherever the disorder is situated, eve-
ry part that has the least appearance of disease, every
indurated gland in the neighbourhood, should be always
taken off*, otherwise the cancer will certainly return;
but no more of the integuments should be removed than
is absolutely necessary: for the smaller the cicatrix that
remains, the less will be the consequent irritation; and from
this, perhaps, the chance of the disease returning may be
lessened. The teguments should, as far as possible, be
brought to cover the wound by the employment of the
interrupted
* From a circumstance which occurred in a case of occult cancer of
the mamma extirpated by Dr Hutchinson, of this city, and of which I
was a witness, I should think it very proper, in every instance, to avoid
cutting the tumor. After the operation, the Doctor's pupil wishing to
examine the whole substance of the cancer, made an incision into it and
there immediately issued forth a considerable quantity of a thin icho-
rous matter. The patient very soon recovered; which, perhaps, might
not have been the case had this matter been discharged into the
wound. For it is very well known that cancerous sores have been some-
times produced from the application of the virus, even to parts covered
with the integuments. 

[ 47 ]
interrupted or twisted suture. 3. After the removal of
the cancer, if the teguments do not entirely cover the
wound, and a hemorrhagy ensues, dry lint should be
used as a dressing; but if there is no discharge of blood,
the lint should be spread with some emollient ointment.
The sore should afterwards be treated as a simple
ulcer, and healed as soon as possible. 4. Some little time
before the healing of the sore, an issue should be introdu-
ced—and this is probably done with greatest advantage,
if made within the vicinity of the cancer. Issues seem
particularly necessary in cases of cancer that proceed from
suppressed evacuations, and have continued a long time ;
and we have no doubt, but that they often prevent the
return of the disease.
The circumstances that should prevent the extirpation
of cancers, are, in general, 1. The appearance of cance-
rous ulcers and schirrous glands in several parts of the
body at the same time 2. The connection of them with
other parts that cannot be removed without danger.
Thus cancers adhering to the trachea, or to the coats of a
large artery, can never, without the greatest risk, be extir-
pated. But large portions of muscles and tendons have
been taken away with cancers without producing much
inconvenience. And there have occurred many instances
of cancerous mammæ, in which there were adhesions to
the periosteum of the ribs, to the clavicle, and sometimes
a chain of indurated glands, extending to the bottom of
the arm-pit, and yet all the diseased parts were with per-
fect safety removed.
3. An operation can never be adviseable, where the
parts affected are so situated, as to prevent their being to-
tally extirpated ; as is the case in cancers of the uterus and
rectum. The indication then, is to palliate the different
symptoms, so as to render the disease as tolerable to the
patient as possible. As, for this purpose, the great object
is 

[ 48 ]
is the abatement or prevention of pain, nothing should
be exhibited internally, or applied externally, that can have
the least effect in producing irritation or inflammation.
A diet of milk, and the lightest vegetables should be or-
dered : no animal food, fermented or spirituous liquors',
should be allowed; and all violent exercise should be
carefully avoided.
The fœtor of cancers is considerably corrected by the
use of hemlock. This may be taken internally in powder
or extract, and applied externally with emollient poulti-
ces in powder, if the juice cannot be had. It commonly
also mends the discharge ; and this much sooner than the
carrot-poultice that has been so much recommended in
foul sores*.
When a good discharge is obtained, the sore should be
treated as a simple purulent ulcer—and particular atten-
tion should be paid to avoid long exposure of the ulcera-
ted surface to the air. The violent shooting pains are re-
lieved sometimes by cicuta—and sometimes by emollient
fomentations—when neither of these succeed, we must
have recourse to opiates.
Besides a variety of other remedies, cicuta, belladonna, and
arsenic †, externally as well as internally, have been much
employed and recommended for the cure of cancers; but we
internal
*Similar good consequences have succeeded the use of common
poke—the ley-poultice—3nd of fixed air.
† Arsenic has been probably the basis of most of the quack medicines
for cancer; such as Guy's, Plunket's, and others. Dr Rush has proved,
by a chemical analysis, that Martin's remedy contained this substance.
It has been observed to occasion various spasmodic affections in some in-
stances, and particularly to affect the muscles of the eyes. We have good
evidence of its producing beneficial effects in many instances, and of ef-
fecting cures in some.
If it is proposed to apply arsenic to an occult cancer, it will be neces-
sary to destroy the cuticle by the lunar caustic or some other substance, or 
by
I

[ 49 ]
have never seen any of them produce any permanent advan-
tage. Mr Justamond has spoken highly of an escharotic me-
dicine composed of steel and sal ammoniac, infused in spirit
of wine, with a certain proportion of oil of tartar and spirit
of vitriol. The edges of the cancers, as well as the hard
excrescences that occur in them, are to be constantly mois-
tened with this liquid; and during the use of it, he like-
wise advises the internal use of flores martiales. From
the trials I have made of these remedies, I have not ex-
perienced any real advantages.
SECT. IX.
On the Cutaneous Ulcer.
There are few diseases less understood than those of the
skin. The descriptions given of them are so confused;
and they are so variously named by different writers, that
it is difficult to collect any thing on the subject satisfactory.
We shall here confine ourselves to some general observa-
tions on those topical complaints of the skin that are apt to
produce troublesome ulcers. These, as well as some others,
have all been included under the general term of Herpes,
from their being apt to spread from one part to another.
The chief varieties of herpes may be comprehended in
the four following species, viz. the Herpes farinosus, pustu-
losus, miliaris, and exedens. 
G The
by a knife, previous to its use. Mr Justamond does not think it necessary
in any case to apply it over the whole surface of the tumor, but merely to
its circumference. He is of opinion that arsenic operates in separating
the cancer by exciting an inflammation, and consequent suppuration, of
the sound parts connected with those diseased. The arsenic is usually
applied either in form of a watery solution, as strong as it can be made,
or mixed with some unguent, or powder. 

[ 50 ]
The herpes farinosus, or what may be termed the dry tet-
ter, is the most simple, both in its nature and treatment,
of all the species. It appears indiscriminately in different
parts of the body; but most commonly on the face, neck,
arms, and wrists, in pretty broad spots of exceeding small
red pimples. These are generally very itchy, but not other-
wise troublesome; and after continuing a certain time, they
at last fall off in form of a white powder, similar to fine bran;
leaving the skin below perfectly sound ; and again return-
ing in form of a red efflorescence, they fall off, and are re-
newed as before.
The herpes pustulosus appears in the form of pustules,
which are originally separate, but afterwards run together
in clusters. At first they seem to contain nothing but a thin
watery serum, which afterwards turns yellow; and ex-
uding over the whole surface of the part affected, it at last
dries into a thick crust or scab. When this falls off, the
skin below frequently appears entire, with only a slight de-
gree of redness on its surface; but on some occasions, when
the matter has probably been more acrid, upon the scab
falling off, the skin is found slightly excoriated. Erup-
tions of this kind appear most frequently on the face, be-
hind the ears, and on other parts of the head ; and they
occur most commonly in children.
The herpes miliaris breaks out indiscriminately over the
whole body; but more frequently about the loins, breast,
perinæum, scrotum and inguina, than in other parts.
It generally appears in clusters, though sometimes in dis-
tinct rings or circles, of very minute pimples, which
from their resemblance to millet, has given the denomina-
tion of the species.—The pimples are at first, perfectly se-
parate ; and contain nothing but a clear lymph, which, in
the course of the disease is excreted upon the surface ; and
there forms into small distinct scales; these at last fall
off, and leave a considerable degree of inflammation be-
low, that still continues to exude fresh matter, which like-
wise  

[ 51 ]
wise forms into cakes, and so falls off as before—The itch-
ing in this species is always very troublesome: and the
matter discharged from the pimples is so tough and viscid,
that every thing applied to the part adheres in such a man-
ner as to occasion a great deal of uneasiness on its being
removed.
The different species of herpes are in common known
by the names of tetter, shingles, and ring-worm; but the last
is most frequently applied to the herpes miliaris.
The herpes exedens, so called from its destroying or cor-
roding the parts which it attacks, appears commonly at
first in the form of several small painful ulcerations, all
collected into larger spots of different sizes, and of various
figures, with always more or less of an erysipelatous-like
inflammation. These ulcerations discharge large quanti-
ties of a thin, sharp serous matter; which sometimes forms
into small crusts that in a short time fall off; but most
frequently the discharge spreads along the neighbouring
parts, where it soon forms ulcers of the same kind.
Although these excoriations or ulcers do not, in general,
proceed further than the true skin; yet sometimes the
discharge is so corrosive as to destroy the skin, cellular
substance, and on some occasions, even the muscles them-
selves. It is this species that should properly be termed
the depascent or phagedenic ulcer; but ulcers of the
herpetic kind have, with great impropriety, been com-
monly supposed connected with scurvy, and thence have
been termed scorbutic : Whereas it is very certain, that
herpes is a complaint generally joined with a state of
the body entirely opposite to that which takes place
in scurvy, viz. the plethoric and inflammatory, is ve-
ry different in its appearance from scorbutic ulcers, and
requires very opposite remedies.
This species of herpes appears at different times in every
part of the body, but most frequently about the loins, where
it often spreads so as to surround the whole waist. It seems
to 

[ 52 ]
to be easily communicated by contagion ; that is, by the ap-
plication of the virus, by the intervention of clothes and
other substances. I have known even the dry species of
the disorder communicated thus.
There is as much confusion and uncertainty among au-
thors respecting the cure of cutaneous diseases, as with re-
gard to their description. It has always been supposed,
till lately, that these complaints originated from some ge-
neral morbid affection of the system. And it was even be-
lieved to be unsafe to attempt their cure in any other way
than by correcting the disease of the fluids which it was
supposed produced them. But it is strange that this opi-
nion should not have been rejected when It was known
that they could be cured by topical applications. It was
formerly the practice to direct long debilitating courses of
medicines—but whenever internal medicines are now di-
rected, it is with a view to restore the diminished discharge
of perspirable matter; which, from want of cleanliness,and
from some other causes, being long retained on the surface
of the body, and there turning acrid, may often, it is pro-
bable, give rise to many cutaneous affections. And, ac-
cordingly we find, that all such remedies prove more or
less effectual as they keep up a more or less free perspira-
tion. And what puts it beyond a doubt that they pro-
duce their good effects in this manner is, that warm bath-
ing and cleanliness alone, in many instances, will cure these
diseases effectually.
In the treatment of all the species of herpes, the first and
principal circumstance to be attended to is, that not only
the parts affected, but even the whole surface of the body,
be kept as clean and perspirable as possible; for which pur-
pose nothing is of so much importance as the frequent use
of warm bathing, together with gentle frictions, with clean
linen cloths; this last, in the dry species, may be applied
over the diseased parts. When these circumstances are
properly 

[ 53 ]
properly attended to, few or no internal remedies are ne-
cessary in the slighter degrees of herpes.
Of external applications, the several drying and astringent
remedies are most to be depended on---lime-water, decoc-
tions of the different kinds of boles, and of the astringent
earths, often remove slight cases of these complaints. A
watery solution of saccharum saturni, applied in cataplasms,
or on soft linen rags, is somewhat more powerful— But in
inveterate cases, a solution of corrosive sublimate of mercu-
ry in water is more to be depended on than any of these.
About 10 grains to ℔j. of water is in general a proper
proportion.
Ointments prepared with these substances are not more
effectual than the watery solutions; the latter are more
cleanly, and therefore claim a preference.
When the disease has been of long standing, and especi-
ally if large quantities of matter are discharged, it becomes
necessary to have recourse to other remedies.
The more obstinate and virulent such complaints are,
the greater attention becomes requisite to the promotion of
a free discharge by the skin; for which purpose, together
with warm bathing, warm diluent drinks, should be plen-
fully allowed. New whey answers in this view very well.
Although sarsaparilla and mezereon have been much re-
commended for this purpose, I never knew them to pro-
duce more beneficial effects than the common decoction
of the woods. This may be rendered occasionally more
diaphoretic by adding fifteen or twenty drops of tincture
of antimony to each cup full. A free perspiration may in
common be kept up by taking two or three pounds of the
decoction in the course of every twenty-four hours.
Crude antimony, to the quantity of two drachms in the
day, is also a useful and gentle diaphoretic. Its efficacy
is often rendered greater by conjoining a small quantity of
gum

[ 54 ]
gum guaiacum with it, by which means it proves gently
purgative.
In plethoric patients, laxatives often prove serviceable.
Those of the cooling kind only should be used. Sea-wa-
ter answers very well, when the partient's stomach will
bear it; but cream of tartar, made into an electuary with
an equal quantity of sugar, and some mucilage of gum a-
rabic, forms a much more agreeable laxative.
An issue is always necessary in the more inveterate spe-
cies of herpes, and should be one of the first remedies ;
without which, as in ulcers, the disease is very apt to re-
turn after being cured.
As considerable inflammation sometimes attends herpes,
and particularly the herpes exedens, the saturnine applica-
tions become very necessary. Warm poultices and fomenta-
tions almost constantly tend to increase the disease, by
spreading the humour.
When the ulcers penetrate deep, it is necessary to dress
them with ointments, composed either of zinc, saccharum
saturni, or white precipitate of mercury, and hog's lard.
The proportions of zinc and axunge may be ʒij. in fine
powder of the former to ʒvi. of the latter.
When these remedies do not succeed in the cure of her-
pes, which is seldom the case, there will be reason to
suspect that some other disease subsists at the same time--
This, on accurate examination, will frequently be found
to be the lues venerea. In this case, mercury must be ad-
ded to the remedies already advised.
A combination of scabies or the itch with herpes some-
times occurs, and produces a tertium quid, almost as
loathsome as the leprosy. In this case, the treatment ne-
cessary for scabies must be joined with that used for the
removal of the herpes. Mercury will frequently cure the
itch, and often removes herpes ; but as it sometimes fails
in 

[ 55 ]
in the former disease, and sulphur hardly ever does, the
latter should be preferred.
In every herpetic eruption to which children are liable,
sulphur seems the most effectual remedy; and when o-
thers have failed it should always be tried. The sulphur
vivum is much stronger than the flores sulphuris, and
should therefore be used in preference.
There is a variety of herpes, which frequently affects
the face, and occurs more particularly in females, ex-
ceedingly distressing and difficult to remove—-All the
common remedies are often ineffectual in curing it.
I have succeeded in many such cases by the use of the fol-
lowing preparation : ℞. lac. sulphurus ʒii. sacchar. µj.
aq. rofar. ʒviii. ♏︎. The eruption is to be bathed with
this, morning and evening, first shaking the vial. When,
however, it is thought proper to use mercury, the ungu-
entum citrinum, prepared with a less quantity of acid
than is usually employed, is the most effectual prepara-
tion of it I have ever used.
The tinea capitis and crusta lactea of children, belong to
the species of herpes pustulosus, and require the same ge-
neral treatment. In the former, it is of great consequence
that the hair should be cut short; and the solution of
sublimate succeeds remarkable well.
Issues seem particularly useful in curing and preventing
herpetic diseases in children; and they may, with the
greatest safety, be healed up after the fifth or sixth year of
their age. As the quantity of fluids which, before that
period, appears to be discharged by different eruptions
upon the surface, seems then necessary to be applied to the
nutrition of the body.
SECT. 

[ 56 ]
SECT. X.
On the Venereal Ulcer.
We now come, in order, to consider the ulcers con-
nected with a general affection of the system ; and shall
first treat of the venereal ulcer.
Although, by the term venereal ulcers, is generally
meant those which are a part of syphilis ; yet chancres,
which are not always connected with any general disease
are also included under it. They may therefore be divi-
ded into those that appear as primary symptoms of the
disease, and such as may be more properly considered as
symptomatic.
Of the former kind are chancres in general, wherever
situated, whether upon the parts of generation, the nip-
ples, or lips. Those ulcers may also, in some cases, be rec-
koned primary, which remain after the bursting of bu-
boes that have arisen from an infection lately communica-
ted, and before there is a probability that the whole sys-
tem is affected.
Such ulcers are considered as symptomatic, as arise in
consequence of a general taint of the habit. Of this kind
are all those which succeed to old buboes, and such as
appear along with other venereal symptoms a considerable
time after infection; the most common situations of which
are, the throat, palate, nose, the parts immediately above
the bones of the cranium, tibia, humerus, and other hard
bones thinly covered with flesh.
In many cases, it is difficult to make this distinction in
venereal sores; but unless it is always done, we cannot di-
rect the proper mode of treatment. The principal means
of distinction are obtained either by information from the
patient
2 

[ 57 ]
patient, or from the appearance of the different sores
themselves.
If, soon after exposure to infection, an ulceration appears
upon the part to which the virus was immediately appli-
ed, together with swellings of any of the glands in the
course of the lymphatics, we may be almost convinced that
these are only local affections. Such ulcerations are
termed chancres. They appear at first, as small miliary
spots, which soon rise and form little vesicles; these upon
bursting, discharge sometimes a thin watery fluid, and on
other occasions, a more thick yellow matter. The edges
of such sores are generally hard and painful; and as well
as the glandular swellings already described, are com-
monly attended with more or less inflammation.
The symptomatic venereal ulcers are in general, more
troublesome than chancres. They are distinguished, 1.
By information from the patient. 2. By their situation;
and, 3. By their appearances. Thus if a patient who
has symptoms of infection in his constitution, is attacked
with one or more ulcers, whether in consequence of exter-
nal injuries or not; and if they resist the common me-
thods of cure, there can be little doubt of their being in-
fected by the general taint. But when it cannot be as-
certained that the patient is affected, by his own informa-
tion, we must endeavour to form a judgment from the si-
tuation and appearances of the ulcer itself.
Venereal ulcers from an old infection generally appear
immediately above the bones, and particularly above such
as are but thinly covered with muscles. They first ap-
pear in the form of a red, and somewhat purplish efflo-
rescence, considerably diffused. This soon rises into a
number of very small pustules, which ooze out a thin
fretting serum. At first, these pustules when observed
through a glass, appear perfectly distinct; but they at last
run together, and form one large ulcer, whose edges are
H commonly 

[ 58 ]
commonly ragged and somewhat callous; and there is ge-
nerally a light red appearance, extending a considerable
space beyond the sore and efflorescence.
Sores of this kind have frequently the form of a cup,
with the narrow part at the bottom. But when carious
bones lie at the lower part, they are generally filled up
with fungous excrescences. They are seldom attended
with much pain. The discharge from them is at first
thin, but at last puts on a very characteristic appearance;
being of a consistence rather more viscid and tough than
good pus, with a very loathsome, though not the ordina-
ry fetid smell, and a very singular greenish yellow colour.
The distinction of venereal sores into primary and symp-
tomatic, is of consequence in directing the proper treatment.
For the former might be cured merely by destroying the
venereal matter with caustic, if attended to before any ab-
sorption had taken place. But as it is impossible to ascer-
tain whether the virus has entered the system or not, when
we are applied to, the cure of chancre should never be
trusted to topical applications; but, together with these,
mercury should be always used internally ; and to prevent
a further absorption of matter, the healing of the sore should
be accomplished as soon as possible.
This distinction points out to us likewise, that in ul-
cers from, an old pox, we ought never to make use of
such dressings as have a tendency to heal them soon; but
should rather trust entirely to the internal use of mercury,
and to such applications as merely keep them clean and
easy. For the healing of such sores then affords the
surest index of the removal of the general disease.
As we are seldom called early enough to destroy the
virus in chancres by caustic, and indeed until it would be
somewhat dangerous to attempt it, after wiping the sores
clean, I generally sprinkle them with finely powdered red
precipitate of mercury, and over this apply lint spread
with 

[ 59 ]
with common ointment. This answers very well in all
cases unattended by inflammation. It seldom occasions
much pain or irritation: and produces a slough, which in
the course of a dressing or two, generally comes away, and
leaves the ulcer perfectly clean. When in this state, the
sore would probably heal if nothing more than cerate was
applied to it, but for fear any venereal matter should still
remain, I commonly then dress it with the strong mercurial
ointment. In this manner chancres are in general easily
cured, and with much less mercury given internally than
if allowed to remain open a considerable time.
By long continuance however, and the neglect of proper
remedies, these ulcers put on the appearances and nature of
those that depend on a general infection; and consequently
require the same method of treatment. They are very apt
to become inflamed and very painful ; and more especially
when seated on the penis. Where this is the case, it is
sometimes necessary to order bleeding : but in general, the
saturnine poultice will be sufficient to moderate the inflam-
mation. After the removal of the inflammatory symp-
toms, the best application is common wax ointment.
There are two modes of throwing mercury into the sys-
tem ; the one by giving it internally by the mouth, and the
other by introducing it into the body through the absor-
bents on the skin by means of friction ; but, as the last me-
thod is by much the most troublesome and in convenient,
and is not attended by any peculiar advantages, the former
is now, I believe, generally preferred.
Those preparations in which the mercury has undergone
no other operation than triture, as the quicksilver pill, P.
Edinb. are in general the best. When this is not found to
answer, the mercurius corrosivus sublimatus, or mercurius
calcinatus, may be tried: and it is sometimes necessary to use
a variety of preparations before a cure can be effected.
But 

[ 60 ]
But, in whatever form mercury is employed, it should
always be continued until a soreness of the mouth is in-
duced, as that is the only certain indication of its having
entered the system. This soreness in very slight degree,
should be supported until the cure is perfected.
In order to guard against the mercury's running off too
quickly by the mouth, and producing troublesome saliva-
tion, which it is very apt to do, it has been recommended
to determine the operation of the medicine in some degree
to the skin by the use of warm bathing—not only during the
use of the mercury, but previous to its being begun— This
effect may, in some degree, be obtained with less risk from
cold, by the use of a flannel shirt, by drinking plentifully
of decoction of the woods or sarsaparilla: and by avoid-
ing cold. Where the warm bath can be conveniently used
it should, as being more powerful in its effects, without
doubt be employed. It also has a good influence in pre-
venting the operation of the mercury on the bowels.
By the use of these different remedies, venereal ulcers
will commonly soon be removed, The mercury should
be continued for a longer a shorter time after the disappear-
ance of the symptoms, according to the inveteracy or stand-
ing of the disease.
It sometimes happens that after a long exhibition of mer-
cury, and when there is reason to suppose that the venereal
taint of the habit is altogether eradicated, the ulcers can-
not be brought to heal. In this case there will be room
to suspect that some other disease may have subsisted in the
the constitution together with the lues venerea, and that
both may have had some share in the production of the ul-
cers. When the nature of this disorder is ascertained,
proper remedies to correct it must be conjoined with those
before given.
Venereal 

[ 61 ]
Venereal ulcers are sometimes rendered obstinate by a
caries of some bone, independent of any other disease. This
is to be suspected when they are seated upon or near any of
the bones, and particularly if there occur fungous excres-
cences. To the remedies for the venereal affection, we
must then add the treatment proper for caries. See section
on the carious Ulcer.
When neither caries nor any constitutional affection
seem to prevent the healing of such ulcers, and they appear
to grow worse; and particularly when the system seems
much debilitated by the confinement and effects of the re-
medies, the best and most effectual mode of treatment is, to
order a light nourishing diet, with fresh air and exercise.
This by invigorating the body often produces surprising
cures. The Peruvian bark is here also of service.
Old sores of this kind, on account of the sloughs with
which they are usually covered, require stimulant dress-
ings. The following ointment is very proper, ℞, ung.
basil. flav. ℥j. merc. præc, rubr. ℥ij. M. When they be-
come clean, they are to be treated in the usual way.
When the glands are the seats of venereal ulcers, it is
sometimes necessary to destroy the whole, or a considera-
ble part of such as are much hardened, by caustic, before a
cure can be obtained.
Although venereal ulcers are in general to be cured by
proper treatment, yet some instances have occurred, in
which they have resisted all the efforts of nature and
art, and at last have carried off the patient in great
misery.—-* such cases probably are only to be met with
in hospitals.
SECT.
* They are sometimes met with in private practice, and after
resisting all the methods recommended by different writers, have been
known to recover solely by the use of a free diet and exercise. 

[ 62 ]
SECT. XI.
On the Scorbutic Ulcer.
The characteristic marks of ulcers that occur in scurvy,
are as follow :—They never afford a good pus ; but a
thin fœtid sanious matter, mixed with blood; which at
length has the appearance of blood coagulated, and is
with difficulty separated from the surface of the sore. The
flesh beneath this is soft, spongy, and very putrid—Escha-
rotics to remove the sloughs answer no good purpose, for
they certainly appear again at the next dressing—Their
edges are generally of a livid colour, and puffed up by
excrescences beneath the skin. If compression is employ-
ed to keep the fungus from rising, it generally produces
a gangrenous disposition, and always renders the member
œdematous, painful, and for the most part spotted.
As the disease increases, they shoot out a soft bloody
fungus, resembling boiled liver ; which often rises in a
night's time to a monstrous size; and if destroyed by
caustic or the knife, bleeds plentifully, and returns again
by the next dressing. They continue a considerable time
in this condition, without affecting the bones—and are
produced by the slightest wound or bruise, in scorbutic
persons.
This description is only applicable to scorbutic ulcers
that accompany very great putrescency in the system at
large ; for such inveteracy is not often met with, except
in long sea-voyages ; but in Scotland, slighter degrees of
the same kinds of sores are often seen, and sometimes ac-
companied with the most characteristic mark of scurvy,
viz. soft spongy gums. They generally appear among
the lowest class of people, and seem to originate rather
from want of food in general, than from confinement to a
particular 

[ 63 ]
particular kind. They seldom are produced in parts pre-
viously sound; but ulcers already formed, and wounds
inflicted during the prevalence of a scorbutic affection,
always degenerate into sores of this kind. Most of
the ulcers of the poor in Scotland partake of a scorbu-
tic taint.
The immediate or proximate cause of scorbutic ulcers,
as well as of every other symptom of scurvy, may be re-
ferred to a certain degree of putrescency in the fluids.
This may be induced by a variety of causes, the most ma-
terial of which are, living constantly upon salt provisions ;
a total want of vegetables ; with exposure to a cold, moist
atmosphere. See Pringle, Lind, and Huxham on the
Scurvy.
The cure of scorbutic ulcers must depend chiefly on the
correction of the putrid diathesis of the system; for which
purpose, vegetables of all kinds, but especially those of an
acescent nature, with milk and whey, are found to be cer-
tain remedies. The different secretions, especially those
by the kidnies and skin, and more particularly the last,
which is in common almost entirely obstructed, should be
gently promoted. Laxatives, as tamarinds, manna and
cream of tartar, are also very serviceable—These remedies,
joined with total abstinence from salted food, and atten-
tion to avoid all the other exciting causes, commonly re-
move all the symptoms of scurvy. The ulcers should be
dressed with powerful antiseptics. Lind recommends
ung. ægyptiac. and mel rosarum acidulated with spirits of
vitriol.
In the scorbutic ulcers that occur in Scotland, it is
seldom necessary to confine the patient to an antiscor-
butic course. And they are more effectually removed
by the gradual allowance of a generous diet, with a
moderate proportion of good wine, or perhaps what
is better, of porter or strong beer. Peruvian bark
internally

[ 64 ]
internally, and applied to the ulcers in decoction, is a very
useful remedy in these cases ; but the best external appli-
cation while much putrescency remains, is the carrot poul-
tice; when this is removed, the ulcer is to be dressed as
in other cases. Issues are also to be used occasionally.
SECT. XII.
On the Scrophulous Ulcer.
By scrophulous ulcers, are meant those sores which are
consequent to swellings, symptomatic of scrophula or king's
evil.
Scrophula begins with indolent, somewhat hard, co-
lourless tumors ; which at first chiefly affect the conglo-
bate glands of the neck ; but at length attack the cellular
substance, ligaments and bones.—These swellings are
more moveable than schirri, softer, and seldom much
painful; they are tedious in coming to suppuration;
very apt to disappear suddenly, and again to rise in some
other part of the body. There is a remarkable softness of
skin in this disease, a kind of fulness in the face, and ge-
nerally large eyes, and a very delicate complexion.
Scrophulous ulcers seldom yield a good discharge; af-
fording upon their first appearance, a viscid, glairy, and
sometimes a whitish curdled matter,that afterwards changes
to a more thin watery sanies. The edges are frequently
painful; and always much tumefied. As long as there is
any scrophulous diathesis in the system, such sores often
remain for a great length of time, without shewing any
disposition either to heal or grow worse: at other times
they heal very quickly, and again break out in some other
part of the body.
A variety of causes have been mentioned as tending to
produce scrophula, viz. a crude indigestible food ; bad wa- 
I ter;  

[ 65 ]
ter; living in low damp situations ; its being an heredi-
tary disease, and in some countries endemic, &c. But,
whatever may be the exciting or predisposing causes, the
disease itself either depends upon, or at least is much con-
nected with a debility of the constitution in general, and
probably of the lymphatic system in particular : the com-
plaint first shewing itself by affections of the latter. This
is evident from the nature of many of the causes, and from
such remedies as are found to prove most serviceable in the
cure.
Gentle mercurials are sometimes of use as resolvents in
scrophulous swellings*; but nothing has such good effects
as the large use of peruvian bark. Chalybeate and sulphure-
ous waters too, have frequently proved serviceable : and
a long use of mild saline aperients have been found benefi-
cial. Cold bathing, and particularly in the sea, together
with moderate exercise, is often of singular service; as like-
wise change of air, especially to a dry climate.
Until the general schrophulous taint is removed, it is
dangerous to heal the ulcers; all that should be done,
therefore, should be, to give as free a vent to the matter as
possible, and to prevent the formation of sinusses.
The best applications are the saturnine preparations :
these remove that inflammatory complexion they assume
when relaxants are employed; and tend much to prevent
the spreading of the sores.
When, however, the ulcers become swelled and pain-
ful, and discharge a very corrosive matter, we may suspect
a caries to be at the bottom of the sores. Nature must then
be assisted, where it is practicable, by the removal of such
parts of the bones as are most diseased, and have become
loose. But this cannot be done when the large joints are
affected : In that case, as amputation is not always advisea-
I ble,
* Compresses dipped in a solution of sal ammoniac, in vinegar and wa-
ter, and applied to the tumors before any inflammation appears, have
been found useful. 

[ 66 ]
ble, for fear of the disease returning, we must trust to nature
for a cure. Here the general remedies, formerly mentioned,
should be diligently employed. I think I have seen cicuta
have very good effects in mending the discharge from
the ulcers, when joined with the bark.
When it will be safe to heal the ulcers, issues should al-
ways be introduced. Gentle compression has uncommonly
good consequences in sores of this kind.
CHAP. III.
SECT. I.
Of the Symptoms and Causes of White Swellings of the
Joints.
THE term white swelling has commonly been ap-
plied to such enlargements of the joints as are not
attended with discolouration of the integuments ; the only
symptoms which at first take place, being a greater or less
degree of swelling, with a deep seated pain. In the pro-
gress of the disease, however, inflammation affects all the
adjoining parts, as well external as internal; and when this
terminates in suppuration, it is not uncommon for openings
to be formed all around the diseased joints.
There seem to be two species of this disease, entirely
different in nature from each other. In the one, a cure is
often in part, and sometimes wholly obtained; whereas the
other is always beyond the reach of art.
Swellings 

[ 67 ]
Swellings of this kind occur more frequently in the
large than in the smaller joints; thus, at least twice as
many are met with in the knee and ancle joints, as in
all the rest of the body besides.
§ I. Of the Rheumatic species of White Swelling.
This disease begins with an acute pain, which seems to
be diffused over the whole joint, and frequently even ex-
tends along the tendinous expansions of the muscles. There
is from the beginning, an uniform swelling of the whole
surrounding teguments in greater or less degree; but is al-
ways so considerable as to occasion an evident difference
in point of size between the diseased, and the found joint of
the opposite side. A considerable tension generally prevails ;
but there is seldom, in this period of the disorder, any ex-
ternal discolouration.
The patient from the beginning, suffers much pain from,
the motion of the joint; and, finding it easiest in a relaxed
posture, keeps it generally bent , this often produces a rigi-
dity in all the flexor muscles, which is often afterwards
with difficulty removed. If the disease is not now carried
off, the swelling augments gradually; and has sometimes ac-
quired thrice the natural size of the part. The cuticular
veins become turgid and varicose : the limb below the tu-
mor decays considerably in its fleshy substance, at the same
time that it frequently acquires an equality in point of
thickness, by becoming œdematous ; the pain now begins to
be more intolerable, especially when the patient is warm;
and abscesses form in different parts of the swelling, and
run in various directions, but frequently without inter-com-
munication. In these a fluctuation is generally evident up-
on pressure.—These swellings have a peculiar elastic feel.
When the collections of matter have an opening formed
to them, they discharge at first a pretty good pus : this,
however,

[ 68 ]
however, soon degenerates into a thin fœtid ill-digested
sanies ; and has never any remarkable influence in reducing
the size of the swellings. If the sores are not kept open by
art, they soon heal up, and others are formed by collections
in different places; so that in some cases, the surrounding te-
guments are entirely covered with cicatrices remaining after
such ulcers.
Long before this period, the patient's health suffers con-
siderably ; first from the pain, which is often so violent as
to take away both sleep and appetite, and afterwards from
the absorption of the matter.
When the discharge of matter commences, the effects of
its absorption begin to appear ; these are quick pulse, night
sweats, and weakening diarrhœa, which generally at last
Carry off the patient, unless the disease is cured.
I have had several opportunities of examining limbs af-
fected with white swellings, that were amputated in very
early periods of the disease, on account of the intolerable
pain, and an apprehension of the complaints being incura-
ble. In all these instances the only morbid appearance,
was a preternatural thickness of the surrounding ligaments,
without any disease of the joint whatever. The degree of
this enlargement did not appear always proportionate to
the duration of the complaint. In an advanced stage, it
always was considerable ; and was generally attended by an
effusion of a thick glairy matter into the surrounding cel-
lular substance, which probably causes the peculiar elastic
feel of the swelling.
The different abscesses run in various directions through
this matter, without seeming to mix with it.—A great ma-
ny small hydatids are also observed in some instances, in dif-
ferent parts of the tumor—And, in the farther progress of
the disease, all these together form a confused mass.
All these appearances I have met with, without any con-
comitant affection of the bones of the joint. When the
complaint,

[ 69 ]
complaint, however, has continued very long, the ligaments
are destroyed by the acrimony of the matter, which in con-
sequence abrades the cartilages, and then renders the bones
carious. The tendons are neither enlarged nor hardened.
§ 2. Of the Symptoms of the Scrophulous White Swelling.
In this species the pain is generally more acute than in
the other; and instead of being diffused, is more confined
to a particular spot, most frequently to the middle of the
joint. The pained part appears sometimes to be no larger
than a dollar. The swelling is at first commonly very in-
considerable. The least motion gives pain; hence a con-
traction of the limb is at length produced as in the other
species. As the disease advances the pain and swelling in-
crease ; and an evident enlargement of the ends of the bones
takes place.
In process of time the tumor acquires the same elasticity
as occurs in the rheumatic species ; varicose veins appear—
abscesses are formed—On examination the bones are found
carious, and parts of them are discharged at the sores that
are produced.—By the farther continuance of the disease,
the constitution suffers in the same manner, as in the vari-
ety first described.
When joints are dissected in the first stages of the
disorder, the soft parts seem to be very little affected;
but in all that I have examined, there was constant-
ly observed an enlargement either of the whole ends
of the bones, or of their epiphyses; frequently of
those on one side of the joints only; but in some,
both bones have been diseased. This enlargement some-
times is the only morbid appearance; but generally,
and always in the advanced stages, the soft spongy parts
of such bones are found to be dissolved into a thin, fluid,
fœtid matter; and that in some cases without the cartilages
being much affected. These, however, are at length dis-
solved ; 

[ 70 ]
solved ; and then the different hard and soft parts inter-
mixing, exhibit an inconceivably confused mass.
In the advanced stage of the complaint the soft parts
are generally affected. The ligaments become thickened,
and the cellular membrane is filled with the same glairy
matter that is produced in the rheumatic white swelling.
§ 3. Of the Causes of White Swellings.
The causes of the rheumatic species may be, sprains that
particularly affect the ligaments of the joints, bruises, lux-
ations, and whatever can tend to produce inflammation of
the ligaments. A rheumatic diathesis or disposition is pro-
bably also a principal cause of this disease. For rheumatism
is known to attack particularly the ligaments, or other deep
seated membranes, and more especially affects the larger
joints—Hydarthrus or white swelling also occurs in the
same habits that are most subject to rheumatism, viz. the
young and plethoric.
That it is the ligaments that are first affected in this dis-
ease is evident from the history and dissections. From
these we may conclude, that this complaint is at first al-
ways occasioned by an inflammation of the ligaments of the
joints. And we may consider the different matters that
are formed, to depend on the difference of parts affected in
the course of the disease.
The other species of the disorder, from the symptoms
enumerated, and the appearances on dissection, seems evi-
dently to be originally an affection of the bones ; the soft
parts seeming only to suffer in the progress of the disease
from their connection with and vicinity to these. It sel-
dom is the consequence of any accident; and the patient
is seldom able to account for it.
This disease is generally attended with known symptoms
of scrophula; or the patient has had them at an earlier pe-
riod

[ 71 ]
riod of life, or at least is of scrophulous parents. From
these, and the above described circumstances, it is probable
the disorder is of a scrophulous nature.
SECT. II.
Of the Treatment of White Swellings.
In the rheumatic white swelling, as it is always at first
of an inflammatory nature, considerable advantages are ob-
tained in common, by the use of an antiphlogistic course.
The first remedy which should be employed is blood-let-
ting—This is most effectual if the blood is drawn immedi-
ately from the affected part, by cupping, performed on
each side of the joint. At least eight or ten ounces should,
if possible, be discharged at each time, and this should
be repeated according to circumstances. When a suffici-
ent quantity of blood cannot thus be obtained, leeches
should be had recourse to.
A small blister should be immediately applied on the an-
terior part of the joint; and the part afterwards kept run-
ning until the wounds from which the blood was dischar-
ged, are so far healed, that a vesicatory may be laid on
one side and as soon as this is nearly healed another should
be placed on the opposite side of the joint. By thus ap-
plying them alternately to each side, a constant stimulus is
kept up; which, in deep-seated inflammations, seems to
have a greater effect than the discharge produced from
them.
Cooling laxatives, at proper intervals, are also of use ;
and the patient should, in every respect, be kept upon a strict
antiphlogistic course. From an attention to all these cir-
cumstances the disease has frequently been removed.
The 

[ 72 ]
The inflammatory symptoms being mostly gone, and
while there are yet no appearances of the formation
of matter, mercury, not given so as to salivate, but merely
to affect the mouth gently and to keep it somewhat sore
for a few weeks, I have sometimes known of use. The
best form of employing it in this case is by way of unc-
tion—℥ij. of a weak mercurial ointment should be rubbed
into the part three times a-day; and as the friction maybe
very serviceable, it should be continued an hour each time.
By the French writers, falls of warm, and of cold water, on
swellings of this kind are much recommended. There is
the greatest reason to suppose, from the known relaxing
powers of moisture when joined with heat, that a proper
application, and particularly of warm emollient steams may
prove more useful than any other remedy. The friction
in the use both of warm and cold water has probably a
considerable influence; and the chief effect I think, can be
attributed to that only in the latter case. I have some-
times seen it employed with advantage.
Although by the use of these remedies, the disease is of-
ten entirely removed; yet, in many instances, when the
pain and swelling are chiefly or entirely gone, it frequently
happens, from the bent position in which the limb has been
kept, that the use of the joint is entirely lost, and it con-
tracts such a rigidity, that very great pain attends any at-
tempts to move it.
It has unfortunately happened that this contraction has
been generally attributed, either to an union of the ends of
the connected bones, or to an inspissation of the synovia;
both of which are incurable. But from dissections we
may confidently conclude, that except in the most advanced
state of the disease, the first does not occur in one case in
twenty ; and that it is very doubtful whether the last is
ever produced.
3 The 

[ 73 ]
The immobility of the joint is consequently to be consi-
dered as the effect of a contracted state of the flexor mus-
cles, and tendons; which, in several instances, some of
which were thought to be of the worst species of anchylo-
sis, I have seen totally removed by the application of emol-
lients. See chap; on Contractions of the Limbs.
After the formation of matter, no considerable advantages
Can be expected from any of the remedies we have above
recommended. In that case, the discharge of the collections
should be made as soon as possible, by the employment of
the seton—This can easily be effected, and sometimes has
been the means of saving many such diseased joints.
Amputation should never be had recourse to unless the
patient's constitution is so much reduced, that there would
be considerable risk from any farther delay.
When the disease has destroyed the ligaments, and per-
haps the cartilages and bones of the joint, amputation is
the only resource; See chap. on Amputation.
All the above remarks, relate particularly to the rheu-
matic white swelling. With respect to the more fatal spe-
cies, the scrophulous, we can offer nothing satisfactory.
When the small joints are affected, and the diseased parts
of the bones begin to cast off, a cure may be sometimes
promoted by assisting the efforts of nature; but in all the
larger joints, it is not probable that any other resource than
amputation will ever afford much relief. And even the ef-
fects of this can seldom be depended on as lasting; for
while the scrophulous taint subsists in the constitution, the
disorder will most probably appear again in some other
part. On account of the violence of the pain, it is how-
ever necessary sometimes to run the risk of this;
 When it does not appear adviseable to perform the ope-
ration, we must trust to palliatives. Of these, opiates in
large doses, by moderating the pain and procuring sleep,
are generally the most useful. The general remedies and
diet proper in scrophula, are also to be recommended.
K CHAP 

[ 74 ]
CHAP. IV.
Of Sutures.
THE intention of sutures, is to unite parts that have
been divided. The sutures in present use are dis-
tinguished into the true or bloody, and the false or dry.
The true sutures are the interrupted, the glovers, and the
twisted; these are performed by the needle. The union
of parts produced by the medium of adhesive plasters has
been termed the dry future.
SECT. I.
Of the Interrupted Suture.
This is the species of future that has generally been made
use of in deep wounds ; but we shall endeavour to make it
appear hereafter, that it is not so well adapted to such cases
as the twisted future.
In order to a proper retention of the parts, in forming
sutures in general, it has usually been considered necessary
to carry the needle to the bottom of the wound, so as to
give no room for the accumulation of matter; and this has
commonly been done by introducing it from without in-
wards, and then from the wound to the same distance on
the opposite side. But, the interrupted suture is more
neatly and easily performed, by passing both ends of the
thread from within outwards, by means of a needle fixed
on each. When they are carried through, the needles are to
be 

[ 75 ]
be removed, and the threads remain untied, until all that
are found necessary are passed.
The number of ligatures must depend chiefly on the ex-
tent of the divided parts. One suture has generally been
said to be sufficient for an inch of wound, but when mus-
cular parts are cut tranversely, a greater number in pro-
portion to the extent of the sore will be necessary. A li-
gature should be introduced at every angle of a wound,
however inconsiderable it may be.
In passing the ligatures it has been a rule to pierce the
skin at a distance from the edges of the wound equal to its
depth, in order to prevent them from cutting through the
parts. But it is very seldom proper to make the space more
than an inch, or less than half an inch. The form of the
crooked needle proper for forming the interrupted suture
is delineated in plate vii. fig. 6. The size of the needle, as
well as the strength of the ligature, must always be pro-,
portioned to the depth of the wound, and the retraction of
the parts. The ligatures ought nearly to fill eyes of the
needles; and in order to make them pass easily, to render
them durable, and easily susceptible of a flattened form,
by which they are less liable to cut through the contained
parts, they should be well waxed. While the surgeon is
tying the threads, the lips of the wound should be pressed
together by an assistant. The ends of the ligatures are
usually carried twice through the first noose, to prevent
them from slipping. This forms the surgeon's knot. The in-
sertion of lint beneath or between the knots, as recommend-
ed by some, prevents them from being well made, and has
little good effect. It is necessary to tie the threads imme-
diately above the wound, in order to give an equable sup-
port to each edge of it.
SECT.

[ 76 ]
SECT. II.
Of the Quilled Suture.
The quilled suture is formed by a quill, or piece of plas-
ter, rolled up into the form of a quill, and placed on each
side of a wound, one of which is included in the doubling
of the ligature, and the other is pressed by the knot.
This suture has been used in very deep wounds, and
supposed to give better support than ligatures alone, which
sometimes cut through the parts ; but it is evident that the
threads must make as great a pressure when the quills are
used, as when they are not; and consequently, that this spe-
cies of suture might with propriety be entirely laid aside,
SECT. III.
Of the Glover's Suture.
The glover's suture consists in a series of stitches connect-
ed with each other, and continued in an oblique spiral di-
rection along the course of the divided parts. The use of
this suture has been confined to wounds of the intestines:
but even these may be more perfectly united by the inter-
rupted future. See chap. on Wounds of the Intestines.
It will therefore follow, that the glover's stitch is en-
tirely unnecessary to a surgeon.
SECT. 

[ 77 ]
SECT. IV.
Of the Twisted Suture.
In making the twisted suture, we unite divided parts by
means of threads twisted around pins or needles pushed
through their edges. This suture has seldom been employed,
except in the hare-lip; but it is preferable to any other species
in all wounds that are not more than an inch and a half in
depth, because better calculated to retain the parts in contact.
In very deep wounds the interrupted suture must necessari-
ly be used, on account of the difficulty and pain that would
attend the introduction of pins to form the twisted suture.
The pins made use of for twisting the threads upon,
should be flat, as in plate ix. fig. 7.; as the whole pressure
falls upon them, and when thus made they are not so apt to
divide the parts as ligatures. Those usually employed are
of silver, with steel points ; but as gold pins are not so lia-
ble to acquire a crust by immersion in fluids, and require
no steel points, they should be preferred. They ought,
in general, to be from an inch to an inch and an half in
length, of a proportionate breadth, and have heads for
the fingers to press upon.
In performing this operation, the divided parts must be
brought nearly into contact by an assistant, leaving only such
a space as will allow the surgeon to see that the pins are car-
ried to a proper depth. A pin is then to be introduced on
one side externally, pushed inwards to within a little space of
the bottom of the wound, and carried through the opposite
side, to the same distance from its edge that it was made to
enter at on the other side. The distance at which the pin
should be entered from the edge must be determined by
the depth of the wound, and the degree of retraction of,
its sides, as in making the interrupted suture. If the pins
do 

[ 78 ]
do not pass easily, the instrument termed porte-aiguille
may be used to push them forward.
The first pin being thus passed very near one end of the
wound, and the parts still supported, a firm waxed
ligature should be carried three or four times around and
across it, so as to describe the figure of 8, and sufficiently
tight to draw the lips of the wound into close contact.
The thread should then be secured by a loose knot, and
another pin introduced. The ligature is now to be
loosened, and applied to this pin as directed for the first,
and others passed at proper distances, the whole length of
the wound, all being connected by the same ligature.
A pin should always be placed near each end of the
sore, to prevent the separation of its extremities. In large
wounds the pins should be three-quarters of an inch dis-
tant from each other; but in the smaller, a greater num-
ber in proportion to the extent of sore will be necessary.
When the sutures are all formed, the wound should be
covered by lint wet with mucilage, to exclude the external
air. The introduction of lint beneath the ends of the pins
has a tendency to make them cut the parts. When they
give uneasiness, a piece of thin linen spread with adhesive
plaster will be better. I have never known the appli-
cation of a bandage after this operation productive of
good effects, but have often seen it occasion troublesome
inflammation.
In general, the pins should be suffered to remain from
five to seven days, according to the depth of the wound.
But when the patient is unhealthy, a longer time may be
necessary*.
As
* In young healthy subjects the union is often completed in half
the time ; but perhaps the safest way is to leave the pins in the parts till
a small degree of digestion appears. 
 

[ 79 ] 
As soon as they are removed, a bandage may be used
with advantage, to support the newly-united parts. But
perhaps strips of leather spread with glue, applied to each
side of the cicatrix, and connected by ligatures, would be
preferable.
Of the dry suture we shall treat hereafter.
CHAP. V.
Of the Ligature of Arteries, and other artifi-
cial means of stopping Hemorrhagies.
IN every wound, the first circumstance to be attended
to is the hemorrhagy. This is either produced from
the large arteries, or by a general oozing from the smaller
vessels. In the first case, a temporary stoppage of the
discharge should be immediately attempted by com-
pression, until the permanent security of ligatures can
be obtained. In the head and trunk, the easiest method
of pressure is formed by lint or soft linen retained firmly on
the mouths of the vessels by the hand or a bandage; or if
the superior part of the vessels can be compressed it answers
better, as ligatures can then be applied with more ease.
When the wound is in the extremities, and compression
can be made on the superior part of the artery, it should
immediately be done by means of the tourniquet. Plate
iii. fig. 5.
Previous 

[ 80 ]
Previous to the application of the tourniquet, a cushion
three inches in length, and one and an half in breadth,
should be placed immediately above the principal
artery, and well secured by two turns of a roller. Over
this roller the strap of the tourniquet is to be firmly fix-
ed, the screw being on the side of the limb opposite to
the cushion : one turn of the screw is generally sufficient;
See plate and explanation.
As the ancients were ignorant of the use of the tourniquet
and of ligatures, they endeavoured to remove hemorrha-
gies by applying actual cauteries or hot irons to the large
vessels, and lint covered with styptic powders, to the
smaller. But these often failed. Even lately, agaric, cha-
lybeate solutions, and the mineral acids have been much
recommended. These in many cases do not produce the
desired effect. When ligatures can be well applied, they
invariably succeed; and in the larger vessels should alone
be depended on.
Various methods have been used for tying arteries;
The common practice at present is, by means of a curved
needle to pass a ligature of sufficient strength around the
mouth of the vessel, including a quarter of an inch of the
contiguous parts : but, as tying the nerves and muscles often
produces not only partial but general spasms, and always
a great deal of pain, it is adviseable to include the artery
only in the ligature, by employing forceps, or rather the te-
naculum, Plate vii. fig. 5. In very deep wounds the
needle may be necessary; but such cases rarely occur. Ex-
perience from repeated comparative trials has convinced
me, that the mode recommended is as secure as that by the
needle; and when it is used the ligatures come away much
sooner, generally at the third or fourth dressing; which is
often of very great advantage. I have seen instances of
the ligatures remaining for weeks when the needle was
employed, and some cases in which they were at last cut
away by the surgeon,
3 The 

[ 81 ]
The forceps do not answer well in tying small arteries ;
they might therefore, with propriety, be entirely laid
aside, as the tenaculum or hook is equally applicable to the
large and small arteries. The manner of using it is as fol-
lows:
In order to detect the arteries to be tied, the tourniquet
must be loosened, and as soon as the largest artery is dis-
covered, the surgeon fixes his eye upon it, and immediate-
ly again tightens the tourniquet. An assistant then forms a
noose in the ligature, and placing it over the end of the ves-
sel, the operator pushes the point of the tenaculum thro'
the sides of the vessel, and pulls as much of it out as he
thinks should be included in the surgeon's knot now to be
made by the assistant. For greater security a second knot
should also be formed. In making the knots, a very small
addition to the force requisite for restraining the hemorr-
hagy, is sufficient.
In this manner all the arteries that can be distinguished
should be secured: For fatal hemorrhagies have some-
times been produced from very inconsiderable vessels,
when the patient has become warm in bed. Loss of blood,
fear, or cold, often occasion such a retraction of the smal-
ler arteries, that it is difficult to detect them :—To ef-
fect this, the tourniquet should be loosened, and, the wound
well washed with a sponge and warm water; and if the
patient is faintish, a glass of wine or some other cordial
should be given.
As in some instances we are unable to tie arteries by
means of the tenaculum, we should be provided with nee-
dles of various forms and sizes. Those used in forming
the interrupted future are very well adapted to the tying
of arteries. In using the needle, it should be introduced,
armed with a ligature, at the distance of a sixth or eighth
of an inch from the artery, pushed to a depth sufficient for
retaining the thread, and carried one half round the vessel.
L It

[ 82 ]
It must now be withdrawn, and being again pushed for-
ward till it has encircled the mouth of the artery, is then
to be pulled out, and a knot formed on the ligature as al-
ready directed.
Hemorrhagies to an alarming degree are frequently pro-
duced in extensive wounds by a general oozing from the
surface of the sore; and sometimes it is with difficulty they
are suppressed. They seem to proceed from two very dif-
ferent circumstances : 1st. In robust habits, either from too
great a quantity of blood, an excess of tone in the vessels,
or a combination of both ; or 2dly. And more frequent-
ly, in relaxed debilitated habits, from a dissolved state of the
blood, a want of tone in the vessels, or a concurrence of
both these.
In healthy constitutions, the discharge of blood from the
smaller vessels of wounded parts is commonly soon remo-
ved by the contraction of these vessels, and the discharge
of a glutinous fluid from them, which is diffused over the
surface of the wound : But when it continues in such de-
gree as to shew a morbid state, it is to be attributed to one
of the causes abovementioned. In robust habits relief is
to be obtained by opening a vein; or perhaps more ef-
fectually by untying one of the principal arteries of the
part and suffering it to discharge freely; by keeping the
patient cool; giving him cold acidulated drinks ; obliging
him to avoid motion, particularly of the part; covering
the wound with lint; and by applying a bandage over
it. In all these cases, and particularly when violent spas-
modic affections supervene, a large dose of opium is one of
the most effectual remedies, and should be exhibited as
soon as the patient has been bled and put to bed. When
we have reason to suppose the disease is supported by the
second set of causes mentioned, a generous diet, and a free
use of Port, Madeira, or other good wines, should be al-
lowed ;  

[ 83 ]
lowed; the patient should be kept cool; mineral acids,
particularly the vitriolic, must be given; rest of body en-
joined ; and opiates, to obviate pain or spasm, liberally ad-
ministered.
Together with these general remedies, particular dres-
sings, adapted to the state of the system, should be applied.
Dusting the parts with starch or wheat flour, or gum arabic
in fine powder, has been useful in all states of the body, but
particularly in that of debility. In this case, lint moisten-
ed with tincture of myrrh, traumatic balsam, and other sti-
mulating applications, are very serviceable. When these
do not prove effectual, an equable pressure by a bandage,
or the hand applied over the dressing, will seldom fail*.
* This last mode of pressure is much the best, and has succeeded in
some aneurisms, where it could be made immediately upon the orifice of
the wounded artery.
CHAP. 

[ 84 ]
CHAP. VI.
Of Blood-letting.
SECT. 1.
Of Blood-letting in general.
IN all general affections where blood-letting is consider-
ed necessary, the blood is discharged by an opening
made in an artery or vein. The former operation is cal-
led arteriotomy; the latter phlebotomy. In local affections,
particular benefit is often afforded by dividing a number
of the smaller vessels of the part diseased; this is termed
topical bleeding.
We shall first consider phlebotomy. The choice of a vein
in this operation, must be determined by the particular
circumstances of the patient. The veins from which
blood is usually drawn, are those of the arm at the
flexure of the cubitus or fore arm, the jugular veins, and
those of the ankles and feet. On certain occasions, blood
is also taken from the veins of the hands, tongue, and
other parts.
In blood-letting in general, as the position of the pati-
ent has some influence on the effects of the operation, it
should be precisely fixed. When fainting is likely to be
induced, and we do not wish to risk it, an horizontal pos-
ture is to be preferred ; but if we expect advantages from
the fainting, the patient should be placed erect. The part
to  

[ 85 ]
to be operated upon should be so situated, as that the
principal light of the apartment may fall directly up-
on it: and the surgeon ought always to be seated; as he
will then bleed with much more steadiness and nicety than
if he stands*. When the patient is properly fixed, a ban-
dage should be applied to the member to be operated upon,
to produce an accumulation of blood in the veins ; but not
so tight as to obstruct its passage in the corresponding ar-
teries.
Various instruments have been invented to bleed with;
but there are only two now in, use; the lancet and the
phleme.
The phleme is placed immediately on the part to be
cut, and by means of a spring is struck suddenly into the
vein. Its inconveniencies are, that we must regulate the
depth to which it is to go, before we apply it; on which
account, if the vein lies deeper than supposed, we may
not reach it; and there is danger of its wounding arteries,
or other parts beneath the vein, if should go too far †.
These disadvantages do not attend the use of the lancet,
and therefore it certainly ought to be preferred.
The lancet should be spear-pointed-—it then enters
the integuments with little pain ; and forms an opening in
them very little larger than the orifice in the vein, which
renders it an easy matter to stop the discharge.—These ad-
vantages are not derived from the broad-shouldered lan-
cet in common use.
The ligature having been made for a short time to pro-
duce some swelling in the veins, that vein is to be selected
which
* This depends upon habit-—those accustomed to operate standing
wiil perform with more ease to themselves, than if they were seated.
† Notwithstanding these obvious objections, the phleme is very uni-
versally used here, among the bleeders, in preference to the lancet; and
even some medical practitioners employ it. I have very seldom heard of
any material bad effects from its use-—never but of one case of aneu-
rism.

[ 86 ]
which rolls less than the others on being pressed with the
finger, even if it should be somewhat deeper than those
near it-—Veins that lie contiguous to arteries and tendons
should, if possible, be avoided; although a dextrous ope-
rator may often open them with perfect safety.
When a vein is made choice of, the surgeon, if he is to
use the right hand, grasps firmly the member, an inch and
an half below the part to be operated upon with his left,
and makes such a pressure on the vein, with the thumb, as
will interrupt the communication between the inferior part
of it, and the part above the thumb, and will render the
teguments somewhat tense. The lancet being bent to ra-
ther more than right angles, is then to be taken between
the thumb and fore-finger of the right-hand of the opera-
tor, and leaving one half of the blade uncovered, he rests
his hand on the remaining fingers, and then pushes the
point of the lancet into the vein, and carries it forward in an
oblique direction, until the orifice is sufficiently large. The
point ought neither to be raised nor depressed, lest it should
wound parts unnecessarily. The instrument is now to be
withdrawn, and the left hand removed as soon as the cup
for receiving the blood is applied. While the blood is
flowing, the member should be kept in the position it had
when the incision was made; otherwise the skin may slip
over the orifice in the vein, obstruct the discharge, and
produce ecchymosis;
If the wound is made longitudinally, it does not admit
of a free discharge; and if across the vein, it is difficult to
heal. The size of the orifice must depend on the circum-
stances of the disease for which the bleeding was ordered.
In general, when the spear-pointed lancet is used, an
eighth of an inch will be sufficiently large; but when we
employ the common lancet, a quarter of an inch will not
be too much.
It 

[ 87 ]
It sometimes happens that the blood is not freely dischar-
ged, either from faintishness, or from the opening in the
skin receding from that in the vein. In the first case,
it will be proper to admit a stream of air into the apart-
ment, to give some wine or other cordial, and have the pa-
tient placed in a horizontal posture. If the blood does
not then flow as we wish it, the part should be put into a
variety of positions, the muscles should be thrown into ac-
tion by moving something in the hand, if the arm is ope-
rated upon; and if the pulse is feeble in the inferior part
of the member, we should loosen the ligature.
As soon as a sufficiency of blood is drawn, the com-
pression should be taken off, and if the discharge does not
then cease, the thumb should be applied above, and the
fore-finger below the orifice, and it being well washed and
cleared of blood, its sides should be brought exactly to-
gether, and there retained by a strip of adhesive plaster.
This will generally be sufficient; if it is not, it will be pro-
per to apply a linen compress over the plaster, and secure
both with a roller.
The wound will commonly heal by the first intention,
or without the formation of pus ; but troublesome conse-
quences sometimes ensue. Of these the most material are
thrombus or ecchymosis ; wounds of arteries, nerves, or
tendons contiguous to the vein ; and inflammation of the
internal coat of the vein operated upon.
SECT. II.
Of a Thrombus or Ecchymosis.
A thrombus is a small round tumor produced by extra-
vasated blood insinuating itself into the cellular membrane.
When this swelling is more diffused it is termed an ecchy-
mosis  

[ 88 ]
mosis. In bleeding, it is commonly induced by the orifice
in the skin receding from that in the vein. Immediately
on the appearance of such swellings the ligature should be
removed, and again applied, as soon as the limb is brought
into the position it had during the operation. Should not
this succeed in dispersing the tumor, or at least in pro-
curing a free discharge of blood, the ligature must again
be taken off; and if the necessary quantity of blood has
not been drawn, another vein should be opened.
These swellings in general go off of themselves ; but if
they do not, they may often be dispersed by the applica-
tion of compresses wet with brandy, or a solution of sal
ammoniac in vinegar. If these have not the desired effect,
the tumor should be laid open, the blood taken out, and
the wound then healed in the usual mode.
SECT. III.
Of Wounds of the Arteries.
The only certain method of knowing whether an ar-
tery is wounded through the vein, in bleeding, is to com-
press the vein above and below the orifice; if the artery is
wounded, the discharge will then continue, or be increased;
if it is not, it will cease. The flow of blood being per
saltum, is a fallacious criterion, because it may happen from
a vein lying immediately above an artery.
As soon as we are certain of an artery being thus wound-
ed, as much blood should be suffered to flow as the state
of the body will admit of, and the wound should then be
closed by adhesive plaster ; rest should be enjoined, and
the body kept cool; gentle purgatives must be given, and
blood-letting repeated occasionally. By these means, the
system will be relaxed, and we shall have some chance of
3 healing 

[ 89 ]
healing the wound. If this is not accomplished, the effusi-
on of blood forms a species of aneurism.
It has been the common practice in wounds of the ar-
teries, to apply immediate and strong compression, by
means of compresses and bandages ; but it is evident that
this, from the obstruction it gives to the passage of the
blood, according to its degree, must either increase the he-
morrhagy by producing an increased action in the artery,
or cause a gangrene in the parts below.
SECT. IV.
Of Wounds in the Nerves and Tendons from Bleeding.
These accidents arise from carrying the lancet through
the back part of the vein; and may be avoided by keep-
ing the point of the instrument in a straight direction*, in-
stead of depressing it after it has entered the cavity of the
vein.
If immediately on the introduction of the lancet the pa-
tient complains of exquisite pain, we may rest assured that
either a nerve or tendon has been wounded.
In some cases, by proper management, the pain will gradu-
ally go off entirely without any bad consequence whatever.
At other times, however, the pain soon increases, a small
degree of swelling takes place; the lips of the sore become
somewhat hard and inflamed; and in the course of about
twenty-four hours from the operation, a thin watery serum
begins to be discharged at the orifice.
If relief is not soon obtained, these symptoms generally
continue nearly in the same state for two or three days
longer. At this time, the pain becomes greater, and in-
M stead
* See Section I.

[ 90 ]
stead of being acute as before, is now attended with a burn-
ing heat, which gradually augmenting proves, during the
whole course of the disease, exceedingly distressing. The
fullness and hardness in the lips of the wound begin to in-
crease, and the swelling by degrees extends over the whole
member ; from the foot, if the operation has been perform-
ed there, over the whole lower extremity; and from the
elbow, if the bleeding has been done in the arm, down
the fore-arm, and along the humerus over the pectoral
muscle and other contiguous parts.
The parts at last become exceedingly hard and tense;
an erysipelas frequently appears over the whole member;
the pulse becomes generally very hard and quick; the
pain intense, and the patient very restless ; twitchings of
the tendons occur, on some occasions, a locked jaw and
other convulsive affections supervene; and all these symp-
toms continuing to increase, it most frequently happens
that the sufferings of the patient are only terminated by
death.—All the instances of accidents of this kind that
I have seen have ended fatally.
By some, the symptoms we have enumerated have
been attributed to wounds of the tendons ; others sup-
posing tendons to be destitute of sensibility, have im-
puted them, in all cases, to wounds of the nerves: And
Mr Hunter of London, is entirely convinced that they
are the consequence of an inflammation of the internal
coat of the vein operated upon—He has traced this
inflammation in horses, and even in the human sub-
ject, to a considerable extent in the vein, and in some in-
stances, even to the heart. The matter formed in conse-
quence, Mr Hunter supposes to produce death, by being
carried to the heart in the course of the circulation. But
although there can be no doubt that this inflamed
state of the vein may often occur, yet we are clearly of opi-
nion, that the violent pain experienced immediately af-
ter 

[ 91 ]
ter the puncture, cannot be occasioned by the wound of
the vein; and that the inflammation of its internal surface
ought rather to be considered as symptomatic of the pre-
vious affection of a nerve or tendon, than as the sole and
primary cause of the symptoms which we have above de-
scribed as consequent to bleeding.
In order to obviate the usual consequences of this acci-
dent, a considerable quantity of blood should be immedi-
ately discharged at the orifice, the limb should be kept
perfectly at rest, for some days, care being at the same
time taken that the muscles of the part be all preserved in
as relaxed a state as possible; the patient should be kept
cool, and on a low diet; and if necessary, laxatives should
be administered.
By this treatment, we may frequently prevent all bad
symptoms ; and when these do occur, from injudicious
management, they prove fatal as much from negligence
in the subsequent treatment, as from any thing peculiarly
bad in the nature of the accident.
When, however, notwithstanding the employment of
the means recommended, the lips of the wound grow
hard and inflamed, the pain increases, and especially if the
swelling becomes more considerable, we must have re-
course to other remedies. Topical bleeding, by leeches
applied as near as possible to the lips of the wound, fre-
quently affords much relief: and when the pulse is full and
quick, it is necessary to employ general bleeding to a very
considerable extent.
As applications to the part, warm emollient poultices
and fomentations have been strongly recommended. I
have used them; but never with good effect—-And it is
probable, that as the membranous parts affected are in-
capable of yielding a good pus, to produce which, has
been the object of their use, they prove hurtful by the
heat they communicate.
By 

[ 92 ]
By Heister and others, instead of emollients, oil of tur-
pentine, tincture of myrrh, and other heating applications
are advised. But suspecting that they would increase the
symptoms, by irritating parts rendered already exquisitely
sensible by disease, I have never employed them.
I can, however, from repeated experience assert, that
cooling astringents, and particularly the saturnine pre-
parations, afford much more ease and effectual relief than
warm emollients. In all such cases, therefore, immediately
after bleeding, the swelling ought to be covered with soft
linen moistened with the saturnine solution ; and this being
kept constantly wet for a few hours, the part should then
be covered by pledgits spread with the saturnine or Gou-
lard's cerate. These preparations should be alternately
used till the tumor entirely subsides.
The febrile symptoms must be moderated by keeping the
patient cool; on a low diet; preserving a lax state of the
bowels; and if necessary, by repeating blood-letting.
For the violence of the pain, which often prevents the
patient altogether from sleeping, opiates should be freely
exhibited; and when twitches of the tendons and other
convulsive symptoms occur, medicines of this kind become
still more necessary; but it is to be observed that unless
they are given in large doses, they certainly aggravate in-
stead of hastening the disease.
When every thing we have advised proves ineffectual,
and the life of the patient appears to be in imminent danger,
the only remedy from which much advantage is to be ex-
pected, is a free and extensive division of the parts in which
the orifice producing the mischief was at first made.
In performing this operation, in order to prevent an in-
convenient discharge of blood from the smaller vessels, or
a dangerous hemorrhagy from the larger, it will be necessa-
ry to have a tourniquet applied on the superior part of the
limb. When this is done, a large transverse incision should
be 

[ 93 ]
be made through the teguments of the parts chiefly affec-
ted, and carried across the original orifice in the vein.
The surgeon must then, by cautious dissection, wiping the
blood away frequently with a sponge, and avoiding the ten-
dons, larger arteries, and veins, endeavour to discover the
the wounded nerve; if he cannot accomplish this, he
should still continue the incisions till he gets to the perios-
teum. The tourniquet should then be loosened; and if the
wounded part has been divided, the pain will cease. If the
pain continues, the adjacent tendons, and particularly that
which lies beneath the vein, should be accurately examined;
and the one in which a wound or inflammation is disco-
vered should be entirely divided. If neither wound or
inflammation appears, the tendon which lies most conti-
guous to the vein should be cut through; and if one or
two others should be liable to suspicion from their situa-
tion, we should not hesitate to divide them all. When
this is done, it seldom happens that relief is not immediate-
ly derived from it.
The tourniquet must now be slackened as much as
possible, and such arteries as have been wounded must be
secured. The parts are then to be covered with soft easy
dressings, and the wound is to be treated as in other cases.
The mode of treatment here recommended, I have seen
practised with the greatest success.
SECT. V.
Of Blood-letting in the Arm.
It appears to me, that the fixing on the sore part of the
arm at the elbow, as the usual place for blood-letting, is a very
capital error, on account of the risk we run of wounding the
nerves, tendons, and arteries contiguous to the veins; and
especially 

[ 94 ]
especially as it can be performed with equal ease, and with
much less danger, in the neck, the lower part of the legs,
the ankle, and the feet. The only reason that can be given
for the practice is, that the veins appear here more con-
spicuous than in other places.
In applying the ligature previous to bleeding in the arm,
we should place it about an inch or an inch and a half a-
bove the joint of the elbow, and the knots should be made
on the outside of the arm, that they may not interfere with
the lancet.
As the median basilic vein appears in general more con-
spicuous than any of the rest, and is less covered with cel-
lular substance and the tendinous expansion of the biceps
muscle, it should be preferred. The incision also gives
less pain on account of these circumstances.
The operation is more neatly performed, if the right
hand is used in bleeding in the right arm, and the left in
the left arm of the patient, than if the right hand is used
in both cases.
In very corpulent people, it sometimes happens that
the larger veins cannot be seen; but when they can be
sensibly felt, they may be opened with perfect safety. In
some cases again, the veins of the arm can neither be
seen nor felt. The ligature may then be applied to the
middle of the fore-arm, and a vein of the wrist or back of
the hand, may generally be opened with ease.
SECT. VI.
Of Blood-letting in the Jugular Vein.
THIS operation is sometimes judged necessary in inflam-
mations of the throat, disorders of the eyes, and other af-
fections of the head.
There


[ 95 ]
There is no branch of the external jugular vein that
can be opened with propriety, but its principal posterior-
ramification ; and even this lies so deep, that a consi-
derable degree of pressure is necessary to bring it well
into view. In order to produce this, it is commonly ad-
vised to place the thumb upon the vein, about an inch or
an inch and an half below where the opening is to be
made. This, however, is seldom sufficient; for the blood
on being stopped in this branch, passes off by others com-
municating with it: so that unless the vein on the other
side of the neck is also compressed, the vein to be opened
can never be fully distended. In order to do this, a com-
press should be applied over it, and a ligature carried above
this, and knotted under the opposite arm-pit.
The patient's head being supported, the operator should
then make a firm pressure on the vein with his thumb, and
with a lancet penetrate at once into the vessel, making an
opening somewhat larger than that advised in bleeding in
the arm, on account of the greater difficulty of procuring
a sufficient quantity of blood. Adhesive plaster alone
commonly restrains the discharge.
It has been directed to make an incision down to the
vein with a scalpel, and to use the lancet merely for opening
the vein ; but this precaution is entirely unnecessary, and
sometimes may injure the operator in the opinion of the pa-
tient.
SECT. VII.
Of Blood-letting in the Ankles and Feet.
IN these cases, the ligature being applied just above the
the ankle joint, all the branches of the vena saphena, both
in the inside and outside of the foot, generally come into
view; and wherever a proper vein appears, it may be o-
pened with safety.
The


[ 96 ]
The use of warm water prevents us from ascertaining
the quantity of blood discharged, and is perfectly unne-
cessary.
The bleeding generally ceases immediately on the remo-
val of the ligature, so that nothing more than a strip of
adhesive plaster is necessary to be applied to the wound.
WHEN it is found necessary to discharge blood from
the penis, the veins can easily be brought into view by the
application of a ligature ; but in the tongue, in the exter-
ternal hemorrhoidal veins, and other parts where compres-
sion cannot be applied, all that the surgeon can do, is to
make an orifice in the most evident part of the vein, and
if a sufficient discharge is not thus produced, to immerse
the parts in warm water, where this is practicable.
SECT. VIII.
Of Arteriotomy.
ARTERIOTOMY seems hardly in any case, to have better
effects than opening a vein ; and is always attended with
much hazard, notwithstanding what has been said by
theorists to the contrary, when practised on the larger
vessels. The different branches of the temporal artery
are those only from which blood is taken in ordinary
practice; but any of the small arteries that  lie superficial,
or contiguous to bones, and admit easily of compression,
might be opened with perfect safety ; as those of the fin-
gers at the middle of the last phalanx. The opening may
be made as in common phlebotomy ; but if the artery is
deeply covered with cellular substance, it will be necessary to
expose
I

[ 97 ]
expose it to view by the scalpel, before making the orifice
with the lancet; for if the vessel should be entirely divi-
ded, it would retract and put a stop to the evacuation.
If the blood should not flow freely, it will be pro-
per to compress the artery immediately above the orifice:
And when a sufficient quantity is obtained, we may com-
monly restrain the evacuation by applying a compress and
roller as directed in venæsection.
If this does not flop the discharge, it may with tolera-
ble certainty be suppressed, either by cutting the artery
entirely across at the orifice; by taking it up with a needle
and ligature; or by obliterating its cavity by a gradual and
constant compression. For this last purpose, a small semi-
circular strip of steel covered with leather, to reach from
temple to temple, with a compress of linen, answers much
better than a common bandage.
SECT. IX.
Of Topical Blood-letting.
TOPICAL bleeding is performed either by means of
leeches; by flight scarifications with the shoulder or edge
of a lancet; or by the instrument termed a scarificator.
When the last mode is employed, it is necessary, in order to
produce a sufficient discharge of blood, to apply cupping
glasses over the divided parts. These promote the evacu-
ation by having the air contained in them rarefied immedi-
ately previous to their application.
With a view to produce this rarefaction and consequent
suction, heat is now usually applied to the cavity of the
glass, either by supporting the mouth of it for a few
seconds above the flame of a taper, or by throwing in-
to it a piece of bibulous paper impregnated with spirits of
N wine


[ 98 ]
wine, and set on fire. The last is the easiest and best
mode—by the former we are very apt to crack the glass if
the flame be suffered to touch it. The cup should be ap-
plied directly upon the part, when the paper is nearly
extinguished.
As soon as this is done, the scarifications, if well made,
begin to discharge freely ; and as soon as the glass is near-
ly full of blood, it should be taken away; which may be
easily done by raising one side of it. When more blood
is wished to be taken, the parts should be bathed in warm
water, then dryed, and another glass exactly of the size
of the former, instantly applied—and thus, if the scarifica-
tions have been sufficiently deep, almost any necessary
quantity of blood may be drawn ; but when this cannot
be obtained from one operation, the trial should be repeat-
ed, as near as possible to the parts already cut.
When it is wished to discharge the blood as quickly
as possible, two or more cups may be applied at once,
and previous to the scarifications, for a few seconds, as well
as afterwards.—The wounds made by the scarificator
should be well cleared of blood, and dressed with soft
linen or lint dipped in milk or cream.
Dry cupping consists in the mere application of the
glasses, without any scarification. This may be very useful
where we wish to determine a quantity of blood to a par-
ticular spot.
When cupping cannot be used, we generally have re-
course to leeches for the topical evacuation of blood. In
order to make these animals fix on a particular spot, they
should be suffered to creep upon a dry cloth or board for
a few minutes previous to their application ;-the part
should be moistened with milk, cream or blood :-and they
should be confined to it by a small wine glass. As soon as
the leeches have separated, the bleeding is in common
promoted


[ 99 ]
promoted  by covering the parts with linen wet with
warm water; but the application of cupping glasses an-
swers the purpose much better.
Scarification with the edge or shoulders of a lancet is
sometimes necessary, and particularly in inflammations of
of the eye-ball, where it often proves a very effectual re-
medy.
In performing this operation, the upper eye-lid being
supported by an assistant, and the lower by the left hand of
the surgeon, a number of slight scarifications should be
made through the vessels that seem most turgid on the tu-
nica conjunctiva. The eye should then be bathed in
warm water to encourage the discharge.
It has been recommended to use a speculum in order
to keep the eye steady; but this  is totally unnecessary,
and by its pressure it may perhaps be injurious.
The beards of barley, drawn over the surface of the eye
in a direction contrary to their spiculæ, have been much
extolled to produce a discharge of blood—but this gives
such exquisite pain that it is now going out of use.
CHAP. 

[ 100 ]
CHAP. VII.
Of Aneurisms.
SECT. I.
General Remarks on Aneurisms.
ANEURISMS are tumors formed either by the dila-
tation of the coats of arteries; or by blood effused
from arteries into the contiguous parts. The first species
has usually been denominated the true aneurism ; but it
may with greater propriety be called the encysted. The lat-
ter species has been generally termed the false ; but from
its appearances, I think it ought to have the appellation
of the diffused aneurism.
In the true or encysted aneurism, when externally situ-
ated, the tumor, when first observed, is commonly very
small and circumscribed ; the skin retains its natural ap-
pearance ; when pressed with the fingers, a pulsation
corresponding with that of the artery below is evidently
distinguished; and with very little force, the tumor may
be made to disappear entirely. If it is not removed when
in this state, after some time the swelling gradually in-
creases, and becomes more prominent; but the skin for
a considerable time retains its natural appearance. The
tumor is not painful, even on pressure ; continues of an
equal softness ; and its contents may generally still be
made to disappear by pressure. At length, when the
swelling


[ 101 ]
swelling becomes very large, the skin grows pale, and in
the more advanced stage of the disease, œdematous ; the
pulsation still continues ; but the tumor, now in some parts
soft, in others hard, does not yield much to pressure.
The swelling continuing to increase, becomes gradually
exceedingly painful; the skin turns livid, apparently verg-
ing to a gangrenous state; at last a bloody serum oozes
from the teguments ; and if a mortification does not take
place, the skin cracks in different parts, and the blood
bursts forth from the artery. In the large vessels of the
trunk, this generally produces almost instant death ;  but
in the extremities, the hemorrhagy may be restrained by
the tourniquet.
In aneurisms of the larger arteries, the contiguous parts
suffer considerably. The bones appear to be particularly
affected; and in different cases are much deranged, and
sometimes entirely dissolved. These consequences have
even occurred in the thigh and arm.
Various causes may be supposed necessary to the pro-
duction of encysted aneurisms.
1. As we know of no reason why partial debility should
not occur in arteries as well as in other parts, we
may consider this as one of the most frequent causes of the
disease, when it cannot be traced to any external accident;
as is commonly the case in aneurisms of the aorta, and o-
ther internal arteries. And when weakness is produced in
the smallest degree, a dilatation must necessarily follow,
and be constantly increased, from the action of the blood.
2. The external coat of an artery being destroyed by a
wound, the inner tunic will be incapable of resisting the
impulse of the blood; and thus  an aneurism will be rea-
dily induced. Such cases are most frequently produced
by blood-letting in the arm.
3. The external coat of an artery is sometimes destroy-
ed


[ 102 ]
ed by the matter of abscesses and ulcers, and occasions
aneurismal swellings in the manner just explained above.
4. As arteries receive, in many situations, considerable
support from the adjoining parts, aneurisms may be pro-
duced from a removal of these parts. This appeared to
be the only cause of several aneurismatic tumors that oc-
curred in a case of gangrene which destroyed a part of
the thigh.
5. In blood-letting in the arm, it sometimes happens
that the artery is wounded through the vein when it lies
in contact: with it; a communication being thus formed,
the arterial blood, by its impetus, produces a dilatation of
the coats of the vein, and thus forms what has been term-
ed the varicose aneurism. This may with propriety be
considered as encysted, because the blood is confined to
the cavity of the vein. Soon after the injury, the vein
communicating with the wounded artery, begins to swell,
and gradually acquires a large size ; and when any consi-
derable anastomosis occurs near to the part affected, be-
tween it and the contiguous veins, these also become
much enlarged. By pressing upon the swelling, it may be
made to disappear entirely ; and if it is of considerable
size, the blood on being forced out of it, makes a very
singular, hissing kind of noise. This, when it occurs, is a
very characteristic symptom; but it is not always met with.
There is a very singular tremulous motion discovered in
the dilated vein, attended with a perpetual hissing noise,
as if air was passing into it through a small aperture. If
a ligature be applied immediately below the swelling, and
made so tight as even to stop the pulsation in the limb, the
swelling in the veins does not seem affected, and when
removed by pressure, instantaneously returns on the pressure
being taken off. If the swelling is removed, and a slight
pressure be made on the orifice in the artery by the point
of the finger, the veins will remain perfectly flaccid, until
the


[ 103 ]
the removal of the compression from the orifice ; and this
happens even if the circulation in the artery is not entire-
ly obstructed below.
In the same manner, if the artery be compressed above
the orifice, so as to stop the passage of the blood, that tre-
mulous motion and hissing noise in the swelling ceases in-
stantly; and if the veins are now emptied as before, they
will remain so until the pressure upon the artery is remov-
ed. In some instances, it happens that if a ligature be
applied an inch or two above the swelling, and another as
much below it, so tight as to prevent the circulation in the
tumor, by compression, all the blood contained in it may
be made to pass into the artery; from whence it imme-
diately returns on the pressure being removed.
When this disease has continued for any length of
time, and the swelling has become considerable, the trunk
of the artery above the orifice generally grows preterna-
turally large, while the branches below become propor-
tionably small. Hence the pulse in the inferior part of
the member is always more feeble than that in the sound
limb.
The diminution of the branches of the artery may be
readily accounted for from the direct passage of so great a
part of the arterial blood from the trunk into the corre-
sponding vein ; but no satisfactory reason has  yet been gi-
ven for the enlargement of the artery above the swelling.
The diffused or false aneurism occurs in various parts
of the body; but we shall here confine our description to
that species which we know to be most frequently occa-
sioned by a wound made directly into an artery, and
which it is commonly in the power of art to relieve.
This disease is frequently produced by a wound of the
artery in blood-letting in the arm; and indeed when
the artery is thus wounded, an aneurism is almost always
the


[ 104 ]
the consequence. The following is the usual progress pf
the complaint.
A small tumor, about the size of a horse-bean, gene-
rally rises just at the orifice in the artery, soon after the
discharge of blood has been stopped : at first it is soft,
has a strong pulsation, and yields a little upon pressure ;
but it soon acquires a firm consistence by the coagulation
of the contained blood.
If the swelling is not now improperly treated by com-
pression, it generally remains nearly of the same size for
several weeks, when it begins gradually to increase ; and if
seated in the usual place of blood-letting in the arm, it pro-
ceeds rather farther up than the orifice, and extends more
inwardly than towards the outer part of the arm, probably
on account of the expansion of the biceps muscle being there
less firm than in the external and under part. The enlarge-
ment of the tumor proceeds with much more quickness,
and is much more diffused in some instances than in o-
thers; this seems to depend chiefly on the degree of lax-
ity of the parts into which the blood is effused. Thus, in
some instances, swellings of this kind have been many
months, and even years in arriving at any considerable
size ; whilst in others the blood has been diffused over the
whole arm, from the elbow to the shoulder, in the course
of a few hours after the artery was wounded.
I am convinced that the compression commonly advised
in wounds of the arteries, has also a considerable influ-
ence in producing a diffusion of the blood. If the pressure
could be applied over the orifice alone, it might be advan-
tageous ; but by every mode yet recommended, the refluent
blood is much obstructed in its passage; and this must
evidently distend the wounded artery in an equal propor-
tion, and increase the quantity of blood which escapes by
the orifice.
3 When


[ 105 ]
When compression has not been applied to such tumors,
unless there is a very unusual degree of laxity in the sur-
rounding parts, the swelling increases in a gradual man-
ner ; but it does not become much more prominent,
rather diffusing itself among the adjacent parts; by de-
grees it acquires a very firm consistence; and the pulsa-
tion, which was at first considerable, always diminishes in
proportion to the hardness and size of the tumor, inso-
much that it is sometimes scarcely perceptible.
In the first stages, if the blood thrown out lies very
deep, the skin preserves its natural appearance, and does
not change its colour till the disorder is much advanced.
It frequently happens however, that the blood is thrown
out at first with such violence, as to get into immediate
contact with the skin, and change it to a livid colour;
and in some instances, either from the quantity extrava-
sated, improper treatment, or negligence, a mortification
has been induced.
As the tumor increases, the patient, who in the first
stage did not complain of much uneasiness, is distressed
with severe pains, stiffness, want of feeling, and immobi-
lity of the whole member ; and these symptoms continuing
to augment, if the tumor is not previously operated upon,
the teguments at last burst; and when the artery is of con-
siderable size, and we do not have immediate recourse to
means to prevent it, death must certainly be the conse-
quence.
A variety of causes may be productive of the diffused
aneurism.
1. Violent bodily exertions may be considered as the
most frequent origin of the rupture of arteries internally
situated ; but these cases do not come properly under
our consideration in this place.
2. The corrosive matter of sores and abscesses by en-
O tirely


[ 106 ]
tirely destroying the coats of arteries, may occasion this
species of the disease.
3. The sharp splinters of a fractured bone being push-
ed into a neighbouring artery, have produced aneurisms.
4. Violent blows have been known to bring on aneu-
risms. This can scarcely happen in any other situation
than on the head ; on account of the arteries being there so
particularly exposed, and lying so near a firm bony substance.
5. It has been affirmed by respectable authority, that
diffused aneurisms have been produced, although rarely,
by the arterial coats bursting before the teguments with
which they are covered in cases of the encysted species.
6. The most frequent causes are punctures with sharp
instruments, as swords and cutlasses, but particularly the
lancet; which last may be considered as having been pro-
ductive of nine-tenths of all the aneurisms that ever have
occurred.
It has happened, in many instances, that aneurisms have
been mistaken for abscesses and other collections of matter;
have been opened ; and death has been the consequence.
Swellings of this kind are sometimes with much difficulty
distinguished from some others. In the beginning of the
disease, the pulsation and other circumstances characterise
it sufficiently; but in an advanced stage, when the tumor
is very considerable, and has lost its pulsation entirely, no-
thing but a very minute attention to the previous history
of the case, can enable as to form a judgment of its na-
ture.
Those swellings with which aneurisms are most likely
to be confounded, are soft encysted or scrophulous tu-
mors and abscesses, situated either immediately above, or
so nearly in contact with an artery, as to receive the influ-
ence of its pulsation; which is often communicated in a
very considerable degree when the artery is large. But
there is one symptom, which, when it occurs, and is
connected


[ 107 ]
connected with a strong pulsation in the tumor, may cer-
tainly determine the disease to be an aneurism; viz. the
contents of the tumor being made to disappear with ease
upon pressure, at the same time that they return instanta-
neously on the compression being removed. This symp-
tom, however, cannot attend when the contents of the
swelling have become hard and firm. Upon the whole,
therefore, as in many instances the nature of the disease
cannot be with certainty ascertained, the practitioner
should always, in such doubtful cases, proceed upon the
supposition of its being aneurismatic.
It is only in the trunk of the body, in the neck, axilla,
upper part of the thigh, or groin, that so much caution is
necessary; for when tumors of this nature are seated on
the lower part of the extremities, or on the head, we may
with safety open them; because if they should chance to
be aneurisms, there will be no danger in removing them
in the mode hereafter recommended.
In forming a prognosis in aneurisms, we must chiefly
attend 1. To the manner in which the disease appears to
have been produced. 2. The part of the body in which
it is situated; and, 3. The age, and habit of body of the
patient.
1. If an aneurism has come come on in a gradual man-
ner, without any apparent injury having been done to the
part, and without any violent bodily exertion having im-
mediately preceded it, there will be great reason to sup-
pose that the disease depends upon some paralytic or other
general affection, either of the trunk of the vessel in which
it occurs, or perhaps of the whole arterial system ; so that
no great success is to be expected from any means attempt-
ed for the patient's relief: whereas, there will be room
to suppose, if the tumor has evidently succeeded to a
bruise or other external accident, that the operation will
be attended with complete success, provided the ligature
to


[ 108 ]
to be made, does not entirely destroy the circulation in the
part.
In the varicose aneurism, we may generally venture to
make a more favourable prognosis than in any other spe-
cies of the disease: for it has been found in different in-
stances, that this does not make so rapid a progress as the
others ; that after acquiring a certain size, it does not af-
terwards grow much larger; and that any inconvenience
produced by it, may be sustained with tolerable ease for
many years. Drs. Hunter, Cleghorn, Pott, and others,
relate instances that confirm these circumstances, and
prove that the operation can very seldom be necessary to
remove this variety of the disease.
2. When an aneurismal swelling is so situated, that no
ligature or compression can be applied for putting a stop
to the circulation in the part, if the artery is large, there
would be the utmost hazard in opening it; as the patient
would probably lose more blood than his strength could
bear, before the artery could be secured. Hence in aneu-
risms situated on the trunk, neck, axilla or groin, we can
never make a favourable prognosis ; for the tumor will
certainly at last burst, and the most fatal consequences
will probably ensue. And in the humeral or femoral ar-
teries before their division the success of the operation
will always be doubtful; although there are well attested
instances of the limbs preserving nearly all their powers
after the destruction of the principal trunk. In those
cases, the circulation must be carried on by the smaller
branches, from their anastomosing with each other.
In aneurisms of the extremities, as the success of the
operations depend, in a great measure, on the probable
chance there is for the circulation going on in the under
part of the limb, our prognosis should, all other circum-
tances being alike, be more or less favourable according
to the lower or higher situation of the disease—But when
they


[ 109 ]
they arise from an external cause, other circumstances be-
ing favourable, it may be established as a general rule, that
they should be always removed when the life of the pa-
tient might be endangered by the bursting of the tumor.
3. The age and habit of body of the patient, in every
instance, should have considerable influence in determining
the opinion of practitioners as to the effects to be expected
from the operation : for in no instance does health and
youth give greater advantages, than in the operation for
the removal of aneurisms.—In the earlier periods of life,
the vessels can easily accommodate themselves to the chan-
ges thereby produced; but, in old age, we may readily sup-
pose the smaller arteries to be altogether incapable of that
degree of distension which is necessary for supplying the
want of the principal artery of a part.
A difference in these circumstances may account for the
various success that has attended the operation in many
instances where the causes and appearances were nearly
alike; and more particularly for the bad success that has
followed the removal of aneurisms in the popliteal ar-
tery.
SECT. II.
Of the Treatment of Aneurisms.
THE use of pressure has been indiscriminately recom-
mended in every species of aneurism, and in all their stages;
But it should never be employed in any period of the dif-
fused aneurism. In the early stages of the encysted, in-
deed, while the blood can be pressed entirely out of the
sac into the artery, it often happens, by the use of a ban-
dage of soft and somewhat elastic materials, properly fit-
ted to the part, that much may be done in preventing the
swelling from increasing; and on some occasions, by the
2 continued


[ 110 ]
continued support thus given to the weakened vessel, com-
plete cures have been obtained. In the varicose aneurism
more particularly, pressure is very useful*.
It is to be observed that the pressure should never be
greater than to afford an easy support to the parts affected;
for if it is, by the reaction which will be excited, it will
do more harm than good. During the use of compression,
the patient should be kept on a low diet; when necessary,
blood should be drawn ; the bowels should be kept lax ;
and all violent exercise, particularly of the part affected,
should be carefully avoided. When there is much pain,
opiates should be freely exhibited.
This treatment will apply to every aneurism not intended
to be operated upon; but is particularly proper in all
swellings of this kind, situated on parts where the opera-
tion is inadmissible.
When the operation for the aneurism is judged necessary,
the first step to be taken in it, is to apply a tourniquet to
the superior part of the member diseased. The patient
should be fixed on a table of such a height as will allow
the surgeon to be seated. The limb being properly secu-
red  by an assistant, the operator is now with a scalpel to
make an incision through the teguments, beginning about
half an inch above or below the swelling, and carrying it
along
* Aneurisms of the leg may sometimes be cured by compression—two
instances have occurred, where the posterior tibial artery was opened, and
a large aneurismal sac formed in the usual way—the operator having fully
dilated the sac, and cleared it of coagulated blood, applied a small bit of
sponge fixed to the extremity of a ligature, to the orifice in the artery,
then filling the wound completely with dry lint, continued a compression
with the hand during twenty-four hours, after which, compression by a
pretty close bandage, prevented any further hemorrhagy, and the eighth
day the lint was removed: the sponge adhering two or three days longer,
and coming away with some difficulty, induced the operator, in a second
instance, to make use of lint alone. The wound was filled up in three
weeks, and the man preserved the perfect use of his limb.


[ 111 ]
along the whole course of it, and about a half an inch be-
yond it. The blood should then be wiped away, and the
softest part of the tumor being discovered, an opening
ought to be made into it with a lancet large enough for
admitting the operator's finger ; which being introduced
into the orifice, the whole tumor is to be laid open by
running a blunt-pointed bistouri along the finger, first
from below upwards, and then from above downwards.
All the coagulated blood and tough membranous fila-
ments that are commonly found here, being now removed
by the fingers of the operator, the cavity is to be well dry-
ed; the tourniquet must then be entirely loosened, in or-
der to discover the orifice from which the blood has flow-
ed. This being done, we must next prevent any farther
effusion. Various means have been proposed to accom-
plish this. In order more effectually to preserve a free cir-
culation of blood in the inferior part of the member, it has
been recommended, 1. To apply a piece of agaric, vitriol,
alum, or other astringent, to the orifice, in order if possible
to produce a re-union of its sides ; and 2. To make use
of the twisted suture, with the same intention *.
To the first of these methods it may be objected, that
no astringent with which we are acquainted, is possessed
of
* Mr le Comte, in wounds of the arteries, instead of the usual modes,
from experiments on sheep and dogs, recommends the introduction of
a quill split and covered with ribband, in such a manner as to include the
whole artery; and to secure it by tying the ends of the ribband.—Mr
Vicq d'Azyr made some experiments in presence of his pupils on the
crural arteries of dogs ascertain the effects of this treatment.  A good
deal of inflammation and discharge was produced—the apparatus was
removed with some difficulty in about  three days; and the wounds healed
in about fifteen—In three instances the cavity of the artery was entirely
obliterated, yet the animals did very well. In some others, the circula-
tion was well carried on afterwards through the arteries.
In every case, the hemorrhagy was entirely restrained, immediately
on tying the ribbands. Hist. de la Soc, Roy. de Med. tom. 1. page 302. 
                      


[ 112 ]
of such powers as to deserve much confidence ; for al-
though they have often put a temporary stop to such he-
morrhagies, yet there are very few well authenticated
instances of their having produced any permanent advan-
tage ; and when trusted to, they have generally given a
great deal of distress to the patient and trouble to the sur-
geon.
With respect to Mr Lambert's ingenious proposal of
stitching the orifice in the artery, it would probably suc-
ceed in restraining the bleeding ; but it is evident that it
could not be employed when the artery lays at the back
part of the tumor, which is the case almost in every in-
stance. And by the diminution of the cavity of the artery
which it must necessarily produce, there is every reason to
fear that it must tend very much to the production of a
dilatation immediately above the stricture.
This mode has yet been employed but in one case, that I
know of: the above objections arise merely from reason-
ing on the subject; its utility must therefore be decided by
future observation.
Neither of the abovementioned methods being found
eligible, we now proceed to describe the ordinary manner
of securing the orifice in the artery by means of ligatures.
A small probe being introduced at the opening in vessel,
and the artery thus raised from the adjacent parts in
order to avoid the nerves*, a firm, broad, waxed ligature
must then be passed round, about the eighth of an inch
above the orifice, and another at the same distance be-
low it, by means of a blunt curved needle, plate viii. and
tied in the mode formerly directed in chapter V.
We direct the ligatures to be made as near as possible to
the orifice, for fear of losing the benefit of anastomosing
branches. And we advise a blunt needle, because when
the
* It will facilitate this part of the operation, when the disease is on a
joint, to bend the limb. B.


[ 113 ]
the sharp-pointed needle is used, there is a risk of injuring
parts unnecessarily, and the operation is performed with
more difficulty.
After the upper ligature is made, the tourniquet should
be loosened, in order to see whether any blood will be dis-
charged by the wound in the artery. If it flows in any
considerable quantity, it affords a proof that the circula-
tion will be tolerably well carried on, by the smaller bran-
ches, in the inferior part of the limb. But we are not to
despair of success if this should not be the case.
The ligatures should be left long enough to hang out at
the edges of the wound, that they may be easily with-
drawn when necessary.
It has been advised to insert two other ligatures very
near to those first made, and leave them untied, in order to
guard more effectually against hemorrhagy; but the tour-
niquet is a sufficient and better security, and should
always be left on the member for several days after the
operation.
When the ligatures are formed, the tourniquet should
be loosened entirely; and if no blood is then discharged
at the orifice in the artery, we may be satisfied that they
have been properly made. The wound is to be now co-
vered with soft lint, with a pledgit of some emollient over
it; and a compress being applied, the whole is to be
supported by a bandage, just tight enough to keep on the
other applications.
The patient is then to be put to bed, and the member
laid in a relaxed posture upon a pillow : and as the ope-
ration is always tedious and painful, a full dose of lauda-
num should be given, and repeated occasionally according
to the degrees of pain and restlessness.
In some cases, the pulse in the inferior part of the mem-
ber has been perceptible immediately after the operation :
This, however, is a rare occurrence; for as the disease is
seldom met with but in the joint of the elbow, as a conse-
P quence


[ 114 ]
quence of bleeding, and as the brachial artery before its
bifurcation, is most commonly the subject of the operation,
it can but rarely happen.
Immediately after the operation, the patient complains
of want of feeling in the whole member ; and as it is gene-
rally cold for a few hours afterwards, it will be proper to
to keep it covered with flannel, and have it gently rubbed
now and then. In the space of ten or twelve hours, al-
though the numbness still continues, the heat of the parts
generally begins to return ; and it often happens that in
the course of a few hours more, all the inferior part of the
limb becomes preternaturally warm.
In the mean time, the patient being properly attended to
as to regimen, by giving him cordials arid nourishing diet
when low, and confining him to a low  diet, if his constitu-
tion is plethoric, the limb being kept in an easy posture
towards the end of the fourth or fifth day, and sometimes
sooner, a very feeble pulse is discovered in the lower part
of the member; which becoming gradually stronger, the
patient in the same proportion recovers the feeling and use
of the parts.
As soon as matter forms freely about the sore, which is
generally about the fifth or sixth day, an emollient poul-
tice should be applied over it for a few hours, to soften
the dressings, which may then be removed. The ligatures
should not be taken away before the second or third dres-
sing. The dressings being renewed every second or
third day, according to the quantity of the discharge, the
sore commonly heals easily ; and although the limb may
remain sometime numb and weak, yet it generally at last
recovers its powers.
We have hitherto described the most favourable termi-
nation of the operation—In some instances, instead of a
return of circulation, and of the feeling and use of the
parts, they continue cold and insensible. From mere
want 
                    


[ 115 ]
want of blood, therefore, a mortification commences, and
proceeds to its last stages, notwithstanding every thing that
can be done to prevent it. If the patient survives the ef-
fects of the gangrene until a separation occurs between
the diseased and healthy parts, amputation of the member
will then be the only resource.
CHAP. VIII.
Of Herniæ.
SECT. I.
Of Herniæ in general.
THE term Hernia, in its general acceptation, im-
plies a tumor produced by the protrusion of some
part or parts from the cavity of the abdomen.
The situations in which these swellings usually appear, are
the groin, scrotum, labia pudendi, the upper and fore-
part of the thigh, the umbilicus, and the different points
between the interstices of the abdominal muscles,
Part of the intestinal canal or omentum, are the most
common contents of herniæ ; but there are instances of
ruptures of the stomach, uterus, liver, spleen, and
bladder.
From these circumstances of situation, and contents, all
the different appellations are derived by which hernias are
distinguished. Thus they are termed inguinal, scrotal,
femoral,

[ 116 ]
femoral, umbilical, or ventral, from the part in which
they make their appearance. When the tumor is confin-
ed to the groin, the hernia is said to be incomplete, and is
termed bubonocele; but when it reaches to the bottom
of the scrotum, it is said to be complete, and receives the
name of oscheocele. When a portion of intestine alone
forms the tumor, it is called an enterocele or intestinal her-
nia ; when a piece of omentum only is protruded, it is
termed epiplocele, or omental hernia ; and if both intestine
and omentum are down, it is called an entero-epiplocele, or
compound rupture.
The term rupture arose from a supposition that in most
cases of hernia there was a laceration of the peritonæum,
or membrane surrounding the abdominal viscera; and this
seemed to be confirmed by these viscera being, in some cases
of scrotal hernia, found in contact with the testicle; but it
is now well ascertained, that in hernia the peritonæum is
never ruptured except from external violence ; and that
in common cases it is merely carried before the protruded
part, and only suffers from dilatation. When the part
displaced is found in contact with the testis, it always pas-
ses down along with the testis, or before the opening by
which that descends is at all or firmly closed. This species
is usually termed the hernia congenita, and hardly ever is
produced except in the early months of infancy.
The production of hernia in the usual form, is to be
explained from one or more of the following circum-
stances :
1. Whatever tends to produce a diminution of capacity
in the cavity of the abdomen, must occasion a proportional
risk of some of the contained parts being pushed from their
natural situations. Violent coughing, crying, laughing, or
great bodily exertion, frequently operate in-this manner in
producing herniæ.
2. Falls, in consequence of the violent derangement
they


[ 117 ]
they produce in the abdominal viscera, are often the im-
mediate causes of ruptures.
3. Persons of a preternatural laxity of frame, are very
liable to herniæ, on the application of the abovementioned
causes; from the containing parts not being sufficiently
firm to resist the weight of the different viscera.
4. Sprains induce a laxity of the part injured, and ope-
rate in the manner of general weakness in occasioning
herniæ.
5. It has been observed, that the inhabitants of those
countries in which oil is much used as an article of diet,
are particularly liable to herniæ.
These various causes, it is evident, must most readily
operate in inducing herniæ, in those parts of the parietes
of the abdomen that are weakest. Hence we find them to
occur most commonly at the openings of the external ob-
lique muscles, under the arch formed by Poupart's liga-
ment, and at the umbilicus. They happen also between
the interstices of the muscles, but not frequently.
Whenever an hernia is formed, except in the case of
the hernia congenita, a portion of the peritonæum must
go along with the protruded viscus, and forms what has
been termed the hernial sac.
On the first appearance of the disease, the sac is com-
monly small, as such swellings seldom acquire any great
bulk at once; but by repeated descents of the bowels, it
often becomes very large ; and then frequently gets a
very considerable degree of firmness and thickness.
Hernial swellings frequently arise and continue a length
of time, without occasioning any bad symptoms ; but as
troublesome consequences often succeed to them, when
their reduction can be accomplished with propriety, it
should always be effected as quickly as possible.
All the bad symptoms occuring in hernias, proceed ei-
ther from obstruction to the passage of the fæces, when
the


[ 118 ]
the intestinal canal forms the tumor, or from a stoppage
of circulation, by stricture on the prolapsed parts : hence
they will always  be more or less hazardous according to
the nature of the parts protruded. Thus an omental
hernia is not so dangerous as a rupture of an intestine, or
other part more essential to life ; but even this may occa-
sion the most fatal effects.
The following are generally the symptoms of a stric-
ture on the protruded viscera sufficient to produce either
a stoppage of the circulation, or of the fæcal contents of
the alimentary canal, when this is affected.
An elastic colourless swelling is observed on the part af-
fected ; a slight pain is felt not only in the swelling itself,
but if part of the intestines is down, an uneasiness is felt
over the whole abdomen ; and this is always increased by
coughing, sneezing, or any other violent exertion. The
patient  complains of nausea; frequent retching ; can get
no discharge by stool; becomes hot and restless ; and his
pulse is commonly quick and hard.
If the swelling is entirely formed by intestine, and no
fæces are contained in it, it has a smooth equal surface, is
easily compressible, and immediately returns to its former
size on the pressure being removed ; but when fæces are
collected in the gut, as they are apt to be when the
disease is of long standing, it has considerable inequalities.
When the tumor is composed both of omentum and
gut, its appearance is always unequal, and it feels soft and
somewhat like dough, and of course not so elastic as when
intestine alone is down. If omentum alone forms the
swelling, no obstruction to the discharge of fæces ever
occurs, and of course the symptoms are never so alarming
as when the intestine is concerned, and the tumor is
weighty in proportion to its size.
But although in simple herniæ the contents may be in
general distinguished ; yet, when they are complicated, it
can never be done with any certainty.
Should


[ 119 ]
Should not the symptoms we have described be now
removed, the nausea and retching terminate in fre-
quent vomitings, first of a bilious, and afterwards of a
more fœtid matter ; the belly becomes tense; the pain
grows more violent; a distressing convulsive hiccup comes
on; the fever, which before was trifling, now be-
comes considerable; and a total want of rest, and great
anxiety continue through the whole complaint. These
symptoms, after some duration, are succeeded by a sudden
cessation of pain; languid and interrupted pulse; cold
sweats; languor of the eyes ; and subsidence of the ten-
sion of the belly. The swelling of the affected parts dis-
appears ; the teguments covering them change from a red-
dish inflamed cast to a livid hue ; and a crepitous windy
feel is distinguishable all over the swelling.
If the protruded parts have not of themselves entirely
gone up, their return is now generally with ease produ-
ced by slight pressure, and the patient then discharges freely
by stool; but the cold sweats increasing, the hiccup be-
comes more violent, and death is at last ushered in by its
usual forerunners, subsultus tendinum, and other convul-
five affections.
As the stricture which prevents the return of the pro-
truded parts is the cause of all the morbid symptoms, the
indication of cure is to effect its removal. This is to
be accomplished either by a reduction of the displaced
parts without a division of the strangulating part, or by
an incision into or through the part producing the stric-
ture, so as to admit of a replacement of the substances de-
ranged.
In the treatment of hernia, the first circumstance to be
attended to, very perfectly, is the placing the patient in such
a posture as will  probably favour the return of the  pro-
truded parts. Thus when the swelling is in the groin or
forepart of the thigh, the thighs and legs should be raised
considerably


[ 120 ]
considerably higher than the head and trunk; and, in
instances, it some has been found necessary to have the pati-
ent placed perpendicularly upon his head, and there well
shook about. In exomphalos, or umbilical rupture, the
body should be erect; and in cases of ventral hernia, a
horizontal posture is to be chosen.
While the patient is thus fixed, the surgeon should
endeavour to produce a return of the parts, by gentle
pressure with the fingers. In the inguinal and scrotal
herniæ, this should be made obliquely upwards towards
the os ileum; in the femoral, it should be made directly
backwards; in the umbilical, downwards and back-
wards ; and in the ventral hernia, directly backwards.
When the hernia is of considerable size, the pressure is
most conveniently and effectually made, by grasping the
swelling with one hand from the bottom upwards, while
with the sore and middle fingers of the other hand, we
endeavour to push up the contents of the tumor. This
operation has been termed taxis.
If a very moderate degree of pressure, for none other
should ever be applied, does not reduce the swelling, o-
ther means should immediately be employed. Blood-let-
ting according to the strength of the patient, is here par-
ticularly serviceable, and may safely be carried to very
great extent; and it has sometimes been found useful to
manage it so as to induce fainting.
To remove the obstinate costiveness that so commonly
attends, it has been a general practice to order stimulating
purgatives ; but these, in almost every case, do much inju-
ry by increasing the nausea, and by adding to the tension
and pain of the swelling. The best mode of opening the
body, is by injecting clysters of tobacco smoke, by means of
the machine, plate v. fig. 8. until it has the desired effect,
or until much nausea is produced, or some swelling of
the abdomen.
2 Although


[ 121 ]
Although this remedy frequently fails, yet it is much
preferable to purgatives given by the mouth ; and if it
should not be laxative, it may always be serviceable by the
anodyne quality which it possesses. Acrid suppositories
have been used at the same time with purgatives, but no
great dependance should be placed on them.
Opiates are often of great use, not only by easing pain,
but by tending to relax the stricture*.  As their exhibi-
tion by the mouth is commonly prevented by the nausea,
they may be given clysterwise, alternately with the tobac-
co smoke. General warm bathing is a very serviceable
remedy ; but warm applications to the swelling do injury
by rarefying the contents of the hernia, and thus increas-
ing its size.
The applications on which I place most dependance
are the cold saturnine solutions, and vinegar and water;
with these cloths are wet, and kept constantly on the
swelling. In several instances I have used ice and snow
with evident advantage.
By these several means herniæ are often entirely remo-
ved ; but it also frequently happens that they produce no
relief; and the symptoms instead of lessening become
more violent. In this situation, the division of the parts
producing the stricture is our only resource.
It is one of the most difficult points in surgery to ascer-
tain when this operation should be put in practice. If it
should be too long delayed, the patient will infallibly die ;
and if performed too early, we may be subjected to
blame. There are many instances of strangulated herniæ
continuing for eight or ten days, and being then replaced,
the patient has done very well: whilst, on the other hand,
Q they
* Several cases of strangulated hernia, attended with great pain and
tension, have been happily reduced by a strong opiate, without any ma-
nual assistance, the protruded parts retiring themselves as soon as the
opiate had produced sleep.


[ 122 ]
they have proved fatal, and when apparently in the same
degree, within forty-eight hours.
From hence, although the operation is attended with
some risk, it may with propriety be established as a general
rule always to proceed to it, if a strangulated hernia is not
otherwise relieved in two or three hours at farthest.
The French surgeons seem to be more successful than
the German or British, entirely from the circumstance of
their having more early recourse to the operation.
Although in general it is proper to reduce herniæ as
soon as possible ; yet there are some instances in which it
would be improper to attempt it. Thus, herniæ some-
times continue a long time without producing any bad
symptoms whatever, and contract adhesions to the sur-
rounding parts, which can only be removed by the opera-
tion. In such cases, unless symptoms of strangulation
come on, nothing more should be done than to keep the
bowels lax, and apply a suspensory bandage to the swel-
ling.
Where a hernia has been reduced either by taxis or
division, its return can only be effectually prevented by
the proper application of a steel truss, (plate vi. fig. I.) and
by avoiding violent exercise, and particularly sudden ex-
ertions.
Many years since, there were a variety of methods used
to cure herniæ radically, such as ligatures applied so as to
close the sac, and caustics to destroy it; but all of these
have been found ineffectual to accomplish the end pro-
posed, and many of them have been fatal to the unhappy
patients.
SECT.


[ 123 ]
SECT. II.
Of the Bubonocele.
IN the bubonocele the swelling begins in the groin, and
gradually descends into the scrotum in men, and into the
labia pudendi in women.
The diseases with which inguinal and scrotal herniæ
are most likely to be confounded, are glandular swellings
in the groin, hernia humoralis or inflamed testicle, and
the different kinds of hydrocele.
Buboes are readily distinguished from herniæ by their
hardness in the first stage, and the fluctuation of fluid in
their suppurated state, and by the absence of the general
symptoms of herniæ.
In hernia humoralis the hardened state of the testicle
and epidydimis; their exquisite painfulness to the touch ;
the want of swelling in the spermatic process and of the
general symptoms of hernia, afford sufficient means of dis-
crimination.
In hydrocele the swelling is more equal than in hernia,
and usually begins below; but in hydrocele of the sper-
matic process, it sometimes happens that the tumor com-
mences even within the opening of the abdominal mus-
cle, and by degrees falls downward s: in this case, the
absence of the general symptoms of hernia will generally
establish the nature of the case. But in some instances, it
seems impossible to ascertain with certainty the real state of
the disease. In these circumstances we can only proceed
with safety upon the supposition of its being hernial.
When every other means recommended for the re-
moval of hernia in general has failed in bubonocele, we
must then have recourse to the operation ; which is thus
to be performed :
A


[ 124 ]
A table of convenient height being placed in a good
light, the patient must be laid upon it, having the head
and body almost horizontal, and the buttocks somewhat
raised by pillows. The legs hanging over the edge of
the table, ought to be so far separated as to admit the ope-
rator between them; and should be secured by an assistant
on each side, who should keep the thighs so much raised
as to relax all the abdominal muscles.
The patient should empty the bladder; and the parts hav-
ing previously been shaved, an incision should now be made
with a scalpal through the skin, beginning at least an
inch above the superior end of the tumor, and continuing it
down to the bottom of the scrotum. This should always
be done : it enables us to finish the operation more conve-
niently, and prevents a lodgment of the matter after-
wards formed.
The operator then goes on to divide slowly the cellu-
lar substance and the tendinous-like bands, which, unless
the disease is very recent, are universally met with, either
loose upon the surface of the hernial sac, or on some occa-
sions, passing as it were into its substance. Even this in-
cision should be made very cautiously, because there are
some instances upon record, in which the spermatic vessels
have been found on the anterior part of the swelling, al-
though they are almost always behind it; and we would
run a risk of wounding them, should this be the case, by a
hasty incision.
Before making the division of the skin and cellular sub-
stance, the tumor should be grasped with the left hand, so
as to render it somewhat tense on the anterior part, and
kept so while the incision is made with the right hand.
The hernial sac should now be very cautiously dissected
through, as near the lower part as possible, because that is
generally filled with bloody serum, and we consequently
there have the least chance of wounding the intestine.
We


[ 125 ]
We may tell when the sac is cut through by a blunt probe
passing easily in. The sac in recent cases, and particular-
ly of bubonocele, is thin, but in long continued herniæ,
it often acquires an astonishing thickness.
The opening first made being enlarged so as to admit
the fore-finger, a narrow blunt-pointed bistoury, (plate
vii. fig. 9.) should be introduced, to which the finger ser-
ving as a director, the hernial sac is to be divided its whole
length, from below quite up to the opening in the muscle.
The protruded parts* now come fully into view ; and
should be very carefully examined ; if they are not gan-
grened, even although they should seem considerably in-
flamed, they should, if possible, be immediately returned
into the abdomen.
In making the reduction, whether intestine, omentum,
or both have been found, those parts which appear to
have come out last should be first pushed back ; and the
finger should be applied to that part of the gut with
which the mesentery is connected; as by these precautions
we are less liable to do mischief, and accomplish the reducti-
on with more facility. During the reduction, the thighs
should be somewhat more elevated than during the pre-
vious part of the operation. When the disease is recent,
and has not often occurred, it sometimes happens that by
pulling out a little more of the gut than was before  in
the sac, the obstruction to its replacement will be remov-
ed; however, when we cannot do this with great ease, it
should not be attempted.
If our attempts for reduction of the part fail, we must
proceed then to the enlargement of the opening in the
tendon. This is to be performed by entering the finger
at the opening above the protruded parts, introducing
the
* In enterocele, late observations have taught us, that the coecum, ap-
pendix vermiformis, and part of the colon, have as frequently been con-
tained in herniary sacs as the ileum or any other part of the tube.


[ 126 ]
the blunt bistouri, and the finger serving as a director, and
being kept a little beyond the point of the instrument, a
free incision should be made obliquely upwards, so as mere-
ly to continue the separation in the fibres of the tendon,
without dividing them.
It often happens in long continued cases, that adhesi-
ons not only of the protruded parts to those adjacent to
them take place, and to each other, but also that they
are discovered by the introduction of the finger, internal-
ly. The opening should therefore be large enough to
admit a separation of the latter. When adhesions of the
parts deplaced to each other occur, if slight, they should
be separated by the fingers or the scalpel; but if considera-
ble, the parts should be returned as they are. When ad-
hesions of the intestines to the sac or omentum are found,
and are very firm, parts of the latter two may be with safety
dissected off; or when there is a firm connection be-
tween the gut and sac, or omentum and sac part of the
sac may be safely dissected off, and returned into the ab-
domen.
When the omentum protruded is gangrened, or by
the pressure it has sustained in the sac any considerable
portion of it becomes much hardened, such part should
be expanded on the hand, and cut off with a pair of scis-
sars; and if any considerable vessel is divided, it should
be tied. It has been observed that ligatures on the omen-
tum, as formerly recommended, have been productive of
bad consequences;—none such have succeeded the return
of it without them.
When a part of the intestine is discovered to be morti-
fied, it should be cut out; and if this does not extend the
whole circumference of the gut, the part above it should
immediately be connected by ligature to the wound in the
abdomen. By this means, the fæces will be discharged
externally, and in some instances the wound in the intes-
tine

[ 127 ]
tine has gradually healed. Where the mortified part is
considerable, the sound ends of the gut should if possible
be brought into contact, united as directed in the chapter
on gastroraphy, and both connected to the wound. In
some instances where a very considerable portion, a foot
e. g. has been gangrened, by this mode the ends of the in-
testine have coalesced, and the patient has done very well.
But should not this fortunately happen, a passage is se-
cured to the fæces by the groin: the consequence of their
being voided internally would inevitably be death.
When the found intestine is connected to the wound, and
not till then, the opening in the tendon should be enlarged
as much as is necessary; if it is done before, the mortified
portion may slip up together with the sound part. When
the sac is found to be thick, hard, and much enlarged, as
its preservation can answer no good purpose, all the late-
ral and fore parts of it may be cut off with safety; but the
posterior part should be suffered to remain, because it is
commonly connected to the spermatic vessels.
The operation being now finished, the wound is to be
dressed with soft lint, retained by a suspensory bag stuffed
with lint, and the patient put to bed; taking care that his
loins be somewhat higher than the rest of the body. An
opiate should then be given; he should be kept cool; if ple-
thoric, in order to remove the fever which succeeds, he
should be bled; a low diet should be directed; and a fre-
quent use  of laxatives. When, however, the body has been
previously much debilitated, a nourishing diet should be
advised.
The sore having easy dressings applied to it as often as
seems necessary, and the proper diet, &c. being attended
to, if the patient survives the first three or four days, he
will in general recover. And as soon as the wound is
well cicatrized, a truss ought to  be properly fitted to the
parts, and worn constantly afterwards.
It


[ 128 ]
It has been recommended to stitch the external wound ;
but as this may prevent the discovery of protrusions of the
intestine, which are apt to occur during the cure, it ought
never to be done.
It has been advised by many French surgeons to endea-
vour to reduce the intestine, &c. without dividing the sac;
but although, if this is practicable, we might in some in-
stances do right, in many others we should probably
return mortified parts, which would certainly be follow-
ed by death. And besides, there are some cases in which
the strangulation has been produced by one part of the in-
testine being wound around another, as the appendicula
vermiformis around the ileum; when it is obvious no
good effects could result from the operation.
By some authors again, it is recommended to reduce not
only the bowels, as just described, but even the hernial sac
itself, without opening it: by others, among whom is
Mr Pott, this is deemed impossible. But I have seen a
hernia of five or six days duration in which it certainly oc-
curred; the patient died, and dissection put it beyond a
doubt. Mr le Dran relates instances of the same kind.
The same objections occur to this practice that operate a-
gainst returning the intestines without examination of them.
Although bubonocele happens most frequently in males,
yet it sometimes also takes place in females; and in some
cases, the protruded part has descended to the bottom al-
most of the labia pudendi. The general method of treat-
ment is the same in both sexes.
In modest women, this disease sometimes occurs to consi-
derable degree without our being made acquainted with
it;—it should always be suspected when the symptoms of
colic occur to a very alarming degree, and examination
should be made to ascertain it.
3 SECT.


[ 129 ]
SECT. III. 
Of the Hernia Congenita.
THE treatment of this species of hernia, in general ac-
cords with that of common bubonocele. In laying open
the parts, when the operation is adviseable, great caution
is necessary, as the thin vaginal coat of the testis forms
the hernial sac. And in dressing the wound, the vaginal
coat should be brought to cover the testis; and great care
should be taken to avoid irritating dressings, and long ex-
posure to the air.
SECT. IV.
Of the Crural or Femoral Hernia.
The seat of this species of hernia is the upper and an-
terior part of the thigh, under the firm tendinous apone-
urosis of the fascia lata; the parts being protruded through
the opening by which the femoral artery and vein pass
out. In sore instances they are found immediately over
these vessels ; in others on the outside of them; but more
frequently they lie on the inside, between them and the
os pubis.
The same general treatment that was recommended in
inguinal hernia is applicable here; but it must be observed
that the pressure in reduction should be made directly up-
wards.
In performing the operation, the external incision should
extend from an inch above to an inch below the tumor: and
when all the parts above the ligament are divided, if
those protruded are to be returned, their reduction may
R here


[ 130 ]
here be often accomplished, without cutting the ligament,
by placing the patient in a favourable posture. This
should therefore be always attempted ; for it is almost im-
possible to make a free division of the ligament in any di-
rection, without wounding the spermatic vessels and epi-
gastric artery; and it is by no means so easy a matter to
secure the latter as has been represented. On this account
an instrument, (pi. v. fig. 7.) has been invented for di-
lating the opening; but this probably would seldom be of
any use, because the ligament, it is to be supposed, is stretch-
ed nearly as much as possible by the protruded parts.
I have once used a method which answered very effec-
tually, and was without the risk of the mode commonly
advised. It consisted in gradually dissecting the ligament
until a very thin lamella only was left; which then  admitted
of a sufficient distention to suffer the return of the deplaced
parts. I guarded the parts below by insinuating my for-
finger into the opening between the gut and ligament, and
then made my incision, which was about an inch long.
In this as well as every other case of hernia, except bu-
bonocele, it is better to use an adhesive plaster to retain
the dressings than any bandage.
Women are most subject to femoral rupture;—they are
relieved in the manner above directed.
SECT.  V.
Of Exomphalos, or Umbilical Rupture.
THE parts in this rupture pass out at the navel; its con-
tents are very various; most commonly they consist of
omentum; sometimes of intestine ; and in some instances of
part of the stomach, the liver, and even the spleen. The
sac becomes sometimes so connected with these parts, that
doubts


[ 131 ]
doubts have been entertained of its existence; but it is al-
ways very evident in recent cases. The sac and integu-
ments have been in some instances bursted by the contents.
Umbilical hernia occurs most frequently in infancy, soon
after birth; of adults, the corpulent are most liable to it,
from the greater perviousness of the umbilicus in them, pro-
duced by the constant distention of the abdominal muscles;
and for the same reason pregnant women, in the latter
months, are particularly subject to it.
A proper bandage or truss will generally be effectual
in preventing returns of this hernia: and pregnant women
should be particularly attentive to it on its first appearance,
as their particular situation has a tendency to render it
worse.
As omentum commonly forms herniæ of this kind,
they are seldom productive of dangerous symptoms: but
when these occur, and cannot be removed without, the
operation must be had recourse to as in other cases. The
division of the part producing the stricture may be safely
made in any direction; but those who wish to avoid
wounding the umbilical ligament or former vessels, may
make it on the left side, a little upwards and outwards.
In other circumstances we must proceed as in other cases
of hernia.
SECT. VI.
Of Ventral Hernia.
IN this species of hernia the parts are protruded
into the interstices of the abdominal muscles. It occurs
in every part of the abdomen, but most frequently near
the linea alba; and when the stomach forms the swelling
it


[ 132 ]
it appears just under, or by the side of the xiphoid carti-
lage.
The treatment recommended for the exomphalos is ap-
plicable to all ventral herniæ.
SECT. VII.
Of the Hernia of the Foramen Ovale.
THE general mode of treating hernias is proper here
except that instead of dividing the ligament, which would
be attended with the utmost risk of cutting some large
vessel that it would be impossible to command, it will be
proper to attempt its gradual dilatation, by the blunt curved
hook (pi. v. fig. 7.), when an operation is necessary.
The tumor is generally so small that this disease is not
often detected from the appearance of swelling, till it is too
late to apply an effectual remedy, unless pain and other
symptoms of strangulated hernia occur to point it out.
In this rupture the tumor is formed in men near the up-
per part of the perinæum, and in women, near the under
part of one of the labia pudeadi. In both sexes it lies up-
on the obturator externus, between the pectinæus muscle
and the first head of the triceps femoris, and passes down
through the foramen ovale by the side of the blood ves-
sels and nerves.
SECT. VIII.
Of the Hernia of the Urinary Bladder.
THE hernia cystica occurs in the groin or scrotum
through the opening in Poupart's ligament; in the sore
part


[ 133 ]
part of the thigh, under this ligament; in the perinæum
through the muscular interstices ; or in the vagina. The
part of the bladder protruded, is never covered by the
peritonæum. It sometimes is protruded by itself, and at
other times is accompanied by intestines and omentum.
When complicated with bubonocele, it is found behind
the hernial sac, and between that and the spermatic process.
This hernia is usually known by a tumor attended with
fluctuation, which subsides when the patient voids urine-
When the swelling is small, water is made without pressure;
but if large, it is necessary not only to press it, but often to
lift it up.
A simple hernia cystrica is commonly produced by a sup-
pression of urine. In the treatment therefore, this should
be guarded against as much as possible; and when no ad-
hesions take place, and the bladder can be reduced, a truss
should then be worn for a considerable time. When the
parts cannot be returned, a suspensory bag is the only
probable means of relief. When the bladder falls into
the vagina, after reducing the parts by laying the patient
on her back with the loins elevated and pressing  with the
fingers from the vagina, future descents may be prevented
by the use of a proper pressary : and the same means may
be used when the intestine protrudes into the vagina.
When the operation is necessary to remove cyftic herniæ,
the dissection should be very cautious, on account of there
being no sac.
It sometimes is thought proper to cut into the bladder
in order to remove stones from the protruded part; in this
case, as well as when it is accidentally wounded in the ope-  
ration, or part of it has gangrened, it will be adviseable to
preserve its prolapsed situation until the wound is healed,
in order to prevent the evacuation of the urine internally,
which would probably have bad effects.
CHAP.


[ 134 ]
CHAP. IX.
Of the Hydrocele.
SECT. I.
General Remarks on Hydrocele.
THE term Hydrocele is applied to watery swellings
situated in the scrotum or spermatic cord.
These, as well as every other species of tumor in the
scrotum or groin not immediately produced by the pro-
trusion of parts from the abdomen, are by ancient writers,
termed false or spurious herniæ, in opposition to those de-
cribed in the last chapter, which they distinguished by the
appellation of true herniæ. This distinction is of no kind
of use; and indeed nothing written on the subject of her-
niæ until the present century, is of much useful applica-
tion : the discoveries of late anatomists and surgeons have
now, however, made it intelligible and satisfactory.
All the varieties of hydrocele may be comprehended
under the two following species, viz. the anasarcous and
the encysted. In the former, the water is diffused all over
the part affected; and in the latter, it is confined to one
or more distinct bags, and a fluctuation of fluid is gene-
rally perceptible to the touch. The scrotum and its con-
tents, as well as the spermatic process, are liable to both
species of the disease.                     
SECT.


[ 135 ]
SECT. II.
Of the Anasarcous Hydrocele of the Scrotum.
THIS disease is usually symptomatic of general dropsy ;
but in some few instances, it is merely a local affection.
Thus it has been the consequence of the pressure of a tu-
mor on the lymphatics' of the part; of external injury ;
and of the effusion of urine from a rupture of the u-
rethra.
AS soon as water is collected in any considerable quan-
tity in the scrotum, a soft, inelastic, and colourless tumor
is observed over the whole of it; this gradually increases,
and often extends up into the groin and penis ; and dis-
tends the parts so much as at length, in some instances, to
burst them. After some continuance the skin acquires a
whitish shining appearance ; and the largeness of the swel-
ling is frequently productive of a great deal of inconveni-
ence and distress.
This disease is so well characterised, that there can be no
danger of confounding it with any other.  As it common-
ly depends on a general cause, its radical cure must be ac-
complished by the general remedies of dropsy; but we
are often under the necessity of affording a temporary re-	
lief, by evacuating the fluid of the particular part. This
has been done in four different ways; by seton, by the
trocar, by incisions, and by punctures. All these, except
the trocar, evacuate the water very effectually ; but punc-
tures have the least troublesome consequences, and there-
fore should be preferred.
The trocar, seton, and scarifications, often produce, in a
little time after their use, erysipelatous inflammation and
consequent gangrene ; and even punctures have had such
effects, but much more seldom.
Scarifications


[ 136 ]
Scarifications are usually made about an inch in length,
to the depth of the cutis vera, and about two or three in
number, with the shoulder of a lancet. Punctures are
made to the same depth with the point of the lancet, and
about five or six generally suffice. They may be repeated
in a few days if the first seem insufficient; and the parts
should be kept as dry as possible after the operation.
When inflammation succeeds, a cold solution of saccha-
rum saturini, or aqua calcis, are the best applications to re-
move it. Should these fail, and gangrene come on, the
remedies for gangrene in general should be had recourse to
Although in these cases, mortification often terminates
fatally; yet very unexpected cures are sometimes obtain-
ed. There is an instance of the whole scrotum separating
and leaving the testes bare; but these were soon covered
by a cellular substance, and the patient recovered.
When this disease is induced by swellings in the abdo-
men or groin, obstructing the return of the lymph, they
should, if possible, be removed ; if this cannot be done,
punctures must be made as palliatives.
It sometimes happens that suppression of urine, produ-
cing a bursting of the urethra, induces this complaint in a
very sudden manner. In order to prevent the formation
of sinusses, which will be apt to occur in these cases, an
incision should be made into the most depending part of
the scrotum, and carried deep enough to reach the wound
in the uerthra. By this means a free vent will be given
to the urine which has been collected, or will be dischar-
ged. If a stone in the urethra produces this suppression,
it should be cut out; if it originates from a collection of
matter, this should be discharged ; and if the obstruction
aries from caruncles in the urethra, they should be re-
moved by bougies.
The cause being thus removed, if there is no constitu-
tional affection, and the wound is dressed with soft appli-
2 cations,


[ 137 ]
cations, the opening into the urethra will commonly heal ;
but where there are general complaints, and particularly
if the patient is syphilitic, it often happens that it baffles
all the powers of medicine.
Local scrotal anasarca has been also produced from the
rupture of a hydrocele of the tunica vaginalis testis, when
large, by jumping from a great height, or a violent blow;
and also in the operation of tapping in that disease, from
suffering the orifice in the teguments to recede from that
in the vaginal coat before the water is all discharged.
In both these cases, the cure should consist in laying
open the tumor; not only for the the evacuation of the
diffused water, but also for producing a radical cure of
the hydrocele of the vaginal coat.
Of the encysted hydrocele there are two varieties : 1.
When the water is contained in the tunica vaginalis : and,
2. When it is contained in the sac of a hernia.
SECT.  III.
Of the Hydrocele of the Vaginal Coat of the Testis.
THIS disease is induced either by a too abundant depo-
sition of the fluid usually exhaled into the cavity of the
vaginal tunic, or a defective absorption of it.
In the commencement of the complaint, a fulness is ob-
served at the lower part of one of the testicles, which gra-
dually increases, and produces a tumor often of consider-
able size. This although compressible at first, can ne-
ver be made to disappear by pressure ; and as it increases
the skin becomes more tense. The tumor is at first glo-
bular, but gradually becomes pyramidal, being larger be-
low than above; and after some continuance it often rises
quite up to the opening in the abdominal muscles; so that
S if 


[ 138 ]
if it is not combined with hernia, or hydrocele of the cord
itself, the spermatic process may always be distinctly felt
in the early stage of the disease. The weight of the swel-
ling being now very considerable, the skin of the parts ad-
jacent is dragged along with it in such a manner, that the
penis shrinks considerably, and sometimes almost disap-
pears ; and the testicle, which commonly lies at the back
part of the tumor, cannot now be evidently discovered.
On a minute examination, however, a hardness may be
felt where the testis is connected to the scrotum ; and a
fluctuation of fluid may in general be distinguished.
It sometimes happens when the tumor is very tense, that
the fluid cannot be evidently discovered; neither this, how-
ever, nor the want of transparency in it when exposed to
the light of a candle, should determine against its exist-
ence ; for the last mentioned circumstance may be occasi-
oned by a discolouration of the fluid, or a thickening of
the tunic. When the swelling, however, appears trans-
parent, as it frequently does, it affords a corroborating
proof of the existence of water.
The tumor itself is not painful, but its weight always
produces some uneasiness in the back ; this may however
be prevented or alleviated by the use of a suspensory ban-
dage.
These are the common symptoms when the disease is
confined to one side of the scrotum, which is usually the
case; but in some instances both sides are equally affected.
The diseases with which this is most likely to be con-
founded are, scrotal herniæ; the anasarcous hydrocele of
the scrotum; the encysted hydrocele of the spermatic
cord ; the sarcocele or schirrous testicle; and the hernia
humoralis, or inflamed testicle.
But if we attend to the characteristic marks of each
of these affections, there can in general be little danger of
mistake : these have been already given, or will be taken
notice


[ 139 ]
notice of hereafter. In some cases of sarcocele combined
with an effusion of water into the vaginal coat,  there will
be some difficulty, and it is even sometimes impossible to
ascertain the complaint: however, no danger will arise
from the mistake, if we proceed in the cautious manner
hereafter pointed out.
In forming a prognosis in this disease, we must be di-
rected almost entirely by the habit of body of the patient.
The affection is in general local, and in a healthy constitu-
tion it may almost always be removed, and that with little
or no risk ; but in constitutions otherwise diseased ; in old
people ; and in infirm habits, although the complaint may
often be cured, yet there is always some danger to be
feared from the consequent inflammation, fever, and suppu-
ration.
As long as a swelling of this kind keeps within mode-
rate bounds, which often happens  for a considerable
time, patients generally submit to the inconvenience it oc-
casions, rather than have an operation performed to relieve
them : and this is the only means to be depended on ; for
notwithstanding what has been said  of  the beneficial ef-
fects of purgatives in these cases, I have never seen them
of any kind of service*.
The methods of treatment proposed are either intended
to produce permanent relief, or only a temporary ease.
The last is termed the palliative, the former the radical cure.
When the tumor has acquired such a size as to become
inconvenient, if the patient either refuses to submit to the
operation for the radical cure, or his state of health ren-
ders that improper, the palliative treatment, or a mere e-
vacuation
* Dr Shippen, professor of anatomy and surgery in this city, has in
more instances than one, removed this disease by the free use of drastic
purges, and anointing the part with mercurial ointment. But the Doctor
is of opinion with Mr Bell, that they will generally be ineffectual; and
in his lectures strongly recommends the use of the knife if the patient
will suffer it to be employed.


[ 140 ]
vacuation of the water by puncture, is the only means we
can employ ; and this is hardly ever at all hazardous.
The puncture is made either by a lancet or the common
trocar. To the use of the lancet it may be objected,
that it does not produce a free evacuation of the water ; for
as the opening in the skin recedes from that in the vaginal
coat, the water is either entirely stopt or insinuates itself
into the cellular substance of the scrotum.—The difficulty
of introducing the common trocar, renders it a dangerous
instrument on account of the contiguity of the testicle;
and many instances have occurred wherein the testis has
thus been materially injured, even in the hands of expert
operators. The objections to these instruments do not,
however, apply to the trocar with a lancet point, (plate vii.
fig. 3.4.) which I sometime since recommended: it ought
therefore to be preferred to both of them.
In performing this operation, the patient should be seat-
ed on a chair, with the tumor hanging over the edge of it:
the operator with his left hand grasping the swelling on the
back part, so as to push the water as much as possible in-
to the anterior and under part where the puncture is to be
made; he then makes an opening through the skin and
cellular substance, of half an inch in length, with the shoul-
der of a lancet. This ensures an easy passage to the trocar,
gives but very little pain, and divests the operation of all
hazard.
The trocar is now to be taken in the right  hand of
the operator, the head of it being fixed in the palm, and
the fore-finger placed along the course of the instrument, so
as to leave as much uncovered as it is thought proper
should enter the vaginal coat; and this being introduced
in a gradual easy manner, the stillette is to be withdrawn
immediately on the end  of the canula having entered the
cyst. If the tumor is not very large, all the water may be
evacuated at once; but if it is of considerable size, the
sudden


[ 141 ]
sudden discharge of the fluid might, by taking away too
quickly the support it afforded to the vessels of the testis
and its coat, endanger a rupture of some of them; it will
therefore be better to stop the discharge now and then
for a few seconds ; and when the whole is evacuated, the
wound may be closed by adhesive plaster, a soft compress
applied above this, and both secured by the T bandage.
The patient being laid in bed, it commonly happens that
in a few hours all uneasiness goes off, and he may go a-
bout his ordinary business ; in some instances, however,
the wound inflames and suppurates; and there are not
wanting cases in which a permanent cure has thus been
obtained.
This operation is easily performed, and seldom produc-
tive of mischief; but when the patient has been allowed
to go about immediately after the operation, or the tap-
ping has been incautiously performed, it has sometimes
been succeeded by very troublesome symptoms. And
even when properly managed, if the patient is very infirm,
this may happen. Mr Pott relates two instances of this
kind that terminated fatally. Hence it should not be
risked in very diseased habits.
The intention of every means at present in practice for
the radical cure of this species of hydrocele, is either
to admit of a union between the  cellular substance of the
scrotum and the tunica albuginea, by a destruction of the
tunica vaginalis, or by exciting such a degree of inflamma-
tion on the parts as may obliterate the cavity of the tunica
vaginalis, by making it adhere to the tunica albuginea.
The several modes of effecting these intentions, are ex-
cision of the tunica vaginalis ; the application of caustic;
the use of a seton; and a simple incision of the sac.
The three last are almost the only methods now in use ;
and the caustic is the only one of them by which the sac
has been supposed to be destroyed; but it is exceedingly
doubtful


[ 142 ]
doubtful, notwithstanding what Mr Else says to the con-
trary, whether this ever takes place.
By Mr Douglass we are recommended  to destroy the
vaginal coat entirely; he directs us, first to dissect out an
oval piece of the scrotum, and having then laid the vaginal
coat open, to cut it away by a pair of scissars ; but if any
one is inclined to follow this mode, he will seldom find it
necessary to cut off any part of the scrotum, and will per-
form the operation more easily with a scalpel than with
scissars.
The method of cure by caustic is thus conducted at
present; the scrotum being shaved, a piece of common
caustic paste, of the size of an English six-pence, is to be
applied upon the anterior and lower part of the scrotum,
and to be there well secured by adhesive plaster, in order
to prevent it from spreading. It is to remain five or six
hours, and then be removed. An emollient poultice, or
some digestive, must afterwards be applied over the scro-
tum, and the whole suspended by a bandage.
Inflammation, we are told, is soon induced over the whole
tunica vaginalis ; and the febrile symptoms which succeed
are to be moderated by blood-letting, clysters, &c. In a
few days the escar separates  and comes  away; and in a
gradual manner, in the course of four, five, or six weeks,
the whole  tunica vaginalis comes off; when the wound
immediately cicatrizes, and a compleat cure is obtained.
When the seton is to be used, the following is the me-
thod directed by Mr Pott. He uses a trocar; a silver
canula, five inches in length, and of such a diameter as to
pass easily through the canula of the trocar; and a probe,
six inches and an half long, having at one end a fine tro-
car steel point, and at the other an eye which carries a
cord of  coarse white sewing silk, of such a thickness  as
will pass easily through the long canula. With the tro-
car, the inferior and anterior part of the tumor is to be
pierced;


[ 143 ]
pierced ; and as soon as the perforator is withdrawn, and
the water discharged, the seton canula is passed through
that of the trocar, till it reaches the upper part of the tu-
nica vaginalis, and can be felt in the very superior part
of the scrotum. This being done, the probe armed with
its seton is to be conveyed through the latter canula, the
vaginal coat and teguments to be pierced, and the seton
drawn through the canula till a sufficient quantity is
brought out at the upper orifice, when the canulas are to
withdrawn.
About the end of the third day, the parts begin to in-
flame ; fomentations, poultices, a suspensory bandage,
temperate regimen, and laxatives, are ordered to keep the
symptoms moderate : as soon as the inflammation subsides,
which is generally about the tenth or twelfth day, the se-
ton is to be diminished at every subsequent dressing, by
withdrawing six or eight threads : the dressings consist of
a small pledgit on the wounds, and a plaster of ceratum sa-
turninum over the scrotum.
This mode of performing the operation I approve of,
except in the circumstance of introducing the seton, which
I think is more easily executed, and with less danger of
injuring the testicle, in the manner directed in the section
on abscesses.
The operation by the simple incision is thus performed.
The patient being placed on a table of convenient height,
and being properly secured by two assistants, with the
scrotum lying nearly upon the edge of the table, the ope-
rator should grasp the tumor with one hand so as to hold
it firmly, and make it somewhat tense on its anterior part;
and with a common scalpel in the other, he should now
divide the teguments from the superior part of the tumor,
along its anterior surface down to the most depending
part.
The


[ 144 ]
The scrotum retracting a little, the vaginal coat is laid
bare, and the operator is to make an opening into it with
a lancet large enough to receive his fore-finger, at the su-
perior part where the first incision began; the finger be-
ing inserted, the probe pointed bistouri is to be carried a-
long it until the sac is divided quite to its lower extre-
mity.
The incision is directed to be made from above, on ac-
count of its being thus most easily performed ; and to be
carried the whole length of the tumor, because the for-
mation of sinusses is then prevented.
When the sac appears much thickened, it will facilitate
the cure to remove part of it on each side; but when
this is not the case, the dressing should be immediately fi-
nished, in order to prevent any bad effect from the air
coming in contact with, and irritating the testis.
The testicle is generally found to be of a soft texture,
and pale; in some instances it is considerably enlarged;
and in others it is reduced to a very small size : as the
cure advances, however, it generally regains its former
bulk.
It sometimes happens that both sides of the scrotum
are affected with hydrocele: in  such cases,  we are by
some directed to lay both open at the same time by a dou-
ble incision ; but it has been more common, on account of
the inflammation thus induced, to subject the patient to
two distinct operations, by delaying one until a recovery
from the effects of the other. But it is much more ad-
viseable, instead of either of these modes, to lay open the
septum scroti, after operating on one side, and thus effect-
ing the cure of both diseases at once. The partition of the
scrotum is entirely cellular, consequently we run no risk
of doing injury by dividing it. I have done this in two
instances with complete success.
The
2


[ 145 ]
The success of this operation depends very much on a
proper dressing of the wound. If thetesticle has been push-
ed out of the scrotum, it should be immediately replaced,
and a thin piece of soft lint inserted between it and the
edges of the wound, the whole length of the tumor, so
much being left out as will cover the lips of the sore, and
the remainder pushed about half way to the bottom of
the sac. A compress of soft linen is then to be applied o-
ver the tumor, and the whole supported by a suspensory
or T bandage. The patient being now carried to bed, an
anodyne should be given to him; and he should be direct-
ed to avoid motion as much as possible.
The lint is introduced in order to excite an inflamma-
tion over the whole surface of the tunics, and thus prevent
partial adhesions and consequent sinusses.
When the inflammatory symptoms which succeed to
this operation do not run high, it is not necessary to do
any thing for some days ; but when they are considerable,
we must employ blood-letting, laxatives, and a cooling diet;
and apply fomentations and poultices to the part, in order to
induce a plentiful suppuration, which tends more effectu-
ally than any thing else to take off bad symptoms.
In general, about the fourth day the parts should be
fomented and poulticed; and by the fifth or sixth the
dressings come off. The edges of the sore now appear
hard and swelled, and the matter discharged is thin and
discoloured ; the lint should then be all removed as soon
as it will come away easily, which is usually at the third
or fourth dressing. The sore should be dressed every day
or two, according to  the quantity of the discharge; and
the poultices should be continued till a plentiful suppuration
comes on, which generally happens by the twelfth or four-
teenth day.
The swelling and sore now gradually lessening, the only
dressing necessary, is lint covered with a pledgit of cerate;
T and


[ 146 ]
and in four, five, or six weeks, according to circum-
stances, the cure is completed.
From an attentive observation of the effects of the three
modes of operation last described, in a very great variety
of cases, in different places, I am induced to conclude that
they are all equally capable of producing a radical cure;
but that the simple incision effects this with less trouble to
the operator and risk to the patient than either of the other
two; and that of the others, the caustic is to be preferred
to the seton.
I have seen all these methods produce troublesome symp-
toms ; such as great pain and tension of the abdomen, in-
flammation and fever; but the seton, from the irritation it
gives to the testicle, more frequently occasions them than
either of the others. The seton induces such a plenti-
ful suppuration also, in many cases, that the matter cannot
be evacuated at the openings, and in consequence forms
troublesome sinusses.
Another important objection is, that it does not admit
of a free examination of the testis, or of the fluid contained
in the sac. In simple hydrocele this would be of no con-
sequence ; but if the testicle should be much diseased, the
irritation of the cord on it might produce very troublesome
and alarming symptoms : And there are several instances
upon record in which the first surgeons have mistaken
hydro-sarcocele for simple hydrocele, and vice versa; indeed
in some cases, there is no certain means of discrimination.
In such, the surgeon should always proceed upon the sup-
position of the disease being hydrocele; and if on laying
open the swelling, the testicle should be in such a state as
to require extirpation, it should be immediately removed.
The fluid in hydrocele is frequently contained in hy-
datids: This forms another objection to the seton; which
is obviously illy calculated for its removal in that case.
The


[ 147 ]
The treatment by caustic is liable to one very material
objection, viz. that of being productive of sinusses and
abscesses in the scrotum and cellular substance connecting
this to the tunica vaginalis. This is never the consequence
of the simple incision; and on this account, because it
brings the state of the testicle more evidently into view;
and because experience has taught me that it produces the
least troublesome symptoms, I am clearly of opinion that
it ought to be chosen in preference to the cure by seton or
caustic*.
SECT. IV.
Of the Hydrocele of a Hernial Sac.
THERE are several instances of this disease upon record;
and as it occupies nearly the same situation with the simple
hydrocele of the tunica vaginalis, it is often a matter of
difficulty to distinguish them, and sometimes an impos-
sibility.
In
* The latest experience seems to justify this opinion ; and instead of
applying warm poultices and fomentations, if soft compresses, dipped in
a solution of the saccharum saturni, are immediately laid on the simple
dressings, and kept constantly wet, no more swelling or inflammation
will attend the operation, in most cases, than is necessary to induce a
union of the tunica vaginalis with the testicle.
These tumors are sometimes of a most enormous size.—A man who
had laboured under one for nine years, and worn a suspensory truss for
it as a rupture, had the operation performed by incision, and two gal-
lons of a brown turbid fluid, with a large quantity of a substance like
that of the meliceris, was discharged. The veins of the scrotum were en-
larged like those of the gravid uterus in the last month of pregnancy.
Warm spirituous fomentations and dressings were employed in this case
to restore the lost tone of the parts, and in about six months the wound
was closed, the scrotum and tunica vaginalis contracting to a very mo-
derate size.


[ 148 ]
In this species the testicle is usually more evident at the
lower part of the tumor than in simple hydrocele; but
when the disease is combined with hernia congenita, as it
frequently has been, this will not be the case. When the
parts forming the hernia are down, the fulness they pro-
duce along the spermatic cord, serves in some measure to
denote the complaint And if the watercan be made to pass
into the abdomen by pressure, this affords a certain charac-
eristic : But where it happens that the neck of the sac has
been closed by the pressure of a truss, or any other cause,
this mark cannot appear. In such a case, the only means of
distinction will be, an acquaintance with the previous his-
tory of the disorder :—no bad consequence could however
ensue from a mistake, as the treatment adapted to simple
hydrocele applies equally to this variety.
When the protruded parts still remain down, unless
the operation for bubonocele is submitted to at the same
time, no other should be attempted than that of discharg-
ing the water by means of a small trocar, when the size
of the swelling renders it necessary : because the exposure
of the intestines to the air might be productive of mate-
rial injury.
The simple incision should always be used for the ra-
dical cure of this disease, on account of the risk of injur-
ing parts that might be protruded, by the employment of
the seton, or of caustic.
SECT. V.
Of the Anasarcous Hydrocele of the Spermatic Cord.
THIS disease is seated in the cellular membrane which
envelopes the spermatic process of the peritonæum.
It is, in some instances, symptomatic of ascites or anasarca;
in


[ 149 ]
in other cases, it is a local affection, and is produced from
an obstruction in the lymphatic vessels of the part, by schir-
rous abdominal viscera, or by the pressure of a truss.
When the disease is symptomatic, it is clearly marked;
when it is merely local, it appears as a colourless tumor in
the course of the spermatic cord, soft and inelastic, and
not attended with fluctuation. In an erect posture it is ob-
long, but in a recumbent situation it is more flat, and some-
what round. It does not in common extend lower than
the inferior part of the groin; but in some cases, it goes
quite to the bottom of the testicle, and stretches the scro-
tum to a great size. By pressure the swelling can be made
to recede entirely, or at least in great part, into the cavity
of the abdomen; but it instantly returns to its former si-
tuation on removing the pressure.
When this disease depends on a general affection, it com-
monly disappears with the removal of that affection ; but
when it is local, and has become inconvenient, an incision
is to be made into it, the whole length of the tumor, so as
to evacuate all its contents ; and the wound is then to be
dressed with lint, and treated as a simple sore from any
other cause.
SECT. VI.
Of the Encysied Hydrocele of the Spermatic Cord.
IN this disease the water is contained in one or more dis-
tinct cysts, or cells. It commonly begins by a small tu-
mour in the spermatic process, just above the epidydimis;
although, in some instances, it begins in its superior part.
By degrees it extends upwards, and on some occasions so
far downwards, as to reach from the abdominal muscles
to the bottom of the scrotum. The testis can always
be


[ 150 ]
be distinguished at the back part of this swelling, and quite
unconnected with it: and a fluctuation of fluid is always
perceived on pressure. The tumor is commonly of a pyra-
midal form, and is not at all altered in size by pressure.
When the water is contained in two cells, the line of
division is commonly evident, by the tumor being there
somewhat puckered, or sometimes diminished in its dia-
meter. A similar appearance takes place when this species
is combined with a real hydrocele of the tunica vaginalis,
at the upper extremity of the tunic.
The diseases with which this is most likely to be con-
founded, are the hydrocele of the vaginal tunic, the ana-
sarcous hydrocele of the spermatic cord, and a hernia of
the intestines or omentum. But an attentive consideration
of the phœnomena of these complaints, and of those at-
tending the one we are treating of, will in general effec-
tually prevent the mistaking one for any other of them.
This, as well as the anasarcous hydrocele of the cord, and
the œdematous tumor of the scrotum, are all frequent in
infancy. They are then, in common, soon removed by the
application of spirit of wine, or infusion of rose leaves with
alum. Dr Monro recommends the fumes of benzoin.
But in adults, these applications are seldom effectual; and
we are under the necessity of employing an operation, as in
hydrocele of the vaginal tunic, when it arrives at an in-
convenient size.
In accomplishing a radical cure, the incision is particu-
larly proper on account of the water being sometimes con-
tained in more than one cyst; and because there is a possi-
bility of confounding this disease with hydrocele accompa-
nied by hernia.
In the description we have given of the five species of
of hydrocele, we have necessarily enumerated the particu-
lar symptoms of each uncombined with those of any o-
ther ; but it sometimes happens that two, three,  or even
four


[ 151 ]
four, occur at the same time in the same person. In such
cases there will sometimes be considerable difficulty in ascer-
taining the precise state of the complaints; we can only
form a judgment of this, however, from an attention to the
symptoms which usually happen in the separate state of
each variety.
CHAP. X.
Of the Hematocele.
THE hematocele is a tumor in the scrotum or sper-
matic cord produced by extravasated blood. Its
usual seat is in the tunica vaginalis; but it is sometimes
produced in the spermatic process, and now and then in
the dartos.
Tumors of this kind are usually the consequence of a
rupture of some of the blood vessels of the parts, from exter-
nal violence. They have been occasioned by blows, and by
a wound from a trocar or lancet in tapping for the hydro-
cele. In the latter case, the water drawn off is, in com-
mon immediately tinged with blood; but in some in-
stances, this is not the case; and the effects of the accident
do not appear until all the water is evacuated, and then a
tumor of considerable size is frequently produced in a very
short space of time. In very large hydroceles the blood
vessels have been ruptured merely from taking away the
support which they have received from the pressure of the
water by its sudden evacuation.
Hematocele


[ 152 ]
Hematocele when seated in the scrotum, is to be distin-
guished from hydrocele by the livid colour of the parts ;
and when in the tunica vaginalis, by the greater weight of
the tumor in proportion to its bulk, and often by the man-
ner of its production.
In the beginning of the anasarcous or diffused hemato-
cele, whether it be seated in the scrotum or spermatic pro-
cess, when produced by slight external violence, the appli-
cation of ardent spirits, or of a solution of alum, will some-
times effect a discussion: but if this fails, the tumor is
to be laid open, and treated as a hydrocele; except that if
a ruptured blood-vessel is discovered, it will be absolutely
necessary to secure it by a ligature. The hematocele of
the vaginal coat is to be removed by a similar operation:
But when the bleeding vessels cannot be detected, as some-
times happens also in the hematocele of the spermatic pro-
cess, and the hemorrhage cannot be restrained by the usual
remedies, we are under the necessity of having recourse to ex-
tirpation of the testicle, as the only effectual means of relief.
Mr Pott describes a species of hematocele, in which the
blood is contained within the tunica albuginea testis;
which he thinks proceeds from a relaxation or dissolution
of part of the vascular structure of the testis ; and which
when any considerable quantity of fluid is collected,
produces a fluctuation somewhat like that of a hydrocele
of the vaginal tunic.
When this affection is mistaken for a hydrocele, and an
opening is made with a trocar, a dark-coloured blood is
discharged nearly of the consistence of thin chocolate ; but
although the swelling is somewhat lessened by the operation,
yet no considerable alteration is effected by it; and as the
testicle is rendered useless by the disease, Mr Pott advises
its removal, as the only effectual remedy.
I have met with a disease very similar to this ; except that
the blood never appeared to be extravasated, but to be still
contained
3


[ 153 ]
contained in the vessels of the testis; although they were
in an enlarged state. In such cases, when nothing more
was done than merely to support the parts by a suspensory,
they have continued stationary for a great length of time;
a circumstance which does not occur either in true hema-
tocele, or in hydrocele: but where upon the supposi-
tion of the collection being a hydrocele, an instrument
was introduced for the evacuation of its contents, the
tumor became painful, and increased, and at length
grew so troublesome by frequent discharges of blood, that
castration was rendered absolutely necessary.
But even extirpation of the testicle does not afford relief
in every case; for the blood-vessels of the whole spermati-
cord sometimes become so soft and spongy, that fresh he-
morrhagies occur, perhaps at  every dressing, and render
repeated ligatures necessary. And in one case in which I
was concerned, the hemorrhage burst out so repeatedly,
that the patient at length died from the effects of it.
This tumor is to be distinguished from hydrocele, by
being heavier in proportion to its size ; by the fluctuation
being less evident; and by an increase of it being prevent-
ed by the use of a suspensory bandage.
U CHAP.


[ 154 ]
CHAP. XI.
Of the Varicocele, Cirsocele, Spermatocele,
and Pneumatocele.
BY the first of these terms is meant, a varicose disten-
sion of the veins of the scrotum; which form a tu-
mor of hard knotty inequalities, seldom attended with
pain, and only inconvenient from its size.
The cirsocele is a tumour of the same nature, seated in the
spermatic vein, and extending from the superior part of
the scrotum to the abdominal muscles;
Both these affections are sometimes produced by tu-
mors, the pressure of a truss, or other causes of obstruct-
tion to the return of the venous blood:—in such cases
the removal of these causes should therefore be the first
step towards a cure.
But when a general relaxed state of the veins gives rise
to them, and this is the melt common cause, remedies to
recover their lost tone should be employed. For this pur-
pose, we should direct the use of a suspensory bandage; a
horizontal posture; the cold bath; and the application of
a solution of alum and other astringents to the parts affected.
By these means every affection of this kind may be pre-
vented from increasing, and so far relieved as to render the
harsh modes of cure by the knife, the cautery and ligature,
recommended by ancient writers, unnecessary.
By the term spermatocele is meant a morbid distension
of the epidydimis and vas deferens, produced by a stagna-
tion


[ 155 ]
tion of semen. This may be occasioned by tumors, stric-
ture, or inflammation about the caput gallinaginis, or in
the course of the vas deferens: the last is probably the
most frequent cause.
Inflammation is to be removed by the common remedies.
In general tumors should be either extirpated or brought
to suppuration; if they are venereal, a mercurial course
should be directed. Castration has sometimes been em-
ployed as a dernier resort; but we cannot suppose it ever
to be very necessary.
The appellation of pneumatocele has been applied to tu-
mors of the scrotum produced by air. This disease has
been described by the ancients as a frequent occurrence;
but it is extremely doubtful whether it ever exists as a lo-
cal affection : and it is most probable that hernia or hy-
drocele have been usually mistaken for it. As a part of
general disease, it may happen either from a wound of
the lungs, or from a putrescent state of the fluids. In the
former case, punctures with a lancet will be an effectual
mode of cure; but in the latter, nothing will probably be
of any advantage.
CHAP.


[ 156 ]
CHAP. XII.
Of the Sarcocele, or Schirrous Testicle.
BY sarcocele is understood a firm fleshy kind of en-
largement of the testicle; much more hard than that
occasioned by inflammation.
An unusual degree of hardness, attended with a trifling
enlargement, and inconsiderable pain of the testicle, are the
usual indications of the commencement of this disease:
these symptoms gradually increase for some time; and
then often remain stationary for a great length of time.
In a very few instances they have been prevented from in-
creasing, or even removed, by a moderate diet, keeping
the belly open, a proper suspension of the tumor, and a-
voiding violent exercise. Such instances are however
very rare; and generally in more or less time, the tumor
becomes larger; grows ragged and unequal on its surface;
and the pain becomes more severe, frequently darting sud-
denly through the substance of the swelling.
The inequalities on the surface of the tumor increase by
degrees :—on some occasions, a considerable quantity of
serum is extravasated into the tunica vaginalis, and gives
the appearance of a common hydrocele; at other times,
partial collections of matter are formed throughout the
body of the tumor; which increasing, at length the scro-
tum bursts, and a thin fœtid bloody matter is discharged.
The spermatic cord, after the tumor has acquired a con-
siderable size, becomes hard and enlarged, but seldom be-
fore;


[ 157 ]
fore; and often not till matter has been formed. By de-
grees it grows very knotty and painful throughout its
whole extent.
Although the discharge of matter increases in quantity,
the tumor instead of lessening continues to increase; the
edges of the sores become hard, livid, and retorted; and
fungous excrescences shoot out from different parts of
them.
The patient now becomes emaciated and pale; and the
disease, which in this stage is a most malignant cancer, con-
stantly increasing, at length carries him off in the greatest
misery.
This is the general progress of the complaint, unless it
is interrupted by a timely extirpation. But as it assumes a
great variety of appearances, it is impossible to convey a clear
idea of them in description. In some instances the tumor
remains almost indolent for a number of years ; while in
other cases, it goes through all the stages we have descri-
bed in the course of a few months.
In the greatest number of cases, the disease begins in the
testis ; but it now and then makes its appearance first in
the epididymis, and sometimes even in the spermatic cord.
Hernia humoralis seldom terminates in sarcocele, but
there are indisputable evidences of its ending, in some in-
stances, in that disease.
Schirrous affections of the testicle have been attri-
buted to the water sometimes met with in the tunica vagi-
nalis at the same time; but there can be little doubt but
that this collection of fluid is produced by the disease of
the testis, and ought not to be considered as the primary
affection. The disease formed by this combination has
been termed hydro-sarcocele; and it is often with difficulty
distinguished from simple hydrocele. In some instances
there is no possibility of determining the real nature of the
case


[ 158 ]
case, but from exposure of the parts by an incision. The
previous history of the disease must give the chief light in
these doubtful instances.
In forming a prognosis in sarcocele, we are to be direct-
ed by the age and habit of the patient, the duration of the
disease, and its state at the time.
Thus, we may have more hopes of success in young
healthy subjects, particularly if extirpation is to be ad-
vised, than in those of an advanced age and infirm habit;
and indeed when the system is otherwise much diseased,
there can be little or no advantage expected from any
thing.
If the complaint has proceeded very slowly, there is
reason to think that it is of a mild nature, and that the
habit is not so much affected as if its progress has been
very rapid.
And, as long as the testicle is only somewhat hard and
enlarged, without the formation of matter, and without any
disease of the cord, if the constitution is otherwise healthy,
there is a probability Of success from any operation that
ought to take place; but when the opposites of these cir-
cumstances occur, and particularly if there is an ulceration
of the testis, there will be little reason to expect a favour-
able event.
With respect to the spermatic cord, whenever this is
merely enlarged by the weight of the testicle producing a
varicose state of its vessels, or a watery deposition in its
cellular substance, and is not painful in itself, the extirpa-
tion of the testicle may be admitted, if no circumstance of
general disease forbids it; but if the cord has become en-
larged, hard, knotty, painful to the touch, adherent to the
neighbouring parts, and ulcerated, and the affection ex-
tends quite up to the abdominal muscles, castration should
always be forbid.
No remedy but extirpation can be depended on for the
removal


[ 159 ]
removal of sarcocele The most important circumstance
to be determined then, is the period at which the opera-
tion is most adviseable.
Although this disease, in some instances, remains station-
ary for a long time, or proceeds very slowly, yet in the
greater number of cases, its progress is very rapid. When
therefore, bleeding, laxatives, a suspensory bandage, or
mercury, when it has probably originated from a venereal
source and other occasional remedies, have been ineffec-
tual, and the tumor daily increases in size, and becomes
more painful, the operation should be instituted without
delay; but while the disease remains stationary and indo-
lent, it can never be considered as absolutely necessary.
The method of performing castration is as follows :—-
The patient must be placed horizontally on a table of con-
venient height, with his legs hanging down, to be secured
by an assistant on each side. The parts being previously
shaved, an assistant must hold the tumor, if very large, if
it is not, the surgeon should manage it himself. Grasping
it firmly with one hand, he should make an incision with
a scalpel in the other, along the whole extent of it, be-
ginning at least an inch above the part where the cord is
to be cut, and carrying it through the skin and cellu-
lar substance quite down to the end of the scrotum, by
one cut of the knife.
The vas deferens should then be separated from the blood-
vessels; and a firm waxed ligature being carried around the
artery and vein, avoiding the nerve, by means of the cur-
ved blunt needle, (plate vii. fig. 2.) a running knot should
be made on them, a quarter of an inch above where the
cord is to be divided.
The cord being here cut across, the lower part of it and
the testicle, are then to be dissected out with the scalpel.
When this is effected, the ligature is to be untied, and the
artery and vein, if possible, separated from the nerve by the
tenaculum,


[ 160 ]
tenaculum, and secured. The ligature above may be left
loose, and is to serve as a security against hemorrhagy.
When it is necessary to divide the cord near to the o-
pening in the abdominal muscle, it will be proper to leave
the ligatures a few inches long, lest a retraction of the
cord within the abdomen, which sometimes happens
when it has been much separated from the parts beneath,
should take place. If the scrotal artery should be divided
during the operation, it should be immediately tied.
The wound is now to be dressed with soft lint, secured
by a compress, and the T bandage, or a suspensory bag.
The patient being then laid to rest, and an opiate admi-
nistered, the sore should not be dressed till a free suppura-
tion takes place; which will generally happen about the
fifth or sixth day ; and the dressings may afterwards be re-
newed once in two days, or oftener, according to circum-
stances.
Sometimes, after this operation the patient complains of
much pain in the sore, and of tension and uneasiness over
the abdomen : in these cases, warm fomentations should
be applied to the abdomen, and an emollient poultice to
the sore.
In performing castration, no portion of the skin should
be removed, unless from the size of the tumor it has be-
come very thin, or it is inflamed or ulcerated; in which
cases, after making the first incision to the extremity of the
spermatic cord, two semilunar incisions should be conti-
nued to the end of the scrotum, so as to include all the
diseased skin ; and this is to be afterwards dissected off
with the testicle.
3 CHAP


[ 161 ]
CHAP. XIII.
Of the Diseases of the Penis.
SECT. I.
Of the Phymosis.
THE disease called phymosis is formed when the pre-
puce has got forward over the glans penis, and
cannot be drawn back;
It is produced by whatever tends to swell the glans, or
to excite inflammation and stricture of the preputium: and
in some people, the prepuce is so tight, as to render them
liable to this disease from very trifling causes; It origi-
nates frequently from allowing a collection of the mu-
cus behind the glans to take place, and continue till it be-
comes acrid ; but the most frequent cause of it is the ap-
plication of the venereal virus to these parts.
In slight and recent cases, warm emollient fomentations
and poultices are commonly effectual remedies. At the same
time it will be proper to inject part of the fomentation
between the prepuce and glans frequently, in order to re-
move any matter that may be there accumulated from
chancres or other causes.
When the inflammation is very considerable, blood-let-
ting may be necessary; and this will be more effectual if
the blood can be taken from the penis by the lancet; if
this cannot be accomplished, it may be drawn from the
arm. Topical bleeding by leeches might be very useful ;
X but


[ 162 ]
but when the disease originates from a venereal cause,
the wounds thus caused are apt to terminate in troublesome
sores. Laxatives, rest, and low diet, should also be di-
rected.
When all these remedies fail, and especially if chan-
cres are confined under the prepuce, the discharge from
which might injure the prepuce and glans, it will be ne-
cessary to remove the stricture by cutting through the
prepuce its whole length. This will be most easily
and effectually accomplished by a very small bistouri,
concealed in the groove of a director, and somewhat
curved at its extremity. These being introduced between
the glans and prepuce, to the upper part of the latter, the
operator is to keep the director firm with one hand, and
with the other is to push the point of the knife through
the membrane; the director being then withdrawn, the
bistouri is to be drawn forward so as to divide the pre-
puce entirely.
The operation should be performed on the side of the
penis, in order more effectually to avoid the large veins.
The parts beneath should now be cleaned with warm
water; and the sore being covered by lint, and a compress
of linen laid over it, the whole may be secured by a small
linen bag connected to a circular band around the body.
In the subsequent treatment, care should be taken to
insert a piece of lint between the divided prepuce and
glans, otherwise troublesome adhesions may take place;
and if the venereal disease exists in the habit, a mercurial
course will be absolutely necessary to the healing of the
sore.
In cases where the prepuce is found excessively long,
instead of dividing it longitudinally, it will be better to
take off a part of its whole circumference*.
SECT.
* This will be most easily and effectually performed by making
lateral incision first.


[ 163 ]
SECT. II.
Of the Paraphymosis.
BY the term paraphymosis is meant a morbid retraction
of the preputium, producing a stricture behind the glans
penis. This disease is produced most frequently by a ve-
nereal taint; but it may originate from whatever tends to
occasion a preternatural fullness of the glans, or a con-
striction of the prepuce, or both.
In the commencement of this complaint, the prepuce
may be sometimes brought over the glans by pushing the
nut gently back with the thumbs, while the fingers are
employed in moving the prepuce forward; but this should
never be attempted in an advanced stage, as it is then not
only unsuccessful, but often injurious.
As paraphymosis usually arises from an enlargement of
the glans, warm fomentations instead of proving servicea-
ble often do mischief. Nothing answers so well as satur-
nine applications ; and immersing the swelling frequently
in a cold solution of saccharum saturni, will often remove
it when all other remedies fail. When the penis is much
swelled and inflamed, the patient should be kept cool, and
on a low diet, gentle laxatives should be exhibited, and
some blood may be discharged from a vein of the penis.
These remedies will often succeed; but when they are
ineffectual, the swelling and stricture increasing; an œde-
matous swelling appears in the prepuce, and often ac-
quires a considerable size ; and unless the stricture is re-
moved, a mortification of the glans will be very apt to
occur.
When therefore, the means above advised do not remove
the complaint, and the symptoms just mentioned begin to
come on, the stricture should be removed by making a deep
scarification

[ 164 ]
scarification on each side of the penis, directly behind the
glans, about half an inch in length, and of such a depth
as to divide the prepuce just at its termination.
As soon as the hemorrhagy stops, the wound should be
dressed with lint, and a plaster of cerate, and a soft poul-
tice should be applied over the whole tumor. The parts
should afterwards be dressed in the ordinary way. If the
stricture should not have been completely relieved by the
first incision, a second should be made.
Mercury will be necessary, if the cause of the disease has
been venereal.
SECT. III.
Of Amputation of the Penis, &c.
A NECESSITY for amputation of the penis is most com-
monly induced by gangrene from paraphymosis and other
causes, and by cancerous sores affecting it.
In performing this operation, a circular incision is to be
first made through the sound skin on the verge of the sore,
and the skin being then drawn back, all the diseased parts
are to be removed by one stroke of the knife. All the ar-
teries that bleed freely, which are generally two or three
in number, ought then to be secured by ligature; and the
oozing of blood, that afterwards occurs from the surface
of the wound, may sometimes be commanded by sprinkling
the sore with starch, or finely powdered gum arabic: but
when these do not succeed, a small silver canula being in-
troduced into the urethra, and there secured by bandage
the discharge may be restrained by passing a narrow roller,
moderately tight, upon the remaining parts.
It has been recommended by some, in order to avoid
hemorrhagy, to remove the penis by making a ligature
around


[ 165 ]
around it; but it is taken off with much more ease and
certainty by the scalpel. Others are so little apprehensive
of hemorrhagy, that they advise us to trust entirely to
compression for restraining it. I once saw a patient lose
his life by following this plan*.
The wound should be dressed with lint, covered with
starch, or powdered gum arabic, and a compress of linen,
with a hole in it large enough to pass over the canula, be-
ing applied, the whole should be secured by the T band-
age. The subsequent treatment must be similar to that
of wounds mother parts.
Before proceeding to this operation, it should be known
with certainty, whether the glans penis is really diseased;
and when there is any doubt, the prepuce should be taken
off to ascertain it.
When the frenum of the penis is so short as to produce
uneasiness or pain on erection, it may with the utmost
safety be divided by a pair of scissars; and after this is
done, a piece of lint should be inserted between the lips of
the wound to prevent their re-union.
It sometimes happens, that the urethra in male children
terminates before it reaches the end of the penis. Some-
times there is no external opening; at other times, there is
a small orifice at some distance from the extremity of the
yard.
When there is no opening externally, if the urine is
found to stop at a particular part, the introduction of a
small trocar from the  point of the yard, along the course
that the urethra ought to take, until it meets with the urine,
will always afford immediate relief; and by the use of
small bougies the sides of the passage may be rendered cal-
lous, and an opening thus preserved. But when any open-
ing
* In two cases of amputation of the penis in the Pennsylvania hospital,
a very trifling hemorrhage was easily restrained by dry lint, and mode-
rate compression.


[ 166 ]
ing is discovered, whatever be its situation, if it affords a
passage to the urine, the operation had better be delayed to
a more advanced age, when a piece of flexible catheter can
be introduced to preserve the opening made by the tro-
car.
CHAP. XIV.
Of the Stone. 
SECT. I.
General Remarks on urinary Calculi.
PARTICLES of stone have been formed in almost
every cavity of the body, but they are most frequent
ly met with in the urinary organs. A variety of cau-
ses may concur  in producing this  deposition of earthy
matter from the blood or secretions.
1. If a greater quantity of earthy substance be taken into
the circulating fluids than can be suspended by them, the
superabundance must necessarily be separated; and the
deposition will most readily take place in the bladder and
kidneys, from the urine containing a greater proportion of
earth than any of the other secretions.
2. There is reason to suppose that a long continued use
of water, or of wines which contain a great quantity of
earth, has a tendency to overcharge the circulating fluids
with earthy matter.
3. A


[ 167 ]
3. A constant use of a great proportion of solid food
seems to have a considerable effect in producing an accu-
mulation of earthy matter in the fluids ; and hence, in such
cases, probably arises the benefit from directing a large use
of diluting drinks.
4. A superabundance of earthy matter being once pro-
duced in the blood, various circumstances may concur to
form depositions of it in the different cavities; of these,
a sedentary life is one of the principal; and hence those
who use least bodily exertion are most subject to calculous
complaints. When they occur in poor labouring people,
as they frequently do, they may with probability be attri-
buted to their diet; the effects of which are too powerful
to be obviated by exercise.
5. Whatever effects predisposition may have in occasi-
oning calculi, the introduction of any substance that can
serve as a nucleus, will almost certainly produce a stone,
in whatever cavity it is lodged. Thus, a particle of sand,
of blood or coagulable lymph, may, in consequence of
spasm or inflammation, be confined in the pelvis of the kid-
ney or bladder, and there acquire such a size, from the
constant deposition of earthy matter, that it cannot be car-
ried off by the urine; and afterwards, in  a longer or shorter
time, acquire a considerable size, according to the quantity
of earth with which the urine is impregnated.
It is very doubtful, whether a stone is ever formed in
the urinary passages without the intervention of a nucleus.
Nuclei of various kinds, such as hairs, needles, musket and
pistol bullets, pieces of bougies, and a variety of other ar-
ticles, have been met with in the centre of urinary calculi;
but particles of blood, or coagulable lymph, most frequent-
ly produce them.
By a difference of food at different periods of the disease;
by the stone being formed slowly or more quickly; and
perhaps by other causes not known, or not easily expli-
cable


[ 168 ]
cable when known, it commonly happens that the differ-
ent lamellæ of which calculi are composed vary consider-
ably in colour and consistence; thus the external layer is
frequently soft and friable, the next hard as marble, and
the internal lamella as soft as dough.
Calculi that are hard, covered with spiculæ, or large, are
usually productive of more bad symptoms than those that
are soft, smooth, or small.
One of the first symptoms of urinary calculus, is an uneasy
sensation at the end of the urethra, which, for some time,
is only discovered on taking violent exercise, or immediate-
ly after voiding urine. This becomes by degrees more
severe and frequent. There is a strong propensity to make
urine frequently; and it is commonly voided in small quan-
tities, perhaps drop by drop. When flowing in a full
stream, it often stops suddenly, and particularly when
there is much collected. Nor do the efforts of the patient
answer any good purpose, unless he changes his posture :
For as the obstruction proceeds from the stone bearing
against the neck of the bladder and orifice of the urethra,
nothing else but its removal from that situation will afford
relief; and this is best effected by elevating the pelvis.
The urine is sometimes clear; but it is usually thick, and
deposits a mucous sediment; and when the disease is in
violent degree, it is sometimes tinged with blood. When
the stone is large, a dull uneasy sensation is always expe-
rienced about the neck of the bladder ; and the irritation
produced by it frequently induces a very troublesome to
nesmus.
All these symptoms are uniformly increased by exer-
cise, particularly by riding on horseback :—from a long
continuance of pain, and the want of rest which constant-
ly is induced, the patient's general health becomes much
impaired; and unless the cause of the disease is now re-
moved, his misery is, in general, only terminated by death.
2 The



[ 169 ]
The existence of calculus can only be rendered certain
by the patient's passing small stones or fragments of stones
with the urine, or by feeling the stone in the bladder by
the intervention of a found: because all the abovemention-
ed symptoms may originate from a tumor or ulcer in the
bladder, or from tumors pressing on the neck of the blad-
der. However there will, in general, be great reason to
suppose it when all or most of the phenomena described
occur.
The sound also affords us, in many instances, the only
means of determining whether the calculus be seated in the
bladder, ureter, or kidney. For although a stone in the
pelvis renis usually produces symptoms which do not in com-
mon attend vesical calculus, such as pain the back, frequent
nausea, retching and vomiting, yet these are not such inva-
riable concomitants as to afford any certain characteristic.
SECT. II.
Of founding or searching for the Stone*.
THE operation of founding is thus to be performed :—
the patient being laid upon a bed, with his thighs some-
what elevated, the surgeon is to grasp the penis with the
left hand, and then introducing the found (pi. iii. fig. 3).
previously warmed and oiled, into the urethra, with the
concave side towards the abdomen, he must push it gently
forward with his right hand, while he draws the penis
on the instrument with his left.
When the sound is carried a sufficient length, it will com-
monly slip easily into the bladder; but now and then
Y some
* The instrument termed a catheter, and by means of which it is some-
times necessary to evacuate the urine, is used exactly in the mode here
directed for the introduction of the sound.


[ 170 ]
some difficulty is experienced in passing through that part
of the urethra which is surrounded by the prostate gland;
when the instrument stops here, we should not attempt to
force it forward, as it may thus be made to penetrate thro’
the urethra; but the fore-finger of the left hand, well
oiled, should be introduced into the rectum, which by ele-
vating the staff at the same time that it is gently pushed on-
ward, will commonly procure its easy entrance into the
bladder. Depressing the handle of the sound will some-
times answer the purpose, but the above described mode is
usually more effectual.
This is sometimes a difficult operation, and it requires
frequent performance to execute it with dexterity: an ex-
pert surgeon however will seldom fail in it, if the parts are
not much affected with inflammation, swelling, or ulcera-
tion.
The staff, when entered into the bladder, is to be gently
moved about with one hand, in order to make it touch the
stone. When the calculus is small, it may lie near the
neck of the bladder in such a manner as to suffer the sound
to pass over it; when this is suspected, a finger should be
introduced into the rectum to alter its situation. If this
should not succeed, the patient should be put into, a variety
of postures until the stone can be felt. The best position, in
general, is to have the pelvis elevated above the trunk and
head : by this, if the stone is not contained in a cyst, which
rarely happens, it may commonly be moved to the fundus
vesicæ.
The operation should be repeated several times when
there is room to suspect a calculus, and it is not discovered
by the first attempt.
The sensation communicated to the operator when a stone
strikes the staff is so peculiar, that an attentive and expe-
rienced surgeon can never be deceived in it; but, in some
instances, 


[ 171 ]
instances, a hardened state of the bladder has unfortunately
been mistaken for a stone,
SECT. III.
General Remarks on the Operation of Lithotomy.
THE presence of a stone in the bladder being ascertain-
ed, the means to be employed for the patient's relief is the
next object of consideration.
Although lime-water, diluted caustic alkali, and some
other articles have, in particular instances, mitigated the
pain, and lessened the frequency of paroxysms ; yet there
has not been one case well authenticated, in which the
stone in the bladder has been dissolved by the use of any
remedy whatever.
As all lithontriptics are liable to material changes in
their passage from the stomach to the bladder, it has been
proposed to inject such substances into the bladder, and
thus bring them into immediate contact with the stone.
But it has been found by various experiments, that no sub-
stance powerful enough to have any effect upon a stone,
can be thus injected, without the greatest hazard of injur-
ing the bladder very materially.
From what has been said, it appears that no hopes can
reasonably entertained of the removal of a calculus, but by
a chirurgical operation.
Although a great proportion of those who are cut for
the stone recover, yet a considerable degree of danger al-
ways attends the operation. Children appear to recover
more readily from its effects than adults ; and it is likewise
observed, that old people from the fifty-fifth to the se-
ventieth year, whose constitutions have not been much
broken, run less risk than men in the full vigour of
life.


[ 172 ]
life. This seems to arise from inflammatory symptoms
being then less apt to supervene ; for from these the chief
danger of the operation is produced. But at whatever
period of life the patient may be, the event will be fa-
vourable or otherwise according to the general health, and
degree or continuance of the topical affection.
If the bladder has even become ulcerated, and the pa-
tient is young, and his general health is so good that we
need not be apprehensive of the effects of the hemorrhagy,
the operation may be tried ; but if, on the contrary, toge-
ther with an ulcer in the bladder, the patient is advanced
in life and infirm, we should advise the palliatives, a
free use of mucilaginous drinks, the warm-bath and
opium, and avoid the operation; as it would most proba-
bly, in such circumstances, be fatal.
There have been various modes of performing the ope-
ration of lithotomy used at different times, and in different
places. In performing it by the lesser apparatus, or cutting
on the gripe, the finger is introduced into the rectum, and
the stone pushed by it towards the perinæum; an incision
is then made immediately on the tumor formed by it
into the bladder, and the stone removed. This was
the only mode in use from the time of Hippocrates to  the
beginning of the fifteenth century ; when Johannes de
Romanis proposed the operation by the greater apparatus,
which was performed nearly in the manner of the lateral
operation, except that a blunt gorget, or some other instru-
ment was used, by which the parts were directed to be
dilated for the passage of the stone; but it always happen-
ed that they were much torn. The inconveniences that
were found to attend this method, suggested the idea of
cutting into the bladder immediately above the os pubis.
This was first practised by Franco, a French surgeon, who
published an account of it in 1561. It has been termed
the


[ 173 ]
the high operation ;  and was much used in many parts of
Europe till near 1730.
As all these methods of operation have been by expe-
rience found much more objectionable than the lateral o-
peration, they have for many years past given place to it
almost universally*.
SECT. IV.
Of the Lateral Operation.
This operation was invented by Frere Jaques, a French
ecclesiastic, about the year 1697. Since that time it has
undergone various alterations.—We shall describe it in its
most improved form.
In order to prevent the patient from going to stool soon
after the operation, the bowels ought to be well emptied
by a laxative given the preceding day; and a clyster should
be exhibited a few hours before the operation, with a
view to evacuate entirely the contents of the rectum.—As
the bladder, when in a collapsed state, is liable to be cut in
different places, the patient ought to drink plentifully of
some diluting liquor, and to retain his urine for some
hours before he is laid upon the table; and when the
urine cannot be retained voluntarily, it will be proper to
use a flight compression on the penis.
The perinæum and parts about the anus being shaved,
the patient is now to be laid upon a table of convenient
height firmly fixed, and there well secured in the follow-
ing manner: Let a noose be formed in the double of a
piece of broad strong tape about three feet in length ;
the patient's wrist being introduced at this noose, he
ought
* For this reason, it is thought unnecessary to enter into a particular de-
tail respecting them in this work. 


[ 174 ]
ought then to take a firm hold of the outside of the ancle
of the same side, when, by different turns of the tape a-
round the hand, ancle and foot, they are to be well se-
cured together ; and the hand and foot of the other side
are afterwards to be tied in the same manner.
The operator must now introduce a grooved staff, (plate
iii. fig. 6) of a proper size; and the stone being again dis-
tinctly felt, not only by the surgeon, but by the assistants
also, the patient must then be put into the posture in
which he is to be kept during the remainder of the operat
tion. A pillow, for convenience, may be placed under
his head ; and in order to elevate the pelvis considerably
above the abdomen, two pillows at least, should be laid
under the buttocks, which ought to project an inch or
two over the end of the table. By observing this direction,
we give less chance of injuring the bladder in several pla-
ces, and more particularly if it should not be distended
during the operation.
There should be an assistant on each side, to secure the
arms and legs of the patient; one must prevent him from
moving the upper part of his body, another must ma-
nage the staff, and a fifth will be necessary to hand the in-
struments to the operator.
The surgeon, after having again felt the stone with
the staff, is now to make the handle of it pass over the
right groin of the patient, so that the instrument may be
felt on the left side of the perinæum ; and in this position
it ought to be preserved by the assistant, who with his
right hand should hold the handle of the staff, while with
his left he elevates and supports the scrotum.
The thighs of the patient being sufficiently separated
by the assistants ; and the surgeon being seated between
the patient and the window, in such a manner as to make
the light fall directly upon the parts to be cut, an inci-
sion is now to be made through the skin and cellular sub-
stance,


[ 175 ]
stance, at least four inches in length in a full grown per-
son, and proportionably less in smaller people ; beginning
a little to the left side of the rapha, about an inch from
the termination of the scrotum, and proceeding in an ob-
lique direction along the perinæum, between the tubero-
sity of the ischium and the anus, until it is extended at
least an inch beyond the latter. This should be done by
one stroke of the scalpel: by a continuation of the inci-
sion, the erector penis, accelerator urinæ, the transversa-
lis perinæi, and levator ani, are also to be divided. If
in making this incision any considerable vessel should
be cut, and especially if the patient is much weakened, it
should be immediately tied.
It is to be particularly observed, that the easy extraction
of the stone, and tying of arteries that may be cut, depends
very much on these incisions being very freely made.
The operator is now to search for the staff with the
fore-finger of the left hand; and having found it, he is to
push his finger along the course of it till he passes the bulb
of the urethra, when, with the edge of his knife turned
towards the groove of the staff, he is to divide the mem-
branous part in its whole course, from the bulb to the
prostate gland, by one cut of the scalpel; and as the fin-
ger is made use of as a director, and kept between the
rectum and the knife, the gut is thus preserved from in-
jury, and the incision made with perfect safety. A divi-
sion of the bulb of the urethra, as  commonly directed, is
never necessary, and is almost always succeeded by con-
siderable hemorrhagy, and the formation of sinusses.
The prostate gland, which may be evidently discovered
by the finger, is next to be divided. This may be done
by an expert surgeon with a lateral stroke of the scalpel ;
but as in the hands of common operators, the rectum
might be frequently wounded by the knife, it will be best
to employ the cutting gorget (pl. iv. fig. 3) as commonly
directed


[ 176 ]
directed, or what I consider as superior to this, a cutting
director*, (pl. v. fig. 1,4.) In using these, the nail of the
index of the left hand ought to serve as a conductor to
the beak of the gorget or director; which being introdu-
ced into the groove of the staff, the surgeon is now to rife
from his seat, take that instrument from the assistant;
and having raised it so as to form nearly a right angle
with the body of the patient, he must, with his left hand,
hold it firm in this situation; while, with his right, he
pushes on the director, taking great care that the point
be kept in the groove of the staff, till it has passed freely
into the bladder; a circumstance which is evidenced by the
urine rushing freely out at the wound.
The staff is now to be withdrawn, and the finger to be
introduced, in order, if possible, to discover the situation of
the stone; a pair of forceps (pi. iv. fig. i, 4.) is then to be
carried along the gorget or director into the bladder, and
the latter is then to be taken out slowly, and in the same
direction in which it Was entered, left any part might be
cut unnecessarily.
If the stone has been previously discovered by the finger,
it is commonly easily laid hold of with the forceps ; but
when its situation is not known, it is often difficult to
meet with it. The forceps must necessarily be introduced
shut; but as soon as they have entered the bladder, they
should
* Mr Bell says, that his cutting director, from expanding more in the cut-
ting part, divides the prostate gland, &c. much better and more freely
than the gorget; and from being more contracted in the blunt part,
gives less chance of injuring the urethra, by bruising or lacerating it—
But the contusion or laceration of the urethra or bladder is not occasion-
ed by the blunt part of the gorget, but by the extraction of the stone,
particularly when it is large ; in which case, an enlargement of the wound
with the scalpel, upon the stone, is perhaps preferable to breaking it with
the forceps. Mr Bell's cutting director does not appear to possess as much
certainty in its direction and management as Mr Hawkin's cutting gor-
get ; and still wants the test of more general experience to recommend it. 


[ 177 ]
should be gradually opened, and there moved about in
various directions, until the stone can be laid hold of.
When the calculus is small and difficult to find, it is most
frequently concealed in the lower part of the bladder near
its neck; in this case it may be brought within reach of the
forceps by introducing the finger into the rectum, and
thus elevating this part of the bladder*.
When the stone is got within the forceps, the operator
should introduce his finger, to discover whether it is pro-
perly fixed ; and if he finds that a stone of any considera-
ble length is laid hold of in such a manner as to make its
longest diameter press transversely with respect to the o-
pening in the bladder, it should be turned with the finger;
or if this cannot be done, it should be suffered to slip out
of the instrument, and again be laid hold of, if possible, in
a more favourable position. The surgeon should then
gradually extract it; having his right hand firmly fixed
on the extremity of the handles of the forceps, and the
Z left
* Mr Bell tells us that when much difficulty occurs in discovering a
stone, it has been alledged that  it is often contained in a cyst ;-he
acknowledges that the stone is often covered with coagulable lymph,
which gives the appearance of a cyst or bag, but says we are unacquaint-
ed with any process by which an adhesion can be produced between the
stone and bladder; and that dissection has never discovered one well au-
thenticated instance of this kind. But the following case would seem to
render this opinion somewhat doubtful.
A boy about sixteen years of age had suffered the severest symptoms of
the stone for several years, has been frequently founded by many gentle-
men of the profession, but no stone could be felt; at length it was slightly
touched by one of them. The operation was then determined on, and
when the operator had introduced his forceps into the bladder, no stone
could be found; upon which he introduced the fore-finger of his left hand
into the bladder, and was enabled to feel a small portion of the stone thro'
an orifice of an apparent cyst in which it was contained ; then carrying
the cutting gorget upon his finger as a director, introduced the beak in-
to the orifice, dilated the cyst, and turned the stone into the common ca-
vity of the bladder, when it was readily laid hold of, and extracted.


[ 178 ]
left near to the common axis, and making the pressure al-
most downwards, in the course of the wound, because he
will thus meet with less resistance, and do less injury, than
by pressing in all directions as we are commonly advised.
When there is considerable resistance to the passage of
the stone, the state of the divided parts should be exami-
ned ; and if any part of the muscles which should have
been cut are still found entire, they should be immediately
laid open with the scalpel, while the forceps is held firm-
ly in the left hand.
As the risk of this operation is in a great measure pro-
portioned to the size of the stone, it would perhaps be ad-
viseable, whenever this is so great as to endanger much
injury to the parts through which it is to be extracted, to
endeavour to break it with the forceps already introduced,
or with a pair with very large teeth and a screw. When
this is done, all the fragments must be carefully removed
by the forceps or scoop, or by injecting large quantities of
warm water.
When a stone is extracted with a smooth polished sur-
face, it is commonly supposed that there are others re-
maining in the bladder, and e contra; but no dependance
can be placed on this; and therefore, as soon as one stone
is extracted, the operator ought to search first with his
finger, and afterwards with the forceps, or what is better,
the searcher*, as long as any stones are to be discovered.
The hemorrhagy from the urethra and bladder should
not, in general, be restrained, until the stones are all ex-
tracted, as it tends to prevent inflammatory symptoms;
when this is accomplished, ligatures may commonly be
made on the arteries, but if this cannot be accomplished,
a large canula, (pl. v. fig. 2) covered with linen, will usu-
ally answer to compress them. But sometimes it happens,
that
* An instrument in the form of a sound, except that it is made gradu-
ally somewhat larger from the beginning of the curvature to the end.


[ 179 ]
that notwithstanding every precaution, some of the deeper
seated vessels will continue to pour out blood, which collects
in the bladder in great quantities. In these case, as much
as possible should be taken out with a scoop, ( pl. iv. fig. 2.)
and warm water then injected to remove the remainder.
In some instances, when this has not been done, the blad-
der has by degrees become filled by a bloody coagulum,
which has prevented the secretion of urine, and at length
occasioned death. In order to prevent such an unfortunate
occurrence as much as possible, the patent should, imme-
diately after the operation, be placed with the pelvis low,
so as to keep the wound in a depending situation. 
As soon as the hemorrhagy has ceased, the patient
should be untied, and a piece of soft lint being insert-
ed between the lips of the wound, the thighs should
be laid together, and the patient carried to bed; when
a large dose of opium should be given to him.
When the stone has been easily extracted, the patient
remains tolerably free from pain, and frequently procures
some sleep during the first three or four hours after the
operation ; but when the stone has been large, and with
difficulty extracted, a severe pain in the lower part of the
the abdomen often supervenes in an hour or two. This is
sometimes easily removed by fomentations and anodyne
clysters : but, in other case, it increases constantly, and
when with this, a hardness and swelling of the abdomen
occur, fullness and quickness of pulse, which go on to be
augmented, much danger is to be apprehended. As these
symptoms originate from inflammation, bleeding, clysters,
warm flannels or bladders of warm water to the abdomen,
should be used freely, according to circumstances ; and
particular benefit is often derived from the semicupium.
These remedies, together with opiates, low diet, and di-
luent drinks, will frequently remove very alarming symp-
toms : but in some instances, notwithstanding every thing 
that


[ 180 ]
that is used, the pain and tension of the abdomen increase;
the wound has an unfavourable appearance; the feverish
symptoms augment; and death at length closes the scene.
When the case terminates happily, the wound by degrees
acquires a healthy aspect; the urine in some instances passes
by the urethra from the beginning ; but in most cases, it
comes away by the wound for the first two or three weeks;
the pain in the abdomen gradually abates; and the feverish
appearances are in a short time entirely removed.
The cure is perfected in a longer or shorter period ac-
cording to the circumstances of the patient's health. In
a few cases of young healthy boys, I have known the
wound cicatrised in less than three weeks ; but in others,
this not accomplished till the sixth, seventh, or eighth
week. In some instances again, although a great part of
the wound is healed readily enough, yet a small opening is
left, at which the urine continues to be discharged, and
which at length becomes fistulous ; this cannot be relieved
but by another operation. The prevention of such an oc-
currence depends very much on a proper dressing of the
wound. The dressings should be light, and care should
be taken that the sore heals properly from the bottom.
In order to prevent a troublesome excoriation of the
buttocks,* which is apt to be occasioned by the constant
passage of the urine over them, they should be frequently
washed with brandy, or with lime-water.
In patients of a weak habit, an incontinence of urine is
apt to succeed to this operation; this commonly goes off
upon a recovery of the former strength; which will be much
aided by a use of the cold bath, of peruvian bark, and of a
nourishing diet. As palliatives for incontinence of urine,
a jugum for compressing the urethra, and a receptacle for
the
* This will be effectually prevented by cleansing the parts with a soft
sponge dipped in milk and water, and anointing them with cream two
or three times a day, changing the under sheet at every dressing.


[ 181 ]
the urine, properly fitted to the penis, and constantly
worn, will be found very useful.
Women, from the shortness of the urethra in them, are
much less liable to the stone than men, and when it does
occur, and an operation becomes necessary, it is much more
easily performed. From the peculiar conformation of the
the female, it cannot be executed in the manner we have
directed for males.
The best mode of performing lithotomy in women is
as follows:—the patient being placed on a table, and se-
cured in the manner already directed, a female grooved
staff is to be passed through the urethra into the bladder;
and the operator keeping it firm with his left hand, is
with his right to introduce the beak of the cutting director
or gorget into the groove, and to run it carefully along till
it has entered the bladder. He should now introduce his
finger upon the director; and having discovered the
stone, he should proceed to extract it in the manner we
have already recommended.
Instead of cutting, it was formerly the practice to attempt
a dilatation of the urethra; but by the instruments used, and
by the passage of the calculus, the parts were so lacerated,
that an enuresis was commonly consequent to the operation.
It has also been proposed to cut into the bladder from the
vagina; but in this mode parts are injured which by the
other method may be avoided; the stone is in many cases
with difficulty discovered, and is not easily extracted:
fistulous sores are very apt to be produced; and a cicatrix is
occasioned which might be productive of pain, obstruc-
tion, and perhaps laceration in delivery, should the patient
afterwards become pregnant. Most of these inconveni-
ences are entirely a voided by the method above advised.
Although the lateral operation is in general to be prefer-
red to any other mode hitherto proposed, yet in cases where
the


[ 182 ]
the stone is known to be of a very large size*, I should
undoubtedly advise the high operation, provided the patient
was of a proper age, i. e. below thirty; for it has universal-
ly happened that those above this age have died, when the
lateral method has been employed. This preference arises
solely from the greater ease in extracting the stone; which
is a circumstance of the utmost consequence; for it ap-
pears from observation, that when the stone is very large,
e. g. above 8 oz. in weight, the proportion of deaths from
the lateral operation, is about 1 to 10 ; whereas when the
stone is small, not above 1 in 20 die from its effects.
Mons. Louis proposes as an improvement on the com-
mon method of performing the lateral operation, to cut
the bladder itself, with an instrument adapted to the pur-
pose, after the external incision, and avoid opening the ure-
thra, or prostate gland. This is said to prevent inconti-
nence of urine, and other troublesome consequences which
often ensue from the operation executed in the common
way. But it is evident, that this method must frequently
produce troublesome fistulous sores in the contiguous
parts, on account of the opening in the bladder receding
from that of the external parts, and thus permitting the
insinuation of the urine among them.
Frere Cosme advises the substitution of an instrument of
his own invention (pi. v. fig. 1). to the gorget, for the di-
vision of the internal parts. In using it, after the staff is
laid bare in the usual manner, the beak of the instrument,
or lithotome caché, as he terms it, is to be introduced
into the groove, and being pushed forward till it reaches
the bladder, the spring is then to be pressed down, so as
to raise the knife from its sheath, when the operation is to
be finished by withdrawing the instrument in such a di-
rection,
* Which may be determined by, or at least inferred from, the long
continuance of the disease ; the sense of weight about the neck of the
bladder; and particularly from the touch of the finger in ano. B.



[ 183 ]
rection, as may divide the neck of the bladder and prostate
gland, in the same manner as by the gorget: after this the
operation is to be finished in the usual way, by the intro-
duction of the forceps, &c.
The most material objection to this instrument is, that
by it more of the bladder maybe injured than ought to be
cut: for as it must be introduced far into that organ before
it is expanded, we will be very apt to wound the side, or
even the fundus of it. And we can never with any cer-
tainty determine the extent of the incision that will be
made ; and thus if in withdrawing it, it is made to press in
any degree more to one side than the other, very different
parts may be cut in different cases*.
SECT. V.
Of Nephrotomy.
CALCULI in the kidneys always produce such a train of
distressing symptoms, not to be removed by internal reme-
dies, that some surgeons have proposed making an incision
down to them, in order to effect their removal. But the
impossibility of ascertaining the presence of stones in these
parts, and the danger and difficulty of the operation, ought
to deter us from ever attempting it. It is only in cases
where the calculus has produced an inflammation termi-
nating in abscess which points externally, that an incision
can be made with propriety: in such instances, the tumor
may be safely opened as soon a fluctuation is perceptible,
and the stone extracted, if it is not then discharged with
the pus and urine. The ulcer is afterwards to be treated
in
* The same objection appears to be applicable to Mr Bell's cutting
director, and will continue unless that instrument acquires a sanction by
future experience.


[ 184 ]
in the usual way—it is apt in some instances to become fis-
tulous.
SECT. VI.
Of Stones in the Urethra.
IN calculous complaints stones are often passed with
the urine; and when they are pretty large and rough, they
frequently lodge in the urethra, and produce pain, inflam-
mation and swelling of the parts, and always a partial, and
often a total suppression of urine. In some instances, when
the disease is long neglected, this suppression and conse-
quent tumor, terminate in a rupture of the urethra; to
which succeeds a diffusion of the urine into the cellular
substance of the penis, scrotum, and perinæum.
When the symptoms are not very violent indeed, blood-
letting, general or topical, according to circumstances
should be used; warm oil should be injected frequently
into the urethra; the patient should be immersed in a warm
bath; a full dose of laudanum should be given to
him, in order to remove the spasmodic contractions of
the urethra, which often very much impede the passage of
the stone : And the patient should carefully avoid taking
any thing which will increase the quantity of the urine;
as this will probably in most cases augment all the symp-
toms.
As soon as by the use of the above remedies there is
reason to suppose a relaxation is produced, the surgeon
should endeavour, by gentle pressure, to push the stone for-
ward along the course of the urethra: But no instruments
should be used to extract it; for these often do injury by
irritating the membrane of the urethra.
When


[ 185 ]
When a suppression of urine is induced, it becomes ne-
cessary to have recourse to an operation, as soon as the
means above recommended are found ineffectual. If the
discharge of urine is practicable, from the urethra not be-
ing entirely filled by the stone, the patient is sometimes in-
duced to let it remain from dread of the operation. In
such cases, the calculus often acquires, in a short time, a
great increase of size by the deposition of earth from the
urine.
When calculi in the urethra are to be removed by an
operation, this is performed by cutting directly upon them,
and taking them out with a scoop, or forceps; but the
method of doing this must vary according to the situation
of the stone.
If the stone is fixed in the canal near the bladder, it has
been advised to push it back into the bladder by a staff; but
as it might there acquire a larger size, and render litho-
tomy afterwards necessary, it is much more eligible to ex-
tract it. In doing this, the patient should be secured on
a table in the manner directed for lithotomy; and an as-
sistant suspending the scrotum and penis, the surgeon, after
oiling the first and second fingers of his left hand, should
introduce them into the anus, and with them press firmly
on the parts immediately behind the stone; an incision is
then to be made through the teguments and urethra down
to the stone, which should be removed by the pressure of
the fingers behind it, or by the forceps or scoop. The af-
ter treatment must be similar to that of lithotomy.
When a stone is fixed farther forward in the urethra,
the skin should be drawn as much as possible past it, either
backward or forward ; and the stone being then secured
by pressure, a longitudinal incision should be made upon it
through the urethra, sufficiently large to admit of its easy
extraction by the forceps or scoop. The edges of the
wound are afterwards to be entirely cleared of fabulous
A a matter,


[ 186 ]
matter, and the skin allowed to regain its former situation:
by this means the wound in the urethra will be entirely
covered by skin that has not been injured, and it will
usually heal by the first intention. If, however, any urine
should escape into the cellular substance through the
sore, it must be let out by an incision.
When the stone is so near the end of the penis as to be
seen, it may often be removed by a small pair of forceps ;
and this may be facilitated, when necessary, by dilatation
of the urethra from its extremity. But when this fails,
an incision must be made, as before directed. Soft dres-
sings should be used; and when the wound is nearly healed,
a hollow bougie, a short silver tube, or a small catheter of
elastic gum, should be introduced into the urethra, in or-
der to preserve its proper size.
The most unfavourable situation in the urethra for a cal-
culus is just below the scrotum; for if it makes its way
into the scrotum, or it is necessary to make an incision up-
on it, large and troublesome collections of urine are very
apt to be produced : as soon, therefore, as it is discovered
in this situation, it should, if possible, be pushed farther
forward or backward: but if these should both be imprac-
ticable, we ought to begin the incision at the under part
of the scrotum, immediately on one side of the septum, and
continue it upwards till the stone is distinctly felt, when it
is to be laid bare, and extracted in the manner already di-
rected. This manner of making the incision gives a free
passage to the urine that escapes from the urethra, and ren-
ders the extraction of the calculus easy. During the ope-
ration an assistant should keep the testis out of the way;
and care should be afterwards taken that the wound heals
from the bottom.
When urine continues to be discharged by a preternatu-
ral opening  of the urethra, for any length of time, if the
calculous diathesis remains, stones of a large size will fre-
quently


[ 187 ]
quently form in the cellular substance contiguous to the
opening; they should be removed by incision, the for-
ceps, and scoop, and the wound then carefully healed from
the bottom.
In females, stones seldom become fixed in the urethra ;
when they do, they are commonly easily removed by insi-
nuating the end of a blunt probe behind them, and then
pulling it forward; or when this does not succeed, it may
be effected with safety by cutting open the extremity of the
urethra, so as to admit a pair of forceps to extract the
stone.
CHAP. XV.
Of Incontinence of Urine*.
THE usual causes of this disease may be reduced to
the following heads :
1. Irritation about the neck of the bladder, produced by
the friction  of stones contained in it. Hence it is fre-
quently a symptom of calculus; and is entirely relieved
by lithotomy. When this is not to be employed, it is often
considerably alleviated by remedies which diminish the ir-
ritability of the bladder; particularly by a free use of mu-
cilaginous drinks, and of opiates.
2. Paralytic affections. In these cases it is often
only apart of general disease; the sphincture appearing to
lose
* Enuresis.


[ 188 ]
lose its power of contraction entirely, while the 'detru-
for urinæ or muscular coat of the bladder retains its full
vigour. The remedies to be here employed are tonics,
particularly peruvian bark, chalybeates, and the cold
bath.—But the application of cold, by dashing water on
the perinæum and anus, is the most effectual remedy.
Cloths wet with vinegar and water, or solution of sacch.
saturni, have also been of use.
3. Laceration in the operation of lithotomy, and in de-
livery; In these cases the same remedies as were directed
where the disease is the consequence of palsy, are to be em-
ployed, and frequently remove the complaint.
But, in many instances, in all the varieties of inconti-
nence of urine, it happens that no cure can be obtained.
In such, all we can do is, to prevent the urine from in-
commoding the patient as much as possible.
When the disease originates from palsy or laceration,
compression of the urethra by the jugum or yoke, (pl. xi.
fig. 2.) answers this purpose very effectually. For wo-
men, pessaries of sponge may be employed; but if the ir-
ritability of the parts do not admit of these, passaries of
ivory or any solid wood, made very smooth and oiled,
should be placed across in the vagina.
When the incontinence proceeds from irritation about
the neck of the bladder, these instruments cannot be used:
In such cases, all that can be done is to fit a convenient
reservoir for the urine to the penis in men, (such as in pl.
xi. fig. 1.) and to apply sponge and soft linen, to absorb it
in women.
CHAP.


[ 189 ]
CHAP. XVI.
Of a Suppression of Urine*.
AN impediment to the evacuation of urine from the
bladder, constitutes a very alarming, and general-
ly very painful disease*. It may originate;
1. In paralysis, and particular paraplegia, from the bo-
dy of the bladder losing its power of contraction, while
that of the sphincter is retained. It is also thus frequent-
ly induced from a too long continued and voluntary re-
tention of the urine. In these cases, the introduction of
the catheter, (pl. v. fig. 3.) which is similar to the
operation of sounding †, proves commonly a certain re-
medy ; and when the complaint is produced in the man-
ner last described, it will contribute much to a permanent
cure to use the catheter constantly, as soon as an incli-
nation is felt to discharge the water collected;
2. From the uterus, in the last months of pregnancy,
pressing upon the neck of the bladder. In such cases, as
the catheter is very easily introduced in females, in or-
der to prevent an over-distension of its coats or a rup-
ture of them, it will be proper to use it constantly when
any difficulty in voiding urine occurs.
Tumors in the vagina and neighbouring parts, when large
often compress the urethra likewise in such a manner as to
induce a suppression of urine; it is also a frequent conse-
quence of prolapsus uteri. Until the removal of these
causes,
* Ischuria,
† Chap, XIV. Sect. II.


[ 190 ]
causes, the catheter should be employed occasionally as a
palliative.  When it is adviseable to let a catheter remain
in the urethra constantly, as those of silver give a great
deal of irritation, we should always employ the catheters
made of the elastic resin or gum.
3. From schirrosities of the prostate gland, obstructions
in the urethra from gonorrhæa, and stones impacted in
the urethra. The latter cases have been already treated
of, and the former will be the subjects of a chapter here-
after.
4. From inflammation about the neck of the bladder.
When this arrives to such a degree as to prevent the in-
troduction of the catheter, it constitutes the most alarming
variety of this complaint.
This species often arises from a communication of in-
flammation from the urethra, in cases of gonorrhæa, pro-
duced by the improper use of astringent injections in that
disease. It may also originate from the general causes of
inflammation.
The treatment should consist in general bleeding; the
application of leeches to the perinæum ; the large use of
opiates ; the frequent employment of clysters of warm
milk or water ; and the general use of the warm-bath.
When all these remedies fail, and the introduction of
the catheter is impossible, we have no means of relief left
but puncturing the bladder.
There have been several modes of effecting this proposed;
Mr Sharpe, and others, advise the bladder to be perforated
above the os pubis ; this may be done with a common tro-
car, and with most propriety about an inch or an inch and
a half above the symphysis pubis. As soon as the stillette
has entered the bladder ; it should be withdrawn and the
canula should be suffered to remain in the opening, and be
there secured by a ribband or tape carried around the bo-
dy.


[ 191 ]
dy. It must be stopped by a piece of cork, that the urine
may be evacuated only at proper intervals.
The length of the canula should be particularly attend-
ed to, lest it should injure some of the contents of the pel-
vis ; in fat people it may be two inches long; but in
others not more than an inch and an half.
The bladder is more easily punctured from the perinæ-
um than above the pubes; the urine is more readily eva-
cuated ; and there is less danger of the canula slipping
out of it and injuring the parts adjacent: and hence
I am perfectly of opinion that this mode should be prefer-
red.
In performing this operation, the patient should be laid
upon his back, and his thighs being properly separated and
secured by assistants, an incision of an inch and an half in
length, beginning at the commencement of the membra-
nous part of the urethra, and continued towards the anus,
parallel to the raphe, and half an inch from it, should
be made through the skin and cellular substance. The
trocar should then be pushed into the bladder, a little above
and to the left of the prostate gland, and if the point of
the instrument is somewhat raised, there will be no dan-
ger of wounding the uterus or vasa deserentia. In order
to know when the trocar has reached the bladder, there
should be a groove in the stillette to admit of an immedi-
ate discharge of urine.
As soon as the urine is evacuated, the canula should be
secured in the wound by tapes, or a ribband connected
with it, and a bandage passed around the body.
Whether the puncture is made above the pubes, or in
the perinæum, it will be proper to withdraw the canula
once in two or three days, in order to clean off the fabu-
lous matter that will collect on it, and which might, if it
was suffered to be deposited in considerable quantity, pre-
vent


[ 192 ]
vent the canula from being easily removed. The canula
should remain till the urine can be evacuated by the ure-
thra.
It has been advised lately, to puncture the bladder
through the rectum; but as this would give considerable
risk of wounding the ureters, vasa deferentia, or vesiculæ
seminales, and might afford a passage of fæces into the
bladder, it should certainly never be employed.
When it becomes necessary to puncture the bladder in
women, it can be performed always with most ease and cer-
tainty from the vagina. In doing it, the fore-finger of
the left hand should serve as a director to the trocar, and
the perforation should be made in the part first felt, in or-
der to avoid the ureters. The canula is to be left in the
wound as long as the cause of the suppression exists, and
should be long enough to pass out of the vagina, to be
there secured by tapes connected to the T bandage.
CHAP. XVII.
Of Obstructions in the Urethra. 
OBSTRUCTIONS in the urethra are most frequent-
ly the consequence of gonorrhæa, and consist;
I. In caruncles or fleshy excrescences from the mem-
brane lining the urethra. These, according to my obser-
vation, are similar to those warty excrescences which so
often appear on the glans and prepuce as a consequence of
gonorrhæa, and generally accompany them.—I have
never


[ 193 ]
never found them farther up the canal than half an inch
from its extremity : Mr Daran says he has often seen them
in every part of the urethra; but it is evident that he
confounds them with the other causes of obstruction.
2. In ulcers and cicatrices from ulcers. Ulcers are
certainly produced in the urethra in some cases of gonor-
rhæa. These originate, in many instances, from inflamma-
tion ; but in others merely from the mechanical effects of
the poison. I have seldom found them more than an inch
or two from the end of the penis.
3. In a contracted state of the urethra. Although this
may usually be the consequence of ulceration, yet there is
every probability that it may be produced solely from in-
flammation thickening the parts it affects. Astringent
injections, improperly used, may sometimes be considered
as the cause of this species of stricture;
4. In a total or partial obliteration of the canal, from
the pressure of tumors formed either in the cellular sub-
stance of the urethra, or in the glands connected with it.
This may be the consequence of inflammation from any
cause; and when inflammation terminates in suppuration,
the obstruction is usually removed by the discharge of
matter; but when this does not take place, and the swel-
ling is of long continuance, the opposite sides of the ure-
thra become connected, and produce a total suppression of
urine, unless, which indeed Commonly happens, preter-
natural openings are formed by the force of the urine.
5. In an enlargement of the corpus spongiosum urethræ.
This fullness or thickening is perhaps the most frequent
cause of obstruction, and it has proceeded to such a degree,
in some cases, as entirely to prevent the passage of the
urine. It sometimes is confined to a particular spot; in
other instances it extends a considerable distance; and in
some others it attacks different parts of the canal.
When obstructions of the urethra arise from causes
enumerated under the fourth head, the treatment must be
B b directed


[194]
directed by the particular nature of the tumor or tumors.
When they are indolent or schirrous, and do not penetrate
deep, they may be extirpated; but when the prostate
gland, or any of the parts about the neck of the bladder
are affected with schirrus or ulceration, we can only at—
tempt a cure by internal remedies. Of these, cicuta has
been much used, but seldom with advantage.
In cases of ulceration, uva ursi has been found to give re—
lief; but along continued and gentle course of mercury gives
the greatest prospect of benefit. In themean time, mucilagi—
nous drinks and opiates must be freely used as palliatives.
When the tumors are inflammatory, if they cannot be
discussed, they should be brought to suppuration as spee—
dily as possible, and as soon as a fluctuation of fluid is per—
ceived in them, they should be opened.
If on discharging the matter, the obstruction is not en—
tirely removed, a bougie or flexible catheter should be in—
troduced, and allowed to remain several hours every day
until the passage is entirely cleared.
When the urine, from its obstructed flow by the ure—
thra, forms openings from it through the perinæum and
other contiguous parts, it produces a very distressing com—
plaint. This will be considered in the next chapter.
In all the other cases of stricture we have enumerated,
if the venereal disease subsists in the habit, it must be re—
moved by mercury, at the same time that we pay attention
to the topical affection. As all of them operate by in—
ducing a diminished capacity or contracted state of the
urethra, bougies, which by their pressure tend to remove
this, are our principal remedies.  Independent of their
mechanical power, it is supposed by many that the good
effects of these are, in a great measure, to be attributed to a
suppuration excited by their irritation on the diseased parts;
and hence they have been often composed of stimulating
ingredients. But I am of opinion that this is not the case;
because

[195]
because caruncles, which are supposed to exist commonly
when bougies are found serviceable, do not in fact occur
in more than once in ten such cases, and when they do
exist, they are commonly of a warty nature, and conse—
quently not likely to be removed by suppuration; and be—
cause their effects may readily be accounted for from their
pressure only.
It must be evident that in general medicated bougies
should therefore be discarded from use; because the irri—
tating ingredients of which they are composed, must pro—
bably often do injury to the urethra.
Bougies should be formed of mild ingredients, and made
very smooth; and great care should be taken to have them
of a proper consistence. If made too hard they are apt to
crack, and cannot be introduced or retained with ease; and
if too soft they do not give a sufficient degree of pressure.
The best composition for bougies, that I know of, is as
follows:
ꝶ. Emplast. Diachyl. Simpl. ℥iv.
Ceræ puriss. ℥iss.
Ol. Olivar. opt. ʒiii.
The diachylon should be slowly melted, and the wax
being melted in the oil in a different vessel, they should
then be mixed; and while the mixture is tolerably warm,
let pieces of fine old linen be dipt in it; care being taken,
by means of a spatula, to cover the whole linen equally,
and to make the plaster as smooth as possible.
As soon as the cloth is sufficiently cold, it may be cut
with a sharp pointed knife directed by a ruler, into pieces
from nine to eleven inches in length, and somewhat wider
at one end than the other, for the formation of the bougies.
They should be made of different widths; the middle—
sized bougies will be formed by slips of about five—eighths
of an inch broad at the largest end. On account of the
facility of introduction if will be necessary to make them
taper 
                     

[166]
taper more or less, from about two or three inches from the
smaller extremity.
The strips of linen are to be rolled up as firmly and
neatly as possible by the fingers; and in order to give
them a smooth polished surface, they should be rolled for
some time between a piece of smooth hard wood, and a
plate of finely polished marble, and the points being
rounded, they are then fit for use.
In the application of the bougie, one adapted to the size
of the passage being selected, it should be well oiled, and
the penis being firmly grasped and extended with one
hand, the point is to be inserted into the urethra with the
other, and pushed forward with caution until it meets with
the obstruction; the bougie should be pressed beyond this, if
a moderate force will accomplish it; if not, it should be
withdrawn, and one with a smaller point used the fol—
lowing day.
By repeated cautious trials, bougies may perhaps, in
every instance, be passed: but in using them, whenever the
points yield in any degree, they should be immediately
withdrawn, as they will not then go forward, and their
extraction may be rendered painful if they become twisted.
Catgut alone, smoothed by rubbing on marble, or with
the composition abovementioned, forms bougies of a suf—
ficient degree of firmness for common purposes.
In order to prevent bougies from flipping into the ure—
thra, or bladder, they should be tied by a piece of soft
thread or tape to the penis, or to a bandage passed around
the body.
The length of time they should be suffered to remain in
the urethra, must be entirely regulated by the degree of
pain or uneasiness they occasion; when this is consider—
able, they should not be allowed to remain long, nor be em—
ployed oftener perhaps than once in two or three days; in
this case they ought not to be used but when the patient
can 
         

[167]
can confine himself to his bed, or at least to his apartment:
but when they give little or no pain, they should be worn
as constantly as possible. The bougie should be gradual—
ly increased in size until it fills the whole urethra; and
they should be used for a considerable time after the dis-
ficulty in passing water goes off entirely. Great care should
be taken that they never pass into the bladder, as a part of
them might fall off, and form the basis of a stone. When
the obstruction is seated very near to the bladder, a cathe—
ter should always be made use of instead of a bougie.
Various forms of flexible catheters to remain in the
urethra have been employed; the most convenient that I
have seen consists in a tube formed of flexible silver wire,
wrapped spirally round a steel probe; and this being cover—
ed with a piece of bougie plaster, and the probe being then
withdrawn, the instrument is thus completed. These ca—
theters are not so serviceable, however, as has been ex—
pected: and they should never be suffered to remain long
in the bladder, on account of the plaster on them. When—
ever it is necessary to leave a flexible catheter in the blad—
der, those composed of the elastic resin or gum, should
be employed in preference to them.
Although in general the bougies, composed as above di—
rected, are to be made use of; yet when there is reason to
suppose there is a venereal ulcer in the urethra, about
two ounces of quicksilver, extinguished by honey, should
be added to every six ounces of the plaster when melted.
In women, bougies should always be employed for the
same purposes as in men; but it often happens that tumors
of such a size form in the urethras of females, that it is ne—
cessary to employ a ligature, or the scalpel, to remove
them. By these, even tumors that are connected with the
bladder, may be taken off. In such cases, the urethra
should be laid open on one side, and the vagina need not
be at all injured. But they should not be meddled with,
unless 

[198]
unless they give a great deal of uneasiness, or obstruct the
passage of the urine very much.
Instruments for the application of caustic to carnosities
in the urethra, have been invented and used; but it is evi—
dent, that there must be great risk of injuring the found
parts from this practice.
CHAP. XVIII.
Of the Fistula in the Perinæum.
BY the term fistula in perinæo is understood a sinuous
ulcer in this part, extending most frequently to the
urethra, sometimes to the bladder, and in other instances.
terminating in the scrotum or penis.
In some cases there is but a single opening, and the con—
tiguous parts remain nearly in their natural state: but in
others, together with one or more external openings, there
is a hardness, enlargement, or inflammation of the parts
adjacent, extending, in some instances, from the anus to
the scrotum and sore—part of the penis. And as the urine
is more or less evacuated at the orifices in most instances,
they are often productive of much distress.
The causes of fistula in perinæo are;
1. Wounds and other injuries of the urethra and blad—
der from external violence. Thus it is now and then the
consequence of lithotomy, or of cutting into the urethra for
the extraction of stones.
2. In—            

[199]
2. Inflammation in the urethra terminating in suppura—
tion, and discharge of matter through the perinæum. This
is most frequently the consequence of gonorrhæa. Ab—
scesses formed in the soft parts about the anus, and ex—
tending to the urethra, also occasion perinæal fistulæ.
3. The several circumstances productive of obstruction
in the urethra, and enumerated in the last chapter. These
by impeding the flow of urine through its natural channel,
frequently induce this complaint.
All these causes tend to produce fistula; 1. By the for—
mation of a passage directly into the urethra or bladder, by
external violence, or ulcers and abscesses seated internally;
which may occur independent of any obstruction to the
passage of the urine.
2. By the sole influence of obstructions in the urethra;
in consequence of which the urine occasions a rupture of
the urethra.
In the treatment of the disease, it is of the utmost con—
sequence that we attend to the mode of its production as
thus explained; and as it is sometimes connected with sy—
philis, scrophula, or scurvy, it is evident that in such cases
general remedies must be conjoined with the topical appli—
cations.
When the disease is local, and proceeds from obstruc—
tions in the urethra, and the parts through which the
opening runs are not much affected, the bougie, applied in
the manner directed in the preceding chapter, is almost
the only remedy necessary, and it is commonly effectual.
When the obstruction is removed, which may be known
by the instrument passing in without impediment, and by
the urine flowing in a full stream when the orifice at the
fore is compressed; if the ulcer does not soon heal, it will
generally be found owing to the edges having become
callous. These must therefore be removed in the follow—
ing manner. The patient must be laid upon a table, near— 
ly               

[200]
ly in the posture recommended in lithotomy, and a staff
being introduced into the urethra, so as to pass the open—
ing, it is to be held firmly by an assistant, while the sur—
geon introducing a small probe at the external orifice of
the sore, and cutting upon it in the direction of the sinus,
is thus to lay it open its whole length, even if it extends
to the bladder. All the sinusses, in whatever direction
they run, must be treated in the same way.
When any of the parts through which the sinusses run,
have become extensively hard, a small portion of those
that lie most contiguous to the fores may be removed,
and the remainder will commonly be taken off by the
subsequent suppuration. The staff should be now with—
drawn, and the divided parts gently separated by the intro—
duction of lint, spread with some emollient ointment; a
pledgit of ointment is then to be placed over the sores, and
secured by compresses and the T bandage.
About twenty—four hours after the operation, an emol—
lient poultice should be applied over the dressings; and as
soon as a free suppuration comes on, the whole is to be re—
moved, and light easy dressings should be continued till the
sores are healed from the bottom. The success of the o—
peration chiefly depends on a regular and careful applica—
tion of dressings.
It has usually been the practice to keep a bougie or ca—
theter in the urethra as constantly as possible after this
operation, in order to prevent, it is said, an improper con—
traction of the urethra, and the passage of the urine out at
the wound. But, from much experience, I can pronounce
that the wounds heal perfectly well without them; and that
when they are employed, they keep the urethra so much
distended, that they prevent the ready healing of the sores;
are not effectual in hindering the urine from passing off by
the orifices, if not passed to the bladder, and if they are
passed 

[201]
passed so far, almost constantly excite pain, inflammation,
and swelling about its neck.
The passage of the urine seems to be a very trifling im—
pediment to the healing of the sores; after the operation
of lithotomy, it always passes off by the wound; a cure is
then in common soon obtained, and the use of a catheter is
never thought of. When indeed some stricture occurs in
the urethra after lithotomy, or the cutting the fistulæ, it
will be useful to employ bougies, as in other cases, but never
otherwise.
When the parts in the perinæum have become much
hardened and otherwise diseased, before the opera—
tion is put in practice, we are commonly directed to use
poultices, mercurial frictions, and gum plasters; but I have
never seen any material advantage derived from their em—
ployment.
If the hardened parts are very extensive, and the above—
mentioned discutients are ineffectual, we are usually advi—
sed to cut them entirely away: but although if will be pro—
per to remove the callous edges of sores here, yet such a
painful operation as that must be can rarely, if ever, be ad—
viseable.
When an opening is formed in the urethra by abscesses
seated internally or externally, or by external violence, in—
flammation must be moderated, or suppuration promoted,
&c. according to circumstances; and if the wounds do not
readily heal, the operation above described must be institu—
ted.
By the treatment recommended, most of the affections
we have just described may be removed; but where the
disease is very extensive, and there is some general com—
plaint joined with the topical affection, we are in some in—
stances baffled in all our attempts for a cure.
CC CHAP. 


[202]
CHAP. XIX.
Of the Hemorrhoids, or Piles.
THE term hemorrhois or piles is applied to tumors
in the rectum or its vicinity, produced either by a
distention of the veins, or of the cellular substance, or
both.
When these tumors do not discharge any matter, they
receive the appellation of the hemorrhoides cæcæ, or blind
piles; but when a discharge of blood or serous matter
takes place from them, they are termed the apertæ, open
or bleeding piles.
Hemorrhoidal tumors that discharge freely are usually
small; but when they do not bleed much, or at all, they have
arrived sometimes to the size of a pullet's egg. In the first
case they give little uneasiness, but in the latter they produce
a great deal of pain and irritation, and frequent tenesmus.
These swellings have generally a dark livid appearance;
are at first soft, and can usually be much diminished by
pressure; when they become open,they acquire a firm con—
fidence, and their size is not lessened by pressure of by
the discharge from them. When blind they are generally
most painful.
While the tumors are small and compressible, it is pro—
bable they depend entirely on an enlargement of the veins;
but when they become large, and of a firm fleshy con—
sistence, they are probably Chiefly occasioned by the effu—
sion of blood into the cellular substance.
The 

[203]
The piles are usually induced by a compression on the
hemorrhoidal veins. This compression is most frequent—
ly occasioned by hardened fæces in the rectum; by the
gravid uterus; and by tumors of the rectum, bladder,
mesenteric glands, &c.
In the cure, tumors must, if possible, be removed:—A
frequent recumbent posture must be advised during preg—
nancy; and to obviate or remove costiveness gentle laxa—
tiveness, as cream of tartar, and castor oil, should be oc—
casionally advised. If there is much fever, blood must be
taken, and particularly by leeches applied to the tumid
veins— The swelled parts should be bathed with a solution
of saccharum saturni; and the patient should be kept upon
a low, cooling regimen. An ointment of equal parts of
powdered galls and lard or butter, is a very useful applica—
tion; and an infusion of galls injected in internal piles is
very serviceable. Balsam capivi is also very beneficial as a
laxative and anodyne.
When the discharge of blood in hemorrhois is so great
as to debilitate the system much, and the above means do
not restrain it, it becomes necessary either to compress the
bleeding vessel or vessels, or to tie them. In flight cases,
compression may be made by introducing a silver tube,
wrapped round with soft linen; or perhaps better, by in—
troducing a piece of sheep's gut, tied at one end, into the
anus, filling this by the other extremity with water or
some other fluid, and then tying the lower end.
If the vessels are so large as not to admit of effectual
compression, and are within reach of the tenaculum, they
should be tied.                                    
When hemorrhoidal tumors become so large as to ob—
struct the passage of the fæces, but never before, they
should be removed. If they are seated externally, or not
much more than an inch from the end, of the rectum,
when

[204]
when they can be brought sufficiently low, by bearing
down, they may be easily taken off.
If the swelling is small, and there is no reason to fear
hemorrhagy, it should always be removed by the scalpel;
but when it is large, and we are apprehensive of a consi—
derable discharge of blood, ligatures should always be
preferred to the knife.
Tumors with a broad basis may be safely and easily re—
moved in the following manner: a needle, armed with
two firm waxed threads, being introduced through the
middle of the basis of the tumor, the ends of one of the
threads are to be firmly tied round one half of the swel—
ling, and the other is then to be secured in the same man—
ner by the other ligature. The tumor sometimes drops
off in eight and forty hours, but not commonly in less
than three days. When the scalpel is used, the wound
is to be dressed with lint and soft ointment.
CHAP. XX.
Of Condylomata, and other similar Excrescen—
ces about the Anus.
THE parts about the anus are liable to be affected by
tumors which have received the various names of
condylomata, fici, cristæ, &c. These are all of the same
nature, and require similar remedies.
They are sometimes met with in the cavity of the rec—
tum, but they most frequently affect the external parts.
They


[205]
They are of various degrees of hardness, being sometimes
quite soft, and at other times as firm as a schirrus. They
are differently coloured; some being white, and others of
different shades of red. Sometimes there is but a single
excrescence or two; but most frequently all the parts
about the anus are at last covered by them. They are often
not larger than warts; in many instances, however, they
are about the shape and size of split garden beans. They
seem at first to be mere productions of the cuticle; but
by long continuance they extend to the cutis, or even to
the muscles.
Tumors of this kind should not be touched unless they
become troublesome. When they are to be removed, the
softer kinds will often yield to friction with sal ammoniac,
or washing with a solution of it, or to the use of finely pow—
dered savin. But when the excrescences are hard, the scal—
pel, or lunar caustic, must be employed. The former is to
be preferred; and after the operation, the wounds should
be treated with lint, &c. as in other cases. When we em—
ploy caustic, great care must be taken that it does not
spread to the rectum.
CHAP. 


[206]
CHAP. XXI.
Of a Prolapsus Ani.
A Protrusion of any part of the intestinum rectum be—
yond its usual limits, is termed a prolapsus ani.
This varies very much in degree in different cases.
Whatever tends to debilitate the sphincter ani and adja—
cent parts, will probably contribute to the production of
this disease; but its most common cause is frequent and
violent exertions excited in the rectum itself, by a frequent
use of aloetics; by ascarides; by habitual costiveness; he—
morrhoidal swellings, &c.
The rectum has often remained in a prolapsed state for
a considerable time without injury; but it should always
be reduced as early as possible. This is best effected by the
fingers, in the following manner: The patient being put
into bed, on his face, with his buttocks somewhat ele—
vated, the surgeon should press firmly and equally upon
the protruded part. When this method fails, which its
seldom the case, a proper application of the fingers of one
hand to the superior part, while the palm of the other
hand supports the lower part, will always succeed.
We are to observe that this operation is only to be em—
ployed when there is no inflammation and swelling of the
gut; for when these occur, which happens sometimes,
bleeding, and bathing the part with solution of saccharum
saturni a little warmed to remove them, should be previous—
ly used.
In 

[207]
In order to retain the rectum in its situation after re—
duction, it will be commonly necessary to employ a thick
compress and the T bandage, or Mr Gooch's truss.
The patient should always reduce the gut immediately
after going to stool, and apply his bandage: And to re—
move the debility of the parts affected, he must be di—
rected to the use of steel, bark, and the cold bath: throw—
ing water on the buttocks and under part of the back, is
particularly serviceable. Injections of strong astringents,
as galls, oak—bark, &c. have also been useful: and opium
may be advantageously added to remove irritability of the
rectum. I have used alum and sacch. saturni with bene—
fit; but in general all salines should be avoided.
CHAP. XXII.
Of an Imperforated Anus,
IN some cases of this nature, the rectum is found to be
somewhat prominent at the usual situation of the anus,
and covered merely by the common integuments; but in
others no vestige of the gut can be perceived. In some of
these instances, it has been found to terminate within an 
inch of the usual seat of the anus; in others it has reached
no farther than the top of the sacrum: in some it has been
known to end in the bladder; and in others in the vagina.
As death will in all probability soon be the consequence,
unless an operation is performed to relieve the patient, no
time should be lost. If the end of the rectum is covered
only 

[208]
only by skin, an incision through this is all that is necessa—
ry. But when the gut lies deep, the child should be pro—
perly secured, and an incision of an inch in length made
on the part where the anus ought to be; this should be
cautiously contiued along the coccyx, the finger serving as
a director, till the operator meets with the fæces, or till the
incision is of the length of the finger; a long trocar should
then be pushed forward, in the probable direction of the
rectum, upon the finger.
When the gut is found to terminate in the bladder or
vagina, this operation should also be performed. If in any
case it should fail of success, would it not be adviseable to
attempt an opening above the pubes, or perhaps on the
right side, so as to reach the caput coli, and thus form an
artificial anus?
When the incision is carried deep, it is often a matter
of difficulty to preserve the passage sufficiently open to ad—
mit of the discharge of fæces. Dossils of lint, moisten—
ed in oil, and rolls of bougie plaster, I have found to be
the easiest and best applications; for this purpose, gentian,
sponge tent, and other similar substances, have been em—
ployed; but they always give too much irritation. When
the passage has at any time become too strait, the introduc—
tion of a sheep's gut distended by water, as recommended
in Chap. XIX. is the best remedy. Much atttention is
requisite in these cases; and they often give a great deal
of trouble and perplexity for a long time.
When nothing but the skin is cut, dossils of lint, for a
few days, are the only necessary applications.
CHAP. 
 

[209]
CHAP. XXIII.
Of the Fistula in Ano.
EVERY sinuous ulcer in the neighbourhood of the
rectum is termed a fistula in ano. When the sore
has no communication with the rectum, is is said to form
an incomplete fistula; when the ulcer has two openings,
one into the rectum, and another externally; it is called
complete: and when the sore opens into the gut only, it
is termed an internal or occult fistula.
This disease has also been distinguished into simple and
compound. In the simple fistula there is one or more
sinusses connected merely with the internal ulcer; and the
adjacent parts are all found: but in the complicated or
compound, the parts through which the sinus runs are
hard and swelled; or there is a communication with the
bladder, vagina, os sacrum, and other parts.
In the beginnings of the disease the contiguous parts are
usually found; but after a long continuance of it, and the
disease has spread not only over the parts about the anus,
but even to the perinæum and buttocks, these become hard
and much swelled.
When the matter in the sinusses acquires a considerable
degree of acrimony, instances have occurred in which
the sacrum has become carious, and the vagina and
bladder have been corroded and had the contents of the
rectum emptied into them; but such terrible cases are very
seldom met with.
D d Whatever

[210]
Whatever tends to produce the formation of matter
about the anus, may occasion this disease; such as the
piles; condylomatous tumors; hardened fæces in the rec—
tum; and fevers.
On account of the languid circulation in these parts,
inflammatory swellings are very apt to terminate in suppu—
ration; and sores thus induced heal with difficulty.
As soon as suppuration appears to be coming on, there—
fore, we should employ every means to hasten the forma—
tion of matter; such as warm poultices, fomentations, and
the steams of water; and as soon as pus is produced, it
should be evacuated by a very free incision.
The wound, should be very lightly dressed with some
emollient ointment spread upon lint, and a soft poultice
ought to be applied constantly over the whole. By this
means the hardness will be removed, and a cure will often
be easily accomplished.
A surgeon is, however, seldom called until a fistula is
fully formed; his first object should then be, to ascertain
the course of the sinus or sinusses. When the sores are
external, this can easily be done by the probe alone; but
when they run up by the rectum, the finger should be
oiled and introduced into the gut, at the same time that the
probe is passed in at the ulcer, in order to determine whe—
ther it communicates with the intestine, which is a point
of consequence. When this will not ascertain it, the pas—
sing of the fæces or air at the sore, or water injected at
the sore coming out by the intestine, will sometimes direct
us.
Astringent injections, pastes and ointments, have at dif—
ferent times been used for the cure of fistula in ano; but
experience has proved them to be not only useless, but of—
ten injurious. The real indication is to excite such a
degree of inflammation on the sides of the sinus as will
produce a union of them. This in fislulæ of other parts
is 

[211]
is accomplished either by the introduction of a cord of
cotton or silk, along the course of the sore, or by laying
the whole sinus open, so as to reduce it as nearly as pos—
sible to the state of a recent wound: but as the seton here
gives too much irritation, the latter mode is to be pre—
ferred.
The day before the operation, the bowels should be well
emptied by a laxative, and the rectum should be cleared
by a clyster given a few hours previous to it.
The patient may be either allowed to stand up with his
back exposed to the light of a window, and leaning for—
ward on a chair, table, or bed; or he may be laid on a
table in the posture directed for lithotomy. Which—
ever is chosen, the patient must be firmly held in it; and
the surgeon, after dipping the fore—finger of his left hand
in oil, must introduce it as far as possible into the rectum,
and with his right hand must then enter the probe pointed
bistouri, and carry it forward until he feels the point of
it through the opening in the gut, for we suppose this to be
a complete fistula; he is then to bring the point, guarded
and supported by the finger, out of the rectum, by which
means the sinus will be entirely laid open. If there are
more sinusses than one, they should all be opened. It sel—
dom happens that more than one communicate with the
rectum, but they generally communicate with each other.
When the fistula is incomplete, the only difference be—
tween the operation for it and the one just described, is
that the bistouri must be pushed through the rectum at
the superior part of the sinus.
When the sinus extends very far up the rectum, all that
can be safely done is to divide the sinus as high as the finger
will reach.
The hemorrhage from this operation is very trifling;
and therefore the method of cure by introducing a flexible
piece of lead or silver at the orifice, bringing it back by
the 

[212]
the gut, and then twisting it, is totally unnecessary on ac—
count of the discharge of blood. The pain attending this
mode by ligature, and its tediousness will probably prevent
it from being received into general use.
The wound being cleaned, a piece of soft lint or linen,
covered with a liniment of wax and oil, should be insinu—
ated between its edges, but not so far as to give uneasiness,
A compress and the T bandage being then applied, the
patient should be carried to bed; and the dressings being
renewed after every stool, or about once in twenty—four
hours, the sores will generally heal very well.
By this method, diarrhæa and tenesmus, which often
prove very troublesome when dressings at all irritating,
even dry lint, are employed, are entirely prevented.
Injections are often advised to clean the sores, but they al—
ways do injury. Nothing more is in general necessary than
to remove any fæces which may lodge in the wound.
In some instances, instead of a favourable appearance,
the sore acquires a soft unhealthy aspect, and the matter
discharged from it is thin, fœtid, and perhaps mixed with
blood. A hitherto undiscovered sinus is in these cases
sometimes found upon examination; this should be imme—
diately laid open: but it more frequently happens that this
state of the sore depends upon some general affection,
which till then had not manifested itself. In this case, re—
medies adapted to the disease should be employed. It may,
in some instances, be the consequence of mere debility from
fever or discharge of matter. Tonics, and a generous diet,
will then effect a cure.
When the disease has continued long, experience has
taught me the propriety, and indeed necessity, of forming
an issue; making it discharge freely for some time previous
to the operation.
By these several means, the disease, when confined to the
vicinity of the rectum, may almost always be removed.
In 
 

[213]
In an advanced stage, the matter sometimes not only
separates the skin from the muscles in all the parts adjacent
to the rectum, but even detaches the rectum itself from
the cellular substance, with which in health it is so firmly
connected. In such instances, all that should be done, is
to lay open the intestine as far as it is separated; and if this
is not sufficient to make it apply equally to the surrounding
parts, another incision should be made on the opposite
side of it: by this means, if the constitution is pretty good,
an adhesion will take place between the gut and the parts
contiguous, and a complete cure will be obtained. Si—
nusses seated externally should be treated in the same way.
The dressings in both should be mild, and applied over the
sores only, and not insinuated between their edges.
The occult fistula, or that in which there is no external
opening, is to be distinguished by a discharge of matter un—
mixed with the fæces; by some degree of hardness, swell—
ing or discolouration in the vicinity of the fundament; and
by pain from pressure on it. 
In this species, a scalpel or lancet is to be plunged into
the part where we have reason to suppose the abscess seat—
ed; and the disease being then reduced to the state of a
simple, complete fistula, the operation is to be finished as
was directed for that variety of the disease. The subse—
quent treatment must be similar to that used in other cases
of fistula.
We have hitherto supposed the parts affected to be no
otherwise diseased than by having an abscess seated in
them, and sinusses connected with it; but when by ne—
glect or improper treatment the matter collected does not
find a free vent, the parts contiguous to it become inflamed
and painful, and gradually acquire a considerable and dis—
tressing hardness or callosity. In such circumstances, ex—
perience has taught us that poultices, mercurials, &c. as
advised by some, are perfectly inadequate to the discussion
of 
 

[214]
of any such callosities as are considerable and of long du—
ration; and that it is entirely unnecessary to destroy them
by caustic, or extirpate them with the knife, except they
cannot be preserved but at the hazard of the patient's life.
In instances where these callosities occur, the sinusses
should not only be laid open as directed in simple fistulæ,
but incisions should be made along the whole extent of
the hardness; and if a free suppuration does not sponta—
neously succeed to the inflammation which is commonly
produced, it should be encouraged by warm poultices, and
supported till the greater part of the callosity is removed;
which will commonly happen after some time, if the habit
is healthy. When suppuration cannot be readily induced,
and the edges of the sores become inflamed and painful,
and a fœtid thin matter is discharged, some general disease
may be suspected.
If the edges of the fores are very hard and reversed, it
may be useful to take off a part of them; and if the cal—
lous parts are so separated from those beneath, that they
will probably never adhere to them again, they must be
removed; but in no other circumstances can extirpation, in
any degree, be with propriety advised.
It sometimes happens that the matter collected in fistula
in ano penetrates to the bones; but it oftener happens that
the bones are the parts primarily affected. Thus the
matter may be formed in consequence of caries of the
lumbar vertebræ, os sacrum or coccyx, and find its way
down to the vicinity of the anus.
But the most distressing symptom attendant on fistulæ in
ano, is the formation of a passage between the rectum and
bladder. This is known most certainly by an offensive
dark sediment in the urine, obstructions to the passage of
the water, and the discharge of air by the urethra either
before or after making water. In such cases the patient
lingers 

[215]
lingers for some time, and at length falls a victim to the
disease.
When the bones have become carious from the matter
penetrating to them in this disease, all that art can do is to
preserve a free vent to the matter; to keep the parts clean;
to extract pieces of loose bone; and to strengthen and sup—
port the constitution during the long continued discharge
which will probably ensue, by tonics and nutritious diet,
Some few have recovered by this management; but all
that can in general be expected, is a mere palliation of the
most distressing symptoms.
CHAP. XXIV.
Of the Paracentesis of the Abdomen.
THE operation of paracentesis or tapping is instituted
for the removal of collections of fluid in the abdo—
men.
Ascites, or a collection of watery fluid in the cavity of
the abdomen, is often a symptom of anasarca or general
dropsy; but it is also frequently a local disease, and origi—
nates from compression of the lymphatics, by schirrous
viscera, and particularly the liver.
This disease is known by swelling and tenseness of the
abdomen; difficulty of breathing, particularly in a horizon—
tal posture; and by a sense of fluctuation communicated
to the fingers placed on one side of the abdomen, when
the 
 

[216]
the swelling is forcibly struck on the other. With these
symptoms there are also usually joined great thirst, paucity
of urine, dry skin, and other signs of dropsy.
When the swelling extends equally over the abdomen,
the water is commonly diffused among the different viscera,
and is contained in the peritonæum only; But it some—
times happens that it is collected in different cysts, or in
one of the ovaria, when the tumor is not usually so equal;
nor is the fluctuation so distinctly perceived. The fluctu—
ation depends also on the consistence of the fluid; in some
cases this is thick and gelatinous, though commonly thin
and serous. A great number of small hydatids are also
often found swimming in the water of ascitical swellings.
As diuretics and other evacuants are seldom found use—
ful in local dropsies, and as the viscera may receive injury
by being long surrounded by a fluid in ascites, tapping
should always be advised as soon as a fluctuation is to be
perceived. It is attended with very little pain, and the
danger arising from it in some cases, is to be attributed to
the state of the constitution at the usual time of its per—
formance, rather than to the nature of the operation.
In all large collections of fluid, and particularly in the
abdomen, it has been found dangerous to evacuate their
contents suddenly, without substituting pressure during the
discharge, and for some time afterwards, to the support
these have given to the circulating system—hence the utility
of applying a proper bandage to the whole belly.
The instrument now universally employed for tapping
is the trocar. The flat trocar, with a lancet point, (pl.
vii. fig. 3. 4.) enters the abdomen with more ease, and gives
less pain than the common round trocar with a triangular
point, it should therefore be preferred to it. The part of
the abdomen, which can be perforated with the greatest
safety, is the point lying at nearly an equal distance be—
tween 
 

[217]
tween the umbilicus and the centre of the spine of the ili—
um.
This point being marked with ink, the bandage deli—
neated for the purpose, (pi. xi. fig. 4.) is to be applied
moderately tight, one of the holes being fixed exactly op—
posite to the mark. The patient is to be placed in a ho—
rizontal posture, with the side in which the perforation is.
to be made lying over the edge of the bed. The surgeon
is then to take the trocar in his right hand, and fixing the
head of the stillette in the palm, immediately below his
thumb, and directing the point of it with his fore—fin—
ger, he is now to push it into the cavity of the abdomen;
this may be known to be effected by the want of farther
resistance to the instrument. The stillette being then with—
drawn, the water is to be discharged; taking care to have
the bandage tightened as the water flows— If the patient
becomes faintish, the discharge may be stopped now and
then for a few minutes.
When the discharge is obstructed or stopped by omen—
tum or intestine pressing on the mouth of the canula, a
blunt probe should be inserted into the tube to push them
back. When the stoppage proceeds from the consistence
of the fluid, a larger trocar should be introduced. Some—
times it originates from the water being collected in cysts;
in this case, the canula must be withdrawn, arid the wound
being covered with a pledgit of ointment, the operation
may be renewed immediately, or on the succeeding day,
in the opposite side of the belly; or if swelling appears in
any particular part of the abdomen, the opening should
be made in the most depending portion of it.
If after this operation notwithstanding the use of pro—
per remedies, other swellings should follow, it may be
repeated whenever they have acquired any considerable
size;
E e The

[218]
The wound is to be dressed lightly as already directed;
and the use of the bandage should be continued, as the
support it gives may have some effect in preventing a re—
turn of the disease.
In tympanites, or collection of air in the abdomen, the
swelling is more tense than in ascites, and affords to the
touch nearly the same sensation as is received from a blad—
der filled with air.
In tympanites the air is most frequently contained in the
intestines, and probably is hardly ever found between them
and the peritonæum but in consequence of a breach in
them. Tapping with a small trocar, and with the same
precautions as in ascites, should undoubtedly be used for its
removal when all the other remedies prescribed fail, as it
will give the only chance of relief.
After tapping, both in æscites and tympanites, as soon
as the bandage can be removed with safety, i. e. in about
two days, it should be taken off for a quarter of an hour
daily, and the belly should be well rubbed with some spi—
rituous astringent application, the patient being previously
placed in a horizontal posture.
CHAP. 

[219]
CHAP. XXV.
Of the Paracentesis of the Thorax.
THE operation of tapping the thorax, is indicated
whenever the action of the heart or lungs is im—
peded by fluids collected in the cavity of the chest. The
different kinds of fluids met with there, and requiring eva—
cuation by a perforation, are, serum, blood, pus, and air.
SECT. I.
Of Serum collected in the Thorax*.
WATERY collections in the chest are frequently met
with, and are often combined with dropsy in other parts:
They are, however, in many instances, merely local affec—
tions; and in these only are we to expect advantage from
the paracentesis.
The fluid is contained either in one side of the general
cavity of the thorax or both; in the pericardium; or in the
mediastinum. It requires much attention to ascertainthe
existence of water in the chest, and especially its particu—
lar situation.
A patient complaining of a sense of weight or oppres—
sion in the thorax; of difficult respiration; of more unea—
siness.
* Hydrothorax

[220]
siness in one side of the chest than the other; of inability
to lie on the sound side; of being liable to sudden startings
during sleep, from a fear of suffocation; and if with these
he has frequent cough; small and irregular pulse; and
especially a dry skin, paucity of urine, and other symptoms
of dropsy, there can be little doubt of the presence of this
disease. A sense of undulation, as of water passing from
one side of the chest to the other, is sometimes ob—
served by the patient upon rising suddenly from a horizon—
tal posture; and this contributes also to ascertain the pre—
cise seat of the collection. In order to determine this point
more clearly, the patient should have his breast uncovered,
and one hand being placed upon the ribs near the sternum,
we should strike with the other forcibly near to the spine.
This will answer when the quantity of fluid is considera—
ble: When it is small, we can ascertain its presence
most certainly by standing behind the patient on a chair,
and swinging the upper part of his body repeatedly, by
sudden jerks, from one side to the other.
In long continued affections of this kind, there is some—
times a degree of swelling in a particular part of the chest,
produced by the collected water.
The general symptoms of hydrothorax do not vary
much in whatever part of the chest the water is effused,
In the hydrops pericardii the patient, it is said, complains
chiefly of the middle and left side of the thorax, and there
is a firm undulatory motion perceived between the third,
fourth, and fifth ribs at every pulsation of the heart.
This disease is produced by the causes of dropsy in ge—
neral; and when it is ascertained, as no remedy has yet
been discovered for its removal, the operation should be
always advised as soon as the symptoms appear danger—
ous, and relief is not found from other means. It is thus
to be performed.
The 
            

[221]
The patient should be laid in a horizontal posture, with
the side to be operated upon over the edge of the bed:
The skin over the part to be perforated is then to be
drawn up as much as possible by an assistant, who must
keep it so during the operation; and the surgeon is now,
with a scalpel, to make an incision of about two inches in
length, between the sixth and seventh ribs, in the same
direction with them, and at an equal distance between the
sternum and spine, taking care to avoid the under edge of
the superior rib, on account of the blood—vessels running—
in its groove. This must be carried through the tegu—
ments: the division of the muscles must be no more than
about an inch in length. The pleura is to be very cauti—
ously dissected, in order to avoid all risk of wounding the
lungs, if they should happen in this place to adhere. If
this is not the case, the water will rush out as soon as the
membrane is cut through: should there be an adhesion of
the lungs to it, the incision may be carried an inch or two
nearer the sternum, or it may be made an inch or two
higher or lower.
The opening should be small, and a canula introduced
into it for the more convenient evacuation of the water,
stopping the discharge if the patient should be faintish,
and to prevent the ready access of the air to the cavity of
the thorax. When the water is not in great quantity it
may usually be drawn off at once; but when the collection is
large, partial evacuations may be made at longer or shorter
intervals according to circumstances. For this purpose
the canula should be tied to the body by a ribbon con—
nected with it; and it should be stopped with a piece of
cork. A pledgit of emollient ointment should be laid
over the wound, and the whole being secured by the nap—
kin and scapulary, the patient should be put to rest. Af—
ter a delay, perhaps of a day or two, an additional quanti—
ty may be discharged, and so on till the patient is entirely
relieved. When 
                     

[222]
When the water is effused into both sides of the chest,
it will be necessary to perform two operations to effect its
removal. But as the patient might suffer as much from
the air which unavoidably get into the cavities as from the
water, if both sides were perforated at once, it will be
proper after one operation, to endeavour to expel the
air from the side perforated before we undertake a se—
cond. The easiest and most convenient way of doing
this is to let the patient endeavour, as far as possible, to
fill the lungs with air, immediately after the canula is ta—
ken out. This will expel a considerable quantity by the
orifice; the skin should then be drawn instantly over the
fore, and pressed down during inspiration. This must be
repeatedly done; and by it most of the air may be expel—
led: after which the skin should be drawn over the wound,
and the dressings applied as already directed.
The air might also be extracted by the application of
an exhausted syringe, either of the common kind, or of the
elastic gum.
Air in the chest may not only prove hurtful by imped—
ing the motion of the lungs, but also by inducing inflam—
mation on them, and the other parts within the thorax:
its admission should, therefore, be guarded against very at—
tentively, as well as its expulsion when it has gained an
entrance.
It has been proposed by some to perforate the thorax
farther up than we have advised, and by others lower
down; and a trocar has been recommended for the per—
forator— but it must be evident to those who reflect on the
subject, that the mode we have pointed out is attended
with much less danger and difficulty.
In dropsies of the pericardium, this operation might be
employed with some prospect of benefit. It might be per—
formed by making an opening between any two of the ribs,
from the third to the eighth, and within six inches of the
sternum. 

[223]
sternum. The incision of the pleura should be about an
inch long; and the water would be best discharged by
pushing a small, trocar into the pericardium. If the quan—
tity is small, it may be all drawn off at once; if considera—
ble, it should certainly be done very gradually.
When water is in the mediastinum, which will be render—
ed probable by particular pain and oppression above it, a
piece of the sternum should be taken out by the trepan,
and a perforation should be made into the swelling with
a trocar, and the water cautiously evacuated.
SECT. II.
Of Blood collected in the Thorax.
In general, the symptoms of blood collected in the tho—
rax are similar to those produced by serum; but they are
usually observed to prove more distressing.
Blood may be extravasated into the chest:
1. From wounds of the blood—vessels by sharp instru—
ments.
2. From the splinters of fractured ribs, sternum, or ver—
tebræ entering the vessels.
3. From erosion of the arteries or veins by the matter of
abscesses or ulcers.
4. From the rupture of the vessels by violent exertions,
and particularly by coughing.
As some of the sanguiferous vessels of the lungs them—
selves are usually the seat of the disease, relief is com—
monly more or less obtained by the expectoration of the
evacuated blood; but when neither this, nor blood—letting,
a cooling regimen, and other remedies, prevent the action
of the heart or lungs from being much obstructed, the
operation of the paracentesis should undoubtedly be per—
formed. Mr Sharpe, indeed, is of opinion, that we had
better trust to the coagulation of the blood for the remo—
val
               

[224]
val of the hemorrhagy, and to the absorbent vessels for ta—
king away the blood thus deposited; but it is evident that
if the vessel is small, little or no additional risk will be in—
curred by a perforation, as the hemorrhagy will probably
cease on the patient's becoming faint; and if the ruptured
vessel is large, the patient will probably die, whether the
operation is used or not.
In performing this operation, the directions given in the
preceding section will generally apply; but it must be ob—
served, that when a fractured bone, or some extraneous
body is the cause of the hemorrhagy, the incision should
be made as near the affected part as possible, so that it
may serve for their extraction, as well as for the evacuation
of the blood. And when there is an external wound,
this if properly situated, should be enlarged for the dis—
charge of the blood, instead of making another opening.
As the blood is very apt to coagulate in a little time, if
we find it impossible to remove it merely by an incision of
an inch or so, tepid water should be cautiously injected in
small quantities, and suffered to remain some time in order
to dissolve it.
SECT. III.
Of an Empyema, or a Collection of Pus in the Thorax.
An empyema is probably never met with but as a con—
sequence of pneumonic inflammation. And when a pa—
tient, who has for some time had a fixed pain in the chest,
attended with fever, cough, and other signs of inflamma—
tion, is at last seized with an oppressed respiration; an in—
clination to fit in an erect posture; with a total inability
of lying on the found side; a constant tickling cough; with
frequent shiverings; and especially if there is an accompa—
nying 
‡ 

[225]
nying enlargement of the affected side, or a soft œdematous
fulness of the part in which the pain was at first seated,
we may conclude with certainty that a large collection of
matter is formed.
When the pus thus formed is not soon evacuated by the
mouth, which frequently happens, the only remedy to be
depended on is the paracentesis.
The general rules already given are to be observed in this
operation; except that in whatever part of the thorax, whe—
ther under the sternum, ribs, or other parts, the seat of the
abscess is indicated, either by a long continuance of pain, or
by matter distinguished, there the operation should be
performed. But if the particular seat of the disease is not
pointed out, the perforation must be made in the usual
place.
Collections of matter in the thorax are usually formed
in the lungs, and thence poured into the cavity or cavi—
ties; but in many instances, large quantities of pus are
found between the pleura and lungs, produced from an
inflammation of the pleura alone. In these cases ulcera—
tions are commonly produced, which continue a long
time after the perforation is made.
The constant motion of the lungs; the necessity of avoid—
ing the excitement of that degree of inflammation which is
necessary for the union of the parts; and our being preclu—
ded from the benefit of compression, render the cure of ab—
scesses in the lungs by far more difficult than those seated
in any other part of the body. Hence the discharge usu—
ally continues for life, or if it ceases for any time by the
healing of the sore, it almost constantly bursts out again,
or another operation becomes necessary to relieve the
dangerous symptoms induced. On this account it will be
proper, whenever the opening has much tendency to close,
to enlarge it by the introduction of a common bougie, or
of a short tube of silver for a few hours.
F f SECT.
            

[226]
SECT. IV.
Of Air Extravasated in the Thorax.
AIR collected in the large cavities of the chest, produces
the same symptoms of oppression on the heart and lungs
that are consequent to the presence of water, blood, or
serum.
This collection of air may be produced;
1. By a gangrene of some part within the thorax. This
species of the disease seldom comes under the care of the
surgeon; its removal depends entirely on the cure of the
mortification, which is seldom accomplished.
2. By a rupture of the investing membrane of the lungs
by a violent exertion, as in coughing, crying, or laugh—
ing.
3. By an erosion of the surface of the lungs from ul—
cers and abscesses.
4. By wounds of the lungs from a sharp instrument,
pushed obliquely into the thorax.
5. By a wound of the lungs from fractured vertebræ,
or ribs. A fractured rib is the most frequent cause.
A collection of air in the chest differs from collections of
pus and serum in its symptoms, only in respect to the quick—
ness of their progress; for there are instances of death hav—
ing been induced by it in a few hours. In most cases the
cellular substance of the breast becomes inflated; and if
means are not soon employed to prevent it, the air insinu—
ates itself through every part of the body.
The particular symptoms consequent to a wound of the
lungs from a fractured rib are as follow; a tightness in
the breast; some oppression in breathing; pain in the parts
chiefly 


[227]
chiefly affected; gradual increase of the difficulty of breath—
ing, till at length the patient can breathe only when erect
and leaning forward; flushing and swelling of the face;
feeble pulse, at length irregular; cold extremities; and if
relief is not soon obtained, death.
The emphysematous swelling of the chest and other
parts, which sometimes occurs here, is easily distinguished
by the crackling noise produced by pressure on it. For the
removal of this symptom, scarifications are employed. By
making several incisions, half an inch in length, along the
course of the swelling, and then pressing the air towards
the orifice, a good deal may be evacuated. The place of
this will be supplied by air from the thorax, and if the
quantity which escapes from the wound in the lungs is not
greater than that discharged by the scarifications, the
whole may in this manner be soon removed. But the re—
verse frequently happens; and our only remedy then con—
sists in the paracentesis. This operation affords imme—
diate relief, and is to be performed in the manner already
directed.
CHAP. 

[228]
CHAP. XXVI.
Of Bronchotomy.
THE formation of an opening in the trachea, or
the operation of bronchotomy, is necessary when—
ever respiration becomes so much obstructed from a local
affection of the superior part of the wind—pipe, that life is
endangered.
This operation is attended with very little danger, and
a necessity for its performance may originate;
1. From a spasmodic affection of the muscles of the
glottis, produced by acrid mucus in catarrh, and by bread,
and other substances getting into the trachea.
2. From a piece of bone, flesh, or any other firm sub—
stance lodged in the pharynx, or upper part of the œso-
phagus, and pressing on the trachea.
3. From polypous excrescences reaching far down into
the pharynx. When these tumors are to be extirpated,
the operation is much facilitated by previously performing
bronchotomy.
4. From tumors, particularly those of the schirrous and
fleshy kinds seated externally, as in bronchocele.
5. From swellings of the tongue and glands of the
throat arising from inflammation, either when the parts
have previously been found, or in a schirrous state. It can
never be necessary, however, when these have suppurated,
as mere puncture of the swelling will then relieve the pa—
tient.
6. From 

[229]
6. From suspended animation by drowning, when the
lungs cannot be inflated by other methods.
In order to perform this operation, the patient should
be laid upon a table, with his head drawn back, and limbs
secured by assistants. A longitudinal incision should then
be made with a scalpel through the skin and cellular sub—
stance, an inch in length, on the middle and anterior part
of the trachea, beginning at the inferior part of the thyroid
cartilage. The sterno—thyrodei muscles are thus exposed,
and upon separating these, a considerable part of the thy—
roid gland appears. The cellular substance should then
be divided carefully on the superior part where the iobes of
the gland are separated, in order to avoid the blood—vessels.
The trachea being then laid bare, an opening may be made
into it between any two of the cartilages, by an instru—
ment nearly like a flat trocar, or, if this cannot be had, by
a scalpel or lancet. The perforation must be just large e—
nough to receive a small canula; this should be about two
inches in length, and as much of it introduced as will
give a free passage to the air; the remainder should be
passed through slips of linen, under which is a plaster of
cerate, which may occasionally be in part removed or in—
creased in number, to accommodate it to the degree of
swelling induced. It is better to introduce a smaller canula,
previously adapted to the first, within it, in order to pre—
vent any obstruction to the breathing which might occur
from removing the tube to clean it, if only one was em—
ployed. A piece of crape, or fine muslin, should now be
placed over the opening in the canula, to prevent the ad—
mission of dust, &c. and the tapes connected with the
wings of the tube carried round the neck, and tied.
When extraneous bodies in the trachea cannot be re—
moved from this opening, a covered probe should be intro—
duced to ascertain their situation, and another perforation
should then be made. Whatever be the cause of the ob—
struction 
              

[230]
struction for which the operation is instituted, the canula
should be continued in the opening until that is removed;
and when this is done, the skin should be drawn over the
wound, and a sticking plaster applied to retain it.
CHAP. XXVII.
Of Oesophagotomy.
WHEN substances lodged in the œsophagus can be
seen, they may commonly be removed by a pair
of forceps; but when they are out of sight, we are re—
duced to the necessity either of allowing them to remain
where they are fixed, of pushing them into the stomach,
or of extracting them by laying the œsophagus open.
If the substance is of a soft texture, such as bread, cheese,
or flesh, the best method is to push it into the stomach by
the probang. But when a pin, a piece of sharp bone, or
other firm substance is lodged in the passage, we should not
attempt to push it down; for if this does not succeed, it
may be fixed in the œsophagus. If the pain, and obstruc—
tion to breathing are not considerable, and if aliment can
still be swallowed, no effort should be made to dislodge it;
for it will probably be at length carried down, either from
the effects of some degree of dissolution in the substance
itself, or of a suppuration in that part of the gullet in which
it is fixed. But when the passage of nutriment to the
stomach is entirely prevented, or respiration is impeded to
a 

[231]
a dangerous degree, an incision into the œsophagus, for
the removal of the offending cause, is our only remedy.
Oesophagotomy may be also rendered necessary by tu—
mors and strictures in the superior part of the œsophagus;
but in such cases, the relief it gives is in general merely
temporary, as the diseases which give occasion to it are
usually incurable.
In performing this operation, the patient being secured
as directed for bronchotomy, an incision should be made
with a scalpel, at least two inches in length, through the
skin and cellular substance, on the left side of the neck,
keeping close by the side of the trachea, and commencing
about half an inch above the part where the obstructing
substance is fixed, when this is practicable; and where
this is found impossible, on account of the obstruction be—
ing within the cavity of the thorax, the incision must begin
about an inch and an half above the sternum.
The sterno—thyroidæi, and sterno—hyoidæi muscles, and
a part of the thyroid gland being now exposed, an assist—
ant should pull the muscles gently to the left side with a
blunt flat hook, while another draws the trachea to the
right, so as to admit of the œsophagus being brought into
view. If any large blood—vessel should be unavoidably di—
vided it should now be secured, The œsophagus being
next opened longitudinally, the substance is to be extracted
with a pair of forceps. If the obstructing matter is above
the sternum, and its seat can be discovered, the incision
should be made immediately upon it, and of a sufficient
size for its removal by a pair of small forceps; but when
the substance is in the chest, the gullet is to be opened for
about two inches, and immediately above the sternum;
a blunt probe being then introduced to discover the seat
of the complaint, the substance is afterwards to be ex—
tracted by a pair of straight forceps, when it is near at
hand, or by crooked forceps, if farther down the tube.
When 

[232]
When the operation is performed on account of some
disease, till this can be removed, our principal object is
the conveyance of nourishment to the stomach, and the
opening should then be preserved; but when it is employ—
ed for the purpose of removing a foreign substance fixed in
the passage, as soon as this is accomplished, the parts
should be re—united as speedily as possible. It will there—
fore be prudent to recommend total abstinence from solid
food for several days, and to convey nourishment by inject—
ing broth by the anus, and allowing very small quantities
of milk or soup to be now and then swallowed. The pa—
tient should keep his neck quiet, and the wound should be
treated as similar cases in other parts;
There is by no means that degree of danger attending
œsophagotomy that has been supposed. By proper cau—
tion the larger blood—vessels will be easily avoided, and if
the thyroideal arteries should be divided, they may in com—
mon be readily secured. The recurrent nerve will be in
little danger, although it runs close by the œsophagus, if
proper care is observed, and even if some of its branches
should be divided, the only bad consequence would be a
weakness of voice.
The operation has been more than once successfully per—
formed: —and there are many instances of large wounds
of the gullet healing very well; and if they should become
fistulous and not heal, the patient will have had the only
chance of relief, when they are induced by the operation.
CHAP. 

[249]
so suspect compression, and employ the trepan in the man—
ner already advised.
SECT. IV
Of Inflammation of the Membranes of the Brain from exter—
nal violence.
This dangerous complaint seldom makes its appearance
until some days, weeks, or even months after an injury is
received. In general the first symptom of it is an univer—
sal uneasiness over the head, attended with listlessness and
some degree of pain in the part injured, of which perhaps
the patient has hardly till now, had any cause to com—
plain. The listlessness increases—the patient appears
stupid—the pain in the injured part is gradually aug—
mented, while a sensation of fulness is felt in the other parts
of the head—giddiness and nausea, or even vomiting, come
on—heat and uneasiness appear—the sleep is disturbed and
not refreshing—the pulse is quick and hard—the face is
commonly flushed—and the eyes are from the beginning
somewhat inflamed, and painful upon exposure to light.
In some instances, where the symptoms are accompani—
ed by a wound on the head, the inflammation of the eyes
and flushing of the face seem to be produced by, and con—
tinued from, an erysipelatous affection around the sore; in
which cases, the edges of the sore first become hard and
swelled, and the swelling apparently originating from the
aponeurotic expansion of the muscles of the head, spreads
very quickly over the whole of it, and particularly down
the forehead, in such a manner as to close the eyes. This
swelling is soft, is painful to the touch, and has an erysi—
pelatous appearance. It arises in many instances merely
from the external sore, and is not usually so dangerous as
I i that 

[250]
that puffy circumscribed tumor, to which the parts injured
by the blow are often liable. When it originates from
the external affection, it may generally be soon removed by
the common remedies of erysipelas; but, in a few cases, it
is likewise produced from a previous affection of the dura
mater, when it is of a very dangerous tendency.
In the course of a day or two from the time that these
symptoms become formidable, the part which received the
blow assumes a morbid appearance. If the bone was at first
laid bare, it now becomes pale, white and dry, either over
its whole surface, or in particular spots, which by degrees
extend over the whole; and the edges of the sore, from the
beginning of the bad symptoms, become hard, dry, painful
and much swelled; but when the bone has not been de—
nuded, and none of the soft parts have been divided, but
merely contused, they now begin to swell, become puffy,
and somewhat painful upon being touched; and if the head
be shaved, the skin over the part affected will be found
of a reddish colour. If the swelling be laid open, the pe—
ricranium will be discovered to be detached from the
skull: a small quantity of a thin, bloody, and somewhat
fœtid ichor will be found beneath it; and the bone will
be discoloured as above described.
By the application of proper remedies, these symptoms
may in many instances be removed; but when this is not
the case, or they are not properly attended to, they con—
stantly become aggravated, and delirium, frequent shiver—
ings, coma, or stupor, are superadded to them.
About this period, all the symptoms which we have
described become so much milder, as not to be distinctly
observed, or are altogether lost in those which now begin
to appear. Paralysis of one side is soon followed by deep
coma; the pupils are dilated, and are scarcely affected by
the impression of light; the urine and fæces are passed in—
voluntarily; subsultus tendinum, and other convulsive
symptoms 

[251]
symptoms take place; and death is the certain consequence
if the patient is not soon relieved.
The symptoms described in the two last paragraphs are
indicative of the formation of matter, and can only be re—
lieved by the trepan: those first mentioned being the con—
sequence of inflammation, are to be removed by the gene—
ral remedies of inflammation.
External violence may induce inflammation of the brain,
by depressing part of the cranium; by contusion; and by
producing fissures or fractures of the skull not attended
with depression. The first of these we have already con—
sidered, and shall now proceed to treat of the others.
§ 1. Of Contusions of the Head producing Inflammation of the
Brain.
Contusions of the head are produced, as in other parts,
by blows or falls; and are sometimes accompanied with
wounds, at other times they are not.
The immediate and most frequent effect: produced from
them, when they afterwards prove troublesome, is to de—
prive the patient of his senses, and leave some degree of
giddiness. In a gradual manner, however, he recovers,
so that after a night's rest he appears perfectly well, un—
less a wound was produced at the same time with the con—
tusion, until some days, weeks, or even months after the
accident, according to circumstances, when the symptoms
above described make their appearance.
Hence it is evident, that accidents of this kind, which
at first appear trifling may be productive of very dange—
rous consequences, and therefore that all injuries done
to the head merit a great deal of attention.
In the treatment of contusions of the head, the indica—
tions are;
1. To employ every means preventative of inflamma—
tion. 

[252]
tion. 2. To produce resolution of the inflammation when
it has actually come on. 3. If this cannot be done, and
suppuration takes place, to procure a free vent to the mat—
ter: And, 4. If a gangrene supervenes, to remove it or ob—
viate its effects.
1. Patients recover so speedily from the immediate ef—
fects of contusion, in most instances, that we seldom have
an opportunity of employing the prophylactic remedies of
inflammation. But when this is afforded, we would re—
commend blood—letting, general and topical—laxatives—
the application of solution of saccharum saturni to the
part affected—a low diet, and total abstinence from ex—
ercise.
2. For the removal of inflammation it will be necessary
to employ, 1. Blood—letting—When a sufficient quantity
of blood can be obtained by topical bleeding this should
be preferred; hence leeches or cupping should, if possible,
be used near to the affected part. Deep scarifications with
a lancet or scalpel, when the parts have not been divided
but merely bruised and inflamed, are very serviceable for
this purpose. When general bleeding is necessary, it will
be best to open the jugular vein or temporal artery, and
draw off blood until the pulse begins to flag, if possible, to
the quantity of 20 or 25 ounces: this will be much more
useful than repeated small bleedings. It will be proper to
repeat the bleeding in a few hours if the symptoms conti—
nue violent, to an extent to be determined by the circum—
stances of the case.
2. Strong purgatives, or stimulating glysters—these are
very useful and should never be omitted.
3. Gentle diaphoretics. It is a matter of consequence to
keep a gentle moisture on the skin. If this cannot be effected
by warm fomentations to the feet and legs, and by laying
the patient in blankets, we must employ internal sudorifics.
Dover's powder is apt to excite vomiting; on this account
I 

[253]
I prefer a combination of an antimonial with opium—fif—
teen or twenty drops of antimonial wine, with four or five
of laudanum may be given every two hours until a sweat is
brought on, when a less quantity will serve to support it.
4. Opiates. A prejudice against the use of opium in dis—
eases of this kind has hitherto prevailed; but experience
has convinced me that this is unfounded, and that it may
always be employed with advantage to remove pain or
restlessness.
5. Suitable applications to the injured part. Experi—
ence has evinced to me the utility of producing a plentiful
suppuration from the part affected in all contusions of the
head. For this purpose, when the accident is attended
with a wound, it should be covered with pledgits of lint
spread with some emollient ointment, and soft warm cata—
plasms should be applied over these, and frequently renew—
ed. The symptoms are thus generally mitigated, and
sometimes entirely removed, When there is no wound,
and when from the swelling and pain of the injured part,
sometime after the accident, there will be reason to expect
the coming on of bad symptoms, the tumor should be im—
mediately laid open down to the pericranium; and if this is
separated, it ought likewise to be divided, any matter that
may be collected taken away, and the wound treated as
just above directed.
By the contrary treatment of suffering the swelling to
remain unopened until a fluctuation is perceived, I have
reason to believe that the matter collected, which is gene—
rally thin and acrid, is the most frequent cause of the suc—
ceeding inflammation of the dura mater which often takes
place. It produces this effect by first exciting inflammation
of the parts externally, which is extended to the internal
parts by the communicant vessels. Injuries of the head
very probably, in most instances, operate by inducing an ef—
fusion between the skull and pericranium; this being often
very

[254]
very small, does not occasion any evident tumor until its
acrimony excites an inflammation of the surrounding parts;
and hence we may readily account for the effects of these
injuries not appearing until some time has elapsed after the
accident.
It is to be observed, however, that the treatment we
have just recommended is not applicable to tumors recently
formed from external injuries. These are to be removed
in common by solution of lead, or of crude sal ammoniac,
or by the application of brandy, or some other astringent.
Such swellings give a sensation like that afforded by fractu—
red cranium; but we can never be deceived if we attend to
the concomitant symptoms.
3. When we have reason to suppose pus is formed with—
in the cranium, the only probable means of relief is af—
forded by the application of the trepan, in the manner for—
merly directed in sections 1 and 2.
4. When on perforating the skull, it is found that the
dura mater has become sloughy, with some tendency to
gangrene, the utmost danger is to be dreaded. There are,
however, some instances of recovery, in such cases, upon re—
cord: all that can be done is to keep the sores clean; dis—
charge any matter that may collect; apply soft light dres—
sings, and give Peruvian bark and vitriolic acid in as large
quantities as the stomach will bear them. If there remains
any tendency to inflammation, the diet should be low and
cooling, and the bowels should be kept moderately open;
but if the system is low, and the pulse feeble, wine, and a
generous diet should be allowed.
The operation of trepanning has been recommended in
inflammation of the brain, and in some cases of epilepsy; but
it must evidently be injurious in the former case, from the
irritation it gives to the diseased parts; and in two cases of
epilepsy in which I have seen it employed, there was every
probability 

[255]
probability that it occasioned the deaths of the patients by
exciting inflammation and a consequent suppuration.
§ 2. Of Fissures, or Simple Fractures of the Skull.
By a fissure we understand a mere division of the skull,
not attended with depression: This may either penetrate
the whole thickness of the bone, or be confined to one la—
mella of it; it may also either be attended with a division of
the corresponding teguments, or these may be left entire.
Fissures always require a great deal of attention; for al—
though there are many instances of those of great extent
healing without the occurrence of bad symptoms, yet there
are also instances of very small fissures terminating fatally.
Fissures are often accompanied by original affections of
the brain, and they are productive of danger themselves
by inducing effusions of blood or serum upon the brain,
or by tending to excite inflammation of its membranes.
When effusion take place, as it must immediately be
attended with symptoms of compression, the remedies for—
merly recommended must be employed. The trepan af—
fords the only effectual relief: the fissures should be traced
through their whole extent, and a perforation being made
in the most depending part of each of them, if this does not
prove entirely successful, the operation should be repeated
along the course of the fractures, as long as the symptoms
of compression remain, care being taken to include the
fissure in every perforation.
It often happens that the fissure is so exceedingly small
that it is difficult to distinguish it from the furrows pro—
duced by the blood—vessels, or from the futures. This is,
however, a matter of little consequence with regard to
practice.
When the pericranium is not separated from the cranium
by the accident, but is found separated in a particular part
on 

[256]
on cutting down to it, it affords a pretty certain mark of
a fracture beneath. When the bone is bared by the acci—
dent, it has been proposed to ascertain it by various means.
By pouring ink over the bone it has been said, that it will
sink into the crack and there remain, even if we attempt
to wash it off with water. But it is to be observed, that
unless the bones be very firmly ossified indeed, the ink
will always sink into the sutures, and hence this method 
can seldom be of any use in discovering a fissure. Some
other modes recommended, as by holding a string between
the teeth and striking it; and chewing some hard substance
to excite pain in the part injured, have no effect unless the
injury be extensive, and then they are unnecessary.
It often happens that blood continues to ooze out con—
stantly from the fissure; this, when it occurs, is a very
certain characteristic.
It has been by some advised in all cases of fissure to ap—
ply the trepan, chiefly with a view to evacute any collection
of fluid more freely than it could be done by the fissure;
but, if the fissure is wide, there can occur no necessity for
it; and we know from experience, that those of small ex—
tent frequently do well without the formation of any mat—
ter; and it would certainly not be prudent to advise a ha—
zardous operation merely for the chance of its becoming
necessary. And besides, instances are often met with in
which fissures penetrate no deeper than the external table
of the skull; this cannot be previously known, and could
never need the operation.
I am of opinion, that unless symptoms of compression
come on, the trepan can never be necessary, and that fissures
while unattended by bad symptoms, should be treated
merely as a cause that may give rise to inflammation. The
patient should be bled according to circumstances; the
bowels should be kept open; the sore should be treated
with 
 

[257]
mild dressings; and violent exertions of every kind should
be avoided. *
By these means a cure will frequently be obtained; but
when inflammation is induced, and suppuration is con—
sequent to it, the trepan is to be used as in other cases.
CHAP. XXX.
Of the Diseases of the Eyes.
SECT. I.
Of Ophthalmia, or Inflammation of the Eyes.
THE symptoms of ophthalmia vary somewhat accord—
ing to the particular seat of the complaint; but
those which in general occur are, a preternatural redness
of the tunica conjunctiva, owing to a turgescence of its
blood—vessels; pain and heat over the whole surface of the
eye, attended with a sensation of some extraneous body
between the palpebræ and the eye—ball: and a plentiful
effusion of tears. All these symptoms are commonly in—
creased by motion of the eye or its coverings, arid by ex—
K k posure
* In all these cases, the experience and judgment of the surgeon must
govern his conduct, as no precise positive directions can be laid down for
that variety of cases and circumstances which occur in practice: the young
surgeon should always have recourse to the advice and assistance of those
more experienced, whenever he can procure it; they will not only re—
lieve his own mind, but secure his character from the imputation of rash—
ness or ignorance. 

[258]
posure to light. When the pain produced by light is con—
siderable, we have reason to conclude, that the parts at the
bottom of the eye, particularly the retina, are chiefly af—
fected; but when the pain thus occasioned is not great,
the inflammation is probably confined to the exter—
nal coverings of the eye. In superficial affections, the
symptoms are usually entirely local; but whenever they
are deep seated, there are severe shooting pains through the
head, and commonly fever to a greater or less degree.
The tears discharged are frequently so hot and acrid
as to excoriate the cheeks; and after some continuance of
the disease, together with the tears, there is often a consi—
derable quantity of a yellow purulent like matter dis—
charged. When the inflammation has extended to, or
has originated in the tarsi, a discharge of viscid fluid takes
place from them, which adds greatly to the patient's dis—
tress, by cementing the eye—lids so firmly together, as to
render it very difficult to separate them.
Ophthalmia sometimes, though not very frequently, ter—
minates in suppuration, oftener in obstruction or indura—
tion of some part of the membranes of the eye, but very
rarely in gangrene.
This disease may be induced by whatever occasions in—
flammation in any other part of the body. It is also produced
by smoke; by much light, and particularly from much ex—
posure to the rays of the fun; exposure to fire; to snow;
and by the introduction of sand, lime, or any other extra—
neous body beneath the eye—lids. It is also induced by
scrophula, or lues venerea.
When ophthalmy depends on the two latter causes,
the employment of the remedies adapted to the general
diathesis becomes necessary. We propose in this place
merely to consider the disease when produced by local
causes.
The    

[259]
The indications of cure are, to remove extraneous irrita—
ting substances; to diminish pain and irritability induced;
to remove the turgescence of the blood—vessels of the eyes;
and to prevent a return of the disease.
When inflammation is produced by extraneous sub—
stances between the eye—lids and eyes, they should, if pos—
sible, be removed. The eye may be opened sufficiently to
admit of this by the fingers; but it is more effectually
done, if while an assistant lifts up the superior eye—lid with
a blunt hook, the surgeon depresses the inferior eye—lid.
The substance may by this means be discovered, and if
loose, may be taken out with the end of a blunt probe, co—
vered with a bit of soft linen, or silk; or if it is fixed
in the eye, it may be removed by a pair of small forceps.
It often happens that we cannot discover the offending
matter; in these cases tepid water, or milk and water,
should be frequently injected under the eye—lids, and the
eyes should be frequently dipped and bathed in warm
water.—When the inflammation has subsisted for some
time, it often continues even after its exciting cause has
been removed.
Whenever the topical symptoms are considerable, and
there is much fever, it will be necessary to use general
bleeding, brisk purgatives, and a low cooling regimen.
The light should be excluded from both the eyes;
and the diseased eye should be kept constantly covered, ei—
ther with soft linen soaked in a watery solution of lead, or
with cold poultices composed of this solution and crumb of
bread.
By these means very violent ophthalmias may often be
removed; but instances frequently occur in which they are
not effectual. In such, blood may be discharged by cupping
the temples, or by the application of leeches to them; but
it will sometimes happen, that even these give no relief:
the vessels of the eye itself should then be divided.
This may be done either with the shoulder of a lancet,
or 

[260]
or with a small knife. An assistant supporting the head
of the patient behind, and another securing his hands,
the surgeon with the sore and middle fingers of one hand,
is to separate the eye—lids, while with the instrument he,
makes repeated small scarifications on the turgid vessels,
avoiding those of the cornea, without they seem very much
distended with blood. In order to produce a free dis—
charge from the vessels, the eye should be frequently dip—
ped in warm water, or soft linen immersed in warm water,
should be constantly applied to it.
This operation is very easily and safely performed by
any surgeon of a tolerable degree of steadiness; and a few
drops of blood evacuated by it is frequently of more ser—
vice than any other remedy.
When scarification does not remove the pain, or when
it is not admitted, a little laudanum, dropped into the eye,
will sometimes be effectual in taking it off. The pain as
well as every other symptom produced by ophthalmia, is
often relieved by shaving the head and washing it fre—
quently in cold water. Blisters applied to the head, be—
hind the ears, or on the neck, are likewise advantageous,
as well as issues and setons in the back of the neck.
To obviate that gluing together of the eye—lids which is
apt to take place, particularly at night, it will be proper to
insinuate a small quantity of some emollient ointment be—
tween them, every evening. There are often slight ulce—
rations of the tarsi, which contribute to produce this ad—
hesion: when these are discovered, and are unconnected
with any general disease, they are most effectually removed
by the application of mild mercurial ointment, by means
of a pencil, night and morning, and the use of a weak satur—
nine or vitriolic lotion, once or twice a—day.
It is of great importance to prevent the admission of
light to the eye as long as it is productive of pain; and
even when one eye only is inflamed, both of them should
be 

[261]
be tightly covered with a loose bandage of silk or linen;
and when the patient is able to go abroad, the bandage
(pl. vi. fig. 5.) will be found very useful. The quantity of
light admitted can be easily regulated, and the eyes by it
are neither compressed nor kept too warm.
To prevent a return of ophthalmia nothing is so certainly
useful as cold bathing, general and topical. Shaving the
head, and bathing it daily, has been found of considerable
services. Peruvian bark is also very useful, and when the
disease is periodical, it is the most effectual remedy: all
exciting causes are carefully to be avoided.
SECT. II.
Of Wounds of the Eye—lids, and of the Eye—ball.
WHEN the eye—lids are wounded in a longitudinal direc—
tion, all that is necessary is to bring the lips of the cut to—
gether, and retain them by strips of adhesive plaster, un—
til a re—union takes place: but when the wound is trans—
verse, and particularly if the tarsus is divided, the parts
should be kept together by one or more suture's. The
interrupted future is usually employed, but I prefer the
twisted future. The pins used should be short and very
thin, that they may not injure the contiguous parts; and in
the introduction of them, care should be taken to make
them pass through the fibres of the orbicularis muscle, or
little advantage will be gained by the operation, and that
they do not pass through the internal membrane of the eye—
lid, or they will injure the globe of the eye.
In performing this operation, we should be careful that
the parts are not so closely drawn together, as to impede
the action of the eye afterwards; and as soon as it is fi—
nished, as it is of consequence to prevent the motion of the
eyes

[262]
eyes during the cure, the eye—lids should be closed, and
covered with a piece of soft linen spread with saturnine
cerate; and a compress of lint being laid over the affected
as well as the sound eye, the whole should be retained by a
napkin. Inflammation should be guarded against, or re—
moved if present, and in three days the sutures may be re—
moved, as a union will then probably have taken place.
When so much of the eye—lid is taken off, that the re—
maining parts cannot be brought into contact without im—
peding the motion of the eye—ball, it will be best to leave
them apart, use light easy dressings, and trust to nature
for supplying the deficiency with cellular substance.
Wounds of the eye—ball which penetrate deep, are fre—
quently dangerous from the contiguity of the brain; but
those which go no farther than the anterior part of the
eye, although they may destroy the beauty and utility of
the organ, are not in other respects hazardous.
Wounds of the cornea, particularly if directly opposite
to the pupil, are most frequently productive of loss of sight
in greater or less degree, from the cicatrix consequent to
them; but they do not usually occasion so much inflamma—
tion as those of the same extent in the sclerotica.
These affections are attended with risk in proportion
to their extent; the larger the wound is the greater dan—
ger will there be of inflammation, and of destruction of
sight, from evacuation of the humors of the eye, or from
cicatrices.
The circumstance which requires our chief attention in
wounds of the eye, is the prevention or removal of inflam—
mation; for if a large opening is made in the eye, a great
portion of the humors will certainly be evacuated. All
that art can do is, together with a strict antiphlogistic
course, to keep the eye lightly covered with some emollient
application of the saturnine kind, and to bathe it now and
then with a watery solution of lead. When pain to any
considerable 

[263]
considerable degree occurs, opium may be given in pro—
portion to its violence.
By these means, symptoms of a very formidable appear—
ance will often be entirely removed.
SECT. III.
Of Tumors of the Eye—lids.
THE eye lids are frequently infested with small, trouble—
some tumors of various kinds.
Towards the internal angle of the eye, and most fre—
quently on the under eye—lid, near the punctum lachrymale,
many people are liable to frequent returns of a small en—
cysted tumor of the inflammatory kind, by nosologists
termed hordeolum, but commonly known by the appella—
tion of a stye. This begins with a sensation of fulness, stiff—
ness, and uneasiness of the internal canthus of the eye.
At first the skin is scarcely if at all discoloured, but if sup—
puration follows, which will always be the case if the tu—
mor is left to itself, it becomes first of a pale red, and af—
terwards of a yellow colour towards the upper part, where
it commonly bursts, and discharges a small quantity of a
thick purulent matter. This tumor is very flow in its
progress, and the peculiar appearance of it may be readily
accounted for from its particular situation.
Styes are more frequently met with than any other tu—
mors of the eye—lids, and are usually seated near the nose;
but the other species are situated indiscriminately in eve—
ry part of them. These are of three kinds.
The first we shall mention is commonly of a roundish
form; is somewhat soft; it seems to move when pressed
upon; the skin retains its natural appearance; and from
the contents of it being always of a white and fat—like na—
ture, 

[264]
ture, it is termed steatoma. The matter of which these tu—
mors are composed, is always surrounded by a firm mem—
branous cyst.
From different parts of the eye—lids, we frequently ob—
serve small pendulous excrescences,to hang by very nar—
row necks: on other occasions they are connected to the
skin by means of thin broad bases. Some of these tumors 
being of a soft fleshy consistence are termed sarcomata:
others being hard, are termed verrucæ, or warts.
In the treatment of styes, we are by some directed to en—
deavour to discuss them by astringent applications; but by
this mode we sometimes produce tumors of a hard and in—
veterate nature, and may injure the eye—lids by the appli—
cations themselves. I think it the best practice to endea—
vour by poultices to bring them to a speedy suppuration,
ind then to discharge the matter; the sore usually heals
very speedily, and the parts soon recover their tone, if
bathed with some mild astringent.
Excision alone should be depended on for the removal
of the sarcomata and verrucæ; if caustic or ligature are em-
ployed, they are always tedious in their operation, and
often produce troublesome inflammatory affections.
The patient being seated opposite to a window, and his
head being secured by an assistant, if the tumor is not large
enough to be laid hold of by the fingers, a ligature ought
either to be passed through it or around it, by a needle,
that it may be raised from the parts beneath: if the basis
of the swelling is narrow, it may be separated by one stroke
of the scalpel, but if its attachment to the subjacent parts
is of any considerable extent, it is better to remove it by
cautious dissection. The only dressing in common neces—
sary is lint retained by adhesive plaster.
When we have to remove a steatomatous or encysted
tumor, instead of dissecting off the swelling covered with
the skin, it is better merely to divide the skin and cellular
substance 
                      

[265]
substance by a simple incision entirely across the most pro—
minent part of the tumor with a scalpel, a strong waxed
thread being then passed through the centre of the cyst, an
assistant should by means of it raise the tumor sufficiently,
while the surgeon dissects it entirely out.
If the internal membrane of the eye—lid is divided in the
operation, the lips of the wound in it must be laid as nearly
together as possible, and any superfluous matter that forms
must be frequently removed; but nothing more should be
attempted. When, however, the external skin of the eye—
lid is cut, the wound should be closed by strips of adhe—
sive plaster.
In extirpating these tumors, whenever the cyst is pretty
firm, and the contents are steatomatous, they are more ea—
sily and effectually removed by preserving the cyst entire;
but when the cyst is thin, and especially if its contents are
fluid, from suppuration of some part of it, which is fre—
quently the case, it will conduce to the facility and expedi—
tion of the operation, to puncture the cyst, and discharge
its contents as soon as it is laid bare.*
SECT. IV
Of Inversion of the Cilia, or Eye—lashes.
THE eye-lashes are sometimes so much turned inwards
upon the eye, as to irritate it and produce inflammation and
pain.
L l The
* This species of tumor is frequently so situated as to admit of re—
moval by turning the ciliary ligament outwards, then laying hold of it
with a small hook and dissecting it out, without wounding the internal
skin of the eye—lid. 

[266]
This disease is usually termed Trichiasis or Entropium,
and may depend entirely upon a derangement of the hairs
themselves, which leaving their usual direction, turn in to—
wards the eye—ball; but it more frequently originates from
an inversion of the tarsus, induced either by some unequal
spasmodic affection of the orbicularis muscle in the under
eye—lid, for it seldom occurs in the upper palpebra, or by
a cicatrix in the skin of this part. It is also sometimes the
effect of tumors; and it has likewise been attributed to a
relaxation of the teguments of the eye—lid.
When the complaint is induced merely by a derange—
ment of the hairs themselves, if the hairs have acquired
their full strength, as it will be impossible to bring them
back into a proper direction, they should be pulled out by
a small pair of forceps, which usually gives immediate re—
lief; and to prevent a return of the disease, as soon as the
succeeding hairs have acquired about half their full size,
they should be turned down upon the eye—lid with the end
of a blunt probe, and there retained for one, two, or three
weeks, by covering them with narrow flips of adhesive
plaster, or with strong mucilage or glue by means of a pen—
cil. This method will almost always succeed in the re—
moval of this troublesome and painful complaint.
If trichiasis arises from partial spasms of the orbicular
muscle, the only effectual mode of cure consists in making
an incision through the internal part of the palpebra, so as
to divide the affected fibres. No dressing is necessary to
be applied to the wound.
When a tumor or cicatrix appears to be the cause of the
inversion, it should be dissected out. When, in the latter
case, the disease is not immediately removed by the opera—
tion, the edges of the wound should be united by adhesive
plaster, or, if necessary, by the twisted or interrupted su—
ture. When the operation succeeds there will be nothing
more than soft easy dressings requisite.
It 

[267]
It is not very probable that entropium is ever occasion—
ed by a relaxation of the teguments of the palpebra; when
it appears to be the case, however, a solution of alum in in—
fusion of oak bark will probably remove it; but if this
does not succeed, there is no remedy but the removal of
the relaxed skin by the scalpel, and afterwards uniting the
edges of the wound by future.
Inflammation of the eye is a very constant attendant of
this disease; when it is not removed by taking away the
hairs, the remedies formerly directed for ophthalmy must
be employed.
The upper lid is subject to a dropsical swelling which
sometimes may be productive of trichiasis: This may be of—
ten cured by making two or three small punctures in it
with the point of a lancet; but when this does not suc—
ceed, it will be necessary to cut off a part of the skin with a
scalpel, and close the wound afterwards by adhesive plas—
ter or suture.
SECT. V.
Of the Turning Outwards of the Eye—Lids.
WHEN the internal surface of either of the eye—lids is
turned outwards, so as to fold over any part of the cilia
or of the contiguous skin, the disease is termed ectropium;
when the upper eye—lid only is affected, it has been called
Lagophthalmus.
This complaint is not only productive of deformity, but
also, in many instances, of considerable pain. It may be
induced by an enlargement of any part of the eye, or o—
ther tumors within the orbit; by dropsical swellings of
the palpebra; by violent inflammations of the tunica
conjunctiva lining the eye—lids; by mere relaxation of the
palpebra; 

[268]
palpebra; and by cicatrices of wounds or abscesses, pro—
ducing a corrugation of the skin of the eye—lid.
When the disease is induced by tumors, these must be
removed; when topical dropsy is the cause, it must be
treated as directed in the last section. If inflamma—
tion has given rise to it, and it continues after that has
subsided, deep scarifications into the affected part will be
particularly beneficial: And if the complaint originates
in relaxation, as will be particularly the case in old age,
cold water, brandy, and astringent lotions should be fre—
quently employed; but in aged persons no operation
should be advised.
Cicatrices, from confluent small—pox, and other causes,
sometimes induce this disease. When the contraction is
only in one point, it may be removed merely by an inci—
sion through the skin and cellular substance; but when
there is an adhesion the whole length of the cicatrix, af—
ter making an incision, the skin should be raised by a pair
of small forceps, and the whole of it separated by the
knife from the parts with which it adheres. The cilium
then being restored to its natural place, the skin is to be
kept in a proper situation by adhesive plaister, if possible,
if not, by a bandage, until the wound fills up and heals.
SECT. VI.
Of Concretion of the Eye—Lids.
AN adhesion of the eye—lids to each other, or to the
ball of the eye, is most frequently occasioned by inflam—
mation— It is sometimes met with in new—born children.
When the adhesion is slight, and not of long duration,
it may be removed in general by a blunt probe; but when
the concretion is firm, or any way extensive, it can only
be 

[269]
be separated by the knife. In performing this operation,
the patient's head should be supported by an assistant,
who should likewise support or elevate the upper eye—lid;
whilst the surgeon, with a pair of small forceps, must
raise or separate the under lid, and at the same time,
cautiously remove the adhesion with a scalpel. The eye 
must afterwards be covered with a pledgit of lint spread
with saturnine cerate; and at every subsequent dressing,
a small quantity of the ointment may be insinuated be—
tween the eye—lids. All means of exciting inflammation
should be carefully avoided; and if it comes on, it should
be removed as in other cases.
SECT. VII.
Of Fleshy Excrescences on the Cornea.
THIS disease is denominated from its appearance, Ptery—
gium, or Onyx, by different writers. It is most frequently
met with at the internal angle of the eye, but it attacks other
parts in various instances. In some cases it is small, but
in others, it gradually extends over the whole cornea.
This affection seems to consist in an organic membranous
substance formed by a protrusion of some of the blood—
vessels of the tunica conjunctiva from external violence,
inflammation, or other causes; and its increase is probably
owing to subsequent inflammations. Ophthalmia is its
most frequent cause; and it seldom appears until the dis—
ease begins to subside, or has entirely gone off. During
the inflammatory state, this swelling is generally of a
deep red colour, and very painful; but afterwards, and
when it arises without any previous inflammation, it is of
a pale yellow, and unattended with much pain, unless
irritated.
When the inflammation has gone off, as long as this
complaint does not impede the motion of the eye—lids, we
should 

[270]
should trust chiefly to astringent applications, such as so—
lutions of alum and white vitriol, as strong as the patient
can bear them, perhaps ʒfs of the former, and ℈i. of the lat—
ter to ℥iv. of water, and used three or four times a—day—
A weak solution of corrosive sublimate, as gr. i. to ℥iv. or
verdegris, may also be employed with benefit.
Escharotic powders, as calcined alum, white vitriol, or
verdegris, mixed with loaf sugar, and sprinkled on the
part once or twice a day, have been used. But we should
be very cautious in the application of remedies of this
kind. They may be used alone, or alternated with the
astringents above mentioned.
When these remedies fail in preventing the tumor from
acquiring an inconvenient size, if it is attached to the eye
by a small pedicle only, it may be removed by one stroke
of the scalpel; but whenever it is connected to the whole,
or a large part of the surface of the eye, it has usually
been recommended to dissect off the whole; but this is a
tedious and hazardous operation: The following an—
swers every purpose of it without danger. The patient
being placed upon a pillow on the floor, the surgeon sitting
behind him on a chair, should have the head of the pa—
tient reclined on his knees, with the face so raised, that a
sufficient degree of light may fall on the eyes. The pati—
ent's hands then being secured, the under eye—lid should
be drawn down as far as possible by an assistant, while
the upper palpebra is supported in such a manner by the
surgeon with his left hand, as to expose to view the whole
of the diseased part. A small knife* is now to be employ—
ed in making scarifications through the excrescence near
to and all around its outer circumference, so as to cut
off all communication between the roots and extremities
of
* The knife best adapted to this purpose, is made about the size and
shape of that used for extracting the cataract, except that it is somewhat
more rounded at the point, and has a back like a common scalpel. 
                     

[271]
of those vessels of which it is formed. And in order to
render the operation more certainly successful, after the
discharge of blood induced by the first incisions is some—
what abated, one, two, or more circular scarifications
may be made within each other.
These incisions had better be made by repeated strokes
of the knife through the excrescence, for fear of injuring
the eye—ball; and they may be done with equal safety,
and with more ease, in the manner above recommended
than by lifting the excrescence by a ligature passed through
it, as advised by some operators.
The incisions should be allowed to bleed freely, and
may afterwards be bathed two or three times a—day with
a weak solution of saccharum saturni. If the excrescen—
ces do not seem to decrease in a few days, the operation
may be repeated, and again renewed from time to time, as
long as any part of the disease remains; and whenever
any part of the tumor becomes loose, it may be cut off
but not without.
Although this operation very commonly proves success—
ful, yet there are some instances in which no advantage is
derived from it, and the disease uniformly increases after
its performance: In these cases, we must trust to pallia—
tives. The eye should be frequently bathed with a weak
saturnine solution, and be covered with pledgits of Gou—
lard's cerate. When these applications have no effect,
and the tumor increases to such a size as to destroy vision,
and becomes very painful, it will be necessary, left it should
degenerate into a cancer, to remove it at once, by extirpa—
ting the whole eye—ball.
SECT. 


[272]
SECT. VIII.
Of Abscesses in the Globe of the Eye.
WHEN inflammation of the eye terminates in suppura—
tion, which is seldom the case, it commonly originates
from negligence, or from a scrophulous or some other
general affection.
The effusion of puriform matter into the ball of the eye,
is commonly produced from the internal part of its mem—
branes; by mixing with the aqueous humors it produces
an enlargement of the eye, a loss of vision, and such an
opacity, that, in general, neither the iris, pupil, or crystal—
line lens can be distinguished. In some few cases, how—
ever, the iris is pushed forward, and can be observed
in close contact with the cornea; and the coats of the eye
being here weaker than in any other part, a protrusion
commonly takes place, which, if not opened soon, bursts of
itself, and discharges part, or perhaps all of the contents of
the eye; and at this opening the iris, in a thickened disease
ed state, is very generally pushed out. In some cases,
partial swellings occur likewise in the sclerotica.
During the formation of this disease the patient suf—
fers not only a loss of sight, but severe pains in the eyes,
shooting backwards into the head, are generally attend—
ant, accompanied by constant restlessness, heat, and other
symptoms of fever; and these continue very commonly
until the contents of the eye are evacuated. In some in—
stances there is no pain; but the matter formed is then
small in quantity, and the swelling is chiefly of a watery
nature, probably originating from an increase of the a—
queous humour.
All the varieties of this disease we comprehend under
the name of staphyloma. Small, partial abscesses seated
on 

[273]
on different parts of the cornea or sclerotica; and in which
there is no general affection of the eye, are included under
the title of Hypopyon. In both these diseases, the motion
of the eye—lids is more or less impeded.
All the varieties of the staphyloma require the same
treatment. As it rarely happens that the use of the eye
can be preserved, our chief object in general is; to abate
the violence of the pain, and to remove the deformity pro—
duced. For the accomplishment of the first intention,
the disease is to be treated by the remedies of ophthalmia:
And if, notwithstanding the employment of these, suppu—
ration is induced, and the pain produced by the consequent
increased distension of the eye is very great, nothing but
an incision through its coats so as to evacuate the effused
matter and the thinner humours, will give relief. The
patient's head being secured by an assistant, and the
operator standing before him, the eye—lids may be suffici—
cntly separated by one hand, while the knife recommend—
ed in section vii. being introduced into the most promi—
nent part of the tumor, or into the most depending part
of the transparent cornea, is to be carried forward hori—
zontally until an opening of a sufficient size is formed.
It has been recommended instead of the above described
operation, either to dissect off the protuberant part of
the eye, or to remove it by a ligature; but neither of
these painful modes are in common necessary, nor are they
more effectual than the method we have advised. In some
very long continued cases of staphyloma, indeed, where the
humours of the eye seem to be entirely absorbed or destroy—
ed, and in which the tumor is altogether formed by a thick—
ening of the coats of the eye, and particularly of the iris,
the only effectual remedy is the removal of all the promi—
nent part of the eye; but in common, the disease should be
considered merely as an abscess, and treated as abscesses in
other parts of the body.
M m After 
 

[274]
After the contents of the eye have been evacuated, the
parts should be gently covered with a soft compress moist—
ed with weak lead water, and the patient should be kept
upon a low, cooling regimen, until the wound is healed,
or there is no risk of inflammation.
The hypopyon is to be treated upon the same plan; the
pain is to be moderated by opiates, &c. and as soon as mat—
ter is formed, it should be evacuated by an incision, in
order to prevent a chance of its being discharged into the
globe of the eye, and destroy vision entirely.
The fungous excrescences that occur after operations
in these diseases, may be kept down by the occasional ap—
plication of burnt alum finely powdered, or of lunar
caustic.
SECT. IX.
Of Dropsical Swellings of the Eye—Ball.
A DROSY of the eye—ball is produced solely by an in—
creased quantity of the aqueous humour. The first symp—
tom of the disease is, a sense of fulness in the eye, which
produces a good deal of distress, long before any increase
of size in the eye—ball is perceptible: This at length makes
its appearance; these motion of the eye—lids begins to be im—
ped; and vision gradually becomes more imperfect, until at
length the patient is just able to distinguish light from dark—
ness. At this period too, some part of the eye, most fre—
quently the transparent cornea, generally begins to pro—
trude, so as to form a small tumor. If the contents of the
eye are not now discharged by an operation, the tumor
soon bursts.
In


[275]
In the early stage of this disease there is no difficulty in
distinguishing it from staphyloma; but in the advanced
state this is not always easy to be done. The external ap—
pearances of these diseases are sometimes exactly similar;
but in the dropsy of the eye, the patient is always sensible
to the effects of light; and if the pupil can be distinguished,
light will commonly produce some degree of contraction
in it. It is, however, of no consequence to discriminate
between them, for the treatment adapted to one is equally
proper for the other. See the last section.
In the earlier stages of this complaint, as the consequent
loss of vision seems to originate often merely from disten—
sion, would it not be better to evacuate the fluid, by an in—
cision of perhaps three—tenths of an inch long with the
knife (pi. vii, fig. 8.) into the most depending part of the
transparent cornea; or by introducing a flat trocar with
a lancet point, of the size of a crow quill, about the tenth
of an inch from the cornea transparens, behind the iris, and
at the most depending part of the eye? This might be re—
peated occasionally, if the disease should return. It is an
operation perfectly safe; and after its performance, with a
view to strengthen the eye, and prevent a return of the
complaint, the parts might be bathed frequently with some
astringent lotion.
Instead of discharging the humour by an incision, in an
advanced stage of the disease, when vision is destroyed, it
has been proposed to employ a seton; but it is probable this
would give too much irritation.
SECT. 


[276]
Of Blood effused into the Cavity of the Eye—Ball.
Blood may be effused into one or other of the cham—
bers of the eye by various causes. It has occurred in
some instances of putrid diseases, and in inflammations of
the eye; but it is more frequently the consequence of a
rupture of some blood vessel, from a blow, or from a
wound penetrating into the posterior chamber. When the
wound does not extend farther than the anterior chamber
of the eye, as the vessels surrounding that do not in com—
mon convey red—blood, it seldom occurs as an effect.
Whenever blood is mixed in such quantity with the
aqueous humour as to obstruct vision, it should be remo—
ved by an operation; but when it sinks below the axis of
vision, and produces no inconvenience, it may be suffered
to remain.
The operation for the removal of blood from the eye—
ball is similar to that described in the last section. An
opening should be made in the most depending part of the
transparent cornea, with the knife, about a sixteenth part
of an inch from the junction of the iris with the other
coats of the eye; and thence carrying the point of it ho—
rizontally forward to the distance of about three—tenths of
an inch, it ought at this part to be pushed through the cor—
nea:—by proceeding slowly and steadily, all that part of
this membrane should then be divided which lies between
the two openings made by the instrument at its entrance
into, and its passage from the cavity of the eye, care being
taken to make the incision at an equal distance from the
iris through its whole length.
The aqueous humour, together with the commixed blood,
will now be discharged, particularly if the patient turn his
face 


[277]
face downwards, and the sides of the divided cornea be
separated by a blunt probe, or a small scoop. The cornea
will then collapse, and a compress of lint moistened with
lead water being applied, the wound will soon close, and
the aqueous humour be quickly regenerated.
SECT. XI.
Of the Ulcers on the Globe of the Eye.
THE danger of sores on the eyes depends chiefly on their
situation, but in some measure also on their form. Ulcers
on the cornea, from the cicatrices consequent to them, are
very apt to produce loss of vision in greater or less de—
gree; while those seated on the sclerotica never produce
that effect. And ulcers that are broad and superficial,
although they may induce loss of vision, yet they do not in
addition to this evacuate the humours of the eye, as those
which are deep and narrow often do, either by penetrating
entirely through the coats of the eye, or by weakening
them to such a degree that the humours force a passage for
themselves.
In some cases these ulcers instead of occasioning a loss
of substance, shoot out soft and fungous excrescences.
Ulcers of the eye may occur from a variety of causes, as
from wounds, burns, bruises, &c. and from general affec—
tions, such as lues venerea, or scrophula. But in most cases
they may be traced to inflammation terminating in the for—
mation of matter. Inflammation is likewise a frequent and
troublesome accompanyment of them.
When these affections are attended with much inflam—
mation, all the remedies of ophthalmia in general become
necessary; and when we find a number of inflamed ves—
sels passing directly from the sores along the centre of the
eye,

[278]
eye, it will not only contribute much to the removal of the
inflammation to divide them, but will also be of great ser—
vice in healing the ulcers. This must be done very cau—
tiously, for if the scarifications are made very extensive and
deep, they will be very apt to degenerate into troublesome
sores.
After the inflammatory state of these ulcers is removed,
they should be treated, as ulcers in general, by the appli—
cation of emollient, or of stimulating ointments*, or lini—
ments, of escharotics, or of astringents, according to the par—
ticular circumstances of the case. And if any general dis—
ease is connected with the topical affections, remedies a—
dapted to this should be used at the same time with the lo—
cal applications. Ointments, or escharotics, can be most
conveniently applied by means of a pencil. It is hardly
necessary to observe, that lint or bandages cannot in ge—
neral be used in cases of this kind.
When large pendulous excrescences are produced from
ulcers on the eye, they should be raised by means of a li—
gature passed through them, and then dissected off with
the scalpel. But when they are small, or broad and low,
the eye being fixed with a speculum, lunar caustic should
be applied by means of a pencil over their surface, and be—
fore the speculum is removed, the caustic should be warned
off by a pencil, dipped in warm water or milk.
When the constitution is found, ulcers, of the eye will
commonly heal without much difficulty, but in some in—
stances it happens that they constantly increase in virulen—
cy, notwithstanding every thing used for removing them.
In such cases as soon as they have increased to such a de—
gree as to endanger the communication of the disease to
the parts contiguous to the eye, the eye—ball should cer
tainly be extirpated.
SECT.
* Stimulating applications may be used in these cases with more free—
dom than is generally supposed: Such as corrosive sublimate, verdegris,
white vitriol, &c. B. 

[279]
SECT. XII.
Of Specks or Films upon the Eye.
THE disease termed leucoma, albugo, or nubecula, con—
sists in an opake spot formed on some part of the eye:
When it occurs on the sclerotica, it seldoms requires the
assistance of the surgeon; but when it is seated on the
cornea, it always merits great attention, as a very small
degree of it frequently induces a partial and sometimes a
total loss of vision.
These specks or films are generally of a whitish colour,
and seem to originate, in every instance, from that effusion
which is so frequent a consequence of inflammation. When
an abscess is thus produced, the bursting or opening of it
very commonly leaves an opaque spot, attended with some
degree of prominency of the parts in which it was seated;
but where the effusion instead of being near the surface of
the cornea is dispersed among the different lamellæ of which
that membrane is composed; or when the degree of inflam—
mation has not been sufficient for carrying it on to suppura—
tion, the opacity induced, does not, as in the case of an ab—
scess, form a protuberance, but rather appears to constitute
a part of the cornea itself.
These spots on the eye are of various forms, and of dif—
ferent degrees of magnitude. Whenever they affect the
sight materially, they should certainly if possible be re—
moved. In the cure, it is of the greatest consequence to
to ascertain which of the two varieties above described the
case belongs to. When the effused matter seems to be
spread through the whole substance of that part of the
cornea in which it is seated, without elevating it in any
degree, no advantage can be expected from any external
applications, because we cannot by these remove the dis—
ease 

[280]
ease without destroying the cornea itself. In such cases;
as the opacity is sometimes removed by an exertion of the
system alone, probably by means of absorption, it will be
proper to employ such remedies as we know excite this o—
peration, such as a gentle course of mercury, now and then
brisk purgatives, and issues. But we seldom derive much
advantage from them.*
When there is an evident prominency in the diseased spot,
produced from an elevation and opacity of the external
lamina alone, we can often cure the complaint entirely,
and almost in every case produce an alleviation of it. This
variety of leucoma may be removed either by the knife, or
by escharotics; but in general the former is preferable. The
eye being fixed with a speculum, (pl. vi. fig. 6.) the surgeon
should seat himself between the patient and a clear light;
and then with repeated strokes of the small knife, (re—
commended in sect. vii.) he should endeavour to cut
away all that portion of the cornea which is in any de—
gree separated from the rest. This may be done with
the greatest safety by an operator with a steady hand.
As patients will not always submit to this operation, we
are sometimes under the necessity of employing escharotics.
These may be used sufficiently strong to remove leucoma, in
many instances, without injuring the sound parts contiguous
to those diseased. When escharotic powders are em—
ployed alone, or mixed with emollient ointments, they
should be very finely levigated. The most effectual of
these are red precipitate, or verdegris, mixed with three or
four
* When the opacity is confined to the middle of the Cornea, and the
other parts of the eye are found, Mr Pellier says he has derived consider—
able advantage from enlarging the pupil, by means of a small pair of
curved scissars carefully introduced upon a grooved director, through
an opening in the cornea to the back part of the iris. The cornea is to
be cut exactly as directed in the operation for extracting a cataract, and
the iris is to be divided its whole breadth. If this affection should be
complicated with a cataract, the cataract is to be extracted.

[281]
four parts of fine sugar. Calcined alum, and white vitriol,
combined with egg—shells in fine powder, have frequently
proved useful. A lotion, or wash, seems to be the best form
in which escharotics can be applied to the eye: to make
these, verdegris, white vitriol, or corrosive sublimate, may
be dissolved in water.
As it is impossible to confine any of these applications
to the diseased part; all that can be done is to insert them
within the eye—lid; by the motion of which they are soon
conveyed over the whole surface of the eye. In order to
reap advantage from them, it will be adviseable to em—
ploy two or more at the same time; thus a small quantity
of the powders or ointments may be used evening and
morning, and a wash may be employed twice or thrice in
the day.
SECT. XIII.
Of Protrusions of the Globe of the Eye from the Socket.
THE eye may be protruded from its socket by different
causes: 1. By hypopyon, staphyloma, and dropsical swel—
lings. 2. By external violence. And 3. By tumors form—
ed behind or beneath it.
When the protrusion originates from the first set of cau—
ses, the size of the swelling must be diminished by incision,
and the other means already directed in those cases.
If external violence displaces the eye, and its connection
with the orbit is not entirely destroyed, it should be imme—
diately replaced after removing any extraneous matter that
may happen to have been introduced into the orbit; and
with a view to prevent or lessen the consequent inflamma—
tion, bleeding, general and topical, and a strict antiphlo—
gistic regimen should be advised; the eye should be cover—
N n ed 

[282]
ed with cooling saturnine applications; and light ought
to be entirely excluded from it.
There are several instances upon record of the eye being
entirely thrown out of the orbit, and on its being afterwards
replaced, the patients have entirely recovered the use of it.
When the eye—ball is protruded by a tumor situated be—
neath or behind it, the cure must depend entirely on a re—
moval of the tumor. If the swelling is formed by a collec—
tion of fluid, a cure will sometimes be obtained merely by
laying the cyst open; but when it is of a firmer nature it
must be totally extirpated.
An enlargement of the lachrymal gland has in some
induced this, disease—extirpation of the tumor is then the
only remedy.
Tumors within the orbit, of whatever kind, should al—
ways be removed as soon as they begin to injure the func—
tions of the eye; for if this is long neglected, the adjacent
bones, as well as the eye, may be brought into a diseased
state; and when this seems to be induced in any con—
siderable degree, the operation will come too late.
SECT. XIV.
Of Cancerous Affections of the Eye, and Extirpation of the
Eye—Ball.
IT sometimes happens that ophthalmia and staphyloma
degenerate into cancer. The eye—ball becomes enlarged,
and protrudes beyond the boundaries of the socket; it
acquires a firm, and even a hard consistence; and the pow—
er of vision is destroyed. The tumor has commonly a red
or fleshy appearance; in some instances, a yellow gluti—
nous matter, but most frequently or thin acrid ichor is dis—
charged from the surface of it. For a considerable time
the 

[283]
the patient complains only of heat, or a sensation of burn—
ing in the swelling; but at last he becomes distressed with
severe pains shooting through its substance, and across the
brain to the opposite side of the head.
Whenever this disease occurs, as there is no prospect of
curing it but by extirpation of the whole eye—ball, and as
this is an operation attended with no danger from hemor—
rhagy, or any other cause, it should always be employed as
early as possible. See section on cancerous ulcers.
In performing the operation, the patient should either
be firmly seated in a proper light, with the head supported
by an assistant, or what answers better, he should be laid
upon a table, with his head on a pillow.  When the eye—
lids are diseased, they must be removed with the eye; but
when they are sound, they should be allowed to remain.
By means of two flat hooks, pl. vi. fig. 7.) the palpe—
bræ are to be separated by assistants, and then the operator
is to take hold of the eye with his fingers, if it is sufficiently
protruded; but if this cannot be done, it will be necessary
to pass a broad flat ligature through the centre of it, in
order to secure it during the operation. While this is done
with one hand, the surgeon with a common scalpel in the
other, must endeavour by a slow dissection, to separate the
whole globe of the eye from the parts with which it is
connected. Every diseased part must be removed; but
great care must be taken to avoid injuring the bones.
Whenever the hemorrhagy is considerable, which is
seldom the case, it may be easily restrained by pressure a—
lone; or a piece of dry sponge being applied to the ves—
sels, pressure may be applied with it, by filling the orbit
with lint, and applying a napkin over the whole. If
sponge is used, it will be proper to tie a piece of strong
waxed 

[284]
waxed thread to it, that it may be readily removed when
there is no farther risk of hemorrhagy.*
SECT. XV.
Of Artificial Eyes.
ARTIFICIAL eyes are chiefly useful when the eye has
been but in part removed, or it has been diminished in size
by the operation for staphyloma, or hydrophthalmia; for
when all the globe has been taken away, it is difficult to
fit and preserve them in a proper situation.
They are usually made of a concave plate of gold, of sil—
ver, or of glass, coloured so as to match the eye remaining,
and adapted to the orbit. Those of glass can be fitted more
exactly, and kept cleaner than those formed of metal;
and they should consequently be preferred.
SECT. XVI.
Of Cataracts.
§. I. General Remarks on Cataracts.
A CATARACT is a deprivation of sight, induced by an
opacity of the crystaline lens, or of its capsule†.
Instances
* Though the hemorrhage consequent upon this operation, may be
easily restrained by pressure with the sponge and lint as directed, yet a
violent one has ensued the fourth day after in consequence of a severe
cough which forced out the plug of lint from the socket in the night,
and the patient lost about forty ounces of blood before any assistance
cold arrive. This ought to put young surgeons upon their guard in
such cases.
† M. Pellier, a very able and successful French oculist, tells us, that
cataract is sometimes induced by an opacity in the fluid, with which the
substance

[285]
Instances have occurred in which cataracts have form—
ed in a few hours; but in common their production is gra—
dual. The first symptom is usually a weakness or dimness of
sight; and this commonly takes place long before any alter—
ation in the appearance of the lens can be perceived. This
gradually increases; and after some time, upon examina—
tion, the lens will be found of a dusky hue, and somewhat
opaque. The patient at length either becomes totally
blind, or perhaps is just able to distinguish bright colours,
or light from darkness. The lens grows opaque in pro—
portion to the degree of blindness, and gradually become
white, or of a grey or pearl colour: in a few instances the
opacity is partial, but it is in common extended over the
whole lens.
In
substance of the lens is immediately surrounded. That it is in some cases
complicated with a dissolution, and in others with an opacity of the vi—
treous humour, originating from very violent inflammation, and which
are both incurable; and sometimes with adhesions of the lens to the cap—
sule of the vitreous humour; which is probably the most common cause
of a failure in couching.
He also informs us, that when a cataract is of a firm consistence, it is
almost always of a brown colour; and when fluid, of a cream colour,
except in children at birth, when it is of a milk white; and that the
eye, in the latter case, appears full, and somewhat larger than usual, and
the capsule is considerably thickened: That if it is of a yellow colour, a
small portion of the lens is commonly hard, and the rest fluid: And
that he has seen instances of a black cataract; which is to be dis—
tinguished from a gutta serena, by the pupil retaining its contractile
power. Mr Bell appears to be well convinced, that Mr Pellier is ca—
pable of distinguishing these varieties of cataract by the marks here laid
down.
Mr Pellier prefers extraction to depression of the cataract in every case,
except the pupil is very small. He always fixes the patient with his side
towards the light, during the operation; but the eye opposite to that
operated upon, previously covered, is placed near the light. He separates
adhesions of the lens, or replaces the iris when it is thrown forward, by
means of a small instrument which he terms a curette. When there is
reason 

[286]
In simple cataracts the pupil contracts and dilates ac—
cording to the degree of light in which it is placed; but
when they are combined with gutta serena, it is immovea—
ble, and generally is much dilated. Pain is not a common
symptom of this disease; and when it occurs, it probably
originates from an attendant inflammation at the bottom of
the eye.  
There as no danger of confounding cataracts with any
other diseases of the eye, if a proper attention is given to
the characteristic marks of each.
The body of the lens itself is commonly the seat of this
disease; but in some few instances it is found to depend on
an affection of the capsule, forming what is termed the
membranous cataract.
The proximate cause of cataract seems generally to
consist in some degree of obstruction in the vessels of the
lens,
reason to suppose the cataract fluid, he merely introduces a knife through
the cornea and pupil, and makes an opening in the capsule. When the
membrane is diseased, he always advises us to avoid tearing it, and to ex—
tract it together with the lens. That Mr Pellier ever takes out the cap—
sule together with the lens, by pressure, as he directs, Mr Bell from se—
veral facts, and for very substantial reasons very confidently denies. Mr
Bell advises the blunt probe to open the capsule, as less dangerous than
the knife.
If the cataract is accompanied by an incurable opacity confined to the
middle of the cornea, and every other part of the eye is found, Mr Pel—
lier proposes to enlarge the pupil. See Note to Sect. on Leucoma.
Mr Pellier advises repeated small doses of opiates a few hours after
the operation.  Beside other remedies, he uses a liniment of powdered
alum, or of white vitriol and saccharum saturni beat up with white
of egg, and applied between folds of soft linen, and a little of the latter
insinuated between the eye—lids, three or four times a—day, to remove the
consequent inflammation and pain. When the iris after the operation, is
forced out at the incision by any cause, he says it may be touched fre—
quently with gentle caustics, such as Goulard's extract of lead concen—
trated by long boiling, or any mild antimonial caustic; immersing the
whole eye immediately afterwards in warm milk, or some emollient de—
coction, and then covering it with a compress wet with lead water, &c. 

[287]
lens, induced in some instances by external violence,  but
in others by some internal cause with which we are unac—
quainted. This is rendered probable from the disease of—
ten happening to women about the period of the cessation
of the menses, when obstructions in many parts of the
body are more particularly apt to be induced.
The indications of cure in this disease are, 1. To re—
move the opacity of the lens; or when this cannot be ac—
complished, 2. To remove the lens itself from the axis of
vision.
In the incipient state of cataract, mercurial preparations,
and particularly calomel, are sometimes serviceable. When
inflammation occurs, it must be treated as in other cases.
The extractum hyoscyami, the flammula jovis, and other
vegetable preparations, are much recommended by some;
but I cannot say any thing of them from my own experi—
ence.
In confirmed cataracts of long duration, we seldom de—
rive advantage from any internal medicines; and we are
consequently reduced to the necessity of removing the dis—
eased lens from the axis of vision. This is accomplished,
either by pressing it to the bottom of the eye, by an ope—
ration termed couching, or by removing it entirely from
the eye, by the operation of extraction.
§. 2. Of Couching or Depression of the Cataract.
By the operation of couching,  the opaque lens is sepa—
rated from its capsule, and being pressed down behind the
iris, below the axis of vision, if the operation succeeds, it
either remains there during life, or is dissolved in the
aqueous humour. And although the sight will never be
so perfect afterwards, as it was before the lens became dis—
eased, if the eye be otherwise found, it will be quite suffi—     
cient for the common purposes of life.
As

[288]
As this operation as well as extraction, is always succeed—
ed by inflammation to a greater or less extent, it should ne—
ver be risked unless the patient is blind to such a degree as
to prevent him from following his ordinary business; and
never then, when the cataract is complicated with gutta se—
rena, or with an opacity of the cornea. Although the lens
is frequently harder than natural, and in some instances
softer, this, were it always known, should not influence us
in determining upon the operation.
In order to obviate the inflammation consequent to
couching, it will be proper to confine the patient to a low
regimen a few days previous to the operation, and to give
him two or three doses of some cooling laxative at proper
intervals.
It will be best to have the patient placed in an apart—
ment exposed to the north, during the operation; for al—
though it may be necessary to have a good light, the sun—
shine should not be admitted, as it will, by irritating the
eye, prevent it from being steadily fixed. The patient
should be placed upon a low seat, with his face towards
the window; and the surgeon upon a chair considerably
higher, should be seated directly before him. An assistant
standing behind must be directed to place the patient's
head upon his breast, while he secures it in this situation by
his right hand under the chin, and his left placed upon the
forehead; and the patient's hands should be properly secur—
ed by an assistant on each side.
The assistant is now to raise the upper eye—lid with the
fingers of his left hand; and the surgeon applying the
groove in the speculum, in such a manner that it may receive
the edge of the eye—lid, the opening or circle formed by the
brim of the speculum is to be pressed upon the ball of the
eye till the cornea, and nearly the eighth of an inch of the
sclerotica, is protruded. A steady and equal pressure being
made on the instrument by the left hand of the operator,
I and

[289]
and he having the elbow of the right leaning on a table,
or on his knee, in order to preserve the arm steady, must
take a couching needle (pl. vi. fig. 3.) between the thumb
and sore and middle fingers, while the ring and little fin—
gers are made to rest upon the cheek of the patient: the
point of the instrument is to be carried forward beyond
the external canthus of the eye, and being brought nearly
into contact with the sclerotica, it must be suddenly plung—
ed through this coat somewhat below the centre of the
eye, the twelfth of an inch perhaps, and about one—tenth
of an inch behind the iris.
In order to avoid injuring the iris, the flat side of the
needle is to be introduced towards it; and it is thus to be
carried forward in a horizontal direction, until the point of
it is discovered behind the pupil. The flat surface of the
needle is then to be turned downwards; and the point be—
ing pushed into the upper part of the lens, we endeavour to
depress it to the bottom of the eye by raising the handle of
the instrument: It will be instantly known that this is ef—
fected by the disappearance of the lens, and by the patient
discovering more light than he had been lately accustomed
to. In order to give the operation a better chance of suc—
cess, it will be adviseable to carry the lens slowly on the
point of the instrument towards the outer and back part of
the eye. By this means, the crystalline will be partly
lodged in the vitreous humour, and there will be less risk
of its rising again to its former situation, an occurrence
which has sometimes taken place.
The needle should now be withdrawn, and the specu—
lum taken off; and there will be no harm in making a
cautious trial of the good effects of the operation, by pre—
senting some object: before the eye. A compress of soft
lint wet with a weak saturnine solution should then be
lightly applied over the eye, and this being secured by a
triangular napkin, the patient should be confined in a dark
O o room, 

[290]        
room, and kept upon a low regimen for some time. As
additional preventative remedies of inflammation, a purga—
tive or two may be given, and when necessary, blood
should be taken from the temporal artery, or jugular vein,
or from the vicinity of the eye by leeches.
In the course of three or four days, the dressings may
be removed from the eye. It may then generally be ascer—
tained whether the operation has succeeded or not. The
power of vision does not always immediately return; and
there are instances in which the sight, very imperfect at
first, has gradually become better for several months after 
the operation, which probably happens from the slow sub—
sidence of inflammation excited in the capsule of the lens.
When the first operation is unsuccessful, as soon as the
inflammation produced has gone off, the trial may be re—
peated; and again if this second attempt should not be ef—
fectual. A failure, I am disposed to think, generally arises
from not pushing the lens beneath the vitreous humour,
which by its pressure may probably prevent it from rising.
Experience proves that no bad effect is produced from
doing this, and much harm may ensue from neglecting it.
Couching, as above described, is supposed to have been
performed on the left eye; but in operating on the right
eye, if the needle is to be entered in the usual way at
the external canthus, it must either be done with the left
hand, or if the surgeon wishes to use the right hand, he
must stand or sit behind the patient, having the head sup—
ported on his breast. As there are few surgeons who can
use the left hand with sufficient dexterity, and we cannot
have a good command, of the eye when standing behind
the patient, it will be better to use the needle (pl. vi. fig. 4.)
with which the operator may couch the right eye with
the right hand very well; the only difference between this
and the method already described, consisting in entering
the 
                  

[291]
the needle at the internal canthus, and drawing the cataract
toward the nose.
Instead of couching in the manner we have described,
it has been proposed to pass the needle through the trans—
parent cornea and pupil; but besides that the cataract can—
not thus be so easily depressed, there must be a very great
risk of injuring the iris.
§. 3. Of Extracting the Cataract.
IN proceeding to this operation the patient must be pla—
ced and secured exactly in the manner directed for couch—
ing; and the surgeon must likewise be seated, and have his
arm steadily supported, as advised in that operation. When
the lens is to be extracted from the left eye, the speculum
must be applied in the manner we have formerly mention—
ed, and pressed with the left hand upon the eye, with as
much firmness as is necessary for securing the eye, but
no more, as it would not only give needless pain, but
would press the cornea so near the iris, that this might be
injured by the knife.
The surgeon is now to take the knife (pl. vii. fig. 8.)
between the thumb and forefingers of his right hand, al—
lowing nearly an inch to project past the extremity of his
middle finger; and the point of it being brought into con—
tact with the lucid cornea, it must be made to penetrate
this coat at about the distance of the sixteenth part of an
inch from the iris, in a line running from the external
canthus of the eye directly across the centre of the pupil:
the convex surface of the knife being kept next to the iris,
it must be carried in this direction until the point of it
reaches the other side of the eye directly opposite to where
it entered, and  must there be pushed out until nearly a
quarter of an inch of the instrument is through the cor—
nea. The knife must then be moved slowly downwards
in         

[292]
in such a manner, that all that portion of the cornea, lying
between the point at which it entered and that at which it
passed out, may be divided at an equal distance from the
iris. A semilunar opening will thus be formed sufficiently
large for the passage of the cataract: while this is made,
the pressure of the speculum upon the eye—ball should be
gradually lessened, otherwise the vitreous humour may be
pressed out; but it should not be entirely removed, lest the
pressure of the knife should draw the eye too far down
towards the socket, by which the incision will not be car—
ried sufficiently low, and consequently not made large e—
nough to admit of an easy extraction of the lens.
The, operator must now lift up the flap formed in the
cornea with the flat crooked probe, (pl. vii. fig. 2.) and
cautiously passing it through the pupil, must scratch an o—
pening in the capsule of the lens; the cataract must then
be forced out by a very moderate and equable pressure on
the globe of the eye, by means of the speculum. When
the lens is lodged in the anterior chamber of the eye, and
we cannot remove it by gentle pressure, or with the scoop,
it will be better to enlarge the opening by a pair of small
probe pointed scissars, than to employ much pressure, by
which a great deal of injury may be produced.
With a view to facilitate the passage of the lens, it will
be proper to place a dark cloth between the eye and the
the light, in order to dilate the pupil as much as possible.
When the opacity is found to reside in the capsule of
the lens, we have commonly been advised to attempt its
removal by passing forceps, and other instruments through
the pupil; but as this cannot be accomplished without
great risk of injuring the iris, and other parts of the eye,
I would advise rather to trust to time, and an antiphlo—
gistic regimen to carry off the opacity. This does no
mischief, and I have known cures performed by it; but I
never 

[293]
never knew them to succeed the contrary practice, which
has frequently destroyed the iris entirely.
When the operation is to be performed on the right
eye, it may be done with the same differences as directed
in performing couching, either with the straight knife, or
with the crooked knife, (pl. vii. fig. 10.)
The operation being finished, the patient is to be dressed
and treated in the same manner as directed after couching.
As however a greater degree of inflammation is apt to
succeed to extraction than to couching, bleeding, and a
very strict antiphlogistic regimen, will be more necessary.
In favourable circumstances, the wound commonly heals
in ten or fourteen days, but sometimes it continues open for
several weeks.
When this operation is not performed with sufficient cau—
tion, it often happens that the whole, or at least a consider—
able part of the vitreous humour escapes at the incision. In
some of these cases, the eye always remains sunk in the
head, and useless; but most frequently the globe soon be—
gins to fill again, and in the course of two or three weeks
it commonly acquires its usual size. Whether this arises
merely from an aqueous secretion, or whether the vi—
treous humour is regenerated, is doubtful; but I am
disposed to believe from the effects of the operation in
a case where a cataract was removed from each eye, that
the vitreous humour is in such cases reproduced. This
substance was retained in one eye; it was evacuated from
the other; and yet in a few weeks the patient saw equally
well with both.
As an improvement on this operation, when the cornea
is to be cut, I would propose that it be divided on its supe—
rior part, in the same manner as it is usually cut below.
This, from reasoning, and from experiments on brutes,
I am led to believe would tend considerably to prevent the
escape of the glassy humour, and to lessen the obstruction
to             

[294]
to vision which always necessarily happens, in some degree,
from the cicatrix left on the cornea.
But not only these objections, but all danger of injuring
the iris, which is very frequently more or less hurt by the
passage of the cataract, and from which our want of suc—
cess perhaps generally arises, would be obviated by form—
ing a sufficient opening behind the iris, about the tenth of
an inch beyond the cornea, instead of cutting the cornea
itself, and extracting the lens by the curved sharp pointed
probe, (pl. vii. fig. 1.)
On account of the circumstances just mentioned, from
which a loss of vision, sooner or later, is very frequently
produced by the common operation of extraction of the
cataract; from the less degree of danger from pain, and
injury to the eye, and more especially, from the more
frequent and permanent restoration of vision, from couch—
ing, I am induced to consider it as much to be preferred to
extraction, as this is at present practised.
SECT. XVII.
Of the Fistula Lachrymalis.
EVERY obstruction to the passage of the tears from the
eye to the nose, is usually comprehended under the term
of Fistula Lachrymalis.
This disease assumes a variety of appearances, accord—
ing to the seat of the obstruction, and to the effects pro—
duced by it upon the neighbouring parts. When the la—
chrymal puncta, and the small ducts connected with them,
are obstructed in consequence of burns, wounds, or vio—
lent inflammatory affections, the tears necessarily fall over
the cheek; and this, together with a consequent dry—
ness in the corresponding nostril, constitutes that varie—
ty   

[295]
ty of the disease, which alone should be termed Epi—
phora; for when the obstruction is seated in any other
part of the lachrymal passages, the complaint is attended
with symptoms of a much more perplexing and painful
nature.
When the lachrymal puncta and ducts remain open, if
obstruction takes place in the under part of the lachrymal
sac, or in the duct leading from this to the nose, the first
symptom is a small tumor in the internal canthus of the eye,
which is made to disappear upon pressure being applied to
it, by a plentiful flow of tears passing into the eye, and from
thence over the cheek, and perhaps a greater or less quan—
tity passing into the nose. If the tears are now regularly
pressed out before the swelling acquires any considerable
size, and before they have become acrid by stagnation,
they are, in general, found to be perfectly qf a natural ap—
pearance. This state of the disease has been termed a
dropsy of the lachrymal sac; and by a proper application
of pressure may be often cured.
It most frequently happens however, either from inat—
tention in the patient, admitting of the sac being over—
stretched, or from some other cause, that the disease gra—
dually grows worse— the passage into the nose becomes
entirely obstructed— the swelling in the canthus increases,
but still is unaltered in colour— the tears are then pres—
sed out with more difficulty; and are mixed with a pro—
portion of thick, opake, white mucus— But the patient
seldom suffers much pain, or any other inconvenience than
what arises from the tears and mucus passing over the
cheek.
At length the tumor begins to become tense, red, and
painful to the touch, and the matter pressed out has much
the appearance of pus. The parts gradually become more
inflamed, until the teguments at last burst, and form an
opening in the most prominent part of the swelling, at
which                  

[296]
which the tears and matter are now entirely discharged.
This opening being usually small, heals again in a few
days; but it bursts as soon as any considerable collection
is again formed in it: and it continues thus to form and
discharge alternately, until the opening becomes suffici—
ently large to prevent any further collection. This forms
a sinuous, callous ulcer, sometimes with retorted edges;
and the disease is now properly termed a fistula lachry—
malis.
It happens in many cases, particularly when the habit
is tainted with syphilis or scrophula, an occurrence by no
means unfrequent, that the contiguous bones become cari—
ous: in such circumstances the discharge is thin, fœtid,
and commonly so acrid as to corrode the adjacent integu—
ments; and the sore assumes a different appearance accord—
ing to the general affection with which it is connected.
The prognosis as well as the method of cure in this
disease, must depend entirely upon the nature of; the ob—
struction in the lachrymal passages, and the particular
stage of the affection. When the disease is recent, and
proceeds from inflammation of the lachrymal passages,
which is the most frequent cause, and is induced by mea—
lies, ophthalmia, catarrh, &c. our prognostic may gene—
rally be favourable; but when the complaint is of long
standing, and the bones have become carious from scro—
phula, or the venereal disease, the cure will chiefly depend
on the removal of the general affection, and is seldom
completely obtained.
When the disease is a consequence of tumors in the con—
tiguous parts, e. g. of polypi in the nose which press on the
lower part of the nasal duct, the prognosis must almost
entirely depend on the practicability of removing the
swelling.
If the disease originates from inflammation, the common
remedies of inflammation in general must be used — gene—
ral                   

[297]
ral or local bleeding—laxatives—a low diet—and satur—
nine applications to the parts. In some instances, these
remove the complaint; but in many others, the sides of
the ducts are united by the inflammation, and thus conti—
nue the complaint after the inflammation has entirely sub—
sided.
When the obstruction thus produced is seated in the
puncta lachrymalia, or in the ducts leading from these to
the sac, we are to attempt its removal by inserting a small
probe (pl. vi.) into each punctum, so as to pass it along
the course of the ducts into the lachrymal sac. The open—
ings thus formed, maybe preserved by afterwards injecting,
twice or thrice daily with a small syringe, a weak solution
of alum, or of saccharum saturni, and by keeping at other
times small leaden probes constantly inserted, till the sides
of the ducts are rendered perfectly callous; the tears will
then pass as formerly into the nose. This is a nice, but
not a difficult operation.
Instead of the method we have advised, it has been pro—
posed to introduce a seton into the ducts, and suffer it to
remain until their cavities become callous. Independent,
however, of the difficulty of doing this, it would proba—
bly excite so much pain and inflammation, that it would do
more harm than good.
But the obstruction producing this disease is most fre—
quently situated in the duct leading from the lachrymal
sac to the nose. While this produces no farther inconve—
nience than a frequent discharge of tears over the cheek,
with perhaps a slight swelling forming now and then in
the corner of the eye, nothing  more should be directed
than to press out the tears from the sac by the finger, so
frequently as to prevent them from becoming acrid by stag—
nation, and to avoid exposure to cold, or any other cause
that might excite inflammation of the eye, or other conti—
guous parts.
P p We

[298]
We are indeed advised to attempt the removal of the
obstruction, by inserting probes into the lachrymal or
nasal ducts, or by injecting fluids into these passages. But
besides the difficulty, and sometimes impossibility of per—
forming these operations, the pain and inflammation
excited by them often does a great deal of injury. The
practice of introducing quicksilver into the sac for the re—
moval of the obstruction, will probably seldom be found
serviceable, but it is less exceptionable than the others. A
continued application of pressure, as advised by some, does
not appear to have the least chance of removing the dis—
ease.
Although the palliatives above described should be trust—
ed to in the simple state of the complaint, whenever the
tumor in the angle of the eye becomes larger, inflamed, and
painful, and there is danger of the bones being injured by
the acrid matter collected in the part affected, we are un—
der the necessity of having recourse to a different method
of treatment. In such circumstances, our views must be,
to discharge the contents of the swelling; to procure a free 
discharge in future for the tears from the lachrymal sac
into the nose to prevent the passage from being again obli—
terated: And this being done, to heal the external open—
ing.
While the swelling continues hard, it would be impro—
per to open it, as this would give a great deal of pain,
and the parts below could not then be freely examin—
ed. But a warm emollient poultice should be kept con—
stantly over the tumor until it becomes quite soft; the
point of a lancet should then be pushed into the supe—
rior part of it fairly into the sac, and should be carried
downwards in a straight direction to the most depend—
ing part. When there is already an opening formed,
it should be sufficiently enlarged by a scalpel introduced
upon a director. A few fibres of the orbicularis muscle
will 

[299]
will thus be cut, but this will produce no inconvenience.
The contents of the swelling are now to be gently forced
out; a small dossil of lint spread with emollient ointment
should be inserted between the lips of the wound, and a
slip of adhesive plaster placed above to retain it. As a
plentiful discharge commonly takes place, it is necessary
in general to renew the dressings every day; and in order
to preserve the opening of a proper size for admitting a
free examination of the parts beneath, a piece of prepared
sponge, of such a size as not to irritate the parts, may be
introduced instead of the lint every second or third day;
and the more effectually to prevent its irritation, a piece
of soft oiled linen should be put around it. A piece of
waxed thread may also be tied to it, that it may be easily
withdrawn when necessary.
It was formerly the practice, instead of the dressings
we have recommended, to employ the actual cautery or
escharotics for the purpose of destroying the hard edges
of the sore—This produced a great deal of pain, deformi—
ty, and sometimes an obliteration of the cavity of the dif—
ferent ducts, the consequence of which, was a constant
discharge of tears over the cheek. In many cases, how—
ever, the lachrymal ducts continued open, and a frequent
recurrence of the complaint then succeeded.
By the management we have advised, any degree of
hardness remaining in the wound will soon be removed;
and the sore being cleared of a tough viscid kind of mu—
cus with which it is always covered for a few days after
the operation, we are now to attempt the formation of a
free passage for the tears from the sac into the nose. This
is effected by removing the obstruction in the nasal duct;
or when this is impracticable, by forming an artificial o—
pening directly through the os unguis, from the under and
back part of the lachrymal sac.
With 

[300]
With a view to accomplish the first of these objects, a
firm round pointed probe, (such as in pl. vi. fig. 7.) should
be inserted into the bottom of the sac, and pushed for—
ward with a moderate force in the direction of the nasal
duct; if it enters the beginning of the canal we may then
go on with safety, and a probability of success, but if the
instrument cannot be entered into the canal we should de—
sist, as it is then probably rendered impervious by an ad—
hesion of its sides. When the probe can be passed, the
opening may be preserved by keeping a piece of cat—gut,
or of lead wire constantly in it, until it becomes sufficient—
ly large.
Should every trial for discovering the natural conduit of
the tears be ineffectual, we are reduced to the necessity
of forming an artificial passage for them. This has been
accomplished till very lately by the actual cautery. But the
cautery should never be had recourse to in these cases, be—
cause it is always productive of considerable injury to the
parts contiguous to those which alone ought to be ope—
rated upon; and because every good purpose which it an—
swers can be obtained with equal certainty, and with more
ease and safety, by forcing any firm sharp instrument
from the back part of the sac through the os unguis:
This is best performed by a small round trocar.
In proceeding to this part of the operation, the pa—
tient's head should be supported by an assistant; and the
surgeon, fitting or standing between him and the window,
must introduce the canula of the trocar into the under and
back part of the sac: it must be kept firmly in this situation
with one hand, while the stillette is inserted into it with
the other; and the point of it should then be carried for—
ward obliquely downwards, through the os unguis just
where the sac terminates and the nasal duct begins, and
into the nose, taking care to avoid following the natural
passage, for fear of injuring the os maxillare. The
entrance

[301]
entrance of the instrument into the nose will be followed
immediately by the discharge of a small quantity of bloody
mucus from the nostril. The stillette should now be turn—
ed round until the opening is made sufficiently free, and
then it may be withdrawn. A leaden probe equal in
size to the stillette, being introduced through the open—
ing, the canula may likewise be taken out, and the exter—
nal end of the probe should then be somewhat curved to
prevent it from slipping into the nose. The sore must be
covered with a small pledgit of lint, spread with emollient
ointment, and the whole may be retained with a strip of
adhesive plaster.
The leaden probe should be kept in the sore until the
sides of the passage become perfectly callous, which will
usually happen in about eight or nine weeks. It should be
taken out every day or two, that the matter adhering to it,
and that collected in the sore may be removed: and at each
dressing, infusion of oak bark, solution of alum, or some
other astringent should be injected with a small syringe
from the external opening into the nose. On withdraw—
ing the leaden probe, the external opening should be well
cleaned; and as it has then become very small, it will
soon heal by bringing the sides of it together and retaining
them by adhesive plaster, or when this does not succeed in
a few days, touching the edges with lunar caustic will com—
monly complete the cure very quickly. In the mean time,
moderate pressure by the finger, frequently applied, or by
a machine, should be used, and ought to be continued
until there is reason to suppose the sac and contiguous
parts have recovered their lost tone.
What we have said respecting the propriety of continu—
ing the leaden probe for a considerable time, and of apply—
ing pressure afterwards on the sac, is entirely applicable
when the natural passage of the tears is discovered. In—
stead of a probe of lead some advise a piece of cat—gut, or
of

[302]
of bougie; but these are more difficult to introduce—ab—
sorb too easily the mucus of the part—are apt to be en—
tangled in the bone—and are not so effectual in rendering
the passage callous.
When the disease returns, which is sometimes the case,
after the performance of this operation, it may originate
from some general affection, as scrophula, or syphilis; from
a mere caries of the bone; or from too small an opening
being made.
When the bones are discovered to be carious, the tumor
must again be laid open; an exfoliation of the bones produ—
ced if possible; and then the os unguis must be perforated
as before, if the exfoliation does not form a sufficient open—
ing. If this second operation should be unsuccessful from
the sore again filling up, we will have reason to suspect a 
general affection of the habit, which must be removed be—
fore a permanent cure can be expected. When the taint
of the habit is venereal, large and tedious exfoliations usu—
ally take place, and a perfect cure is not often obtained.
In order to obviate the uncertainty of this operation,
it has been proposed in every case to introduce a silver or
gold canula, either through the natural passage of the
tears, or through the artificial opening; and by leaving it
there, and healing the skin over it, thus to form a passage
which no disease of the constitution can have any effect
upon. But as the operation when well performed, is ge—
nerally successful, and it is a very disagreeable and formi—
dable circumstance to most people to have any extraneous
body remaining for a longtime in a wound, I would never
advise it until the usual operation is found to be ineffectual:
It would then be proper to use the canula: In pl. vi. 
fig. 9. is one of the best forms of it; it should always be 
made of gold, and so long as that the lower part may just
pass 

[303]
pass through the os unguis, while the upper part is covered
by the integuments.*
It has been advised, in order to prevent the imaginary 
bad consequences of splintering the os unguis by the use
of the trocar, to employ an instrument made in the form
of the canula of a trocar, with a handle like that of the stil—
lette, but with a sharp edge. By this a piece of the bone
is easily cut out; but as the operation is more effectually
done with the trocar, and experience shews that there is
no danger from its use, it should certainly be preferred.
CHAP.
* M. Pellier constantly employs this method, and generally accom—
plishes a cure in three weeks, and sometimes in two. He says he ne—
ver fails in finding the end of the lachrymal duct; and always makes
an opening in the course of it, The tube (fig. 9.) is introduced on
the perforator, (pl. vi. fig. 10.) and pressed into the orifice made,
by the compressor (fig. 10.). In order to ascertain whether the tube
is of a proper length, a little milk and water should be injected af—
ter its introduction, and if this passes readily into the note it will do;
if it does not, the tube must be withdrawn and shortened. The
wound must be dressed with lint and cerate for eight or ten days,
or as long as it affords much matter, and then healed by adhesive
plaster; and milk and water should be daily injected through the
canula. 

[304]
CHAP. XXXI.
Of Diseases of the Nose and Fauces.
SECT. I.
Of Hemorrhagies from the Nostrils.
HEMORRHAGIES from the nostrils are in gene—
ral of little importance; but as they sometimes are
dangerous, and have even proved fatal, they always merit
attention.
Cold, in most cases, is an effectual remedy— It should be
applied in a variety of ways: The patient should be plac—
ed in a large apartment, through which a current of air
passes; his food and drink ought to be cold; his face fre—
quently bathed or immersed in cold water, or vinegar and
water; a strong solution of alum, or some other astringent,
should be used as a gargle, and compresses wet with it ap—
plied over the nose:— When in bed he should be lightly co—
vered, and have his head high.
If these means fail, the uncertain remedy of compression
must be tried. Compression may be made by a dossil of lint
introduced into the nostril; but a piece of hog's gut that has
been dried and moistened again, tied at one end, and intro—
duced by means of a probe or director along the nostril
as far as the upper part of the pharynx, and then filled
with some cold liquid, as water, vinegar, &c, and tied at the
end 

[305]
end hanging out at the nostril, is more effectual in restrain—
ing the hemorrhage.
When both these are ineffectual, we must introduce a
strong ligature into each nostril, by means of a crooked
tube, take hold of the ends in the fauces with a pair of
forceps, and draw them out; then tie a bolster of soft lint
to each, large enough to fill the posterior nares, and by
pulling the ends of the ligatures that hang out of the
nostrils, firmly fix the cushions of lint in the upper part of
the pharynx; and afterwards apply a compress of lint to
each nostril, and secure them by tying the ligatures over
them. By this means, if the cushions are well adap—
ted, and firmly fixed, no blood can escape from the nares,
and what is effused will coagulate. The dossils of lint
should remain until the re—union of the vessels has taken
place. By using two ligatures, &c. a more firm and equal
pressure is applied than by the employment of one only,
as commonly advised. Rest should be enjoined after the
the operation.
Future returns of the disease may be prevented by bleed—
ing, cooling laxatives, and a low diet.
SECT. II.
Of the Ozæna.
An ozæna, or ulceration in the nostrils, is often a con—
sequence of catarrh, and is usually attended by a swel—
ling of the adjacent parts. Its most common cause is cold;
but external violence of every kind that terminates in an
inflamed state of the membrane of the nose, such as the ap-
plication of acrid irritating substances, blows, bruises, &c.
may also produce it.
In this state of the disease, astringent applications are
chiefly to be depended on, such as a decoction of
Q q Peruvian 


[306]
Peruvian or oak bark, mixed with solution of alum,
brandy, or other ardent spirits, diluted with water; lime—
water, &c.
Dossils of lint, wet with some of these, should be intro—
duced to the affected part three or four times a day; and
at night, lint spread with an ointment prepared with a
considerable proportion of lap. calam. or zinc. calc.
A collection of matter in the antrum highmorianum
may be mistaken for an ozæna, as the matter is sometimes in
such cases discharged through the nose: Considerable at—
tention is therefore requisite to discriminate these com—
plaints.
When the matter discharged in an ozæna is thin, fœtid,
and of a brown or blackish colour, we have cause to sus—
pect a caries of the contiguous bones, which must be re—
moved before a cure can be expected. This seems to origi—
nate commonly from a lues venerea; but whatever be its
cause, mercury seems to be the best remedy for it. The
local applications abovementioned are also to be employed;
and as fungous excrescences are frequently produced, oint—
ments with corrosive substances may be occasionally used
with the greatest safety, particularly red precipitate and
verdegris, in the proportion of an eighth or ninth part of
the first, and a smaller quantity of the latter, to one of wax
and oil.
When the carious bones have exfoliated, a continuation
of the astringents already mentioned will commonly effect
a cure.
Ozæna is often difficult and tedious of cure when a caries
is attendant; in this case we have no remedy that can
with certainty be depended on. The mode of cure above
recommended will however commonly succeed.
SECT. 


[307]
SECT. III.
Of Imperforated Nostrils!
IMPERFORATED nostrils! in new—born children is a rare
occurrence; but instances of preternatural adhesions of
the nostrils, in consequence of small pox, burns, or venereal
sores are often met with.
Obstructions of this kind are in various degree: when—
ever the breathing is much impeded by them, or a con—
siderable deformity is produced, the assistance of surgery
should be afforded.
When any opening is left in the nostril, a small grooved
director being inserted into it, the passage may be easily en—
larged to its natural size, by running a bistouri or scalpel
into the groove in the course of the adhesion. But when
no passage is discovered, we should endeavour by a cau—
tious dissection with a small scalpel, to discover the nostril,
keeping in a proper direction between the septum and ala
nasi; and when once discovered, it may be easily enlarged
in the manner already described. We must then proceed
in the same manner on the other side. To prevent the re—
union of the divided parts, we should introduce small me—
tallic tubes, covered with soft leather, and spread with
some emollient ointment; these are to be retained by ad—
hesive plaster, connected with them, or by a bandage ap—
plied around the head, and should be used as long as any
soreness continues. Dossils of lint might answer, but the
tubes allow of breathing through the nostrils, distend the
parts more equably, and are more easily retained.
When from burns, small pox, &c. an adhesion of the lip
to the nose occurs, together with the obstruction above—
mentioned, it should be separated slowly by a scalpel, and
the sore thus produced healed before the nostrils are ope—
rated 

[308]
rated on. To remove any contraction of the lip which
may occur, it ought at each dressing to be tied down by a
double—headed roller passed around and over the head.
SECT. IV.
Of Polypi in the Nose and Throat.
THE whole of the nasal cavity, and of the back part of
the throat is liable to excrescences, which from their sup—
posed resemblance to the insects of this name, have been
commonly termed polypi. These most frequently origi—
nate from that part of the membrane of the nose which co—
vers or lines the ossa spongiosa, and in general are confi—
ned to one side of the nose. In some instances, however,
they occupy both nostrils; and now and then become so
large as to be perceptible on looking into the sauces.
Cases have occurred in which they originated from the
pharynx. 
The first symptom of this disease is commonly a partial
loss of smell, attended with a sensation of fulness or ob—
struction in some part of the nose. This increases till a
small tumor or excrescence is perceived in one or both no—
strils, which, in some instances, descends no farther than to
be merely perceptible when the head is somewhat raised;
in others, it falls down upon the upper lip before, and
perhaps pushes back into the throat.
In some, this elongation of the tumor is permanent, but
in most cases the swelling retracts within the nares in dry,
and protrudes only in rainy or hazy weather. In some in—
stances, the swelling appears very considerable in the least
tendency to a damp atmosphere, and even in those who, in
dry weather, were not known to labour under the disease.
Polypi are of various degrees of firmness; most of
them are soft and compressible; but some acquire almost the
hardness 

[309]
hardness of cartilages. Both kinds are apt to bleed on
being fretted, or roughly handled; but those of a soft
spongy nature only are so remarkably affected by the wea—
ther.
The colour of polypi is likewise variable; in common
they are pale and transparent, and these according to my
observation, are usually soft and compressible, while the
more firm are generally of a deep red colour.
In the commencement of the disorder the pain is incon—
siderable, and in the softer kind, it is seldom at any time
considerable; but the harder polypi are generally painful
in proportion to the increase of their size, particularly
when irritated. Polypi also become in some instances une—
qual and ulcerated; a large, thin, and fœtid discharge
takes place from them; a if they are not then extirpated,
are apt to degenerate into cancers, but more particularly
those of a firm texture.
The softer kinds of these swellings when of considerable
size, produce a great deal of distress, by falling on the lip,
and by passing into the fauces, and obstructing degluti—
tion and respiration. In some instances, not only the no—
strils are much distended, but the bones of the nose are
separated and raised.
Polypi are said most frequently to depend on a scrophu—
lous or venereal taint. They may be symptoms of these
diseases, but in such cases we would consider the general dis—
ease merely as an occasional cause of the local affection;
for in almost every case, a local injury may be traced as the
cause of polypus; and upon the whole we conclude it is
always of a local and circumscribed nature. Even when
it originates from syphilis, it remains after the general af—
fection is completely removed.
The harder polypi probably may arise from the same
causes that produce similar tumors in other parts; but they
generally seem to be connected with a caries of the bone
beneath: and this renders them more hazardous and diffi—
cult

[310]
cult of cure than those of a softer nature, which we ima-
gine are commonly produced by a mere distension and re-
laxation of the membrana schneideriana. When any por-
tion of this membrane becomes inflamed from cold, &c.
or is ruptured or eroded, as frequently happens from blow-
ing or picking the nose, a weakness is produced, which is
apt to terminate in a prominency; and this being increased
by every succeeding cold, a polypus comes to take place.
The further progress of the disease may depend on
various causes; but generally it will advance more or less
rapidly, according as the parts are more or less liable to
inflammation. Thus we have instances of polypi remain-
ing small and stationary for a number of years, when the
patients were not much exposed to the open air: while
among poor people who are exposed to every inclemency
of weather, and consequently more liable to frequent ca-
tarrh, the disease advances with great rapidity.
The risk with which polypi are attended is, accor-
ding to my experience, nearly in proportion to their firm-
ness. The removal of the softer kinds may always be un-
dertaken with a probability of success; but in polypi of a
fleshy, or still firmer texture, it is always attended with
considerable hazard, for they often cannot be entirely re-
moved; and even when their removal is practicable, they
are very apt to be regenerated, or to become cancerous.
As long as the hard polypi remain stationary, and are
not attended with pain, if the breathing or deglutition are
not obstructed by them, they should not be touched: but
when the reverse of these circumstances takes place, we
should always endeavour to extract them, provided they do
not adhere throughout their whole extent to the bones, or
these bones are not carious.— A caries of the adjacent
bones is very apt to take place in an advanced stage.
In the soft polypous tumors, astringent applications,
such as solution of alum, decoction of oak bark, vinegar,
or 

[311]
or spirits, frequently prevent them from acquiring an in-
crease of bulk, and will sometimes diminish, but never
remove them. These applications should always be used
on their first appearance.
The methods employed for the removal of polypi have
been, the use of caustics, actual and potential; the passing
of a seton or cord through the nostril, with some corrosive
unguent on the part in contact with the tumor; excision with
the scalpel or scissars; the application of a ligature around
the neck of the tumor; and evulsion or extraction by the
forceps.
Caustics are not employed at present, because they can-
not be prevented from injuring the sound as well as the
diseased parts. The seton is inadequate to the removal of
polypi, and seems only useful when small portions are left
after the extirpation of the greater by other means. When
the tumor originates low enough to admit of excision,
the scalpel should be employed; but this is rarely the case:
and the nostril is often so filled, that we have no room for
the introduction of a knife.
The ligature is the best remedy; it is less painful than
tearing or twisting off the polypus by the forceps, and e-
qually practicable. It is thus to be applied when the
tumor is in the throat.
Take a pliable piece of silver wire, which when dou-
bled, is long enough to pass through the nose into the
pharynx: let the doubled extremity be slowly and gently
insinuated through one of the nostrils, and when it ap-
pears in the throat, let the operator with his fingers open
the doubled extremity sufficiently for passing it over the
pendulous end of the tumor; and having pressed it down
to the root of it, pass the ends of the ligature hanging out
of the nostril, through the pipes of a double canula, simi-
lar to that represented in (pl. iv. fig. 5.) except that the
end is a little crooked; the canula is to be inserted into
the 

[312]
the same nostril, and pushed back along the course of the
wire, till it comes in contact: with the root of the polypus.
The fingers being still continued in the throat to preserve
the ligature in a proper situation, the wire must now be
drawn tolerably tight, and the ends being fixed on the
handle of the canula, it must be left so till the next day,
when it should be drawn somewhat tighter; and this be-
ing daily repeated, the tumor will soon drop off—If small,
in two days, if large, frequently in three: But we must
be careful not to draw the ligature so tight as to cut the
tumor and induce hemorrhagy.
All polypi which originate in the throat, or which pro-
ceed back from the nostril into the sauces, and even those
which are deeply seated in the pharynx, if the ligature can
be applied over them with the fingers, or with a forked
or slit crooked probe, may thus be removed.—Those
which are seated low down in the œsophagus, might pro-
bably be treated in the same way.
When the polypus is fixed deep in the œsophagus, and
on all occasions in which the application of the ligature
is tedious and difficult, it is proper to secure a free respi-
ration, by previously performing Bronchotomy: In such
cases a speculum oris should also be used.
To apply the ligature to a polypus seated in the anteri-
or part of the nose, and which proceeds towards the up-
per lip; let the double of it be passed over the most de-
pending part of the polypus, and be slowly pushed up
to the root of it with a slit probe: the probe being
given to an assistant to keep the ligature in its situation,
the ends of the thread must be passed through the double
canula, (pl. iv. fig. 5.) which being inserted into the nostril
on the opposite side of the polypus, and pushed along till it
reaches the root of it, the ligature should now be drawn so
tight as to make some impression on the tumor, and the
ends 

[313]
ends of it must then be tied to the wings of the instrument,
and daily tightened till the tumor drops off.
Mr Cheselden recommends to pass a ligature through
the nostril into the throat, in such a manner that the dou-
bling may include the root of the polypus, and the oppo-
site ends may be taken out of the mouth and twisted so as
to remove the tumor—this mode would often fail.
For the extraction of polypi by the anterior nares,
straight forceps with eyes have been commonly employ-
ed—and those who choose to use forceps for the removal of
polypi which pass into the throat behind the uvula have used
crooked forceps. Dr Richter, of Gottingen, has inven-
ted a pair of crooked forceps, (pl. ii. fig. 2.) by which pres-
sure may be applied equally to every part of the tumor
included in them—the blades being separately intro-
duced, where the polypus is large. In this respect, and
on account of their facility of introduction, they are the
best yet invented. The blades are connected and intro-
duced like those of the midwifery forceps. The part intro-
duced should always be made small, on account of the
straitness of the passage.
In proceeding to extract: a polypus by the forceps, the
patient should be firmly seated with his head leaning
back, and supported by an assistant behind; and in order
to discover the origin of the tumor, it will be useful to
place the face so that the light of a clear fun may fall into
the nostril. The surgeon is now to take the forceps and in-
sert one blade on each side of the polypus, and bringing
the points as near as possible, or quite to the root or neck
of it, and grasping it firmly, endeavour to extract it entire,
by pulling downwards, or from side to side, or more pro-
perly perhaps by twisting the polypus round till it is com-
pletely separated. By turning it round, the attachment may
be more readily loosened, probably, than by any other way,
and the membrane is not so liable to be torn—and if the
R r polypus

[314]
polypus is firm, it may frequently be brought away at
once; but if soft, it will be extracted piecemeal—as
as much as possible should be removed.
A hemorrhagy in considerable degree often attends the
first attempt to remove the tumor; but this should not be
regarded, unless it be very profuse; and in patients of a
robust habit, even after the operation, it will be proper to
suffer a moderate discharge, as this will tend to prevent
the inflammation which otherwise would be apt to occur.
The means formerly recommended are proper to restrain
the bleeding when it seems proceeding too far. If any
part of the polypus remains and we can bring it into view,
it may be touched with lunar caustic covered with a canu-
la, the day after the operation, and every second or third
day afterwards, till it is removed—when any remaining
part cannot be seen, the seton might be employed to re-
move it; but a bougie, probably, would answer better—
this might also be serviceable in dissipating an incipient
polypus. I have seen very beneficial effects from it in
one case: A hollow silver tube covered with plaster, was
used during part of the time, through which the patient
breathed freely, and which was secured by strips of adhesive
plaster, connecting it with the lip—a piece of tape passed
round the head might be employed for the same purpose.
When polypi are so large that forceps cannot be intro-
duced, it will be proper to lay the nostril open, by divi-
ding the cartilaginous parts by means of a longitudinal
incision; and after extracting the tumor, to re-unite the
wound by an adhesive plaster or by future. There is no
risk in cutting the ala nasi; for if we find, on laying open
the parts, that the tumor cannot, with propriety, be taken
away, the wound will soon heal again.
When a firm polypus has ulcerated, and the cartilages
and bones of the nose are affected, this treatment would be
imprudent; but in the softer kinds which scarcely ever
become 

[315]
become cancerous, and where the cartilages and bones are
not affected, it should be used without hesitation.
In a case of firm fleshy polypus, which filled the nostril so
that the forceps could not be introduced, Dr Richter
pushed a red hot trocar covered by a canula, through the
center of the tumor, and thus formed a passage through
which the patient breathed easily, and by which the tumor
was much lessened.
SECT. V.
Of Extirpation of the Tonsils.
ENLARGEMENTS of the tonsils seem to originate com-
monly from inflammation, and are but seldom if ever schir-
rous; independent of inflammation they are never pain-
ful; they never terminate as far as we know in cancer; and
when the diseased part is extirpated, the complaint never
returns.
Whenever these tumors become so large as to produce
much interruption to the passage of the aliment and air,
they should be removed.
For this purpose, the cauteries, actual and potential, have
been advised; but the impossibility of confining their effects
to the diseased parts should always prevent their employ-
ment. Excision with the, scalpel, or crooked scissars is also
inadmissible, on account of the consequent hemorrhagy.—
The method by ligature is the only proper mode. Silver
wire, or cat-gut may be introduced through the nose, as
in operating on a polypus in the throat, and fixed on the
amygdala, a straight or somewhat crooked canula being
employed in the manner the canula is used in that ope-
ration, and the process conducted exactly in the same way.
The

[316]
The more pendulous the tumor, the more easily will the
ligature be fixed, but in any case the difficulty is inconsi-
derable.
The ligature, if carried through the mouth, would be
very inconvenient; but should any difficulty occur in the
employment of the mode recommended, this may be used.
If it be necessary to remove both almonds, it will be
proper to allow any inflammation that may occur from the
first operation to subside, previous to the removal of the re-
maining  gland.
The mode above described I conceive to be the best; but
the operation may often be done differently. Let a suffi-
ciently strong ligature be formed of waxed thread, and car-
ried round the tumor, either with the fingers or a split
probe. A noose is then to be formed on it and drawn
round the almond by fixing one end of the thread at its side,
with a small steel instrument which is straight, except at the
ends, where it is formed into rings, while the other is
drawn out of the mouth by the other hand of the surgeon.
When the tumor is of a pyramidal form, and broad at the
base, a double ligature being put into the eye of a long nee-
dle, fixed in a handle, with the eye near the point, the nee-
dle is to be pushed through the middle of the swelling
near its base, and the thread being disengaged by forceps,
the needle must be withdrawn. By the assistance of the
ringed instrument, a knot must then be formed on each
half of the tumor.
Both these operations are recommended by Mr Chesel-
den: Mr Sharpe concurs with me in thinking them un-
necessary, and properly superseded by the mode first de-
icribed.
SECT. 

[317]              
SECT. VI.
Of Extirpation of the Uvula.
WHEN the uvula, in consequence of frequent inflamma-
tion, &c. becomes relaxed to such a degree as by irritating
the throat, to induce cough, retching, and vomiting, and
to obstruct deglutition; and when this cannot be remedied
by astringent gargles, extirpation can alone be depended
on for a cure.
This may be effected by excision or ligature:—when
the uvula is merely elongated, the first should be employed;
but where it is much enlarged, as there would be danger
of considerable hemorrhage from the use of the knife,
the ligature should be preferred.
The crooked, probe-pointed bistouri, is the best instru-
ment for cutting off the uvula; but it may be done with a
pair of common or curved scissars. In both cases the
mouth should previously be secured with a speculum oris,
and the uvula should be taken hold of with a pair of small
forceps, or a sharp hook. If much blood is discharged af-
ter the operation, we must use an astringent gargle, or
touch the vessel with lunar caustic.
When a ligature is employed, the mode of fixing it
described in the last chapter but one, may be adopted;
and the canula may be introduced either through the
mouth or nose: or it may be done by Mr Cheselden's me-
thod of tying the tonsils. After passing the ligature, it
should be tied as directed in the case of polypus, by Mr
Cheselden. See Ch. penult.
SECT. 

[318]
SECT. VII.
Of Scarifying and Fomenting the Throat.
FOMENTING the throat is often useful in inflammatory
angina. For this purpose the inhaler of Mr Mudge (pl.
viii. fig. 3.) answers better than any thing yet proposed.
This instrument is equally serviceable in catarrhs, for con-
veying warm vapour to the trachea and lungs.
Scarifying the throat also is often a beneficial remedy in
inflammatory angina; an instrument for this purpose is
delineated in pl. viii. fig. 5.
CHAP. XXXII.
Of the Diseases of the Lips.
SECT. I.
Of the Hare-Lip.
NATURAL deficiencies occur more frequently in the
lips than in any other parts of the body: children
are often born with fissures in one of them, but particularly
in the upper lip. In some there is a considerable deficien-
cy of parts, and in others two fissures with an intermediate
space. These affections are all included under the name of
hare- 

[319]
hare-lip, from a supposed resemblance in them to the lip of
that animal.
The opening is commonly confined to the lip, but some-
times it extends along the palate and uvula into the throat;
and in many instances the bones of the palate are separated,
in part, or altogether wanting.
Deformity is a constant consequence of this disease. It
sometimes prevents sucking, and when in the under lip, is
commonly attended with inability to retain the saliva: and
it is always productive of impediment in the speech. When
the division extends along the bones, chewing and swal-
lowing are obstructed by the food passing up to the nose.
These are reasons for attempting the cure as early as
possible. I have effected this, in healthy children, in the
the third month of their age; and the operation may be
performed thus early with as much probability of success
as at any time of life—Young children are more easily
managed than those at a more advanced age.
The intention of this operation is to cut off the sides of
the fissure, in order to reduce it to the state of a fresh wound;
and then to bring the divided parts into contact, and to re-
tain them there till a firm adhesion takes place between
them.
Some contend that adhesive plasters or bandages, are
fully adequate to the retention of the parts after they are
properly cut; these may succeed in some cases, but they
will frequently fail, and induce a necessity for a second ope-
ration;—when futures are properly employed they ne-
ver fail.
In performing the operation, if the patient is an adult,
he should be seated with his head to the light, properly
supported by an assistant behind; but if a child, he will
be  more firmly secured by being laid on a table, and kept
in a proper posture by an assistant standing on each
side. The operator is now to make an attentive exami-
nation 

[320]
nation of the diseased parts and of those contiguous to them.
The upper lip is to be separated from the gums beneath;
and if a tooth projects it should be removed, as it would
irritate the lip. If there is a projection from the angles
of the divided palate bones, it must be taken off by cut-
ting pliers, (pl. ix. fig. I.) or forceps. One side of the
lip is now to be taken between the thumb and fore-finger
of the left hand, and an assistant doing the same; and
stretching it pretty tightly, an incision must be made from
the under border of the lip to the superior part, with a
scalpel, in which a small portion of the sound parts must
be included; the same must be performed on the opposite
side, terminating in the same point in the upper part of the
lip; by this means, a piece including the fissure, will be
cut out resembling an inverted Λ. 
The vessels should be suffered to bleed freely if the
patient is plethoric; and then the sides of the wound
should be united. To effect this the cheeks should be
pushed forward so as to bring the edges of the wound
nearly into contact, and an assistant behind should support
them in this situation. Pins are then to be introduced in
the manner described, when treating of the twisted suture.
The first should be near the under edge of the lip, leaving
merely space enough to support it. Another should be
inserted in the centre of the cut, and a third very near the
superior angle of it.—In infants two pins will suffice.
In passing the pins, they should be entered nearly half an
inch from the edge of the wound; and being carried almost
to the bottom, they must be again passed outward in a similar
direction, and to an equal distance on the opposite side of the
fissure. The assistant should now press forward the cheeks
so as to bring the parts into close contact, and a waxed
ligature must be applied over the pins, beginning with the
under one, and having made three or four turns, descri-
bing 

[321]
bing the figure of 8: it should then be carried to the contigu-
ous pin, and being in a similar manner carried round that,
the operation must be finished by passing it to the other;
taking care to draw it so tight as to retain the parts well in
close contact, but not so strait as to irritate them. A
piece of lint covered with mucilage should now be put
over the cut—it should also cover the ends of the pins,
that they may not be entangled by the bed-clothes, &c.
When there is a great deficiency of parts, and the
edges of the wound are with difficulty brought together,
an oblong piece of leather spread with common glue, or
with a strong mucilage, being applied over each cheek, and
reaching from the angle of the jaw to within an inch of
the pins on each side, each piece of leather should have
three firm ligatures fixed to the end next the lip, which
should be made to pass between the pins, and be tied so
as to retain the parts together.
The pins should remain five or six days, and during
this time the patient should be fed on spoon-meats, and
be prevented from laughing, crying, or stretching the
mouth in any way.
When the hare-lip is double, there is a necessity for per-
forming the operation twice: But we should complete the
cure of one lip before attempting to operate on the other.
The incision should always be extended to the upper part of
the lip: the sides of it should be exactly of an equal length,
and to insure this, it will be proper previously to mark
the length and direction of the cut with ink—and the lip
should be equally and tightly stretched during the incisions:
for this purpose, curved forceps may be used to lay hold
of the lip, and the incisions made along the side of them in
the proper direction.
Some writers direct us to introduce a piece of paste-
board, lead, or tin beneath the lip, and cut upon it; but
the incision is more easily made as above directed. Scis-
S s sars 

[322]
sars may employed with as much safety and ease as the
scalpel.
Flexible needles are used by some instead of the pins
we have recommended, but they are not so proper. In
passing the pins, particular care should be taken that they
go nearly through to the opposite side of the lip; other-
wise a fissure may remain in the inner part of the lip, and
a troublesome oozing of blood may take place behind.
Death has ensued from this discharge, in consequence of
ignorance of its quantity, from the patient's being direct-
ed to swallow his saliva. This should induce us to forbid
swallowing the saliva, while it is tinctured with blood—
Besides this dangerous inconvenience, sometimes a small
quantity of blood taken into the stomach, excites nausea
and vomiting, which stretch the lip and separate the clo-
sed parts.
Fissures of the lip, from whatever cause, are to be treat-
ed in this way; except that in a recent wound, all that is
necessary is to insert the pins and apply the ligatures.
While any inflammation continues in wounds where sup-
puration has commenced, we should avoid the applica-
tion of the ligatures; but as soon as this subsides, the
operation may be used with as much success as when the
wound is recent.
In cases where the bones of the palate are separated,
after uniting the soft parts, some advantage may be ob-
tained from a thin plate of gold or silver fitted to the
arch of the palate, inserted in the fissure, and fixed by a
piece of sponge stitched to the convex side: The sponge
should be dry when inserted, and the moisture it imbibes
will retain it. By this means the speech and swallowing
will be much aided. When, however, the fissure is wider
externally than within, sponge cannot be applied.—A
plate with gold springs to fix on the contiguous parts has
been proposed, but it does not succeed.
SECT. 

[323]
SECT. II.
Of the Extirpation of Cancerous Lips.
THE under lip is more subject to cancer than any other
part of the body; and the scalpel alone can be trusted to
for relief. When the whole lip or a considerable part is
affected, the diseased parts must be removed, the artery
tied, and the sore dressed as a recent wound. This un-
covers the teeth and gums, and produces an incapacity of
retaining the saliva, and a difficulty of swallowing liquids;
but there is no alternative—When an inconsiderable por-
tion of the lip only is affected, the edges of the wound
should be united by, the twisted suture as already descri-
bed: By this means much deformity and inconvenience
will be prevented; and the disease will be less apt to re-
turn, than when it is treated without employing suture.—
If a third of the lip remains, the suture may be used: If
succeeded in a case in which mere extirpation had been
twice tried.
When the disease extends to the cheek, a transverse in-
cifion of the cheek as well as a longitudinal one of the lip
will be necessary, and both are to be afterwards closed by
by pins and ligatures.
CHAP. 


[324]
CHAP. XXXIII.
Of Diseases of the Mouth.
SECT. I.
Of Dentition.
IN Dentition, the gums covering the teeth that are a-
bout to appear become inflamed and full—the child
frequently rubs them—the saliva is generally increased,
though in some rare instances lessened in quantity—The
bowels are irregular; sometimes costiveness, and some-
times diarrhœa occurs: Fever is produced; and some-
times subsultus tendinum, and convulsions.
When opiates, blisters, and particularly warm bathing,
fail to relieve the symptoms, making an incision through the
gums directly upon the approaching tooth or teeth is fre-
quently effectual; this is commonly termed scarifying the
gums. It should be employed early, and repeated two or
three times over the same tooth if necessary. A gum lancet
is the best instrument to perform this operation with; but a
lancet or bistouri may be employed. The incision should
be of a crucial form, and carried down to the tooth: It
commonly heals easily; and often instantly relieves chil-
dren who appear to be in the most imminent danger.
Pain over the whole jaw, with inflammation and swel-
ling of the gums and cheeks, often extending to the throat,
sometimes occur from the approach of the second set of
teeth, particularly from the dentes sapientiæ; the same
treatment 

[325]
treatment will commonly suffice for the removal of these
symptoms. It is oftener unsuccessful when the dentes sa-
pientiæ produce the irritation, than when it originates from
any others; and extraction of the offending tooth, will
alone succeed in many instances.
SECT. II.
Of Derangement of the Teeth.
THE second set of teeth frequently appear in an irregu-
lar manner; some of them will be farther out of the jaw,
and others farther in, that they ought to be. This often
produces considerable deformity; and seems to occur most
frequently in the incisores or canini, and seldom or ever
in the molares.
Derangements of the teeth originate; from a deficiency
of space in the jaw, in consequence of which, they cannot
all be admitted into one circle; from a natural conforma-
tion; or from some of the first set remaining after the se-
cond have appeared.
When the derangement seems owing to any of the first
set remaining, these should be immediately removed; and if
it is caused by those of the second set being too large for
the space allowed them, we should not hesitate to take some
of them away. When the teeth which occupy the circle
are regular and good, the tooth or teeth which are out of
the circle should be pulled; but when either of the con-
tiguous teeth do not fill the space so properly as these
would do, or are rough and disagreeable in appearance,
it will sometimes be adviseable to pull one of those in the
circle, and endeavour to bring the others in the natural
range. Nature will then sometimes supply the vacancy; but
if she does not, as soon as the body of the deranged tooth
has 

[326]
has passed out of the gums, it should be connected firmly to
the adjoining teeth by a ligature, tightened from time to
time, until the tooth is brought within the circle. A plate
of gold or silver fixed to the contiguous teeth, and made
to surround those deranged, so that when pressed by the
opposite jaw it acts with considerable force in bringing
the teeth together, is a mode very troublesome, and much
less effectual.
A ligature may be applied, perhaps in the best manner
yet known, by passing a thin plate of gold perforated with
several small holes, and exactly fitted to the sides of those
teeth opposite to the one to be moved, then over four con-
tiguous teeth, tying it to them by waxed thread; and af-
terwards putting a piece of flexible wire or catgut through
two of the holes; carrying the doubling of the ligature
over the tooth to be moved, drawing the ends through the
holes, and fixing them with pliers. The ligature should
be tightened every three or four days until the tooth is
properly placed.
Deformity is frequently the consequence of an opening
in the anterior part of the jaw, produced either by a de-
ficiency of one or more teeth, or from their being acci-
dentally knocked out. If a surgeon is called immediately
after an accidental loss of teeth, he should replace them if
not broken; or if the patient chooses, one or more teeth
may be transplanted: If an inflammation and swelling have
already come on, these should be previously removed.
When several teeth are lost, artificial teeth may also be
fixed to those that remain firm. If one tooth only is want-
ing, in young people, a ligature fixed round the two con-
tiguous teeth will often by degrees draw them together:
this nature sometimes in part effects; but, in that case, the
points only will approximate.
SECT. 

[327]
SECT. III.
Of Gum-Boils.
THE gums are very frequently subject to abscesses, be-
cause they are much exposed to the causes productive of
them. Gum-boils may originate from cold, and other com-
mon causes of inflammation; but they more commonly are
produced from tooth-ach. They occur not only from ca-
ries, but also from inflammation at the roots of the teeth.
A gum-boil commonly appears after a fit of tooth-ach
has continued for some time: It begins with pain, and a
small tumor in the part; the cheek soon after swells, and
frequently the whole face. When suppuration takes place,
the swelling becomes pointed, and if not opened soon
bursts on the side of the gum, or between the gum and
teeth. Effectual relief is afforded by the discharge of
matter; but as the cause commonly remains, the discharge
continues till this is removed; or if the opening closes, the
disease is commonly soon renewed. When indeed inflam-
mation at the root of a tooth is the cause, and the peri-
osteum is not separated, a cure may be produced, after the
discharge of the matter, by the union of the sides of the
abscess: But when the tooth is carious, its root denu-
ded, or when a part of the jaw is carious, removal of the
diseased parts will alone accomplish a cure.
Where inflammation at the root of the tooth is the cause,
the abscess should be laid completely open, a dossil of
lint introduced, and the wound healed from the bottom.
But when incision will not be admitted, we should inject
tinct. myrrhæ, lime-water, spirits, and tinct of bark diluted
to remove the discharge. If the affection is seated very
deep, so that there is danger of a caries of the jaw from the
impost- 

[328]
imposthumation, we should use warm fomentations to the
part, and warm stimulating substances, such as a roasted
onion, to that part of the gum most affected, in order to
excite a suppuration, that may point into the mouth; and
as soon as matter is formed, we should open the abscess. A
free depending orifice should afterwards be preserved, till
exfoliation takes place, and a cure is completed. Where
there is a scrophulous or other constitutional affection,
the ulceration is commonly very troublesome, and only
yields to remedies for the general affection.
SECT. IV.
Of Abscesses in the Antrum Maxillare.
WHATEVER tends to produce inflammation in the mem-
brane lining the antrum highmorianum may produce ab-
scesses in it; such as blows on the cheeks; inflammations of
the membrane lining the nares, and even long continued
inflammations of the eyes spreading into the antrum.
Much exposure to cold has frequently produced them;
but repeated violent tooth-ach is their most common cause.
Mr Hunter considers the obliteration of the duct leading
from the antrum to the nose as a frequent source of these
collections; but this appears to me to be merely a conse-
quence of some of the other causes, and to be occasioned
in common by adhesive inflammation.
The first symptom of this complaint is some degree of
pain over the cheek; which frequently continues a consi-
derable time before any swelling comes on. This increases,
and extends perhaps to the eye, nose, or ear; at length
a hard swelling appears over the whole cheek, which af-
ter some continuance points, most frequently in the center
of the cheek, a little above the roots of the posterior mo-
2 lares.


[329]
lares. In some instances, the matter bursts out between
the roots of these teeth and the gums, and prevents the
discharge externally; this probably takes place in com-
mon, when the roots of the teeth penetrate the antrum.
For the most part too, as soon as matter is formed, some
of it is discharged by the nostril when the patient lies on the
opposite side with the head low. In judging of the ori-
gin of a discharge by the nostril, we must consider that it
may be produced from inflammation of the membrana
schneideriana; from an ozæna; from affections of the fron-
tal sinusses; and from abscesses in the lachrymal sac, as
well as from matter in the antrum maxillare.
As soon as we have evidence of the disease, if a perfora-
tion is not made to discharge the matter, the bones of the
cheek will be elevated, and at last rendered carious. The o-
pening may either be made into the side of the antrum, where
it projects over the two great molares, or one of these teeth
may be taken out, and a perforation made directly up-
wards in the course of one of the fangs. The last is the
only effectual mode. If either of the large molares is dis-
eased that should be removed; but if they are both sound,
the one next the dens sapientiæ should be taken away, be-
cause the antrum is thinnest beneath  it.
Sometimes the matter is discharged immediately on
drawing the tooth, either from having penetrated the
socket, or from the of maxillare being corroded by its con-
tents. If the opening thus formed, is insufficient to admit
of a free discharge, it should be enlarged; but if no open-
ing occurs, one is to be made by pushing a trocar, or some
other proper sharp instrument, into the antrum, in the di-
rection of one of the fangs. In performing this, the pa-
tient should be seated on the floor opposite to a clear light,
and his head laid on the knee of the operator, who may
either stand or sit behind him. The instrument should be 
T t withdrawn
                      

[330]
withdrawn as soon as by the non-resistance to its point we
find it has entered the cavity.
As soon as the matter is discharged, a wooden plug,
with a knob at its head, should be introduced into the ori-
fice, to prevent the air and food from entering it. This
plug should be removed twice or thrice a day, to admit of
a free and quick evacuation of the collected matter; and a
cure will commonly soon be obtained. But in some cases,
either from relaxation of the membrane of the antrum, or
other causes, the discharge continues considerable a long
time. In this case, liquids moderately astringent should be
frequently injected; but nothing should be used which con-
tains any solid matter, that might be deposited in the an-
trum: I commonly use a solution of alum, brandy diluted,
or lime-water. When the bones are carious, of which
we may be satisfied by the appearance and smell of the dis-
charge, or by the probe, we cannot expect a cure till exfo-
liation has taken place.
Blood may be effused into the antrum, from blows, &c.
and require this operation.—Worms sometimes are pro-
duced in it; they are indicated by violent pains in the re-
gion of the cavity, not induced by any obvious cause. In
this case an opening should be made immediately above the
roots of the large molares, and after extracting all the
worms we can find, oil, a filtrated solution of affaœtida, or
a weak infusion of tobacco, should be injected from time to
time, to destroy any that may remain.
It has been proposed by Mr Hunter, to perforate the
antrum through the nostril; and with equal propriety it
might be perforated through the roof of the mouth; but it
must be obvious, that the mode above recommended is in-
finitely preferable to either.
By the means we have advised, almost every disease
from 
                      

[331]
from collections in the antrum maxillare, may be remov-
ed; but there are complaints apparently originating from
an enlargement of the bones of the cheek, which frequent-
ly only terminate in the death of the patient. In abscesses
of the antrum, the cheek seldom swells very much; and
when the disease has been of long duration, if the matter
does not find an opening into the nostril, of along the
roots of the teeth, it commonly points towards the promi-
nent part of the cheek; but when no matter is collected,
and the disease proceeds from an affection of the bones,
although the swelling gradually arrives to a considerable
size, it spreads equally over the cheek, without pointing at
any particular part, except in the last stages when suppu-
ration occurs in some of the soft parts. Till the skin is
inflamed, which only happens in an advanced period, the
swelling remains colourless. But the most characteristic
mark of this species of swelling, is the remarkable degree
of elasticity which it acquires: The bones yield to pres-
sure, and on its removal instantly return to their former
situation. If an incision is now made into them, they ap-
pear soft and cartilaginous, and sometimes somewhat ge-
latinous.
In the instances of this disease, where carious teeth
appeared to have some effect in producing it, their re-
moval has produced a temporary stop to its progress;
and in some others, long continued, gentle courses of
mercury, with decoction of mezereon, have had the same
effect; but no permanent benefit arises either from in-
ternal medicines or external applications.
SECT. 


[332]
SECT V.
Of Excrescences on the Gums.
THE gums are liable to excrescences of different de-
grees of firmness, from the hardness of a wart to the soft-
ness of fungus, nearly of the colour of themselves, but
are seldom painful—These excrescences impede masti-
cation—they occur most frequently in the under jaw and
inside of the teeth, and commonly adhere throughout
their whole extent. They frequently originate from cari-
ous teeth, and sometimes from caries of the alveoli.      
Removal of the diseased bone will commonly be followed  
in these instances, by disappearance of the excrescence; but
if it is not, the tumor should be extirpated. I never knew
either a hemorrhagy of any consequence, or a cancer to
succeed the extirpation. When the excrescence is attached
by a narrow neck, a ligature should be applied to it; but
when it has a broad base, we must use the scalpel. In pro-
ceeding to the extirpation, the patient should be firmly
seated opposite to a clear light, and the head should be
supported by an assistant behind; and unless the patient
has a good deal of resolution, a speculum oris should be
used. A common scalpel will frequently serve for the dis-
section, but a curved knife and crooked scissars will some-
times be better, and should be at hand. The tumor must
be elevated with a dissecting hook that has two fangs,
which is here much preferable to the common hook. Great
care should be taken not to injure the parts connected
with the tumor unnecessarily; but if it is firmly connect-
ed to the gums, a part of them should be removed, even
to the depth of the socket; although this may induce a
danger of injuring the teeth. A moderate discharge of
blood may be suffered; but if it tends to profuseness,
the

[333]
the patient should take some brandy or tincture of myrrh,
into the mouth; and if this does not restrain it, lunar
caustic should be applied to the wound. Dressings to
the sore, are, from its situation, inadmissible. For some
days after the operation, it should be washed with a warm
emollient decoction; and if a cicatrix does not then readi-
ly form, lime-water, port-wine, or any mild astringent,
should be applied to it.
SECT. VI.
Of Loose Teeth.
THE teeth are frequently loosened by external violence;
as falls and blows; and often by improper force in
pulling those contiguous to them. In these cases, they
should be fixed as firmly as possible in their former situa-
tions, by pressing them as far as they will go into the lock-
ets, and there securing them by ligatures of Indian weed,
cat-gut, or waxed silk, carried round the adjoining
teeth; and the patient should live on spoon-meat till they
become fast. In youth this practice will commonly suc-
ceed; but in old age, loose teeth from any cause can seldom
be again firmly fixed, and in very advanced periods of life,
it ought not perhaps to be attempted. The teeth also be-
come loosened by deposition of tartar, between the roots and
the gums; and in some cases between the roots and sockets.
In these cases, scaling off the tartar will commonly remove
the complaint—this should be done as early as possible.
Sponginess of the gums, and their separation from the
teeth, frequently produce looseness of the teeth. This
sometimes occurs from the use of mercury; and often
happens in scurvy. When it originates from scurvy, a
removal of the general disease is the remedy. But it of-
ten 

[334]
ten occurs as a local affection; and then deep scarifications
of the gums, occasionally repeated, is the best and most ef-
fectual mode of cure—This often produces an adhesion of
the gums to the teeth: and then, astringent gargles made
of tinctures of Peruvian and oak barks, and of myrrh,
and a strong solution of alum, with cold water, should be
employed frequently, and the teeth should not be used
till they have been for sometime firm. Astringents used
before an adhesion of the gums to the teeth takes place,
often renders them hard and incapable of forming a con-
nection with the teeth. When the teeth have long been
loose, there is but little chance of making them fast again.
This disease is sometimes produced by abscesses between
the roots and alveoli of the teeth—(vide chapter on gum-
boils.) It also occurs in old age, from a removal of the
alveoli; probably in consequence of the osseous matter being
absorbed, when nature cannot afford a supply of it—this
case is irremediable.
SECT. VII.
Of Cleaning the Teeth.
THE teeth sometimes lose their colour, and acquire ei-
ther a dusky yellow hue, or become black to a certain de-
gree, without any adventitious matter being perceptible
on them. 2. They, on some occasions become foul, and
give a disagreeable taint to the breath, from a long remo-
ra of the mucus of the mouth. But, 3. The most fre-
quent cause of foul teeth, is the deposition of a calcare-
ous kind of matter from the saliva. Some will have the
teeth thickly incrusted with this substance a few weeks after
having them cleaned; and most people are subject to such
a deposition in greater or less degree. It first appears on
the 

[335]
the fore-teeth, in the angles between two of them, where
they are least rubbed by the tongue or lips; but the effects
of mastication commonly prevent it from spreading to the
points of them. In many cases it is confined to one or
two teeth; but in others a continued crust seems formed
all over the whole jaw; and this sometimes to so great a
degree, as to disfigure the cheek externally, and to have
been mistaken for an exostosis of the jaw-bone.
Slight ulcerations of the gums are often produced when
any considerable quantity of this tartar is collected, which
frequently insinuates itself between the gums and alveoli
so as to separate them a good deal from each other.
Acids will dissolve and remove the tartar, but at the
same time they injure the enamel, and many have lost their
teeth from the use of them. Scaling instruments afford
a certain relief, and from a proper application of them no
harm can ensue. When the teeth are once well cleaned,
frequent washing with cold water, and rubbing them every
second or third morning with burnt bread, Peruvian
bark, cream of tartar, chalk, or any other mild application,
in fine powders will generally keep them clean and white.
The instruments employed (such as in pl. ix. fig. 5. 6.)
should be moderately sharp; but their edges should not
be very fine, or they will turn or break. In perform-
ing the operation, the patient should be seated on a low
chair, with his face to the light, and his head supported
by an assistant: the surgeon should sit opposite to him, and
wrapping the fore-finger of his left hand in a wet cloth,
should press firmly on the point of the tooth, while the
back part of the instrument will form a point of resist-
ance for the thumb of the same hand. The sharp edge
of the instrument is now to be insinuated beneath the under
part of the incrustation, avoiding the neck of the tooth
for fear of loosening it: it must then be pushed with firm-
ness to the superior part of the tooth, and repeatedly ap-
2 plied 

[336]
plied till the incrustation is removed. When the teeth are
all cleaned, they should be rubbed well with a piece of
sponge in the form of a brush, covered with a fine powder
prepared of equal parts of cream of tartar and Peruvian
bark.
The teeth sometimes acquire a kind of foulness and lose
their colour, when there is no apparent deposition on
them. Moderate friction with a scaling instrument will
frequently remove this. But the worst kind of foulness
is when they become black, and seem perforated with a
number of small holes. Alkaline applications are the best
in these cases; they often render the teeth clean, and never
injure them. A lather of common soap, or a solution of
salt of tartar applied over the teeth with a pencil brush will
often answer. When the disease is thus removed, frequent
washing with cold water, and rubbing them with the above-
mentioned powders, are the most effectual preventatives
of a return; but they are often unsuccessful. This variety
of the affection seems to depend on a putrescent cause, for
it is evidently attended with a mortification of the teeth;
and hence antiseptics would probably prove useful.
Lucerne and alkanet roots dried and beat at one end into
the form of a brush, are very proper to rub the interstices
between the teeth; but no kind of brush should be em-
ployed to rub the roots of the teeth, or the upper parts of
the gums; because they may separate the gums from the
teeth. For this reason I always make use of a piece of
sponge, fixed on a small handle, which may be used with
the greatest safety.
SECT. 

[337]                   
SECT. VIII.
Of the Tooth-ach.
THIS disease, besides its usual symptoms of pain in one
or more of the teeth and swelling in the contiguous gums,
is frequently attended with a swelling of the cheek; and
pain and inflammation in the eye and ear of the affected side;
and to these perhaps succeed fever, with its consequences.
These symptoms may originate, 1. From the nerve and
other parts within the cavity of the tooth affected being laid
bare, either by external violence, or by the enamel falling
off in consequence of caries, or some other affection. 2.
From inflammation of the parts within the tooth, or of the
membrane which surrounds the root of it. And, 3. From
sympathy, i.e. in consequence of affections of distant
parts; as from diseases of the eye, of the ear, and of the
stomach.
§ 1. Of Tooth-ach from the Nerve being laid bare, and of
the Methods of Extracting Teeth.
From  whatever cause the nerve of a tooth becomes ex-
posed, pain, and many other of the symptoms abovemen-
tioned, will be the inevitable consequence. This does not
seem so much to be produced from the mere exposure of
the nerve to the action of the aliment and air, as from a
certain degree of irritability induced by the exposure; for
we frequently see the cavity of the tooth laid open by ex-
ternal violence, and nothing more than a temporary pain
somewhat proportioned to the accident induced: and it
often happens, that teeth gradually moulder away with-
out any pain or uneasiness whatever being produced.
These occurrences could not take place if a mere denuda-
dation 
U u
                     

[338]
dation of the nerve was the ultimate cause of the tooth-
ach.
An irritable state of the nerve may be brought on by
various causes; and more particularly by saccharine,
acid, and other stimulating substances contained in the
food, being frequently applied to it—by a too frequent
use of tooth picks—and by much exposure to a stream of
cold air, and especially if this is at the same time moist.
The operation of these causes in inducing tooth-ach
when the nerve is already exposed, by the destruction of
the enamel from external violence, or from caries and a
consequent decay of the osseous part of the tooth, is easily
understood; but the production of a caries of the enamel,
when no external violence has been applied, the most fre-
quent cause of the complaint, has not been so satisfactorily
explained.
It has been placed in the large use of acids, and in the
lodgement of putrescent particles of the aliment on the
teeth, from want of washing the mouth after meals.
With respect to the first of these, there is no doubt
that they prove injurious to the enamel, and should there-
fore be avoided: And the second should certainly also be
guarded against; because it not only gives a disagreeable
fœtor to the breath, but also contributes to the forma-
tion of an inconvenient incrustation on the teeth. It does
not, however, appear that caries of the teeth is the con-
sequence of either of them. If acids occasioned it, it
should affect all the teeth, or at least a considerable part
of them, at the same time, and in an equal degree; where-
as it almost always begins in a small point, and extends
itself very gradually. And if it was the consequence of
the lodgement of putrescent particles, it should always
appear in those parts of the teeth which are nearest to
each other; but we know this is not the case. And it
does not appear, from experiment, that the immersion of
teeth extracted from the body, when they would proba-
bly 

[339]
bly be much more readily affected with putrescency than
while they retain the living principle, for a considerable
time in putrid matter, has the least effect in producing a 
carious state of them.
Upon the whole, I am of opinion that caries of the
teeth is generally an effect of some constitutional cause.
It often begins in one tooth, and is afterwards extended to
a less or greater number of others: And I have seen instances
in which the whole of the teeth were extracted one after
another as the disease extended itself, and the patient at
last received no permanent benefit, from the pain fixing
upon the jaw.
This view of the subject shews the impropriety of re-
moving teeth so frequently as is usually done. For if,
upon extracting the first or second tooth that becomes
carious, as soon as the violence of the pain renders it ne-
cessary, a third or a fourth should be affected, the patient
should always be advised to submit to the pain rather than
to have it removed, as the disease is then probably syste-
matical, and will soon affect more—and it will often hap-
pen, that if one fit of the tooth-ach is borne, the same
tooth will never again be seized by it.
In cases of carious teeth, it has been a prevailing prac-
tice to remove the affected part with a file, in order to pre-
vent the disease from spreading; but I have almost univer-
sally seen this detrimental. It cannot have the effect ex-
pected from it; and it becomes injurious by exposing the
sound parts to the air, and whatever is taken into the mouth.
When so much of the enamel is removed, either by ca-
ries or external violence, as to form a hollow of any mag-
nitude, we may frequently prevent the tooth-ach, and pre-
serve the teeth, by filling up the opening. If this is large,
and particularly if narrow at the bottom and wider exter-
nally, mastick and gum-lac, or even bees-wax, will be
very proper for the purpose; but when the opening is
small 
                       

[340]
small, and the tooth is much hollowed internally, some of
the metals are preferable. Gold-leaf is then frequently
made use of; but nothing answers so well as common tin-
foil. As much of this as appears necessary being cut off,
it should be pushed in gradually (by the instrument deline-
ated pl. viii. fig. I.) beginning at one end, until the cavity
is completely filled; any portion which may be left should
then be cut off, and the surface of the whole made perfectly
smooth by a small burnisher. Before the cavity is stopped,
the nerve should always if possible be rendered insensible,
either by delaying the operation for a few weeks after the
nerve is laid bare, or by daily dropping into the opening a
small quantity of oil of thyme, origanum, or some other
essential oil.
When the size of the opening prevents hard substances
from being retained, instead of using wax and the other
soft bodies above recommended, it has been proposed to
stuff the tooth with tin-foil or gold-leaf, and retain it by
means of a small peg driven through a hole drilled in the
tooth. But this will not answer either when the external
opening is very wide, or when the sides of the tooth are 
very thin.
Besides this means of preventing the return of tooth-
ach, the patient should as much as possible avoid exposure
to cold; his head should be kept warm; and it will be of
great importance, and sometimes indispensible, that he
should live in a dry situation.
For the removal of tooth-ach from exposure of the
nerve, the only remedies I have found useful, are anodyne
and corrosive applications to the part itself, and extraction
of the tooth. Slight cases are sometimes relieved, or even
altogether removed, by applying opium or laudanum to the
nerve: camphor alone, or joined with these, is also in some
cases of benefit; and ether is now and then of use: but as
these, and other applications of a milder nature, are often
3 unsuc-


[341]
unsuccessful, we are then under the necessity of employing
those which will destroy the nerve entirely. A long continu-
ed use of any of the strong essential oils will in some cases
render the nerve somewhat insensible, but will not destroy
it so effectually, as to prevent a risk of future returns of
the tooth-ach. This may be accomplished by the use of
any of the concentrated mineral acids, by lunar caustic, or
by the use of the actual cautery. In making use of the caustic
or acids, however, we should be very careful to prevent
them from spreading to the contiguous parts. The ac-
tual cautery may be employed without a rifle of this, but
it gives so much pain, and is so tedious in its operation, that-
few patients will submit to an effectual application of it.
A piece of pointed small wire may be made use of as a cau-
tery, when the instrument (pl. viii. fig. I.) cannot be had.
When all these remedies fail, or are not employed to a
sufficient extent, we are under the necessity of destroying
the nerve by the extraction of the tooth; and this being
done, if the tooth is not much decayed, or is not broken,
particularly if it be one of the incisores or canini, after the
socket is cleared of blood, it may be replaced, and will in
time prove as useful as ever. See section on transplanting
teeth.                                      
Teeth may be extracted either in a perpendicular or la-
teral direction, or by making them turn upon their axes,
by depressing the coronæ or upper parts of them.
As the removal of teeth in a perpendicular direction,
would necessarily be attended with less violence to the con-
tiguous soft parts, than by taking them out laterally, it
should undoubtedly be preferred wherever it is practi-
cable. This however can only be the case in the extrac-
tion of the incisores and canini, unless some of the others
are loose; because we have not sufficient room to ap-
ply the instruments for effecting it in the molares.
These last must therefore always be drawn laterally, not-
withstanding 

[342]
withstanding that not only the soft parts must thus be
bruised or lacerated, but the alveolar processes broken.
The best instrument yet invented for drawing teeth in
a lateral direction, is the common key instrument. In o-
perating with this, if the tooth is in the lower jaw, the
patient should be seated in a chair, in a clear light, with
his head supported by an assistant standing behind; but if
it be in the under jaw, he should be seated upon a pillow,
with his head turned back, and supported upon the knees
of the operator standing behind him. In order to prevent
the gums from being torn, and to admit of a proper ap-
plication of the key, the gums should be separated from
the teeth by the scarificator or gum-lancet. The patient
having cleared his mouth of blood, the point of the claw of
the key must then be pressed as far down between the gum
and tooth as possible, and retained there by the fore-finger
of the left hand, while the fulcrum or heel of the instru-
ment, previously covered with soft linen, being placed as
far down-as it will go upon the gums on the opposite side
of the tooth, the operator must now with his right hand
apply gradually such a force as he may find necessary for
moving it; and by turning the hand sufficiently, any tooth 
may generally be drawn at one pull: where one effort
however is not sufficient, and particularly in the molares,
it will be better, as soon as the tooth is loosened, to turn the
claw to the opposite side, and thus render it sufficiently
loose to be taken out by the forceps.
With a view to prevent the loosening of teeth contigu-
ous to the one drawn, the edges of the latter may be taken
off by a thin file, smooth on one side.
By this method the incisores and canini may likewise
be pulled, as well as in the manner hereafter described.
The alveoli of the teeth seem to be so nearly of an equal
degree of strength on each side, that in the extraction this
merits no attention. Neither is it a matter of any conse-
quence

[343]
quence to regard the direction of the roots of most of
the molares, for these run equally divergent on either
side, and except in the two last, which should always be
drawn to the inside, on account of the situation of the co-
ronoid process of the lower jaw, it is perfectly indifferent
with respect to both these circumstances, whether the ex-
traction is made towards the inside or outside of the jaw.
Even if the tooth is particularly decayed on one side, if the
gums are properly separated, it is of little importance
to which side the tooth is pulled:—whatever direction is
used, the socket must necessarily be broken on both sides.
The heel of the instrument should always be made long,
as it will then injure any particular part of the gums by
its pressure much less than if it is short.
Even when a tooth has been cautiously extracted,
troublesome circumstances sometimes occur from the ope-
ration:—these are, bruising of the gum, separation of
splinters of bone from the jaw, and alarming hemorr-
hage. In the first case, if any part of the gum is nearly
separated, it should be cut off with a pair of scissars; the
mouth should then be fomented with warm milk, or any
emollient decoction; and if there is a probability of a sup-
puration taking place, this should be promoted by the ap-
plication of roasted figs, and the abscess afterwards opened
if necessary.
When the alveolar process only is broken, it will be of
little consequence; but if the solid part of the bone is
splintered, as will more particularly be apt to happen in
children, a tedious sore will very probably ensue if it is
not treated with great care. All loose pieces of bone should
be immediately removed, and the rest will either come
away afterwards, during the formation of matter, or be
easily taken out; and if the constitution is sound, the ulcer
will then heal, but not before.
Hemorr- 

[344]
Hemorrhagies of any importance seldom occur; but in
cases, where any of the larger arteries of the parts con-
tiguous to the tooth are divided by the force used in the
operation, very alarming hemorrhagies sometimes take
place. Taking a mouthful of cold water, red wine,
brandy, vinegar, or alcohol will sometimes restrain them;
if these fail, compression may be tried, by putting a dossil
of lint into the opening, and making a constant pressure
on it by keeping the mouth shut. This will almost al-
ways stop the bleeding; should it, however, be unsuccess-
ful, the actual cautery is alone to be depended on.
For the purpose of extracting teeth in a perpendicular
direction, the common teeth forceps will generally an-
swer. In applying this, it should be pressed as far down
upon the tooth as possible, otherwise it will be apt to break
off the upper part of it; and the tooth should not be pul-
led directly upwards, but should be twisted alternately
from one side to the other until it becomes loose. If the
forceps are found to give insufficient force for the extrac-
tion, the key should be employed.
When the upper part of a tooth is entirely destroyed,
leaving nothing but the fang or root, or what is common-
ly termed a stump, it may be removed very readily by the
use of a simple or crooked lever, usually called a punch,
previously separating the gums, as in extracting whole
teeth. In using this, it should never be pushed lower
down than is just sufficient to give a firm rest upon the
fang; for if it is carried very low, the force employed is
in a great measure lost against the strong part of the alve-
olus on the opposite side. When the tooth is merely
loosened by the punch, it may be removed with the for-
ceps.
§ 2. 


[345]
§ 2. Of Tooth-ach from Inflammation.
Tooth-ach sometimes originates entirely from an inflam-
mation, either of the membrane surrounding the root, or
of the parts within the body of the tooth. This species is
indicated by a severe and permanent pain of a tooth which
is to appearance sound; and especially when the affection
has evidently been induced by exposure to cold, or when it
is connected with other symptoms of inflammation, such
as an inflamed state of the contiguous cheek, swelling and
suppuration in the adjoining gums, &c.
Although in most instances we may trace this variety of
tooth-ach to cold, yet it may also be induced by any other
cause of inflammation in general. It is also in some cases
the consequence of a swelling of the fang of the tooth.
But whatever be the cause of the inflammation, it is al-
ways attended by a very great degree of pain; probably
on account of the bone with which the membrane is
surrounded, preventing it from readily yielding to disten-
sion.
In the cure of tooth-ach from inflammation, the gene-
ral remedies of affections of this kind in other parts are
found the most useful. Local blood-letting, either by
scarifying the contiguous gums, or by the application of
leeches, often gives relief. I have known a blister applied
directly opposite to the affected parts remove the pain en-
tirely; and a large dose of laudanum is often very useful,
by lessening the irritation. The head should be kept warm
by covering it with flannel; and fomenting it with the
steams of a decoction of emollient herbs, or even with
warm water, will often procure relief when every other
remedy has failed. In some cases, cold water, vinegar, or
spirits, taken into the mouth prove serviceable; but warm
applications are generally best.
X x When

[346] 
When this complaint cannot be removed by the reme-
dies already recommended, we are reduced to the necessity
of advising the extraction of the tooth: but in this case,
we should be particularly careful to avoid a hasty extrac-
tion, more especially if we have reason to believe there is
an enlargement of the fang or fangs. After the tooth is
removed, if it is uninjured, we are commonly advised to
replace it; but in this variety of tooth-ach, and even when
none but the parts contiguous to the tooth are inflamed, I
have seldom or ever seen the practice successful.
3. Of Tooth-ach arising from Affections of distant Parts.
We judge that this variety of tooth-ach occurs when
there are no symptoms of either of the species described
in § 1 and 2. It may originate from rheumatism, from
an arthritic diathesis, from hysteria, from pregnancy,
and from a foul state of the stomach.
In this last case, which is indicated by the state of the
tongue and other circumstances, emetics often give imme-
diate relief; and then the exhibition of Peruvian bark, par-
ticularly if the fits of the disease have returned periodically,
will be the best means of preventing returns. Opiates
never are of service, but often do injury by producing
nausea, &c. - and even increase the pain. But when the
complaint originates from gout, rheumatism, or hysteria,
opiates will generally remove it entirely; and a return
may be obviated by keeping the parts warm. In hysteri-
cal tooth-ach, ether, combined with opium, has succeed-
ed when every thing else had failed. Opiates are never of
permanent benefit in tooth-ach from pregnancy: general
blood-letting is often the only effectual remedy—Apply-
ing leeches to the gums will sometimes answer the pur-
pose.
SECT. 


[347]
SECT. IX.
Of Transplanting Teeth.
BY this operation we understand the removal of teeth
from one living body to another.
In the transplantation of teeth, we are to be directed
by the following considerations:
1. As the operation is in general employed more with
a view to obviate deformity than to be productive of any
real advantage, it is seldom practised with the molares:
but it might be done with the two first of these as well as
with the incisores and canini; the others could hardly in
any case be transplanted, on account of the number and
divergence of their roots.
2. In order to ensure success, the alveoli and gums must
be perfectly sound. They must be entirely free from
scurvy and lues venerea; and the patient must not have
undergone a salivation for some considerable time before;
nor must he use mercury for some time afterwards. His
being subject to gum-boils need not prevent the opera-
tion.
3. It is also necessary that the sockets be full and com-
plete; and hence it will seldom be admissible where teeth
have remained long in the state of stumps; because the
waste of the fang is generally accompanied by a corre-
sponding diminution of the socket; whence there would
not probably be room enough left for the roots of a sound
tooth.
4. It is only in youth and middle-age that the operation
is admissible. In childhood it can never be necessary; and
in old age, the sockets of the teeth are commonly much les-
sened; and it is not probable, that a firm union can then
take 

[348]
take place by an inter-communication of blood-vessels as
in other cases.
5. The transplanted tooth should fit the socket as ex-
actly as possible; if it be too large, a small part of the fang
may be filed off, but the corona should never be touched,
for fear of producing a subsequent caries. The surface of the
tooth should be also somewhat lower than that of the rest,
to prevent pressure on it.
6. In order to preserve the socket and gums into which
the tooth is to be placed in as sound a condition as pos-
sible, the displaced tooth should be removed with the for-
ceps in preference to the key.
7. When the socket is cleaned, and the new tooth in-
serted, it must be tied to the two contiguous, in order to
keep it in its place until it becomes firmly fixed. If it is
one of the canini, the ligatures, which should be made of
several threads of fine silk waxed, should be first tied round
the upper part of the new tooth, and after it is inserted,
connected to those adjoining as close as possible to the
gums. But when an incisor, or small molaris, is trans-
planted, it answers best to fix the ligature first to one of
the fastened teeth, and afterwards to connect it to the
others. If the ligatures become loose they should be im-
mediately renewed; and the patient should avoid every
thing which has any tendency to loosen the tooth. He
should live upon spoon-meat during the cure, and guard
very carefully against cold and moisture.
In favourable circumstances, the tooth will become fast
in the course of eight or ten days; but it will sometimes
remain loose for two or three months.
Although diseases are very seldom communicated by
this operation, yet as there can be no doubt that this has
sometimes been the case, we should always guard as much
as may be against the possibility of it. For this purpose,
teeth should never be transplanted from people who are not
perfectly 


[349]
perfectly healthy; and they should always be immersed
for a few seconds in luke-warm water, and afterwards well
wiped.
SECT. X.
Of the Ranula.
TUMORS are frequently met with beneath the tongue, or
one or both sides of the frenum; these are all known by
the term ranula. They are seldom attended with much
pain; but they become in some instances so large as very
much to impede the sucking of infants, and the mastica-
tion, and even the speech of adults. In some cases they
contain a fatty matter; but in nineteen cases of twenty,
they are filled almost entirely with a thin limpid liquor,
resembling the saliva; and we find, on cutting into them,
that they are often produced by a stoppage of the salivary
ducts, from calculous concretions forming in them. The
tumor generally bursts when it arrives at the size of a large
nut, leaving an ulcer which is difficult to heal, unless the
cause be discovered. The concretions are of various sizes;
I have in several instances found them as large as a kidney-
bean.
Whenever these swellings are not of a firm consistence,
the most effectual mode of treatment is to lay them open
with a scalpel from one end to the other; the calcareous
particles will then easily be discovered; and these being
removed, and the sore washed with warm water, or some
other emollient, it generally soon heals. But if there is af-
terwards any difficulty in curing the ulcer, it may be
bathed with tincture of bark, or some other astringent.
Old fistulous sores of these parts will be commonly found
to depend on a calcareous matter; and by making an inci- 
sion

[350]
sion down to this, and removing it by a scoop or forceps,
they will soon be cured.
When tumors in this situation are of a fatty or firmer
consistence, they should be totally extirpated; and this
may be easily done unless they lie deep, and are very large.
They may usually be removed without any danger of divi-
ding the larger arteries: and the hemorrhagy may then be
easily restrained by spirit of wine, or tincture of myrrh. But
if any large vessels should be cut, as ligatures cannot possibly
be applied to them, it will be necessary to have recourse to
the potential or even the actual cautery. If the tumor
cannot be held by the fingers during the operation, a small
hook will answer this purpose better than the forceps
which are usually employed. 
SECT. XI.
Of Ulcers of the Mouth and Tongue, and Extirpation of the
Tongue.
THE tongue, and other parts within the mouth, are li-
able to all the variety of ulcers incident to other parts of
the body, and the treatment they require is nearly similar.
When they originate from the lues venerea, scrophula, or
scurvy, the general remedies of these diseases become neces-
sary; but when the affection is local, topical remedies are
alone to be employed.
Local ulcers of the mouth appear to be most fre-
quently occasioned by the sharp points of broken or ca-
rious teeth, which irritate or destroy part of the inside of
the cheeks, or of the side of the tongue; when this is the
case, the teeth should be smoothed with a small file. If
sores appear to be induced by the formation of tartar up-
on the teeth, this must be removed as formerly directed.
The 

[351]
The removal of the original cause is usually soon followed
by the cure of the sore; but when this is not the case, we
may frequently derive advantage from washing the mouth
with decoction of bark, a solution of alum, and other
astringents. Notwithstanding the use of these, mercury,
and of every other remedy, the sores, in some cases, con-
stantly become worse: They grow ragged and unequal
about the edges; discharge a thin fœtid sanies; and then
become very painful.
As long as a sore of this kind continues small, and shews
no tendency to spread, there will be a chance of its heal-
ing. But whenever it constantly grows larger, and more
painful, notwithstanding the employment of the remedies
above recommended, we will have reason to suppose it of
a cancerous nature, and should certainly advise its removal
by immediate extirpation.
When the ulcer is small and superficial, it may be remo-
ved with ease and safety; but when it is large, this is attend-
ed with difficulty and danger. However, whenever the
whole of the parts affected can be taken away, as the ope-
ration affords the only remedy, it should certainly be
risked.
The easiest and most effectual method of removing a
deep seated cancer in the cheek, is to make an incision
through the whole substance of the cheek, beginning at
the contiguous angle of the mouth, and ending at the same
part, after carrying it round the sore. The diseased parts
being thus entirely removed, the sides of the cut must
be brought into contact, and secured by the twisted su-
ture.
In removing any considerable portion of the tongue by
the knife, the hemorrhagy is the only occurrence pro-
ductive of danger. To remove this the surgeon should
provide himself with all the ordinary remedies. When
ligatures can be passed round the vessels, which may be
done 
                     

[352]
done farther back in the mouth than is commonly sup-
posed, they should undoubtedly be employed. If the
tenaculum or crooked needle cannot be used for this pur-
pose, the apparatus described for tying schirrous tonsils,
must be had recourse to. But when the vessels cannot
be secured by either of these methods, keeping the mouth
filled with astringent infusions or solutions, and particu-
larly a solution of alum or diluted vitriolic acid, will some-
times be effectual in restraining the discharge; if these
do not succeed, the potential or even the actual cautery
must be employed as the last resource.
As this is a formidable operation, it has seldom been
performed; and indeed it should not be attempted but by a
surgeon of great firmness and experience.
SECT. XII.
Of the Division of the Frenum Linguæ.
THIS operation becomes necessary when the frenum of
the tongue is either so short, or continued so near to the
point of it that it impedes the sucking of children. It is
usually performed by a scalpel or a pair of scissars; the
child being laid across the nurse's knees, and the surgeon
elevating the tongue with the middle finger of the left
hand, while he makes the incision with the right, taking
care to avoid the larger blood-vessels of the tongue.
SECT. 

[353]
SECT. XIII.
Of the Division of the Parotid Duct.
THE duct of the parotid gland is sometimes divided
in extirpating cancerous sores from the cheek; some-
times by accident; and if the divided parts are not
retained in contact until they heal, it often happens that
the internal part of the wound closes, and a constant dis-
charge of saliva takes place over the cheek, which at
length produces a tedious fistulorus sore.
In case of a recent division of this duct, the ends should
be brought together, and retained by adhesive plaster,
or the twisted suture, as may seem most proper; but when
this has been neglected, or fails of success, as the inner part
of the duct becomes closed, it will be necessary, for a cure,
to make an artificial opening into the mouth, and endeavour
to form a union between this part and the upper portion
of the duct which leads from the parotid gland. For this
purpose, a sharp pointed perforator, somewhat larger than
the duct, should be entered on the side of the sore op-
posite and contiguous to the under extremity of the su-
perior part of the duct, and carried obliquely, in the na-
tural direction of the canal, into the mouth. A leaden
probe exactly the size of the perforator, should then
be introduced along the course of the opening, and re-
tained there until the sides of it become callous; the probe
should afterwards be withdrawn, and the extremity of
the duct drawn into contact: with the superior part of
the artificial opening by means of adhesive plaster, and
retained until a firm union has taken place. It will
facilitate the union between the parts, if the edges of
each are made raw with a lancet or scalpel, before
they are brought together. The patient should live upon
Y y spoon-


[354]
spoon-meat till a cure is effected; should speak little or
none; and make as little exertion with his jaws as
possible.
CHAP. XXXIV.
Of Diseases of the Ears, and Operations
practised upon them.
SECT. I.
Of Deafness.
WHATEVER tends to obstruct either the mea-
tus auditorius or eustachian tube, or to induce
diseases of the tympanum, or parts connected with it, will
be productive of deafness to a greater or less degree.
Obstructions in the eustachian tube may be occasioned
by enlargement of the amygdala from any cause; by
venereal ulcers in the throat; and by polypous excrescen-
ces. A removal of the first and last of these causes, will,
in many instances, effect a cure of this variety of deaf-
ness; but when it is a consequence of ulceration or of in-
flammation, as the extremity of the duct will probably be
obliterated, it will be irremediable. It has been proposed
to open the duct by inserting a curved blunt probe into it,
or even to inject some mild liquid into it with a curved
syringe: there will probably, however, be no advantage
derived

[355]
derived from such attempts, from the difficulty attending
them.
The meatus auditorius may be obstructed in various
ways. It may be imperforated at birth—it may have ex-
traneous bodies forced into it—tumors or excrescences
may form in it—and there may be so copious a secre-
tion of wax into it, as to give more or less obstruction.
We shall consider each of these cases separately.
§ I. Of an Imperforated Meatus Auditorius.
This disease seldom occurs. It may be formed either
by a thin membrane spread over the mouth of the passage,
or by a fleshy kind of substance occupying more or less of
the cavity. In both these cases, the only remedy is af-
forded by an operation.
The patient's head being secured in a proper light, the
operator with a small sharp-pointed bistoury should make
an incision of a proper length, exactly on the spot where
the external passage should terminate, and carry it gradu-
ally through the obstructing substances, either till the re-
sistance is entirely removed, or till there is reason to fear
that the tympanum would be hurt if it were carried
deeper: the instrument should then be withdrawn; and
in order to prevent the parts from adhering together, a
bit of oiled bougie should be introduced and retained un-
til the cure is completed, removing it daily to wipe off
any matter produced.
In this manner deafness may often be removed, when
the obstruction does not extend quite to the tympanum;
and it should always for obvious reasons be attempted
about the time when the child begins to speak. At a more
early period the child could not bear it; and if longer de-
layed it might produce dumbness.
§ 2. 

[356]
§. 2. Of Extraneous Bodies lodged in the Ear.
A great deal of pain and uneasiness is often produced
from this cause. Children frequently push small peas,
cherry stones, lead drops, and other substances into their
ears; and flies and other insects frequently creep into them.
When these lie near the extremity of the passage, such
as can readily be taken hold of should be extracted with
small forceps; but peas and other round bodies are more
easily removed by a curved probe, or by means of the in-
strument (pl. viii. fig. 4.) and their extraction will be much
facilitated by previously dropping a little oil into the pas-
sage.
When insects have got so far into the ear that they can-
not be taken out with forceps; the best method of remov-
ing them, is by throwing in warm water, or any other mild
fluid, with a syringe; and this will be much facilitated by
previously killing them with tepid oil held for some time
in the passage by reclining the head on the opposite side.
I prefer oil, because it is less liable to do injury than almost
any thing else.
If the substances insinuated have become much swelled
by the absorption of moisture, it will be best to break them,
either with the forceps, or with a small sharp hook, before
attempting their removal.
§. 3. Of Excrescences in the Meatus Auditorius.
THE auditory passage is as liable to polypous excres-
cences as the nose and throat; but they seldom arrive to
a large size, and are generally of a firm consistence.
They are sometimes pendulous by one pedicle; but in other
cases they seem to consist merely in a general thickening
of the membrane of the conduit.
These 

[357]
These substances may be removed either by the knife
or ligature. When they lie near the external orifice, and can
be laid hold of by forceps, or a dissecting hook, they may
be easily cut out with a probe pointed bistouri; and with-
out any danger from hemorrhagy; but when they lie
deep, it will be most convenient to remove them by liga-
tures. This may be done by means of a split probe and
a double canula, as advised in polypi of the nose.
But in cases where the excrescence extends a consi-
derable way along the membrane, instead of being pendu-
lous by a small neck, neither of these methods is appli-
cable. Bougies will here generally succeed as well as in
obstructions in the urethra. In the introduction of them
however, we must be careful not to pass them to the
depth of the tympanum, or they may do more harm than
good. Escharotics have been recommended in these cases;
but they must always give some risk of injuring the tym-
panum.
§. 4. Of Deafness from Wax collected in the Ears.
THE wax is sometimes collected in the ear in such large
quantities as to induce a considerable degree of deafness;
and in some instances it has become almost as hard as wood.
This variety of deafness may readily be ascertained; for
in a proper position and good light, we may see along the
meatus quite to the tympanum. The safest and easiest
method of removing the wax is by throwing in warm milk
and water, or soap suds, or some such article; previously
dropping in a little oil to lubricate the passage.
Although obstruction of the external passage of the
ear is the most frequent cause of deafness; yet it sometimes
originates from diseases of the tympanum and parts within
it; and it will take place to a certain degree, if the exter-
nal

[358]
nal parts of the ear be destroyed; or if there be a defi-
ciency of wax in the auditory conduit.
The bones of the ears are sometimes diseased in scro-
phula; all that then can be done is to keep the parts clean,
and free from the disagreeable smell induced by the dis-
charge from the carious bones, by injecting warm milk
and water morning and evening. We should however
carefully distinguish this from a discharge consequent to
abscesses in the meatus, and to inflammation of its mem-
brane, or perhaps of the tympanum, which very frequent-
ly occurs, and which is, in my opinion, generally impro-
perly treated. Contrary to common practice, I always
endeavour to check the discharge when recent, as soon as
possible, by the use of moderately astringent injections,
such as brandy diluted, solution of alum, and others;
and in long continued cases, after the introduction of an
issue, near the part, I do not hesitate to follow the same
plan. I have never seen any bad consequences from this
mode of cure; and if the discharge is suffered to remain
any length of time, it not only relaxes the tympanum, but
may even destroy it.
When deafness arises from a relaxation of the tympa-
num, or from any deficiency in the external parts of the
ear, some assistance may be derived from concentrating
sound, so as to make a stronger impression on the organ of
hearing, by means of the instrument delineated in pl. ix.
fig. 2. or others of a somewhat similar construction.
If a deficiency of wax appears, dropping a little oil of
almonds, or any other mild oil into the ear once or twice
daily is sometimes useful. In some cases, I have found be-
nefit from the use of soft soap, and from strained galba-
num mixed with oil and onion juice; these besides keep-
ing the passage moist, may, by acting as gentle stimuli, in-
duce a return of the secretion.
2 
SECT. 


[359]
SECT. II.
Of Perforating the Lobes of the Ears.
THIS operation is seldom performed at present but for
the purpose of ornament. The perforation should be
made as high on the lobe as with propriety it can be done;
the part should be previously marked with ink; and a piece
of cork should be placed beneath the lobe. The perfora-
tor usually is employed, about the size of the hare-lip pin,
has a handle at right angles with it, and is enclosed in
a canula. After pushing the instrument through the ear
until the canula comes out at the lower side, the cork is to
be withdrawn with the perforator fixed into it. A small
piece of lead is then to be inserted into the tube remaining
in the ear; and this must be left until the passage becomes
callous, moving it a little every day.
CHAP. 

[360]
CHAP. XXXV.
Of the Wry Neck.
THE neck may be so much bent to one side, as to
produce deformity either by an original mal-confor-
mation of the bones; by a preternatural degree of contrac-
tion in the muscles of one side of the neck, particularly of
the sterno-mastoideus; or by a contraction of the skin in
consequence of extensive sores and burns.
In the first case we can afford no relief; but in the two
last we can with certainty remove the complaint.
The wry neck has almost universally been attributed to
a contraction of the sterno-mastoideus muscle; but in every
instance of this kind that has fallen under my notice, it has
been induced by a contracted state of the skin alone*.
Whichever be the cause, however, the disease will be most
effectually and safely removed by a gradual incision with
a scalpel through all the contracted parts, from above
downwards. The divided parts can only be effectually
preserved apart afterwards, by supporting the head until
the wound heals.
A contraction of the skin beneath the chin, drawing the
head down upon the breast, is to be removed in the same
manner.
CHAP.
* In the London Medical Journal for 1790, there are related two
cafes of wry neck, from an affection of the muscles, which were
cured by electricity applied to the antagonists of the muscles con-
tracted. 

[361]
CHAP. XXXVI.
Of the Diseases of the Nipples.
WHEN the nipple is so far sunk into the breast that
the child cannot take hold of it, it becomes ne-
cessary to draw it out by means of nipple glasses. These
may be used either by the patient herself, or by an assistant.
They are made of glass alone, or of a glass cup connected
to a bag of gum elastic.
The best remedies for cracks or ulcerations of the nip-
ples, are mild, astringent, and drying applications. The
parts may be bathed with lime-water, port wine, or bran-
dy and water, and afterwards covered with unguentum
nutritum, or Goulard's cerate. The first is the best; but
whichever of these ointments is used, they should be en-
tirely washed off before the child is allowed to suck, on ac-
count of the lead contained in them. The child should
not be permitted to suck oftener than is absolutely neces-
sary; and when one nipple only is sore, he should if pos-
sible be confined to the well breast, and the other should
be drawn occasionally. The nipples should be covered
with small wooden cups, perforated to let the milk through;
in order to prevent the clothes from retarding the cure.
Z z CHAP. 

[362]
CHAP. XXXVII.
Of Issues.
ISSUES are small artificial ulcers formed in different
parts of the body for procuring a discharge of pus.
It is now very well established, that these are only useful in
proportion to the quantity of the matter they afford: (See
Chapter on Ulcers.) And as this is the ease, they may be
placed in any situation most convenient to the patient.
In the formation of issues however, it is to be observed,
that they should never be placed immediately above a bone
thinly covered, directly above a tendon, very contiguous
to a large blood-vessel or nerve, or upon the belly of a
muscle. The best situations for issues are, the space be-
tween the tendons on the  back of the neck, the middle of
the upper side of the humerus, and the hollow on the in-
side of the knee above the flexor tendons. They may like-
wise be inserted between two of the ribs, and on each side
of the vertebræ of the back; or wherever there is a suffi-
cient quantity of cellular substance for the protection of
the parts beneath.
Issues are formed, by removing the skin by epispas-
tics; by making an incision with a scalpel or lancet; by
the application of caustic; and by the introduction of a
cord.
If a blister is used, it must be exactly of the size of the
intended sore; and after its operation, a discharge of
matter may be kept up by dressing daily with cerate mixed
with 

[363]
with cantharides. If incision or caustic is to be employed,
an opening must be made of a sufficient size, and preserved
by inserting daily some extraneous body covered with
ointment, and secured by a compress and bandage.—Peas
are commonly employed: but kidney beans, gentian root,
or aurantia curaslavantia cut into a proper form, will also
answer very well.
When the opening is to be made by incision, the skin
should be supported on one side by an assistant, and on the
other by the surgeon, who should then make a cut of a
sufficient length and depth for receiving the number of
peas intended to be put into it. The common lapis infer-
nalis answers best for making an issue by caustic. It should
be first reduced to powder, and made into a paste with
water or soft soap; a piece of leather spead with Bur-
gundy pitch, or any adhesive plaster, with a small hole
cut in the centre of it, should then be placed upon the part.
The caustic being put into this opening, the whole should
be covered with another adhesive plaster. These precau-
tions are necessary to prevent the caustic from spreading
farther than the part upon which it is wished to operate.
In the course of ten or twelve hours the caustic may be re-
moved, as by this time it will have produced an eschar of
a sufficient depth. In three or four days the eschar will
separate, and the opening must then be filled with peas as
above directed.
When we wish to discharge a very large quantity of
matter by issue, and particularly from deep-seated parts,
we effect it by the introduction of a cord of cotton or silk,
forming what is termed a seton. The parts at which the
cord is to enter should always be marked with ink; and this
being put into the flat needle (pl ix. fig. 3.) and the parts
supported by an assistant, the needle should be pushed in at
one of the spots marked, and carried out at the other,
leaving two or three inches of the cord hanging out at
each 

[364]
each orifice. The irritation which the seton gives soon
produces a plentiful discharge of matter; which may be in-
creased or diminished, by covering the cord daily before it
is drawn, with a mild or irritating ointment.
CHAP. XXXVIII.
Of the Inoculation of the Small-Pox.
THERE is reason to suppose that almost all eruptive
diseases, as well as some others, may be communi-
cated by inoculation; but the operation is seldom practised
but for the communication of the small-pox. The plague
and measles have been given in this way. The latter has
been tried in Scotland, but without advantage.
The small-pox can only be communicated with certainty,
in inoculation, by means of the matter taken from some of
the pustules, and applied to a wound made in some part
of the body. This is now commonly done in a very sim-
ple manner: The point of a lancet, previously moistened in
the matter, is insinuated through the cuticle, so as slightly to
injure the cutis vera. If the matter has become hard it
should be softened by warm water or steam.
The operation may be done in any part of the body;
but the arm is generally preferred. In order the more
certainly to ensure success, it may be performed in two or
more places; but always at such a distance apart that the
inflammation produced may not extend from one to the
other

[365]
other—on each leg or thigh for instance. No dressing is
employed; and about the end of the second or third day,
if the operation has succeeded, the wounds will have be-
come red, swelled, and painful.
CHAP. XXXIX.
Of Wounds.
SECT. I.
Of Wounds in general.
A WOUND maybe defined, a recent solution of con-
tinuity in any of the softer parts of the body, at-
tended by a corresponding division of the integuments.
Wounds must necessarily exhibit great variety in their
nature and appearances, according to the parts injured,
the manner in which they are produced, and their extent.
Thus wounds in the muscular parts are very different in
their appearances and nature, from those which affect ten-
dinous parts; those made with a cutting instrument are
materially different from contused or lacerated wounds;
and punctured wounds are generally productive of very
different effects from those which are more extensive.
We shall at present confine ourselves to the description
of the phenomena which usually take place in the most
frequent 

[366]
frequent form of this affection, what we term a simple
incised wound.
The first appearance we observe in a wound of this
kind, is a separation of the divided parts; the degree of
this depends on the depth and length of the wound, and
on the direction of it with regard to the fibres of the part.
This last circumstance has a very considerable influence in
this respect, for when the fibres of a muscle have been
cut transversely, they will separate sometimes to such a de-
gree, as to give reason for supposing that a part of them
has been removed; and it often happens that a wound of
some depth in the direction of the fibres, will produce so
little retraction of the skin that it appears almost as a line.
The next appearance is the hemorrhagy, which takes
place to a greater or less extent, according to the size of
the cut, and the size and number of the blood-vessels di-
vided. If this is neglected, or is not worth attention, the
irritation produced by the injury, as well as by the exter-
nal air, excites the vessels to contraction, and thus stops
the discharge. The discharge of red blood gradually
ceasing, a serous fluid oozes out for a few hours, and the
whole surface of the sore then soon becomes more or less
dried, or covered over with coagulated blood.
The pain in these wounds is at first commonly inconsi-
derable, unless a nerve or tendon has been partially divid-
ed, in which cases it is usually severe. But in a few hours
it becomes more considerable and more or less of inflam-
mation succeeds; and if the wound is large, a propor-
tionate degree of fever. These symptoms increasing, mor-
tification is at length produced in some instances; but for
the most part, the surface of the wound, which for some
time remained perfectly dry, is gradually rendered moist
and soft, by a thin serum oozing into it, which being al-
lowed to collect, is at length changed into purulent mat-
ter; and in general, the general and topical symptoms of
2 inflammation 


[367]
inflammation abate more or less quickly according as this
formation of matter is more or less plentiful; and go off
entirely when a free suppuration takes place.
From this view of the progress of the symptoms of a
wound, it is evident, that in its treatment, it should be
chiefly attended to as an exciting cause of inflammation.
When no organ of importance to life is wounded, and
when the cut is seated in a fleshy part, if nature be not im-
peded in her operation, the whole surface of the sore be-
comes covered with granulations, when a proper suppura-
tion has taken place; and a cure is gradually accomplished
in the manner described in the chapter on ulcers.
This favourable termination may be prevented by a va-
riety of causes; but those which arise solely from the na-
ture of the wound are, too great or too small a degree of
inflammation, and a want of a free discharge of the matter
that is produced*: Thus punctured wounds are very apt
to be accompanied by too much inflammation; and lodge-
ments of matter frequently occur in them. In contused
wounds the texture of the parts are sometimes so much in-
jured, that the circulation is stopped, and a mortification
is occasioned. And wounds attended with much lacera-
tion are particularly liable to produce gangrene, ultimately
from exciting too much inflammation.
In forming a prognosis in wounds, besides the circum-
stances just described, it will be necessary to pay attention
to the age and habit of body of the patient; the texture
of the wounded part; the part of the body injured; and
the rifle of a communication of the effects of the wound
to the adjacent parts.
Thus it is well established by experience, that wounds
are much less hazardous, and heal more readily in youth
and middle-age than in very advanced periods of life; but
it does not appear that healthy old age is any obstruction
in
* These are circumstances that require particular attention. B. 

[368]
in a great many cases, particularly in the operations of li-
thotomy and amputation, to the healing of wounds; on
the contrary it is often advantageous, by giving less ten-
dency to inflammation.
It is well known also, that wounds are much less painful,
and heal more easily-in some parts than in others, in mus-
cles, e.g. than in tendons, or glands.
With respect to the situation of a wound, it is obvious
that wounds in the extremities, when confined to parts
lying above any of the hard bones, are not so hazardous as
those which pass into any of the joints; and in other parts,
wounds which penetrate any of the larger cavities must be
more dangerous than those which do not run so deep. This
may be occasioned by the chance of some organ being direct-
ly injured, either by air or other extraneous bodies finding
access to the exposed cavities, or by the lodgement of
matter.
It is also to be considered that wounds, which at first did
not appear to be attended with any risk, may eventually
prove mortal; thus the lungs, stomach, aorta, or recep-
taculum chyli may be wounded slightly, and at length
prove a very unexpected cause of the patient's death.
Wounds also prove fatal in some instances, from a com-
munication of inflammation to parts which were not pri-
marily injured in any degree; and they may likewise ter-
minate in death from mismanagement in diet, dressings,
and other circumstances.
SECT. 

[369]
SECT. II.
Of the Cure of Simple Incised Wounds.
OUR first attention, in wounds, is to be directed to the
hemorrhagy; both on account of the safety of the patient,
and of ascertaining the extent and nature of the injury.
Hemorrhagies are to be restrained by the tourniquet, or
by pressure with the hand, according as the wound is seat-
ed on the extremities, or on the trunk, or head, until the
vessels can be tied, either by means of the tenaculum or
needle. If necessary, the wound should be enlarged in or-
der to admit of the application of the ligature; and this
practice if properly attended to, would we believe have
saved many limbs which have been amputated, from the
supposed impossibility of otherwise restraining the bleed-
ing.
When the injured arteries run in the substance of a bone,
as they cannot then be tied, they should be cut entirely
across, and their consequent contraction will, perhaps al-
ways, remove the hemorrhagy.
If the discharge proceeds from the very small vessels on
the surface of the sore, remedies of a different kind from
those just mentioned must be employed. See chap. on the
means of removing hemorrhagies.
The bleeding being stopped, we are then to examine the
wound carefully, and remove all extraneous substances that
can be taken away without giving much pain, or danger of
injuring parts of importance; any others that may be pre-
sent must be left to be thrown off by the consequent sup-
puration. This practice will often prevent very trouble-
some inflammation. But it is to be observed, that we are
to be in some measure guided in our conduct here, by the
nature of the substance lodged in the wound; for instance,
3 A lead
                   

[370]
lead has often lain a considerable time in the body without
being productive of injury; but almost every other sub-
stance seems to produce bad effects to a greater or less
degree.
Where the fingers will effect the purpose, they should
be preferred to forceps, or any other instrument, for the
removal of substances from wounds. Sand, dust, or small
pieces of glass, &c. are best removed by bathing the parts
in warm water, either by means of a sponge, or of a syringe,
or by pouring it upon them: And in doing this, as well as
in using the fingers or forceps, much of our success will de-
pend on putting the patient in such a position, as will most
effectually relax the injured parts, and produce as wide a
separation of the lips of the wound as possible.
We are in the third place, to proceed to the employment
of those means which will probably heal the wound in the
most easy and expeditious manner. Wherever the nature
of the injury will admit of it, the divided parts should be
brought into contact: the irritation excited by the wound
itself will then generally be productive of a certain de-
gree of inflammation, which will accomplish a union in the
course of a few days, by the intervention of a glutinous
fluid exhaled from the vessels. This connection is, in many
instances, soon considerably strengthened by the formation
of blood vessels. The wound is then said to be healed by
the first intention; and this mode of cure should always,
when it appears practicable, be attempted. If the parts
cannot be brought into contact, they should be made to
approximate as much as possible, as this will, in every in-
stance, expedite the cure.
The advantages of this method of treatment are, that
very extensive wounds are very quickly cured, the parts
being usually united in the course of five days; a large
and often materially injurious discharge is prevented;
the free motion of parts that would otherwise be lost is
often 

[371]
often preserved; the scar produced is very small; and the
wounded parts are well covered by sound skin.
The means of drawing and preserving divided parts in
contact, are, bandages, adhesive plasters, and sutures. With
respect: to the first, although the uniting bandage may be
used in longitudinal wounds in the extremities and head,
yet it seldom keeps the parts smooth and even, when used
alone, and in transverse wounds it can be of no benefit at
all. It may, however, be often serviceable in aiding the
effects of adhesive plasters: These should always be pre-
ferred to any other remedies in wounds that do not pene-
trate much deeper than the cellular membrane; and where
the loss of substance prevents the edges from coming to-
gether, the plasters are to be applied in such a man-
ner as to bring them as close as possible.* But in all
wounds that penetrate to any considerable depth, when
their lips can be brought into contact, the twisted suture is
the best means of retaining them.—(See chapter on Sutures.)
The interrupted suture which is most frequently employed,
does not support the parts so well; the ligatures are apt to
tear or cut the parts; and they frequently leave disagree-
able marks.
It is of consequence to observe, that where the use of su-
tures or adhesive plasters has been neglected at the first,
they may be employed with advantage during any stage of
the sore, as the parts will unite at any time very readily;
and it will expedite the cure very much to bring the edges
of the ulcer into contact whenever it can be done.
The good effects of futures and plasters will be much
aided by a proper posture of the patient; and indeed with-
out this be attended to, they will be of little advantage.
When the parts are brought together in the manner di-
rected, in order to prevent the access of air, it will be bet-
ter
* The form and size of the plasters must be regulated by the judg-
ment of the surgeon. 

[372]
ter to cover them with lint spread either with mucilage of
some mild gum or some unctuous substance.
If the patient is low and emaciated, it will be proper to
allow him a light nourishing diet; but if he is plethoric, or
liable to inflammatory complaints, he should be confined to
a strict antiphogistic course, in order to prevent too great a
degree of subsequent inflammation.
Should the symptoms of pain and inflammation continue
moderate, the dressings should never be removed till the
cure be completed; but whenever the pain in the wound
becomes severe, as it will, if not properly attended to, be
productive of so much inflammation as to frustrate our in-
tention, the dressings should be removed, and the parts
gently, and for some time, rubbed or bathed with some
emollient oil. If this proves insufficient, general and topi-
cal bleeding, and opiates, must be employed, according to
the circumstances of the case. These will generally re-
move the inflammation; but if they should not have this
effect, it will be necessary to take away the ligatures or
plasters entirely, and accomplished a cure in the ordinary
way.
In general, even in very large wounds, the sutures or
plasters may be removed about the fifth or sixth day, as a
union will by that time have been produced, and they may
then be disadvantageous.
It has been objected to the method we have advised,
that where arteries are tied, the ligatures will prevent the
union of the divided parts, and that sinusses are very apt to
be formed, and produce the same effect: but when the cure
has been properly conducted, I have never found these cir-
cumstances to occur in such degree as to afford any valid
ground of objection.
When wounds do not admit of a union by the first in-
tention, the most effectual method of preventing the occur-
rence of bad symptoms, is to promote a speedy and plenti-
3 ful


[373]
ful suppuration, by the remedies formerly recommended
for this purpose, viz. poultices and fomentations. These
should be applied immediately when the pain is very great;
but when this is moderate, we had better defer the use
of them until the effusion necessary for the formation of
pus has taken place, which will probably be in the course
of a day or two, left the inflammation should be prevent-
ed from arising to the necessary degree. The use of
these remedies should be omitted as soon as the pain
and inflammation have subsided, and a free suppuration
has taken place; because a longer continuance of them
would do injury by relaxing the parts to too great a de-
gree; and the sore is then to be treated in the manner for-
merly advised, in the chapter on Ulcers.
The immediate applications to recent wounds should
always be mild; dry lint or sponge are very commonly re-
commended, but lint spread with a mild ointment is less
irritating, and in my opinion, of consequence more proper.
The first dressings of wounds should be removed as
soon as they appear to be covered with matter; this will
generally happen about the fourth or fifth day; but it must
necessarily depend on the health of the patient, and other
circumstances. The application of poultices above the
dressings after the second day, puts it into our power to
remove them sooner than we otherwise could, by softening
them, and promoting the suppuration. The nature of the
subsequent dressings must depend upon the particular nature
and appearances of the sore. See chapter on Ulcers.
The symptoms which more particularly require atten-
tion in wounds, are, pain, inflammation, and convulsive af-
fections. The first of these usually goes off in a short
time; but when it continues very violent and for a longer
time than usual, it will be necessary, in the first place, to try
the effects of opiates: Should not these give permanent
relief, we should carefully search for the cause. This will
sometimes 

[374]
sometimes be found to consist in extraneous substances 
lodged in the wound; these should therefore be searched
for, and removed, either by the fingers, injections of warm
water, or by immersing the parts in warm water or milk
for a considerable time, by which they may be dissolved
and washed out.
If these trials do not remove the pain, it will often be
found to originate from inflammation. This is to be re-
moved in the usual way; but particularly by the applica-
tion of leeches to the edges of the wound, and by scari-
fying the periosteum, if the inflammation appears to be
seated there. There is not so much danger of inducing
exfoliation of the bone by this proceeding, as by suffering
the inflammation to continue, and perhaps terminate in
the formation of matter.
When the pain appears to be deep seated, and does not
seem to originate from either of the causes already mention-
ed, it may with some reason be attributed to a partial division
of a nerve or tendon. In this case, although putting the
part in, a relaxed position may afford some ease, no effec-
tual relief will be given by any remedy, but an entire divi-
sion of the injured nerve or tendon. This being made,
the limb should be relaxed, and the part affected covered
by an emollient poultice. If this should fail, either from
the division being made incompletely, or from its having
been too long deferred, there will be great reason to fear
the patient will die convulsed, notwithstanding the use of
opiates, and every other remedy.
In some instances, the pain instead of being deep seated,
is found to originate from a peculiar degree of irritability
of the nerves on the surface of the injured parts. It is not
then usually severe, but it often prevents the patient from
sleeping, and occasions a thin acrid discharge. In these
cases, large doses of opium give the most certain relief;
and a weak solution of opium, or of saccharum saturni,
are 

[375]
are the best external applications. Poultices often increase
instead of relieving the complaint.
Subsultus tendinum, and other slight spasmodic affec-
tions are frequent consequences of wounds; these are par-
ticularly apt to occur after amputation, and then produce
very disagreeable and sometimes dangerous consequences.
They are evidently the effect of pain and irritation from the
wound, and are often relieved considerably or entirely, by
putting the whole body, and particularly the part wound-
ed, into an easy relaxed posture. If this fails, opiates will
commonly succeed: and these should always be given in
small quantities, frequently repeated; for large doses are
very apt to nauseate or puke, and to be productive of an
increase of the spasms after their immediate effects are
over.
The most alarming convulsive affections consequent to
wounds, are the locked-jaw and tetanus. These are most
apt to occur in warm countries, but occasionally are met
with in every variety of climate. They are frequently the
effects of trifling injuries; a small scratch, for instance,
which does not penetrate to a greater depth than the skin
will sometimes induce them; and when they happen as
the consequences of large wounds, they do not commonly
make their appearance until the sore seems nearly healed.
Upon the first symptoms of these affections, the patient
should be immersed in a bath of warm water as long as he can
bear it, or what will perhaps be preferable, a bath of warm
milk, or of water impregnated with oil; in fat broth, e. g.
As the warm bath has often failed, some practition-
ers have had recourse to cold bathing; but although this
has proved frequently useful in tetanus, it is still doubtful
whether it can be equally serviceable in trismus, or locked
jaw, the most dangerous species of these affections.
Opium appears to be the most useful internal medicine,
and it seems more proper to give it in moderate doses, as
above 

[376]
above directed, so as to keep the system constantly under its
effects, than to exhibit it in very large quantities at a time;
as this last method appears to induce that state of the body
which it was meant to prevent, when the immediate effects
of the medicine are gone off, viz. a great degree of irrita-
bility. Æther and musk have been joined with opium, but
they have not been productive of any important benefit.
As external applications, emollient animal oils seem to
be those that we may expect to be most serviceable; such
as the oil obtained by boiling recent bones in water, and
that afforded by fowls. Mercurial ointment seems chiefly
useful as an emollient. Opium moistened with spirit or
water, or in the form of laudanum, has been rubbed or ap-
plied on the contracted parts with benefit.*
At the same time that these remedies are employed, the
patient should be supported by mild nourishment given by
the mouth, when this can be done; and by clysters of
strong broths, if the contraction of the jaws prevents the
exhibition of food by the mouth. In order to avoid this
last
* Dr Rush, professor of the theory and practice of medicine in the
college of Philadelphia, in wounds of nervous and tendinous parts,
as preventatives of these spasmodic affections, advises dilatation, and 
dressing with spirits of turpentine, or some other stimulant sub-
stance; and tells us, that where this plan has been properly fol-
lowed, so as to excite an inflammation of the part, he has never seen
them produced. The Doctor believes tetanus to be founded in re-
laxation, and that in order to remove the affection, it is necessary
not only to restore the natural vigour, but to excite something like
inflammatory diathesis in the system. Agreeably to this idea, be-
sides the cold bath, oleum succini, Barbadoes tar, mercury, and the
other tonics and stimulants which have heretofore been recommend-
ed, he employs wine, bark, and blisters, together with the topical
remedies above mentioned. Electricity, as suggested by the Doctor,
has lately been used with success in New-England, as we learn from
a publication of the Medical Society at New-Haven.
The happy effects of Dr Rush's method, in several instances, seems
much in confirmation of his opinion. See Med. Obs. and Inq. by
Benj. Rush, M. D. 

[377]
last circumstance, it will be adviseable to remove a tooth or
two, when the symptoms of trismus seem approaching; or
if this is then neglected, to extract them afterwards.
When a locked jaw is the consequence of a wound in the
extremities, if it does not yield to the remedies above re-
commended, it has been advised to amputate the member;
but experience has shewn this practice to be not only in-
effectual but in many instances to have increased the dis-
ease.
SECT. III.
Of Punctured Wounds.
A WOUND is said to be punctured when it is made with
a small, pointed instrument, such as a small sword; and
when the external opening is small and contracted in pro-
portion to its depth.
Injuries of this kind are more dangerous and difficult
of management than incised wounds of a much greater ex-
tent; from deep seated nerves and other important parts
being more apt to be partially hurt; from extraneous
bodies being carried to a depth from whence they cannot
be easily removed; from the matter afforded being more
apt to lodge within them; and from their edges adhering
often with difficulty.
In superficial punctures, where we are certain of being
able to extract any extraneous matter, and where the in-
flammation is for the most part moderate, compression may
be used, and will seldom fail of effecting a cure. When
they are deep, and will admit of a seton being used, I ap-
ply emollient poultices until they suppurate freely, and
there is no reason to fear that the inflammatory symptoms
will afterwards go too far; a cord is then introduced               
nearly
3 B 

[378]
nearly equal in size to the opening, and being allowed to
remain till there is ground to believe that any extraneous
matter lodged in the wound is discharged, it is then lessen-
ed, and the cure finished by compression alone, as directed
in the treatment of sinuous ulcers. When the wound is
laid open at both ends, the cord may be easily introduced
by means of a seton probe; but when there is but one
external opening, a counter-opening must be made, either
by cutting with a scalpel, on the end of a blunt probe, or
by means of a lancet-pointed needle passed through a canu-
la, and thus introduced into the sinus.
But although a cure of such wounds may be thus ac-
complished, yet I am well convinced, that wherever the
practice is safe, the laying them open immediately after
the accident, by means of a probe-pointed bistouri, or a
scalpel and director, should be preferred: for by this
means, all extraneous bodies are at once brought into view;
hemorrhagies are easily restrained; all that pain and
trouble which sometimes occur from a partial division of
nerves or tendons are directly obviated; the inflammation
which so often follows punctured wounds will not be so
apt to run high; and much time will be saved.
When the puncture runs deeply among the larger
muscles, and especially in such as are contiguous to large
blood-vessels or nerves, this practice cannot be fully adopt-
ed with safety; and we must be contented to lay open the
parts as far as it can be done with propriety, and trust to
the consequent suppuration for bringing off any extraneous
matters that may be lodged in the wound, and to com-
pression for a completion of the cure. Or, as a seton may
in some cases be passed where it might be dangerous to
make a deep incision, that practice may be tried.
But it is to be observed, that when a puncture runs in
such a direction as not to admit of a counter-opening, a se-
ton can never be employed; and we must trust to a proper
application

[379]
application of pressure, not merely for preventing any
lodgement of matter, but for effecting a cure by producing
an adhesion of the divided parts. And when this method,
or setons fail, astringent injections, such as lime-water, weak
solution of saccharum saturni or of alum, or claret or port
wine and water, may be advantageously employed, in or-
der to check too great a discharge of matter, or pro-
duce a certain degree of callosity in the sides of the sore:
But they should never be used before, as they tend to dimi-
nished the proper degree of inflammation, and wash off the
pus in too great a degree; and thus prevent the formation
of granulations, and the adhesion of the sides of the
sinus.
In punctured wounds where setons cannot be employed,
it is sometimes difficult to prevent the external opening
from closing, long before any tendency to heal appears in
the bottom of the sore; and if this be not attended to, much
mischief is apt to ensue from matter collecting beneath, and
bursting out from time to time. With a view to prevent
this occurrence, tents are employed. Those that are hol-
low are to be preferred to solid tents of any kind; for they
admit of a constant and free discharge of the matter that
is formed, while solid tents, from preventing any discharge
but at the stated dressings, are very apt to make the matter
insinuate itself between the different layers of muscles, and
thus give time for an absorption of it into the system; on
this account, if they are employed at all, they should never
fill the aperture entirely. Silver and lead are commonly em-
ployed to form hollow tents; the latter is preferable, be-
cause it gives least irritation, and may be more easily adap-
ted to the form of the sore. Solid tents may be formed of
sponge, gentian, or any other substance that swells with
moisture.
Tents should never be employed when their use can be
at any rate dispensed with; and as the discharge will com-
monly 

[380]
monly preserve the opening of a wound free, they can be
very seldom necessary*.
SECT. IV.
Of Lacerated and Contused Wounds.
A WOUND is said to be lacerated, when the parts are torn
asunder, and the edges of the sore are ragged and unequal;
and contused, when made by a blunt or obtuse body.
These varieties of wounds, although in fact much more
dangerous than simple incised wounds, do not at first ex-
hibit such alarming appearances. For instance, there is
seldom much hemorrhagy attending them: a limb has been
torn off without any bleeding at all being produced; and
indeed the hemorrhagy as well as the pain, generally seems
to be in an inverse proportion to the extent of the injury.
The retracted edges of lacerated and contused wounds
become almost immediately swelled, from effusion into the
cellular membrane. When the injury has not been con-
siderable, the effected parts are generally thrown off in
the form of sloughs by a subsequent suppuration, and a cure
is readily effected by the means advised in simple incised
wounds; but if the texture of the parts is very much de-
stroyed, and particularly if any of the larger arteries have
been obliterated, there will be reason to fear that gan-
grene will be the consequence. When this surpervenes,
in healthy constitutions, and where the wound is not very
extensive, the mortified parts will often separate, and a cure
will
* As all tents act more or less as extraneous bodies, they can very
rarely, if ever, be employed with propriety, in the healing of sinous
or punctured wounds; free dilatation is the most certain mode of suc-
ceeding in such cases.

[381]
will be afterwards accomplished; but in opposite circum-
stances, there will be great reason to expect death may be
the consequence. If gangrene does not so immediately
follow the injury, yet where this has been very extensive,
so great a degree of inflammation often succeeds as ulti-
mately to produce it.
Hence it is obvious, that in these wounds our principal
object is to guard against mortification; and that the
means by which we effect this must vary according to cir-
cumstances. As the violence of the inflammation is the
most frequent cause of the gangrene, our attention must be
principally directed to obviate this. Blood, therefore,
should be taken away in such quantities from the injured
vessels, as the nature of the affection may indicate, and the
strength of the patient admit: after this, if necessary, the
arteries may be tied. The wound is then to be cleared of
all extraneous substances as formerly directed, and the
parts placed as much as possible in their natural situation;
but no kind of suture should be employed. If the violence
has been considerable, and especially if the patient com-
plains of much pain, it will be still necessary to take away
blood cautiously according to the strength of the patient;
and particularly by leeches applied as near as possible to
the edges of the sore.
The parts affected should then be dressed with pledgits
of some emollient ointment, and over this a warm poultice
should be applied. The poultice, together with warm
fomentations, should be renewed three or four times a-day,
in order to promote a speedy suppuration; which is the
best means of removing all the bad symptoms, and of pre-
venting gangrene. When pus begins to be freely formed,
the parts that have been much injured, gradually separate;
and as soon as they have come away, the edges of the
wound may be brought together by plasters or bandages,
or
3

[382]
or the sore may be treated as a common ulcer, according
to circumstances.
When notwithstanding the means made use of, gangrene
actually comes on, the mode of treatment must be entirely
changed, and we are to depend on the remedies recom-
mended in the section on mortification.
SECT. V.
Of Wounds in the Veins.
WOUNDS in the veins heal with much more ease, and
are attended by much less danger than wounds of the arte-
ries, both on account of their having less muscular sub-
stance on them, and the less degree of force with which
the blood is moved in them, and because the obliteration
even of the largest external veins, is of little consequence,
the anastomosing branches readily supplying the want of
them.
A longitudinal wound will generally heal if covered
by a piece of lint, or soft linen; or at any rate if dried
sponge or agaric is applied to it, and secured by mode-
rate pressure. But in transverse cuts, when compression
cannot be used, or is insufficient to restrain the hemor-
rhagy, the vessel should be tied by the tenaculum or needle, 
as directed in the case of wounded arteries.            
SECT. 

[383]
SECT. VI.
Of Wounds in the Lymphatics.  
LYMPHATICS are sometimes cut in blood-letting, in ex-
tirpating tumors, and in opening buboes and other glan-
dular collections of matter. When the smaller branches
only are injured, they readily heal with the rest of the
wound; but when the vessel is large, and does not heal
so soon as the other parts, but continues to pour out its
contents, producing inconveniency, and debilitating the
patient, we should put a stop to the discharge. If this can-
not be effected by compression, the vessel should be secured
by a ligature. This is a much more certain method than
the application of astringents dried sponge, agaric, puff
ball, or cauteries, recommended by some.
SECT. VII.
Of Wounds in the Nerves, and Tendons, and of Ruptures of
the Tendons.
WITH respect to wounds of the nerves and tendons, we
must refer to what has been said on the subject, in the
chapter on blood-letting, and in section 2. of this
chapter.
In cases of ruptured tendons, it was formerly the prac-
tice to bring the ends into contact, and retain them by su-
tures; but it is now very well established by experience,
that this is unnecessary, and that if they can be brought
nearly together, they will contract such adhesions to the
neighbouring parts, that the use of the limbs will be very
perfectly 
                      

[384]
perfectly restored; and by this means a great deal of trouble
to the surgeon, and pain to the patient may be prevented.
Wherever a wounded tendon is situated, or even when
the tendon alone is ruptured, without any injury being done
to the external parts, the limb should be placed in such a
position as will most readily admit of the retracted ends
being brought nearly together; the muscles of the whole
limb must then be tied down with a roller, applied mode-
rately tight, so as to prevent them entirely from moving
during the cure, and the parts placed in the most easy and
relaxed posture. Thus, when the tendon of the rectus
femoris is the seat of the injury, the leg should be kept
stretched out, while the thigh should be somewhat bent;
and when the tendo achillis is affected, the knee should
be constantly bent, and the foot stretched out.
In ruptures of the tendo achillis, in order to keep the
divided parts in their proper situation, the patient should
wear a slipper, connected to a broad piece of quilted
ticken laced round the upper part of the leg, by a quilted
strap. The slipper should be open at the end, in order to
admit of a free motion of the toes.
When the patient is able to go abroad, which may be
the case in about two weeks, he should wear a very high-
heeled shoe, to the back part of which a strap should be
fixed, long enough to be fastened to the garter.
The patient should wear this for several months at
least, and be very careful to avoid any violent exercise,
for a long time, for fear of again rupturing the newly
healed parts.
SECT. 

[385]
SECT. VIII.
Of Wounds in the Ligaments.
OUR observations on this subject are chiefly applicable to
wounds of the capsular ligaments; as the ligaments situ-
ated far from the surface of the body are not much ex-
posed to external violence, and are out of the reach of
applications. 
The ligaments are rendered extremely sensible by dis-
ease, and wounds of them are often productive of very
alarming consequences. For although, in some instances,
lacerations, by the heads of bones being pushed through
them, and wounds of them, have readily healed; yet in ge-
neral, the symptoms which ensue from injuries to them are
very severe and hazardous. Nothing alarming appears
perhaps at first, or for several days after the accident; but
at length the patient feels an uneasiness and stiffness of the
joint; these gradually increase; and the parts soon become
swelled, tense, and inflamed.—The pain now grows exces-
sive; a sense of tightness around the articulation comes on;
and the inflammation spreads all over the limb.
If the wound in the ligament is large, the synovia is often
immediately discharged in considerable quantities; but the
subsequent swelling gradually stops the flow of it, and the
sore becomes dry and sloughy. In a few days however,
extensive suppurations begin to form in the joint; and if
these are laid open, synovia is discharged with the pus.
This relieves the tension and pain; but a succession of ab-
scesses is apt to take place, which at length materially injure
the patient's health.
These effects almost always result from wounds in the
large joints, if they are not healed very quickly, and al-
most without the formation of matter. They seem to be
3 C chiefly 


[386]
chiefly the result of the admission of air to the internal
parts of the joints; and on this account, in incised wounds,
where it is practicable, as soon as extraneous substances
that may have been carried into the cavity have been re-
moved, the skin should be pulled over the wound, so that
the cut in that and in the ligament may not correspond, and
the divided parts of it connected by adhesive plaster, or
sutures. As sutures are too apt to excite inflammation, the
plasters should in general be preferred: These should be
aided by the application of a flannel roller around the
joint. The patient should be in bed when the dressings
are applied, that he may not be obliged to move the limb
soon; and the limb should be placed on a pillow in such
a situation, as will most effectually relax the integuments:
If the wound is on the anterior part of the joint of the
knee, for instance, the leg must be extended, and if on the
back part, it must be bent.
In order to prevent inflammation, the patient should
be put on a low diet; laxatives should be used; moderate
perforation should be excited; and he should lose some
blood.
By this treatment I have known many of these wounds
to heal very readily; but when it has been neglect-
ed, or is not effectual, and inflammation has taken place,
local blood-letting is the most beneficial remedy. In
robust habits, eighteen or twenty leeches should be ap-
plied as near to the parts affected as possible; and this
should be daily repeated as long as the continuance of the
inflammation may render it proper. The wound may be
dressed with some simple ointment; but one of the best ap-
plications to the joint is the steam of warm vinegar. Fo-
menting the part with decoction of white poppy heads
will be sometimes very useful in lessening the pain: but in
general it will be necessary to employ large doses of opi-
ates.
These 

[387]
These means properly employed will often remove the
inflammation; but when they do not, it terminates in large
abscesses, partly within the joint, partly in the substance of
the ligament, and in part in the cellular substance conti-
guous. All that can be done then, is to promote the for-
mation of these when they have begun, and to discharge
the matter as soon as suppuration is completed, by open-
ings in the most dependant parts of the tumors. If not-
withstanding this treatment, the disease continues until the
patient becomes hectic, and much debilitated, as any far-
ther attempt to save the limb will be hazardous, amputa-
tion should be had recourse to. See chapter on Amputa-
tion.
SECT.IX.
Of Wounds in the Face.
IN injuries of this kind, it is an object of importance to
prevent deformity. To effect this, the divided parts should
be laid as exactly together as possible; and if the wound
is in the direction of the fibres of the injured part, or is su-
perficial in any direction, they may be kept in contact by
adhesive plasters; but wherever the wounded parts retract
much, it will be necessary to employ sutures. The twisted
suture, particularly for the lip, is to be preferred to any
other. See section on Hare-lip.
When wounds penetrate the salivary ducts, the treatment
directed in chapter xxxiii. must be employed.
In the fore-head, wounds are apt to be attended with trou-
blesome hemorrhagy; and when this cannot be restrained
by compression, or the artery cannot be readily tied, which
will happen sometimes if it lies in the bone, a part of the
external lamella, or if necessary of the whole substance of
the 

[388]
the bone, maybe removed, in order to enable us to apply
a ligature to the vessel.
SECT. X.
Of Wounds in the Trachea and Oesophagus.
THESE wounds are most frequently the consequence of
an attempt to effect suicide.
When the trachea is divided longitudinally, adhesive
plasters will be found adequate to the retention of the se-
parated parts in contact. They will also be sufficient in
slight transverse wounds, if aided by a proper posture of
the head: Indeed in all wounds of this kind, it is abso-
lutely necessary to the cure, that the head be kept bent as
much as possible down upon the breast; this will be most
certainly effected by connecting a night-cap placed on the
head, with a roller carried round the body.
In all deep transverse wounds of the trachea, it will be
necessary to employ the interrupted suture. But as the li-
gatures, if carried into the trachea, are apt to excite cough-
ing, which has in some instances torn out the stitches, I
have in different instances succeeded very well by passing
them merely through the integuments, in the following
manner; a flat needle with a slight curvature, and thread-
ed with a broad flat ligature, being inserted at the wound,
and passed slowly up for the space of an inch as close as
possible to the trachea, it is then to be pushed out with
the ligature; and the other end of the thread being armed
with a needle, must in like manner be passed through the
teguments of the opposite side. After a sufficient num-
ber of ligatures are passed, they should be secured with
running knots, that they may be easily untied if necessary;
adhesive plasters should then be applied over the whole.
I 

[389]
I have not yet had an opportunity of ascertaining whe-
ther this method will succeed, when the wind-pipe is en-
tirely cut through; but it is probable it will. If how-
ever, it is thought necessary to stitch the trachea itself, we
should carry the needle from within outwards, for fear of
doing mischief. Three ligatures will generally be found
sufficient; one anteriorly, and the others at the sides.
Wounds in the œsophagus are to be managed nearly in
the same manner with those of the trachea, but they are
more dangerous; as well on account of the greater difficulty
of reaching the part injured, from its depth, and the lower
part of it being apt to be drawn below the sternum; as from
the difficulty of conveying nourishment to the stomach
which they produce; and from the vicinity of the recurrent
nerves, the carotid arteries, and jugular veins.
Our first object in divisions of the trachea and œsopha-
gus must be to stop the hemorrhagy; not only on account
of the loss of blood, but to obviate the cough and nausea,
which are very injurious, and which are the consequences
of the blood getting into the lungs and stomach. All the
divided arteries and veins should therefore be secured im-
mediately. A wound of the carotid artery is usually imme-
diately fatal: if the surgeon is called in time he should how-
ever make a ligature on both ends of it. Should the jugular
vein be partially divided, we may attempt to effect a cure by
compression, made either by a common bandage, or where
much pressure is required, by a machine which does not
interrupt the respiration; but if it be cut through, it must
be tied.
As soon as the bleeding is stopped, the œsophagus must
be stitched in the manner advised for the re-union of the
trachea; and in order to effect this more readily, the ex-
ternal wound should be enlarged without hesitation when
it is judged necessary.
Longitudinal wounds in the gullet might very probably
be cured merely by adhesive plasters.
SECT. 

[390]
SECT. XI.
Of Wounds in the Thorax.
§ I. General Remarks.
WOUNDS in the thorax are in general dangerous in pro-
portion to their depth: Those which affect the integu-
ments only, if properly treated, are seldom productive of
any important consequences; but the smallest wounds pe-
netrating the cavity of the chest, will, in some instances, be
attended by the most alarming symptoms, particularly if
the contained viscera are injured.
The first object in these wounds is to ascertain whether
they have entered the thorax: This may be generally done;
by putting the patient into a proper position, and then care-
fully examining the wound by means of the fingers, or a
probe; by ascertaining the form of the instrument with
which the wound was inflicted, and the length to which it
seemed to be pushed; by liquids injected returning imme-
diately, or lodging in the wound; by air being discharged
from the wound; by an emphysematous swelling of the
contiguous teguments; by the quantity of blood discharged
from the wound; by the appearance of the blood; by
blood being discharged from the mouth; and by the state
of the pulse and respiration.
1. The patient should always be placed as nearly as pos-
sible in the posture he was when he received the wound,
during the examination; for it must be obvious, that in
some postures, from the mobility of the muscles and ribs,
a wound, in reality deep, may be made to appear very su-
perficial.                                             '
2. The depth of the wound may, in some instances, be
ascertained by the eye; but when this cannot be done, 
nor

[391]
nor the fingers employed to discover it, on account of
the opening being very small, a bougie should be employ-
ed: This gives less pain, and is less apt to do injury than a
metallic probe. But the examination should be very cauti-
tiously made, and soon desisted from, if we cannot ascertain
the extent of the injury very readily; because the patient
may suffer from the attempt, and the symptoms which fol-
low will soon determine the matter.
3. The size and form of the instrument, the direction
it appeared to take, and the depth to which it was pushed,
should always be ascertained with as much exactness as
possible, as these circumstances may undoubtedly assist us
in forming a judgment of the depth of the wound.
4. When these means do not enable us to form an opi-
nion, the injection of some mild liquid, as warm water, may
be tried. If this returns immediately, the wound is pro-
bably not deep; if it remains altogether, or in great part,
without producing any external swelling, we cannot doubt
in forming a of its having penetrated the chest.
5. If air passes out at the wound during inspiration,
there will be reason to suspect that the lungs are injured.
However, in cases where there is no adhesion between the
lungs and the pleura, this appearance may be produced
from the admission of air, by the wound, into the cavity:
The patient should therefore be directed to make several full
inspirations, in order to discharge the air that may thus be
collected; and at the end of each, the skin should be drawn
over the wound to prevent more from getting in: The
whole will thus soon be evacuated; and then if air still
rushes out during inspiration, we may conclude with cer-
tainty that the lungs are wounded.
6. Emphysematous swellings, produced by the air from
the lungs insinuating itself into the cellular membrane, are
more apt to be the consequence of punctured than of ex-
tensive wounds, and especially of those which run oblique-
ly.

[392]
ly. It is to be observed however, that emphysema may al-
so be produced from the admission of external air by the
wound.
7. When the quantity of blood discharged is very con-
siderable, and particularly if it is not stopped by compres-
sing the intercostal artery, we may with certainty con-
clude that some of the thoracic viscera are wounded. That
the lungs are injured may be inferred from the frothy and
very red appearance of the blood; and particularly if the
patient discharges blood by the mouth.
Lastly, When wounds do not penetrate deeper than
the teguments, the pulse and breathing are not at all af-
fected at first; but when they enter the thorax, and parti-
cularly if they affect the lungs, or any other part of its
contents, an immediate change in the state of the pulse and
respiration is produced. The wound may, however, pass
to a considerable depth, if it is inflicted where there is an
adhesion between the lungs and pleura, without producing
any extravasation, and consequently without injuring the
state of the pulse or breathing; but when either blood or
air gets into the cavity of the chest, the breathing immedi-
ately becomes difficult, and the pulse feeble, oppressed,
and intermitting.
§ 2. Of Wounds in the external Teguments of the Thorax.
WOUNDS which do not go deeper than the cellular
membrane, heal as readily in these parts as in any other
situation; but those that reach the intercostal muscles, and
particularly punctured wounds of considerable extent, are
very apt to penetrate the cavity of the thorax at length,
if great attention is not paid to the timely evacuation of
the matter formed. When these kinds of wounds are not
very extensive, the best method of treatment is to lay them
entirely open with a scalpel and director, and then heal
2 them 


[393]
them carefully from the bottom; but when the puncture
is of considerable length, the cure by seton is to be prefer-
red. Some advise, instead of a seton, to employ compres-
sion; but this cannot be used to a sufficient degree
without impeding the respiration: and besides this bad
effect, it would endanger an insinuation of the matter pro-
duced into the cavity of the thorax.
It is particularly necessary in wounds of this kind to a-
void exercise, especially of the chest; hence coughing,
laughing, and even talking, should as much as possible be
avoided. The patient should be kept on a low cooling re-
gimen; the bowels should be gently opened; and, if neces-
sary, bleeding should be employed.
§ 3. Of Wounds which penetrate the Cavity of the Thorax.
THESE are often productive of alarming consequences;
chiefly from the admission of the external air by them, and
from extravasation of blood between the lungs and pleura.
The latter circumstance generally arises from a wound of
the intercostal artery: As this vessel is of a considerable size,
it should always be secured as soon as possible. This may
generally be done, by drawing it out from the groove in
which it is situated, by means of a tenaculum somewhat more
bent at the point than usual, after dilating the wound; but
when this cannot be executed, from the ribs being much co-
vered with fat, or any other cause, a broad flat ligature
may be readily passed round the rib, and a small dossil of
lint tied by means of it upon the bleeding artery. This, if
done with care, may be performed with the greatest
safety.
When the surgeon is called in time, he may thus prevent
any considerable quantity of blood from being discharged
into the chest; and as soon as the hemorrhagy is stopped, he
may then proceed to expel the air in the manner directed
3 D in 


[394]
in § I. of this section. The wound may afterwards be
secured by adhesive plasters, a napkin, and scapulary ban-
dage.
If however, blood is extravasated in such quantities, or
such a formation of pus is consequent, as produces a con-
siderable oppression of breathing, the paracentesis must be
employed as directed in the chapter on that subject. But
it should be particularly observed, that as instances have
occurred in which absorption of small quantities of blood
or other fluids has taken place, the operation should never
be advised unless the violence of the symptoms render it ab-
solutely necessary; and we should rather trust to the
chance of the first, than run the risk of the last.
§ 4. Of Wounds of the Lungs.
WOUNDS in the lungs require the same general treat-
ment with those which merely penetrate the cavity of the
chest; but as they are more hazardous, they demand a
more particular attention. The danger of them arises
from the hemorrhagy, or a subsequent suppuration in the
lungs.
The hemorrhagy is most effectually checked by copious
bleeding, so as to induce fainting; by keeping the patient
in a cool apartment, and perfectly at rest; by cooling
laxatives; and by a low diet. It is also of the greatest
consequence to keep the lungs as free from action as pos-
sible: Hence coughing, laughing, much speaking, and
even the making deep inspirations, should be carefully
avoided.
Notwithstanding all our efforts, however, the patient
will sometimes die from the hemorrhagy; or the extra-
vasation of blood will obstruct the breathing materially;
or abscesses will be formed in the substance of the lungs.
The latter circumstance only remains to be considered.
Collections

[395]
Collections of matter in the lungs may be discharged
either by the mouth, by the wound, or into the cavity of
the chest. We are in this place to pay attention only to
those cases in which the abscess formed bursts into the
wound, or at least is discovered pointing towards it. As
soon as this is known by an oozing of pus, or by introdu-
cing the finger between the ribs, an opening should be
made into the abscess as in other cases. By doing this, we
avoid the hazard of immediate death, which often happens
from the matter being discharged in great quantities into
the bronchiæ, and at the same time prevent the pus from
passing into the chest, which might render another opera-
tion necessary. In cases of this dangerous kind, when the
stoppage of a previous discharge of matter has taken place,
and all the usual symptoms of a fresh collection have come
on, I would even advise the external wound to be en-
larged to the extent of two or three inches, in order to
discover the seat of the abscess, and when this is ascer-
tained, to make an opening into it, by the careful introduc-
tion of a bistouri along the finger, at whatever depth it be
seated. I have used this practice in two instances; and in
both of them was obliged to go nearly the length of my
finger into the substance of the lungs: the patients were
instantaneously relieved, and are now in good health.
In the subsequent treatment of these abscesses, we must
be careful that the sore heals from the bottom; and this
will be most effectually accomplished by the use of a hol-
low oval tent. See section on Punctured Wounds.
When any part of the lungs protrudes from a wound
in the chest, it should be immediately replaced; but if this
is neglected until a part of them becomes gangrenous, this
should be cautiously removed, and the rest replaced. If
the incision be confined to the mortified part, no hemor-
rhagy, or other bad consequence will arise from it.
§ 5.

[396]
§. 5. Of Wounds of the Heart, of the large Vessels connected
with it, and of the Thoracic Duct.
THE slightest wounds of the heart are probably always
ultimately fatal; for the weakness induced by them on a
particular part, will necessarily be productive of aneurism,
which always perhaps has a rapidly fatal termination.
The most probable method of preventing this, or at least
of delaying it is, to lessen the action of the heart by co-
pious blood-letting, low diet, laxatives, and avoiding fa-
tigue of every kind.
The same observations apply to wounds of the large
blood-vessels about the heart.
We may judge the thoracic duct to be wounded, when
the instrument has penetrated to the part in which it is
situated; when the discharge is altogether white like chyle,
or mixed with a considerable quantity of it; and when the
patient becomes daily weaker from it, than he would be-
come from a wound of the same size in any other part.
In order to prevent the diameter of the duct from be-
ing distended, which at the same time will tend to lessen
the extent of the wound, the patient should be kept upon
a cooling and very spare diet, and should take his food and
drink in very small quantities at a time; the bowels should
be kept open; and bodily exertion of every kind, and par-
ticularly that which affects the breathing to considerable
degree, should be avoided.
§. 6 Of Wounds of the Diaphragm, Mediastinum, and Peri-
cardium.
WOUNDS in the diaphragm are known by the situation
of the injury, and by the concomitant symptoms. The
breathing is rendered difficult; and pain is produced all
over 
                     

[397]
over the parts to which the diaphragm is connected, and
in the region of the stomach; sickness, vomiting, and hic-
cup, take place; and pains in the shoulders sometimes occur,
together with cough, delirium, a quick hard pulse, and
other symptoms indicating inflammation and fever. In-
voluntary laughter is said to take place in some instances.
It is a common opinion, that wounds of the tendinous
part of the diaphragm are more dangerous than those which
affect the muscle itself; but this opinion is not established
by experience: patients seldom recover from the effects
of either.
In order to obviate the inflammation and irritation,
blood-letting is chiefly to be depended on; and together
with this we should employ gentle laxatives; large doses
of opium joined with musk; and warm fomentations to
the thorax and abdomen; and enjoin rest, and a low diet.
These wounds, if small at first, soon become enlarged by
the constant action of the diaphragm; and some of the ab-
dominal viscera then usually pass into the chest, and in-
crease the danger.
The circumstances most to be feared from wounds of
the mediastinum, are extravasation of blood into the chest,
and inflammation, with its consequences. And wounds of
the pericardium prove sometimes dangerous by preventing
the collection of the lymph necessary to the easy motion of
the heart, and by allowing this fluid to spread through the
cavity of the chest. The general observations on the ma-
nagement of wounds penetrating the thorax, will apply to
that of injuries of both mediastinum and pericardium.
In every wound which enters the thorax, where a cure is
not effected without the formation of matter, the cure is
apt to be tedious, and a discharge of matter to take place
for a long time, perhaps for life. But it is much better to
suffer the inconveniency thus produced, than to attempt
its removal by the use of astringent or other injections; as
they 

[398]
these are often productive of inflammation, and other bad
consequences, but never of good effects, at least according
to my observation.
SECT. XII.
Of Wounds of the Abdomen.
§. I Of Wounds of the Teguments and Muscles of the Ab-
domen.
WOUNDS of this kind merit particular attention, on ac-
count of the danger there is of their effects being commu-
nicated to the contiguous viscera.
It must be our first object in all wounds in the region of
the abdomen, to determine whether or not they penetrate
the cavity. When their extent is not evident to the sight,
it may commonly be ascertained; by a proper examination
with the fingers or probe, after putting the patient into
the posture in which he received the wound; by ascer-
taining the form and size of the instrument, the depth to
which it went, and the direction it appeared to take;
by the quantity of blood discharged; by the attending
symptoms; and by the matter discharged by the wound.
When the wound will admit the finger, we may always
determine with certainty the extent of it; but probes
should not be depended on in these cases, because they
readily pass among the parts, in almost any direction,
with a very little force. Injections are of no service to
determine this matter, because they are so very apt to
spread among the muscles and cellular substance.
The size of the instrument, its direction and the appa-
rent

[399]
rent depth to which it entered, should also be considered,
and may assist us in our judgment.
When the quantity of blood discharged is very great, we
may conclude almost with certainty, that some of the large
internal vessels are injured, for there is no external artery
but the epigastric that can afford much discharge, and it may
be soon ascertained whether this is wounded. It is to be
observed however, that even the largest internal artery may
be cut, and still no external discharge of blood take place.
The internal hemorrhagy will, however, soon be eviden-
ced; by the patient becoming weak and faint; by a weak-
ness of pulse, and cold sweats; and if the discharge does
not soon stop, by every other symptom of approaching
death.
A discharge of fæces, of bile, of the pancreatic juice,
and even of chyle, sometimes appear, and determine with
certainty that some of the abdominal contents are wound-
ed. This is also ascertained, if large quantities of blood
are thrown up from the stomach, or discharged by stool.
Urine may be discharged by a wound which does not pe-
netrate the cavity of the abdomen, because the kidneys and
ureters are situated behind the peritonæum.
When none of the symptoms which we have described
as indicative of wounded viscera appear, and the pain is
not in violent degree, we may conclude it very probable,
that the wound has not reached the cavity of the belly.
Our principal view in that case, as in similar wounds of
the thorax, is to prevent inflammation, and the lodgement
of matter, by bleeding, low diet, laxatives, rest, and a pro-
per attention to the wound, as recommended in the last
section. It will however, be necessary to observe, that as
any weakness of a part of the abdominal parietes, will be
apt to induce a protrusion of some of the viscera, it will be
proper, in order to prevent this, that the patient be kept as
much as possible in a horizontal position, and when he at-
tempts 

[400]
tempts to sit or walk, that the debilitated part be supported
by a flannel bandage, passed two or three times around the
body: And it will be adviseable to continue the use of
this roller for a considerable time after the wound is
healed.
§ 2. Of Wounds which penetrate the Cavity of the Abdomen
without injuring its Contents.
WE may in general conclude, that a wound penetrating
to the cavity of the belly, has not injured any of its con-
tained parts, if the abdomen does not become tense and
painful, if the pulse continues soft, and if the heat of the
body is not increased.
Wounds of this kind are never devoid of danger; for
those which at first show no alarming symptoms whatever,
sometimes at last terminate fatally. This seems to arise,
either from the admission of air to the cavity of the abdo-
men, which induces inflammation of some the viscera, or
from the formation of pus, which not finding a vent, col-
lects in the peritonæum.
In these wounds therefore, after securing any blood-
vessels of the muscles or teguments which may be cut, and
which should be done as soon as they are discovered, our
next object should be, to prevent as much as possible the
access of the air. In small wounds, this may be done by
the use of adhesive plasters, a compress and bandage: And
the same attention to the prevention of inflammation,
by bleeding, laxatives, and rest, as recommended in § 1.
of this section, should be employed. If notwithstanding
this treatment they continue open for some time, they
should be dressed as seldom, and as expeditiously as pos-
sible. Should inflammation supervene, the usual remedies
must be had recourse to; and if this terminates in gan-
grene, the treatment proper for gangrene in general, will
3 be


[401]
be applicable. When the inflammation ends in suppura-
tion, and the quantity of matter collected is productive of
disagreeable symptoms, it should be discharged by the tro-
car introduced obliquely. But this operation should not
be advised until we can clearly ascertain the case, and the
patient suffers inconveniency from the matter formed; be-
cause it is attended with some danger, and small quantities
of matter will often be absorbed. By the use of a trocar,
and particularly by an oblique introduction of it, less
chance will be given for the admission of air to the viscera
than if a scalpelisused. I have employed this practice in two
cases with success; while two patients in similar circum-
stances died after the use of the scalpel.
Wounds penetrating the abdomen may prove dangerous
by admitting of a protrusion of some of the viscera contain-
ed in it. In such cases the prolapsed parts should be re-
turned as speedily as possible into the belly, provided they
are not actually gangrenous; in which case, the parts of the
intestine at which the mortification terminates, must be con-
nected to the external wound by future, in order there
to form an artificial anus. If however, the protruded
parts are covered with sand, dust, or any other extra-
neous matters, these should be carefully washed off,
by bathing the parts in warm milk and water before they
are reduced.
In performing the reduction of the intestines some ad-
dress is requisite. The patient should be put into the pos-
ture that will most effectually relax the parts in which
the wound is seated, with his head and chest somewhat
lower than the belly and buttocks. The surgeon having
his fingers dipped in warm oil, or covered with soft oiled
linen, should then endeavour to replace the parts, by begin-
ning his pressure at one of the ends of the gut, and continu-
ing it along the doubling to the other. If the intestine con-
tains much air, he should endeavour to make this pass in-
3 E to


[402]
to the part within the belly by gentle compression; and if
this is ineffectual, or the intestine cannot otherwise be readi-
ly returned, as must happen sometimes when the wound is
small, the external opening must be enlarged. In order
to make the enlargement in the safest manner, an incision
should be carried in a cautious and gradual manner with
a scalpel through the integuments and muscles; and as
soon as the peritonæum is bared, a probe-pointed bistouri
should be introduced between this and the gut, with which
the membrane is to be cut until the finger can be introdu-
ced, and this serving as a director, the opening may then be
enlarged to as great an extent as may appear necessary.
The incision should always begin at the lower part of the
wound, be carried downwards, and in the direction of
the muscular fibres.
In order to remove the air from the protruded intes-
tine, we have by some been advised to puncture the gut
with a needle; but this must certainly be considered as a
very dangerons practice.
Small wounds of the abdomen may be healed by keep-
ing the patient in a proper posture, with his head and but-
tocks elevated; by preventing costiveness; and by the use
of a flannel roller: but extensive wounds must always be
closed either by the interrupted or the quilled suture. See ch.
iii. This operation is termed gastroraphy. In performing
it, the patient should be laid in an easy relaxed posture; the
fore-finger should be introduced to guard the abdominal vis-
cera from the needle; and the needle should be entered at
the wound and brought out at the distance of an inch from
the edge of it. The sutures should not be more than three
quarters of an inch from each other, and the first and last
should be made within half an inch of the extremities of the
wound. The wound should afterwards be covered with
some unctuous substance spread upon lint, in order the
more effectually to prevent the access of air; and that a
subsequent

[403]
subsequent protrusion of any of the contents of the belly
may be more effectually guarded against, a roller should
be passed several times around the body. The patient is
afterwards to be treated according to the symptoms which
ensue.
We are commonly advised to leave an opening in the
inferior part of the wound for the evacuation of any mat-
ter that may be formed: but as this cannot possibly answer
the intended purpose, unless the injury affects the lower
part of the abdomen; as it can only be preserved by the
use of a tent, the irritation of which may be very injuri-
ous; and as the ready access thus afforded to the external
air must necessarily be productive of very bad consequences
in many instances; I have no doubt of the propriety of
closing the whole wound in the manner above directed;
and that it will be better to trust to the absorption of any
matter which may be afterwards formed, or even to its
evacuation by the trocar, than to confide in this precarious
mode of treatment.
In favourable circumstances the wound will unite in six
or seven days; but when the ligatures give much pain,
and especially when the abdomen becomes very tense, the
knots should be untied, until by bleeding, fomentations, and
gentle laxatives, these symptoms are removed; and the
parts may then be again drawn together and secured as
before.
§ 4. Of Wounds of the Intestines.
WOUNDS of the intestines are commonly attended by
nausea, violent pains in the belly, cold sweats, and faintings;
and by the discharge of blood by the mouth and anus, and
of fœtid air by the wound
In these cases, where the injured part is not protrud-
ed, we are directed by some authors to enlarge the wound
and 

[404]
and search for it; but more mischief would probably be
done by the extent of the cut that would thus be necessary,
and from the exposure of the intestines to the air, than
would be compensated by the benefit from the discovery.
The practice therefore should not be attempted; especi-
ally as there have been instances of recoveries from wounds
of the intestines which could not be reached.
When the wounded part of the intestines is prolapsed,
it should undoubtedly be sewed up, in order to prevent the
effusion of fæces into the abdomen: This is best effected
by the glover's stitch. In making this, a small, fine, round
needle should be used, and armed with silk; and in order
the more effectually to guard against producing a diminu-
tion of the cavity of the intestines, the needle should be in-
serted from within*. The stitches are all to be in a con-
nected series, and the needle always entered in opposite
places of the lips of the wound; by this means it will go
in a diagonal line from one side of the wound to the other;
and the stitches should be made at about the distance of 
two-tenths of an inch from each other. Both ends of the
thread are to be secured by knots.
We are commonly advised to leave the end of the thread
hanging out at the wound, that the whole may be with-
drawn at the proper time; but when more than one or
two stitches are taken, this must be a matter of some dif-
ficulty, and less injury would probably be done by leaving
it within, in which case it will chiefly pass into the cavity
of the gut probably, than by an attempt to draw it out.
When the intestine is cut entirely through, and both
ends protrude at the wound, the best practice perhaps, is
to stitch them to the peritonæum and abdominal muscles,
exactly opposite and contiguous to each other; to dress them
lightly,
* In the common method of performing this operation, both sides
of the gut are perforated at the same time. B. 

[405]
lightly, keep the wound clean, and trust to nature to effect
a cure. The fæces must necessarily for some time be dis-
charged by the sore, but there are instances of the ends
of the intestine becoming firmly united in a very little
time.
Another method of treatment, is to insert a tube of thin
parchment or of paper, or rather a piece of tallow made
of the diameter of the intestine, into the upper end of it,
and afterwards to carry this, with the substance used with
it, into the lower portion of the gut about an inch; and
then connect them with a fine needle and thread all round,
either at the end of the inferior part only, or there, and
likewise just above the extremity of the superior portion
of the intestine. Tallow should be preferred to parch-
ment or paper, because it will soon melt and come off with
the fæces. The upper part of the gut may be distin-
guished from the lower by the peristaltic motion in it
being more remarkable, and by the discharge of chyle
instead of fæces from it.
When only one end of a divided intestine hangs out at the
wound, we are usually advised to connect it to the perito-
næum and other parts contiguous to the wound, and if
this happens to be the superior portion, and not to be near
to the upper part of the small guts, it is said the patient
may live, under the inconvenience of an artificial anus; but I
am clearly of opinion that as the other end of the intestine
is probably not far from the wound, the incision should
always be enlarged so as to admit of the introduction of
the fingers to search for it; for this will not add much to
the danger; and should the protruded part be the lower
end, the patient will inevitably die in a short time, if the
other is not found and connected in the manner above di-
rected.
In case of gangrene of the gut, whether complicated
with
3

[406]
with a wound or not, the treatment should be the same.
Vide § 3.
Wounds of the intestines are always hazardous; but it
does not appear, from experience, that the difference of
the part injured makes any difference in the degree of
danger.
§ 5. Of Wounds of the Stomach.
WOUNDS of the stomach are known by vomiting of
blood; by nausea to a violent degree; by languor and hic-
cough; and by the food and drink being evacuated at the
wound soon after they are swallowed. Deep wounds in
the left hypochondrium or in the epigastrium must neces-
sarily enter the stomach; but those which are inflicted
obliquely in any part of the abdomen may reach it; and
wounds may penetrate this organ when it is full, which
would not extend to it when empty.
There are many instances upon record of wounds of
the stomach being cured; but they are always to be consi-
dered as dangerous.
Wounds of the stomach require the same treatment as
those of the intestines. They are more readily discovered;
and when the part injured does not protrude it should be
searched for, stitched and replaced: It may always be
reached except it be the posterior portion.
In order to prevent inflammation and distention of the
stomach, the patient should be put upon as low a diet as
his strength will bear; and his food should not be given
in greater quantities at a time than a couple of spoonfuls.
Indeed we might venture here, as well as in wounds of the
upper part of the small intestines, to trust altogether
to nutritious clysters, at least for a few days but in wounds
of the larger intestines the injection might pass more easi-
ly 

[407]
ly into the cavity of the belly than if the food was given
by the mouth.
§ 6. Of Wounds of the Omentum and Mesentery.
WHEN any part of the omentum is nearly separated
from the rest, or has become cold, so as to induce a dan-
ger of gangrene, it should be immediately taken off; but
when these circumstances do not occur, it should be re-
turned as soon as possible into the abdomen. See chap.
on Herniæ.
In wounds of the mesentery, when any of its vessels are
divided,they should be tied, in order to prevent the effusion
of blood or chyle into the cavity of the abdomen; and the
ends of the ligatures should be left hanging out at the
wound, that these may be removed as soon as they sepa-
rate.
§ 7. Of Wounds of the Liver and Gall-Bladder.
THE liver may be injured by any wound that penetrates
the right hypochondrium or epigastrium: if the cut in it is
not deep, it often heal as readily as it would in any other
part of the body, but when it passes to a considerable depth,
it is always dangerous, from the risk of injuring some of the
numerous blood-vessels of this organ; from the interrup-
tion it may give to the secretion of bile; and from admitting
the bile to be poured into the cavity of the abdomen.
That the liver is wounded, may be inferred from the
quantity of blood discharged being more considerable than
could probably proceed from the vessels of the teguments
and muscles; from bile being mixed with this blood; from
bile, tinged with blood, being discharged by the stomach
and anus; from swelling and tension of the abdomen; and
from pain on the top of the shoulder.
All

[408]
All that can be done in cases of this kind, is to guard
against a profuse discharge of blood by the usual remedies;
and to discharge collections that may take place in the
abdomen by proper openings.
Wounds of the gall-bladder are more dangerous than
those of the liver, because they heal with more difficulty,
and are more certainly productive of effusion of bile into
the abdomen. In some instances, the bile being obstruct-
ed in its flow to the duodenum, has accumulated in the gall-
bladder, and produced a very large swelling; an adhesion
has taken place between the bladder and the parietes of
the abdomen; the swelling has burst, and the wound has
at length healed; but in general these cases terminate un-
favourably:— All that we can do is to procure as free a
vent to the bile as possible, and to discharge it by an open-
ing when it collects in the abdomen.
§ 9. Of Wounds in the Spleen, Pancreas, and Receptaculum
Chyli.
WHEN the spleen is laid bare we can easily ascertain
whether it is wounded or not; but unless this is the case
we have no certain test to discover it. Except that
wounds in this viscus are not so dangerous as those in the
liver, the same general observations apply to both.
Wounds of the pancreas can seldom be discovered on
account of its situation*; but a division of its duct, by
discharging the pancreatic juice into the abdomen, may do
material injury to the constitution by injuring digestion;
and the collection thus made may ultimately require the
aid of surgery.
Wounds
* A man who had received a wound in the abdomen with a shoe-
maker's broad paring knife, had a portion of the pancreas protruded
at the orifice, which was cut off close to the integuments, and the
rest being returned into the cavity, the man recovered.

[409]
Wounds of the receptaculum chyli must always be
very dangerous, by depriving the patient of nourishment.
Nothing more can be done in such cases than to discharge
any collection formed, by an operation, when this appears
to be necessary.
§ 9. Of Wounds of the Kidneys and Ureters.
THE external coverings of the kidneys may be hurt,
without any symptom of importance being produced; but
if the pelvis renum, or ureters are wounded, some or all of
the following symptoms are occasioned: pain over the
whole loins, in the groin, yard, and testicles; nausea and
vomiting; and bloody urine, passed with pain and difficulty;
and the wound commonly terminates in a fistula, which
remains during life.
When the wound is inflicted anteriorly, the urine is
apt to be extravasated into the cavity of the abdomen;
but when it is given from behind, or from the side, the
urine will either pass out at the opening, or will spread
through the contiguous cellular substance. In the first
case, the danger will be very great; but in the latter, if
the patient survives the hemorrhagy, he may escape with
the inconvenience of a fistulous opening, through which
the urine will be discharged. All that we can attempt is
to prevent the urine from lodging; and if the wound ac-
quires callous edges, to remove these by the knife or cau-
stic, so as to give them some chance of at last uniting.
§ 10. Of Wounds of the Bladder.
WOUNDS of the bladder are in general readily enough
distinguished by the urine coming away by the wound,
and by that which passes through the urethra being tinged
with blood.
Injuries of the upper part of the bladder prove more
3 F hazardous


[410] 
hazardous than those of the part covered by the perito-
næum: in the first case, the urine is chiefly extravasated
into the belly, by which the most dangerous symptoms are
commonly produced; and in the last, it is evacuated by
the wound.
When the under part of the bladder is wounded, mild
dressings should be applied; and we must obviate inflam-
mation by bleeding, laxatives, and a low diet, and parti-
cularly by warm bathing and fomentations. If the up-
per part is injured, the edges of the wound might be con-
nected by the glover's stitch, as advised in wounds of the
intestines; but some have proposed to connect the open-
ing in the bladder to the external wound; this however
would be apt, for obvious reasons, to do more harm than
good, except when the anterior part of the bladder was
wounded. In every case I would prefer the first method.
§ 11. Of Wounds of the Uterus, and its appendages.
It is obvious, that in judging whether a wound has pe-
netrated the uterus, our opinion must be in some measure
influenced by the particular state of that organ at the time,
as the extent of it depends entirely on the circumstance of
its being impregnated or not; and if impregnated, on the pe-
riod of the pregnancy. In the case of unimpregnation a
wound of that part will not be attended by any peculiar
symptoms; but during pregnancy, it will either produce
abortion, or the quantity of blood discharged externally,
or into the abdomen, will be considerable.
Where symptoms of abortion come on, nothing should
be done to remove them; but where they do not take
place, and there is reason to suppose the patient may suffer
from the hemorrhagy, the delivery should, if possible, be
effected in the natural way; if this cannot be done, the
wound should be enlarged and the child taken out through
it. 

[411] 
it. In other circumstances these wounds require no pecu-
liarity of treatment.
Wounds of the larger blood-vessels of the abdomen and
pelvis always prove very soon fatal, because they lie out of
the reach of chirurgical assistance; and wounds of the
larger nerves of these parts are followed by a palsy, for
which we know no remedy.
SECT. XIII.
Of Poisoned Wounds.
THE stings of wasps, bees, and other infects, of this
climate, although sometimes productive of a good deal of
pain, seldom induce any other bad consequence. The ap-
plication of vinegar or spirit of wine immediately after the
injury, often prevent the inflammation which would
otherwise follow; but when this actually comes on, cold
water seems the best remedy. For the sting of a scorpion,
as well as of the wasp and other infects in warm cli-
mates, the same remedies have succeeded.
The bite of a viper always merits great attention; for
although it does not appear that the poison is in general
thrown out unless the animal is much irritated, yet as this
cannot be certainly determined immediately, we should
constantly proceed upon the supposition of the wound
being poisoned.
This poison generally operates on the system in the
course of twelve or fourteen hours. The patient at first
complains of a violent burning pain in the injured part;
this soon begins to swell; inflammation succeeds, and is
often extended over the whole body: The patient be-
comes languid and faint, and the pulse low and feeble;
he complains of giddiness, nausea and vomiting; and of a
fixed 

[412] 
fixed pain in the region of the heart: The whole surface
of the body becomes yellow; and this as well as the yel-
lowness of the urine which occurs, is evidently the conse-
quence of the diffusion of bile; cold sweats, and convulsive
twitches come on; and if relief is not obtained, death is
speedily the consequence.
In order to prevent these symptoms, the only certain me-
thod is, either to cut out the injured part immediately, or
to destroy it with the actual or potential cautery: And
this may probably be done with good effect while no
bad symptom has come on; but the sooner it is put in
practice, the greater chance will there be of its proving
effectual. Suction, either by the mouth, or by instruments,
should never be trusted to.
After the operation, a plentiful suppuration should be
excited, either by stimulating ointments, or by emollient
poultices, according to the state of the wound, with re-
spect to inflammation.
When the poison has entered the system, the rubbing
the body all over with warm olive oil, and giving about
an ounce of it every hour, has been said to obviate its bad
effects in many instances. But the efficacy of this remedy
is rendered very doubtful by late observations; and it
would seem that the supporting a plentiful perspiration is
more to be depended on. For this purpose, eau de luce
has been particularly recommended; but it is probable,
that the common form of volatile alkali would be equally
useful. Theriaca, and many other remedies, have been
highly extolled, but none of these appear to merit confi-
dence.
With respect to the bites of mad animals, when their
effects are extended to the system, so as to produce hydro-
phobia, we cannot depend on any remedy with which we
are at present acquainted for their removal. As a preven-
tative of these, the most probable means is to remove the
Injured part by cutting it out, or destroying it, by means of
the 

[413] 
the actual or potential cautery, and exciting a plentiful 
supuration afterwards. As the effects of the bite are sel-
dom communicated to the system for several weeks, and
sometimes not for six months, this treatment would pro-
bably succeed, if employed at any period before these
come on. The sore should afterwards be kept running,
for a considerable length of time.
Sea-bathing and frictions, with mercurial ointment, to-
gether with its application to the sore, have been much
depended on by some as preventatives. When the hy-
drophobia actually makes its appearance, it will almost al-
ways be fatal; the treatment proper to be then directed,
belongs to the province of medicine.
When wounds are poisoned by the matter of diseases,
as sometimes happens to surgeons in dressing cancerous and
venereal ulcers, the most effectual remedy is, to cut out or
destroy the part. This must also be the best practice when
sores are infected with vegetable poisons. With respect
to metallic poisons, they seem only hurtful by irritating or
corroding the edges of sores; and require no peculiarity
of treatment.
SECT. XIV.
Of Gun-shot Wounds.
As gun-shot wounds exhibit the same appearances, ex-
cept that they are usually in more violent degree, and re-
quire the same general treatment with contused wounds
from other causes,* it is not necessary here to enter very
particularly into the consideration of them.
Our first object in these cases should be to prevent in-
flammation; for from the supervention of this, gangrene, or
extensive
* See Section on Contused Wounds. 

[414] 
extensive suppurations, which are the consequences most
to be dreaded, almost always originate. Hence, above all
other remedies, blood-letting should be freely employed.
The very beneficial effects of bleeding in general, but
more particularly of the abstraction of blood from the in-
jured parts themselves,* in wounds of this kind is very
clearly evidenced by this fact, that some of the most re-
markable cures have occurred among those patients who,
after an engagement, are left some time upon the field; by
which means they always loose a great quantity of blood.
With respect to the extraction of extraneous sub-
stances, which is next to be attended to, the same general
directions are to be observed as in the case of punctured
wounds.
When a ball cannot readily be extracted by the wound,
or by a counter opening, it should be suffered to remain,
unless it is lodged within a bone, when it should always be
removed, if this can be done without danger to the pa-
tient; because in such a situation it is productive generally
of great inflammation, swelling, and pain, of all the conti-
guous parts. In taking out balls, or other substances, we
should be very cautious in the introduction of forceps
and other instruments. Where they can be seen, forceps
may be used; but unless this be the case, it will be gene-
rally better to effect their removal by making a counter
opening, so as to admit of their being laid hold of by the
fingers.
When the wound is of little extent, instead of this
practice, whether the ball is lodged or no, if it can be done
safely, it will be better to lay the wound entirely open; by
this the ball is more easily extracted, and the cure will be
expedited. The dressings should be some emollient oint- 
ment spread on lint, and over this a poultice of bread and
milk. To these applications the lead ointments may some-
times
* See Section on Contused Wounds.

[415] 
times be substituted with advantage. An opiate should then
be given, and the patient laid to rest in an easy relaxed
posture.
The general treatment afterwards coincides very exact-
ly with that formerly recommended in wounds attended
with contusion: Suppuration should be promoted, and
the matter which forms, discharged by a proper position
of the patient, and by opening every collection which ap-
pears; while at the same time the patient's strength is
kept up by tonics and a nutritious diet.
When a long continued and excessive discharge affords
room for supposing that some extraneous body, or pieces
of bone may still remain in the fore, a careful examination
should be made, and they should be removed. When
none of these can be discovered, as some substance, such
as cloth, may still be there, though it cannot be felt, if a
seton can be used, it should be immediately introduced; and
often after a considerable length of time, the drawing of
the cord has brought out such substances, and a cure in
consequence has been soon effected.
Opium is particularly serviceable to abate pain and ir-
ritation in every stage of these complaints, and should be
given liberally.
Hemorrhagies are sometimes apt to take place upon
the separation of the sloughs which are produced in gun-
shot wounds; and as they are often preceded by heat and
throbbing pain in the parts, they may frequently be pre-
vented by copious bleeding, particularly from the contigu-
ous parts by leeches; but when the bleeding actually comes
on, if the vessels are of any considerable size, they must be
tied in the usual way. When there is any danger of con-
siderable hemorrhagy in these cases, the patient should al-
ways be provided with a tourniquet, that he may restrain
the discharge until assistance can be procured.
Scarification of gun-shot wounds, and even dilatation of
2 them 

[416] 
them, except in the circumstances and manner we have al-
ready directed, does not appear to be at all necessary or
useful.*
When from the situation or direction of the wound a
seton cannot be used in the manner directed in punctured
wounds, which should undoubtedly be done in sinuous ul-
cers
* The following facts respecting gun-shot wounds are inserted in
the Medical Journal for 1790. They are communicated by a Dr.
Jackson, and tend to shew, that the practice of indiscriminately dila-
ting gun-shot wounds in the first instance so generally recommended
hitherto, except where it is absolutely necessary for the removal of
pieces of bone, or extraneous substances, instead of expediting their
cure, often tends to retard it by the additional pain and inflammation
it generally excites.
In 1779, a number of militia-men were wounded in Georgia,
where they could receive no surgical assistance. Their wounds were
merely bound up with rags; and they appeared to heal much more
readily than those in similar circumstances that were treated by sur-
geons in the usual mode. After another engagement, a part of the
wounded were conveyed to hospitals; some remained in the woods
without any medical aid. The latter, the circumstances of the
wounds being alike, healed with nearly twice the rapidity with which
the others did. In 1781, after the battle of the Cowpens, in South
Carolina, those who received surgical assistance, neither got well so
soon, nor with so little trouble as those who cured themselves. The
whole were lodged in country huts.
Dr. Jackson further tells us, that in the warm climates of South
Carolina and Georgia, he always found warm poultices and fomen-
tations injurious; and that he derived much benefit from the appli-
cation of laudanum and spirituous liquors, and more particularly
From pouring cold water on the wounded limbs.
From the Doctor's observation it would also seem to appear, that
rest, in flesh wounds, is not only unnecessary, but often injurious.
After the battle of Guilford, North-Carolina, all the wounded who
could be carried off, were either conveyed in litters, in waggons, or
on horseback: while they were in motion the progress to healing was
rapid; when they halted for a few days, this was retarded; and
when they stopped altogether, it was in some degree retrograde.
The latter circumstance was probably owing to the more free access
to spirituous liquors, which was then obtained. 

[417] 
cers from this cause, compression should be employed as 
in other similar cases.
With respect to the treatment of gangrene from gun-
shot wounds, and to the propriety of amputation in them
from that and other causes, we must refer to the section
on mortification, and chapter on amputation.
CHAP. XL.
Of Burns.
BURNS vary in appearance, according to their degree
of violence, and to the manner in which they are
produced. Those which do not destroy the cuticle, and
which merely irritate the skin, operate like cantharides, by
exciting an increased action in the exhaling vessels of the
part, by which vesications are formed, in extent and num-
ber proportioned to the violence of the cause: but when
the skin or subjacent parts are destroyed, no vesicles are
produced; a black gangrenous slough is first observed,
and when this separates, an ulcer is left of a depth pro-
portioned to the extent of the burnt part.
The pain in burns is generally considerable; but it is in
common greater where the skin has been merely irritated,
than when it has been entirely destroyed. The irrita-
tion and pain are indeed in some cases of extensive burns,
so violent as to induce a very high inflammation and fever;
and such a degree of torpor sometimes comes on, that it at
3G last 

[418] 
last ends in death. This fatal termination is, in some in-
stances, induced by an extensive mortification taking place
soon after the accident.
In the treatment of burns, our first object is to procure
ease as speedily as possible. Where the skin is not de-
stroyed this can be accomplished by immersing the part
in cold water, or suddenly plunging it into boiling water,
or any other fluid, nearly of the same heat. Emollients
sometimes procure immediate relief; but in general,
astringents are more beneficial, such as brandy or other
ardent spirits. In these the parts may be immersed; or
when this cannot be done, they may be covered with li-
nen soaked in them. These applications give a momentary,
increase of pain at first; but this is soon succeeded by a very
agreeable soothing sensation. Strong lead water, a strong
solution of alum, or common ink, are also very effectual
remedies. None of these applications seem chiefly useful
by preventing vesications, which they do when early em-
ployed, because they are more effectual in abating pain
after these are formed. Whatever is made use of should
be continued until the pain goes off.
Together with the external applications, opium should
be liberally taken internally, according to the degree of
pain and irritation. Besides removing these, it seems to
be the best remedy for that drowsiness which often oc-
curs.
I am of opinion, that the vesications which occur in
burns, should not be opened until the pain has gone off;
because the admission of air always gives an increase of this;
but as soon as the irritation induced has subsided, they may
be opened with advantage; as the lodgment of the serum
upon the skin may probably render it tender, and perhaps
even produce ulcerations. In order to prevent any bad ef-
fects from the admission of air, small punctures should be
made in preserence to incisions. A liniment of wax, oil,
and 

[419] 
and saccharum saturni is the easiest application after 
the discharge of the serum.
When the inflammatory symptoms run high, bleeding,
laxatives, and other remedies suited to inflammation in
general become necessary; and the ulcerations which
succeed must be treated in the usual way. See Chapter
on Ulcers.
When burns occasion a loss of substance, it will perhaps
be better to expose them to the air for a day or two, as
the slightest covering produces pain, and to apply either a
liniment composed of equal parts of lime water and lin-
seed oil, Goulard's cerate, the unguentum nutritum, or
weak lead water. The first is generally to be preferred.
As soon as the pain and irritation have thus been remov-
ed, the sore is to be dressed as in other cases.
In burns from the explosion of gun-powder, some of
the grains of the powder are apt to be forced into the skin.
If these are not removed they will increase the irritation,
and perhaps produce permanent marks. They may most
readily be removed by a needle or some other small in-
strument; if these do not take them all away, an emollient
poultice will complete their removal; this indeed is the
best application in injuries of this kind, for a few days, not
only for this purpose, but to prevent subsequent inflam-
mation. There are some parts, such as the fingers,
toes, nostrils, and palpebræ, which will be apt to
adhere together when burnt, if attention is not given to
prevent it. This will be effectually done by the interpo-
sition of some parts of the dressings.
Ulcers from burns are very apt to become fungous:
when this is observed, the fungus is to be removed by
leaving off the use of emollients, and employing gentle
astringents, and compression; and if these do not succeed,
by the use of caustics.
CHAP.

[420]
CHAP. XLI.
Of Tumors.
SECT. I.
Of Tumors in general.
EVERY preternatural enlargement, in whatever part.
of the body it is seated, may be termed a tumor.
Tumors may with great propriety be divided into those
which from the beginning are attended with inflammation,
and those which are not evidently accompanied by this
affection: the first may be termed acute or inflammatory,
and the last chronic or indolent. Phlegmon and angina are
instances of the former; aneurism and polypus of the latter.
Such of these as have not been already treated of, or will
not be with more propriety considered in some other chap-
ter, we shall now proceed to speak of.
SECT. II.
Of Acute or Inflammatory Tumors.
As we have already treated of inflammation in general,
we hall in this place merely take notice of those circum-
tances which, from the peculiar situation of the tumors, we
are 
 

[421] 
are about to pay attention to, or some other cause, require
some peculiarity of treatment.
§ 1. Of Erysipelas.
Erysipelas is a variety of external inflammation distin-
guished from phlegmon, (See chap. i. sect. I.) by the co-
lour of the inflamed part not being of so bright a red,
but having a more dark copper-like appearance; and by the
swelling being not very evident in any particular place, but
rather diffused, and ending as it were imperceptibly, upon
the surrounding parts,
Erysipelas seldom penetrates deeper than the skin; and
any effusion with which it is attended, is commonly thin
and acrid, and not often convertible into pus. As the ulce-
rations which this effusion sometimes produces are always
difficult to heal, it should be our first object to prevent it
from taking place. The supposed risk attending this prac-
tice, and of attempting the discussion of erysipelatous affec-
tions, appears from experience to be totally founded in
prejudice.
The most common applications in the first stage of erysi-
pelas, and perhaps the best, are fine flour, starch, and hair-
powder. These commonly give considerable relief; but
I believe they effect this rather by soothing that uneasy sen-
sation which usually accompanies erysipelas, and lessening
the increased action of the vessels which occasions the effu-
sion, than by absorbing the matter when poured out. Unc-
tuous and moist applications of every kind are generally
supposed to be injurious; nevertheless, in some cases which
were not benefited by the remedies abovementioned, I
have experienced immediate relief from exposure of the
part affected to the air, and wetting it now and then with
a weak solution of saccharum saturni, without any subse-
quent disadvantage being occasioned by the practice.
Experience 

[422] 
Experience also establishes the utility of bleeding accord-
ing to the circumstances of the case. Topical blood-let-
ting, however, being apt to be productive of troublesome
sores, must not be used. Gentle laxatives, and mild sudo-
rifics, should also be employed, and a cooling regimen ob-
served.
By these means, most erysipelatous affections may be dis-
cussed; when however, they terminate in effusion to
any considerable degree, an opening should be made in
the most depending part of the collection, and some of
the saturnine ointments used as a dressing to the sore.
§ 2. Of inflammation of the Ear.
INFLAMMATION seated in the membrane of the meatus
auditorius, is commonly very painful, from the part affected
not readily yielding to the increased quantity of fluid pro-
pelled into it.
The treatment must be determined by the stage of the
complaint. If the inflammation has continued so long
as to give reason for supposing it will terminate in
suppuration, the ear should be frequently bathed with
warm emollient steams, and warm poultices should be
applied over it. But in the beginning of the affection, we
should generally try to prevent suppuration; because the
discharge of matter which ensues will be apt to continue
a considerable time, and perhaps terminate in deafness.
Resolution will be most effectually promoted by the appli-
cation of a blister behind the ear; and by dropping a
little laudanum, or spirit of lavender, mixed with oil,
into the passage, we may generally abate the pain and
irritation, and consequently promote the resolution very
much.
We will often be unable to prevent the formation of
matter; and when this has taken place, we should endea-
vour 

[423] 
vour to assist its evacuation by bathing the ear in warm
water, or by injecting warm water into it. These will
often stop the discharge; but when they do not, lime wa-
ter, or a weak solution of sacch. saturni, may be employed,
and will seldom fail, if the soft parts alone are affected.
When the bones are diseased, which will be known by the
fœtor, and black or brown colour of the discharge, all
that should be done, is to keep the passage clear by injections.
§ 3. Of Angina.
In inflammatory angina or quinsy, besides the general
remedies of bleeding, purgatives, &c. topical bleeding is
found to be more particularly beneficial. In pl. viii. fig. 1.
an instrument is delineated for scarifying the throat; and
when this is timely and freely employed, it will commonly
prevent suppuration very effectually: Should this occur,
however, the same instrument will be proper to discharge
the matter collected. To promote the formation of pus,
nothing is more beneficial than inspiring the steams of
warm milk, or any other emollient decoction, by means
of the machine represented in pl. viii. fig. 3.
§ 4. Of Inflammation of the Liver.
When notwithstanding the employment of the reme-
dies of internal inflammation in general, and of mercury,
which has been found so particularly beneficial in hepatitis,
the disease terminates in suppuration, the aid of surgery of-
ten becomes necessary.
When the abscess is seated on the convex part of the li-
ver, and is of considerable size, it will readily be disco-
vered by the touch. But when this is not the case, a
continuance of the pain in the right shoulder and neck,
an appearance of swelling in the region of the liver; an
3 œdematous

[424] 
œdematous affection of the integuments in this part; but
particularly the occurrence of frequent shivering fits,
will pretty certainly denote that suppuration has taken
place.
Abscesses of the liver have been known to burst through
the diaphragm, so as to be emptied into the thorax: in
some few cases, the matter has been carried into the duo-
denum, by the ductus communis, choledochus; and
fometimes by the great arch of the colon adhering to the
liver, a communication has been formed between them,
by which the pus has been evacuated; but for the most
part, when it is not discharged by an external open-
ing, it bursts into the cavity of the abdomen. In or-
der to prevent such a fatal termination, as soon as we
have reason to suppose that matter is collected, even if
it should not probably have yet been converted into pus,
an incision should be made with a scalpel through the
teguments, in the most depending part of the tumor, and
on reaching the abscess, it may either be opened with the
scalpel or with a lancet; but a trocar would perhaps be
presferable to either, as by means of that we have it in
our power to evacuate the matter gradually, which is a
point of consequence in all large collections. With a
view to prevent this opening from closing before the cyst
collapses sufficiently to hinder a farther collection of
matter, it should be afterwards somewhat enlarged. A
pledgit of lint, dipped in oil, or spread with some emolli-
ent ointment, should then be insinuated between the edges
of the wound, so as to prevent them from uniting until
the ulcer heals from the bottom; a process which will be
much hastened by the use of compression, applied by
means of a roller carried round the body.
Ulcers in the liver heal sooner, and with less trouble
than in any other part of the body. But when they do
not readily fill up, which will very seldom be the case,
it 

[425] 
it will be proper to introduce a canula, in order to pre-
serve a free discharge of the matter which forms.
A free use of bark, and a nutritious regimen will always
be very necessary and useful in the suppuratory stage of
this disease.
Practitioners are generally of opinion, that unless the
collection of matter takes place in the convex part of the
liver, no attempt to discharge it by an external opening
can with propriety be made; but wherever it is situated
a vent should certainly be procured for the matter; for if
it is not evacuated externally, it will most probably be
emptied into the abdomen, and inevitably occasion death.
When the matter is poured into the abdomen or chest,
the only chance of saving the patient will be by drawing it
off by the operation of the paracentesis, as soon as possible.
§ 5. Of Inflammation and Abscesses in the Breasts of 
Women.
Inflammation in the breast may be produced by any
cause which occasions it in other parts of the body; but
it is more particularly apt to be occasioned in nurses by
an obstucted flow of milk from a sudden orimprudent
exposure to cold. The breast becomes stiff, swelled and
painful; the milk runs off in small quantities; and the pa-
tient is seized with restlessness and fever.
This complaint, in my opinion, should always be treated
in the manner advised for inflammation in general. In
order to effect the resolution of the tumor, the patient
should be bled according to her strength; have purgatives
given; and be kept upon a low cooling diet: And as the
pain is usually very considerable, opium should be given
freely to alleviate it. In order to remove the tension, the
breast should be gently rubbed with althæa ointment or
oil; but the applications most to be consided in are those
3H of

[426] 
of a cooling astringent nature, such as a solution of sal
ammoniac in vinegar and water, spiritus mindereri, and
the saturnine preparations. Cloths dipped in these should
be constantly applied; by which, and the other remedies
advised above, almost every case of this kind may be re-
moved.
But instead of this method of treatment, when the in-
flammation has been of long continuance, and the pain and
tension accompanying it are very considerable, it will be
better to endeavour to bring the tumor to suppuration, by
warm poultices and fomentations; and when matter ap-
pears to be formed, to discharge it by an opening in the
most depending part of the collection; at least an open-
ing should be made whenever the matter appears to be
pointing at an improper part.
As I have always found drawing off the milk to give
relief, I constantly advise it to be done; and when the
child cannot lay hold of the nipple, nipple glasses must
be employed.
§ 6. Of the Inflammation of the Testes.
INFLAMMATION of the testes may be induced by cold,
external violence, or by any other cause of inflammation in
general: but it is most frequently occasioned by violent go-
norrhœa. In this case it appears to be produced by an exten-
sion of the inflammation from the urethra along the vasa
deferentia; and is commonly the consequence of a stoppage
of the running from the use of irritating injections, or other
causes. This circumstance is very generally attended by
an increase of inflammation; to abate which nothing is
more effectual than a return of the discharge. This is
the most probable manner of accounting for the relief
which a return of the running, in such instances, gives to
the testes.
This 

[427] 
This disease rarely terminates in suppuration. The
most effectual remedy for its removal is blood-letting;
and particularly by means of leeches applied to the part
affected. The swelling should afterwards be kept con-
stantly wet with a solution of saccharum saturni; the scro-
tum and testes should be suspended; the bowels should
be kept moderately open; a low diet should be ordered;
and the patient should be confined to a horizontal pos-
ture. If the case is venereal, it will be absolutely neces-
sary to employ mercury; and when the disease is the
consequence of a sudden stoppage of the discharge, we
should endeavour to produce a return of this by bathing
the penis in warm water; by injecting warm oil into the
urethra; or by the use of bougies.
If the swelling should suppurate, which will very
rarely happen, an opening should be made in the most
depending part of the collection, and the sore afterwards
dressed in the manner advised in other cases of abscess.
§ 7. Of Venereal Buboes.
Swellings in the lymphatic glands from the absorp-
tion of the venereal virus, are termed Venereal Buboes.
They may appear in any gland seated between a venereal
sore and the heart; but they are most frequent in the
groin, in consequence of chancres on the penis. In some
instances they occur from the matter of a gonorrhœa;
and in some others they arise without any previous ulce-
ration or discharge from the penis, the matter appearing
to be absorbed without any erosion of the skin.
As it is now very well known, that the quantity of ve-
nereal matter is increased by buboes being brought to
suppuration, and that the sores produced by them are
often very difficult to heal; few doubt of the propriety
of endeavouring to remove them by resolution. 
In

[428]
In order to effect this, the patient should be put upon
an antiphlogistic regimen; his bowels should be kept
open by purgatives; leeches should be applied to the
gland; and it should be kept constantly wet with a strong
solution of saccharum saturni. And along with these
mercury should be employed in as large quantities as may
appear necessary; and it will be most beneficial if made
to pass through the diseased gland, by rubbing the mer-
curial ointment into some part where it may be absorbed
by the lymphatics that go to the part affected; thus in
inguinal buboes, it should be applied on the leg or thigh.
By these remedies, buboes, if taken in time, may
generally be discussed; but when this cannot be done,
either from the disease having subsisted too long, or from
a complication with scrophula, scurvy, erysipelas, or
phlegmon, the use of the mercury should be intermitted
for some time, until by a change of diet and other circum-
stances, we may give a chance of making a second trial of
it more successful.
When a bubo seems proceeding to suppuration, this
should be promoted by the use of fomentations and poul-
tices as in other cases; and as soon as matter is formed it
should be discharged. There have been various methods
of effecting this. Some advise a small puncture with a
lancet; others an incision, the whole length of the swelling:
some again, recommend it to be accomplished by the applica-
tion of a caustic; while others are advocates for leaving the
bubo to form an opening of itself. Either of these me-
thods may succeed in simple venereal buboes, provided a
sufficient quantity of mercury is given; and each of them
may occasionally be followed by sores difficult to heal.
The local treatment her should be nearly similar to
that advised in collections of matter in other parts. In
general, an opening should be made merely sufficient for
giving vent to the matter. In very large buboes indeed,
the 

[429] 
the teguments are often rendered so lax, and their texture
is so much destroyed, that it will be advise able to remove
part of them by caustic; but in common it will be sufficient
to make an opening from the middle of the tumor, where
it usually points, to the most depending part. In small
buboes a mere puncture will often answer the purpose; or
they may even be allowed to burst; but this should never be
depended on in large collections. When the integuments
remain unusually firm, I have sometimes succeeded by the in-
troduction of a small cord. And lastly, from having observed
buboes which discharged the matter contained in them by a
number of small openings to heal very readily in general, I 
have in several instances imitated the process by making se-
veral small punctures with a lancet, and with very good ef-
fects. I attribute the suceess in such instances to the exclu-
sion of the external air, which must be the consequence of
this method.
The patient should continue the use of mercury constanly,
for if he intermits it, the sore will not heal so rea-
dily. The ulcer, however, often proves tedious, even where
we are convinced that a sufficient quantity of mercury has
been given to eradicate the syphilitic virus. The edges be-
come hard and thin; the matter discharged, thin, acrid, and
fœtid; and the sore gradually becomes more extensive; or
if it heals in some parts it breaks out in others, giving a
honey-comb appearance to all the under part of the ab-
domen, and upper parts of the thigh. The patient suffers
a great deal of pain; becomes hectical; loses his rest and
appetite; and becomes very much emaciated.
In such cases, we must first be certain that the patient
has taken a sufficiency of mercury, and that no sinuses are
left in which matter can be lodged. In these instances, I have
known cicuta very beneficial: I have seen ulcers healed
by mixing the juice of the fresh herb with a common poul-
tice, which had resisted all the common applications; when
given 

[430] 
given internally, the fresh juice has been more effectual
than any other form of it. The belladonna and hyoscya-
mus, have never appeared to me to produce any material
advantage. And neither sarsaparilla nor guaiacum have
been useful; but mezereon has alone evidently cured some
patients in whom all the usual remedies had failed. A
drachm and an half may be boiled with ʒij of liquorice-
root, in three pints of water to a quarts and that quantity
of the decoction drank daily.
But the most effectual course that I have tried is, the ap-
plication of caustic all round the edges and hardened 
parts of the sore, at the same time that opium in consider-
able quantity is given internally. On those days in which
the caustic is not applied, red precipitate should be used to
the sores, either sprinkled over them, or applied in an oint-
ment. The first few applications of these commonly give
pain, but this soon subsides, and the discharge seldom fails
to alter from a thin sharp sanies to a thick well digested
pus.
Opium alone has been lately given in very large quan-
tities for the cure of the venereal disease;—to the extent of
half a drachm or more three times a day. I have seen no
proof of its curing any venereal affection; but I have seen
several instances of such sores as we have above described,
completely cured by the use of it. It does not however
appear that it is more effectual when given in very large
quantities, than when so much only is exhibited as is neces-
sary to alleviate or remove the pain. Its utility seems to me 
to depend entirely on its narcotic or anodyne powers; by
these it removes that state of irritability with which these
sores are affected, and thus destroys the disposition of the
vessels to form that kind of matter, which by its acrimony
seems to perpetuate itself; and this being done, and other 
circumstances being favourable, nature alone will seldom 
fail in accomplishing a cure.
This 

[431] 
§ 8. Of Lumbar Abscesses.
EVERY collection of matter seated on the loins may
be termed a Lumbar Abscess: but at present we mean to
confine our observations to that variety of the disease
which originates about the superior part of the os sacrum,
and in which the matter is contained in a cyst lodged
on the anterior surface of the internal iliac and psoas
muscles.
These abscesses are always preceded by tension over the
loins, and a pain, which often shoots up along the course
of the spine, and down towards the thighs, and frequently
by some difficulty of standing erect. In some cases these
symptoms are suspected to be nephritic; but for the
most part they give an appearance of lumbago. When
suppuration takes place, shivering sits are apt to occur;
but the pain which was at first acute, becoming dull and
less perceptible, the patient is made to believe that he is
getting better, until the matter, after falling gradually
down behind the peritonæum, is observed to point exter-
nally, either at or near the anus, or on the upper and
fore part of the thigh, where the large blood-vessels pass
out beneath poupart's ligament from the abdomen. In
the latter case, which most frequently occurs, the
matter being beneath the tendinous fascia of the thigh,
instead of pointing at any particular part, falls gadually
lower, until,in some cases, it reaches almost to the knee.
The tumor is seldom attended with more pain than
might be expected to occur from the distension of the
fascia and contiguous parts by the matter beneath; there
is no discolouration of the skin, which often retains its na-
tural appearance to the last; and a fluctuation of a fluid is
evidently discovered through the whole extent of the tumor,
particularly when the patient is erect; for in this posture,
the

[432] 
the swelling is always more tense than when the patient
is lying horizontally, because a considerable part of the
matter then runs along the sac towards its origin in the
loins.
When the matter passes down towards the anus, this
complaint may be mistaken for a common phlegmon; and
no inconvenience will arise from treating it as such. But
when it falls down beneath poupart's ligament, its ap-
pearances are so similar to those of a crural hernia, that
the one has often been unfortunately mistaken for the
other. This however, can only have arisen from a want
of proper attention to the characteristic symptoms of each.
Besides the other distinguishing marks, whenever the
lumbar abscess extends low down, in an erect posture
the part of the cyst at the top of the thigh exhibits no
appearance of swelling. And should the diseases be
combined, which must very rarely be the case, as the
matter of the abscess and the protruded abdominal viscus
or viscera will be contained in separate sacs, the compli-
cation will be easily detected.
This disease seems, in general, to be induced by a bruise,
twist, or some other injury to the small of the back; in such
cases, whenever the pain produced is considerable, blood-
letting should be immediately advised, and every part of the
antiphlogistic regimen observed. Cupping, with deep sca-
rifications, seems to be the most effectual remedy, and I have
no doubt, would often prevent the formation of this dis-
agreeable complaint, if early employed to a proper extent:
It almost always gives relief to the pain, however violent
it may be. Blisters, opiates, and gentle purgatives, should
also be occasionally made use of.
In some instances these remedies will fail; and in others
we are not called in until suppuration has taken place.
When this is the case, I have no doubt of the propriety of
discharging the matter collected by an opening with a tro-
2 car

[433] 
car, when the case is well ascertained, and by cautious 
disfection when there is any doubt of its nature. A canula
may afterwards be introduced to give a more free exit
to the matter; and if the discharge does not diminish consi-
derably in the course of two or three weeks, lime-water or
some other moderate astringent may be injected, to put a
stop to it. But if this should never happen, it will be bet-
ter for the patient to submit to the inconveniency than to
risk the discharge of the matter into the abdomen, or the
corrosion of the bones adjacent, by suffering the abscess to
remain unopened.
§ 9. Of the Paronychia or Whitlow.
The paronychia is a painful inflammatory swelling, oc-
cupying the extremities of the fingers under the nails.
All the varieties of this complaint distinguished by dif-
ferent writers, may be comprehended under the three fol-
lowing, and even these differ only in point of depth of situ-
ation.
In the first, the patient complains of an uneasy burning
sensation for several days over the end of the finger; the
part becomes tender and painful to the touch; a slight
degree of swelling takes place, but with little or no disco-
louration; and if the inflammation is not removed by re-
solution, an effusion is at last produced between the skin
and the parts beneath this, if discharged, appears to
confist in a thin, clear, and acrid ferum; and its removal
generally gives immediate relief.
In the second species, the same symptoms occur in a more
violent degree; the pain is more fevere, and is attended
by uneasiness over the whole hand. The effusion is not
so perceptible, and is found to lie beneath the muscles, or
between these and the periosteum of the finger.
3I And 

[434] 
And in the third variety, the pain in the end of the finger
is still greater; and the whole extremity becomes stiff, swel-
led, and painful: The lymphatics leading from the finger,
and even the glands in the arm-pit, become swelled and
inflamed; and an incision being made, discovers the effu-
sion to be seated between the periosteum and bone, the
whole phalanx being in general carious.
These swellings are often the effects of external violence,
and particularly of punctures, and contusions; but they
happen more frequently from some cause with which we
are unacquainted.
I always treat paronychia upon the same plan that I
employ in the removal of other inflammations. In the early
stage of it, I endeavour to discuss the swelling: First, By
the application of leeches to the pained part of the finger,
and by general blood-letting in the more extensive species
of the complaint. The leeches often remove the most vio-
lent pain almost immediately. After these have been used,
immersion of the pained parts in strong brandy, or even in
spirit of wine, is one of the best remedies; and when the
wounds made by the leeches are somewhat healed, or
when these animals have not been applied, spirit of turpen-
tine, or strong vinegar, may be employed in the same man-
ner. Opiates should also be used in quantities propor-
tioned to the violence of the pain.
When an effusion has taken place, an opening should
be made to it; because there is no chance of converting it
into pus, and as long as it remains it gives the patient ex-
quisite pain, and because it is apt to injure the contiguous
parts. When the collection is superficial, it may be dis-
charged by a puncture with a lancet; but when it is deep-
seated, care must be taken to avoid injuring the tendons of
the finger by the incision which will then be necessary.
If the matter lies above the periosteum, the wound made
is to be treated as a fore from any other cause; but when
it 

[435]
it is found beneath the periosteum, as the bone is always
found to be more or less carious, I am clearly of opinion,
that the best practice is to remove the whole phalanx im-
mediately. This may be done with the greatest ease, and 
saves much time and trouble both to the patient and sur-
geon. The sore afterwards heals without difficulty; care
being taken that it fills up from the bottom; and little dis-
advantage is experienced from the loss of bone. The nail
which is commonly lost, is in general soon reproduced.
If the common method of treatment by poultices, fo-
mentations, &c. is pursued, and the bone is left to come
out of itself, when diseased, matter is apt to lodge beneath
the nail, troublesome fungous excrescences to arise, and
the process is usually painful and tedious. 
It does not appear, that more than the last phalanx of
the finger suffers in this complaint; but when from impro-
per management, the surrounding soft parts become in-
flamed, swelled, and ulcerated, it often is at last ne-
cessary to amputate the finger, in order to prevent the
disease from spreading to the hand.
§ 10. Of Chilblains.
These are painful inflammatory swellings, to which the
fingers, toes, heels, and other extreme parts of the body
are liable, on being much exposed to severe cold. The
swelling is generally of a deep purple, or somewhat of a
leaden colour; the pain is not constant, but acute and
shooting; and for the most part there is an intolerable de-
gree of itching all over the swelling. In some cases, the
skin cracks, and discharges a thin, somewhat fœtid matter.
And when the degree of cold has been very great, or it has
been very long applied, all the affected parts are very apt
to gangrene and slough off, leaving a very foul ill-condi-
tioned ulcer.
Delicate 

[436] 
Delicate children, and old people, are most subject to
chilblains; and it is observed that they are particularly
apt to be severe in scrophulous habits.
The best mode of preventing them, is to avoid exposure
to cold and moisture; and especially to snow, which seems
particularly injurious; and when a person has once been
affected, as they are very liable to return, he should be
careful to keep the injured parts warmly covered during
the winter. Cold bathing has also been useful.
Every precaution that can be taken will, however, not
always be successful in preventing this complaint. But it
may often be mitigated by bringing the affected, parts gra-
dually to their natural heat, instead of warming them very
quickly. The patient should be put into a cold room; and
the frost-bitten parts should be well rubbed with snow,
and afterwards immersed in very cold water; he should
keep at a distance from the fire for a considerable time,
and during this, the parts may be rubbed with salt, or
immersed in warm wine.
A person much benumbed with cold should not have
warm cordials given to him immediately. A glass of cold
wine may be at first allowed: Afterwards warm wine
may be given, either alone or mixed with some of the
warmer spices; or ardent spirits may be used.
These remedies are however only necessary in the more
severe affections of this kind. In common cases of chil-
blains, it will be sufficient to rub the parts with spirit of
turpentine, or camphorated spirit of wine; and to keep
rags moistened with these constantly applied to the parts.
When chilblains ulcerate or crack, poultices may be ap-
plied for a few days, to induce a proper suppuration; but
if they are continued for any length of time they render
the sores fungous and difficult to heal. The daily applica-
tion of caustic to the edges, and of precipitate ointment to
the rest of the sore, after the poultices are discontinued,
seems 

[437] 
seems the best method of treating them. The diachylon
simplex is also a good application.
§ 11. Of Sprains and Contusions.
CONTUSIONS of the softer parts of the body, and sprains
of the tendons and ligaments of joints, are usually produc-
tive of immediate painful inflammatory swellings, and
which, when in considerable degree, require a great deal
of care and attention.
The swelling is chiefly produced by the effusion of
blood or of serum, from the vessels ruptured by the inju-
ry. When the serum only is poured out, the skin retains
its natural colour for some time; but when blood is extra-
vasated, the skin is of a deep red, or of a leaden colour from
the first.
In the treatment of these affections, our views must be
first directed to prevent the swelling, and afterwards to
prevent or remove inflammation.
Swellings of this kind, when confined to the integuments
or muscles, are often removed in a little time by absorp-
tion; but those which affect the tendons, or ligaments, if
not properly attended to, are very apt to continue a great
while, and prove very troublesome: On this account they
should have a careful attention. Astringents are the best ap-
plications to prevent the swelling; such as lees of red wine,
ardents spirits, and vinegar, or even cold water if these
cannot immediately be had, either in its usual state, or ren-
dered colder by art. In one or other of these the part
should be immersed for about an hour.
These remedies fortunately happen to be equally adapt-
ed to the prevention of the effusion, and the inflammation
which is so apt to occur. But in considerable injuries of
this kind, after the use of them as above directed, it will be
proper further to endeavour to obviate the latter symptom
by the application of leeches, or if the muscular parts only
are

[438] 
are hurt, by cupping and scarification. Blood should thus
be repeatedly drawn as long as the inflammation continues.
This seems equally effectual, whether the parts affected be
deep-seated or near the surface.
If the fever induced is very considerable, it will also be
proper to use general bleeding; and for obviating the pain,
to exhibit opiates. Any other remedies of inflammation
in general which may seem indicated, should likewise be
employed.
After bleeding, the best application to the part for a few
days is a solution of saccharum saturni; and to remove the
thickening of the tendons which sometimes follows sprains,
pouring warm water upon the part for a quarter of an
hour at a time, three or four times a day, is frequently
very useful. Salt water, or the water of some of the mine-
ral springs, seem to be more beneficial than common water.
The rubbing the parts frequently with warm emollients
has also a good effect.
During the cure of a contusion or sprain, it is very ne-
cessary to keep the part in an easy relaxed posture.
When the swelling and pain is nearly removed, and the
parts remain weak and relaxed, pouring cold water from
some height, or dashing it upon them once or twice daily,
is the most beneficial remedy. A flannel roller applied mo-
derately and equally tight over the whole extremity, is also
very useful for preventing or removing the œdema which
is apt to follow in these cases, from the debility induced;
and likewise as a preventative of rheumatic pains, some-
times consequent to these affections.
SECT. 

[439] 
SECT. III.
Of Chronic or Indolent Tumors*.
§ 1. Of Encysted Tumors.
UNDER this term we usually comprehend all those
swellings that are contained in cysts of a preternatural for-
mation; and these as well as various tumors of the sar-
comatous kind, are in common language termed wens.
All the varieties of encysted tumors seem to be induced
either by an accumulation of serous matter, or of the fat,
which is deposited in the cellular membrane, from a de-
fective absorption, or too great a deposition of them, in a
particular part, which by some cause has had its com-
munication with the rest of the membrane destroyed.
When the contents are of the consistence of honey,
the tumor has been termed meliceris; when of a soft
cheesy consistence, or resembling dough, it is called an
atheroma; and steatoma, when it is formed of fat.
But there are various degrees of consistence in each of
them. Thus the steatoma is sometimes soft like butter,
and at other times as firm as suet; and the contents of
the atheroma and meliceris are sometimes equal in hard-
ness to new cheese, and at other times are not firmer than
the thinnest honey.
The matter forming steatomatous tumors we conclude
to be of an oily or fatty nature; and that their different
degrees of consistence will depend upon the remora of
their contents, and upon the quantity of the thinner
parts
* Although chronic tumors, as has already been mentioned, are
not primarily and necessarily attended by inflammation, yet it is 
to be observed, that any variety of them, by the distenion they 
give the skin, may eventually produce it. 
B.

[440] 
parts of them that have been absorbed. And we think
it probable, that the atheromatous and melicerous tumors
are originally formed by a deposition of serum, with
perhaps a considerable proportion of coagulable lymph;
and that their degrees of consistence will depend upon the
quantity of lymph contained in them, their duration, and
particularly upon their having been inflamed, and the de-
gree of the inflammation.
In general, an experienced practitioner will be able to
distinguish the nature of these tumours before they are open-
ed: thus the steatoma is usually of a firm consistence, loose,
and rolls under the skin more readily than the others; and
its surface is apt to be unequal: the atheroma is soft and
compressible, but no fluctuation is observed in it; and in
the meliceris, the fluctuation of a fluid is in general very
distinctly perceived. But, in some instances, from the cir-
cumstances mentioned in the last paragraph but one, it
must be evident, that we may be sometimes mistaken in
our judgment of the nature of these tumors; and their
combination will contribute likewise to deceive us. The
steatoma is very rarely joined with either of the others;
but the atheroma and meliceris are more frequently com-
bined. It is to be observed also, that the first species is
rarely found where fat is not usually deposited in a state
of health; thus I have never met with it on the head,
where the other species frequently occur. None of them
are often seated on the abdomen; probably owing to the
parietes of the abdomen being soft and yielding, and
consequently not so liable to ill effects from pressure, as 
the soft parts which lie contiguous to bone.
These tumors appear small at first, and increase in size
very slowly. They are of very different shapes and
sizes: On the head they are commonly round and
smooth, and seldom grow larger than an egg, probably
from the teguments not being so capable of much distensi-
3 on

[441]
on as in other parts, where they have arrived sometimes
to such an enormous size as to weigh forty pounds.
They are never painful at first; and the skin for a con-
siderable time retains its natural colour. But when they
become large, the veins of the skin, as well as those of the
sac, become large and varicose; and the prominent part
of the swelling acquires a clear shining red colour. Even
now the tumor is not painful, unless it be injured by ex-
ternal violence, which will very readily excite inflamma-
tion in the skin. It then becomes tender and painful, and
soon bursts, if not prevented by an artificial opening.
From the same cause which influences the size of these
affections, their progress seems rendered more or less ra-
pid: hence they sooner terminate on the head than in any
other situation.
The firmness with which they are attached to the conti-
guous parts seems to depend on the parts with which they
are covered, and their having been inflamed or not, and
the degree to which the inflammation, when they have been
seized with it, has extended. They are sometimes quite
loose and moveable, particularly while they continue
small; and at other times they are firmly fixed, and in some
instances from the beginning.
It was formerly the practice to attempt the discussion of
encysted tumors by the application of mercurial ointment,
mercurial and gum plasters, and a variety of other things;
but experience has now proved, that nothing but a chirur-
gical operation can be depended on for their removal.
The meliceris should be treated as a common abscess. If
small, its contents may be discharged by an incision with a
lancet, and then it may be dressed in the ordinary way until
it fills up or adheres from the bottom. But if it is large,
to prevent the admission of air which would be injurious,
a seton should be employed in the manner directed in the
3K section 

[442]
section on suppuration. This is the most effectual mode
of treatment I have ever seen employed.
When the contents of the tumor are too firm to be dis-
charged in this manner, it becomes necessary either to emp-
ty the cyst by an extensive incision, or to dissect it, with
its contents, entirely out. If the bag adheres very firmly
to the contiguous parts, it will be better to lay it entirely
open, and only take away those parts of it which are loose.
By this, we may effectually remove its contents; and the
cure may be afterwards accomplished with equal certainty,
by preserving the wound open until it heals from the bot-
tom, or by drawing the edges together, and trusting to
moderate pressure, and the common effects of inflamma-
tion for producing a re-union. It is usually thought ne-
cessary to remove the whole of the cyst; but experience
disproves this. When it is to be done, however, it will
contribute much to the facility of the operation, to make a
longitudinal incision through the tumor, and remove its
contents before we begin to diffect: it out. After its remo-
val the teguments should be laid together, and secured by
adhesive plasters or futures, and an equable compression
then made over them, in order to produce a cure by the
first intention.*
If any arteries of considerable size are cut in the opera-
tion, they should be immediately secured by means of the
tenaculum; and the ligatures should be left hanging out at
the wound. The trifling impediment that this will give
to the cure, will be much more than compensated by the
security from hemorrhagy, that is derived from the prac-
tice;
* Though many of the encysted tumors, which Mr Bell describes 
as successfully treated by a simple dilatation, or the use of the seton, 
may have been radically cured, yet instances enough occur of their 
filling again, where the whole or greater part of the sac has been left,
to put young surgeons on their guard in tumors of any considerable 
size, where the safest way is to remove the sac entirely.

[443]
tice; for should the bleeding be even very trifling, it might 
considerably retard the cure. The ligatures may gene-
rally be taken away readily and with safety at the second or
third dressing.
In common cases it is not necessary to remove any por-
tion of the skin, for although it may appear too extensive
at first, it usually contracts so much in a little time as mere-
ly to cover the parts beneath. But in large tumors, where
the skin is in very large quantity, or where it has become
excessively thin, or ulcerated, it will be proper to remove a
part of it. This will be best effected by two semilunar
incisions, including as much of the skin as ought to be ta-
ken away, and then diffecting it off with the cyst. The
subsequent treatment is to be the same as if no part of it
was removed. In such cases we are advised by some to
employ caustic for the removal of the skin; this should,
however, never be done except the patient will not admit
the use of the scalpel.
§ 2. Of Ganglions.
By the term ganglion, we mean an indolent, moveable
tumor, formed upon the tendons in different parts of the
body, but most frequently on the back part of the hand,
and joint of the wrist.
These swellings are distinguished from the encysted by
their elasticity. They seldom become large, or painful; and
for the most part the skin above them retains its natural
aspect. If laid open, they are found to contain a tough,
viscid, transparent fluid, resembling the white of an egg.
Ganglia may be generally removed, if early attended to,
either by moderate and frequent friction, or by compres
sing them by means of thin plates of lead, or any other
ductile metal. We should be careful not to use these
remedies

[444]
remedies in such a manner as to inflame the parts; as
troublesome sores may be the consequence.
If these means fail, and the tumors become trouble-
some by impeding the motion of the joint or in any other
way, but not otherwise, they may be removed, either by a
mere incision into them, or if they do not adhere firmly to
the tendons, by cutting them entirely out, in the manner ad-
vised in the case of encysted tumors. The sore thus pro-
duced is to be kept open until it heals from the bottom;
which will commonly happen without much difficulty.
§ 3. Of Swellings of the Bursæ Mucosæ.
THE bursæ mucosæ are small membranous bags, seated
upon, or contiguous to all the larger joints, containing a
thin, transparent and gelatinous fluid, which seems intend-
ed to lubricate the parts upon which the tendons move
that pass over the joints. A preternatural accumulation 
of this fluid, produced more particularly by sprains, con- 
tusion, and rheumatism, constitutes the disease we are now
to treat of. 
This species of swelling is seldom attended with much 
pain; it yields to pressure, but is much more elastic than a 
tumor from pus; at first it is always confined to one part 
of a joint, but in some cases it at length extends almost 
round it; and the skin always retains its colour, unless it 
becomes inflamed. When rheumatism produces the 
swelling, its contents are commonlv very like the synovia; 
but when it is the consequence of sprains, together with 
this fluid there is usually a considerable quantity of pretty
firm concretions. In some few instances, however, these
Concretions are soft.—Their consistency may generally be 
ascertained by the touch.
When these tumors are the effects of rheumatism, they
may perhaps be always dispersed in time, by keeping the 
parts 

[445]
parts warm with flannel; by frequent frictions; by fre-
quently pumping warm water upon them; or by the appli-
cation of blisters. But if they originate from sprains, al-
though they may long remain flationary, they can seldom
be discussed. An operation then becomes necessary for
their removal whenever they become troublesome.
This consists informing an opening to discharge the con-
tents of the tumor, and preserving the wound open until
it fills with granulations from below.* When the sac
cannot be opened through its whole length, on account of
the contiguity of tendons,it will be best to lay it open at
each end, and after pressing out the contents, to pass a small 
seton through it.
These operations should be done with a great deal of
care; and when the seton is used, it should be introduced
with a blunt probe, and suffered to remain no longer than
till a slight degree of inflammation is excited, on account
of the contiguity of the joint; and when it is withdrawn,
the cure is to be completed by gentle pressure with a
roller.*
A
* A great deal of difficulty has sometimes happened in consequence 
of a dilatation or removal of these tumors, particularly where they 
do not heal by the first intention. The most successful mode of 
opening them is by drawing up the external skin, then puncturing 
the tumor with a lancet, and when the fluid is entirely discharged 
suffering the external to pass beyond the internal orifice. A com-
press dipped in lead water, is then to be applied, and retained with 
a moderately tight bandage, enjoining perfect rest and quiet for several
days.
* Dr A. Monro, of Edinburgh, has lately published a valuable
work on the subject of the bursæ macosæ, or as he is disposed to term 
them, the vesicæ unguinosæ and as it is very probable, that collec-
tions in these have often been mistaken for affections of a very differ-
ent nature, it may perhaps be useful to add some observations from 
this treatise, to what Mr Bell has said on the subject.
The Doctor tells us, that he has discovered one hundred and forty
bursæ, 

[446]
A considerable stiffness of the joint usually remains af-
ter the removal of these tumors. The best remedies for
this, are frictions with emollient ointments, and the appli-
cation of warm steams.
§ 4. Of Colleclions within the Capsular Ligaments.
These collections may consist of blood; of matter from a
previous inflammation; or of serum, forming what are
usually termed dropsical swellings of the joints.
They may be distinguished from collections in the bur-
sæ mucosæ, by the contained fluid passing readily from 
one side of the joint to the other; by its being diffused over 
the 
bursæ mucosæ in all; thirty-three in each of the superior, and thirty-
seven in each of the inferior extremities. Many of them are placed 
on the inner sides of the tendons, between these and the bones. Many 
others cover not only the inner, but the outer side of the tendons, or 
are interposed between the tendons and external parts, as well as be-
tween those and the bones. Some are situated between the tendons 
and the external parts only, or chiefly; some between contiguous ten-
dons, or between the tendons and the ligaments of the joints. A 
few are interposed where the processes of bones play upon the liga-
ments, or where one bone plays upon another. Some of the bursæ 
communicate with each other; some with the cavities of the joints.
In the latter case the communication seems sometimes to be formed 
by long friction; and particularly occurs in the joints of the shoulder 
and knee; and especially just below the inferior part of the first, and 
immediately above the superior part of the last. This connection 
does not seem to be productive of bad effects, even when it is not 
formed originally.
The Dr has proved very satisfactorily the similiarity between the 
structure of these sacs and that of the capsular ligaments, as well from 
an examination of their structure and uses in a healthy state, as from 
the effects of diseases upon them. With respect to the latter, he 
finds that they are rendered exquisitely sensible by inflammation; 
and that either depositions of fluid matters, or the formation of so-
lid substances of different kinds, occur not only from rheumatism,
but

[447]
the whole of it; and by being generally painful: and
from abscesses in the cellular membrane, by the matter in
the latter being superficial, and extending beyond the
boundaries of the capsular ligaments.
The nature of the fluid collected in these swellings may
be ascertained by the circumstances preceding them, and
by the symptoms with which they are accompanied.
Thus when a violent bruise of a joint is immediately suc-
ceeded by a large effusion within the capsular ligament,
it will probably be found to consist chiefly of blood. Of
this I have seen a remarkable case. When inflammation of a
joint terminates in effusion, it will probably consist of a
serous matter, with some tendency to purulency. And if
the tumor succeeds to rheumatic affections, there will
be reason to suppose, that it is produced entirely from
serum.
The species of this affection which is consequent to
rheumatism, may generally be discussed by the remedies of 
similar collections in the bursæ mucosæ; or if these fail by
the use of a laced stocking or roller, applied as tight as
can be borne. But if this should be unsuccessful, the pa-
tient had better submit to the inconveniency occasioned
by the disease, than run the risk of the inflammation so
apt to follow an opening made in the ligament for its dis-
charge. When, however, any matter is collected in the
joint, which may do mischief by remaining in it, or which
can-
but also from gout and scrophula. In one instance, the Dr has found 
not less than fifty cartilaginous bodies within the bursa situated be-
hind the tendon of the flexor pollicis longus. He is of opinion, from 
some facts, that all solid substances in these sacs consist in excrescen-
cies from them, and that they are always nourished by peduncles con-
necting them to the sacs; and hence, if these peduncles are any how
broken, the excrescencics never afterwards increase in size.
Dr Monro seems to be of opinion,that when an operetion becomes
necessary in these affections, it should be either similar to that advised 
in §4. or to the one recommended in §5. of this section, according as 
the substance to be removed is fluid or solid. 

[448]
cannot be readily absorbed, an opening should be made to
remove it. This is the case when blood, or matter formed
by inflammation, is effused.
As the danger which attends this operation, seems to 
depend greatly on the admission of air into the joint;
it should be conducted in such a manner as to prevent this
as much as possible. For which purpose a trocar should
be employed, and the skin being previously drawn tightly
to the upper part of the swelling as soon as all the
fluid is evacuated, it should be returned to its place. The
wound should then be closed by adhesive plaster, and the
joint moderately compressed by a roller, or a laced stock-
ing: And in order to guard more effectually against in-
flammation, if the patient is plethoric, he should be bled;
and a strict antiphlogistic regimen should be observed.*
§ 5. Of Concretions and Excrescencies with the capsular
Ligaments.
These affections induce a great deal of pain in some in-
stances, and always impede more or less the motion of the
joint. In some cases, the offending substances are small
and loose, and as firm as cartilage; and in others, they
are of a soft membranous nature, sprouting from an eroded
surface of one of the bones forming the joint, or from the
inner surface of the capsular ligament.
In the latter, which remain fixed nearly in the same si-
tuation, the pain is constant, but it is seldom severe; but in 
the former, it is only felt in particular fituations, perhaps 
when the connecting membrane gets between the ends of
the bones, but it is then often excessively violent, and
sometimes so excruciating as to produce fainting.
These substances can only be removed by an operation; but
as this, altho' sometimes followed by no bad consequences,
has
* All these remedies will fail, if the patient does not observe the 
most perfect rest and quiet.

[449]
has in many instances produced such a violent inflamma-
tion in the ligament and adjacent parts, and other bad ef-
fects, as to render the amputation of the limb ultimately
necessary, it should be advised with great caution. From a
good deal of experience, I am of opinion, that where
the concretions appear, on examination, to be perfectly
loose and detached, if the pain which they excite is very
fevere, rather than submit to a long continuance of it, we
should venture to take them out; but whenever there is
reason to suppose they are connected with any part of the
joint, the patient should be advised to suffer the pain, which
may in general be rendered moderate by avoiding exer-
cise, rather than to run the risk attending the extirpation
of them. If, indeed, the pain, notwithstanding every means
employed to mitigate it, becomes insupportable, amputation
of the limb should be recommended, as less hazardous than
the excision of the tumor when attached to the capsular li-
gaments.
The operation for the removal of loose bodies may thus be
performed: If the joint of the knee or ankle is affected, the
patient should be laid upon a table or bed; but if the joints
of the arm are to be opened, he may sit; and the limb
should be firmly secured in the most convenient posture.
The surgeon should then endeavour to fix the substance with
the left hand towards the upper part of the joint, that the
synovia may not escape by the wound to be made, the skin
being previously drawn up as much as possible from the
part to be divided. An incision is now to be made with a
scalpel through the teguments and ligament, directly upon
the substance, of such a size as will admit of its being ea-
sily taken out; which may be done either with the finger,
or with a blunt probe passed beneath it. If it is found to be
connected by small filaments either to the ligaments or car-
tilages of the joint, these should be cautiously divided with
a probe-pointed bistouri, or probe-pointed scissars, after
drawing out the substance itself as far as possible with
3L small 

[450]
small forceps, or a small hook, when the texture of it will 
admit of the use of this. If there are several concretions, 
they should, if possible, be all removed at the same opening;
but where this is not practicable, on account of their lying
on opposite sides of the joints, after allowing the first inci-
sion to heal, a second opening must be made.
After the concretion is removed, the skin should be im-
mediately drawn over the wound in the ligament, and the
incision of the skin should be closed by adhesive plaster.
The limb should be kept as much as possible in one pos-
ture until the wound is healed; and a strict antiphlogis-
tic regimen should be observed. For the farther treatment
of such cases, we must refer to the section on wounds of
the ligaments.
§ 6. Of Anasarca or Oedema.
These terms are applied to dropsy in the cellular sub-
stance; which is known in common by coldness and pale-
ness of the part affected, and by its retaining the mark of the
finger when pressed. These swellings are generally con-
nected with some systematical affection; but they some-
times occur in particular parts, and from causes which af-
fect those parts only. Thus they are induced by contusions
or sprains of the legs or arms; by tumors pressing upon
the larger lymphatics; and by some of the lymphatics of a
limb being by some means divided.
In cases of local swellings of this kind, if they are indu-
ced by tumors, the removal of these will alone effect a
cure; if they are the consequence of debility in a limb, from
sprains or bruises, the best mode of cure will be to support
the parts by means of a flannel roller, or laced stocking,
until they recover their tone from the use of cold bathing
and frictions; and when they are occasioned by a lympha-
tic being cut, as sometimes happens in extirpating glands
from 

[451]
from the arm-pit, small punctures in the lower part of 
the limb gives immediate and the only relief.
In those swellings of the feet and legs which occur in
general dropsy, all that a surgeon can with propriety do,
is to discharge the fluid by punctures with a lancet *. This
gives temporary ease, and I think ought to be employed
earlier than it usually is, in order to prevent the loss of tone 
in the cellular membrane which must necessarily be the
consequence of much distension. See chap. ix. sect. 2.
§ 7. Of the Spina Bifida.
The term spina bifida is applied to those soft small swel-
lings which sometimes appear on the spine, in new-born
children, most frequently between the two last lumbar ver-
tebræ. A fluctuation is perceived in them, and the fluid
they contain can in part be pressed into an opening which
occurs between the spinous processes of the two vertebræ
in which they are seated. This opening is found to depend
either on a deficiency of bone, or merely on a separation of
the processes. The disease always proceeds from serum
deposited within the coverings of the spinal marrow; and
is for the most part local; though in a few instances it has
been found connected with hydrocephalus.
In some cases children have lived under this disease for
two or three years; but in general they die in the space of
a few months. All the assistance that art has hitherto been
able to afford, has been to support the tumor by a ban-
dage; and thus to retard its increase. Opening it has al-
ways been followed by death, either immediately, or with-
in a few hours.
Proceeding upon the supposition, that the want of the
necessary support to the membranes of the spinal marrow
from
* We are commonly advised, as one means of lessening the chance
of gangrene in these cases, not to make the punctures in the most de-
pending part of the limb.

[452]
from the deficiency of bone, may be the cause of this dis-
ease, and not the effect, as has been generally supposed,
might not some advantage be derived from a ligature ap-
plied round the base of the tumor so as not only to remove
it, but to draw the bottom of the cyst together, and thus
give a proper support to the parts beneath? And as an
additional help, as soon as the tumor drops off, a firm stuff-
ed pad might be applied over the opening in the vertebræ,
and secured by a proper bandage?
A swelling of the same appearance, in similar circum-
stances, and probably of the same nature with spina bifida,
appears sometimes on the head; death is also the conse-
quence of opening it.
§ 8. Of Scrophulous Tumors.
For a description of scrophulous swellings, and the ge-
neral remedies for them, we must refer to what was said on
these subjects in chap. ii. sect. 12.
With respect to the chirurgical treatment of scrophulous
swellings, I have never observed any good effects from the
use of any applications hitherto recommended, but have
repeatedly seen some of them, and particularly those of a re-
laxing quality detrimental; and hence I am convinced that
the best practice is to trust them to nature through their
whole course, except when they are seated over the cavities
of the thorax or abdomen, or any of the larger joints,
when they should be opened as soon as a fluctuation of
fluid is perceived in them, either by means of a seton or
trocar, or of a scalpel or lancet, according as the collection
is large or small. With respect to the subsequent treat-
ment, see section on Scrophulous Ulcers.
When these swellings are deeply seated in the breast,
they are more firm than they usually are in other situa-
tions, and have probably sometimes been mistaken for real
schirri; but a careful attention to the characteristic symp-
toms 

[453]
toms of the different diseases, will always enable us with 
certainty to discriminate between them. The circumstance
of the first being connected with symptoms of a general
disease, is alone sufficient for this purpose.
§ 9. Of the Brouchocele.
Every tumor of an indolent nature, occupying the fore
part of the neck, is commonly termed bronchocele.
The various affections of this kind are,
1. Aneurisms of the carotid artery. These do not fre-
quently occur; they are usually the immediate consequence
of some violent exertion, such as laughing or coughing,
and are to be known by the marks of aneurism in general.
2. Encysted tumors, particularly of the melicerous kind.
These frequently are met with on the course of the trachea,
and often extend from one ear to the other. They are seated
in the cellular membrane, and are distinguished by the ge-
neral signs of meliceris.
3. Tumors formed by the membrane lining the trachea
being forced out between two of the cartilages by violent
sneezing, coughing, or laughing. In these cases the swel-
ling will be at first small; and although soft and compres-
sible, no fluctuation will be perceived in it.
4. Swellings of the lymphatic glands of the neck from
scrophula. These are sometimes of such a size as to ex-
tend over the whole course of the trachea. They are
known by the usual symptoms of tumors of this kind.
5. Enlargements of the thyroid gland, constituting the
disease which is mentioned as so common among the inha-
bitants of the Alps,* and which is supposed to arise from
the use of snow-water. This tumor has been known to
extend all across the throat, from one angle of the jaw to
the other. At first it is usually soft; no fluctuation is per-
ceived
* Goûetre.

[454]
ceived in it; the skin is unaltered in its appearance; and it 
is not painful. As the swelling increases in size it becomes 
firm or elastic in some parts, and perfectly soft in others; 
the skin acquires a copper colour, and the veins of the 
neck grow varicose; the face then becomes flushed, and the
patient complains of frequent head-achs, and of stinging
pains through the body of the tumor.
6. Swellings that appear to be formed chiefly of con-
densed cellular substance with effusions of a viscid matter
in different parts of them. Of these I have seen two in-
stances. In both, the tumour was supposed to originate
in the thyroid gland; but on diffection this was found
much diminished in size. In one case, the disease was chief-
ly on one side the neck; but in the other it reached from
ear to ear, and from the sternum to the chin. In both cases,
the tumor subsisted for a great number of years; and it was
fatal but in one of them. At first it was soft and compres-
sible, no fluctuation was perceived in it, and the skin was
unchanged; but as it enlarged, it became hard in some
parts, very elastic in others, and soft and fluctuating in
other parts; the superficial veins became turgid, and the
face of a livid colour, from the obstruction to the passage
of the blood. In one case, the patient complained much
of giddiness; and in both, the breathing was much ob-
structed.
In the aneurismal bronchocele, it must be evident that the
only chance the patient can have, must be derived from
the common operation for aneurism; and this must neces-
sarily be in some instances very hazardous.
When the disease arises from encysted tumors, the treat-
ment applicable in other situations, will be equally proper
in the neck. And however large the steatoma may here be,
it is in general so slightly connected with the contiguous
parts, that its removal may always be safely attempted. A
large opening in the lower part will be sufficient for athe-
roma, 

455] roma; and the meliceris may be cured either by incision, or 
by a seton.
Where the swelling is formed by a hernia of the tra-
cheal membrane, gentle compression, and attention to avoid
laughter, coughing, or any other exertion which might have
any effect in increasing the complaint, is all that can be
done. In scrophulous bronchocele we must depend chief-
ly on the general remedies of scrophula; and to remove
the compression of the trachea or veins of the throat which
they may give, as soon as their contents are found to be
fluid, they should be evacuated.
In an enlargement of the thyroid gland, frequent fric-
tions, and saponaceous and mercurial plasters, have been
useful in the beginning of the complaint; but when it has
arrived to any considerable size, no internal or external
medicine with which we are at present acquainted is of any
material service; and an attempt to extirpate the offending
part must always be very hazardous, and has we are told,
proved fatal; but in cases where it has not grown large,
and is constantly increasing, and the usual remedies fail, I
think it would be very proper to attempt the relief of the
patient by cutting out the swelling. As we are, however,
seldom applied to in the beginning of the disease, we must,
in common, be content with palliating the most urgent
symptoms as they arise.
In the last species, mercurial ointment rubbed on the
part has proved useful in the first stage; blisters appeared
also in one case to retard the progress of the complaint;
but in the latter stage, as the tumor extends to a great depth,
and to attempt its removal would be dangerous, and as it is 
in great part solid, no considerable advantage could be ex-
pected from merely laying it open, and the fore thus pro-
duced might perhaps degenerate into cancer: we are there-
fore reduced to the necessity of employing nothing but pal-
liatives. 
§ 10.

[456] 
§ 10. Of Nævi Materni.
NÆVI MATERNI are those marks which are found on dif-
ferent parts of the body at birth; and which are by some
supposed to originate from impressions made on the mind of
the mother during pregnancy. They are of various forms,
but their colour is in general a deep red. Those which rise
more or less above the skin, are alone the objects of surgery.
These tumors remain sometimes stationary for a long time,
or perhaps during life; but in other cases, they increase in
size very rapidly. I once saw a tumor of this kind in a
child of a year old, of the size of a goose egg, which at
birth was not larger than a pea. They feel firm and fleshy;
and in common have broad bases; though in some cases
they are pendulous, and hang by very slender attachments
to the contiguous parts.
Nævi materni seem to differ only from other sarcomata,
in being more plentifully supplied with blood-vessels; and
they require the same treatment. They should always be
extirpated when they appear to be increasing in size. In
doing this, the whole tumor is to be diffected off with a
scalpel, and the arteries being secured, the edges of the re-
maining skin are to be drawn as near together as possible, and
retained by adhesive plasters or futures, and the cure af-
terwards conducted in the usual way. When the swelling
is connected merely by a narrow neck to the contiguous
parts, a ligature should be employed instead of the knife.
§ 11. Of Warts.
Warts appear to be produced from the cutis and cu-
ticle: If left to themselves they generally waste away, or fall
off; and it is only when they grow so hrge, or in such situ-
ations as to become very troublsome, that they should be
I removed 

[457] 
removed by art. When they have a narrow base, they
maybe taken off by a ligature; but if their base be broad,
it will be necessary to employ caustics, or the scalpel, for
for their removal. The former are usually preferred.
As caustics, the lapis infernalis, the lunar caustic, a solu-
tion of quicksilver in an equal quantity of nitrous acid,
pulvis sabinæ, oleum tartari per deliquium, or spirits of
hartshorn, will either of them be effectual; but as most of
them are apt to excite too much inflammation, they
should be used very cautiously. The best remedy I
have tried, is rubbing them with sal ammoniac crud. moist-
ened, two or three times a day. It excites neither inflam-
mation nor pain, and seldom fails, except in the very hard
species.
Warts frequently appear upon the penis in the venereal
disease, and often continue long after the virus is eradicated.
Mercury in such cases is of no benefit; and if the parts are
kept clean, or when they produce matter, washed with some
gentle astringent, such as lime water, they will generally
disappear of themselves after some time. When, however,
it is determined to remove them, either the scalpel or cau-
stic may be employed. After the use of the former, in order
the more effectually to prevent their return, the parts may
be touched with lunar caustic.
It must be particularly observed, that no application
should be repeated which produces inflammation; and
when the scalpel is used, we should rather take off some
of the sound skin, than run the risk of injuring the wart
itself, or of leaving any part of it; for, from want of at-
tention to these circumstances, a great deal of mischief may
be produced: a necessity for the amputation of a limb has
been the consequence of a neglect of the last.
3M § 12. 

[458] 
§ 12. Of Fleshy Excrescences.
No part of the body is exempted from the formation of
fleshy excrescences. They are of various sizes; are gene-
rally somewhat more red than the healthy skin; have about
the same degree of firmness that the lips possess; and are
seldom painful. They have the appearance of muscle,
when laid open; but, on a close examination, appear to
consist chiefly of cellular substance, in which are a great
number of blood-vessels, very much ramified.
Escharotics are seldom effectual in removing these tu-
mors, and are very apt to irritate and excite inflammation
in them. We should, therefore, never trust to remedies
of this kind, and always make use of the scalpel, or a li-
gature. The latter should be employed when the excres-
cence is pendulous by a small neck: and the scalpel, when
the base of the tumor is broad. After carefully diffecting
out the tumor, the skin should be brought to cover the
wound, and the cure conducted as in other cases.
§ 13. Of Corns.
CORNS appear in different parts of the body, but more
particularly on the toes and soals of the feet. In some
cases they appear to be of a horny inorganic nature; but in
others, they-are evidently supplied with blood-vessels and
nerves. They are commonly seated in the skin, but they
sometimes reach to the periorteum, and are in that case apt
to be productive of pain and inflammation, and particular-
ly wben they are seated on the joints, or parts thinly cover-
ed with flesh.
The best preventative of corns is to avoid pressure on
the parts liable to be affected. The most effectual method
of removing them seems to be to pare off all the inorganic
part 

[459] 
part, after bathing them for half an hour or so in warm
water, and immediately afterwards to apply the emplastrum
gummosum over them, spread on soft leather. By repeat-
ing this occasionally, the corns will be kept easy, the hard
knots will often come away, and the vacancy thus produ-
ced will be supplied by cellular substance.
$ 14. Of a simple Exostosis, Venereal Nodes, and Spina
Ventosa.
An exostosis is an indolent hard tumor originating from
a bone. In some cases it is altogether a local affection,
produced by a superabundance of callus in fractures, by a
deep wound of a bone, or by an erosion of the substance of
a bone from an ulcer. In others, it is symptomatic of some
general disease, particularly of syphilis and scrophula. In
the first case it is termed a venereal node; and when it ap-
pears as a symptom of scrophula, which it frequently
does, it is usually denominated a spina ventosa.
Exostoses, when proceeding from external injuries, are
seldom attended with pain; and after attaining a certain
size, commonly remain stationary. But when they ori-
ginate from an internal cause, they are generally pain-
ful from the first; probably from the difficulty with which
the periosteum admits of distension; and they continue
to increase until they ulcerate, or until the constitutional
affection is eradicated.
In venereal nodes, the periosteum is often found infla-
med and much thickened; and in some cases, a small quan-
tity of a thin acrid serum is effused between it and the bones,
which makes the swelling appear larger in the bone than
it really is. This has given rise to the supposition that the
periosteum is the original seat of the complaint; but it
seems more probable that the bones are primarily affect-
ed, from the disease occurring only in the advanced
stages 

[460]
stages of syphilis, and generally seizing the hardest parts 
of them.
The spina ventosa affects the whole substance of bones,
but more particularly the extremities of those forming the
joints of the knee, ankle, elbow and wrist. A pain is the
first symptom of it; and it appears to the patient to be
seated in the very center of the bone. This is sometimes
the only sign for a few days; but in general there is like-
wise some fullness observed in the part.
When these swellings occur in the middle part of bones,
as sometimes happens in the hands and feet, they are apt
to advance rapidly; and when the soft parts ulcerate, a
thin, ill-conditioned matter is discharged, and the bones
on examination will be found carious. But where the 
larger joints are affected, the disease arrives to this state in
a much more gradual manner; and then lays the founda-
tion for a species of white swelling. See chap. on White
Swellings.
When the tumours terminate in sores, the softer parts
of the bones are found dissolved; and on the matter which
they produce being discharged, the remaining cavities have
the appearance of being formed by all the interior part of
the bone being scooped out, nothing being left but the hard
external lamella. The bone in this state exhibits appear-
ances very similar to those of scrophulous sores in the softer
parts; and as the spina ventosa is, in one stage or another,
almost always accompanied by other signs of scrophula, I
am clearly of opinion that it should be considered as a
scrophulous affection.
In exostoses from a local cause, nothing but a chirurgical
operation will effect a cure; this may therefore be employed
whenever they become so large as to prove troublesome
or painful.
The patient being placed upon a table, and secured by
assistants, if there is any risk of cutting large arteries, a
tourniquet 

[461]
tourniquet should be applied above the disease; an inci-
sion should now be made through the teguments above the
tumor, and carried, if the parts will admit of it, an
inch or more beyond each end of it. It is after-
wards to be continued down to the bone, taking great
care to avoid cutting the contiguous muscles, tenions,
veins, arteries, and nerves. If the diseased part is
merely a small knob that can be admitted into the
head of a trepan, it may be taken off by that instrument;
but when it is too large for this, a common amputa-
ting saw may be employed to remove it; and after taking
away all the spiculæ, the divided parts may be brought in-
to contact, and retained by adhesive plaster. They may
thus heal by the first intention; but even if this should be
frustrated by pieces of bone coming away, or if exfoliation
should take place sometime after the healing of the
wound, will still be better than to treat the case from the
first as an open sore.
When an exostosis is found to surround a bone entirely,
it will be necessary to take out that portion on which the
disease is seated, when it can be done with propriety.
As this, however, cannot well be executed when the bones
of the hands or feet are affected, it will be better to take
out the whole bone. But in the long bones, as those
of the thigh, leg, or arm, we may safely venture to perform
this operation; and trust to nature for supplying the defi-
ciency: for there are many instances of whole bones be-
ing regenerated in people of healthy constitutions. When
a part of a bone is to be removed, after laying it bare, a
piece of pasteboard, or a thin sheet of lead should be pas-
sed beneath it, in order to protect the parts below from the
saw.
As soon as the bone is taken off, a pledgit of lint, spread
with common cerate, or diped in oil, should be insinuated
between the lips of the wound, and the manifold bandage
may then be applied. As the free discharge of mat-
ter 

[462]
ter is of consequence, this should be carefully attended to,
not only in the after position of the limb, but also in mak-
ing the incision.
When there is but one bone in the part operated upon,
the arm for instance, it will be necessary to pay particular
attention to keeping it of its natural length during the cure.
Machines have been invented for this purpose; but they
are unnecessary if the patient is attentive to the proper ma-
nagement of the part, and when employed, they are very
apt to be productive of inflammation and other inconve-
niencies.
During the cure, the chief object is to prevent matter
from lodging between the contiguous found parts. If this
is accomplished, and the wound dressed lightly, it will
soon fill up and heal. The granulations between the ends
of the bone will gradually become hard, and if the health
continues good, the limb will become equally useful as be-
fore.
Exostoses wherever seated are to be always treated in the
same manner.
Venereal nodes are in the beginning relieved by the use
of mercury alone. Mercury should not, however, be
applied to the tumors; for I have reason to believe it has
often been injurious; but they should be bathed in a solu-
tion of saccharum saturni, or some other mild sedative
should be applied to them; and these, by tending to re-
move inflammation, may assist in the discussion of the tu-
mor. When the system is properly charged with mercury,
if the disease still increases, I have sometimes relieved the
pain immediately by leeches applied over the tumor.
When these have failed, blisters have, in some cases, been
effectual.
Should these means, however, have been too long ne-
glected, should the tumor advance with rapidity, or should
acrid matter be confined within the periosteum, an incision
down 

[463]
down to the bone, along the tumor, will often give imme-
diate ease. The matter thus evacuated is frequently a thin
brown sanies, and sometimes a viscid transparent mucus.
The incision heals very readily by the ordinary treat-
ment, in some cases, even where the bone is considerably
enlarged: The tumor indeed will often remain during life,
but without producing any inconveniency; and unless it
occasions considerable deformity should never be meddled
with. But if, notwithstanding the use of mercury to a pro-
per extent, the wound shews no tendency to heal, it will
be better, for some time at least, to try the effects of a 
discontinuation of it. Should the body be contaminated by
some other disease, the removal of this will often effect a
cure. And when there appears a tendency to exfoliation in
the bone, as this process alone will remove the complaint,
such remedies should be employed as will expedite it as
much as possible. See Sect, on Carious Ulcer.
After all the diseased part of the bone is removed, the
sore will usually heal without difficulty. But when the
cure is retarded by a thickening of the periosteum and
other parts, in consequence of a long continuance of the
complaint, the sore should be dressed with strong precipi-
tate or verdegris ointment; or if these are not powerful
enough, it should be touched with the common or lunar
caustic, once in two or three days. These will produce a
separation of the slough, and in consequence, probably
soon heal the ulcer.
In some instances, venereal nodes are mere swellings of
the periosteum; and in that case they give little uneasiness,
and often subside merely from the use of mercury, or of a
blister, and no advantage is derived from cutting into them.
But when they consist in an affection of the bone itself, they
are always more or less painful, are very hard, advance slow-
ly, and are never removed but by an exfoliation.
With respect to the cure of spina ventosa, when it ap-
pears in different parts of the body at the same time, all
that 

[464]
that can be attempted, is to support the constitution with a
proper diet; to advise bark and cold bathing as the best to-
nics; and when the pain is fevere, to moderate it by the
use of opium. But when it is confined to one part, as of-
ten happens in the knee and other large joints in cases of
white swelling, it becomes frequently adviseable to remove
the part affected by an operation. See chap. on Amputa-
tion, sect. last. When the complaint affects the middle of
the bones, the diseased part only may be removed, or the
whole bone taken out, as above directed, in cases of exos-
tosis.
CHAP. XLII.
Of Fractures.
SECT. I.
General Observations.
A FRACTURE maybe defined a solution of conti-
nuity in a bone, produced by external violence.
This affection receives various appellations, derived either
from its direction, or from the symptoms with which it is
accompanied: Thus it may be transverse, oblique, lon-
gitudinal, or simple, if there is a mere division of a
bone; or compound, when there is an external wound
of the soft parts, leading to the injured bone. This
I is 
 

[465]
This is the only distinction of fractures, that is useful or
necessary.
The existence of a fracture is in general easily discovered
by manual examination. It is only in simple fractures that
a difficulty can occur; and more particularly, if the conti-
guous parts have become inflamed and painful. In such
cases we must be directed in our opinion, by a care-
ful attention to the age and habit of the patient; the site
of the supposed fracture; the situation of the limb when
the injury was received; and to the attending symptoms.
1. Thus the bones are much more brittle in old age
than early in life, and consequently are much more rea-
dily broken. In infancy the bones bend very much instead
of breaking, upon the application of a moderate force.
Different diseases also induce a brittleness of the bones.
Lues venerea has this effect to such a degree, that the bones
are fometimes broken by the action of the muscles alone.
Scurvy has the same effect; and likewise what is termed
mollities ossium.
2. Bones are more apt to be fractured in those parts of
them which are firmest, and consequently least flexible, as
in the middle; and, those which are thickly covered with
soft parts are much less liable to be broken, than those
which lie near the surface; thus the thigh-bone is not so
frequently fractured as the bones of the arm and leg.
3. With respect to the situation of the part injured, it
is evident, that a bone lying on an unequal surface may rea-
dily be fractured by an inconsiderable force, while, if 
equally supported, it will bear a very heavy weight with-
out injury.
And lastly, The concomitant symptoms are to be attend-
ed to. Those of fracture are generally, pain, swelling, and
tension of the contiguous parts; a more or less crooked
and distorted state of the limb; a crackling or grating noise
3N on 
 

[466]
on the parts being handled; and loss of power to a certain
extent in the injured limb.
Pain in fractures chiefly arises from the ends of the dis-
placed portions of bone irritating the soft parts, and from
the injury to the latter by the accident. It is seldom very
great; but in some cases it is so violent, as to be productive
of spasmodic affections of the muscles of the limb, great
degree of inflammation and fever, subsultus tendinum,
general convulsions, and delirium; and if the cause is not
soon removed, death very commonly succeeds. This is
usually preceded by gangrene of the parts contiguous to
the fracture; but, in some instances it seems to be occa-
sioned merely by the violence of the fever. It must be
obvious, that these symptoms will be most readily induc-
ed by an oblique fracture.
A grating noise on handling the part, and distortion
and loss of power in the limb, almost always attend frac-
tures: When they are longitudinal, which seldom hap-
pens, they cannot indeed occur.
But besides these leading symptoms which immediately
take place, there is often a great degree of ecchymosis pro-
duced by the ends of the bone wounding an artery or vein;
and a wound of the teguments in compound fractures.
The most important consequences of fractures are, stiff-
ness and immobility of the injured limb; distortion of the
parts chiefly affected, either from a fulness or thickness re-
maining in the contiguous muscles or ligaments; an exu-
berancy of callus; a contracted state of the contiguous
joints; or a marasmus or wasting of the limb itself. All
these will will be considered hereafter.
In judging of the event of a fracture, we are to consider,
1. The age and habit of body of the patient; thus bones
unite much sooner in youth, and particularly in infancy,
than in old age. Indeed it has been said, that it is often
impossible to procure the re-union of bones in advanced
age; but I never have met with an instance of this kind.
Lues 

[467]
Lues venerea and scurvy, are often considerable obstacles
to the cure of fractures, and sometimes prevent it en-
tirely.
2. The situation and part of a bone that is injured.
Thus we know that fractures of the small bones of the
arms, hands, legs, and feet, and of the chest, heal much
more readily than those of the humerus and thigh-bone.
The difficulty in the thigh often arises chiefly from our not
being able to retain the ends of the bone in contact. And
when any of the larger bones are fractured near to their
extremities, we find the danger to be greater, and the pro-
spect of a complete cure much less than when they are
broken near the middle; for here the shortness of one end of
the bone makes the retention difficult; and the symptoms
which ensue are apt to be severe, on account of the conti-
guity of the capsular ligaments, and tendons, which may
be more or less injured. And as the ends of the bones are
more spongy, they do not unite equably and soon; and col-
lections of matter and exsoliations are very apt to take
place. These fractures are frequently productive of stiff
joints, pains and swellings, which often continue a long
time, and sometimes during life. Such troublesome cir-
cumstances seem to originate more from the nature of the
injury in most cases, than from the mismanagement either
of the patient or surgeon.
3. The degree of the symptoms: for the prognosis must
obviously be favourable, or otherwise, according as these
are mild or violent.
4. The concomitant circumstances: thus the fracture
may be accompanied by contusion, laceration, or dislocation
of the contiguous parts; according to the degree of which
will be the danger.
5. The kind of fracture. It very commonly happens
that simple fractures are unattended by bad symptoms, and
are soon cured; but in general, although there are many
instance. 

[468]
instances to the contrary, the smallest external wound com-
municating with the injury in the bone, will be productive
of danger.
The indications in the cure of fractures are, 1. To re-
place the deranged parts of the bone. 2. To retain them
in this situation as long as necessary. And, 3. To obviate
symptoms which occur during the cure.
When bones are fractured directly across, they are ei-
ther not moved out of their natural situation, or the de-
placement is so inconsiderable that they are easily reduced;
but when the fracture is oblique, the ends of the broken
bones are apt to pass each other so as to produce much
deformity and pain.
Previous to attempting the reduction of a fracture, the
limb or part should be put into such a position that all its
muscles will be as much as possible relaxed. When this is
done, the surgeon may commonly replace the bones him-
self; but when assistance is necessary, the upper part of the
limb should be held firm, while the lower part is gently
extended, still keeping the muscles relaxed as much as pos-
sible. The displaced portions of bone should then be gently
reduced, so as to render the limb as similar as possible to
the found one, in order to ascertain which, they should be
brought as near together as convenient.
The bones are to be retained in their proper situation by
compresses and bandages, and by keeping the limb in an
easy posture, and as much fixed as possible. The appli-
cations should be made with no greater degree of tightness
than is absolutely necessary for retaining the bones in
their situation.
The time required for rendering the re-union of bones
sufficiently firm, must depend upon the age and habit
of body, the violence of the injury, attention of the pati-
ent, and other circumstances; but in general, in healthy
middle aged people, and in favourable circumstances, a
fracture 

[469]
fracture of the femur, or bones of the leg will get well in 
two months; an os humeri, or bone of the fore-arm, in six
weeks; and any of the bones of the hands, fingers, feet,
and toes, in three weeks. In infancy and childhood, frac-
tures heal more quickly; and in old age they require a
much longer time.
In simple fractures, to which these observations more
particularly apply, the inflammation and other attending
symptoms usually subside in a few days, if the bones are
kept in their places; but in some cases they constantly in-
crease from their first appearance. To obviate these, it will
be always adviseable to make use of some astringent appli-
cation, such as a solution of sacchar saturni, of sal ammon.
cr. or sp. mind. and when this has not the desired effect,
to employ topical bleeding, by leeches. These have a most
happy effect in removing the inflammation, and thus pre-
venting greater part of the bad consequences of frac-
tures, formerly enumerated. If the swelling and pain in
a fractured limb have continued long, the most effectual
relief is obtained from frictions with emollient oils, and
from warm bathing, particularly in the medicinal waters.
To check an overgrowth of callus, the application of
astringents, and of moderate compression with a thin plate
of lead, retained by a roller, are useful; but these will not
be always successful.
The ends of fractured bones sometimes remain loose
and unconnected long after they should, according to the
common progress of cures in such cases, have been united;
this may originate; from some constitutional disease, as
lues venerea, scurvy or rickets; from the ends of the bones
not having been constantly in contact; from a portion of
a muscle, a tendon, or ligament falling in between the di-
vided parts; and from the bene being broken in different
parts, and in small pieces. This circumstance has also
been 

[470]
been observed to happen more peculiarly during preg-
nancy.
When the want of re-union depends on some general
disease, the proper remedy of such disease becomes neces-
sary to a cure; and indeed it will be always prudent to at-
tend to this when the fracture is first produced.
If the defect of union arises from the bones not being in
contact, it will accomplish a cure, in recent cases, to appose 
them: But when the osseous matter which should have
joined the bones has become smooth and hard, as in long
continued instances of this kind, and they move freely on
each other without giving pain, it will answer no good
purpose to bring them together; and the only mode of
relief will be to lay their ends bare by an incision, and by
removing a small portion of each, with a trepan or
a common saw, reduce them to the state of a simple frac-
ture. This operation should always be advised when the
injury affects the large bones of the extremities; but in
the bones of the fingers and toes, of the metacarpus and
metatarsus, the clavicles and ribs, where no great disad-
vantage is experienced from it, it will be adviseable rather
to submit to the inconveniency.
This operation is painful and tedious; as the incision
must be pretty extensive, and must be made with great
caution in order to avoid the large blood-vessels; but it is
perfectly safe, and has been followed with complete suc-
eess, nature supplying fully the place of the removed por-
tion of bone.
In compound fractures, all detached portions of the
bone that will not probably unite with the larger parts
should be immediately removed; but in simple fractures
where the skin remains entire, as we cannot judge of the
nature of the injury to the bone with any exactness, we
must always proceed as formerly directed, at first; and
when the union seems to be prevented in the usual time by
any 

[471]
any detached pieces of bone, an incision should be made
down to them, and they should then be removed by the
fingers or forceps.
Another cause preventing the re-union of bones, is a
portion of muscle, or some other soft part passing between
them. This is to be supposed when the pain and tension
of the injured part have been more severe than usual from
the first; when particular motions of the limb give se-
vere pain and twitchings of the muscles that move it; and
when the ends of the bone do not unite at the usual time.
In this case we should endeavour to remove the interposed
substance, by putting the limb into a variety of positions.
As this, however, will seldom succeed, it will be commonly
necessary to make an incision down to the affected parts:
If the callus is found soft, a cure may be effected merely
by bringing the bones into contact; but if it has become
hard, it will be absolutely necessary to remove a small por-
tion of it as above directed.
Effusion of blood around the injured bone sometimes
prevents a re-union of it. When a large vessel is wounded
by the bone, the extravasation of blood is in some cases so
considerable, and the limb becomes so much swelled, that
it will be necessary to lay it open, and tie the vessel; but
when the swelling does not arrive to an alarming height,
we are rather to trust to the contractility of the artery for
stopping the hemorrhagy, and to the absorbents for re-
moving the blood already effused. In some such cases,
where the blood has remained longin contact with the bone,
the periosteum becomes separated for a considerable space,
no callus is produced, no union takes place, and a fœtid
sanies is commonly discharged from the sore: A cure
cannot then be effected until the denuded parts of
the bone exfoliate. As the exfoliation is a very tedious
process, it will render the cure more speedy and certain to
remove 

[472]
remove those parts of the bone from which the periosteum
is separated, by means of a saw.
SECT. II.
Of Fractures of the Nose.
FRACTURES in the bones of the nose require very parti-
cular attention, because they are apt to impede respiration,
to affect speaking, and the sense of smelling; and in some
cases, to produce polypi, and tedious ulcers; and because of
the contiguity of the brain.
When any part of the bones have been raised above the
rest, it must be pressed into its place by the fingers; and
such parts as are forced into the nostrils must be elevated
with the end of a spatula, or some such instrument. If any
portion is either very nearly or entirely separated from the
rest, it should be removed.
When the reduction is properly made, the bones will ge-
nerally remain in their situations of themselves—If there 
is a wound it must be dressed in the usual way: And in-
flammation must be obviated by saturnine applications, or
if necessary by local bleeding.
If, however, the bones will not remain firmly in their
places of themselves, it will either be necessary to introduce
small tubes adapted to the size of the nostrils, previously
covered with cerate spread on lint, and secured by tape
passed around the head, or to apply a compress and roller
over the nose, according as the bones fall into the nares, or
are raised too high. By this treatment we may commonly,
accomplish a cure, unless the bones have been very much
broken, when if they cannot be re-united, all the detached
pieces must be removed, and the wound healed as well as
possible.
SECT. 

[473] 
SECT. III.
Of Fractures of the superior Maxillary, and Cheek Bones.
The vicinity of these bones to the eye, by which they
are apt to induce ophthalmia, and the situation of the an-
trum maxillare, a removal of a part of the bone form-
ing which is apt to induce deformity, and render a cure te-
dious, make fractures of them important.
The displaced parts of the bones must therefore be very 
carefully reduced to their natural situations, either with the 
fingers, or with a narrow spatula. When the parts are laid 
open, the wound should be dressed in such a manner as will 
most probably prevent subsequent deformity; and a piece of 
adhesive plaster should be employed to retain the dres-
sings. Blood-letting, and an antiphlogistic regimen, must
be advised to obviate inflammation which might ensue.
If the antrum is injured, as the matter formed cannot
be readily evacuated from the prominent part of the cheek,
it will be necessary, in order to effect a cure of the ulcers
produced, to make an opening in the most depending part
of the cavity in the manner advised in chap, xxxiii. sect. 5.
SECT. IV.
Of Fractures of the inferior Maxillary Bones.
Fractures in the lower jaw bone may be always rea-
dily discovered.
In reducing them the patient should have his head firm-
ly secured in a proper light, and the surgeon should then
replace the parts deranged, by introducing one hand with-
in the mouth, and pressing on the other part of the jaw
3O with 
 

[474]
with the other. If a tooth is seated in the course of the 
fracture, which is the case very generally, as it may retard
the cure, by acting as an extraneous substance, it should be
removed; but when any of the teeth not in the site of the 
fracture, are forced out, they should be replaced, and tied 
to the contiguous firm teeth.
The fractured parts may be very well kept in their situ-
ations, by a thick linen compress applied along the jaw from
ear to ear, retained by a four-head linen roller. See chap-
ter on Bandages.
During the cure, the patient should be kept quiet; he
should avoid speaking and laughing, or the use of the jaw
in any manner, as such as possible; and he should be fed
entirely on spoon meat. When the bandage is removed,
which must be done as seldom as the nature of the case
will admit of, an assistant should support the parts with his
hands during the dressing. The management of the frac-
ture of one or both sides of the jaw bone is exactly similar.
In the first case, the patient may be allowed to eat meat,
and speak in about three weeks; but in the latter not in less
than five.
SECT. V.
Of Fractures of the Clavicles and Ribs.
THE clavicles and ribs, from their structure and situation
are more liable to fractures than any other bones of the
body.
A fracture of the clavicle is in common very easily
known by the usual symptoms of fracture. The end of
the bone connected with the shoulder is generally pulled
to some distance from the other, and below it, by the.
weight of the arm; and the motion of the arm is impeded.
This fracture may be reduced merely by raising the arm
to 

[475]
to a proper height; and the ends of the bone may be re-
tained in their natural situations, by affording a proper sup-
port to the arm; this is usually done by a sling hung round 
the neck, adapted to the length of the arm, and equably
applied to it; but it is much more effectually accomplished
by the machine, pl. xii. fig. 3.
The position of the head and shoulders must be varied
in different cases; sometimes the ends of the clavicle are
best retained when they are raised; and at other times
when the head is bent forward.
In other circumstances, these fractures are to be treated
as similar injuries in other parts. The inflammation will, in
general, be sufficiently moderated by the common saturnine
applications. And when the bone is splintered, which must
always be dangerous on account of the vicinity of the sub-
clavian artery, the loose parts must be removed with great
care, and the wound dressed in the usual way.
In general, where circumstances are favourable, the frac-
tured parts will unite in a fortnight; but the corresponding
arm should not be freely used for three or four weeks.
Fractures of the ribs are in common very easily discover-
ed by the touch. For the most part the symptoms they
induce are very trifling; but in some cases, the pain is very
severe; the breathing becomes difficult, attended by cough,
and perhaps a spitting of blood; and the pulse becomes
quick, full, and sometimes oppressed.
These symptoms are the consequence of the fractured
ends of the rib being pressed in upon, and tearing the
pleura and lungs. The injury to the latter, in some cases,
produces emphysema; (chap. xxv.) and a wound of the in-
tercostal artery, an effusion of blood into the cavity of the
chest.
It will always be the safest practice, in every case of frac-
tured rib, to discharge as much blood as the strength of the
patient will admit of, to have him kept quiet, and upon a
low 

[476]
low regimen. If the ends of the bone are not in contact,
they should be brought together, if possible; and to retain
them, a broad leathern belt, lined with quilted cotton or
flannel, should be tightly applied around the body, and
worn for several weeks.
When a difficulty of breathing is kept up by air escaping
from a wound in the lungs, or by blood escaping into the
cavity of the chest, or when the pain is kept up by the rib
pressing upon the pleura, it will be necessary to make an
opening with a scalpel. In the latter case, this should be
done directly upon the injured part; and, on the rib being
laid bare, the depressed portion of it should be raised, either 
with the fingers, forceps, or spatula. When the oppressed 
respiration is occasioned by effused air or blood, the ope-
ration of the paracentesis becomes necessary.
SECT. VI.
Of Fractures of the Sternum.
A SIMPLE fracture of the sternum requires a treatment
similar to that of a fractured rib. More danger, however;
may arise from a part of this bone being forced into the
chest, on account of the vicinity of large blood-vessels; but
the pain in the part, and other symptoms induced are the
same.
When the pain, cough, oppressed breathing, and other
symptoms do not yield to bleeding and an antiphlogistic
course, the only effectual method of affording relief will
be, to make an incision upon the injured part large enough
to admit a free examination of the bone, and then to raise
the depressed piece, either by means of a scalpel or levator,
if the opening will admit them, of when this is not the
case, with a trepan, in the manner advised in a fractured
skull; and the sore produced may afterwards be treated in
the usual way.
This 

[477]
This operation may be done with safety, and should un-
doubtedly be tried: No other mode of cure yet proposed,
gives any chance of suceess.
SECT. VII.
Of Fractures of the Vertebræ, os Sacrum, Coccyx, and ossa
Innominata.
Fractures of the vertebræ may be produced by falls
and blows; But they are most frequently met with as the
consequences of gun-shot wounds.
The spinous and oblique processes of the vertebræ may
be broken without any immediate danger; but, in general,
there is such a shock given to the spinal marrow by the
cause producing the fracture, that it ultimatey ends in the
death of the patient; and a fracture extending through
the body of the vertebra will probably always prove fatal.
We judge that the vertebræ are fractured by the touch,
by the violence of the injury, and the severity of the pain,
and by the parts beneath the injured vertebræ becoming
paralytic when the spinal marrow is affected.
When any of the external parts of the vertebræ are loose,
they may be in general replaced by the fingers; and by
confining the patient as much as possible to one posture, and
by the use of the napkin and scapulary, and compresses, we
may retain them in their situations until they unite with the 
rest or the bone. When this cannot be done, however,
instead of leaving the patient to his fate, according to the
common practice, wherever the spinal marrow is compres-
sed, we ought certainly to lay the injured part freely open,
that we may get access to the bone, and if possible raise it
to its proper situation, or, if necessary remove it. This has
been done with such good effect as to relieve a patient en-
tirely 

[478] 
tirely who lad been rendered paralytic by a bullet passing 
into one of the vertebræ. The operation can never in-
crease the danger.
In fractures of the sacrum, the treatment must be nearly
similar to that advised for fractured vertebræ, except that
where the lower part of the bone is injured, as well as in
fractures of the coccyx, and is thrown inwards, we may
in some instances replace it by introducing a finger into the
anus, while the fingers of the other hand are employed ex-
ternally.
Where any deep-seated part of the ossa innominata is in-
jured, the patient should be confined as much as poaaible to
an easy position until the bones are probably united; and
bleeding and a proper regimen should be employed as pre-
ventatives of inflammation.
In more external fractures, the displaced parts may of-
ten be reducd to their proper situation; and a bandage
adapted to the site of the injury, will retain them until a
cure be effeded.
SECT. VIII.
Of Fractures of the Scapula.
A FRACTURE of the scapula does not often occur; but
when it does, it is always difficult to cure, and commonly
induces a permanently stiff and unwieldly state of the cor-
responding arm.
Besides the general symptoms of fracture, this injury is
attended by stiffness and immobility of the arm; and when
a part of the bone is forced in upon the lungs, by in em-
physematous swelling.
In reducing this fracture, all the muscles connected with
the scapula must be as much as possible relaxed. By raising
the 

[479]
the head and shoulders, we relax those of the back; and if 
the humerus be supported at the same time, the deltoid
muscle will be so much relaxed that the fractured part
may be easily replaced. The keeping all these parts as
much as possible in this state, and the application of a rol-
ler for the particular retention of the separated part, is all
that can be done. And, in order to obviate that violent
degree of inflammation which is apt to succeed, blood-let-
ting, and particularly topical evacuation, should be freely
employed.
SECT. IX.
Of Fractures of the Humerus.
Fractures of the humerus are in general vety easily
detected, by the seat of the pain, inability to move the part,
and the other general symptoms of fracture.
By bending the elbow moderately and raising the arm
nearly to a horizonial direction, in a line with the body, we
relax all the muscles of the arm, and the surgeon may then
commonly reduce this fracture without assistance; but
when this becomes necessary, an extension may be made
by one person grasping the arm near the shoulder, and an-
other just above the elbow.
When the bone is reduced, it is to be secured in its situ-
ation by a splint, of the kind represented (pl. xii. fig. 1.)
laid along the whole outside of the arm, and another along
the inside, both covered with soft thin flannel, to prevent
them from galling the parts; and while these are secured
by one assistant, and the fore-arm supported by another, a
flannel roller should be applied moderately tight over the
whole.
The fore-arm should be supported by a sling, (pl. xii.
fig. 3.) but it will be better, even in bed, that it should be
I in 

[480] 
in a hanging position, so that it may have some effect in 
pulling the lower part of the humerus gently downwards,
and thus prevent the ends of the bone from overlapping
each other, than to have it laid on a pillow horizontally.
Unless the arm becomes much swelled and painful, the
bandage should not be removed until the seventh or eighth
day, when we may cuatiously examine whether the bone is
perfectly in place or not; and any accidental displacement
may then be easily remedied.
Fractures of the humerus heal more readily than those
of any other part; all circumstances being favourable, ge-
nerally in less than four weeks; and, if well managed, are
seldom productive either of lameness or distortion.
SECT. X.
Of Fractures of the Bones of the Fore-Arm.
THESE fractures very frequently occur. When both
bones are broken, there is seldom any difficulty in disco-
vering the state of the injury; but when one only is frac-
tured, especially if it be the radius, as the firmness of the
other prevents its displacement, it requires some attention
to discover it. The seat of the pain, however, points out
the part injured.
If a great deal of attention is not given to these frac-
tures, they are very apt to induce a permanent stiffness
in the arm, and more particularly when the radius alone
is broken; probably from the difficulty of keeping it in
its situation, owing to its having a rotatory motion inde
pendent of the ulna.
In order to reduce a fracture in the fore-arm, the pa-
tient being seated, and the muscles of the arm relaxed by
bending the elbow and wrist, the limb should be extend-
ed to such a degree, by one assistant grasping it above
the 

[481]
the fracture, and another beneath it, as will allow the
surgeon to replace the bones with exactness. This being
done, such a splint as represented plate xii. fig. 1. co-
vered with soft flannel, and so long as to reach from the
elbow to the tops of the fingers, and of such a breadth as
to go round more than half the arm and hand, should be
placed along the ulna. Another splint not quite so broad
must be placed along the course of the radius, and both
may be secured either with a flannel roller or a twelve-
tailed bandage.
The palm of the hand should always be turned to-
wards the breast, as this is not only the most convenient
position, but it most effectually prevents the motion of
the radius. The arm after being dressed as above direct-
ed, should be hung in the sling, plate xii. fig. 3. and al-
lowed to remain in it during the night.
We have directed the splints to be very long, because
it is of great consequence to prevent the motion of the
fingers; for if this is permitted, it not only tends to
support inflammation and pain, but also to displace the
bones.
A partial dislocation of the bones of the wrist is a fre-
quent concomitant of a fracture of the radius; by which
the risk of a stiff joint, or of a painful permanent swell-
ling of the arm becomes considerable. This should
therefore be particularly attended to in the treatment.
See chap. on Dislocations, and sect. on Fractures in Ge-
neral.
The olecranon is sometimes fractured without any inju-
ry being done to the rest of the ulna, particularly from
falls or bruises on the elbow. In this case, in order to
keep the fractured parts in contact, the fore-arm must be
kept extended by means of a long splint laid along the in-
terior part of it, from the middle of the humerus to the tops
of the fingers, secured by a roller. The arm should be allowed
3P to

[482]
to hang by the patient's side, to which it should be fixed 
with one or two straps.
But lest a stiffness of the elbow might be the conse-
quence of keeping the arm constantly extended during
the cure, the dressings should be removed about the eighth
or tenth day, and daily afterwards; and the fore-arm be-
ing for some time moved slowly backward and forward,
and the joint rubbed with any emollient oil, the arm may
then be secured as before.
SECT. XI.
Of Fractures of the Bones of the Wrist, Hands, and Fingers.
THE bones of the wrist are seldom fractured except by
shot from fire-arms, or by some heavy substance passing over
them, from their readily giving way to any ordinary force
applied to them. Fractures of them do not readily unite,
because of their being so small; and on this account, as
well as of the vicinity of tendons and ligaments, which
induces a considerable degree of inflammation, anchylosis,
or stiffness of the joint are very common consequences.
After replacing the bones, the most effectual preventative
of these effects is copious bleeding from the parts in-
jured. The arm and hand should then be dressed in the
manner directed for a fractured fore-arm.
Fractures of the metacarpal bones should be dressed either
with a splint of wood or of pasteboard applied on the in-
ternal part of the hand and fore-arm, and above these
with the splints and bandage advised in the last section.
Fractures of the fingers are frequent, and easily cured.
The best splint for them is a piece of firm pasteboard,
adapted to the parts by being previously moistened, ex-
tending the whole length of the fingers, and secured by
a 

[483]
a narrow roller.The more effectually to ensure a perfect
cure, a large splint of the kind, (Plate XII. fig. 1.) or of
firm pasteboard, may be applied to the inside of the hand,
and secured by a roller, so as to prevent any of the fin-
gers from being moved; and in order to preserve the mo-
bility of the joints of the fingers, the bandages and
splints should be removed about the tenth or twelfth day,
and daily afterwards, and the fingers bent and extended
several times.
SECT. XII.
Of Fractures of the Thigh-Bone.
THE os femoris is most frequently broken near the mid-
dle; and next to this, its neck is most apt to be fractured.
When the lower part is the seat of the injury, the frac-
ture is in general easily distinguished by the grating noise
produced by rubbing the ends of the bones together; by
the limb being much shortened, if the fracture be oblique,
or if the ends of the bones have been displaced in cases
of transverse fracture; by great pain and tension of the in-
jured part; and by the limb being unable to sustain the body.
It is, however, often difficult to distinguish fractures of
the neck of the femur from dislocations of this bone. As it
is of considerable consequence to make this discrimination,
a very careful attention is requisite; and by this the distinc-
tion may be commonly made. In nineteen cases out of
twenty, the head of the femur when dislocated, is pushed
inwards and downwards, owing to the brim of the aceta-
bulum being not so deep internally as in other parts, as well
as to the muscles not being so strong; while perhaps in an
equal number of fractures in the neck of the femur,
the bone is pushed upwards, on account of accidents of
this

[484] 
this kind happening most frequently from falls upon the
knees, or perhaps upon the feet, when the legs are stretch-
ed out, by which a very considerable force is necessarily
brought to act against the neck of the thigh-bone, where it
is least able to give resistance. In such fractures, the leg is 
much shortened, often several inches; the trochanter is
found much higher than that of the other thigh; and the
knees and toes are turned inwards. On the contrary, in
dislocations the leg is considerably lengthened; the head
of the bone and the trochanter are found near the groin,
with a corresponding vacancy where the trochanter ought
to be; and the toes are turned out.
In fractures, the extremity may be turned with much
more ease from side to side, than when the head of the fe-
mur is luxated. The tumor formed by the head of the
bone and trochanter in the latter case, is also much greater
than that produced from the trochanter alone in fractures.
We are very apt to obtain but an imperfect cure in frac-
tures of the thigh, and particularly when the neck of the
bone is the part injured. This arises, 1. From the diffi-
culty of ascertaining the direction of the fracture, on ac-
count of the bone being so thickly covered. 2. From the
impossibility of discovering whether the reduction be pro-
perly effected. 3. From the difficulty of retaining the ends
of the bone in their proper situations, when they are well
reduced: This is particularly the case when the neck of
the femur is the part affected, and when the fracture is
oblique. The thigh-bone is also more affected by bodily
exertions than most others.
In reducing fractures of this bone, the thigh should
form an obtuse angle with the body, and the joint of the
knee be moderately bent. The ends of the bone may ge-
nerally be easily brought into contact, if there be not
much tension or swelling, while one assistant gently extends
the lower part, and another secures the upper part of the
thigh 

[485]
thigh. There is the greatest difficulty when the neck of
the bone is broken; but we may commonly succeed, if one
assistant secures the body while another makes an extension
at the lower part of the thigh.
When this mode fails it will be necessary to have re-
course to extending machines.
There is usually much greater difficulty in retaining the
ends of the femur in contact, than in reducing them to
their proper situation. In order to accomplish this, a firm
splint reaching from the top of the hip-joint to a little be-
low the knee, and broad enough to cover at least one-
half of the thigh, should be covered with soft flannel,
laid upon a twelve-tailed bandage supported by a pillow,
and applied to the outside of the thigh. Another splint
long enough to extend from the groin to a little below the
knee, and so broad as to cover one-third of the thigh,
is to be placed on the inside; the manifold bandage be-
neath the large splint, must then be applied, so as to make
a moderate and equable pressure over the whole limb.
The patient should be placed on a hair matrass which
will not yield much, on his back, with the body turned
toward the affected side, and have the knee moderately
bent, and this as well as the leg should be raised somewhat
higher than the body.
In order to have the limb more secure from displace-
ment, it will be proper to put a long splint of wood be-
neath the middle of the pillow, and fix it by two broad
straps firmly buckled on the upper part of the thigh:
And besides this, to have the pillow connected to the
matrass by straps. To prevent uneasiness from the weight
of the bed-clothes, two or three hoops fixed in a frame
should be placed over the thigh.
Left the bones might be accidentally displaced, but
especially if pain and swelling should come on, the band-
age should be undone, and the upper splint removed in
order

[486]
order to admit of an examination of the injured part.
If pain, inflammation, or swelling, have come on, it
may be proper, before a renewal of the dressing, to apply
leeches and other remedies to the parts affected; but
when none of these symptoms have come on, and the bone
is in its proper situation, the bandage and splint should be
immediately reapplied.
Adults, in favourable circumstances, will generally be
cured in six weeks; but all violent exertions should be
carefully avoided till after the eighth or tenth week.
In order to prevent rigidity and uneasiness in moving the
limb, after the cure, it will be proper, in a fortnight or
less after the accident, to permit the patient to lie more on
his back, and the knee to be daily bent or extended.
This mode of cure will very commonly succeed very
perfectly; but some cases of oblique fracture occasionally
occur in which it is almost impossible to prevent the end,
of the bones from slipping by each other, and by uniting
at their sides, make the limb shorter than it ought to be.
In order to prevent this disagreeable circumstance, va-
rious methods have been devised; by these it is intended
to keep the limb in a constant state of extension: Some
have proposed to fix the body and then extend the leg by
an apparatus below; others trust to an extension of the
extremity only. But these means can never be employed
while any degree of inflammation is present; and even
this does not exist, they give so much uneasiness that they
can seldom be made use of. The pain, swelling, &c. some-
times arrive to so great a height, that even a simple band-
age cannot be admitted till after their subsidence.
SECT. 

[487] 
SECT. XIII.
Of Fractures of the Patella.
FALLS and blows of the knee are the causes produc-
tive of fractured patella. The bone is most frequently
broken transversely; sometimes longitudinally; and in
some instances, into three or four different pieces.
Under proper management, this fracture seldom pro-
duces much stiffness of the knee joint, after a few
months; and when this does occur, it is hardly in con-
sequence of the callus produced, as this must be in very
inconsiderable quantity, but probably originates from the
concomitant inflammation of the internal parts of the joint,
or from the knee being kept too long in a fixed and ex-
tended position.
The patient being placed on a firm bed, and the leg ex-
tended, in order to relax the muscles connected with the
patella, a firm wooden splint well covered with soft wool,
or fine flannel, should be placed beneath the extremity,
and reaching from the upper part of the thigh to the end
of the leg; to this the limb must be secured by two
straps between the ankle and knee, and one or two be-
tween the knee and top of the thigh. The different parts
of the bone are then to be brought as nearly together
as possible by the hand.
In order to prevent the inflammation which probably
would succeed to the injury, blood should be drawn
from the joint by leeches; and when it actually comes
on, saturnine and other astringent applications should be
freely employed until it subsides. When this is the case,
the bone must be examined: If the parts remain nearly.
in contact, a large pledgit of Goulard's cerate should be
I laid 

[488]
laid over them, and a hooped frame should support the
bed-clothes above; but if the different parts of the bone
are much separated, it will be necessary to replace them,
and retain them by bandages, or slips of leather spread
with glue or adhesive plaster. When the fracture is lon-
gitudinal, this is easily accomplished; but when it is tran-
sverse it is a matter of some difficulty.
In cases of the latter kind it will be proper to bring
the parts of the bone as nearly into contact as the pati-
ent can admit of without pain or uneasiness; but it is
not necessary that they be brought to touch, because
a very perfect cure has been effected when they could not
be brought within an inch of each other. Various me-
thods have been employed to support the parts of the
bone in contact; but whatever bandage or machinery is
employed to keep them together, should only act on the
superior part of the patella, because that alone can resist
the reduction *.
The bandages should not be removed until the twelfth
or fourteenth day, if pain and inflammation do not render
it necessary earlier; and the joint may then, and afterwards
every second or third day, be moderately bent, in order to
prevent an immobility of it, which would be apt to occur
without this precaution.
The rectus muscle is sometimes torn from its insertion
into the patella by a fall on the back with the knee bent;
a suffi-
* In transverse fractures of the patella, Mr. Sabatier, from much 
experience, is of opinion that no splints or bandages are at all neces-
sary or useful. He advises the thigh the be moderately bent, and the 
knee to be in a slight degree of flexion also; and both to be laid 
upon pillows. Wherever he has employed splints or bandages, or 
seen them employed, they have been necessarily soon removed, on 
account of the inflammation and swelling induced by them: It is to 
obviate these symptoms that he has found the propriety of keeping 
theknee slightly bent. See Histoire de Acad. Roy, des Sciences,
pour l'an. 1783.

[489] 
a sufficiently long continued extension of the limb, toge-
ther with the general treatment recommended in fractured
patella, will remove this complaint.
SECT. XIV.
Of Fractures of the Bones of the Leg.
WHEN one bone of the leg only is broken, there is
sometimes a difficulty in ascertaining the fracture, but
when both are broken, which is more commonly the case,
it is readily discovered. In the former case, however,
as the found bone generally supports the other in its place,
this is of no great consequence; nothing more than con-
finement, till an union is effected, being necessary.
The leg is most frequently fractured just above the
ankle; and particularly when the fibula is the seat of the
injury.
In the management of this fracture, the general prin-
ciples apply which were laid down in the treatment of a
fractured thigh. During the redaction, the muscles should
be relaxed by bending the knee and slightly extending the
foot; and an assistant at the upper end of the limb and one
below, will easily extend the leg sufficiently. The limb
being laid upon its outside, and the knee slightly bent, the
splints, plate XII. fig. 2—7. or those made in the manner
of fig. 1. should be applied, and retained by the twelve-
tailed bandage: the splint on the outside should always
reach from a little above the knee, below the ankle, with
a view to prevent the motion of either of these joints, by
which the bones are apt to be displaced. If the patient is
very restless, or troubled with spasmodic affections of the
muscles of the leg, it will be better, as an additional secu-
rity, to apply a splint of wood of the form, plate XII. fig. 2.
3Q and

[490]
and filled with soft wool, to the outside of the leg, and 
fasten it by means of a couple of straps. The foot should
also be always supported by a strip of linen, connected on
each side of the leg to the bandage.
If it is thought proper, instead of lying on his side, the
patient may have the leg placed on the frame, plate x.
fig 6. and lie on his back; and this or the side, may
be occasionally used in the same patient during the cure,
for the sake of ease and variety: No change of posture
should however be permitted for the first ten or twelve
days. And when the position is altered, the leg should
always be kept in the same degree of curvature.
In making the apposition of these bones, our sole object
should be to raise the inferior part of the bone; for this
is almost always drawn beneath the upper, by the weight
of the foot, and the contraction of the muscles on the-
back part of the leg.
SECT. XV.
Of Fractures of the Bones of the Foot and Toes.
THE foot is very much exposed to injuries of this kind;
they are detected by the signs which denote fractures in
general, and require a treatment similar to that of fractured
hands. In every case, a large splint should be applied over
the sole of the foot; and the foot and ankle should be
moved as litde as possible during the cure.
SECT. XVI.
Of Compound Fractures.
COMPOUND fractures are produced by external violence,
and frequently by the bones, in cases of simple fractures
being

[491] 
being pushed through the corresponding integuments.
This may happen either from the bone being fractured so
obliquely as to terminate in a sharp point, or from the ap-
plication of a very tight bandage.
Compound fractures are always attended with danger.
That the risk in these cases originates chiefly from the ad-
mission of air to the bone, is rendered probable from
this, that in the worst variety of simple fracture, the pa-
tient commonly gets well without the occurrence of any
bad symptoms; but if, in the progress of the cure, the end
of the bone should by any accident be pushed through the
teguments, the pain immediately becomes more violent; the
inflammation increases; fever takes place; spasms proba-
bly affect: the limb; and to these frequently succeed either
gangrene, or extensive suppurations.
Our first object in fractures of this kind, is to restrain
the hemorrhagy when it is profuse; and our next, to de-
termine whether it will be proper to attempt to save the
limb, or to recommend immediate amputation. The for-
mer is to be accomplished by the usual means: The lat-
ter is a point which has given rise to much dispute. I
am clearly of opinion, that in private practice, and in
other cases, where the patient can be well attended to
in every respect immediately after the accident, and du-
ring the whole of the cure, that amputation should never
be advised, unless the bones are so much shattered that they
cannot re-unite, or the texture of the soft parts is comple- 
tely destroyed: But when proper attention cannot possibly
be paid to the patient, as is usually the case in the army
and navy, it will be a good general rule to advise
the immediate removal of the limb, if the accident affects
the bones of the arm, fore-arm, thigh, or leg. This im-
portant point will be more particularly considered hereaf-
ter in the chapter on Amputation, sect. I.
Where we attempt to save the limb, all extraneous bo-
dies 

[492]
dies should be removed, as likewise all portions of bone that 
are entirely separated, and will not be likely to unite,
either by means of the fingers, forceps, cutting pliers, or 
saw; and if this cannot be easily done without, the wound 
should be enlarged by the scalpel. But it is to be observed 
that any piece of separated bone which is broad at the base,
and would probably unite if brought into its proper situa-
tion, should be replaced.
All the coagulated blood being removed, and any ar-
tery that may be cut being secured, the bones should be ap-
posed; the wound should then be covered with a pledgit
of lint spread with emollient ointment, and the limb should
be laid on a firm splint, and in a relaxed posture.
That we may have free access to the injured part without
moving it, the many-tailed bandage should always be pre-
ferred to a roller;* and the limb should be fixed on a frac-
ture box; (pl. x. fig. 6.) it may be either bent or straight,
as seems most proper.
In order to guard against inflammation, to the violence
of which may always be traced the gangrene or abscesses
which sometimes supervene, it will be proper, to use gene-
ral bleeding; to apply leeches to the edges of the sore,
when the inflammation becomes considerable; and to em-
ploy opiates, saline laxatives, and a low cool regimen.
The dressings should be removed once or twice a-day, ac-
cording to the quantity of matter produced; and pledgits
of lint spread with cerate should be applied to the wound.
When inflammation comes on, it will be proper to apply
warm emollient poultices frequently, in order to excite a
plentiful
* In order to preserve the bandage clean, and thus prevent a neces-
sity for a frequent removal of it, the late Dr. Jones, of this city, 
always applied a piece of fine oil cloth next to the limb. In all cases 
of fracture, instead, of placing the splints beneath the bandage, 
many practitioners apply the bandage first, and fix the splints above 
these, either by means of straps, or pieces of tape. See Jones on
Wounds and Fractures. 

[493]
plentiful suppuration, as this is the best preventative of 
gangrene; but as soon as the inflammation has subsided,
they should be omitted.
When the discharge of matter becomes very great, the
fore should be dressed with gentle astringents, such as lint
dipped in a solution of sacchar. saturni; and the patient
should be supported by a nourishing diet, a free use of
wine, Peruvian bark, and elixir of vitriol. If the matter
cannot be freely discharged by a proper position of the
limb, or cannot be sufficiently absorbed by lint or sponge
applied to the sore, a counter opening must be made to
give it vent. This excessive discharge will sometimes be
occasioned by loose pieces of bone: These should there-
fore be searched for, by the finger if possible, if not, by the 
probe, and extracted.
If the inflammation should terminate in gangrene, the
treatment formerly recommended, or hereafter to be ad-
vised, is to be employed. See fection on Gangrene, and
chapter on Amputation.
Various machines have been recommended by different
authors, for forcibly retaining fractured limbs in their
proper situations, but they are in general unnecessary. In
particular circumstances, that mentioned in section xi. of
this chapter, may be useful for keeping the fractured bones
extended; and considerable advantage may be derived
from it in keeping the bones steady, when it is necessary
to remove the patient from one place to another; but in
common practice I have never derived any advantage from
any instrument used for this purpose.
CHAP. 

[494]
CHAP. XLIII.
Of Luxations.
SECT. I.
General Remarks on Luxations.
A BONE is said to be luxated when that part of it
forming a joint is displaced. If the end of the bone
is forced entirely out of the cavity in which it is lodged,
the dislocation is said to be complete; but where any part
of the bone rests upon the edge of the socket, incomplete.
Luxations may be either simple, i.e. unaccompanied by
any other affection; compound, when accompanied by a
wound, laying open the cavity of a joint; or complicated,
when joined with a fracture.
Luxations are usually produced by external violence, ap-
plied either in leaping or falling, by blows, and violent
twists and disfractions of the different bones of a part; but
they are also produced by a morbid weakness or relaxation
of the muscles and ligaments of a joint, from palsy or rheu-
matism; and by the pressure of matter collected in a joint,
and of sarcomatous tumors and exostoses. Those produ-
ced by external violence are chiefly the objects of surgery.
The general symptoms of such dislocations are, inabili-
ty to move the limb; pain, tension, and deformity of the
part injured; and in some cases, inflammation, subsultus
tendinum, and fever. In general, the motion of the limb
I is
 
 

[495]
is impaired in proportion to the extent of the luxation; but 
in some cases, particularly in the larger joints, the most par-
tial affection renders the joint stiff, and immoveable, and 
gives the most exquisite pain on every attempt to move it. 
The deformity must always be proportioned to the extent 
of the injury; but the inflammation and subsultus are of-
tener excited to a greater degree by a partial than by a com-
plete dislocation.
The swelling that first takes place in cases of dislocation
is always inflammatory, and necessarily consequent to the
violence done the parts; and should be carefully distin-
guished from a secondary swelling, that, in some cases,
spreads over all the inferior part of a limb, which is pale
and œdematous, and seems to originate from a compression
of the lymphatics. This is most commonly an attendant of
dislocations of the humerus and thigh: In these a numbness,
from compression of the nerves, is also very apt to occur.
There is seldom any difficulty in distinguishing complete
dislocations; but it is not always easy to discriminate be-
tween contusions or sprains, and subluxations, or incom-
plete dislocations.
In forming a prognosis in dislocations, we are to consider,
the form and structure of the joints; the nature and extent
of the affection, together with the degree of violence by
which it was produced, and the circumstances which it
may be complicated; and the duration of the injury.
It is chiefly in joints which admit of much motion that
dislocations are met with, viz. where the articulations are
by ball and socket, and by ginglymus.
It has been supposed that the capsular ligament is always
ruptured in luxations: I am, however, of opinion that
partial dislocations. may happen without any rupture of
the ligament; but I believe this is always torn in complete
luxations, and sometimes almost entirely from its insertion.
Where the disease proceeds from the gradual formation

[496]
of a tumor within the joint, and where the ligament is
perhaps much relaxed from any cause, no rupture may take
place; but when the luxation is produced by external
violence, it cannot be supposed that the bone can be for-
ced several inches from its natural situation without lace-
rating the capsular ligament.
The pain which more particularly attends partial dislo-
cations, probably proceeds from the stretching of the liga-
ment, by the pressure of the displaced bone.
In forming a prognosis in luxation, the distance to which
the head of the bone is forced, and the degree of violence
producing the affection, are to be particularly attended to.
A partial dislocation will be more easily and certainly re-
duced than where the displacement is complete—And
where the violence has not been very considerable, the in-
flammation, and other symptoms, will not be in great de-
gree, and vice versa.
The complication of fracture with luxation is very un-
favourable. When the luxated bone only is broken, and
particularly if the fracture is near its neck, it is difficult 
to reduce it; but when the receiving bone is broken, not on-
ly a great degree of inflammation, and its consequences, are 
apt to follow, but if the injury extends to the socket, there 
is always a considerable risk of a stiff joint succeeding.
The difficulty of reducing a dislocation is, cæteris paribus,
proportioned to the duration of the displacement. For in 
a little time, the head of the bone will form a socket for it-
self among the muscles, and be firmly grasped by them,
and the natural socket will at length be more or less filled
by the contiguous soft parts, and perhaps have part of its
brim worn off by the action of the muscular fibres passing
over it. It does not appear from dissection, that an inspis-
sation of the synovia, which has been said often to take
place, ever occurs in these cases.
It is also to be observed, that the patient's age and health
influence 

[497]
influence the reduction of a bone. Thus, in advanced life, 
and in delicate constitutions, it is accomplished with much 
more ease than in the vigour of youth, and in robust habits 
of body, where the superior strength of the muscles has a 
considerable influence in counteracting it.
The indications in dislocations are; to reduce the displaced
bone into its natural situation, with as much ease and expe-
dition as possible; to retain it in this situation until the
injured parts have recovered their tone; and to obviate
pain, inflammation, and other symptoms that supervene. 
If the soft parts are much contused and inflamed, we
should not attempt the reduction, until, by the application
of leeches, and of saturnine preparations, by a low regimen,
and putting the limb in a relaxed posture, these effects of
the injury have subsided. But where the contiguous parts
have not suffered in this manner, the sooner we attempt to
put the bone into its proper situation the better.
In almost every case of luxation, it is the bone forming the
lower part of the joint only that is displaced; hence the on-
ly attention we have to give to the upper part, is to keep it
firm and steady, while we endeavour to replace the under
part of it. In effecting the latter, our chief obstacle con-
sists in the action of the muscles connected with the joint;
these not only refill our attempts for reduction, by keep-
ing the bone in the place to which it is pushed, but often
draw it out of its natural direction, and fix it firmly in some 
adjacent cavity; and the trials we make are very apt to sti-
mulate the muscles to stronger action, and thus increase
the difficulty of the reduction. Hence the necessity of
putting all these muscles as much as possible into a state of
relaxation, in order to remove a luxation.
When this is done, we may commonly succeed by the aid
of assistants alone; but in some cases, such force is requi-
site that we are obliged to have recourse to machinery. It
should however be very particularly observed, that no more
3R force 

[498]
force ought to be employed, in any case, than is suff- 
cient to bring the end of the dislodged bone on a line with
the end of that to which it is to be apposed; that this
force be applied only to the bone displaced; and that it be
applied in a very gradual manner, and in such a direction
as appears best adapted to that in which the dislocation
was made. As soon as the ends of the bones are brought
on a line, the ordinary action of the muscles will com-
monly bring them into their natural situation; but if this
is insufficient, a gentle pressure must be employed for the
purpose. 
There is seldom any difficulty in retaining the bone in its
proper situation, after reduction, unless it has been fre- 
quently displaced; the surest method is, to put the limb
into a relaxed posture, and support the bone with a band- 
age, until the surrounding soft parts have recovered their
tone.
The symptoms that require the greatest attention, both
before and after reduction, are, pain, inflammation, and
swelling. These commonly abate after the replacement:
but while any degree of inflammation continues, it should 
be carefully attended to, as being the most common source
of the other symptoms, as well as of the chronic pains
which frequently succeed. See chapter on Contusions.
When luxations are complicated with fractures of the
displaced bones, if the fracture is at some distance from the
luxated part, it will be no impediment to the reduction; 
the fracture may then be treated in the usual way; but
when, it is so near the end of a bone that this cannot be
taken hold of, it renders the case difficult and uncertain. 
In the smaller joints, as those of the fingers and toes, the
reduction may sometimes be made; but in the larger, as 
the hip-joint, and that of the shoulder, we must allow the 
fracture to be cured before we remove the luxation.
In compound luxations, where there is a wound of the
joint,

[499]
joint, the treatment recommended in compound fractures
will be applicable after the replacement of the bone, our
object being to obviate inflammation, and its consequences.
What we have hitherto said, relates in general to luxa-
tions produced by external violence; when they are the
consequence of tumors or collections of matter, they are
almost always incurable. If the diseased parts can be ta-
ken off, it should always be advised; but when this cannot
be done, all that art should attempt is, to give as free a dis-
charge as possible to any matter that may form, and to sup-
port the body by a proper diet.
When dislocations proceed from a relaxation of the li-
gaments and tendons which connect the bones, a perfect
cure is seldom obtained; all that can be done is to support
the limb with a bandage, and to brace the relaxed parts by
cold bathing, electricity, and other tonics.
SECT. II.
Of Luxations of the Bones of the Cranium.
THE bones of the cranium are frequently separated at
the futures, in cases of hydrocephalus: If the collection is
removed, all that we can do is to support the parts by a
bandage.
Openings are also produced by external violence, parti-
cularly by falls from great heights. Such accidents are
almost always fatal. The only assistance surgery can afford
is to support the parts by gentle pressure with a bandage;
to direct blood letting, and other remedies, according to
the violence of the symptoms; and to keep the patient quiet,
and in a proper posture during the cure.
SECT. 

[500] 
SECT. III.
Of Luxations of the Bones of the Nose.
THESE accidents seldom occur; but they are always ea-
sily known. In reducing them, the patient's head should be
supported by an assistant, while the surgeon reduces the
bones with the fingers; or more readily, when the luxation
is inward, by introducing a small tube into the nostril.
The bone may then be retained by keeping the tube in the
passage by means of tapes passed round the head. If the
luxation is outwards, it will be necessary to employ a
double-headed roller for the retention.
SECT. IV.
Of Luxations of the Lower Jaw.
A LUXATION of the lower jaw can happen in no other
direction than forward and downward: And it is common-
ly the effect of yawning, by which the condyles are
thrown over the anterior boundaries of the cavities with
which they are articulated.
This dislocation is discovered, by the chin being thrown
forward and downward, while the mouth remains open;
and by pain on attempting to shut the mouth. The pa-
tient can neither speak distinctly, nor swallow but with
much difficulty. If only one side of the jaw is luxated, as
sometimes happens, instead of falling directly down, the
bone is pushed downwards, and towards the side unaf-
fected, Convulsions, and even death, are, by the ancients,
mentioned as consequences of this accident, but I have ne-
ver seen them occur; and they can only happen, probably,
from mismanagement.
With 

[501] 
With proper attention we can seldom fail in reducing
this luxation. The patient being seated on a low chair,
with his head supported, and the surgeon standing before,
with his thumbs properly guarded, should push them as
far as possible between the teeth, the lower part being ap-
plied to those of the under jaw; the palm of each hand is
to be fixed on the outside, while with his fingers he lays a
firm hold of the angles of each jaw. The jaw should now
be pulled forward until it moves from its situation, and
then pressed forcibly down by the thumbs, and moderate-
ly backwards by the palms of the hands. The jaw will
now commonly slip into its proper situation, and then the
thumb should be instantly withdrawn. If but one con-
dyle is thrown out, the only difference of treatment neces-
sary is, that the force used for depressing the jaw, should
be chiefly applied to the side dislocated.
The thumbs are very apt to be bitten if they are not
well protected, or if they be not instantly withdrawn on
the bone's slipping into its place. The end of a handker-
chief is usually wrapped round them; but fine leather an-
swers much better; and iron covered with leather would
be still preserable.
After the luxation is reduced, as the condyles are very
apt to slip out again, for some time, the patient should be
very careful to avoid gaping, or any other cause which
might have a tendency to produce that effect.
SECT. V.
Of Luxations of the Head.
THESE luxations are produced by the head being for-
ced with such violence forward, as to stretch or rupture
the ligaments by which the tooth-like process of the second
vertebra 

[502]
vertebra is connected to the occiput: And this com-
monly happens from falls from great heights, or from horse-
back.
When the head is luxated, it always falls forward on the
breast; the patient is deprived of sensibility instantane-
ously, and lies as if dead; and soon dies, unless the luxa-
tion is speedily reduced.
Dislocations of the head commonly terminate fatally;
but as recoveries have sometimes happened from them,
there is reason to suppose, that death is frequently the con-
sequence of the want of timely assistance. An attempt for
the reduction should always be made, if possible, instanta-
neously after the accident.
The patient being seated upon the ground, and support-
ed by an assistant, the surgeon standing behind, should raise
the head from the breast; and the assistant being desired to
press down the shoulders, the head should be gradually 
pulled straight up till the dislocation is reduced; and if this
is not accomplished by moderate extension, the head may
be gently moved from side to side. A sudden crack is
heard on the reduction taking place; and if the patient be
not dead, it is immediately ascertained by a partial, and in
some cases, by an entire recovery of all his faculties.
These, however, in some instances, always remain im-
paired.
The patient should be laid in bed immediately after the
reduction; the head should be kept raised, and for a
considerable time in one posture, by means of a proper
bandage; venæfection and laxatives should be employed;
and a low regimen advised.
SECT. 

[503] SECT. VI.
Of Luxations of the Spine, Os Sacrum, and Os Coccygis.
A COMPLETE luxation of any of the vertebræ probably
never happens without a concomitant fracture; and is, per-
haps, always immediately fatal, from the effects it must
necessarily produce on the spinal marrow, and the contents
of the thorax or abdomen: It can, therefore, never be an
object of surgery.
Partial dislocations may however occur, and the patient
may live a long time afterwards; but he will probably sel-
dom entirely recover. These are usually the consequence,
of falls from great heights, of violent blows, or of heavy
weights passing over the body.
They are distinguishied by dislortion of the part; by the
touch; and by the symptoms they usually induce, such as
palsy of the parts below the injury, and either a total sup-
pression of urine, or an involuntary discharge of urine and
fæces.
The vertebræ are, in common, luxated either directly
forward, or to one side; and hence it is very difficult to
accomplish their reduction. The most certain method
perhaps, is to bend the body slowly forward, as far as
pofssible, over a cask, or any other cylindrical large sub-
stance, and if the luxation is to one side, towards the side
affected: No machinery by which much force is em-
ployed should ever be used. Whatever means is made
use of, however, will be seldom successful when the bone
is much displaced.
When any part of the sacrum is dislocated, all that can
be done is, to replace it as well as possible by external pres-
sure, and by bending the body forward in the manner we
have mentioned.
The 

[504]
The coccyx is more frequently luxated than any of these
bones, from being more exposed to injuries. It may be
thrown either forward or backward. It is apt to be for-
ced outwards in laborious births; and sometimes from
large collections of hardened fæces in the rectum.
This injury is known, by pain all over the loins, particu-
larly about the junction of the coccyx with the sacrum, and
from actual examination with the fingers.
In luxations inwardly, from falls or blows, the patient
complains of pain, and a sensation of some hard body com-
pressing the under part of the rectum; tenesmus comes on,
and difficulty in passing the fæces; and, in some instances, a
suppression of urine takes place. These luxations are readily
detected, by introducing the finger into the anus; and by
passing it as far as possible up the rectum, and supporting
the external parts with the other hand, they may be easily
reduced.
Outward luxations of the coccyx are in common reduced
without much difficulty, merely by external pressure 
with the fingers; but it is often difficult to retain the bone
in its place. This is most effectually done by a compress,
and the T bandage.
As dislocations of any of these bones, and particularly
those of the coccyx, are very apt to produce inflammation,
which often terminates in abscesses difficult to heal, we
should employ general and topical bleeding, and laxatives,
and direct an easy posture for the patient, and alow regi-
men, in order, if possible, to prevent it.
I SECT. 

[505] 
SECT. VII.
Of Luxations of the Clavicles.
LUXATIONS of the clavicles do not happen so frequently
as fractures of them; and generally take place at the ends
next to the sternum. They are easily discovered; and are
commonly attended with a considerable degree of stiffness
and immobility in the corresponding shoulder.
A dislocation of the clavicle is readily reduced by mo-
derate pressure with the fingers, especially if the arms and
shoulders be at the same time drawn back; but it is diffi-
cult afterwards to retain the bone in its place. This is 
usually attempted by bandages; and particularly by a long
roller, applied so as to form the figure of eight upon the
shoulders and breast; but this, if applied with sufficient
tightness to keep the bone in its place, will always impede
respiration. The machine represented, (pl. xii. fig. 6.)
answers the purpose better than any thing else I have seen;
for at the same time that it keeps the shoulders back, and
raises the head, the straps which pass over the upper part
of the breast act with sufficient force to keep the bone in
its situation. The fore-arm should also be moderately
supported, to prevent the shoulders from being too much
drawn back.
SECT. VIII.
Of Luxations of the Ribs.
IT has been generally supposed that the ribs cannot be
dislocated; but it has been proved by dissections that
they are sometimes luxated inwards.
3S A 

[506]
A luxated rib will produce nearly the same symptoms
that occur from a fracture; but it may be distinguished, by
the pain being most severe at the articulation, and by no
part of the bone yielding to pressure except this spot.
In general, a luxated rib will probably return to its na-
tural situation from its own elasticity, when the cause of
the injury is removed; but if it does not, the best method
of reducing it will be, to bend the body forward over a
cask, or some other cylindrical substance, while the vertebræ
immediately above and below the rib are pressed inwards
with as much force as can with safety be applied to them.
After this, a thick compress of linen should be laid over
the vertebræ mentioned, and another along the most promi- 
nent part of the dislocated rib, and the two immediately 
contiguous; and a broad roller should then be passed
over them, and two or three times around the body, in
order to retain the replaced rib and the vertebræ in their
situations: And to prevent the roller from moving, a sca-
pulary bandage, a strap connected with it behind, car-
ried between the thighs and fixed to it before, should be
employed.
For the prevention of inflammation, and other disagree-
able effects, which are very apt to ensue from this luxa-
tion, bleeding, a low and cooling regimen, and opiates are
the best remedies.
SECT. IX.
Of Dislocations of the Humerus at the Shoulder.
FROM the construction of the joint at the shoulder, dis-
locations oftener happen there than in all the other joints
of the body together. The os humeri is most frequently
luxated downwards, from its meeting with least resistance
in 

[507]
in that direction. It is sometimes pushed downwards and
forwards, beneath the pectoral muscle, and between the
coracoid process of the scapula, and the middle of the cla-
vicle and lodged on the ribs. In a few cases, it is dislocated 
downwards and backwards; but it can never be thrown
upwards without being accompanied by a fracture of the
acromion, of the coracoid process, or of both. But al-
though the direction the bone takes depends in some mea-
sure on the resistance it meets with, it also is influenced
by the part which is the immediate seat of the injury.
A dislocation of the humerus is evidenced, by inability
to move the arm; by severe pain being excited on attempt-
ing to bring it near the side; by its being shorter or longer
than the other arm; by feeling the head of the bone; and
by discovering a vacancy beneath the acromion. In order to
ascertain these circumstances, the found arm should be com-
pared with the other.
In long continued eases, the whole arm is apt to become
œdematous, and somewhat insensible from the pressure of
the bone on the lymphatics and nerves.
In simple and recent luxations of the humerus, we may
in almost every instance accomplish a reduction, without
much difficulty; but in long continued cases, all our at-
tempts are frequently rendered abortive, either from the
head of the bone having formed a socket among, and be-
coming firmly connected to, the contiguous parts, or from
a diminution of the cavity of the natural socket. In such
cases, therefore, no great degree of force should be much
persisted in to accomplish a reduction; for besides giving
a great deal of pain, it is apt to render the motion of the
head of the bone in the artificial socket more stiff than it
was before.
It is generally said, that a reduction is more easily effect-
ed when the bone is in the axilla, than when it is pushed
forward beneath the pectoral muscle; and more easily
when 

[508]
when in this situation, than if it is lodged backward be-
neath the spine of the scapula. The latter appears to be
the case; but in the others, I have found no difference.
I have often reduced a dislocated humerus by pressing
back the scapula with one hand, while I extended the
arm gently with the other, bending the elbow moderately,
and raising the arm nearly to a right angle with the body
in such a direction as to prevent either the pectoral or ex-
tensor muscles of the arm from being stretched. A grea-
ter degree of force than can thus be applied is, however,
sometimes necessary. The following is the method by
which I have always succeeded in recent cases: The pa-
tient is seated on a chair, and his body secured by a long
broad belt passed round it, and given to assistants, or tied
round a post; a firm band of leather, four or five inches
broad, and lined with flannel, as represented in pl. xi.
fig. 4. is now to be tied round the arm immediately above
the elbow. The three straps or cords connected with
this band being given to assistants, they must be desired to
extend the arm in the relaxed position we have mentioned,
and in a slow, equable manner, while another assistant
standing behind is employed in pressing the scapula back-
wards. The surgeon himself stands most conveniently on
on the outside of the arm: he is to direct the degree of
force to be employed, and to point out the direction in
which the arm is to be extended; he may also support the
fore-arm, and retain it bent at the elbow, as already
mentioned. As soon as the head of the bone is drawn
past the brim of the socket, the extending force should be
lessened, and the reduction will then in common be accom-
plished by the action of the muscles of the joint; or it may
be effected by moving the arm gently in different direc-
tions. A crack is usually heard on the bone slipping in;
immediate relief is afforded; and the shoulder resumes its
prominency.
The 
 

[509]
The arm must always be extended in that direction
which gives the least resistance: when the head of the
head of the bone is pushed forward beneath the pectoral
muscle, or thrown backward, the arm should be raised
to a right angle with the body; but in the most frequent
kind of luxation in this part, where the bone is fixed in the
arm-pit, the arm should be drawn somewhat obliquely down-
ward. It is to be observed, however, that we should always
vary the direction of the extension as soon as ever we meet
with any considerable resistance.
The mode of treatment I have just recommended
will succeed generally, even in cases of long standing,
where a reduction is practicable; but when a greater
force is required than can be applied in this manner, the
instrument, represented plate III. fig. 1. invented by Mr.
Freke, answers the purpose with more ease and safety
than any other I have seen employed. By this machine
we can make a gradual extension in any direction. For
the mode of applying it, See the plate and explanation.
A great variety of methods, all however much more
objectionable than the one we have advised, have been
practised in the reduction of a dislocated humerus. 1. The
arm being forcibly extended by laying hold of the fore-
arm, the heel of the surgeon is by some directed to be
applied to the head of the bone in order to push it up;
and sometimes a ball, or some ether round substance, is
placed between the heel and bone. By this method the
elbow and fore-arm may be unnecessarily injured; the
muscles which may, and ought to be relaxed, are kept ex-
tended; and the head of the humerus must be often
forced up against the neck of the scapula, or other con-
tiguous parts, and thus tend effectually to counteract the
extension. 2. Others attempt to reduce the bone, by ap-
plying a rolling-pin covered with cloth or flannel, to the head
of the bone while an extension is made. This is liable to a
material 

[510]
material objection just mentioned. And neither this mode
nor the first can be applicable when the bone is luxated
backward or forward, because they can at any rate only
act in raising the bone. 3. It has been a practice with
some to have a towel or girth passed round the os humeri
near its head, and over the head of the surgeon, in order
to raise the bone while the extension is made. This is
objectionable for the third reason mentioned in describing
the first mode.
In order to increase the powers of extension, when
these methods have been fruitless; 4. The amber of Hippo-
crates has been used; but this is liable in a very great de-
gree to the objection to the 3d method. 5. The pa-
tient has been suddenly suspended, by the dislocated arm,
from a ladder or high door. We are told this has often suc-
ceeded. 6. The patient has been suspended by two or
three men standing on a table; and the bone thus reduced
in some instances. 7. The patient has been raised by the
arm by means of pullies fixed in the ceiling of a room.
This has also succeeded in cases where other means have
failed.
All these modes are, however, liable to great objections;
the extension is made in so forcible, sudden, and irregular
a manner, that more mischief is often done to the soft
parts, although defended by flannel or leather, than can be
compensated by the reduction of the bone; and as the
arm must always be extended in the same direction, it must
obviously in some cases give a great chance of fracturing
a rib, the scapula, or the humerus itself.
8. A machine has been invented for conjoining the
power of the amber with the mode just described; this
must necessarily be more dangerous than either of those
methods separately. And, 9. Ropes and pullies have
been employed to dislodge the displaced bone; by which 
as

[511]
as much force as ever can be necessary may be readily
applied.
The swelling, inflammation, and pain, when conco-
mitants of luxation, are to be removed by the usual reme-
dies, but chiefly by the application of leeches.
The round head of the biceps cubiti which passes
through the shoulder-joint, is apt to be separated from
the humerus, and induces pain, stiffness, and unwieldiness
of the arm. The most certain method of reducing it is, to
move the arm in a variety of directions from time to
time; and we know that it is replaced, by an instantaneous
removal of the distress.
In order to prevent the humerus from falling out of
its place after reduction, the best method is to support it
by the sling represented plate XII. fig. 3. until the parts
recover their tone: Blisters and the cold bath, have also
been useful to restore this.
SECT. X.
Of Luxations of the Fore-arm at the Joint of the Elbow.
THESE luxations occur more frequently upwards and
backwards than in any other direction; they can hardly
be produced forward or laterally, without an accompany-
ing fracture of the upper part of the ulna.
Luxations of the fore-arm are readily distinguished,
unless the soft parts have become swelled and inflamed.
When the luxation is backward, the olecranon is felt on
the back part of the arm, and the condyles of the humerus
are pushed forward. When the olecranon is broke, and
the ulna and radius thrown forward, they are also apt to
be drawn upward on the anterior part of the humerus,
and the conyles of that bone are discovered behind. A
complete 

[512]
complete lateral luxation can never occur unless the soft parts
are much lacerated. In whatever way the displacement is
made, the joint becomes immediately immoveable.
In the reduction of these dislocations, the patient should
be seated, and the arm firmly secured by an assistant: When
the bones are luxated backward, the fore-arm should be
moderately bent, in order to relax the flexor muscles; it
should then be gradually extended, and if while this is
done, the curvature of the elbow is proportionably in-
creased, we will seldom fail in the reduction. Where
the olecranon is broken, and the ends of the ulna and ra-
dius pushed forward and drawn up upon the humerus, we
must extend the arm while in a straight position; and the
extension must be continued until the ends of both bones
are pulled somewhat lower than the most depending part
of the humerus, when they will soon regain their situation
by the action of the muscles, or be easily forced into it.
In lateral dislocations of these bones, the extension must
also be continued till they have passed the end of the hu-
merus, and then they may be pushed laterally into their
places. In every variety, the extension should be made
by assistants grasping the arm just above the wrist; and
while this is done, the surgeon should press down the
heads of the bones.
After the reduction, the elbow should be kept mode-
rately bent, and the arm as much as possible at rest, until
the parts have recovered their tone.
Instances have occurred of the separation of the bones
of the arm from each other at both their points of con-
nection; but this has happened more frequently at the
wrist than at the  elbow. It is known by the motion of
the joint being impaired, and the other usual symptoms
of dislocation.
In general, the luxated bone is easily reduced, but it is diffi-
cult to retain it in its place. The best method of effecting this
is 

[513]
is by means of splints, extending from the elbow to the
ends of the fingers, and secured by a roller, and by after-
wards putting the arm in the sling, represented plate XII.
fig. 3.
SECT. XI.
Of Luxations of the Bones of the Wrist.
THESE bones are most readily dislocated outwardly;
and may be displaced either separately or several of them
together, and either at their connection with the arm,
with the metacarpus, or with each other.
The injury is generally ascertained without difficulty;
but in some cases of incomplete dislocation of a single bone,
if the parts are not examined with a great deal of atten-
tion, the symptoms are very apt to be attributed to a sprain,
and the consequence will be a lameness of the limb for
life.
We are generally advised to push these bones into their
places while the wrist is laid flat upon a table; but it will
be better to have it supported by assistants, as we can then
have access to both sides of it. They are to be retained
by splints and bandages, in the manner advised in the last
section; and topical bleeding should be freely used in or-
der to prevent the inflammation which is so apt to come
on.
3T SECT. 

[514]
SECT. XII.
Of Luxations of the Bones of the Metacarpus and Fingers.
DISLOCATION of the metacarpal bones, and of those
of the fingers, do not So often occur as might be expected;
probably from the articulations being So easily moveable
that they readily yield to any force applied to them. They
are detected without any difficulty in every instance.
When the metacarpal bones are dislocated at the wrist,
the best method of replacing them is, to keep the arm
fixed, and to push them downward, while the hand is left
loose. When the first phalanx of any of the fingers is dislo-
cated at the metacarpus, it is to be reduced by one assistant
fixing the hand, while another draws down the dislocated
finger by grasping the first phalanx. Dislocations of the
other joints of the fingers and thumb are to be managed
in a similar manner.
In the reduction of these dislocations it should be ob-
served that the bone should never be pulled down until it
be somewhat raised from the bone contiguous; on account
of the end of it being larger than the middle, which cir-
cumstance might otherwise entirely frustrate the reduction.
SECT. XIII.
Of Luxations of the Femur at the Hip-Joint.
It has been doubted whether a luxation of the femur at
the hip-joint has ever taken place: But I have seen instances
in which its existence has been proved by the patient's be-
ing instantaneously relieved by the efforts of the surgeon.
The os femoris, it is said, may be luxated either upward
and 

[515]
and backward, upward and forward, downward and back-
ward, downward and forward, or directly downward.
The first and third of these have very seldom been met
with; and the most common variety, and the only one I
have seen, is that in which the bone is thrown downward
and forward, and lodged in the foramen ovale. The rea-
son why this is most frequently met with is, that there is
a vacancy in the os innominatum forming the socket on the
interior part, which is covered only by a ligament.
When the luxation is upward and backward, the leg
will be considerably shorter than the other; the great
trochanter will be higher; the knee and foot will be
turned inward, and it will give a good deal of pain to at-
tempt to alter their direction.
If the femur is thrown upward and forward, the leg
will be shortened; the head of the bone will be felt rest-
ing upon the os pubis in the groin; the great trochanter
will be on the upper and anterior part of the thigh, and a
vacancy will be found in its proper situation; the knee and
toes will be turned outwards; and if the dislocation be
not soon reduced, pain and inflammation will probably af-
fect the spermatic cord and testis.
If ever the luxation be downward and backwards, the
leg will be considerably lengthened; the knees and toes
will be turned inwards; and the great trochanter will be
lower than it ought to be. When the head of the bone
passes directly downwards, the leg will be longer and
the trochanter lower, but the knees and toes will retain
their natural situation.
In the most frequent species of luxation, the leg appears
considerably longer than the other; the knee and toes
turn outwards, and cannot be moved inward or outward
without pain; all the muscles of the internal part of the
thigh are tense and painful; the femur cannot be felt on
the outside farther off than the middle of the thigh; a
vacancy 

[516]
vacancy is felt in the usual place of the great trochanter,
which is found farther down and on the anterior part of
the thigh, while the head of the bone is felt a little be-
low the groin.
Recent luxations of the femoris may with proper ma-
nagement be almost always reduced; but for the reasons
mentioned when treating of dislocations in general, those
of long duration often baffle all our efforts.
In reducing this luxation, the extension must vary in its
direction according to the variety of the affection; and the
head of the bone should always be completely raised above
any projecting part of the contiguous bones before any o-
ther attempt is made to reduce it: As this will remove the  
principal impediment to the reduction, if the muscles of  
of the limb be at the same time relaxed, the bone will  
easily be drawn into the socket, when the dislocation is
upward, or pushed into it, when downward.
In the most common luxation of the thigh, where the
head of the bone is pushed downward and forward, I
have succeeded in the following manner: The patient be- 
ing laid upon his back across a bed, and firmly secured by
an assistant or two, a broad strap, or table-cloth properly
folded, is passed between his thighs and over the groin,  
on the found side, and given to two other assistants; a si- 
milar strap is passed around the luxated thigh as near as
possible to its head, the ends of which must be given to  
an assistant standing on the opposite side. The belt, plate   
XI. fig. 4. being previously fixed upon the under part of  
the thigh, the straps connected with it are given to an as-
sistant or two, while the knee is supported by another as-   
sistant with the leg moderately bent. The extension should   
then be made by the assistants who have the charge of the
straps connected to the belt; but it ought not to be carried  
farther than is considered necessary for drawing the head of  
the bone down to the under part of the foramen ovale, which   
may                                                  

[517]
may be effected by a moderate force. The strap round the
upper part of the thigh must be firmly pulled, and the thigh
drawn upward and inward, the assistants standing some-
what higher than the patient, until the bone has probably
cleared the foramen ovale. At this time, the knee should
be moved somewhat inward, and the thigh be pushed up-
ward and obliquely outward, by the assistant keeping one
hand on the knee, while he holds the foot with the other,
keeping the leg moderately bent.
The surgeon may judge that the head of the bone is
sufficiently raised when it appears to be about an inch
higher than when the force was first applied. If it yields
with difficulty, we may suppose that some part of it has
become fixed in the upper part of the foramen; in which
case the force in the direction recommended must be dis-
continued, and the assistants at the knee being directed to
increase the extension downward, it will afterwards be
more easily raised.
When this method fails, and it is judged necessary to
employ greater force than can be thus applied, we may
have recourse to Mr Freke's machine, plate III. fig. 1. or
to ropes and pullies. But it is to be observed, that no as-
sistance of this kind can be necessary when the dislocation
is downward.
The violent distension of the muscles and laceration of
the ligaments of the joint with which this affection must
be necessarily attended, render a great deal of attention
necessary for a long time after the reduction. Bloodlet-
ting, topically, should be freely used according to circum-
stances, and rest should be enjoined until the parts have
recovered their tone.
I do not believe that a subluxation of this joint, as
mentioned by some, can possibly take place, on account of
the roundness of the head of the thigh-bone, and the
narrowness of the brim of its socket.
3 SECT. 

[518]
SECT. XIV.
Of Luxations of the Patella.    
THE patella may be luxated partially or completely,
upward, downward, inward, or outward; and either by
itself, or with the bones of the leg. It cannot, however,
be completely luxated in any direction without a rupture
of the ligament which connects it to the tibia, or of the
tendon of the rectus femoris, which is inserted into the
upper part of it, or of both; and it will be most easily
dislocated internally.
Luxations of the rotula are easily discovered, unless the
parts have become swelled and inflamed; in every case
they produce lameness, and pain, on motion of the knee-
joint.
During the reduction of this bone, the patient should
be placed on a bed or table, and his leg should be kept
extended by an assistant. The surgeon should raise the
bone somewhat, by pressing down the outward edge of it,
previous to an attempt to push it into its place, in order
to avoid the condyles of the femur or the tibia. When
the luxation is complicated with a displacement of the
bones of the leg,  these must be replaced before the pa-
tella can be reduced.
SECT. XV.
Of Luxations of the leg at the Knee-joint.
THE bones of the thigh and leg are so firmly connect-
ed, that they are less frequently separated than those form- 
ing any other joint of the body: They cannot be com-
pletely 

[519]
pletely luxated, unless the teguments, tendons, and liga-
ments which tie them together be ruptured. When how-
ever a luxation happens, it may be produced nearly with
equal ease on either side; but it may occur more readily
backward than forward.
There is no difficulty in distinguishing a luxation
of the knee. It is to be reduced by fixing the thigh
firmly, and extending the leg in as relaxed a position as
possible, until the ends of the bones are entirely clear of
each other, and then pushing them together.
As inflamm tion is more particularly apt to supervene
to this luxation, the patient should observe a strict antiphlo-
gistic course; local bleeding should be freely used, and re-
peated according to circumstances; and the limb should
be kept a considerable time at perfect rest.
A separation of the fibula from the tibia, at one or both
ends, is very apt to be mistaken for a sprain; but an at-
tentive examination will secure us from this. It should
be replaced as soon as possible, and retained by a bandage
until the parts recover their tone.
SECT. XVI.
Of Luxations of the Foot at the Ankle-joint.
THE astragalus may be luxated either backward or
forward, or outward or inward, but it is more frequently
pushed inward than in any other direction. It cannot be
luxated outwardly without breaking the end of the fibula.
Dislocations of this joint are in general easily discovered by
the pain and lameness they produce, as well as by the ob-
vious alteration which they occasion in the appearance of
the foot. They are to be thus reduced: The patient be-
ing placed either on a table or a bed, and the leg with the
knee 

[520]
knee bent, firmly secured by an assistant or two; the foot
is then to be extended in a relaxed posture, until the most
prominent part of the astragalus has passed the end of the
tibia, when it will either slip into its place, or may be easily
forced into it.
Besides the usual antiphlogistic course which we have
recommended in luxations of all the larger joints, it is par-
ticularly necessary here to keep the limb for a considerable
time perfectly at rest, especially when the fibula is broken;
because if the bone be not retained exactly in its situation
till a cure is effected, this important joint may be kept
weak during life, or be rendered stuff and very painful.
Any weakness remaining after injuries of this kind, is
most effectually obviated by a firm thin iron plate applied
along the outside of the leg, and connected with the shoe.
Mr. Gooch has invented a machine for this purpose.
SECT. XVII.
Of Luxations of the Os Calcis, and other Bones of the Foot.
The os calcis is sometimes dislocated laterally, by itself;
and at other times, together with the astragalus, is displaced
at its junction with the os naviculare and cuboids down-
ward, outward, or inward; but hardly if ever upward.
Luxations of these bones are very readily discovered by
the pain and lameness which they always occasion, and by
the alteration of shape in the foot which they induce.
A dislocation of the os calcis is more difficult to reduce 
than that of almost any other bone of the foot: This is to be
effected by fixing the leg in a relaxed position, and mode-
rately extending the foot, previous to attempting the co-ap- 
tation of the bones. 
The 

[521]
The rest of the bones of the tarsus, as well as those of
the metatarsus and toes, are to be replaced when dislocated
by the same general treatment that was recommended in
luxations of the hand.
CHAP. XLIV.
Of Distorted Limbs.
DISTORTIONS of the limbs may originate either
from a diseased state of the bones, or from a con-
tracted state of the muscles, or both. They may occur ei-
ther from an original mal-conformation, or as the conse-
quence of some disease at an early or later period after
birth.
In infancy, as the bones are soft, they may be rendered
crooked by children being made to walk too early. There
are also some diseases which render them preternaturally
soft, so that they readily give way to the ordinary action of
the muscles, as well as to the weight of the body, and
thus lose their natural direction. But the most frequent
cause of distorted limbs is that contraction of the flexor
muscles, particularly in the knee and elbow, which is often
induced by an inflamed state of the joints, from the pa-
tient keeping them constantly bent for a considerable length
of time.
When the distortion originates from an adhesion of the
bones forming a joint, nothing can give relief but amputa-
3U tion.

[522]
tion. (See chap. on Amputation). But when the contracted
state of the muscles and tendons is the cause of it, which
is most frequently the case, we may in almost every in-
stance afford considerable relief: And, where a limb is
crooked from the bone being bent, whether it may have
happened from improper management during childhood,
or from the effects of the rickets, or any other disease, we
may very commonly, by timely attention, either remove it
entirely, or render it much less considerable.
In distortions from contracted muscles, by the use of
emollients and gradual extension, I have relieved, and
sometimes cured, patients who had been lame for several
years, and whose cases had been deemed hopeless. As
emollients, the animal fats and oils are the best; but what-
ever is used must be employed for a considerable length of
time, and in a very ample manner to be beneficial. All the
contracted muscles and tendons, from their origins to their
insertions, must be well rubbed with the substance made use
of, at least half an hour three times a-day; and the limb should
be kept constantly moist with, or as it were immersed in the
emollient, by being covered with flannel well soaked in it.
While the frictions are used, the limb should be slowly,
though firmly, extended to as great a degree as the patient
can easily bear; and an apparatus should afterwards be ap-
plied to prevent the muscles from contracting.
Even where the extension is not necessary, as in joints
merely stiff without any distortion, emollients are often very
useful.
Where the distortion proceeds from the curvature of
a bone, if this is not of long duration, and especially when
it occurs in childhood, we may very frequently remove it
by making a constant pressure, gradually increased, on the
the convex side of the limb, until the bone is brought into
its natural direction. This deformity is most frequently
met with in new-born children, and in ricketty patients;
and 

[523]
and commonly affects the legs. If the bones of the leg
are bent outward, it causes the foot to be turned inward;
and the foot is turned outward when the leg is bent in-
ward: In the latter case, patients are termed Valgi; and in
the former, Vari.
The distortion of the feet in these cases, has by many
been attributed to a diseased state of the ankle; but who-
ever will take the trouble of examining the complaint with
attention, will be convinced that it is, at least in common,
a mere consequence of the affection of the leg; and there-
fore, that our views in its removal must be chiefly directed
to the latter.
The cure of this variety of distortion can only be effected
by a proper application of pressure to the leg-bones. This
is most easily and effectually given by a firm splint of iron
fixed on the the concave side of the leg, and extending
from the corresponding condyle of the femur to the foot,
secured by one or two broad straps passed round both the
leg and the splint. If the splint is covered with soft lea-
ther, and properly fitted to the parts, it gives no uneasiness;
and by drawing the straps tighter from time to time, the
pressure will be gradually increased as above directed.
It is sometimes sufficient to fix the ends of the splint in
the shoe; but in other cases, it is necessary to connect it
with a frame beneath the shoe, and fixed to it, in order to
keep the foot in its proper position.
It is obvious that the treatment of distorted limbs must
be varied according to the particular nature of the case:
this must be left to the judgment of the surgeon
CHAP. 

[524]
CHAP. XLV.
Of Distortions of the Spine.
THE spine may be distorted in various directions;
outwardly, inwardly, or laterally; and, in some
cases, we meet with it in all these directions at the same
time, and in the same person.
This disease arises from external violence; but it is
more frequently a symptom of a weakly constitution.
Besides the deformity which these distortions produce,
they are very apt to injure the health by compressing the
viscera of the abdomen and thorax, and by inducing pa-
ralytic affections of the lower extremities from the pressure
they make upon the nerves. They appear at all ages;
but more frequently about puberty than at any other pe-
riod, and more commonly in girls than in boys. In gene-
ral, the effects resulting from them are observed before
the cause is suspected.
When distortions of the spine occur in infancy, the pa-
tient appears to be suddenly deprived of the use of his
limbs; but at more advanced periods, he complains for
some time of feebleness, and of want of feeling in the
lower extremities. By degrees this insensibility increases;
and he is often observed to stumble, and drag his legs in
walking; nor can he stand erect for any length of time
but with much difficulty. At last the legs become entire-
ly paralytic; and when the spine is thrown much forward,
so as to compress the abdominal or thoracic viscera, diffi-
culty of breathing, and complaints in the bowels to a con-
siderable 

[525]
siderable degree, are induced. In some cases, the paralysis
takes place in a few days from the first appearance of the
disease; and it sometimes becomes gradually less, though,
according to my observation, it is never entirely removed.
When the curvature is first discovered, we sometimes
find that only one of the vertebra; is displaced; at other
times, two or more; and it often happens that where one
bone only has been affected in the beginning, that several
adjoining are seized in the after progress of the complaint;
and, in some cases, there is reason to suppose that the de-
formity is a consequence of an affection of the vertebral
ligaments alone. When one bone only is deranged, the
patient is always rendered more completely paralytic than
when several are affected, and the disease is more speedily
fatal. For in the first case, the patient almost always dies.
Within the course of a year or two, or less; while in the
latter, he frequently lives as long as if no such disease had
subsisted. The difference of pressure on the spinal marrow
necessarily produced, will account for this difference in
the appearances of the disease; and likewise for the symp-
toms becoming in some instances less remarkable in the
course of the complaint than they were at first.
As this affection often proceeds from weakly persons in-
dulging too much in particular postures, every habit of
this kind should be carefully guarded against on the first
appearance of the complaint; and if a particular habit is
is already contracted, its opposite should be advised. That
the body may lie as much as possible upon an equal sur-
face, a hair matrass, laid upon boards, should be used in-
stead of a feather bed.
By attention to these circumstances; by the use of an in-
vigorating diet, the cold bath, bark, and other tonics,
the disease has, in some cases, been prevented from advanc-
ing so far as it probably would have otherwise gone; but
where any of the bones have been affected, I have never
seen 

[526]
seen a complete cure obtained. Mr. Pott speaks highly of
the effects of drains placed as near as possible to the tu-
mor. He advises an issue to be made with caustic, on
each side of it, large enough to admit of a kidney-bean, and
the bottom of the sore to be sprinkled occasionally with
powdered cantharides to keep it running*. I have em-
ployed this method with advantage when the ligaments
were the seat of the complaint; but when it has appeared
to prove serviceable where the bones were affected, I am
of opinion that the change was rather induced by the pres-   
ure upon the spinal marrow being lessened as above ex-
plained. 
All the advantage that can be derived from the use of 
machinery in this disease, must be from the support that
that it can give to the head and shoulders. This indeed
is 
* It may perhaps not be amiss to give a more particular descrip-
tion of Mr. Pott's method: To form the issue he prefers caustic.
He tells us, that the caustic to be applied, should in adults, be large
enough to form an oval eschar of about an inch in length, and nearly
three quarters of an inch in breadth at the broadest part. One should
be so applied on each side of the curvature, that the portion of skin
covering the spinal processes of the protruded bones shall be left en-
tire. In a few days, when the sloughs begin to loosen, the middle of
them should be cut out, and a large kidney-bean, or some peas, put
into each: Upon the entire separation of the eschars, the sores may
be filled constantly with peas or beans; and powdered cantharides,
or some other stimulant may be now and then applied to them;
these will keep them running, and may perhaps produce some other   
good effects.                                                 
The issues should be kept open until the patient has recovered his 
general health. This period will vary exceedingly; in some, cures
have been perfected in two months; in others, in not less than two
years, two-thirds of which perhaps has passed without any signs of
amendment.
Mr. Pott relates many cases in which there could be no doubt
of the bones themselves being diseased, that were perfectly relieved
by the method above described. See Pott's works, VOL. III. 

[527]
is an object of the first importance; and it can be very
well attained by the use of the machine represented in
plate XII. fig. 6. If this point is not attended to, the
weight of the head will constantly tend to increase the
distortion.
CHAP. XLVI.
Of Amputation.
BY the term amputation, we usually understand the
removal of a limb.
This operation in itself is not difficult; but it is often
very hazardous; and it requires the utmost attention to de-
termine the particular circumstances in which it can with
propriety be performed.
SECT. I.
Of the Causes which may render Amputation necessary.
AMPUTATION may be rendered necessary by the causes
enumerated under the following heads.
1. Bad compound fractures.
2. Extensive lacerated and contused wounds.
3. A portion of a limb being carried off by a cannon-
ball, or in any other manner, if the bones be unequally
broken and not well covered.
4. Ex- 

[528]
4. Extensive mortifications.
5. White swellings of the joints.
6. Large exostoses, whether they be confined to joints,
or spread over the whole bone, or bones of a limb.
7. Cases of extensive caries accompanied with bad
ulcers of the contiguous soft parts.
8. Cancer, and some other ulcers of an inveterate na-
ture.
9. Various kinds of tumors.
10. Particular distortions of a limb.
We shall consider each of these cases in the order men-
tioned.
(1.) In cases of compound fractures which occur in
the army and navy, where the patients cannot be duly at-
tended, where they must be much jolted and moved from
place to place, if the bones are so much broken that
when apposed they do not support each other firmly, and
the soft parts are likewise much injured, I am perfectly
of opinion, that, in general, immediate amputation should
be advised.
In private practice, however, where the patient can
from the first be placed in an easy comfortable situation,
from which he need not be removed until the cure is com-
pleted, where can have all the advantages of good air,
a proper regimen, and good medical assistance, very few
cases will occur in which amputation should be recom-
mended. The only cause which, in such circumstances,
can render an immediate performance of its proper, is the
bones a limb, together with the soft parts being so
shattered and bruised, that there will be no chance of the 
member being rendered useful by any attempt that might
be made to save it.
But it is particularly to be observed, that unless the o-   
peration can had recourse to soon after the accident,
it cannot again be admissible for a considerable time; for
I whenever

[529]
whenever a limb has become swelled and inflamed, it can
in no case, but with the utmost danger, be taken off until
these symptoms subside.
And numerous observations have ascertained the fact,
that amputation at this period, i. e. as soon as the inflam-
matory symptoms have gone off, and before the patient has
been too much weakened by the discharge*, succeeds
much better than when it is instituted immediately after the
accident. In the latter case, death seems to be induced,
by the violence of the symptomatic fever, which often-
times induces fatal hemorrhagies; by the great and sudden
change produced in the circulating system; and by the vi-
olent agitation of mind excited by the operation, and which
seems to be more particularly induced at that time.
Although amputation is seldom necessary in private prac-
tice, yet in the subsequent treatment of compound frac-
tures, it is sometimes rendered proper:
1st. By profuse hemorrhagies, which cannot otherwise
be stopped; produced by some of the arteries being
wounded by the ends of the fractured bones, as well as
other causes.
2dly. By extensive mortification. This we shall consi-
der hereafter. And,
3dly. By the ends of fractured bones remaining dis-
united, attended with the discharge of such large quan-
tities of matter that the patient runs a risk of sinking un-
der it.
In every case, when the last mentioned circumstances
occur, and continue, notwithstanding every thing is done
which would probably tend to remove them,  such as the
taking away all loose pieces of bone, the preserving the
limb steadily in one posture, regular dressing of the sore
3X as
* The operation seems to succeed better, whatever may induce a
necessity for it, when the patient is somewhat weakened. 

[530]
as often as seems necessary, allowing a nourishing diet, and
a plentiful use of bark, nothing will so certainly save the
patient as the removal of the limb.
(2.) Wounds not accompanied by fractures of the con-
tiguous bones seldom require amputation: But when-
ever a limb is lacerated, or contused to such a degree as to
have all the large blood-vessels destroyed, there will then be
no prospect that the circulation can be preserved in it, im-
mediate amputation should be advised: Mortification is
particularly apt to occur in such cases. It also happens,
that amputation, although it does not appear necessary at
first, will become advisable afterwards, either from he-
morrhagies which cannot be stopped, extensive gangrene
or large discharges of matter, as in cases of compound
fracture.
(3.) When a portion of a limb has been removed by a
cannon-ball, or some other means, and the bones are much
broken and perhaps splintered, the muscles and tendons
left of unequal lengths, and much lacerated and bruised,
as the operation can be performed in the same time that
the broken and splintered pieces of bones, and the injured
parts of the muscles and tendons can be removed; as it
will make a much less sore, which consequently will heal
sooner and form a better stump than if the original
wound is left, and no amputation employed, I have no
doubt of the propriety of an immediate performance of
the operation*.
(4.) In all cases of mortification by which the whole or
a very great portion of the soft parts of the limb are de-
stroyed, amputation is the only resource. But it should
never be employed until the gangrene has fairly stopped
its progress; and then I am of opinion we should perform
it                                                
* Here the surgeon's judgment and experience can alone deter-
mine the degree of injury which renders amputation necessary.

[531]
it as soon as possible, and without waiting, as advised by
some, for the separation of the diseased parts.
(5.) White swellings of the joints are only to be re-
moved, in some cases, by amputation. The particular cir-
cumstances in which this is advisable are described chap.
III. The cause of the success of the operation in long
continued instances of Hydarthrus, is probably similar to
that above assigned in some cases of compound fractures.
(6.) Certain cases of exostosis, in which the tumor is
productive of much inconvenience and injury to the pa-
tient, and which cannot be otherwise removed, require
amputation. See chap. XLI. sect. iii.
(7.) When an extensive caries is accompanied by ulcera-
tions which have destroyed so much of the soft parts that
a cure cannot reasonably be expected, even if the diseased
bone was removed, amputation is our only remedy. But
we have instances upon record, in which the whole of
some of the larger bones of the extremities have been re-
moved, in young healthy subjects, where the soft parts
have not been very much injured, and cures afterwards
obtained: In such cases there has either been a repro-
duction of bone, or at least the formation of a substance
which supplied its place.
(8.) When cancers on the extremities affect the liga-
ments or bones, and especially if they are extensive, no-
thing but the removal of the limb above the parts affected
can be depended on; and even this sometimes fails. Eve-
ry other species of local ulcer that injures the patient's
health, and which, notwithstanding all the remedies em-
ployed, evidently becomes more extensive, and affords so
large a discharge as might by a longer continuance en-
danger the patient's life, is likewise indicative of amputation.
(9.) Encysted tumors seldom render amputation neces-
sary; but in some instances where they are deep seated,
originating perhaps from the periosteum, they produce
caries 

[532]
caries or even dissolution of the bones, and so injure the
soft parts of the extremity, that the operation is the only
remedy.
We sometimes find part of a limb considerably enlarged
with an uniform hardness in some parts, and in others with
a softness, as if a fluid was collected beneath. This swel-
ling in the beginning usually affects the lower part of the
member, and gradually extends over the whole of it. The
skin at first has its usual colour, but at last it acquires a li-
vid hue. There is no pain in the commencement of the
complaint, but at last it becomes not only painful but ex-
tremely troublesome from its weight. It usually arises
without any evident cause, and often in people who are
otherwise healthy.
Swellings of this kind are at first often mistaken for ana-
sarca; but the effusion into the cellular membrane which
produces them, is tinged with blood, and is of an acrimo-
nious nature. When they are opened, the discharge does
not occasion much diminution in the size of them, and a
painful sore is produced which always accelerates the dis-
ease. Nothing that I have ever seen used seems to retard
its progress; and amputation should always be advised, as
soon as the tumour becomes materially inconvenient; with
me it has always prevented a return of the complaint, when
performed on a sound part of the limb.
Swellings of the aneurismal kind, when very large, and
seated in the ham or thigh, if they have continued so long as
to hurt the texture of the soft parts, inducing an œdema-
tous swelling in them, and so injure the bone, and have had
these effects to such a degree as to preclude all hope of
the parts being restored to health, even if the operation
for aneurism should succeed, admit of no other treatment
than of removal by amputation of the limb.
The aneurism here alluded to, is that which proceeds
from a dilatation of the artery, and in which the coats of the
vessel

[533]
vessel have burst, and a considerable effusion of blood has
taken place into the cellular membrane. In the latter
stages of this affection, the swelling becomes so large, that
the beating of the artery is scarcely, if at all* perceptible;
from which it has sometimes been mistaken for a tumor of
a different kind: The history of the case will, however,
generally lead to a knowledge of its nature.
(10.) Where a limb is otherwise perfectly found, it sel-
dom happens that mere distortion of it can be a sufficient
cause for amputation; but the distress produced by this af-
fection, sometimes induces patients to request the perform-
ance of the operation, when more gentle means fail of re-
moving the complaint.
The difficulty of determining the exact period of the va-
rious above enumerated complaints, at which amputation
should be employed, and the blame which a surgeon is so
apt to incur if he proceeds to the operation while the
smallest doubt remains of its propriety, should induce
every practitioner previous to a performance of it, to re-
quest the advice of some others of his profession, in all cases
where he considers it necessary.
I SECT. 
* In a case of aneurism of the arm from a wound in blood-letting,
operated upon in the Pennsylvania Hospital in the year 1787, and in
which part of the limb was excessively swelled, there was not the least
degree of pulsation in the tumor: notwithstanding that it was evident
to the operator, Dr Foulke, as well as to most others present, it was
the trunk of the brachial artery which was wounded, and it was ne-
cessary to tie a considerable ramification also, which was cut during
the operation, and which was perhaps two inches higher than the
wound of the arterial trunk, the patient recovered perfectly in a
short time. 

[534]
SECT. II.
General Remarks on the Method of Amputating Limbs.
This operation till lately was attended with a great deal
of danger; in the present improved method of performing
it, however, perhaps not more than one death will hap-
pen in twenty cases, even in hospital practice.
The circumstances which, in amputation, more particu-
larly require our attention, are, the choice, when this is in
our power, of the part to be operated upon; the preven-
tion of hemorrhagy; the division of the skin, muscles and
bones, in such a manner as to admit of the stump being
entirely covered with skin; the including the arteries a-
lone in the ligature; securing the teguments in a proper si-
tuation, so as to prevent them from retracting after the
operation; and a proper subsequent treatment of the case.
Next to securing the patient from hemorrhagy, the
most material of these is the saving such a proportion of
the soft parts as will cover the stump, so as to heal the
sore as nearly as possible by the first intention; for with-
out this, the wound produced by the removal of a large
limb is always extensive; the cure accordingly proves te-
dious; and in many cases, the discharge is so excessive,
that the patient's health is irreparably hurt by it. In order
to remedy these inconveniences, various attempts have been
made at different times. At first, the soft parts were cut
down to the bone by one stroke of the knife, and the bone
afterwards sawed at the edge of the retracted muscles. It
was afterwards proposed by Mr. Cheselden to divide the
soft parts by a double incision; first to cut through the skin
and cellular substance, and then to divide the muscles
at the edge of the retracted skin; by this means the saw
was applied higher in the bone, and the stump was better
covered 

[535]
covered both with muscles and skin. Still, however, an
extensive sore was left, which in the thigh seldom healed
in less than three months, and often required five or six;
the stumps were often, from the retraction of the soft parts,
pyramidal; and after they were healed, sometimes an exfo-
liation occurred at a distant period.
To prevent the retraction of the soft parts from the bone,
a roller was applied from the upper part of the thigh to
the end of the stump; and Mr. Sharp, as an additional help
to the cure, proposed to keep the teguments near together
by sutures: But the last method was found injurious, and
the former inadequate.
In consequence of the supposed impossibility of improv-
ing this method of operating so as to shorten the cure, and
prevent a pyramidal form of the stump, about the year 1768,
different surgeons attempted to revive the flap operation,
which had been first practised near a century before by an
English surgeon of the name of Loudham. See section v.
The objections to this method of operating were, however,
so forcible, that it has never been brought into general use.
And practitioners by attention to the common mode of am-
putation have so improved it, that a sufficient quantity of
teguments is saved to cover the whole end of the stump;
and by this means, unless the patient is of a bad habit of
body, or the inflammation induced runs very high, the
whole wound usually heals in the course of two or three
weeks, and the greater part of it, or perhaps the whole,
by the first intention, without the formation of matter.
This I consider as one of the most important improvements
in the modern practice of surgery. I was induced to em-
ploy it from observation of the inconveniences resulting
from the want of attention to the saving of skin in various
operations, but particularly in this; and ever since 1772,
I have made it a constant rule to save as much integument
as possible in all kinds of operations where I conceived it
might 

[536]
might expedite the cure. It was not till 1779, that Mr.
Allanson of Liverpool published an account of his improve-
ment of the common method of amputation, and which
he recommends from the experience of nine years. This
is considered by many as the best mode of operating yet
published; but although by it the wound is chiefly healed
without the formation of matter, yet the reasons to be
hereafter mentioned, induce me to give a preference to the
method I make use of, and which I shall now describe.
SECT. III.
Of Amputating the Thigh.
In amputating either the thigh or leg, the patient should
be placed upon a table of ordinary height, with the legs
and arms secured and supported by assistants.
The flow of blood should then be stopped by the tourni-
quet, in the manner formerly directed in chapter v. and
it is of consequence that in this operation the instrument
should be applied so high, as that the cushion placed upon
the femoral artery should reach the groin. The part of
the thigh at which the amputation is made, must be in a
great measure directed by the state of the disease, but in
every case, as the utility of the limb will be proportioned to
its length, no more of it should be taken off than is abso-
lutely necessary. An assistant now grasping the upper part
of the thigh with both hands, so as to draw up the skin and
cellular substance as much as possible, the operator stand-
ing on the outside of the patient, should divide them with
a circular incision down to the muscles; this may in gene-
ral be done by one stroke of the amputating knife; (pl. ii.
fig. 2.) but in large limbs, it is more easily done by two.
The assistant continuing to draw the teguments upwards,
the 

[537]
the cellular substance connecting them to the muscles be-
neath, should be divided with the edge of the knife, until
as much of the skin is separated, as the operator thinks
will cover the stump completely.
The muscles should now be divided close to the edge of
the retracted skin, and down to the bone, by one perpen-
dicular stroke of the knife, beginning with the muscles on
the inside of the thigh, and continuing it round the limb
till it terminates where it commenced. By keeping his
eye constantly upon the knife, the surgeon may easily avoid
cutting the integuments in making this incision. Instead
of proceeding now to the sawing of the bone, in the com-
mon way, we will more certainly form a good stump if
the muscles be previously separated by the knife from the
bone for about an inch. The whole of the soft parts be-
ing drawn up as far as they have been separated by a re-
tractor,* the periosteum should then be divided, by car-
rying the knife round the bone directly beneath the re-
tractor, carefully avoiding injuring the membrane above
where the bone is to be divided, as it might produce sub-
sequent exfoliations. The saw, (pl. iii. fig. 4.) should now
be applied where the periosteum is cut, and the bone di-
vided by long and steady strokes. During the fawing the
leg should be held very firmly and steadily in the same di-
rection; if it is too much raised, the motion of the saw will
be impeded, and if depressed, the bone will be apt to be
splintered. Should any sharp points or splinters remain,
they ought to be immediately removed with the nippers,
(pl. IX. fig. 3.)
The retractor must now be taken off, and the trunk of
3Y the
* A retractor is usually formed thus: Take a piece of leather, ei-
soft or firm, eighteen inches in length, and about six wide, cut out a
small round on oval piece in the middle, and from the hole thus made
divide the strip to one end. The mode of applying it is too obvious
to need description. 

[538]
the femoral artery being drawn out with the tenaculum, a
sufficient ligature should be made upon it before the tour-
niquet is loosened; all the arterial branches which can be
discovered on loosening the tourniquet, and washing the
wound with a sponge and water, should then be secured;
taking care to leave the ends of the ligatures of a sufficient
length to hang without the lips of the wound. The sur-
face of the wound being well cleared of blood, the muscles
and teguments should be drawn down till the skin com-
pletely covers the stump, and retained in this situation by
an assistant, until a flannel or cotton roller, previously fixed
round the body to prevent it from slipping down, be ap-
plied in such a manner as to support and fix them; for
which purpose it should be passed two or three times
nearly in a circular direction, round the upper part of
the thigh, and should afterwards be continued in a spiral
direction almost to the end of the stump, and moderate-
ly tight. It should then be pinned, as much of it being
left loose as will pass two or three times around the stump.
The ends of the divided muscles being placed with as
much equality as possible over the bone, the edges of the
skin must be laid exactly together, so as to form a straight
longitudinal line along the centre of the stump. When there
are only one or two ligatures, they should be left hanging
out of the inferior angle of the wound; but when there are
several, they should be divided between the two angles, to
prevent the parts from suffering by a large extraneous body
fixed at any one place. An assistant retaining the edges of
the skin in contact, two or three slips of adhesive plaster
must be laid across the stump to preserve them nearly in
this situation: and the whole end of the stump should now
be covered with a large pledgit of soft lint spread with
Goulard's cerate, or the ceratum e lap. calam. Over this
there should be placed a soft cushion of fine tow, and a
compress 

[539]
compress of old linen; and for the purpose of retaining
them, as well as to make a gentle pressure on the stump, a
slip of linen, three inches in breadth, should be laid over
them across the stump. The remaining part of the roller
is to be employed to six this, by passing it two or three times
round the stump; and the pressure formed by the cross
strap may afterwards be increased or diminished at pleasure,
by drawing it with more or less tightness, and fixing it with
pins to the circular roller.
While we are applying the roller, the tourniquet should
be taken off; but it must be replaced immediately after
the stump is dressed. If left loose it gives no uneasiness,
and it enables the attendants to check any hemorrhage
which may succeed; a circumstance which merits attention
for several days after the amputation of any of the extre-
mities. The patient should now be carried to bed, and
the stump, contrary to the usual practice, ought to be laid
somewhat lower than the rest of the body; for this purpose
the bed should be made with a moderate declivity from
above downwards, and nothing should be put beneath the
stump but a little fine tow.
To prevent the limb from being moved inadvertently, as
well as to guard in some degree against the effect of those
spasms which often prove troublesome after this operation,
I commonly fix the stump down to the bed, by placing a
strip of linen or flannel across near the end of the stump,
and another at the upper part of the thigh, and connect-
ing them by pins to the roller, and by pins or pieces of tape
sewed on them to the matrass*, to which tape is also to be
fixed. A basket, or hooped frame, should now be put over
the stump, to protect it from the bed-clothes; and an ano-
dyne ought then always to be given, to prevent or remove
pain and restlessness.
As
* A matrass is much preferable to a feather bed. B.

[540]
As hemorrhagies often happen many hours after the o-
peration, the attendants should be directed to examine the
stump frequently; and if any material discharge takes place,
to tighten the tourniquet so as to restrain it till the surgeon
can attend. This perplexing circumstance has never ta-
ken place in any considerable degree, when the method we
have advised has been employed; but in the old mode of
operating, the large surface exposed to irritation is very apt
to induce spasms, which sometimes terminate in fatal he-
morrhagies. When there is merely a trifling oozing of blood,
it need not be regarded; but if the discharge is so great as
to lead to a suspicion of its proceeding from a large artery,
the dressings should be removed, and the vessel tied.
Troublesome spasms in the muscles of the stump suc-
ceed sometimes to this operation: If these are not taken off
by laying the limb in an easy position, we must trust to
opiates for their removal.
In order to remove the inflammation and tension of the
wound, and the fever, which to a greater or less degree, al-
ways succeed to amputation, it will be proper to confine the
patient to as low a diet as the state of his strength will per-
mit. Where there is much vigour, bleeding should be
used as soon as the symptoms of fever come on, and gentle
saline laxatives should be given. This treatment is seldom
necessary but for a few days; and afterwards would be in-
jurious.
Where the stump is not covered with skin, as in the com-
mon mode of operation, and a free suppuration is expected,
the dressings should not be removed till the fourth or fifth
day; but in the method I recommend, the stump should al-
ways be examined at the end of the third day after the  ope-
ation. For this purpose it should be supported by an assist-
ant, while a few turns of the roller are taken off; and the
dressings totally removed. In a few cases, the parts will be
found to be united by the first intention; but for the most
part 

[541]
part there will be a small quantity of matter all over the
surface of the stump, and chiefly at the lower angle of the
wound; and the parts will be red, tense, and painful to the
touch, with a small separation between the edges of the
divided skin. The surface of the stump should now be
covered with a pledgit of emollient ointment, and a cushion
of soft tow being laid over this, the cross strips of linen and
roller should be again applied.
The wound ought to be thus dressed every other day; *
and generally about the seventh or eighth day, the inflam-
mation will be so far removed, that the ligatures may be
drawn out; at least this should be gently attempted at eve-
ry dressing, because they will now impede the healing of
the wound. While the roller continues clean, it may remain,
but as soon as it becomes sullied with matter, it should be
changed. It should always be employed for three or four
weeks, but if continued longer, it is apt to diminish the
size of the limb.
As soon as the sore becomes clean and begins to granu-
late, the pain and tension being now gone off, the cure
may with propriety be completed by drawing the edges of
the wound together, by means of strips of a moderately ad-
hesive plaster. By this management, even the largest stumps
will generally heal in three or four weeks, often in less,
in private practice, where every desirable advantage can be
had; but in hospitals, where the patient often suffers more
from the bad air, &c. than from the operation, the success
is not so great. In some instance, large sinusses form in
the stump between the teguments and muscles, and retard
the cure considerably; and sometimes a cure cannot be ob-
tained at all, without the assistance of good air and diet.
But for one instance of this kind from the operation we
have described, there will be twenty from the usual mode.
It
* In most parts of the United States, during the summer season at
least, it will be generally necessary to dress more frequently.

[542]
It should not be our object to heal the stump in the first
instance, without the formation of matter; when this is
done, by the use of strong adhesive plasters, &c. the tegu-
ments are apt to be very uneven, and the ligatures are re-
moved with difficulty; but when the cure is accomplished
gradually, as above directed, the ligatures may be easily
taken out, and the stump is always left smooth and equal.
The circumstances of consequence, in which Mr. Allan-
son's method of amputation differs from the mode I have
recommended, consist chiefly in the manner of dividing the
muscles, and the after position of the skin. After separa-
ting as much skin as necessary, he directs a double edged
knife to be applied to the inner edge of the vastus inter-
nus, and at one stroke to cut obliquely through the mus-
cles, upwards as to the limb, and down to the bone, so as
to lay the bone bare about two or three fingers  breadth
higher than is usually done by the common perpendicular
incision; the point of the knife is then to rest upon and
revolve round the bone, while the incision of the muscles
is continued round the limb in the direction that was first
given to it. The quantity of skin saved, and muscular
substance taken out, must be in such a proportion to each
other, that by a removal of both, the whole surface of the
wound will be afterwards easily covered, and the length
of the limb not more shortened than is necessary to obtain
this end.
Mr. Allanson directs the skin and muscles to be placed
over the bone in such a direction as that the wound shall
appear only as a line, with the angles at each side; and,
instead of securing the dressings with a part of the roller,
he directs a manifold bandage to be employed.
I have used this method of operating; but I find it
much more exceptionable than that I have above described.
The removal of such a large portion of muscular substance
as is done by Mr. Allanson's oblique incision, produces a
hollow 

[543]
hollow, which not only retains the matter, but which pre-
vents the stump from being so equal and smooth as when
the skin is supported by a flat muscular surface, in the man-
ner we have advised. Nor is the bone so well covered by
muscle, and the danger of exfoliation so well avoided, by
his method as by that I have described above. But if the
ultimate advantages resulting from both were equal, the
latter mode would claim a preference on account of its
greater facility of performance. It is almost impossible
to avoid mangling the skin in making the oblique incision
of the muscles, and the assistants which Mr. Allanson di-
rects to prevent this, must be apt, not only to embarrass
each other, but the operator.
Mr. Allanson's reason for placing the lips of the
wound transversely is, that after the cure, the cicatrix
will be drawn near the lower edge of the extremity by
the superior force of the posterior muscles, and conse-
quently that the pressure on the stump in walking will be
afterwards made upon the sound skin. But I have found
no inconveniency from the cicatrix being opposite to the
bone, and the lodgement of matter which is so pernicious,
and would probably be so apt to occur from the method
recommended by him, is to me a sufficient reason for pre-
ferring the perpendicular position of the integuments.
SECT. IV.
Of Amputating the Leg.
WHENEVER the state of the disease will admit of the leg
being amputated just above the ankle, it should be always
done in preference to taking it off at the usual place about
four inches below the patella; because the operation is
there performed with more ease and safety to the patient,
on 

[544]
on account of the smaller diameter of the leg and the greater
proportional quantity of soft parts, which enable us to co-
ver the sore more completely, and heal it sooner; and
because machines may be fitted to it which are much
more pleasing to the eye than the wooden ones commonly
used; and with which the patients are rendered capable
of walking very well, as they preserve the use of the knee
joint.
But when this is not admissible, as the cure of a leg
amputated immediately below the knee is always tedious,
owing to the great extent of bone at this part, and the de-
ficiency of soft parts, and as the bone is equally well de-
fended from the pressure of an artificial leg when the ope-
ration is performed above the knee, I would always give a
preference to the latter, when it was optional.
If, however, the usual place is chosen, the same general
directions that were given for the amputation of the thigh,
will apply to the operation here, except that the tourniquet
need not be placed much above the knee, having the cushion
on the artery in the ham: and as the teguments are close-
ly attached to the bone on the fore-part of the leg, they
must be rolled up, when a sufficiency of them is separated,
to keep them out of the way of the knife. The muscles
are to be cut just below the insertion of the flexor ten-
dons of the leg; and the interosseous parts must be divided
with the end of the amputating knife, or with a smaller
knife termed a catline.
In sawing the bones, the instrument should be applied
to both at the same time, to prevent a risk of splintering
them; and in the application of the roller, two or three
turns above the knee will be sufficient.
In operating above the ankle, the most convenient part
is about nine inches below the knee, measuring from the
condyles of the femur, both on account of accomplishing
a speedy cure, and of adapting an artificial extremity to the
3 stump. 

[545]
stump. The cure is usually produced in less than three
weeks, and the surface of the stump will be equal, and co-
vered entirely with sound skin.
SECT. V.
Of Amputating with a Flap.
THIS operation was invented a century ago, in order to
obviate the disagreeable consequences of the usual method
of amputation. In performing it, a flap of skin and muscles
was preserved, sufficiently large to cover the whole stump.
The flap operation was never received into general use,
because it was found difficult to restrain the hemorrhagy,
when it happened to recur after the flap was applied and
fixed in its situation; for, in order to discover the bleeding
arteries, it was necessary to undo the whole; because the
flap was found not to adhere uniformly over the surface
of the stump; and, because the pain and inflammation
produced, was more considerable than that which was con-
sequent to the usual mode.
To remove these objections, Mr. O'Halloran, about the
year 1768, proposed to dress the stump and flap as sepa-
rate sores for the first twelve days; and the risk of he-
morrhagy, and the inflammation, having then gone off, to
secure the flap on the surface of the stump by plasters and
bandages till they united.
By this improvement, the operation was rendered more
safe and certain; and it is probable that it would gradually
have come into general practice, if the improved method
which we have already described, had not in the mean time
been introduced: But, notwithstanding this is generally pre-
ferable, yet, wherever the  divided parts cannot otherwise
be properly covered with skin, the flap operation ought
certainly to be employed. This will be the case in ampu-
tating the arm at the shoulder, the thigh at the hip-joint,
3Z and

[546]
and the fingers or toes. But as some may perhaps prefer
it when the operation is performed immediately below the
knee or above the ankle, or in the arm and fore-arm, it will be
proper to describe the method of doing it in all these places.
SECT. VI.
Of Amputating the Thigh and the Hip-Joint.
THIS has always been considered as a very hazardous
cooperation, and there are consequently very few instances
of its having been performed; but, as in the method I
shall recommend there is very little hazard from he-
morrhagy, and so much skin is saved, that the sore can be
entirely covered by if, and consequently will heal in a
few weeks, whenever, cases occur which would otherwise
terminate in the death of the patient, we should certainly
not hesitate to perform it.
The circumstances which most commonly render this ope-
ration necessary, are, gun-shot wounds, accompanied by
fractures of the upper part of the os femoris, and spina ven-
osa, or caries of the head of it: It may also be proper in
the cases formerly noticed, when treating of amputation
in general.
In performing this operation, the patient should be placed
upon a table, on the sound side, and secured by assistants.
Let the tourniquet be applied as near as possible to the top
of the limb, the femoral artery having the cushion fixed
on it just below Poupart's ligament. Let the integuments
and tendinous fascia of the thigh be divided by a circular
incision, six inches from the top of the thigh; that is, at
least three inches beneath the band of the tourniquet.
Let the retracted skin be pulled an inch upwards; and
then let the muscles be divided at its edge down to the
bone. The arteries are then to be secured. This being
done

[547]
done, take a scalpel larger than the common size, and
commencing at the upper edge of the circular cut on the
posterior part of the thigh, make an incision down to the
bone, and carry it up of the same depth to a little above,
the great trochanter, into the joint. Let a similar cut be
made on the opposite side of the limb, at a sufficient dis-
tance from the femoral artery, and completely down to the
bone. Let these two portions of flesh be now dissected
from the bone, and the flaps formed by them be taken
care of by assistants, while any artery divided, is tied as
soon as it is observed. The joint being laid bare, the femur
must be moved in different directions, and particularly in-
wards, where it yields most readily, from the brim of the
acetabulum being lowest, until it is so far turned out of
the socket as to admit of the round ligament being reached
with the point of a scalpel, or a firm probe-pointed bis-
touri, and divided, when the limb maybe removed.
If the aœtabulum is sound, our prospect of a cure will
undoubtedly be more favourable than if it is carious: But
in whatever state the bones may be, our treatment of the sore
must be so directed as to heal it as much as possible by the
first intention. After removing the coagulated blood, and
placing the muscles as nearly as possible in their natural si-
tuations, the flaps should be drawn together so as to cover
the sore, as completely, as may be; they should be secured
in this situation by three or four sutures, by adhesive plas-
ters, and by compresses retained by abroad flannel roller
passed several times round the body and over the stump;
care being taken to leave the ligatures hanging out of the
wound.
The patient must now be put to bed, and treated as in
other cases, except that a, more particular attention will
be requisite to prevent and remove inflammation and fever:
And it will be proper to advise a very moderate, diet for a
considerable time afterwards. 
The 

[548]
The ligatures may be removed in about ten or twelve
days. Collections of matter will probably be very apt to
form in the stump; and if pressure does not remove them,
they must be discharged by puncture with a lancet.
SECT. VII.
Of the Flap Operation immediately above the Knee.
THIS operation may be performed either with one or
two flaps; but one is commonly to be preferred. The
fore part of the thigh affords the best flap; and it should
be chosen, not only on this account, but because any matter
collected during the cure may be more readily discharged
than when the flap is formed on any other part.
The patient being placed on a table, the tourniquet ap-
plied, and the skin drawn up, the extent of the flap should
be marked with ink. This should be somewhat less in
length than the diameter of the limb, and equal in breadth
to the limb itself; and it ought to be of the same width
all the way to within a little of its termination, where it
should be rounded off so as to correspond with the figure
of the sore on the back part of the limb. The extreme
point of the flap should reach to the end of the limb,
unless the teguments are diseased, in which case it must
terminate where the disease commences; and its base
should be where the bone is to be sawed.
The flap being marked out, the surgeon standing on the
outside of the limb, should enter a straight double edged
knife, with a sharp point, (plate II. fig. 5.) at the outside of
the base of the intended flap, and carrying the point close
to the bone, should push it through the teguments at the
mark on the opposite side. The edge of the knife must
then be carried downwards, in the direction marked out;
and 

[549]
and as it draws towards the end, the edge of it should be
somewhat raised from the bone, so as to make the extremity
of the flap thinner than the base, by which it will apply with
more neatness to the surface of the sore. The flap being sup-
ported by an assistant, the teguments and muscles on the
back part of the limb, should, by one stroke of the knife,
be cut down to the bone, about an inch below where it
is to be sawed; and the muscles being separated from the
bone, to this height, by the point of the knife, the soft
parts must all be separated with the leather retractor un-
til the bone is sawed. The arteries are to be tied in the
usual way; and the muscles and teguments should then
be drawn down, and secured with a flannel or cotton
roller, as advised in the common mode of amputation.
If the flap is to be immediately applied to the stump,
the coagulated blood must be washed from both, and then
they are to be connected by three or four sutures, and
dressed as directed in the last section. The dressings may
be renewed in three or four days; and as soon as the liga-
tures are taken away, and the inflammation has subsided,
any part which was not at first covered, may have the
skin drawn over it and secured by adhesive plasters.
But, when Mr. O'Halloran's method is adopted, the
whole surface of the stump is to be covered by a
pledgit of lint, spread on both sides with some emollient
ointment; the flap is then to be laid on this; and another
pledgit of the same kind being placed over the whole, the
dressing is to be finished in the usual manner. The ap-
plications may be removed in three or four days; and a-
bout the twelfth or fourteenth day, or whenever the in-
flammation has subsided, and the ligatures are taken away,
any matter that may be on the sores is to be removed
with a soft sponge, and the flap is then to be laid down upon
the stump, to be there secured by sutures, or by adhesive
plasters, and the common dressings.
Of 

[550]
Of these two methods, Mr. O'Halloran's seems to me,
to be much the best. The cure is accomplished sooner,
often in three weeks, and it is attended with much less
pain and inflammation, by the secondary union he proposes,
than by attempting to heal the wound by the first inten-
tion, without the formation of matter.
In order to form two flaps, a circular incision must be:
made through the teguments and muscles at the lower
part of the limb, having the edge of the knife turned
obliquely upwards; then let the sharp pointed knife above
mentioned, be pushed through the soft parts down to the
bone on one side, and where the bone is to be sawed; the
under edge of it being then turned obliquely outwards,
let the muscles be divided down to the circular, incision.
A similar flap must be formed on the opposite side of the
limb; and the intermediate parts being divided, the bone
must be sawed, and the wounds dressed as formerly di-
rected.
SECT. VIII.
Of the Flap Operation below the Knee.
THE method of operating here, is nearly similar to that di-
rected to be employed above the knee. We have hitherto been
advised to form the flap on the back part of the leg; but
I would prefer the outside, whether the operation is per-
formed immediately below the knee, or at the distance for-
merly recommended above the ankle, on account of the
matter that will be produced finding a more ready dis—
charge, than when the usual part is chosen.
CHAP.

[551]
SECT. IX.
On Amputating the Foot, Fingers, and Toes.
WHENEVER the whole foot is diseased, it becomes
necessary to take off the extremity at the part we have
mentioned above the ankle, even although the joint be
sound; for if the operation was performed at the ankle,
the wound could not well be covered by skin, and the
length of stump would be inconvenient. But if only
two of the metatarsal bones remain found, and particu-
larly if these are seated internally, the diseased parts alone
should be removed. When the middle of the foot is alone
affected, the bones should be taken off at the joint; be-
cause they are there amputated with more ease, and the
saving of a small portion of them could be of little or no
advantage; but if the bones situated internally or exter-
nally are the seat of the complaint, as it will be an object
to save as much of the foot as possible, they should be
sawed* immediately above the diseased parts.
On account of the friction in walking, it is particular-
ly necessary to save as much skin as will cover the sore in
this operation. A flap may generally be readily formed
for this purpose; if possible, it should be on the under part
of the foot.
The patient should be placed on a table; and the tour-
niquet applied above the knee. While we are sawing the 
bone, a piece of pasteboard, or of thin wood, must de-
fend the contiguous found bone from the teeth of the in-
strument. The subsequent parts of the operation are to be
managed in the usual way. If sutures are employed, they
should 
* A common springsaw (plate 1. Fig. 2.) is to be used in this
operation.

[552]
should be inserted in such a manner as to avoid the flexor
and extensor tendons.
Fingers and toes are usually amputated in the same man-
ner as the larger extremities, either by preserving a flap
sufficient for covering the stump, and afterwards dividing
the bone with a small spring saw, or by the double in-
cision: But it is much better always to cut them off at the
joints. A flap being marked with ink, and dissected
from the bone with a scalpel, a circular incision should
then be made through the rest of the soft  parts, a little
below the joint, and on a line with the base of the flap.
The finger should then be moved, to ascertain the proper
place in which the lateral ligament should be cut; and when
this is divided, the whole may be readily taken off. The
flap is then to be applied, and secured by adhesive plaster, a
compress, and flannel roller. If it is necessary to tye an
artery, the tenaculum should be used.
SECT. X.
Of Amputating the Ann at the Joint of the Shoulder.
THIS operation may be rendered necessary by, abs-
cesses in the joint; caries of the humerus reaching to the
joint; compound fractures extending to the head of the
bone; gun-shot wounds; and gangrene: and may be
performed with safety, by any surgeon of steadiness, ex-
perience, and accurate anatomical knowledge.
It may be done in different ways, but the following
appears to be the best. The patient should be placed on
his back, upon a table covered with a matrass and blanket.
The tourniquet might be used, if the blood could not be
otherwise stopped: But the best mode of guarding against
hemorrhagy, is, for an assistant to place a compress on
3 the

[553]
the subclavian artery, just above the clavicle, and make a
sufficient degree of pressure on it to stop the pulsation at
the wrist.
The shoulder should be made to project somewhat over
the side of the table; and the arm being stretched out,
and supported by an assistant at nearly a right angle with
the body, a circular incision should be made through the
skin and cellular substance, just at the insertion of the del-
toid muscle into the humerus. The teguments may be al-
lowed to retract about half an inch; and the muscles are
then to be divided at their edge down to the bone. A
perpendicular incision should now be made with a scalpel
down to the bone, beginning at the acromion, about half
way between the centre of the deltoid muscle, and the in-
ner edge of it, and terminating in the circular incision, about
an inch above the brachial artery. A similar cut must
then be made on the back part of the arm, at such a
distance from the first, that the two flaps formed by them
may be of an equal breadth. The brachial artery should
be tied as soon as it is cut by the circular incision, and any
arterial branches that may be divided, should also be se-
cured as soon as they are observed. The flaps should now
be separated from the bone, cautiously avoiding the large
artery; and being supported by an assistant, so as to bring
the capsular ligament into view, an opening should be
made into this, the bone dislocated, and the remaining part
of the ligament divided. The flaps are then to be laid o-
ver the joint, and retained in their places by sutures and
dressings, as in other cases.
The subsequent general treatment is to be similar to
that advised in amputation of the lower extremities. With
a view to prevent any risk of hemorrhagy after the ope-
ration, an experienced assistant should sit with the patient
for the first two or three days, with directions to apply
4A pressure 

[554]
pressure above the clavicle, should any considerable quan-
tity of blood be discharged, until the vessel can be tied.
A cure may soon be expected in favourable circum-
stances; as the muscles appear to unite as speedily to carti-
lage as to bone.
SECT. XI.
Of Amputating the Arm.
THE general observations we have made upon the me-
thod of amputating the thigh and leg, apply with the
same propriety to the amputation of the arm and fore-
arm. But it must be observed, that no more of the arm
should be removed than is diseased, because the stump left
is useful in proportion to its length: And there is no ne-
cessity for making a flap; as a sufficiency of teguments
and muscles may be saved, in any part of the arm, to cover
the stump, by the common operation.
CHAP. XLVII.
Of Removing the Ends of Bones in Diseases
of the Joints.
THERE are several instances upon record of the
ends of the larger bones being removed when dis-
eased, and of the deficiency thus produced being supplied
by 

[555]
by nature. Mr. Park of Liverpool has lately proposed
this operation as a general remedy in affections of the
joints; such as injury to them from external violence,
white swellings, and caries. He thinks it will be chiefly
applicable to affections of the knee and elbow, particular-
ly the latter, and more especially when they proceed from
external violence. Mr. Park relates a case of white swell-
ing of the knee in which it was practised with success.
The fore was healed, but not without much perplexity
and distress, in about ten weeks, and the patient has since
been able to do duty on board of a ship, without the aid
of a crutch. The operation was thus performed.
An incision was made, beginning about two inches above
the patella, and continued about as far below it; another,
crossing this at right angles, immediately above the pa-
tella, the leg being extended, was made through the ten-
dons of the extensor muscles, down to the bone, and
nearly half round the limb: the lower angles, formed
by these incisions, were raised so as to lay bare the capsu-
lar ligament; the patella was then taken out, and the up-
per angles were raised, so as fairly to denude the head of
the femur, and to admit of passing a small catline across the
posterior flat part of the bone, immediately above the con-
dyles, taking care to keep one of the flat sides of the point
of the instrument quite close to the bone all the way.
The catline being withdrawn, an elastic spatula was intro-
duced in its place, to guard the soft parts while the os
femoris was sawed; which done, the head of the bone
thus separated was carefully dissected out; the head of
the tibia was then with ease turned out and sawed off, and
as much as possible of the capsular ligament dissected a-
way, leaving only the posterior part covering the vessels.
More than two inches of the femur was taken off,
and above an inch of the tibia; which was just enough
to admit of the leg being brought into a right line with
the 

[556]
the thigh, the previous contraction of the flexor muscles
being such as to keep the two sawed ends of the bones
in contact. To obviate the inconvenience of the redun-
dancy of teguments, a few stitches were passed through
the edges of the transverse wound, as well as that part of
the longitudinal incision that extended up the thigh. The
lightest superficial dressings were applied, and the limb
placed in a case of tin, from the ankle to the insertion of
the gluteus muscle.
Independent of the difficulty of preserving the limb in a
fixed situation; of the inconvenience of a great depth
of wound; and of the collections of matter which must
inevitably take place, there are two other very forcible
objections against this operation: The first is, that where
the bones of large joints are so much diseased as to render
their removal necessary, the surrounding soft parts are in
general so much thickened, inflamed, or ulcerated, as to
render any attempt to save them very uncertain, and much
more hazardous than the amputation of the limb; and the
second is, the high degree of inflammation which common-
ly succeeds to wounds of the larger joints.
To the first objection, Mr. Park replies, that he thinks
this operation will be peculiarly useful only when the dis-
ease originates from external violence: and to the last,
that the operation has been frequently done without any
subsequent violent symptoms; and that when these have
occurred, they have probably arisen principally from a
partial division of the capsular ligaments, and may com-
monly be prevented by their total removal. But we must
observe, that we can see no more propriety in taking off
any part of the capsular ligament, than there would be in
the removal of the tunica vaginalis in the operation for the
hydrocele. Future experience, however, must determine
the propriety of this part of the operation, as well as of
the merit of the operation in general.
CHAP. 

[557]
CHAP. XLVIII
Of preventing or diminishing Pain in Chirur-
gical Operations.
THE pain induced by operations may be lessened, ei-
ther by diminishing the sensibility of the system, or by
compressing the nerves which supply those parts upon
which the operation is to be performed. Narcotics of every
kind might be employed for the purpose of lessening gene-
ral sensibility; but nothing answers this purpose so well as
opium. As this, however, when given in sufficient doses, is
very apt to induce nausea and vomiting, I seldom venture to
exhibit it before an operation. In general it proves most use-
ful when exhibited immediately after, and then it very com-
monly alleviates that pungent soreness of which patients
at this time usually complain; and by continuing to give it
in proper doses from time to time, we are often enabled to
keep the patient easy and comfortable, till relief is obtained
by the formation of matter, or by the removal of the in-
flammatory tension which usually accompanies every capi-
tal operation: And as this tends very effectually to mo-
derate the subsequent febrile symptoms, it should never
be omitted.
The sensibility of limbs is always more or less diminish-
ed, by the compression on the nerves, produced by the
tourniquet, in amputations and some other operations; but
as this answers the purpose very incompletely, it has been
lately 

[558]
lately proposed by Mr Moore, of London, to compress the
principal nerves so completely as to render the parts beneath
altogether insensible. This he endeavours to accomplish by
means of a semicircular plate of iron covered with leather,
having a compress at one end, which is to be applied im-
mediately above the seat of the nerves, and by a screw pas-
sed in at one end.
In order to obviate the inconveniency which must ne-
cessarily arise from the pressure on the veins by this
machine, Mr. Moore proposes to open one of them du-
ring the operation; but as this might be very injurious to
weak patients, it would be much better to have the instru-
ment formed so as to press chiefly upon the nerves; as this,
however, cannot easily be done, on account of contiguity of
the veins to the nerves, perhaps the same purpose may be an-
swered by compressing the arteries of the limb for a minute
or two before any pressure is applied to the veins, by which
the latter may be previously emptied.
CHAP. XLIX.
Of Midwifery,
THE only operations in midwifery which a surgeon is
called upon to perform, are, the cæsarian section,
and the sigaultian operation or invision of the symphysis
pubis. The object of both these is the same, viz. to ex-
tract the fœtus when the delivery of it cannot be effected
either

[559]
either by means of the exertions of the mother, or by the
aid of the common midwifery instruments, on account of a
preternatural narrowness of the pelvis. By the first, an
opening is made into the uterus for the removal of the
child; and by the latter, the diameter of the pelvis is intend-
ed to be increased, so as to allow: the fœtus to pass in the
usual way by the vagina.
SECT. I.
Of the Cæsarean Operation.
This operation has not only been performed when the
pelvis has been so narrow as not to allow the child to pass
out, but also when the child has been forced into the ca-
vity of the abdomen, after a rupture of the uterus, from
this organ contracting too forcibly before the os tincæ has
been sufficiently dilated.
The cæsarean section is directed to be performed, either
with a view to save both the mother and child; to save the
mother only, when we know that the child is dead; or to
save the child immediately after the death of the mother.
As there are but few instances of the mother being sa-
ved by this operation, some have advised it never to be per-
formed, except in the latter case; but if it is proper at all,
it certainly should be employed, not only then, but in both
the other circumstances mentioned, to give some chance of
preventing death, at least to the mother. The following
is the method of performing it.
The patient should be placed on a table, and laid upon
her back, and her hands and legs properly secured by assist-
ants; her head should be moderately elevated with pil-
lows, and her thighs somewhat raised. The operator
standing one side of the table, is to make an incision with
a 

[560]
a scalpel through the teguments of the abdomen, begin-
ning two inches above the umbilicus, on the outer edge of
the rectus muscle, and from thence about six inches
perpendicularly downwards. The uterus is now to be
laid bare, by continuing the cut through the tendinous
parts of the abdominal muscles and peritonæum; and an
opening being then made in the uterus large enough to re-
ceive the finger, a probe-pointed bistouri is to be conduct-
ed upon this, in order to make the cut of the womb as
long as the external opening. The bistouri is also the best
instrument to divide the peritonæum and tendons.
If any large blood-vessel is cut in making the incision,
either of the external parts or of the uterus, it should be
immediately secured by the tenaculum; and the ligature
should be left long enough to hang out at the external
wound. The child must then be taken out, and the pla-
centa, and any blood that may have escaped, removed as
speedily as possible; the intestines, if they have protruded
being then replaced, the external wound should be se-
cured with three or four sutures, as directed chap, XXXIX.
sext. XI. § 3. The wound being covered with a pledgit
of emollient ointment, the abdomen should be supported
by a flannel roller; and the patient should then be put to
bed, and strictly enjoined to avoid speaking and every kind
of exertion. She should be kept cool, and opiates should
be given to obviate pain*.
3 SECT.
* A new mode of performing the Cæsarean operation is recom-
mended by M. Lauverjat, in a volume on that subject, published at
Paris, in 1788. His method is, to make a transverse incision, of about
five inches in length, through the parietes of the abdomen, between
the recti muscles and spina dorsi. The incision must be made on the
right or left side, higher up or lower down, according as the fundus
uteri happens to be situated, after the membranes have been ruptured
and the uterus has had time to contract. The incision of the uterus
ought to be as near as possible to its fundus, and similar in every re-
spect 

[561]
SECT. II.
Of the Division of the Symphysis Pubis.
THIS operation was suggested by there being in some in-
stances, a certain degree of separation of the ossa pubis
during labour; and by the great danger of the operation
described in the last section. It was proposed in the six-
teenth century by Mons. Pinlau, but Mr. Sigault of Paris,
was the first who put it in practice, in 1777.
4B The
spect to that made in the abdomen, with which it will, at first, corre-
spond
Having given directions for the extraction of the child, and the
proper management of the mother, M. Lauverjat enumerates the
advantages which this mode of operating has over that of the longi-
tudinal incision, hitherto in use. 1. In this way, there is at least
two-thirds of the uterus, towards its inferior part, left untouched.
This cavity retains the lochia till discharged in the natural way. The
longitudinal section leaves no such cavity; hence extravasations in
the abdomen, and the death of at least nine in ten of all who have
been operated on in this manner. 2. The transverse incision is more
favourable to the speedy healing of the wound. The uterus, in preg-
nancy, is extended longitudinally more than transversely; and as the
contraction, after delivery, must be in proportion to this previous ex-
tension, the lips of the transverse incision are brought together, and
soon united; whereas the lips of the longitudinal incision have a natu-
ral tendency to separate in every part, except at the angles. 3. The
lips of the external wound are brought together by the most natural
and easy situation of the patient, (the head inclined forward, and the
thighs bent), and their union is facilitated; but let her lie in what
position we may, the lips of the wound, if made by a longitudinal in-
cision, will separate, and it will be impossible to bring them together
without having recourse to the uniting bandage, which he thinks a
dangerous expedient
M. Lauverjat performed the operation, in this way, on three pa-
tients, with success. The names of two other surgeons are given,
who also performed it successfully four times. No unsuccessful case
is mentioned. 

[562]
The operation is easily performed. The patient must
be laid upon her back on a table; the pelvis should be
raised by two or three pillows, and the legs and arms se-
cured by assistants. The bladder should then be emptied
by the catheter, which should be retained in the urethra,
by an assistant, till the bones are divided, in order to point
out the urethra, and thus prevent it from being wounded.
After shaving the pubes, the operator, standing one side
of the patient, should, with a scalpel, make a longitudinal
incision through the teguments of the symphysis of the
pubes, from the upper edge of these bones nearly their
whole breadth: the cartilage by which they are joined
should then be slowly and cautiously divided; which is
easily done on account of its softness.
The bones now recede considerably from each other;
and to prevent this from taking place suddenly and forci-
bly, the assistants should be directed to support the thighs
carefully towards the close of the operation; and if a suffi-
cient opening is not immediately produced, they may after-
wards be cautiously separated.
The child and placenta are now to be delivered in the
usual way; and the bones should then be put together,
and retained in their situation by a flannel or cotton rol-
ler applied round the pelvis and thighs. The patient
should be kept as much as possible in one posture until the
bones have united, which will probably happen in five or
six weeks: But she should not be allowed to walk, or use
any posture which might change the situation of the bones,
in less than nine or ten weeks. The sore in general heals
with light easy dressings.
The only important objection to this operation is, that it
gains so small a space in that part of the pelvis where an
increase of size is most required; between the sacrum and
pubes: For here the difficulty is almost always met with.
After the division, the diameter of the pelvis in this direction
remains nearly the same, although a separation of at least
two                                                  

[563]
two inches* is produced, from side to side. However, as
even this may in many instances be of essential advantage,
and as the operation is attended with no kind of danger,
for it has, in several instances, been repeatedly performed
on the same woman, it should always be advised in pre-
ference to the cæsarian section. And if future experience
should determine that the child may always be delivered in
this manner, it should even be preferred to the mode of de-
livery by the crotchet.
CHAP. L.
Of Opening Dead Bodies.
THIS operation is employed with a view to ascertain
the causes and seats of diseases. In order to do this
with accuracy, every preternatural appearance should be
committed to paper. After noting the internal marks of dis-
ease, we proceed to examine the external parts. When the
disease has been seated in one cavity, we do not open the
others; but when they are all to be examined, it is pro-
per to begin with the head.
The
* Dr. Orne, of Salem, New-England, performed this operation on
a woman who died in child-bed, and found that 2 3/4 inches were gain-
ed without difficulty: a quarter of an inch more might have been
gained. See an interesting publication by the Massachusetts Medi-
cal Association, entitled Medical Papers. 

[564]
The body being placed upon a table, and the head firm-
ly supported, an incision should be made from ear to ear,
across the parietal bones. The scalp is now to be dissected
from the parts beneath; and half of it being turned back-
ward, and the other half over the face, with a common am-
putating saw, we must divide the cranium, beginning on the
os frontis just above the frontal sinusses, and continuing it
all around. The separated part may then be raised with an
elevator. If we wish merely to know whether any water
be contained in the ventricles, the brain need not be remo-
ved; but if our object is to ascertain the state of the brain,
it must be taken out and examined at leisure. The extra-
vasated blood being afterwards removed by a sponge, the
parts are to be replaced and the scalp sewed by the glo-
ver's stitch, or in any other way agreeable to the opera-
tor: For this purpose, narrow tape and a large curved
needle, with a triangular point, are usually employed.
The cavities of the thorax and abdomen are most effec-
tually exposed in the following manner: Let an incision
be made through the integuments from the top of the ster-
num to the umbilicus, and from thence on each side and
through the muscles, to the top of the os ilium; the tegu-
ments and muscles must now be dissected from the ster-
num and ribs, and the cartilages divided with a strong
knife as near as possible to the ribs. The diaphragm be-
ing then separated beneath, the lower part of the sternum
and cartilages connected with it, being raised and turned
upward, the sternum must either be separated from the
clavicles, or cut across near its upper end.
This will bring the viscera fully into view, and most of
them may then be examined without being removed;
if, however, much accuracy is requisite, all or any part of
them may be taken out, as may be judged necessary.
To prevent the effusion of blood or excrement, two
strong 

[565]
strong ligatures should be passed, at the distance of an inch
from each other, round the lower part of the intestines and
large contiguous blood-vessels, and round the trachea,
œsophagus, and large blood-vessels of the neck. The
parts between the upper and lower ligatures being divided,
all the viscera may then be easily removed by dissecting them
from the contiguous parts, and raising them up as we go
along. When the necessary examination has been made,
the effused blood all washed off with a sponge, and the vis-
cera replaced, the teguments must be drawn over them,
and stitched neatly together.*
In opening diseased bodies, the operator should be very
cautious to avoid wounding his fingers and hands: Death
has been the consequence of neglecting this.
CHAP. LI.
Of Embalming.
EMBALMING, formerly so much in fashion, is now
seldom employed, except for preserving bodies from
putrefaction, during the interval between the death and bu-
rial of the person, when this is to be unusually long. The
following is the present method of performing it. The
brain, and all the viscera of the thorax and abdomen be-
ing
* The glover's stitch is generally employed for this purpose; and
in performing this, either a straight or curved needle may be made
use of. 

[566]
ing removed in the manner mentioned in the last chapter,
they are all, excepting the heart, put into a leaden box with
a considerable quantity of an aromatic antiseptic powder,
prepared with, myrrh, frankincense, cloves, the leaves of
lavender, rosemary, mint, and other similar articles; and
to these are added some of the odoriferous oils. The
blood being taken out of the different cavities, and the
heart replaced, they are all filled with a due proportion of
odoriferous oils or spirits, and the parts afterwards sewed
up. By some, the mouth and nostrils are stuffed with
these powders and oils; and incisions are made into all
the fleshy parts of the body, which are also stuffed with
them, and sewed up: but there is no necessity for this,
unless the body is to be kept for a considerable length of
time, or to be carried a considerable distance; in which
case, the trunk and extremities are firmly rolled up with
bandages, and the whole varnished.
The body is afterwards to be covered with cerecloth*,
secured by tapes or ligatures; and it is then dressed, and
either laid in a coffin, or exposed to view, according to cir-
cumstances.
CHAP.
* The cerecloth is made of linen dipped in a composition of wax,
oil, and rosin, and coloured with verdigris, or red lead.
 

[567]
CHAP. LII.
Of Bandages.
BANDAGES are employed, for the retention of dres-
sings; for stopping hemorrhagies; for removing de-
formities; and for effecting the union of divided parts.
A proper application of bandages is an object of consi-
derable importance; but as it can only be acquired by ma-
nual practice, we shall merely offer a few general observa-
tions on the subject.
1. Bandages should be formed of such materials as are
sufficiently firm for effecting the purpose for which they
are employed, at the same time that they will sit with ease
upon the parts to which they are applied. Hence they
must necessarily be of different materials in different cases.
Thus bandages for herniæ must be very firm and elastic;
while in general, those bandages made of cotton, linen,
or flannel, will serve every purpose. Till of late, linen
was usually employed for bandages; but experience has
now shewn that cotton and flannel are preferable. They
absorb moisture more readily, whether produced by
sweat, or the discharges from sores, at the same time that
they are better calculated, from their elasticity, for yielding
to the swelling which often takes place in fractures and
other injuries.
2. Bandages should be applied just tight enough to effect
the purpose for which they are intended, without incurring
3 any 

[568]
any risk of impeding the circulation, or doing harm in any
other manner.
3. Bandages should be applied in such a manner that
they may be easily loosened, and the parts examined with
accuracy. Hence, in fractures of the thigh, and leg, where  
the limb cannot with propriety be frequently raised, we     
now prefer the manifold bandage to the roller.
4. Bandages should always be laid aside as soon as they
have accomplished the purpose for which they were made    
use of; as they may often do harm afterwards by impeding   
the growth of the parts.
5. The bandages used for effecting different ends in the
same parts must necessarily be different; and those with
the same view in different parts of the body must also vary.
As all the variety of bandages in use are mentioned in the
course of the work, and generally their particular applica-
tion, we shall, in this place, do little more than give a ge-
neral enumeration and description of them.
1. The night-cap, with a band to tie it before, and ano-   
ther behind.
2. The radiated bandage; a roller applied in a crucial  
form over the forehead, top, and back of the head, and un-
der the chin.
3. The uniting bandage; formed of a long roller with
two heads, with a slit or opening in the middle, through
which one of the heads is to be passed.
4. The common roller*: When this is employed for
one of the eyes, it is termed monoculus; when for both, bi-  
noculus.                                               
5. The four-headed roller. This is formed of a long
piece of linen, or other material, divided lengthways, ex-
cept for a little space in the middle of it, in the center of  
which                                               
* In general, the width of rollers may be from one and an half to    
two and an half inches, according to circumstances. 

[569]
which is an oval hole; and is employed in fractures of the
lower jaw. The undivided part is applied to the chin, the
end of which projects through the hole. The two supe-
rior heads are then carried backwards over the occiput,
and returned forward over the os frontis, where they may
be pinned. The lower heads of the roller being reflected
over the chin, are then carried to the top of the head, and
there fastened.
6. The napkin and scapulary. The napkin is about six or
seven inches broad, and when used for the retention of
dressings, should pass but once around the body, and be tied
before by pieces of tape; but when it is employed for a
fractured rib, it should go several times around. It is to
be placed immediately below the arm pits. The scapulary
consists of a slip about three inches broad, and of a length
sufficient to reach from the upper part of the napkin be-
hind, and pass over the shoulders to be connected to it be-
fore; and has the anterior end of it longitudinally di-
vided, the slips being carried on each side of the head.
7. The bandage for compressing the abdomen after the
paracentesis. See pl. xi. fig. 5. and explanation.
8. The truss for herniæ. See pl. vi. fig. 4. and expla-
nation.
9. The suspensory bandage for the penis and scrotum.
This is formed by a small pouch of linen or flannel, or
what is perhaps better than either, of cotton, connected to
a circular bandage passed round the body,  either before
only, or both behind and before.
10. The T bandage. Formed of a strap passing around
the body, to which a broader piece is connected, and slit
longitudinally for better than half of its length; these slips
pass from behind, on each side of the penis and scrotum,
and are pinned to the anterior part of the circular strap. 
11. The manifold bandage. This is formed generally
4C of 

[570]
of six or nine slips of cotton, linen, or flannel, connected
in the middle by another slip, in the manner represented in
pl. xi. fig. 2.*
* This form of bandage is thought by some to be improved, by
having the opposite tails or slips connected so as to form a very obtuse
angle: This makes them apply more neatly to the limb.
THE END.

EXPLANATION of the PLATES*.
PLATE I.
Fig. 1. Represents the instrument termed a trepan.
Every part of it is here represented about one-third less
than the proper size. The upper part of the handle AA,
is made of wood; all the rest of polished steel. B is the
saw. C, the nut of a screw which fastens the upper part
of the saw, which is in the form of that of the perforator,
fig. 7. to the handle of the instrument. D, the nut of
a screw passing through a slit in the handle, and fixed in
the upper part of a moveable pin, E. By pushing up this
nut, the pin is raised so as to be no impediment to the saw-
ing, after the perforation is deep enough to render it  un-
necessary. This pin is usually screwed into the bottom of
the head, and is then to be removed by the key, fig. 6.
The trephine, which is commonly made use of in this
operation, only differs from the trepan, in the form of the
handle; the part of this connected with the saw being
straight, and on a line with it, and the wooden part cros-
sing this at right angles.
Fig. 2. The stand of the levator fig. 5. In using this
instrument, the pin on the moveable ball in the frame, is
to be fixed in one of the holes of the levator: The ball
should be easily moveable in every direction; and the
frame is to be held steadily during the operation.
Fig. 3. A lenticular. This instrument is sharp on one
side,
* In the arrangement of the figures in the plates, the principal ob-
ject has been, to introduce as many as possible; but in describing
them, the instruments particularly, connected as to their uses are
generally explained in succession, without regard to their numerical
distribution. 

[ii]
side, and the button at the end is hollow for receiving the
pieces of bone scraped off.
Fig. 4. A raspatory, for removing the pericranium.
Fig. 7. A perforator, for forming a hole for the recep-
tion of the pin of the trepan. The head of it is to be ex-
actly of the size of that of the saw, as it is connected to the
handle of the trepan in the same manner.
Fig. 8. A common gum lancet.
PLATE II.
Fig. 1. Forceps for removing the bone, in the operation
of trepanning. They are not here represented of the full
size.
Fig. 2. An amputating knife. This instrument is dif-
ferent in form from the Common knife, delineated by Mr.
Bell: It serves for every mode of amputation, and renders
the catlin totally unnecessary. It may be about a foot in
length, including the handle, and an inch and a quarter in
breadth at the broadest part.
Fig. 3. A small spring saw, used in amputating the fin-
gers or toes.
Fig. 4. Forceps for extracting polypi from the nostrils.
This instrument should be somewhat curved when used
for polypi in the throat. See chap. xxxi. sect. 4.
Fig. 5. An instrument invented by Dr. Hunter, of Lon-
don, for applying ligatures around polypous excrescencies
in the uterus.                                               
PLATE III.
Fig. 1. Mr. Freke's machine for reducing luxations.
In order to render this instrument readily portable, it is
divided in the middle, and the two halves are connected by
brass hinges at C, and by two hooks and eyes on the o-
ther side of it. It thus forms, when shut, a box only one
foot 

PLATE II.

PLATE III.

[iii]          
foot eight inches long, nine inches broad, and three inches
and a quarter deep. When one end of it is fixed on the
ground, the other stands high enough to become a fulcrum
or support to the lever B, which is fixed on the roller E
by a large wooden screw, which turning side-ways, as
well as with the roller, forms a circumrotatory motion, so
that it may serve to reduce a luxation either forward,
backward, or downward.
The roller on which the lever is fixed, is just the dia-
meter of the depth of one of the boxes, and into it are
driven two iron pins, the ends of which are received by the
sides of the box, which are an inch thick.
The lever is two feet four inches long, and is cut, and
connected again by hinges at C, to fold up so as to be con-
tained in the box: On the back part of it is a hook to keep
it straight; one end of it is to hang over the roller G, an
inch and an half, which is to be excavated and covered
with buff leather, for the more easy reception of the head
of the os humeri.
The iron roller E has two holes through it, for receiving
two cords from a brace, fig. 2. fixed on the lower part of
the os humeri. This roller has a square end on which is
fixed a wheel D; notched round, which works as a rotchet
on a spring ketch under the lever, by which it is stopped
as it is wound up with a winch; so that at pleasure it may
be let loose by discharging the ketch. 
The brace, fig. 2. consists of a piece of buff lea-
ther, large enough to embrace the arm, sewed on two
pieces of strong iron, curved plates riveted together, one
of them having an eye at each end to fasten two cords in;
the other is bent at the ends into two hooks, which are to
receive the cords after they have crossed the arm above.
In order to keep the patient steady in his chair, and to
prevent the scapula from raising or depressing the lever,
after the limb is drawn forward by the winch, there must
be 

[iv]
be fixed over the shoulder, a girth, with two hooks at the
end of it: This should be long enough to reach the floor
on the other side, where it must be hooked into a ring
screwed into the floor.
Mr. Bell observes, that the strap or girth presses down
the scapula, and thus impedes the reduction; he there-
fore proposes, that it should either be altogether want-
ing, or made with a slit to pass over the arm, so as to
draw back the scapula, and instead of passing obliquely 
downwards, that it should go straight across, and be fixed
in a post on a line with the shoulder. The lever of this
instrument should, he thinks, be fixed, so as to serve only
for support to the arm; or if it is ever used as a lever, it
should be managed with the utmost caution; but this ap-
pears to him both dangerous and unnecessary.
The great advantage of this machine is, that we buy it
are able to apply any necessary force in the most gradual
manner, and in any direction.
Fig. 3. A screw tourniquet. Every part of this in-
strument is here represented of the full size; it may be
made either of brass or steel; and the strap connected
with it ought to be of very firm materials, at least an inch
broad, and of a length rather more than sufficient to pass
round the largest part of the extremities.
As an improvement on this instrument, as here repre-
sented by Mr. Bell, a small screw has been made to pass
through the upper part of the large female screw, so as
to enable the operator himself to keep the strap fixed to
any degree of tightness.
Fig. 4. An amputating saw. This should be about
seventeen inches in length, including the handle, and two
inches and a quarter in breadth, at its broadest part.
Fig. 5. A common sound or staff, used in searching
or sounding for the stone.
Fig. 6. A grooved staff for the operation for lithotomy.
The



PLATE IV.

[v]
The groove is here represented on the side, which is prefer-
red by some, to having it on the back, in the usual way.
The termination of the groove should always be perfectly
free and open, otherwise it will be difficult to disengage
the gorget from it; and its edges ought to be very smooth.
If the instrument has a greater degree of convexity than
here represented, it is not easily introduced, and always
injures the urethra.
A staff for a full grown subject should be twelve inches
long, besides the handle; and for children of seven years
and under, should be from seven to nine inches long.
PLATE IV.
Fig. 4. A gorget somewhat different from the usual
form which is represented by Mr. Bell. This instru-
ment only differs from the common gorget in the con-
struction and direction of its handle. The handle is made
of wood, and is in the same general direction with the blade,
but bent downwards, so as to form a very obtuse angle
with it. In the common gorget, the handle is made in the
manner of that of the cutting director in plate v.
For adults, the gorget should measure from A to B,
five inches and an half; and at its widest part one inch.
The beak should be turned a little forward, and should
be carefully adapted to the groove of the staff with which
it is used.
Fig. 3, 6. Different forms of forceps for extracting the
stone. For adults, they should be ten inches long. Their blades
should not meet when shut, and the teeth should be small,
forming merely a roughness, and be confined to within an
inch of the extremity of the instrument. These circum-
stances will save the bladder from injury, and prevent small
stones from being fixed near the joint, and thus dilating
the instrument.
Fig. 5.

[vi]
Fig. 5. A scoop for removing small pieces of stone that
cannot be taken up by the forceps.
Fig. 1. A probang, for pushing substances fixed in the
œsophagus into the stomach. It consists of a piece of
soft sponge, firmly tied to a piece of flexible polished
whalebone, from fifteen to sixteen inches long.
Fig. 2. A double cannula for removing polypi from the
nostrils. When the polypus is seated in the throat, a ca-
nnula somewhat curved at the end, answers better than the
straight one here represented.
PLATE V.
Fig. 1. A side view of Mr. Bell's cutting-director. It
should be, for an adult, five inches from A to B, and
three inches from B to C.
Fig. 4. A front view. This instrument, in the grooved
part, should be exactly three-eighths of an inch broad, viz.
from D to E; and the cutting part of it from F to G,
should measure nearly an inch.
Fig. 7. A view of Frere Cosme's instrument for litho-
tomy, opened. If the spring C is pressed upon, so as to
raise it out of the nitch B, (of which nitches there are se-
veral) as the handle A is made to move upon a pivot, it
may be turned, and the projecting part of it D, being
turned entirely round, and pressure applied to E, it will
raise the knife F to the elevation here represented. The
point G should be made blunt and round, so as to run
freely in the groove of a staff. The length of this instru-
ment, including the handle, should be ten inches.
After making the incision with this instrument, the
forceps may either be introduced upon the forefinger, or
upon a blunt gorget. It is asserted that a wound of any
determined size may be formed by this lithotome cachée,
as it is termed: And it is preferred by some to the gorget, be-
1 cause 

PLATE V.



[vii]
cause it makes but one cut, while with the gorget, if the
greatest care is not employed we will be very apt to make
two: This, however can only arise from inattention. See
page 175 to 183.
Fig. 8. A silver canula of a flat form, for compressing
the arteries cut in lithotomy which lie too deep to be tied.
This tube should be four inches in length, and an inch
broad: The holes in the brim of it are for the purpose of
connecting it, by pieces of tape, to a circular bandage passed
around the body.
Fig. 5. A male catheter of silver. The holes near its
extremity answer better than a slit, which is sometimes
made, as with these it is not so apt to be entangled with
the urethra. Female catheters are usually made straight,
or with a very small degree of curvature; and rather more
than half the length of the male. The female found should
always be curved. Catheters have been also made of lea-
ther, of flexible wire rolled into the form of a tube, and
covered with bougie plaster, and of the caoutch ouc or e-
lastic gum or resin.
Fig. 2. A machine for injecting tobacco smoke by the
anus. A is a brass box for containing burning tobacco,
screwed on a small brass tube, which is connected to an
elastic leather pipe, wound round with brass wire B, and
which is again fitted to a common glyster-pipe C. In
both ends of the box there is a division of thin brass, per-
forated with small holes; one, for the admission of air, and
the other, for the transmission of smoke. To the box, a
pair of double bellows is to be connected.
The bellows should be of the common size. The box
should be an inch and an half in diameter, and three inches
in length: the brass tube should be six inches in length,
and a quarter of an inch in diameter. The leather pipe
ought to be nearly of the same diameter with the tube, and
4D about 

[viii]
about two feet and an half in length. The glyster pipe
should be somewhat larger than those in common use.
Fig. 3. A hook for enlarging the foramen ovale, in her-
niæ of that part.
Fig. 6. A silver canula, for introducing into the ure-
thra after amputating the penis.
PLATE VI.
Fig. 1. A new form of speculum oculi. The handle of 
it may be made either of steel or of wood, but the rest
of it should be either of silver or of finely polished steel.
In order to enable those who think it the best practice to
withdraw the speculum, in operating for the cataract,
while the knife or needle is in the eye, a vacancy may be
left in the circular part.
Fig. 2. A bandage for the eyes. It consists of two
pieces of polished wood excavated into the form of cups,
and covered with a black or green ribband *.
Fig. 5. A couching needle, to be used with the right
hand in operating on the right eye.
Fig. 7. A flat oval couching needle.
Both of these instruments are represented of the full size.
The handles should be made of light wood, and the steel
part should be exquisitely polished. Neither of them
should exceed forty grains in weight.
Fig. 8. A flat probe, made of gold or silver, for in-
serting through the pupil, in order to tear an opening in
the capsule of the crystalline lens.
Fig. 3. A flat round-pointed needle, somewhat sharp
at the end, for passing a ligature around the artery, in
cases
* This bandage, with the difference of having a small perfora-
tion made opposite to the pupil of each eye, might be used in cases
of strabismus in children. 

PLATE VI.

PLATE VII.

[ix]
cases of aneurism, and a round the spermatic cord, in extir-
pating the testis.
Fig. 4. A spring or steel truss, for an inguinal herniæ
of the right side. There is a bolster or pad, for pressing
upon the opening through which the parts protrude, at
one end, and the leather with which the steel is covered, is
formed into a strap having several perforations near the
end, for connection with the knobs on the back of the pad.
They sometimes have a strap to go between the legs, but
this is in general unnecessary: and are necessarily double
when there is a hernia on both sides.
Fig. 6. A curved probe to be inserted into the lachry-
mal puncta.
Fig. 11. A curved probe to be inserted, by the nostril,
into the nasal duct of the lachrymal sac.
Fig. 9. A small tube, of the size of the lachrymal
puncta; injections are thrown through this into the sac.
The injections are thrown into this tube by a syringe, with
a long and small pipe.                      
Fig. 10. and 12. Instruments employed by Mr. Pel-
lier in the operation for fistula lachrymalis. Fig. 10. is
the tube for leaving in the passage. Fig. 12. B is the per-
forator introduced through A the compressor.
PLATE VII.
Fig. 1. A sharp curved probe for removing the crystalline
lens in the operation proposed in page 294.
Fig. 2. One of the best forms of the knife used in the
operation of extracting the cataract. It should be tolera-
bly strong, and highly polished. Near the point, both sides
of it should be sharp, by which the cornea is more easily
penetrated; but the other part of the back should be
round, which gives strength to the instrument, and lessens
the risk of hurting the iris.
Fig. 

[x]
Fig. 4. A knife of a similar form with the former in the
cutting part, but curved, for performing the operation on
the right eye with the right hand. 
Fig. 8. A scoop for removing either the whole or any part
of the lens, when it lodges in the pupil, or in the anterior
chamber of the eye between the iris and cornea, in at-
tempting its extraction.
Fig. 3. A blunt curved bistouri.
Fig. 5. One of the best and most useful forms of curved
needles. It should have no edge on its concave part, and
be made somewhat round like a lancet, on both sides.
Fig. 6. A tenaculum.
Fig. 7. The canula of the trocar, fig. 10. The trocar
here represented is of the form of a flat oval; and pene-
trates with much more ease than the common round tro-
car with a triangular pointed stilette.
Fig. 9. A hook for separating the eye-lids. It should
be made either of polished silver or steel.
PLATE VIII.
FIG. 1. A scarificator for opening abscesses in the throat,
and for scarifying the amygdalæ. The wings to the ca-
nula, are for compressing the tongue.
Fig. 2-5. An instrument for stuffing hollow teeth with
gold or lead, or for burning the nerve of a tooth.
Fig. 3. Mr. Mudge's inhaler, for conveying steams of
warm water, and other liquids, to the throat and breast.
When used, the grating A ought to cover the hole near it
which shews the passage to the valve. Fig. 6. A section
of the cover, in which is shewn the construction of the
cork valve B, and also the conical part C, into which the
flexible tube D is fixed.
When the inhaler, which holds about a pint, after being
three parts filled with hot water, is fixed in the arm-pit,
under the bed-clothes, the end of the tube E is to be ap-
plied 

PLATE VIII.



[xi]
plied to the mouth; the air, in the act of inspiration, then
rushes into the apertures F, and passing through the hol-
low handle, and afterwards into a hole in the lower part,
where it is soldered to the body, and therefore cannot be
represented, it rises through the hot water, and is received
into the lungs, impregnated with vapour. In expiration,
the contents of the lungs are discharged upon the surface
of the water; and instead of forcing the water back
through the hollow handle, the air escapes by lifting the
round light cork valve B, so as to settle upon the surface
of the body under the bed-clothes. Thus respiration is
completely performed without removing the instrument
from the mouth.
The flexible part of the tube D, is about six inches long,
and fitted with a wooden mouth-piece E, at one end, and a
part G of the same materials at the other, to be received into
the cone C on the cover. This flexible tube is made by
winding a long slip of silk oil-skin over a spiral brass wire.
This should be then covered with a slip of the same size of
thin silk, and both secured by strong sewing silk, wound
spirally round them.
Care should be taken that the different parts of this ma-
chine be closely fitted to each other: And it is necessary that
the area of the holes on the upper part of the handle,
taken together, the size of the hole in the lower part of the
handle and which opens into the inhaler, the opening of
the conical valve itself, and that in the mouth-piece, as well
as the cavity or inside of the flexible tube, should be all
equally large, and of such dimensions, as to equal the size
of both the nostrils: And thus respiration may be perform-
ed with ease.
Fig. 4. A small scoop; the most convenient instrument
for removing peas, and other substances, which may get
into the nostrils or ears.
Fig. 7 Is a representation of a species of forceps, of
which 

[xii]
which Mr. Bell gives no figure. They are very conveni-
ent for the purpose of supporting the parts during a dis-
section, and answer tolerably well for drawing out blood-
vessels, when the use of forceps is thought advise able. The
pin rather higher than the middle of the instrument, is ri-
veted to one blade, and passes through a small perforation
in the other; its use is to keep the blades directly ap-
posed.
PLATE IX.
Fig. 1. A broad flat needle, for introducing cords of
setons.
Fig. 2. An acoustic, or instrument for concentrating
found in cases of deafness: Of this there are various forms.
Fig. 3. A pair of nippers, or cutting pliers, for remov-
ing splinters of bone.
Fig. 4. A pessary. Pessaries may be made of any firm
wood, and should be very highly polished. Before intro-
ducing them, they should be oiled, and have a string con-
nected to them, in order to admit of their easy removal.
The pessaries made of sponge immersed in glue, or melted
wax, compressed till cold, and then cut into proper forms,
answer very well, and particularly if covered with soft
waxed linen, to hinder them from fretting the parts. Those
of the elastic resin lose their elasticity too soon.
Fig. 5. A flat pin for the operation of the hare-lip. The
end of the pin should be of gold, and the point of steel.
Fig. 6. and 7. Two different forms of scaling instru-
ments, for removing tartar, and other matter from the
teeth. There is much variety in the form of instruments
of this kind.
PLATE 

PLATE IX



[xiii]
PLATE X.
Fig. 1. A director. Fig. 2: A pair of crooked scissars.
Fig. 3. A pair of Forceps. Fig. 4. A seton probe: This
is sometimes made small and pointed at one end, instead of
having an eye. Fig. 5. A scalpel: When this is intended
for a pocket case, the handle must be made in the manner
of that of the bistouri. (pl. vii. fig. 3.)
These instruments, with the bist ouri, a tenaculum, (pl.
vii. fig. 6.) a scarificator, or gum lancet, (pl. i. fig. 8.) a pair
of straight scissars, a case for caustic and red precipitate, a
spatula, and a few crooked needles, form a complete set
for a pocket case.
Fig. 6. A fracture  box.* A A. The base or bottom,
formed of deal an inch and an half thick. BB, the two ends
rising from the base, and terminating in the pillars CCCC.
Thee may either be fixed to the pillars, or, in order to ren-
der the machine portable, be made moveable, and fixed for
use by a double pin at each end F. DD, an excavated move-
able piece of wood for supporting the fractured limb. This
part of the machine may be raised to any height by the pins EE
passing through the holes in the pillars CCCC; and it may
at pleasure be raised at one end, and depressed at the other.
HH, two straps connected with buckles on the opposite
side for fixing the limb  after it is properly placed. Be-
fore laying down the leg, the dressings should be all ap-
plied, and the excavated part of the box  lined  with soft
wool.                                                  
* This machine is seldom made use of in this place. Compound
fractures are dressed as lightly as possible, with the bandage and
splints used in simple fractures. A third splint, applied to the back
of the leg, in fractures of this part, will enable the patient to lie on
his back occasionally, and thus answer in some degree the intention
of the fracture box.

[xiv]
wool. G, a hole for receiving the heel, to prevent it from
being hurt when the leg is stretched out.
PLATE  XI.
Fig. 1. A jugum, for compressing the urethra. It con-
sists of a piece of elastic steel, lined with velvet or soft flan-
nel. By means of the screw, A, its width can be regula-
ted; and the cushion B being placed upon the urethra,
any necessary degree of pressure can be applied to it, with-
out interrupting the circulation in the penis to  any consi-
derable degree.
Fig. 3. A receptacle for the urine. It may be made of
tin, silver, or any other metal: It is convex on one side,
and concave on the other which is applied to the thigh.
CD, two tubes for connecting the part into which the penis
is put, by tapes, to a bandage passed round the body. F,
a small tube for fixing the instrument to the thigh. It
may contain three or four gills.
Fig. 2. A manifold bandage, of 12 tails.
Fig. 4. This very useful part of the apparatus for ex-
tending dislocated limbs, is formed of thick shamoy or buff
leather. It is to be tied firmly around the limb with the
straps at each end; and the extension is made by assistants
pulling the straps passed over the hooks: It answers much
better than towels, which are usually employed.
Fig 5. A bandage for compressing the abdomen during
and after the operation of the paracentesis: It is made of
soft leather lined with flannel. A the body of the bandage,
which should reach from ilium to ilium, to be there fixed
by the straps BBBB to the buckles CCCC. The straps
DD, by passing over the shoulders, serve to fix the buc-
kles EE, which pass through between the thighs. The
peforation is to be made through the windon F, which
3 afterwards 

PLATE XI

PLATE XII.

[xv]
afterwards is shut by the straps G, and the buckler H, as
represented by the letter I.
Fig. 6. A pessary for the prevention of herniæ in the
vagina. As steel is apt to rust, this tube should be made
of gold, silver, or ivory, with a cord at one extremity, for
the purpose of withdrawing it when necessary.
PLATE XII.
Fig. 1. A form of the best species of splints, for fractures
of the extremities, perhaps yet invented*. This is not the
most common form, which is oblong, of the same breadth
all the way, but rounded at the ends; but it answers ex-
ceedingly well for the leg or arm. They are made by
gluing a piece of wood† about the tenth of an inch in
thickness, upon leather. The wood is afterwards cut
through to the leather by a knife or a saw, in the manner
represented in the figure.
These splints are preferable to pasteboard, because they
have more firmness, with a sufficient degree of flexibility.
Fig. 2. and 7. Mr. Sharpe's splints*. They are form-
ed of strong pieces of pasteboard made with glue; and are
a little convex externally and concave internally. The
first is the splint to be fixed on the outside of the leg: In
general it should be eighteen inches long, and in width,
two inches and three quarters at the strap next the knee,
and two and a quarter inches at the other straps.
DFDFDF, represent three leather straps, being perfora-
ted near the ends to connect them to the knobs AAA on
the splint fixed upon the internal part of the leg. These
4E straps                  
* To both these kinds of splints some prefer those made in the
shape of Mr. Sharpe's, but formed of flexible pieces of whale-bone,
connected by linen, nearly in the manner of womens stays, and fasten-
ed by thin leather or girthing straps in the mode of Mr. Sharpe's.
† Cedar is usually employed in this city. 

[xvi]
straps should be from fifteen to twenty inches in length,
and one in width, and must be sewed to the outside of the
splint.
G, a part to support the foot; from E to H, it should be
five inches.
C, The foot-strap, twelve inches long, sewed to the end
of the splint, and passing under the heel and through the
leather loop B on the upper splint, to the lowest pin A.
I, a hole, two inches long and nearly one wide, to re-
ceive the malleolus externus.
Fig. 3. A sling, or machine for supporting the fore-arm.
AA, a case of firm leather properly lined with flannel and
wool, of a sufficient length to cover the arm, from the el-
bow to the ends of the fingers, for the left side. B, a col-
lar of soft buff leather for passing over the right arm, in
order to support the fore part of the case; this it does by
means of the strap F passing over the left shoulder, and
fixed to a buckle at C, to prevent it from slipping down.
GH, two straps and buckles for fixing the arm to the case.
Fig. 6. A machine for supporting the head and shoul-
ders; and commonly employed in distortions of the spine.
A, an iron collar, properly covered, for passing round the
neck. By means of the long iron plate connected with this,
it may be raised or depressed at pleasure. BBB, a broad
iron plate, fitted to the back and shoulders. CC, two
straps, to be carried over the shoulders, brought beneath
the arm pits, and fixed to two knobs on the shoulder plates.
D, a strap for fixing the plate going down the back, by
being tied round the body.
Fig. 4. An artificial leg, made of firm hardened leather.
A, an oval piece of the same kind of leather lined with
shamoy, fixed upon a plate of iron C, and moving upon
an axis at the knee. The strap I, with the buckle con-
nected with it, serves to fix it to the thigh. There must
also be an oval piece connected with a similar piece of iron
on 

[xvii]
on the opposite side of the thigh: These plates and pads
should reach about nine inches up the thigh. B, a strap
that comes from the sole of the foot, and goes up the
inside of the leg to the middle of the thigh, where it is
fixed, by a buckle, to a strap coming from the opposite
shoulder; this serves to support the leg very effectually.
Fig. 5. A piece of soft shamoy leather, which fixes by
a buckle and strap round the condyles at the knee, and
prevents the consequences of the leg rubbing against the
knee: The stump hanging loose within the leg, the fric-
tion is entirely sustained by the condyles and patella.
Fig. 8. An artificial fore-arm and hand, made of the
same materials, to be fixed to the shoulder by the straps
DE.
The legs abovementioned are equally useful with the
common wooden legs, and preferable from being neater,
and not liable to break: and they answer better than those
of copper from being considerably lighter, and not apt to
be misshapen by bruises.
Mr. Wilson, of Edinburgh, who is the inventor of this
species of artificial legs and arms, makes three different
kinds, corresponding to the part at which the limb is am-
putated. When the leg is taken off lower than the usual
place below the knee, as recommended in chap. xlvi. sect.
4, the leg above represented answers. The second kind
is intended for those cases where the amputation has
been performed at the usual place below the knee; the
knee then rests upon a soft cushion, but has no flexion; and
the hollow for receiving the thigh goes nearly up to the
hip: It is fixed with straps and hooks, and opens behind
to receive the thigh. When the limb is taken off above
the knee, a joint is formed in the artificial leg. In walk-
ing, the limb is made steady by a steel bolt, running in sta-
ples, on the outside of the thigh, being pushed down; the
knee is rendered flexible by this bolt being pulled up.
The 

[xviii]
The rest is obtained from the leg embracing the upper
part of the thigh, and from the hip resting upon the stuf-
fed thigh-box.
The artificial arms are covered with white lambskin, co-
loured so as to resemble the human skin. The nails are
of white horn coloured. The joints are made in the
shape, and so as to have the motions, of the natural joints.
The fingers and metacarpus are made up to the proper
form, with soft shamoy leather and baked hair. In the
palm of the hand there is an iron screw, in which a screw
nail is occasionally fixed. The head of this nail is a spring
plate, so made as to hold a knife and fork: And by means
of a brass ring on the first and second fingers, a pen may
be used for writing.
The quantity of parts to be supplied, must determine
whether the straps are to be connected to the arm alone, or
to the arm and shoulder.
INDEX. 

[xix]
INDEX.
A.
ABSCESSES in general, 9
Abscesses in the antrum maxillare, 328
Abscesses in the breasts of women, 425
Abscesses in the globe of the eye, 272
Abscesses in the gums, 327
Abscesses in the liver, 423
Abscesses lumbar, 43l
Affections of the brain from external violence, 235
Air extravasated into the thorax, 226
Albugo, 279
Amputation in general, 527
Amputation of the arm, 554
Amputation of the arm, at the shoulder, 552
Amputation of cancerous mammæ, 233
Amputation of the foot, 55l
Amputation of the fingers, 551
Amputation of the leg, 543
Amputation of the penis, l64
Amputation of the thigh, 536
Amputation of the thigh at the hip, 546
Amputation of the toes, 55l
Amputation with a flap, 545
Amputation with a flap, above the knee, 548
Amputation with a flap, below the knee, 550
Anasarca, 451
Aneurisms, 

xx INDEX.
Aneurisms, 100     
Aneurisms, false or diffused, 103
Aneurisms, true or encysted, 100
Aneurisms, varicose, 102
Angina 423  
Anus imperforated, 207
Arteriotomy, 96
B.
Bandages, 567
Blood effused into the eye-ball, 276
Blood-letting in general, 84
Blood-letting in the arm, 93  
Blood-letting in the ankles and feet, 95
Blood-letting in the hemorrhoidal veins, 96
Blood-letting in the jugular vein, 94
Blood-letting in the tongue, 96
Blood-letting topical, 97
Bones, removal of the ends of, 554
Bougies, 195
Bronchocele, 453 
Bronchotomy, 228
Buboes, venereal, 427
Burns, 417
C.
Cæsarean section, 559
Calculi urinary, 166
Cancer of the eye-ball, 282
Cancer of the breast, 233
Cancer of the lip, 323
Carbuncle, 13       
Castration 159
Cataracts, 

INDEX. xxi
Cataracts, 284
Cataracts, depression of 287
Cataracts, extraction of 291
Cerate, common, 25
Cerate, saturnine, 26
Chilblains 435
Cirsocele 154
Compression of the brain from external violence, 237
Concretions of the eyelids, 268
Concretions within the capsular ligaments, 448
Concussion of the brain, 247
Contusions 437
Contusions of the head, 251
Corns, 458       
Couching, 287
Cupping, 97       
D.
Deafness, 354
Deafness, from imperforated meatus auditorius, 355
Deafness, excrescences in the meat. audit. 356
Deafness, extraneous bodies in the meat. audit. ib.
Deafness, wax in the meatus auditorius, 357
Dentition, 324 
Dislocations, 494
Distortions of the limbs, 521
Distortions of the spine, 524
Duct parotid, division of the 353 
E.
Ears, diseases of the 354 
Ears, perforating the lobes of the 359
Ecchymosis 87
Embalming, 

xxii INDEX.
Embalming, 465
Empyema, 224
Erysipelas, 421
Excrescences on the cornea, 269
Excrescences condylomatous, about the anus, 204
Excrescences within the capsular ligaments, 448
Exostosis, 450
Extirpation of the eye-ball, 282
Extirpation of the testis, 159
Eye, diseases of the 257
Eye, cancers of the 282
Eye, dropsical swellings of the 274
Eye, films on the 279
Eye, protrusion of the ball of the 281
Eyes, artificial, 284
Eye-lids, inversion of the 261
Eye-lids, tumors on the 263
F.
Fauces, diseases of the 304
Fistula in ano 209
Fistula in perinæo, 198
Fistula lachrymalis, 294
Fractures in general, 464
Fractures of the arm, 479
Fractures of the clavicles, 474
Fractures of the coccyx, 477
Fractures of the compound, 490
Fractures of the fingers, 482
Fractures of the foot, 490
Fractures of the fore-arm, 480
Fractures of the hand, 482
Fractures of the leg, 489
Fractures of the lower jaw, 473
Fractures 

INDEX. xxiii
Fractures of the nose, 472
Fractures of the patella, 487
Fractures of the os femoris, 483
Fractures of the os sacrum, 477
Fractures of the ossa innominata, ib.
Fractures of the ribs, 474
Fractures of the scapula, 478
Fractures of the sternum, 476     
Fractures of the superior maxillary and cheek bones, 473
Fractures of the toes, 490
Fractures of the vertebræ, 477
Fractures of the wrist, 482
Frenum of the penis, division of the, 165
G.
Ganglions, 443
Gangrene,-— dry, l2
Gouetre, 453
Gums, excrescences on the, 332
Gums, scarification of the, 324
Gumboils, 327
H.
Hare-lip, 318      
Hematocele, 151
Hemorrhoids, 202
Hemorrhagies, means of restraining, 79
Herniæ in general, 115  
Herniæ congenital, 116-129
Herniæ crural or femoral, 129
Herniæ of the foramen ovale, 132
Herniæ umbilical or exomphalos, 130
4F Herniæ 

xxiv INDEX.
Herniæ, inguinal, or bubonocele, 123
Herniæ of the urinary bladder, 132
Herniæ ventral, 131
Herniæ scrotal, or oscheocele, ib.
Herpes, 49       
Hydrocele, 134 
Hydrocele, anasarcous of the scrotum, 135
Hydrocele, anasarcous of the spermatic cord, 148
Hydrocele, encysted of the spermatic cord, 149
Hydrocele, of the tunica vaginalis, 137
Hydrocele, of a hernial sac, 147
Hydrothorax, 219
I.
Inflammation in general, 1
Inflammation of the eyes, 257
Inflammation of the ear, 422
Inflammation of the mamma, 425
Inflammation of the membranes of the brain, 249
Inflammation of the testes, 426
Inflammation erysipelatous, 421
Inflammation phlegmonic, 1
Inoculation, 364
Incontinence of urine, 187 
Inversion of the eye-lashes, 265
Issues, 362
L.
Ligature of arteries, 79
Lips, diseases of the, 318
Lips, cancerous, extirpation of, 323
Lithotomy, 172
Lithotomy by the greater apparatus, 172
Lithotomy by the lesser apparatus, ib.
Lithotomy by the lateral method, 173 
Locked

INDEX. xxv
Locked jaw, 375
Luxations in general, 494
Luxations of the ankle, 519
Luxations of the cranium, 499
Luxations of the clavicles, 505
Luxations of the elbow,	511
Luxations of the fingers, 514
Luxations of the foot, 520
Luxations of the head, 501
Luxations of the knee, 518
Luxations of the lower jaw, 500
Luxations of the metacarpus, 514
Luxations of the nose, 600
Luxations of the os coccyx, 503
Luxations of the os femoris, 514
Luxations of the patella, 518
Luxations of the ribs, 505
Luxations of the os sacrum, 503
Luxations of the spine, ib.
Luxations of the humerus at the shoulder, 506
Luxations of the wrist,	513
M.
Mortification, 12
Mouth, diseases of the, 324
N.
Nævi materni, 456
Nephrotomy, 183
Nipples, diseases of the, 361
Node, venereal, 459  
Nose, diseases of the, 304
Nostrils, imperforated, 307
Nostrils, hemorrhagies from the, 304
Obstructions, 

xxvi INDEX.
O.		
Obstructions, in the urethra, 192
Œdema, 450
Œsophagotomy,	230
Opening dead bodies, 563
Ophthalmia, 257
Ozæna, 305
P.		
Paracentesis of the abdomen, 215
Paracentesis of the thorax, 219
Paraphymosis, 163
Paronychia, 433
Pain, of obviating, in operations, 557
Phlegmon, 1
Phymosis, 161
Pneumatocele, 154
Polypi in the nose and throat, 308
Prolapsus ani, 206
Pus, formation of, 6
R.		
Ranula, 349
Ruptures of the tendons, 383
Ruptures of the capsular ligaments, 385
S.		
Sarcocele, 156
Sarcomata, or fleshy excrescences, 458
Setons,	363
Sounding or searching for the stone, 169
Spermatocele, 154
Spina ventosa, 459
Spina bifida, 451
Sprains, 437
Suppression, 

INDEX. xxvii
Suppression of urine, 189
Suppuration, 6
Sutures, 74
Suture, dry, ib.
Suture, glover's, 76-404
Suture, interrupted, 74
Suture, quilled, 76
Suture, twisted, 77
Stone, the, 166
Stones in the urethra, 184
Swelling, white, 66
Swelling, white, rheumatic, 67
Swelling, white, scrophulous, 69
T.
Teeth, cleaning the, 334
Teeth, derangement of the, 325
Teeth, extracting of the, 317
Teeth, loose, 333
Teeth, transplanting of the, 347
Tents, 379
Tetanus, 375
Throat, scarifying the, 318
Throat, fomenting the, ib.
Thrombus, 87
Tongue, extirpation of the, 350
Tongue, division of the frenum of the, 352
Tongue, ulcers on the, 350
Tonsils, extirpation of the, 315
Tooth-ach, 337
Tooth-ach from the nerve being laid bare, ib.
Tooth-ach from affections of distant parts, 346
Tooth-ach from inflammation, 345
Trismus, 375
Tumors, in general, 420
Tumors, 

xviii INDEX.
Tumors, acute or inflammatory, 420
Tumors, chronic or indolent, 439
Tumors, encysted, ib.
Tumors, from collections in the bursæ mucosæ, 444
Tumors, from collections in the capsular ligaments, 446
Tumors, scrophulous, 452
U.
Ulcer, simple purulent, 21
Ulcer, simple vitiated, 28
Ulcer callous, 34
Ulcer cancerous, 41
Ulcer carious, 36
Ulcer cutaneous, 49
Ulcer fungous, 30
Ulcer scorbutic, 62
Ulcer scrophulous, 64
Ulcer sinuous, 32
Ulcer venereal, 56
Ulcers in general, 17
Ulcers in the mouth, 350
Uvula, extirpation of the, 317
Urethra, imperforate, 165
V.
Varicocele, 154
W.
Warts, 456
Wounds in general, 365
Wounds simple incised, 366—369
Wounds lacerated and contused,	380
Wounds punctured, 377
Wounds poisoned, 411
Wounds gun-shot, 413
Wounds of the arteries, 88
Wounds,

INDEX. xxix
Wounds of the lymphatics, 383
Wounds of the nerves, 89—383
Wounds of the tendons, ib.
Wounds of the veins, 382
Wounds of the capsular ligaments 385
Wounds of the face, 387
Wounds of the eye-balls, 261
Wounds of the eye-lids ib.
Wounds of the œsophagus, 388
Wounds of the trachea, 388
Wounds of the thorax, 390
Wounds of the large thoracic vessels, 396
Wounds of the heart, 396
Wounds of the lungs, 394
Wounds of the thoracic duct, 396
Wounds of the mediastinum, 396
Wounds of the pericardium, ib.
Wounds of the diaphragm, 396
Wounds of the abdomen, 406
Wounds of the omentum, 407
Wounds of the stomach, 406
Wounds of the intestines, 403
Wounds of the mesentery, 407
Wounds of the liver, ib.
Wounds of the gall-bladder, ib.
Wounds of the spleen, 408
Wounds of the pancreas, 408
Wounds of the receptaculm chyli, ib.
Wounds of the kidnies, 409
Wounds of the Ureters, ib.
Wounds of the bladder, ib.
Wounds of the uterus, and its appendages, 410
Wry neck, 360

ERRATA.
Page 17, line 14, for ulcers, read ulcer.
Page 19, line 16, after and, add the former. 
Page 29, line 12, after or, add is.
Page 36, line 17, for this read it.
Page 38, line 28, after prognosis, read the sentence thus:
as well as the nature of the cause, ex-
foliations, &c. And
Page 38, line 30, instead of thus, read and.
Page 55, line 13, for sacchar. ꝶj, read sacchar. saturni ℈j.
Page 55, line 24, for remarkable, read remarkably.
Page 55, line 24, instead of nutrition, read secretions.
Page 117, line 18, for between, read in.
Page 119, line 32, dele very perfectly.
Page 189, line 6, for particular, read particularly.
Page 298, line 22, after nose, add; and
Page 323, line 6, for artery read arteries.
Page 331, line 4, dele only
Page 332, line 4, after themselves, a period, then read
what immediately follows, thus: These
excrescences often impede mastication
and the speech, but are seldom painful. 
Page 334, line 16, after a insert new
Page 259, line 9, place is after employed.
Page 391, line 19, dele in forming a.
Page 416, line 9, dele indiscriminately.
Page 435, line 1, dele found.
Page 438, line 22, for is, read are.
Page 451, line 2, for gives, read give.
Page 452, line 9, dele ?
Page 461, line 17, after wound, add it.
Page 464, line 20, after oblique, insert or 21,--after longi-
tudinal dele or.
Page 511, line 3, dele The.
Page 533, line 28, after in add that.
Page 546, line 19, after in add all.
Page 561, line 8, for Pinleau, read Pineau. 
Explanation of plates, XIII, lines 3, 4, for this is, read probes