* <  < < 
'*/'«.  ___■  *.
*»s& 
 
A
SYSTEM
O F
SURGERY.
EXTRACTED FROM THE WORKS OF
BENJAMIN  BELL,  of Edinburgh
     By NICHOLAS B. WATERS, M. D.

FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHlAj
    AND  ONE  OF THE  PHYSICIANS  AND  SURGEONS
        TO THE PHILADELPHIA DISPENSARY.
  ILLUSTRATED with NOTES and COPPER-PLATES.
          -----------------'■■"BiS.'illl

           SECOND EDITION.



          PHILADELPHIA:

      PRINTED BY BUDD & BARTRAM,
FOR THOMAS DOBSON, AT THE STONE-HOUSE,
      N° 41, SOUTH SECOND-STREET,

                  l802. 
No.  21.
   Diilricl. of Pennfylvania,  to wit :

    BE it  remembered, that on the nineteenth dey ef Atiguft, in the
fixteenth year of the Independence of the United States of America, Tho-
mas Dobfon, of the faid diftrid, hath depofited in this office the title of
a Book, the right whereof he claims, as proprietor, in the words follow-
ingj to wit:
  " A Syftem of "Surgery,  extracted from the Works of Benjamin  Bell,
" of Edinburgh:  by Nicholas B. Waters, M. D.  Fellow of the College
" of Phyficians of Philadelphia, and one of the Phyficians and Surge-
" ons to the Philadelphia Difpenfary.—Illuftrated with Notes and  Cop-
" per-pia.tes."   In conformity to the  aft of the Congrefs of the United
States, intituled,  " An a<5t for the  encouragement  of learning by fe-
curing the copies of Maps,  Charts, and Books, to the Authors and Pro-
prietors of fuch copies, during the times therein mentioned."
                                SAMUEL  CALDWELL,  Clerk
                                     of the Diftricl of Pennfylvania. 
PREFACE.
    SURGERY  teaches  us the knowledge of  all thofe
     difeafes which require manual  operations  for their
removal; their  caufes •,  and the methods  of  preventing
and of  curing them.
   For fome years part it has been a fubjedr.  of regret with
the medical  part  of  the public, and particularly  among
•ftudents,  that  we have had no work on  this  important
branch  of medicine,  which gives a  view of the  prefent
ftate of the  art, in a moderate compafs:   Mr. Bell's  fyf-
tem, although  a mod valuable  production, being extend-
ed to fb great a length, as to be not only expenfive,  but
exceedingly inconvenient.
   To fupply this  defecl, I have repeatedly heard a wifh
expreflcd, by fame of the mod eminent cf the profeflion,
that a felection  of the more eflential parts of Mr. Bell's
treatife  were made; in which,  however, nothing ufefpl,
immediately relating to Surgery, Ihould be omitted.
   Although well aware that I might not execute a work of
this kind in fuch a way as to Obtain the approbation of the
critical  reader,  yet the belief,  however miftaken,  that it
might be done by any perfon tolerably acquainted with the
fubjecl,  If not in  the beft manner  with  refpeft  to lan-
guage,  aj leaft in fuch a manner as  to be  highly  ufeful;
the late Dr. Jones, formerly profeflbr of furgery in King's
College, New-York,  cheerfully engaging to look over the
manufcript, and  add  occafional obfervations,*  furniflied
by  his  own  experience;  Dr. William  Shippen,  profeflbr
of  anatomy and furgery, alfo obligingly promifing to de-
                                                   vote

  * Thefe will be readily diftinguifhed  from  fuch  as I  have given
myfelf,  which  confift chiefly  in extracts from different  authors of
merit. 
IV
PREFACE.
rote a part of his leifure to the perufal of the work;  I de-
termined to rifk  the undertaking.  How far I  have fuc-
ceeded in the attempt, mult be left to  the decifion of my
medical brethren.
  Thofe who  cannot  readily conceive that the eflential
parts of a performance of {even volumes can be  comprifed
in a fingle one of the fame fize, will pleafe to confider, that J
this  one  volume, from the manner in  which it is printed,
contains  at leaf! as much as any two of the original •, and
that the anatomical defcriptions,  defcriptions of operations
and practices which are, at prefent, feldom if ever employ- _
ed, theoretical  difcuflions, and repetitions,  which,  taken
together,  occupy no fmall  part in the  work of Mr.  Bell,
are entirely omitted.
  As Mr. Bell  exprefles his opinion fomewhat differently,
on the fame fubjecf, in different  places, I may  fometimes
appear to have juftly incurred the cenfure of mifreprefenta-
tion; but I beg  that in fuch inftances, a judgment may
not be formed  without a previous attention to every  thing
that  is delivered on the fabjedl in queftion.
  Following the general plan  of the original  treatife,  I
have  attempted no fyftematic arrangement of the difeafes
to be confidered ; becaufe thefe  have feldom much  con-
nection  in their general fymptoms, or in their refpedtive
modes of cure.   When, indeed,  the different fubjedts ap-
peared to be conne&ed, or illuftrative of each other,  they
are generally treated of in immediate fucceflion.
  After  noticing the appearance or fymptoms of the dif-
eafe,  its  ufual and known  caufes are confidered; its  pro-
bable confequences; and the beft method  of treatment:
And  when an  operation of  importance is defcribed, the
parts which fhould be avoided,  as well as  thofe that are
to be divided, are particularly pointed  out. 
CONTENTS.
                 CHAP.  I.
                                               Page.
Of Inflammation and its Confequences,              i
                 CHAP.   II.
On the Theory and Treatment of Ulcers,          17
                 CHAP.   III.
Obfervations on White Szuellings of the Joints,     66
                 CHAP.   IV.
Of Sutures,                                     74
                 CHAP.  V.
Of the Ligature of Arteries, and other artificial
    means of stopping Hemorrhagies,              79
                 CHAP.   VI.
Of Blood-letting,                                84
                 CHAP.  VII.
Of Aneurifms,                                 100
                CHAP.  VIII.
Of Hernia,                                    115
                 CHAP.   IX.
Of Hydrocele,                                 134
                 CHAP.  X.
Of the Hematocele,                             151
                 CHAP.   XL
Of the Varicocele, Cirfocele, Spermatocele, and
    Pneumatocele,                              154
                 CHAP.   XII.
 Of the Sarcocele, or Schirrous  Testicle,         156
                CHAP.  XIII.
 Of Difeafes of the Penis,                      161
                                        CHAP. 
vi           CONTENTS.
CHAP.   XIV.
                                Pajje.
Of the Stone,	166
CHAP. XV.	
Of Incontinence of Urine,	187
CHAP. XVI.	
Of a Supprefifion of Urine,	189
CHAP. XVII.	
Of Obstruclions in the Urethra,	192
CHAP. XVIII.	
Of the Fistula in the Perinaum,	198
CHAP. XIX.	
Of the Hemorrhois or Piles,	202
CHAP. XX.	
Of Condylomata, and other finiilar Excrefcences	
about the Anus,	204
CHAP. XXI.	
Of a Prolapfus Ani,	206
CHAP. XXII.	
Of an Imperforated Anus,	207
CHAP. XXIII.	
Of the Fistula in Ano,	209
CHAP. XXIV.	
Of the Paracentefts of the Abdomen,	2I5
CHAP. XXV.	
Of the Paracentefts of the Thorax,	219
CHAP. XXVI.	
Of Bronchotomy,	228
CHAP. XXVII.	
Of Oefophagotomy,	230
CHAP. XXVIII.	
Of the Amputation of Cancerous Mamma,	233
C H	A P.
 
           CONTENTS.         ?it
              CHAP.   XXIX.
                                              Page.
Of Affeclions of the Brain from external Vio-
    lence,                                     235
               CHAP.   XXX.
Of Difeafes of the Eyes,                        257
              CHAP.   XXXI.
Of Difeafes of the Nofe and Fauces,             304
              CHAP.   XXXII.
Of Difeafes of the Lips,                       318
             CHAP.   XXXIII.
Of Difeafes of the Mouth,                     324
             CHAP.   XXXIV.
Of Difeafes of the Ears, and Operations prac-
    tifed upon them,                            354
              CHAP.   XXXV.
Of the Wry-Neck,                             360
              CHAP.   XXXVI.
 Of Difeafes of the Nipples,                     361
             CHAP.   XXXVII.
Of Ififues,                                     362
             CHAP.   XXXVIII.
 Of the Inoculation of the Small-Pox,            364
              CHAP.   XXXIX.
 Of Wounds,                                   365
                C  H A P.  XL.
 Of Burns,                                   41 *:
                CHAP.  XLI.
 Of Tumors,                                   420
                CHAP.   XLII.
 Of Fraclures,                                 464
                                       CHAP. 
viii CONTENTS.	
CHAP. XLIII. Of Luxations, CHAP. XLIV.	Page 494
Of Distorted Limbs, CHAP. XLV.	521
Of Distortions of the Spine, CHAP. XL VI.	524
Of Amputation, CHAP. XLVII.	527
Of removing the Ends of Bones, in Difeafes of the Joints, CHAP. XLVIII.	554
Of preventing or diminithing Pain in Chirurgi-cal Operations, CHAP. XLIX.	557
Of Midwifery, CHAP. L.	558
Of opening Dead Bodies, CHAP. LI.	5^3
Of Embalming, CHAP. LII.	5^5
Of Bandages,	5fy
 
                        A

SYSTEM  of  SURGERY.
             C   H   A  P.    I.

                    1  i' iKMHi i ""

    On Inflammation and its ConfequenccS.

               S E  C T  I  O N  I.

 Of the Symptoms, Terminations, and Caufes of Inflammation.

    EVERY organized  part of the body is liable to in-
     flammation -,  but as the treatment of this affection,
when feated in the internal parts, belongs to the province
of medicine ; we propofe in  this place, merely to confider
the complaint, with Its  confequences,as it is moll frequent-
ly obferved to occur externally.  And as the  greater part
of the  phenomena  which in general attend it, will  be
underftood from the confideration of Phlegmon, we fhall
confine our obfervations  more particularly to that fpecies
of the  difeafe.
  Phlegmon is  a  circumfcribed tumor,  attended with
heat, rednefs, tenfion, and  a throbbing pain •, and,  if ex-
tenfive, with fever.
  When thefe fymptoms are removed,  and leave the part
lanaltered in its flruclure, the difeafe is faid to  terminate by
refolution.
  If however, in  a fhort time all the fymptoms are aug-
mented, and the tumor becomes foft, fomewhat prominent
                     A                          iq 
                       [   2  ]
in the middle, or  towards the mofl depending part, ac-
quires'a clear,  fbining appearance,  and becomes lefs  pain-
ful ;  the different fymptoms of fever then abate, and  upon
preffure  a fluctuation  is perceived ;  the inflammation is
then faid to end in fuppuration.
   But if all the fymptoms, general as well as topical, ex-
cept the fwelling, continue to increafe, there will be reafon
to apprehend that gangrene will foon take place.
   Gangrene,   or  mortification,  is firft indicated   by  a
change of  colour in the part affected, from a bright red to
a livid or leaden caff,  while fmall veficles, containing a thin
acrid ferum, are difperfed over its furface—the pain abates
and  the pulfe finks—but continues  frequent—the tumor at
laff  lofes  its tenfenefs—turns black  and flaccid—and the
part is entirely deprived of its vital properties.
   Thefe are the mofl common  terminations  of inflamma-
tion  ;  but fometimes, though very rarely, it  ends in fchir-
rus,
   The general exciting caufes of inflammation, are what-
ever tend to produce irritation and  pain.  They are either
external or internal.   The external caufes are,  wounds of
all kinds;  bruifes;  burns,  whether by  the actual  or po-
tential cautery; corrofive  and ftimulating applications,  as
flrong acids, cantharides, and rubefacients 5 ligatures, and
tumors that act as ligatures ; violent  exercife of a particu-
lar part;  and cold  partially applied.   The internal caufes
are morbid matters  of  various kinds; as thofe of fyphilis,
fmall-pox, meafles,  fcrophula, and fevers.
   Thofe circumftances which feem  to give a  predifpofition
to inflammation are, a full plethoric habit of body,  indu-
ced by a very  nourifhing diet, or by want of exercife;  or
perhaps by a combination  of both—Inflammation occur.
alfo  more frequently in young than in old people,  and in
men than in women.
   The proximate caufe of inflammation feems to confift in
an incrcafed action  of  the arteries of the part; and when
                                                    the 
                        I  3   3
the difeafe does not originate from the application of irri-
tating fubflances,  this,  as well  as the increafed action of
the heart when it occurs, feems to be fupported by a fpafm
or conflridtion of the extreme veffels,  either of the parti-
cular part  or  of the general fyflem.   See  Cullens Praft.
Phy/ic. vol. I.
   In almoft every cafe of external inflammation, the prog-
noftick may be favourable.  For if refolution, which is the
eaiieft,  and  molt  defirable mode of termination, is not ef-
fected, fuppuration will mofl readily be the confequence;
and the danger attending that, if the conflitution is other-
wife healthy, is feldom great:—When, however, the dif-
eafe is extenfive,  and the fymptoms very violent,  there is
much danger to be feared; for, independent of the rifk from
the fever itfelf,  if the fymptoms continue  high for any
length of  time,  without fhewing a tendency to refolution
or fuppuration, gangrene will pretty certainly follow : and
in what manner that may terminate is always uncertain.

                    SECT.  II.

      Of  the Treatment of Inflammation by Refolution.

   In  the cure of phlegmon, the firfl indication in general
is to promote refolution.   There are, however, fome cafes
in which  this  is not to be attempted.  Thus inflammato-
ry fwellings, that fucceed to fevers, and other internal dis-
orders, fhould always be  brought to  fuppurate as early as
poffible:  as it is generally fuppofed,  that nature by thefe
points  out an outlet  for  fome fuperabundancy of fluids;
and that it might be attended with danger to give her any
interruption.  And in phlegmons occurring  in fcrophula,
we fhould trufl entirely to the operations of nature; for
if they are repelled, bad confequences might enfue;  and if
brought  to fuppuration  they produce fores  very trouble-
fome to heal.
                                                     In 
                       _  4   .1
  In cafes of incipient phlegmon, where the general  fyf-
tem is not affected, topical remedies merely, with a pro-
per attention to regimen, will often accomplifb a refolution.
But when the effects of the difeafe are in any confiderable
degree extended to the whole fyfiem, it becomes neceffary
at the fame time to pay attention to thefe.
   The firfl  circumftance to be attended to in every  cafe,
is the removal of all exciting caufes that continue to ope-
rate.   Of applications to the part, thofe of a fedative nature
are chiefly to be depended on; and  next to thefe, emol-
lients.   Of the former may be confidered the preparations
of lead diffolved in  vinegar, and the vegetable acid.   Of
the latter,  all the bland expreffed oils,  alone, or joined
with wax, in form  of a foft ointment.
   With refpect  to  fedative  applications,  it  is not meant
to recommend the  whole clafs in external inflammation.
Thus  opium,  one of the mofl powerful fedatives, when
applied externally,  always produces fome  degree of irri-
tation ; and although it perhaps may  have been  very ufe-
ful in  fome fpecies of inflammation', yet it will probably
never  become of  general ufe  in fuch difeafes.
   Warm  emollient  fomentations  too,  although  more
powerful,  as fedatives, in removing tenfion and pain,  than
any other remedy; yet from experience, I am  well  con-
 vinced they always  tend to produce  fuppuration;   and
when this is not occafioned, they leave  fuch a  relaxation
in the parts, as renders the  complete removal of the dif-
 eafe exceedingly tedious.
   Similar objections  may be made to  mofl fedative ap-
 plications.  They do not, however, operate againft the ufe
 of the preparations of lead;  which we may affirm,  from
 the experience of a great many practitioners, to be by far
 the mofl ferviceable  remedies as difcutients, that have yet
  come into general  ufe.   They have been faid to produce
  deleterious effects in fome inflances;  but thefe have been
                                                   very 
                       [   5   ]
very rare; and I have known the greater part of the fur-
face of the body to be covered with them for weeks, with-
out any bad confequences being  occafioned by them.
  Saccharum  faturni,  or the  fugar  of lead,  as  being
the  preparation   whofe  flrength  can  be mofl  exactly
afcertained, fhould be preferred  to any  of the  others.
It is mofl conveniently applied in the form of  a watery
folution;   for  the preparation  of  which  the  following
proportions  in  general  anfwer  very  well: R. Sacch.
Saturn. |fs folve in aceti §iv\ & adde aq.  fontis diflillat.
tbij.  The addition of vinegar  renders the folution more
complete.
  Mr. Goulard's vegeto-mineral  water is preferred by
fome to this preparation:  it is made by  adding two tea
fpoonfuis of  the  Extraclum Saturni  to a quart of water,
and four  tea fpoonfuis  of  brandy.   The quantity of
extract  or brandy to be diminifhed or increafed accord-
ing to  the  nature of the difeafe, or fenfibility of the part.
Cataplafms  made of thefe preparations   and crumb of
bread, fhould be  conftantly applied,  as cold as the patient
can bear them without uneafmefs, and be renewed when-
ever they become hard.  When the inflamed part is not ve-
ry tender, or lies deep, the vegetable acid inftead of the lead
anfwers very well; and an alternate ufe of this and the lead
has, in fome inflances, appeared  to be  more ferviceable
than a continuance of cither feparately.  If, however, the
fenfibility of the  part does not admit of poultices, doubled
pieces of foft linen, moiitened  with the faturnine folution,
fhould be fubflituted to them.
  Emollients tend greatly to remove inflammation : but as
they are lefs efficacious than the preparations of  lead, and
always  blunt the  action of thefe,  they  fhould never
be  employed except  the  tenfion, irritation, and pain  are
very confiderable:  when  any o? the  mild  expreffed oils
may be gently  rubbed over the  inflamed  parts two or
three times a-day.
                                               Topical 
                       [   6  ]
  Topical bleeding fhould  always be  employed  when
the inflammation  is extenfive:  and the blood  fhould be
drawn from a part  as near as poffible to the difeafe.
Refl fhould  be enjoined—and the ufe of animal food,  and
of  fpirituous  and fermented  liquors,  ftrictly  forbid.
And,
  When a confiderable  degree  of fever comes on, it will
be proper to order general bleeding, gentle  laxatives,  and
cooling diaphoretics.  We fhould then procure eafe to the
patient by the exhibition of opium in  large dofes.
  By thefe means, in  the courfe of a few days, refolution
of  the tumor will gently begin  to take place.   The
fame plan fhould  then be purfued, but with caution;  be-
caufe,  if fuppuration fhould at  lafl be produced, its pro-
grefs will be  rendered  flow and  uncertain  by debilitating
the fyflem, and the patient will not be  capable of fupport-
ing the confequent difcharge, fliould  it be confiderable.
   Although we may  generally determine,  in the courfe
of three or four  days, whether  the  difeafe will end  in
refolution or  not •, yet  it muft  be  obferved, that inflam-
mations  in  tough  membranous  parts, often continue a
confiderable  time without  fhewing any tendency to ter-
mination : In  fuch cafes, we fhould never be deterred from
a  perfeverance in  the  ufe of refolvents, unlefs the fymp-
toms of  fuppuration commence, gangrene is threatened, or
an incurable obflruction is feared ; when fuppuration fhould
always be encouraged as much  as poffible.
                  SECT.  III.

                   Of Suppuration.

  Suppuration is that  procefs by  which  the con-
tents  of  tumors and  ulcers are converted into a whitifh,
                                                 thick, 
                     ■  [?]
thick,  opaque, and fomewhat  foetid matter, termed Pus.
This, by many, has been fuppofed to be effected entirely
by a natural exertion of the fyltem; but experience teach-
es us,  that art is capable,  in all cafes,  of  giving confider-
able afliflance.
   With refpect to the  formation of  pus,  various opini-
ons  have  been entertained.  By fome,  pus has been be-
lieved to confift in a diflblution of the blood-veflels, nerves,
and other folids, in the fluids of  inflamed parts.  Others,
have fuppofed it  to  be formed  in the  blood •,  and that
it is from  thence fecreted  into  abfceffes, wounds, and
ulcers.   But the  mofl  probable  opinion  is,  that  pus is
produced by  a certain degree of fermentation upon the
ferous  part  of the blood, after its feparation  into the ca-
vities of ulcers and abfceffes;  and this, in confequence of
the natural  heat of the part,  or of heat artificially appli-
ed.  And it is further rendered probable by experiment,
that as  the  ferum is  depofited more or lefs free  from fat,
red  globules, &c. it will yield a pus more or lefs pure or
vitiated.   Vide Cullen and Pringle.
   When  fuppuration is to be promoted,  all the  means of
producing  refolution  mufl be laid afide.  But as a  certain
degree  of  inflammation is found neceflary for  the  forma-
tion of pus,  it will  be improper to let the inflammatory
ftate fubfide fuddenly.  The diet of the patient fhould there-
fore be regulated by the circumflances of phlogiflic diathe-
fis,or of debility which feem to prevail; and, fuch applica-
tions fhould be made to the inflamed parts as tend  to pre-
ferve in them a proper degree of heat.  This lafl is a cir-
cumflance  of the  utmofl importance—And  the experi-
ments of Mr. Gaber and myfelf on ferum out of the body,
and of  myfelf  on inflammatory tumors in the body, have
made it  evident to me, that the greater the heat is, to a
certain extent,  the fooner fuppuration  will  take  place.
From hence it probably happens,  that  fwellings  near the
heart fuppurate in  much lefs time than thofe more  diflant
                                                  from 
                       C  8   ]
from it;  and the want of a due degree of heat, perhaps,
prevents  the greater part of foft fwellings from coming to
fuppuration-,   which  then form  atheromata, fleatomata,
and  melicerides.
   Warm fomentations and  cataplafms  are the  means
generally ufed for  the  application  of  heat  to  phleg-
mons : and  when  they are  frequently  renewed,  they
anfwer the purpofe very 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 foon as the heat
they at firfl poffefled is diffipated, the moifture they fup-
port, with the confequent evaporation, mufl always ren-
der the part colder than if it had been merely wrapped up
in flannels.
   In order to receive advantage from thefe remedies, the
parts affected  fhould be well  fomented with flannels,
preffed out of fome 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
fhould be applied warm, and renewed every two or three
hours.   Bread and milk,  with  a little butter  or oil, in
common, forms the mofl eligible poultice.
   When there is a  defect of inflammation in  the tumor,
roafted  onions,  garlic, &c. may be added to the poulti-
ces •, but ftrained galbanum, or  fome other  of the warm
gums, diffolved in the yolk of an egg,  or a fmall portion
of cantharides,  are much more elegant and  efficacious
additions.  Plafters  of the  warm gums are ufeful,  and
become neceffary fubftitutes to the poultices, if the patient
cannot be confined within doors.
   Dry cupping, i. e. cupping without fcarification,  upon
or as near as  poffible to the-affected part, in cafes where
inflammation is defective, is alfo eminently ferviceable.
Thefe 
                        -  9  1
   Thefe applications mould be continued, until fuppiira--
tion  takes  place; which feldom  fails  to be the  cafe, in
a  longer or  fhorter time,  according  to the ckcumftan-
ces of the difeafe—The formation of matter is indicated by
a  remiffion of all  the fymptoms.   The throbbing  pain
goes  off,  and a  more dull and conflant pain  fucceeds j
the tumor becomes  pointed at fome particular part, gene-
rally near the middle, where, if the matter is not contained
in a cyfl,  or very  deep-feated,  a whitifh-yellow appear-
ance is  obferved ; and a fluctuation of fluid is plainly per-
ceived upon preffure.   In addition to thefe local fymptoms,
whenever a large collection of pus is formed,  frequent
fhiverings almoft conftantly occur.
   In  the treatment  of  collections of matter or abscesses,
it  is  a  general rule never to open them,  until a tho-
rough fuppuration  has taken  place ; for if it is  done  be-
fore,  they never heal kindly.  An exception to this  rule
occurs  in the treatment  of critical  abfceffes that are pro-
duced in malignant fevers,  and in the plague—Thefe
fhould be  opened  as  foon  as it can  be afcertained that
there is a depofition of fluid.  And collections  of matter/
on the joints, or over  the cavities of  the breafl or belly,
efpecially if  they run  deep,  ought to  be  difcharged as
foon as  any fluctuation can be perceived.  Becaufe, when
the refiflance on every fide is  equal, they may as readily
pour out their contents internally as externally ;  and  the
confequence of a large abfcefs, burfting into  either of  the
large  cavities, is commonly fatal.
   Abfceffes have ufually been  opened either  by  Caufk of
Incifon.  With  refpect to the cauftic, it is  not  attended
with any fuperior advantage to a fimple incifion : It gives
much more pain; it is  more flow in its effects;  and it is
impoffible always to confine its  operation to thofe  parts
which were alone intended  to be affected,   On account
                           B                        of 
of thefe inconveniencies, incilion with a lancet or fcalpel, is
very generally preferred to it.
  When the fwellings are not very large, they are com-
monly opened by an incifion, extending two-thirds of their
length, and terminating  at their lower extremity :  but
abfceffes of  confiderable extent  fhould be  laid open their
whole length.  It has been advifed by fome,  to take away
a part of the teguments, when they are very much ftretch-
ed; but  this can very  feldom  be neceffary or proper—
never indeed, unlefs the parts are completely  dead.
  The inconveniencies of opening abfceffes  with  the knife,
arife from the fuddennefs  of the difcharge of their con-
tents,  and  the admiflion  of air to the   ulcerated furface.
The firft occafions faintings, and other difagreeable fymp-
toms, and the latter often induces an aftonifhing change
in the difcharge, from a well digefted  pus to a thin fanies ;
and that fometimes within fo  fhort a fpace as forty-eight
hours ; and afterwards, if the tumor has been very large,
a hectic fever, which either proves  fatal in  a fhort time,
or terminates in confirmed phthifis. It feems probable that
the  air produces  thefe effects by its  irritation ;  by ftimu-
lating the veffels to  a greater abforption,  and  by rendering
the  matter to be taken up  more putrid.
  None of thefe bad confequences of incifion and cauftic,
follow the ufe of the feton.  It therefore, with  propriety,
claims a preference to both of them.  When the feton is
employed in opening abfceffes, there is little  or no furface
of the lore expofed  to the  air; a gradual  difcharge is occa-
fioned ; it is attended with very little pain  and  inflamma-
tion ;  produces a very fmall cicatrix ; and  generally com-
pletes a cure  in  half the time  neceffary to  accomplifh it
when incifion or cauftic are ufed.
  The feton is  to  be formed as follows :—An opening
fufficiently large  for the cord, being made with a lancet
in the fuperior  part  of the abfeefs,  a   director,  flightly
curved, and having an eye at one  end,  threaded with
                                                      a 
                        C   »   1
a  cord  of candle-wick cotton, or  of  foft  filk,  pro-
portioned in thicknefs to the fize of the tumor,  is then to
be  introduced,  and its  point  to be  pufhed  downwards
until it  is felt externally, exactly oppofite to the mofl de-
pending part  of the fwelling.   The  director being  kept
firm by an affiflant,  an incifion is to  be made  with a fcal-
pel upon its lower end,  fomewhat larger* than the open-
ing firfl made.  The director is now to be withdrawn
downwards, with  fo  much of the cord as will leave two
or  three  inches of it hanging; out of the  lower  orifice.
In about twenty-four  hours after the introduction of the
cord, and daily afterwards, fo  much of it fhould be drawn
downwards  as  will  admit  of  all  that  part  of  it  be-
ing cut off which had been lodged in the abfcefs. In order
to make the cord pafs eafily,  the part to be ufed  fhould
always be rubbed with fome emollient ointment.
   By this method of cure, the gradual difcharge produced,
admits  a gradual contraction of the fides of the cavity, and
the flight inflammation fupported on their furfaces, by the
irritation of the cord,  induces a firm  and fpeedy union of
them.  As the difcharge diminifhes, the feton fhould be
leffened by degrees,  by withdrawing a thread of  the cot-
ton once in two or three days.   At length, when little more
matter is  produced  than may be fuppofed  to arife from
the irritation of the cord, it may be altogether taken out;
and a gentle preffure fhould then be made on the parts by
a roller, until  the completion of the curef.
                                                  Every
  * This will hinder an inconvenient  tranfuding of matter above.  B.
  f Several objections may be offered tp Mr. Bell's method of opening
abfceffes with the feton :  In the firft place, it does not appear to be an eafy
matter to pafs a  feton in the mode  he  directs, through  a large or deep
abfcefs, or that it fhould  anfwer the purpofe he propofes by it.
  In the large deep abfceffes frequently formed in the brearts of fat women,
fuch fmall openings do not difcharge the matter contained fufficiently to
prevent new and troublefome fioufes; and many women are too timid
                                                       to 
                       t   »*  3
  Every thing  that  has been faid refpecting  the cure  of
abfceffes from recent inflammation,  applies with equal pro-
priety,  to all tumors which contain a purulent matter,  or
a fluid not much thicker than pus,
                     SECT.  IV,

                    Of Mortification,

   A complete mortification, or the lafl ftage of gangrene*,
is known by the difeafed part becoming black, by its lofing
all pain and fenfation,  and by its emitting a  confiderable
fetor.—A foftnefs, and entire diffohnion of the different
parts  of the organ affected, alfo in commmon take place.
   There is  a fpecies of gangrene called the dry,  in which
the parts  continue hard and connected a confiderable time
although  entirely  mortified.  This feems to be produced
from  an obflructed flow of blood to the parts, by the prek
fure of tumors,  ligatures, &c.; and is never a confequence
of inflammation.  With refpect to the difeafe termed the
•white gangrene, and in which the parts preferve nearly the
natural colour,  it is very  doubtful  whether it can  with
propriety  be confidered as a gangrene—We mean, in this
place,  to  confine  our remarks more particularly to that
fpecies which fucceeds inflammation.   They are, however,
in general, applicable to all the varieties.
   Eryfipelasf is the  fpecies of inflammation  mofl apt  to
                                               terminate
to pernnt of one opening, inftead of two which muft be made by the fc
ton-nor does frefh good air appear to be fo injurious to wounds as Mr"
Edl feems to think  Upon the whole, further experience feems neceffary
before tins new mode c„n be generally preferred to that in common prac-
tice.                                                  *

  * See what has been already faid on gangrene.
  f See fe>it. on inihznmatory tumort. 
                       t  13   ]
 terminate in gangrene;  and when joined  with phlegmon^
 as it frequently is, it gives that the fame tendency.
   In fome inftances, mortification comes on almofl before
 an inflammation is completely formed.  This  occurs mofl
 frequently in carbuncles.   In thefe, there is  feldom any
 evident fwelling;  and the parts often become gangrenous
 in the courfe of twenty-four hours.  The rapid progrefs
 ufually made in thefe cafes  renders them extremely dan-
 gerous, when very extenfive, or feated on any of the large
 blood veffels or nerves.  If this is not the cafe, the patient
 frequently recovers, with the lofs of the affected part.
   Carbuncles commonly appear without any evident exter-
 nal caufe; and probably depend, in general, on a fcorbutic
 or putrefcent flate of the fluids. They are ufually a fymptom
 in peftilential difeafes ; but fometimes, although very rarely,
 they happen as idiopathic affections.
   Gangrene feems to be produced from a putrid  fermen-
 tation in blood effufed  by the  violent action of the veffels
 in an inflamed part; and to be propagated, by the  affimila-
 tory power of the gangrenous ferment.
   The feparation of the difeafed part is  occafioned by an
 inflammation, and fucceeding fuppuration, of fome irritable
 part to which the mortification is  extended;  and the ge-
 neral fymptoms are readily accounted for from the debili-
 ty induced  by the putrefcent flate of  the  fluids.   See
 Cullen, Pr. Ph. vol. I.
   We fhould never make  a pofitive prognoflic in the be-
 ginning of gangrene :  for patients are fometimes Carried off
 fuddenly, without previoufly  appearing in any imminent
 danger.  When,  however, the difeafe  originates from ex-
 ternal inflammation, is not deep or extenfive,  and has be-
 come flationary, the prognofis may generally be much more
\ favourable than when it is produced from an internal caufe,
 is confiderable in  extent,  and continues to inereafe.  For,
                                                     in 
                        C   14  1
in this cafe, there is always the greatefl danger to be fear-
ed ; and,  even in any confiderable  mortification  from  an
external caufe, the patient cannot be pronounced free from
danger until the entire feparation of the gangrened parts.
   As there have been many inflances in which death  has
fuddenly enfued after  the ceffation of the progrefs of the
difeafe,  and before any general putrefcency has appeared,
we conclude that the fatal termination is then produced,
not from abforption of the putrid matter,  as may be with
probability fuppofed in long continued cafes, but  from the
deleterious effects of  the  gangrened part  on the nervous
fyflem.
   In  the treatment of gangrene,  whenever the general
fymptoms  of inflammation continue to a  confiderable  de-
gree, it will be proper  to order blood letting, laxatives, and
acidulated  cooling drinks.  But evacuations, and particular-
ly blood letting, fhould be ufed with the greatefl  caution;
and never  to a greater degree  than feems abfolutely necef-
fary for moderating the violence of the fymptoms.
   When, however, as is  mofl frequently  the  cafe if  the
difeafe has made any  confiderable progrefs, the patient is
much debilitated,  the  indication is,  to give the fyflem fuf-
ficient  vigour  to  free itfelf from the mortified parts.*
This is accomplifhed by a generous  diet, and a liberal ufe
of tonic  cordials,  and particularly of good wine.  When
very great debility and languor occur, volatile alkali, con-
fectio cardiaca,  &c. may  be given with advantage.  But
of all  the tonic remedies  of  mortification, the  f common
                                                 Peruvian
  * Mr. Pott defcribe3 a fpecies of mortification incident to the toes and
feet, in which opium is a very effectual remedy, and nothing elfe is of any
material benefit.    B.
  \ Befides the advantages  derived from the internal ufe of the bark, we
may, from the experience of many practitioners in this city,  with confi-
dence recommend it as one  of the moft powerful external applications in
this formidable difeafe. 
                        C  15   _
 Peruvian bark*  is the mofl efficacious.  It fhould be  gi-
 ven as foon  as the fymptoms of inflammation are abated,
 and in as large quantities as the flomach will bear—As a
 great irritability  of this organ is very commonly a confe-
 quence of gangrene, it will be befl to exhibit the bark,  ve-
 ry finely powdered,  in combination with fome of  the fpi-
 rituous  waters.   The vitriolic  acid  may  alfo  be given
 with  advantage: and may be mixed with  the patient's
 common drink.
   These are the internal  remedies that can be with mofl:
 certainty depended on.
   There has been a great  variety of external applications
 recommended;   particularly  all  the  warm  gums   and
 balfams, ardent  fpirits, and even alcohol;  and to admit
 of a nearer  application of  them to the  found parts,  deep
 fcarifications through  the  difeafed,  and  into   the  heal-
 thy parts,  have conftantly been advifed.  But it is proba-
 ble  that thefe   ftimulating fubftances, by exciting  too
 flrong irritation,  do more  harm than  good.  And the in-
 cifions alfo  may  do material injury, not only by wound-
 ing blood veffels, nerves,  tendons, &c. but alfo,  by ad-
 mitting  a free entrance of the putrefcent fluids into the
 found parts.  For thefe reafons, and becaufe I have never
 known them productive of  good effects, I have long been
 of opinion  that  they might be entirely laid afide.—Mr
 Pott concurs with me in fentiment,—It will, however,  be
 proper to remove a portion of  the mortified  parts, when
 the difeafe is extenfive ; in  order to leffen the fcetor, and
 contribute to render the healthy parts capable of throwing
 off the remainder : but the fcarifications fhould  never ex-
 tend to the parts  unaffected by the complaint.
                                               Theriaca

  * The red bark, from many  experiments, appears evidently much ia-
ferior to the common  bark.   B. 
                       [  16   1
   Theriaca has long been, and is  now with  fome, a ve-
 ry common application; but I never faw any evident good
 effects from its ufe.
   All the advantages to be derived from the common ap-
 plications in  gangrene, are generally obtained with more
 eafc and certainty, from gently ftimulating  embrocations.
 A weak folution of crude fal ammoniac in vinegar and wa-
 ter anfwers exceedingly well—a drachm of the fait to two
 ounces of vinegar and fix of water, form a mixture of a
 proper  ftrength in  common cafes ;  but  the  degree  of ftU
 mulus may be eafily increafed or diminiflied according to
 circumftances,  by ufirrg a larger or fmaller  proportion of
the fait.
   When a flight inflammation commences  on the verge
of the living  parts,  we  may generally  with certainty ex-
pect a feparation of thofe mortified: but  after fuppura-
tion is perceived, this, without doubt, will very foon follow-
When the feparation is accomplifhed,  the wound is to be
treated  as  a  fimple- purulent ulcer ; while at the fame
time, proper  attention is to be paid to the general ftate of
the fyflem.
   It  fometimes  happens,  that mortifications deftroy fo
much of the foft parts in the extremities, that amputation
becomes abfolutely  neceffary.   In thefe cafes, the opera-
tion fhould never be performed until we are fatisfied that
the progrefs  of the difeafe has entirely ceafed.   When
this is determined, the limb fhould be removed as foon as
poffible.  See chap, on Amputation.
CHAP. 
C   17  3
            CHAP.     II.

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

            Obfervations on  Ulcers in general.

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


                     SECT.  II.

             On the fimple Purulent  Ulcer.

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


                     SECT.  III.

               Of the Simple  vitiated Ulcer.

   The" vitiated ulcer differs only from the fimple purulent
 fore in the nature of the difcharge.
   The  matter afforded  is  either,   i. A  thin, limpid,
 fometimes greenifh  difcharge, termed fanies.   i.  A fome-
 what red-coloured, thin,  and generally very acrid matter,
 termed  ichor; or,  3.  A  more  vifcid, glutinous kind of
 fluid, called  forties.   This  laft  is  alfo frequently  of a
 brownifh  red  appearance,  fomewhat  refembling  the
  grounds of coffee,  or  grurnous blood mixed  with water.
  They are all  more fetid than pus, and  none of them free
                                                    from 
                       [   29  ]
from acrimony—What has been termed ichor, is often fo
corrofive as  to deflroy large quantities of the neighbour-
ing parts.  In confequence of the nature of the difcharge,
the granulations wafte away,  and have a dark brown or
black appearance.   The  pain is  often  confiderable,  and
is proportioned to the acrimony of the matter.
  The caufes of this  ulcer are the fame as thofe produc-
ing the  purulent ulcer;  and  that fpecies  eafily degene-
rates  into this  from neglect or improper treatment;  and
particularly  when the tendinous  parts are the feat  of the
difeafe.
   The progncfis in the vitiated ulcer, may be favourable
when the complaint is not extenfive or is  local, has not been
of  long duration, and  occurs in young, healthy fubjects;
but, in oppofite circumftances, it  fhould always be very
doubtful.
   The quality of the difcharge in ulcers has been above
fhewn to depend chiefly on the different degrees of inflam-
mation in the part; and this is further  confirmed  by the
nature of the remedies that are  mofl effectual in relieving
thefe diforders, which are principally of that kind which
remove pain and irritation.  Thus warm emollient cata-
plafms and  fomentations  often give great eafe, and meli-
orate  the   difcharge   within  twenty-four hours:  thefe
fhould be ufed as formerly recommended to promote fup-
puration, and  the  dreffings applied immediately  to the
fore fhould  be mild, like thofe advifed in the fimple puru-
lent ulcer,  while too great a degree of  inflammation con-
tinues.    When  the  pain is  very  confiderable,  opiates
fhould  be  given,  and  repeated  according  to circum-
ftances.
   The diet  muft be  regulated by the  habit of body;  if
weak, it fhould be  nutritious; if full, the regimen  fhould
be  low.   In the former cafe, the peruvian bark is a very
                                                 effica- 
                       _   3o  3
efficacious  remedy, and fhould be  given  in  dofes  of 5J.
fix or eight times a-day.
  When the abovementioned circumftances  are attended
to,  and the part  affected  is kept at reft in a proper  pof-
ture,  the  fore  is  commonly fooner or later reduced to
the  ftate of the fimple purulent ulcer;  and then requires
the fame method of treatment.
  I have never feen any evident good effects produced by
the  exhibition of nitre; although I have frequently given
it in large  dofes for a confiderable length of time.*


                   SEC T.  IV.

                 Of the Fungous  Ulcer.

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

  *  It has, however, in a few inftanees, been attended with very hanpy
effects in  the  cure of old habitual ulcers of the leg. 
length.   Thefe inftead of  cicatrizing when they are on a
level with  the found parts, continue to  advance until  the
caufe is removed.
   With refpecl to the cure of fungi, when it is found that
they are produced merely by an over-growth of parts,  if
they are not of any confiderable breadth, and efpecially  if
they are not very high, we fhould have  recourfe to  efcha-
rotics.—By many, we are directed to ufe the actual  caute-
ry, and by others the fcalpel; but few  patients  will fub-
mit to either of thefe,  and  particularly as the diforder may
juft as effectually, though' net quite fo expeditioufly, be re-
moved by  means more gentle.
   Of all the cauftic  preparations, the lunar  cauftic is the
beft for this purpofe.  It acts more quickly,  and does  not
give more pain than the milder forts ;  it never fails to pro-
duce the proper effect as many others do ; and it is  not fo
apt to run, and to fpread over the neighbouring parts,  as
fome of the other cauftics.
   The cauftics fhould be liquefied, and  then applied by a
fmall brufh or pencil,  daily or every other day—A ftronj?   /
folution of verdigreafe, fal ammoniac, blue or white vitriol,
will alfo commonly  prove effectual.   But folutions of fil-
ver or mercury  in  nitrous  acid form the  mofl powerful
applications of this kind.   In making the laft we muft ob-
ferve, that one ounce of flrong fpirits of  nitre will diffoive
no more than about fix drachms of quickfilver.   Thefe
cauftics fhould never be  applied to an extenfive  furface at
once.  After their  ufe the  part  fhould  be covered with
lint, as ointments leffen their activity.
   When  the bafe of the  excrefcence is narrow and its
height confiderable, it  fhould be removed by a ligature ap-
plied at its root, and tightened daily.  If, however,  toge-
ther with great height,  the tumor has a broad bafe, this me-
thod will not fucceed; and the following muft  be  put  in
practice.
                                                     4 
                      [  32   _
   A flrong ftraight needle fixed in a handle, with an eye
near the point, being puflied through the tumor at its bafe,
and two flrong waxed threads being introduced at its eye,
it is to be again drawn back, leaving the threads with their
ends hanging out at each fide of the fwelling.  A firm liga-
ture is then to be. formed round each half of the fv/ellingby
the threads, and tightened from time to  time.
  The fungus being by either of thefe  methods removed,
the fore is then to be treated as a fimple purulent ulcer.
  The other fpecies of fungous excrefcence which proceeds
from the granulations not being raifed  on  a good founda-
tion, is generally eafily  diftinguifhed from the preceding
fpecies : It rifes  with  greater rapidity,  and is not fo firm
as healthy granulations.
  As foon as the caufe is difcovered, any confined matter
beneath fhould have  vent given to it  by  a proper  open-
ing ; after which, by  taking care that the fore fills up from
the bottom, the cure will go on eafily in the common way.
There is feldom then occafion for efcharotics, as the fungus
commonly waftes away of itfelf.
                    SECT.   V.

                 On the Sinuous Ulcer.

  By finuous ulcer is meant a fpecies of fore communi-
cating with  one or more openings or cavities,  which are
commonly feated in  the  cellular membrane, between the
interftices of mufcles,  or between  the mufcles and integu-
ments.  By  long continuance, or by the ufe of aftringent
applications,  a  finus often  becomes  hard and  callous in
its internal furface ; and in  fuch a ftate,  from its fuppofed
refemblance  to a pipe, it is termed a fiftula.
-1                                                 The 
                       I   33  J"
   The mofl  frequent  caufe of  finufes, is the want of a
free difcharge of matter formed in ulcers and abfceffes;
which, falling ^o the mofl depending firuahon of the part,
if  it does not there find a  ready paffage by an opening
made to  it, readily infinuates itfelf  into the cellular  mem-
brane,  and proceeds gradually onward till it finds a vent.
Very tight bandages applied immediately  over a fore, and
not made to act on the parts above and below for fome
diftance, are alfo a frequent caufe.
   In healthy conftitutions,  when there is eafy accefs  to
the finus, a favourable prognofis may generally be made;
but when the difeafe has  been of very long continuance,
and particularly if the  finufes open into any of the joints,
or are  beyond the reach of an operation, a  cure is  diffi-
cult, and doubtful.
   The intention of cure, in  every cafe of  finus, is to pro-
duce a coalefcence of its fides, fo as to deflroy any vacui-
ty that may have been  occafioned.
   To effect this, it  is  neceffary firft to make a depending
orifice  for a free exit to the matter; and  then, by a gen-
tle irritation, to induce on the internal furface of the
fore,  a  flight  degree   of inflammation,  and  confequent
adhefion of the fides of the finus.  Both thefe intentions
are anfwered  by the introduction of the  feton, from the
orifice  in the ulcer along the courfe of  the finus   to its
other extremity, where an opening fhould be made in the
manner we formerly directed in abfceffes.   The treatment
is  then to be  fimilar to that of abfceffes in which a feton is
ufed.  Vide  chap.  I.  feet. iii.   A  cord fhould be  intro-
duced into every finus.
   This method is entirely free from danger,  and is admif-
fible in almofl every cafe that can occur.   It is particu-
larly proper  in  finufes in the perinseum: for the cicatrix
formed there after  the opening a large finus by the  knife,
                         E                          is 
                       [  34   ]
 is often more inconvenient and painful than the  original
 difeafe.
   The finufes  being by this means filled up, the ulcers
 with  which  they have been connected,  are  then to be
 treated by the method adapted  to the fpecies  to which
 they belong.
   By many writers,  ancient as  well as  modern, we are di-
 rected, in  recent finufes,  to  ufe healing  injections ;  and
 when  their fides have become callous, efcharotic injec-
 tions  and powders have  been  recommended.   None of
 thefe,  however,  produce  any  permanent good  effects;
 and often convert fimple finufes into the callous.   Others
 advife  to lay open the different finufes, and cut  out the
 whole of the callofities.  This will often effect  a cure;
 but the  pain,  and often  the  danger  attending it,  muft
induce a preference of  the mode above  recommended.
  When, however,  incifion  is  preferred, unlefs  all the
parts  are evidently  callous;  in which cafe  extirpation
may  be  neceffary,  mere  divifion of  the  parts forming
the finus fhould alone be  ufed.   The  free vent  thus giv-
en to  the  matter, and the fuppuration fupervening, will
frequently remove very confiderable callofities.
                    SECT.  VI.


                 On the  Callous Ulcer.


  An  ulcer is  faid to be callous when its edges, inftead
of contratting and  diminifhing the  fize of the fore, keep
at a diftance, turn ragged, and at laft,  by acquiring a
preternatural degree of thicknefs, often  rife confiderably
above the level of the neighbouring parts—the difcharge
                                               afforded 
                        [   35   3
 afforded by it, is commonly a thin vitiated matter.   Vari-
 cofe veins alfo occur as a fymptom, and particularly when
 the difeafe is  feated in  the  lower -extremities;  hence the
 name  of varicofe  ulcer, which this fpecies has acquired,
 from a fuppofition that it was produced from matter fup-
 plied by thefe veins, which frequently have the appearance
 of opening into the fore.   The varices feem  to originate
 chiefly from an obftructed  return of blood, by the pref-
 fure of the callous parts on the veffels.
   The caufes of callofities in ulcers may be all reduced to
 neglect and mifmanagement.  When,  from thefe  circum-
 ftances, the fmall veffels of the edges of ulcers are prevented
 from proceeding in a proper direction, are forced to pufh
 upwards, and even fometimes  backwards, they, by the
 preffure of bandages,  will neceffarily acquire  at  length
 a morbid hardnefs or callofity.
   In the cure of this difeafe, the caufes originally produ-
 cing it are firft to be  removed ;  and the callofities  may
 then be taken away.
   Recent cafes are often  cured merely by the repeated
 application  of warm emollient cataplafms—and  alfo by
 gum-plafters ;  but when the parts have acquired much
 hardnefs, the  only remedies are the  cauftic, or  fcalpel.
 And as the firft is equally certain with the other, it fhould,
 as  the eafieft  method,  be  always  employed.  For  the
 reafons formerly  given, the  lunar cauftic  fhould here
 likewife be preferred.   The folution of filver or of mer-
 cury in nitrous acid, may be alfo ufed  to advantage.   Ei-
 ther of thefe fhould be  applied to the  callous  edges every
 two days, while  the  cataplafms are  ftill  continued as
 long as any degree of foulnefs remains  in the fore.
  For the cure of the varices, it is  not only neceffary to
 remove  their  primary  caufe,  the callofity,  but  like-
wife to reftore the  tone of the veffels  weakened by their
                                             diflention, 
                       C   36   1
diftention, by the application of the  laced flocking, or a
roller*.
  A confiderable fwelling of the adjacent parts very com-
monly occurs; when  this  dees not go off after the hard-
nefs is removed,  the ufe of a flannel  bandage will ufually
prove effectual in diffipating it.

                    SECT.   VII.


                   On the carious  Ulcer.

  By the term carious ulcer we underftand that  fpecies. of
the diforder only which  is connected  with a local affection
of a bone :  whether the difeafe of the bone may have been
always confined to the part,  or exifts  after a general dia-
thefis  which originally gave rife to it  has been removed.f
  When a bone is at firft laid bare, it is impoffible to  de-
termine whether it will become carious ;  as in a great ma-
ny  inftanees this does not follow e>/en a removal of part of
it.   A cure fhould, hov/ever, never be attempted until  this
can be afcertained.
   If at the  end of the fourth day after the denudation of a
bone, it retains its natural appearance,  we may conclude,
with tolerable certainty, that a  caries  will not fucceed.  For
when this is to happen, it generally begins in three days or
 four at fartheft.  The bone begins to lofe its natural heal-
 thy appearance, turns firft of a pale  white, and then of a
 pale yellow.  It fometimes remains  in  this ftate for fome
                                                    days,
   * The  growth of varices may be retarded  by the ufe of the. roller or
 laced ftocking judicioufly applied ; but I never was able to cure old exten-
 five varices by thefe or any other means.
   f Caries appears evidently from its fymptoms, caufes, and method  of
 cure, to be a difeafe exaftly of the fame nature with a fphacelus or gan-
 grene of the foft parts.  B. 
                      L   _•/  J
days,  and by degrees gets a more deep tallow-like appear-
ance.   It  continues thus for a longer or fhorter  time, ac-
cording to the degree of violence with which the injury
has been done;  and afterwards goes through the  differ-
ent ftages of brown and black, until it has  acquired a black
of the deepeft dye.
 .  The  difcharge  from ulcers  of this kind,  is generally
thin; and of a moft difagreeable  fcetor, which always be-
comes  more  confiderable as the diibrder  advances;  at
laft it acquires a blackiili hue, and often a confiderable de-
gree  of acrimony.  As the fevcrai  degrees of blacknefs
go on,  fmall  holes  appear in  the  bone,   and increafe
fo  as at length  to render  it  quite fpongy.   The  carious
part  then generally becomes loofe,  and  when preffed,  a
large quantity of a fattifli, intolerably fcetid matter is forced
out.  This  taints  the  whole difcharge;  and  the fmell  of
it  is fo  very peculiar, as to afford one of the moft  charac-
 teriftic marks of caries.
   The granulations in this ulcer  are foft and flabby, fpring
 up in clufters, and have a dark brown, together with fome-
 what of a  glaffy  appearance.  They ufually advance very
 faft,  and if not carefully attended to, will  be apt to form
 large and troublefome excrefcences.
    All the phenomena  abovementioned, occur  in greater or
 lefs degree, whether one lamina,  or the whole fubftance of
 a  bone is affected.
   When the bone has not been bared, it  is often a matter
 of confiderable difficulty to  difcover  a caries.   If we are
 able  to introduce a probe, and by that means find a rough-
 nefs  on the furface of the bone,  we  may,  with certainty,
 conclude it to be  carious.  And when it is impoffible  to
 reach the difeafed part with  an inftrument,  we may com-
 monly  afcertain the exiftence of a latent caries, by the ap-
 pearance of the fere and the nature of the difcharge.
The 
                      [  33  3
  The caufes of caries may be, in general,  whatever de-
flroys the circulation in the whole or any part of a bone:
as wounds which affect either the periofteum or  bones;
violent contufions  and inflammations of the  periofteum,
terminating in abfcefs or gangrene ; the acrid matter of ul-
cers  penetrating  to, and deftroying  the periofteum;  and
the improper application of  fharp acrid fpirits and pow-
ders to bones merely laid bare.
  It is to be remarked, that deftruaion of the periofteum,
or even the removal of part of a bone is not always follow-
ed" by caries; and this is feldomer a confequence of fuch in-
jury to the cranium than to any other part of the body;
probably from the greater number of  blood-veffels diftri-
buted to that part.
   The prognofis in caries  muft depend  principally on the
following circumftances:  The fituation of  the  difeafed
parts; the nature of the  affected bones; the nature and
degree of the caufe; the fize of the caries ;  the age and
habit of the patient.
   Thus a caries in any of the bones of the flcull,  ribs,  or
vertebrae, from  their fituation near  the vital organs,  muft
be attended with more rifle than  when it affects the bones
of the extremities.  And a caries  near a joint from the
danger of this becoming difeafed,  is always more to  be
feared than when it is confined to the middle of the bone.
The texture of a bone fhould have alfo  confiderable influ-
ence in the prognofis; as well as the nature of  the caufe :
exfoliations being  much  more tedious in the hard and
compact, than in the more foft and vafcular bones,  and a
 wound with a fharp inftrument, does not generally produce
 fo deep or extenfive a caries as that which  commonly fuc-
 ceeds to violent contufions.   The cure is likewife produced
 in a longer  or  fhorter time as the caries  is extenfive or
 not.
   And, laftly,  the habit and age of the patient muft have
                                           ccnfiderable 
                       [  39   3
confiderable weight in making a prognofis.   For the cure
of caries generally proceeds fo flowly, that few can fupport
the difcharge it produces, if they have not previoufly been
perfectly healthy.
  The healing of an ulcer, attended with caries fhould ne-
ver be attempted, until the difeafed bone is removed.   For
if the foft parts above fhould be united, an abfcefs would
be  produced by  the  irritation of the bone beneath, and
force them open.
   In a healthy flate of the body, the feparation of the cari-
ous bone is produced, as in gangrene, by the intervention of
a flight degree of inflammation excited on the extremity of
the found parts—Suppuration follows,  and this, together
with the rifing of granulations,  foon detach the dead from
the living parts.  If we fuffer ourfelves to be directed by
this procefs of nature, we may  often accomplifh in  a few
weeks what would otherwife require many more months
to effect.   The principal indication  of  cure therefore,  it
is evident, fhould be, by repeated and judicious  applica-
tions to excite fuch a degree of inflammation, in the adjoin-
ing  found parts of the bone, as  may be requifite for the
feparation of thofe mortified.
  If the bone is  not  bared,  it  fhould be expofed to view
either by laying open the foft parts  or  removing fome of
them.   The  fafefl and eafieft mode  of  exciting the necef-
fary inflammation, is by making a number of fmall perfo-
rations in the difeafed yart, with the pin or perforator of a
trepan fixed in its handle, to fuch a depth as to give a lit-
tle  pain, every third  or fourth day.  When the caries  is
very deep and extenfive,  it will  fhorten  the procefs to ufe
the fmall head of a trepan.—As foon as any  part of the
bone  becomes loofe  at   the  edges, its feparation will
be  much haftened,  by  daily  infinuating  below  them
the end of a  fpatula or levator,  fo  as to prefs  them up-
                                                 wards 
             ':         C  40  3
wards.   During the feparation of the bone, in order to
obviate the foetor,  the fores fhould be walhed with a de-
coaion of bark, of walnut leaves, camphor diffolved in
fpirits, or lime-water.  The latter I would advife to be al-
ways ufed, as it not only corrects the foetor,  but likewife
diffolves the cohefion of the bony matter.  Pledgits of lint
dipped in thefe fhould be laid on the bone, while the reft
of the fore is dreffed in the ordinary way.
   After the feparation of the caries, the ulcer is  to be
treated as a fimple  purulent fore.
   When  a very large portion,  or the  whole circumfer-
ence of a bone is carious, the fhorteft procefs is to take out
all the difeafed parts by the head of a trepan, ©r-a ftraight
or circular fpring-faw.   This  may  be  done in all  cafes
where  the difeafe  is confined to the middle  of a bone,
except,  perhaps, when the thigh bone is affected.  There
are many inftanees of the regeneration of whole  bones;
hence we fhould never  defpair of a cure where the  part
difeafed can  with  fafety be removed.   When the thigh
bone is extenfively affiled, or when  the ends of the larger
bones forming joints, are carious, amputation is almoft the
only remedy  to be depended  on.   See chap, on Amputa-
tion.                                                 '
   During the treatment of caries, the fame attention is re-
quifite to the patient's habit of body, diet, and regimen in
general, as we have recommended in  other fpecies of fores.
   The  bark is  almoft  the  only remedy that fhould be
ufed internally; but when  the foft parts  become  very
 painful and inflamed, flight  fcarification, or bleeding with
 leeches,  fhould be employed, and opiates fhould be given
freely.
SECT. 
[   41   3
                       SECT.  VIII.


                  On  the  cancerous  Ulcer.*

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

   *  The following obfervations on Cancers, are the refult  of the expe-
rience  of Mr. Berchien, a Swedifh  furgeon of eminence;  and who, in
confequence of having purchafed Mr. Guy's remedy for twenty years,
had  a very great number of patients with cancerous complaints under  his
care from all the northern parts of Europe.  They were publiftu d in the
Swedifh language by Mr. Berchien,  and by him fent to Dr. Adam  Kuhn,
the  prefent profeffcr of  the practice of phyfic in the univerlity of this
place,  who has favoured me with a tranflation of them.
   There are three fpecies of cancers : the cancer genuinus, fungnfus, and
fcrophulofus.  The cancer genuinus, or genuine cancer, is the  moft common.
It ufually appears firft in the form  of a very fmall, hard, and moveable
tumor  or fchirrus: this is ufually fmooth and round:  but in  fome in-
ftanees, it feels like a fmall tendon or firing.  After fome increafe of fize,
it often retains its fmooihnefs; but in  other cafes, it becomes  rough
and  angular, affumes the form  of  a cone, an almond, &c.   It  often
continues of the fame  fize for a number of years; but it alfo frequently
continues conftantly to increafe in magnitude from its  firft appearance.
The tumor  is at firft moveable, but after it has made fome progrefs, it
becomes attached to the adjacent parts.  When  it advances near to  the
furface, it becomes very perceptible to the eye, and the  fkin contracts a
wrinkled appearance.
   A pain, in fome inftanees, is felt before any evident tumor, particularly
in the  cord-like cancer.  In other cafes, there  is no pain until the tumor
appears; and in others  again, which is  moft  frequently  the  cafs,  the
                                                            pain 
                          [   42   3

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

pain does not come on until  the tumor has acquired a confiderable fize;
but after  the pain begins., the fwelling conftantly increafes in  magnitude.
Sometimes a momentary fhooting pain only is felt during the menftrual
flux, or upon changes  of weather; but in other cafes it is continual.
   Not long before the cancer becomes ulcerated, the fkin changes to a
red colour, and is painful to the touch;  it foon after becomes chapped,
and a thin fanies iffues from the  fiffures.   The edges of the fore  foon be-
come hard and uneven, and are  reflected in various directions.   There is
never a good pus afforded, but  the difcharge is a thin fanies or ichor,
which often deftroys  the contiguous parts.
   This fpecies of cancer  attacks various parts of the body;  but particu-
larly the lips, nofe, and breaft.
   The cancer fungofus chiefly occurs in fat women of a lax habit of body
and who have large breafts.   It begins like  the genuinus, with a fmall
moveable hard  tumor;  but it  is more fpungy,  elaftic,  like  a clufter of
fmall tumors, and not fo hard.  Its progrefs is aftonifhingly rapid:  in
 fome inftanees it has  grown from the fize of a nutmeg, to the biVnefs
 of a man's head, in the  courfe  of eight or ten months.  Little blue or
 reddifh fpots, often appear over the furface of the tumor;  which, when
 opened,  difcharge blood, or a bloody ferum.
   When the cancer  ulcerates,  it difcharges fuch  quantities of  a  bloody
 ferous matter, often all at once,  that no dreffings can keep it dry.  From
one or more of the openings, arife large fpongy  lobe-like excrefcenccs
 which fometimes have a refemblance to fheep's liver, and at other times
 have the form of the head of a cauliflower;  and  are hard and  cartilagi-
 nous to  the touch.   Thefe often fpread over the, whole breaft, and  are
 in fome  inftanees, ftrangulated  at their bafe by the fkin.
    This  fpecies affeils not only the breaft, but alfo the neck, fhoulders
 arm?, and  legs.
                                                             The 
                           [   43   3

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

   The  cancer fcrophulofus begins fometimes  like the two other fpecies
 with  a  fingle fchirrus; but in moft inftanees, there arc feveral near each
 other, and which often feem connected: Thefe are not  fo  hard as in
 the genuinus,  and  give little or no pain until  they become open fores,
 and even then but iittle.  In the advanced ftages, the breaft  appears co-
 vered with reddifh blue fpots, and is flat and hard.  The  integuments
 and fubftance  of the breaft being drawn in, fo  as to produce  a furrow in
 the middle, and firmly fixed to the mufcles and ribs.  This attachment
 often occafions a confiderable impediment to refpiration.   The fubcuta-
 neous lymphatic glands become  hardened in  every part  of the breaft,
 and particularly thofe towards the axilla.
   There arc many openings formed ; fome of thefe often dry up in a little
 time, and get a thick white fcab : others continue open—fome of them
 difcharge pus, others a thin foetid black ichor. The edges of the ulcers
 are frequently red and fungous;  and  the  difcharge often penetrates at
 length to the ribs and ftcrnum, and even into the thorax.
   In this fpecies, there are  ufually indurated lymphatic glands in various
 parts of the body,  and other marks of fcrophula;  and it  evidently de-
 pends on a general affection.
   Tumors in  the breaft from milk, have been accufed  of terminating in
cancer; but there is no good evidence of this; and where it has  appa-
rently been the cafe,  I.have no doubt that  there has,  at the fame time,
 been a fchirrus  in the breaft, which has  become cancerous from the  ir-
ritation produced by the milky tumor.
  The general exciting caufes of cancers, are paflions of the  mind, parti-
cularly  grief  or terror, and external violence.  In  the cancer genu-
inus and  fungofus,  t'ntfe  operate locally by  producing,  probably  an
©bftruction in  the lymphatic veffels, and  a  conf.'quent  fchirrus  from
a gradual accumulation of lymph, and abforption of  its thinner parts; -but
 in the cancer  fcrophulofus there is a general difeafe connected with the
                                                          topical 
                           [   44   3

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


topical affection.   From hence it is evident, that the cure of the latter can
only be effected by  conjoining the general remedies of fcrophula with
proper applications to the cancerous part  ; whilft the genuine and fun-
gous cancers may be  effectually removed by timely, topical remedies a-
loue.  The fcrophulous cancer may frtmetimes be cured by an early  and
judicious ufe of mercury,  general and topical, and by hemlock ;  but both
of thefe are injurious  in the other fpecies;  for the cure of which,  we can
with fafety, only depend  on early extirpation, or Guy's powder.-----
   As a confirmation  of the  accuracy of this interefting account of  can-
 cer?. I am  happy to give  the teftimony of Dr. Jones, of this city, whofe
 long experience has  afforded him an  ample  opportunity of  afcertaining
 its agreement with the phenomena,  nature, and proper method of treat-
 ing- thefe dreadful difeafes.
   The Doctor thus expreffes his opinion on the fubject:—Mr. Berchien's
 obfervations on cancers, appear to  be the  refult  of accurate  obferva-
 tion, and great experience ;  from which alone  any genuine improvement
 can be made in the cure of difeafes.
    His  diftinction  of cancers into  the three  general fpecies of genui-
 nus, fungofus, and  fcrophulofus, is well founded,  and merits the fe-
 rious attention of  all thofe who wifh to  treat this terrible  difeafe  with
 propriety.  The two firft may be radically cuied by extirpation with the
 knife or cauftic,  as they appear to  be  local difeafes:  but  the cancer
 -fcrophulofus requires the aid of internal medicine, to correct the vitiated
 habit; though very few inftanees occur of perfect cure.
    The cancer fungofus appears to be more liable to relapft than the ge-
  nuinus ;  and inftanees have  been known, where the  cancer fungofus has
  broke out after it appeared to be perfectly cuied by Guy's powder, and
  remained found above ten years.
     The fame fpecies of cancer  has been  frequently  clofed by  the ufe of
  arfenic; but has often broke out agahi,  and  at laft baffled all remedies.
   Similar confequences have attended a quack noftrum, which has been
   much boafted of in this city for two years paft.
     From thefe inftanees, it appears to be a melancholy truth,  that there
   are cancerous ulcers which baffle  all  the  remedies hitherto difcover-
   ed. 
                      I  45  3
  It however appears evident to me,  that cancer is  ge-
nerally a W, affection, not originally conneaed with  any
conftitutional complaint;  and that a  general  cancerous
taint, feldom, or perhaps never occurs,  but in confequence
of the cancerous virus being abforbed into the fyftem from
fome local  affeaion.  This  opinion  is more particularly
rendered probable, by the fuccefs of extirpation in curing
cancers.   From  a  ftatement of  Mr. Hill,  furgeon in
Dumfries,  it appears that of eighty-eight cancers he  had
extirpated  before the year 1768,  in 1770 there were
two  of the  patients  not  cured :  in  nine  they  had broke
out again ; one was threatened with a relapfe ;  and about
forty remained alive and found.  From  thefe and many
other authenticated facts, we  think ourfelves warranted
in drawing the above mentioned conclufion.  The ill fuc-
cefsoffome furgeons, and particularly  of  hofpital prac-
titioners, may  more juftly be attributed  to the inveteracy
 of the cafes in which they have been ufually confulted,  than
 to any  thing really incurable in the nature of the difeafe.
    Cancers fucceed to external accidents :  to tumors of the
 breafts in nuries and lying-in women mifmanaged ; to fe-
 vers and  other internal diforders, of  which they feem to
 be the terminations: and they happen  to women about
 the time of the ceffition of the menfes.
    All  thefe circumftances probably operate in bringing  on
 cancer, by firft inducing a  preternatural  determination of
 fluids to the part,  which necefTarily diftend and  obftrua
 its veffels  :  from the fmall degree of irritability in thefe, the
 part affeaed being ufually glandular^an indolent tumor or
 fchirrus is thus gradually produced by the accumulation of
 fluid :  this, at length, either from increafe of bulk or from
 external violence is excited to inflammation; which, at a
 lonaer or fhorter period, finally terminates  in the forma-
 tion of the cancerous virus.
    This explanation  will perhaps be admitted  as agreeable 
                        [  4<5  3
at leaft to probability, if  we confider that glandular  parts,
which are almoft always, if not in every cafe, the feat of
cancer,  never afford a  good difcharge :  and, from the
analogy of many other fores which often produce a mat-
ter nearly as acrid as the  cancerous virus, we may certain-
ly  be  allowed to infer, that fome  peculiar  affeaion of
thefe parts may induce the formation of a matter as acrid
as that of cancers : and when  the virus is  thus formed,  it
may in  time  be abfoibed, and produce a general cance-
rous diathefis.
   There is no remedy to be depended on in cancers but ex-
tirpation ; and it fhould be had recourfe  to immediately on
the difcovery  of the difeafe.   With  refpea to the  parti-
cular modes of performing this operation,  we muft  refer
to what will  be faid hereafter; and fhall  only obferve in
this place, i.  That cauftics,  on account of the  irritation
and inflammation they produce, fhould never be preferred
to the fcalpel.   2. Wherever the diforder is fituated, eve-
ry  part  that  has  the leaft appearance  of difeafe,  every
indurated gland  in the  neighbourhood  fhould be always
taken off*", otherwife  the cancer  will  certainly return;
but no  more of the integuments fhould  be removed than
is abfolutely  neceffary :  for the fmaller the cicatrix that
remains, the lefs will be the confequent irritation ;  and from
this, perhaps,  the chance of the difeafe  returning may be
leffened.  The teguments  fhould, as far  as  poffible, be
brought to cover the wound  by  the employment of the
                                              interrupted
  * From a circumftance which occurred in a cafe of occult cancer  of
the mamma extirpated by Dr. Hutchinfon,  of this city, and of which I
was a witnefs, I mould think it very proper, in every inftance, to avoid
cutting the tumor. After the  operation, the Doctor's pupil  wifhing  to
examine the whole fubftance of the cancer, made an incifion into it, and
there immediately iffued forth a confiderable  quantity of a thin icho-
rous matter. The patient  very foon recovered; which, perhaps, might
not have  been  the cafe had  this  matter been difcharged into the
wound.   For it is very well known that cancerous fores have been fome-
times produced from the application of the virus, even to parts  covered
\vith the integuments. 
                       [   47  3
interrupted or twifted future.   3. After the removal of
the cancer,  if  the  teguments do  not  entirely cover the
wound,  and a  hemorrhagy enfues, dry lint  fhould  be
ufed as  a dreffing;  but if there is  no difcharge of blood,
the lint  fhould  be  fpread  with fome emollient ointment.
The  fore  fhould  afterwards  be  treated  as a  fimple
ulcer, and healed as foon as poffible.   4.  Some little time
before the healing of the fore, an iffue fhould be introduc-
ed—and this  is probably  done  with greatefl advantage,
if made within  the  vicinity of the  cancer.   Iffues  feem
particularly neceffary in cafes of cancer that proceed  from
fuppreffed evacuations,  and have continued  a long time;
and we  have  no doubt, but that  they often "prevent the
return of the difeafe.
  The circumftances  that  fhould prevent the extirpation
of cancers,  are, in  general, 1. The appearance of cance-
rous  ulcers and fchirrous  glands  in feveral parts  of the
body at the fame time.  2. The conneaion of them  with
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 greatefl rifk, be extir-
pated.  But large portions of mufcles and tendons have
been  taken  away with  cancers without producing much
inconvenience.   And  there have occurred many inftanees
of cancerous mammas,  in  which there were adhefions to
the periofteum of the ribs, to the clavicle, and fometimes
a chain  of indurated glands, extending to the bottom of
the arm-pit, and yet  all the difeafed parts were with per-
fea fafety removed.
  3.  An  operation  can never be  advifeable, where the
parts affeaed are fo fituated, as to prevent their being to-
tally extirpated;  as is the cafe in cancers of the uterus and
reaum.  The indication then, is to palliate the different
fymptoms, fo  as to render the difeafe  as  tolerable to the
patient as poffible.   As, for this  purpofe,  the great objea
                                                     is 
                        [   48   3
 is  the abatement or prevention of pain, nothing fhould
 be exhibited internally, or applied externally,  that can have
 the leaft  effea in producing irritation  or  inflammation.
 A  diet of milk,  and the lighteft vegetables fhould be or-
 dered : no animal food,  fermented or fpirituous  liquors,
 fhould be allowed;  and all  violent  exercife fhould  be
 carefully avoided.
   The foetor  of  cancers  is confiderably  correaed by the
 ufe  of hemlock.   This may be taken internally in powder
 or  extraa, and applied externally with  emollient poulti-
 ces in powder, if  the juice  cannot  be had.   It commonly
 alfo mends the difcharge; and this much fooner than the
 carrot-poultice that  has been fo much  recommended in
 foul fores*.
   When a good difcharge is obtained, the fore fhould be
 treated as  a fimple purulent ulcer—and  particular atten-
 tion fhould be paid to avoid long expofure of the ulcerat-
 ed  furface to the air.   The violent fhooting  pains are re-
 lieved fometimes  by cicuta—and fometimes  by emollient
 fomentations—when neither of  thefe  fucceed,  we muft
 have recourfe to opiates.
   Befides a variety of other remedies, cicuta, belladonna, and
 arfenicf,  externally as  well as internally,  have been much
 employed and recommended for the cure of cancers ; but we
                                                     have

  * Similar good confequences have fucceeded the  ufe of common poke
—the ley-poultice—and of fixed air.
  f Arfenic has been probably the bafis  of moft of the  quack medicines
for cancer;  fuch as Guy's, Plunket's,  and others.  Dr. Rufn has proved,
by a chemical analyfis, that  Martin's remedy contained this fubftance.
It has been obferved to occafion various fpaimodic  affe&ions in fome in-
ftanees, and particularly to affect the mufcles of the eyes.   We have good
evidence of its producing beneficial effeds in many inftanees, and of ef-
fecting cures in fome.
  If it is propofed to apply arfenic to an occult cancer,  it will be necef-
fary to deftroy the cuticle by the lunar cauftic or fome other fubftance, or
                                                        by 
                        [  49  3
have never feen any of them produce any permanent advan-
tage.  Mr. Juftamond has fpoken highly of an efcharotic me-
dicine compofed of fteel and fal ammoniac, infufed in fpirit
of wine, with a certain proportion of oil of tartar and fpirit
of vitriol.  The edges of the  cancers, as well as  the hard
cxcrefcences that occur in them, are to be conftantly moift-'
ened with  this liquid ; and during the ufe of it, he  like-
wife advifes the internal ufe of  flores  martiales.  From
the trials I have made of thefe remedies, I  have not ex-
perienced any real advantages.


                     SECT.  IX.


                 On  the  Cutaneous Ulcer.

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

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

                  On the Venereal Ulcer.

   We now come,  in order, to  confider the ulcers con-
neaed with a  general affeaion  of the fyftem;  and fhall
firft treat  of the venereal ulcer.
   Although,  by the term venereal ulcers, is  generally
meant thofe which  are a part of fyphilis ;  yet  chancres,
which are not always conneaed  with any general difeafe
are alfo included under it.   They may therefore be divid-
ed  into thofe  that  appear  as primary  fymptoms of  the
difeafe, and fuch as may be more properly  confidered  as
fymptomatic.
   Of the former kind are  chancres in  general,  wherever
fituated, whether upon the parts of generation, the nip-
ples,  or lips.   Thofe ulcers  may alfo, in fome cafes,  be
reckoned primary,  which remain after the burfting of bu-
boes that  have  arifen from an infeaion lately communi-
cated,  and before  there is a  probability that the whole
fyftem is affeaed.
   Such ulcers  are  confidered  as fymptomatic, as arife  in
confequence of  a general taint of the habit.   Of this kind
are all thofe  which fucceed  to old  buboes, and  fuch  as
appear along with other venereal fymptoms  a confiderable
time after  infeaion ;  the moft common fituations of which
are, the throat, palate, nofe,  the parts  immediately above
the bones  of the cranium,  tibia, humerus, and other hard
bones thinly covered with flefh.
   In many cafes, it is difficult to make this diftinaion in
venereal fores ;  but unlefs it is always done, we cannot di-
rect the proper  mode of treatment.  The principal means
of diftinaion are obtained either by information from the
                                                patient 
                      t   57  3
patient,  or  from  the  appearance of  the  different  fores
themfelves.
  If, foon after expofure to infeaion, an ulceration appears
upon the part to which the  virus was immediately appli-
ed, together with fweUings of any  of the  glands in the
courfe of the lymphatics, we may be almoft convinced that
thefe  are  only  local  affections.  Such  ulcerations are
termed  chancres.  They appear  at  firft,  as fmall miliary
fpots, which foon rife and form little veficles;  thefe upon
burfting, difcharge fometimes a  thin watery fluid, and on
other occafions, a more thick yellow matter.  The edges
of fuch fores are generally  hard  and painful; and as well
as the  glandular fweUings  already  deferibed,  are com-
 monly  attended with more or lefs inflammation.
   The  fymptomatic  venereal  ulcers are in general, more
 troublefome than chancres.  They are  diftinguifhed,  i.
By information from the  patient.   2. By  their  fituation;
 and,  3. By their appearances.   Thus if  a patient who
 has fymptoms of infeaion in his conftitution, is attacked
 with one or more ulcers, whether in confequence of exter-
 nal injuries or not: and  if they refill the common me-
 thods of cure,  there can be little doubt of their being  in-
 feaed  by  the general taint.  But  when  it cannot be af-
 certained that the patient is affiled,  by his own informa-
 tion, we muft endeavour to form a judgment from the fi-
 tuation and appearances of the ulcer itfelf.
    Venereal ulcers from an old infeaion generally  appear
 immediately above the bones, and  particularly above fuch
 as are  but thinly covered with mufcles.   They firft  ap-
 pear in the form of a red, and fomewhat purplifh efflo-
 refcence,  confiderably  diffufed.   This  foon rifes  into a
 number  of very fmall  puftules,  which ooze out a thin
 fretting  ferum.  At  firft, thefe puftules  when obfervcd
 through a glafs, appear perfeaiy diftina ; but they at laft
  run together, and  form one large ulcer,  whofe edges are
                             H               commonly 
 commonly ragged and fomewhat callous ; and there is ge-
 nerally a  light red appearance,  extending a confiderable
 fpace beyond the fore and efflorcfcence.
   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 parr, they are generally filled up
 with fungous excrefcences.   They  are feldom attended
 with much pain.   The  difcharge from them is  at  firft
 thin, but  at laft puts on a very charaaeriftic appearance;
 being of a confiftence  rather more vifcid  and tough than
 good pus, with a very loathfome, though not the ordina-
 ry fetid fmell, and a very fingular greenifli yellow colour.
 .  The diftinaion of venereal fores into primary and fymp-
 tomatic, is of confequence in direaing the proper treatment.
 For the former might  be cured merely by deftroying the
 venereal matter with cauftic, if attended to before any ab-
 forption had taken place.   But as it  is impoffible to afcer-
 tain whether the virus  has entered the fyftem or not, when
 we are applied to,  the cure of chancre fhould  never be
 trufted to topical applications; but,  together with thefe,
.mercury fhould be always ufed internally ; and to prevent
 a further  abforption of matter, the healing of the fore fhould
 be accompliihed as foon as  poffible.
   This diftinaion points  out to us  likewife, that  in ul-
 cers from an,  old pox, we  ought never to  make ufe of
 fuch dreffings as have  a tendency to heal them foon ; but
 fhould rather  truft entirely to the internal ufe of mercury,
 and to fuch applications  as merely  keep them clean  and
 eafy.  For  the  healing  of fuch fores then  affords  the
 fureft index of the removal of the general  difeafe.
   As we  are  feldom called early enough to deftroy the
 virus in chancres  by cauftic, and indeed until it would be
 fomewhat dangerous to attempt it, after wiping the  fores
 clean, I generally fprinkle them with finely powdered red
 precipitate of mercury,  and over  this apply lint fpread
                                                  with 
                  -'   C  59   3
with  common ointment.   This anfwers very well in all
cafes  unattended by inflammation.   It feldom occafions
much pain or irritation:  and produces a flough, which in
the courfe of a dreffing or two, generally comes away, and
leaves the ulcer  perfeaiy clean.   When in this ftate,  the
fore would probably heal if nothing more than cerate was
applied  to it, but for fear any venereal matter fhould ftill
remain, I commonly then drefs it with the flrong mercurial
ointment.  In this  manner chancres are in general eafily
cured, and  with much lefs mercury given internally than
if allowed to remain open a confiderable time.
   By long continuance however,  and the neglea of proper
remedies, thefe ulcers put on the appearances and nature of
thofe  that depend on a general infeaion ; and confequently
require the fame method of treatment.  They are very  apt
to become inflamed  and very painful; and more efpecially
when feated  on  the penis.   Where this is the cafe, it is
fometimes neceffary  to order bleeding: but in general,  the
faturnine poultice will be fufficient to moderate the inflam-
mation.    After  the removal of the inflammatory fymp-
toms, the beft application is common wax ointment.
   There are two modes of throwing mercury into the fyf-
tem ;  the one by giving it internally by the mouth,  and the
other  by introducing  it into  the  body through the abfor-
bents  on  the fkin by means of friaion ; but, as the laft me-
thod  is  by much the moft troublefome and inconvenient,
and is not attended by any peculiar advantages, the former
is  now,  I believe, generally preferred.
   Thofe  preparations in which the mercury has undergone
no other  operation than triture, as the quickfilver  pill, P.
Edinb. are in general the beft.  When this is not found to
anfwer,* the mercurius corrofivus fublimatus, or mercurius
calcinatus, may be tried : and it is fometimes neceffary to ufe
a variety of preparations before a cure can be effeaed.
                                                  But 
                      [  6o   ]
  But, in whatever form mercury is employed, it fhould
always be continued until a forenefs of the mouth is in-
duced, as that is the only certain indication of its having
entered the  fyftem.   This forenefs in very fight degree,
fhould be fupported until the cure is perfeaed.
  In order to guard againft the mercury's running off too
quickly by the mouth, and producing  troublefome faliva-
tion, which it is very  apt to do,  it has  been recommended
to determine the operation of the medicine  in fome degree
to the fkin by the ufe of warm bathing—not only during the
ufe of the mercury, but previous to its  being begun—This
effect may, in  fome degree, be obtained with lefs rifle from
cold, by the ufe of a  flannel fhirt, by  drinking plentifully
of  decoaion of the woods or farfaparilla: and by avoid-
ing cold.   Where the warm bath can be conveniently ufed
it fhould, as being more powerful in  its effeas, without
doubt be employed.  It alfo  has a good influence in pre-
venting the operation of the mercury on the bowels.
   By  the ufe  of thefe  different remedies,  venereal ulcers
will commonly  foon  be removed.  The  mercury fhould
be continued for a longer or a fliorter  time after the difap-
pearance of the fymptoms, according  to the inveteracy or
 ftanding of the difeafe.
    It fometimes happens that after a long exhibition of mer-
 cury, and when there is reafon to fuppofe that the venereal
 taint of the habit is  altogether eradicated,  the ulcers can-
 not be  brought to  heal.  In this cafe there will be room
 to fufpea  that fome other difeafe  may have fubfifted in
 the conftitution  together with the lues venerea, and that
 both may have had fome fhare in the produaion  of the ul-
 cers.   When the  nature  of  this diforder is  afcertained,
 proper remedies to correa it muft be  conjoined with thofe
 before given.
Venereal 
                       C  61   3
  Venereal ulcers are fometimes rendered obftinate by  a
caries of fome bone, independent of any other difeafe.  This
is to be fufpeaed when they are feated upon or near any of
the bones, and particularly if there occur fungous excref-
cences.  To  the remedies for the venereal affeaion,  we
muft then add the treatment proper for caries.   See feaion
on the carious Ulcer.
   When  neither caries nor any  conftitutional  affeaion
feem to prevent  the healing of fuch ulcers,  and they appear
to grow worfe; and  particularly when  the fyftem  feems
much  debilitated by the confinement  and effeas of the re-
medies, the beft and moft effeaual mode of treatment is, to
order  a light nourifhing diet, with frefh air and exercife.
This by invigorating  the body often produces furprifing
cures.  The Peruvian bark is here alfo of fervice.
   Old fores of this kind, on account of the  floughs with
which they are  ufually  covered,  require  ftimulant dreff-
ings.  The  following  ointment is very proper,  §> ung.
bafil. flav. |j. mere,  prsec. rubr. 5'ij. M.  When they be-
come clean, they are to be treated in  the ufual way.
   When the glands are the feats of venereal ulcers, it is
fometimes neceffary to deftroy the whole,  or  a confidera-
ble part of fuch as are much hardened, by cauftic, before a
cure can be obtained.
   Although venereal  ulcers are in general to be cured  by
proper treatment,  yet fome inftanees  have occurred,  in
which they  have  refilled ail  the efforts of  nature and
art, and  at laft  have  carried  off  the patient  in great
mifery.—* Such cafes probably  are  only to be met with
in hofpitals.

                                               SECT.

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

                  On the Scorbutic  Ulcer.

    The charaaeriftic marks of ulcers that occur in fcurvy,
  are as  follow:—They never  afford a good  pus ; but a
  thin foetid fanious matter, mixed  with blood ; which  at
  length  has the appearance of blood  coagulated,  and is
  with difficulty feparated from the furface of the fore.   The
  flefh beneath  this is foft, fpongy,  and very putrid.—Efcha-
  rotics to remove the floughs  anfwer no good purpofe, for
 they certainly appear again  at the next dreffing—Their
 edges are  generally of a  livid colour,  and puffed up by
 excrefeences beneath the fkin.  If compreffion is employ-
 ed to keep the fungus from rifing, it  generally produces
 a gangrenous  difpofition,  and always renders the member
 cedematous, painful, and for  the  moft part fpotted.
   As the difeafe increafes, they  flioot  out  a foft bloody
 fungus,  refembling boiled liver ; which often  rifes in a
 night's   time  to a  monftrous  fize; and if deftroyed by
 cauftic or the  knife, bleeds plentifully, and  returns again
 by the next dreffing.   They  continue a confiderable time
 in  this  condition, without affeaing the bones—and are
 produced by  the flighteft wound or bruife, in fcorbutic
 perfons.
   This defcription is  only applicable to fcorbutic ulcers
 that accompany very great putrefceacy in  the  fyftem at
 large ; for  fuch inveteracy is not  often  met with, except
 in long fea-voyages  ; but in Scotland, flighter  degrees of
 the fame kinds of fores are often feen,  and fometimes ac-
 companied  with the moft  charaaeriftic mark  of fcurvy,
viz.  foft fpongy gums.   They generally appear among'
 the loweft  clafs of people, and  feem to originate rather
 from want  of  food in general, than from confinement to a
                                             particular 
                       C   63   3
particular kind.  They feldom are  produced in parts pre-
vioufly found; but  ulcers already formed, and  wounds
infliaed  during  the  prevalence  of a fcorbutic affeaion,
always  degenerate  into fores  of   this kind.   Moft  of
the ulcers  of the poor in Scotland partake of a  fcor-
butic  taint.
   The immediate or proximate caufe of fcorbutic ulcers,
as well as of every other fymptom of fcurvy, may be re-
ferred to a  certain  degree of putrefcency in the fluids.
This may be induced by a  variety of caufes, the moft ma-
terial of which are, living conftantly upon fait provifions ;
a total want of vegetables ; with expofure to a cold,  moift
atmofphere.   See Pringle, Lind,   and  Huxham, on the
Scurvy.
   The cure of fcorbutic ulcers muft depend chiefly on the
correaion of the putrid diathefis of the fyftem ; for which
purpofe, vegetables of all kinds, but efpecially thofe of an
acefcent  nature,  with milk and whey, are found to be cer-
tain remedies.   The different fecretions, efpecially  thofe
by the kidneys and  fkin, and more particularly the laft,
which is in common almoft entirely obftruaed, fhould be
gently promoted.   Laxatives, as   tamarinds, manna and
cream of tartar, are alfo very ferviceable—Thefe remedies,
joined with  total abftinence  from  faked food, and atten-
tion to avoid all the  other exciting caufes,  commonly re-
move all the fymptoms of fcurvy.   The ulcers fhould be
dreffed  with powerful antifeptics.   Lind   recommends
ung. aegyptiac. and mel rofarum acidulated with  fpirits of
vitriol.
   In the fcorbutic  ulcers that occur in Scotland, it  is
feldom   neceffary to  confine  the  patient to  an  antifcor-
butic  courfe.  And  they  are more effeaually  removed
by the  gradual allowance  of  a   generous  diet, with  a
moderate proportion  of  good wine,  or perhaps  what
is  better,  of porter  or  flrong   beer.   Peruvian bark
                                              internally 
                      C  64   3
internally, and applied to the ulcers in decoaion, is a very
ufeful remedy in  thefe cafes;  but the beft external appli-
cation while much putrefcency remains, is the carrot poul-
tice ; when this is removed, the ulcer  is to be dreffed as
in other cafes.  Iffues are alfo to be ufed occafionally.


                   SECT.  XII.

               On  the  Scrophulous Ulcer.

   By fcrophulous ulcers, are meant thofe fores which are
confequent to fweUings, fymptomatic of fcrophula or king's
evil.
   Scrophula  begins  with indolent, fomewhat hard, co-
lourlefs tumors; which at firft chiefly afft-a the conglo-
bate glands of the neck; but at length attack  the cellular
fubftance, ligaments and bones.—Thefe fweUings are more
moveable than fchirri, fofter,  and  feldom much painful;
they are tedious in  coming  to  fuppuration ;  very apt to
difappear fuddenly, and again to rife in  fome other part of
the body.   There is a remarkable  foftnefs of  fkin  in  this
difeafe, a  kind of fulnefs in the face, and generally large
eyes, and a very delicate complexion.
   Scrophulous  ulcers feldom  yield a good difcharge; af-
fording upon  their  firft  appearance, a vifcid,  glairy,  and
fometimes a whitifh curdled matter,  that afterwards changes
to a more thin watery fanies.   The edges  are frequently
painful: and always much tumefied.  As long as there  is
any fcrophulous diathefis in the fyftem, fuch  fores often
remain for a great length of  time, without fhowing any
difpofition either to heal or grow  worfe : at  other times
they heal very quickly,  and again  break out in fome other
part of the body.
   A variety of caufes have been mentioned as tending  to
produce fcrophula, viz. a crude indigeftible food ;  bad wa-
                                                   ter; 
                        C  «S   3
 ter;  living in low damp fituations ;  its being an heredi-
 tary  difeafe, and in  fome countries  endemic, &c.   But,
 whatever may be the exciting or predifpofing caufes, the
 difeafe itfelf either depends upon, or  at leaft is much con-
 neaed with a debility of the conftitution in general, and
 probably of the lymphatic fyftem in  particular:  the com-
 plaint firft fhewing itfelf by affections of the latter.  This
 is evident from the nature of many of the caufes,  and from
 fuch remedies as are found to prove moft ferviceable in the
 cure.
   Gentle mercurials are fometimes  of ufe  as refolvents in
 fcrophulous fweUings*; but  nothing  has fuch good effeas
 as the large ufe of peruvian bark.   Chalybeate and fulphure-
 ous waters too,  have frequently proved ferviceable: and
 a long ufe of mild faline aperients have been found benefi-
 cial.  Cold bathing,  and particularly in the fea, together
 with moderate exercife,  is often of fingular fervice;  as
 likewife  change of air,  efpecially to a dry climate.
   Until  the general fcrophulous taint  is removed,  it is
 dangerous to heal the ulcers;  all that fhould  be done,
 therefore,  fhould be, to give as free a vent to the  matter as
 poffible,  and to prevent the formation of finufes.
   The  beft applications are the faturnine  preparations:
 thefe remove  that inflammatory  complexion  they affume
 when relaxants are employed; and tend much to prevent
 the fpreading of  the fores.
   When, however,  the ulcers become fwelled and pain-
 ful, and  difcharge a very corrofive matter, we may fufpea
 a caries to be at the bottom of the fores.  Nature muft then
 be affifted, where it is praaicable, by the removal of fuch
 parts of  the bones as are moft difeafed,  and have become
 loofe.  But this cannot be done when the large joints are
                          I                    affefted:

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

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

     THE term  white fwelling has  commonly  been apr
      plied to fuch enlargements of the joints as  are not
attended  with difcolouration of the integuments ; the only
fymptoms which at firft take place, being a greater or lefs
degree of fwelling, with a deep feated pain.   In the pro-
grefs of the difeafe, however, inflammation affeas all the
adjoining parts, as  well external as internal; and when this
terminates in fuppuration, it is not uncommon  for openings
to be formed all  around  the difeafed joints.
  There feem to be two fpecies of  this difeafe,  entirely
different in nature from each other.   In the one, a cure is
often in part, and fometimes wholly obtained; whereas the
other is always beyond the reach of art.
                                             Swellings 
                       C   67  3
   Swellings of this  kind occur more frequently m  the
 large than in the fmaller  joints; thus, at leaft twice as
 many are met with in the knee and. ankle joints, as  in
 all the reft of the bodybefides.

      § 1. Of the Rheumatic fpecies of White  Swelling.

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

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

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

         § 3. Of the  Caufes of White  Swellings.

   The caufes of the rheumatic fpecies may be, fprains that
particularly affea  the ligaments of the joints, bruifes, lux-
ations, and whatever  can tend to produce inflammation of
the ligaments.  A rheumatic diathefis or difpofition is pro-
bably alfo a principal caufe of this difeafe. For rheumatifm
is known to attack  particularly the ligaments, or other deep
feated membranes, and  more efpecially  affeas the  larger
joints—Hydarthrus or white fwelling alfo occurs  in the
fame habits that are moft fubjea to rheumatifm, viz. the
young and plethoric.
  That it is  the ligaments  that are firft affeaed in this
difeafe is evident from the hiftory and diffeaions.  From
thefe we may conclude, that  this complaint  is at firft al-
ways occafioned by an  inflammation of the ligaments of
the joints. And we may confider the different matters that
are formed, to depend on the difference of parts affeaed in
the courfe of the difeafe.
   The other fpecies of the diforder, from the fymptoms
enumerated, and the appearances  on diffeaion, feems evi-
dently to be originally an affeaion  of  the bones ; the foft
parts feeming only to fuffer in the progrefs of the difeafe
from their conneaion with and  vicinity to thefe.  It fel-
dom is the confequence of any accident; and  the patient
is feldom able to account for it.
   This difeafe is generally attended with known fymptoms
of fcrophula; or the patient has had them at an earlier pe-
                                                  riod 
C  7i   3
riod of life, or at leaft is  of fcrophulous parents.   From
thefe, and the above defcribed circumftances, it is probable
the diforder is of a fcrophulous nature.
                    SECT.   II.

          Of the Treatment of White Swellings.

  In  the rheumatic white fwelling, as it is always at firft
of an  inflammatory nature, confiderable advantages are ob-
tained in common,  by the ufe of an antiphlogiftic courfe.
The firft remedy which fhould be employed is blood-let-
ting—This is moft effeaual if  the blood is drawn immedi-
ately  from  the affeaed part,  by cupping,  performed on
each fide of the joint.  At leaft eight or ten ounces fhould,
if poffible,  be difcharged at  each time,  and this fhould
be repeated according to  circumftances.   When a fuffici-
ent quantity of blood  cannot thus  be obtained, leeches
fhould be had recourfe to.
  A fmall blifter fhould be immediately applied on the an-
terior part of the joint;  and the part afterwards  kept run-
ning until the wounds from which the blood was  difcharg-
ed, are fo far healed, that a  veficatory  may be laid on
one fide and as foon as this is nearly healed another fhould
be placed on the oppofite fide of the joint.   By thus ap-
plying them alternately to each fide, a conftant flimulus is
kept up;  which, in  deep-feated inflammations, feems to
have  a greater  effea than the  difcharge produced from
them.
   Cooling  laxatives,  at  proper intervals, are alfo of  ufe;
and the patient fhould, in every refpecl, be kept upon a ftria
antiphlogiftic courfe.   From an attention to  all thefe  cir-
cumftances the difeafe has frequently been removed.
                                                  The 
                      [  72   3
  The  inflammatory fymptoms  being  moftly  gone,  and
while  there  are  yet  no  appearances  of the formation
of matter, mercury, not given fo as to falivate, but merely
to affea  the mouth gently and to keep  it fomewhat  fore
for a few weeks,  I have fometimes known of  ufe.   The
beft form of employing it in this cafe is by way of unc-
tion— 5'ij. of a weak mercurial ointment fhould be rubbed
into the part three times a-day ;  and as the friaion may be
very ferviceable,  it fhould  be continued  an hour each time.
By the French writers, falls of warm, and of cold water, on
fweUings of this kind are  much recommended.  There is
the  greateft reafon to fuppofe, from  the  known relaxing
powers of moifture when joined with heat, that a proper
application, and particularly of warm emollient fleams  may
prove  more ufeful than any other remedy.  The  friaion
in the ufe both of warm  and cold water has probably a
confiderable influence;  and the chief effea I think, can be
attributed to  that  only in the latter  cafe.  I have fome-
times  feen it employed with advantage.
  Although by the ufe of thefe remedies, the difeafe  is
often  entirely removed ; yet, in many inftanees, when the
pain and fwelling are chiefly or entirely gone, it frequently
happens, from  the bent pofition in  which the limb has
been  kept, that  the  ufe of the joint is entirely loft,  and
it contraas fuch a rigidity, that very great pain attends any
attempts to move it.
  It has unfortunately happened that this contraaion has
been generally attributed, either to an union of the ends of
the conneaed bones, or to an infpiffation of the fynovia ;
both  of which are incurable.  But  from diffeaions we
may confidently conclude, that except in the moft advanced
ftate of the difeafe, the firft does not occur in one cafe in
twenty; and that it is very doubtful whether  the laft is
ever produced.
                                                  The 
                       [73   3
   The immobility of the joint is confequently to be confi-
 dered  as the effea of a contraaed ftate bf the flexor muf-
 cles,  and tendons;  which, in  feveral inftanees,  fome of
 which were thought to be of the worft fpecies of anchylo-
 fis, I have feen totally removed by the application of emol-
 lients.   See chap, on Contratlions  of the Limbs.
   After the formation of matter, no confiderable advantages
 can be expeaed from any of the  remedies we have  above
 recommended.  In that cafe, the difcharge of the colfeaions
 fhould be made as foon as  poffible, by the employment of
 the feton—This can eafily be effeaed, and fometimes has
 been the means of faving many fuch difeafed joints.
   Amputation fhould never be had recourfe to unlefs the
 patient's  conftitution is fo much reduced, that there would
 be confiderable rifle from any farther delay.
   When the difeafe has deftroyed the ligaments, and per-
 haps the cartilages and bones of  the joint, amputation is
 the only  refource.   See chap, on Amputation.
   All  the above  remarks,  relate  particularly to the rheu-
 matic white fwelling.  With refpea to the more fatal fpe-
 cies, the fcrophulous, we  can offer nothing fatisfaaory.
 When the fmall joints are affeaed,  and the  difeafed parts
 of the bones begin to  caft  off,  a  cure may  be  fometimes
 promoted by aflifting the efforts of nature;  but in all the
 larger joints, it is not probable that any other refource than
 amputation will ever afford much relief.  And even the
 effects  of this can feldom be depended on as lafting; for
 while the fcrophulous taint  fubfifts in the conftitution, the
 diforder  will moft probably appear again in fome  other
 part.   On account of the violence of  the pain, it  is how-
 ever neceffary fometimes to  run the rifk of this.
  When it does not  appear advifeable  to perform the ope-
 ration, we muft truft to palliatives.   Of thefe,  opiates in
large dofes,  by moderating the pain and procuring  fleep,
are generally the  moft  ufeful.  The general  remedies and
diet proper in fcrophula,  are alfo to be recommended.
                         K                 CHAP. 
t  74   3
C   H   A   P.     IV.

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


                   SECT.    I.

               Of the Interrupted Suture.

   This is the fpecies of future that has generally been made
 ufe of in deep wounds;  but  we fhall endeavour to make it
 appear hereafter, that it is not fo well adapted to fuch cafes
 as the twilled future.
   In order to a proper  retention of the parts, in forming
 futures in general, it has ufually been confidered neceffary
 to carry the needle to the bottom  of the wound,  fo  as  to
 give no room for the accumulation of matter; and this has
 commonly been done by introducing it  from without in-
 wards, and then from the wound to the fame diftance on
 the oppofite fide.   But, the interrupted future is  more
 neatly and eafily performed, by paffing  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 
                      C  75  3
be removed, and the threads remain untied,  until all that
are found neceffary are paffed.
  The number of ligatures muft depend chiefly on the ex-
tent of the divided parts.  One future has generally been
faid to be fufficient for an inch of wound, but when muf-
cular parts  are  cut tranverfely,  a greater number in pro-
portion to the extent of the fore will be neceffary.  A li-
gature fhould be introduced  at  every angle of a wound,
however inconfiderable it may be.
   In  paffing the ligatures it  has been a  rule to pierce the
fkin at a diftance from the edges of the wound equal to its
depth, in order to prevent them from cutting through the
parts. But it is very feldom proper to make the fpace more
than an inch, or lefs than half an inch.   The form of the
crooked needle proper for forming  the interrupted future
is  delineated in plate vii. fig. 6.   The fize of the needle, as
well as the ftrength of the ligature, muft always be pro-
portioned to the depth of the wound, and the  retraaion of
the parts.   The ligatures ought nearly to fill the eyes of the
needles ; and in order to make them pafs eafily, to render
them durable, and eafily fufceptible of a flattened  form,
by which they are lefs liable  to cut through the contained
parts, they fhould be well waxed.  While  the furgeon is
tying the threads,  the lips of the wound fhould be preffed
together by an affiftant.  The  ends of the  ligatures are
ufually carried  twice through the firft  noofe, to prevent
them from flipping. This forms  the furgeon's knot. The in-
fertion of lint beneath or between the knots, as recommend-
ed by fome, prevents them from being well made, and has
little good effea.   It is neceffary to tie  the threads imme-
diately above the wound, in order to give an  equable fup-
port to each edge of it.
SECT. 
[  16  1
                     SECT.  II.

                  Of the Studied Suture.

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

                     SECT.  III.

                   Of the Glover's Suture.

   The glover's future confifts in a feries of flitches connea-
 ed with each other, and continued in an oblique fpiral di-
 reaion along the courfe of the divided parts.   The ufe of
 this future has been confined to wounds of the inteftines:
 but even thefe may be more perfeaiy united by the inter-
[ rupted future.  See chap,  on Wounds of the Intejlines.
    It will  therefore follow, that the glover's  flitch is en-
 tirely unneceffary to a furgeon.
SECT. 
£  77  3
                  SECT.   IV.

                Of the Twifed Suture.

  In making the twifted future, we unite divided parts by
means  of threads twifted around pins or needles pufhed
through their edges. This future has feldom been employed,
except in the hare-lip; but it is preferable to any other fpecies
in all wounds that are not more than an inch and a half in
depth, becaufe better calculated to retain the parts in contaa.
In very deep wounds the interrupted future muft neceflari-
ly be ufed, on account of the difficulty and pain that would
attend  the introduaion of pins to form the twifted  future.
  The  pins made ufe of for twifting the threads upon,
fhould be flat, as in plate ix. fig. 7.;  as  the whole preffure
falls upon them, and when thus made they are not fo apt to
divide  the parts as ligatures.   Thofe ufually employed are
of filver, with fleel  points ; but as gold  pins are not fo lia-
ble to acquire a cruft by immerfion in fluids,  and require
no  fleel points, they fhould be preferred.  They ought,
in general, to be from an inch to an inch and an half in
length, of a proportionate  breadth,  and have heads for
the fingers to prefs upon.
  In performing this operation, the divided parts muft be
brought nearly into contaa by an affiftant, leaving only fuch
a fpace as will allow the furgeon to fee that the pins are car-
ried to a proper depth.   A pin is then to be introduced on
one fide externally, pufhed inwards to within a little fpace of
the bottom of the wound, and carried through the oppofite
fide, to the fame diftance from its edge that it was made to
enter at on the other fide.   The diftance at which the pin
fhould be entered from the edge muft be determined by
the depth of the wound, and the degree of retraaion of
its  fides,  as in making the interrupted future.  If the pins
                                                    do 
                      C   78  3
do  not pafs  eafily, the inftrument termed porte-aiguille
may be ufed to pufh them  forward.
  The firft pin being  thus  paffed very near  one end of
the wound, and the parts flill fupported, a firm waxed
ligature fhould be carried  three or four times  around and
acrofs it, fo as to defcribe  the figure of 8, and fufficiently
tight to draw the lips of the  wound into clofe contaa.
The thread fhould then be  fecured by a  loofe knot, and
another pin  introduced.     The  ligature is now  to be
loofened, and applied to this pin as direaed for the firft,
and others paffed at proper diftances,  the  whole length of
the wound, all being conneaed by the fame ligature.
  A pin fhould  always be  placed near each  end of trie
fore, to prevent the feparation of its extremities.   In large
wounds the pins fhould be three-quarters of  an inch dif-
tant from each other;  but in the fmaller, a greater num-
ber in proportion to the extent of fore will be neceflary.
When  the  futures are  all  formed, the wound fhould be
covered by lint wet with mucilage, to exclude the external
air.  The introduaion  of  lint beneath the  ends of the pins
has a  tendency to make them cut the parts.   When they
give uneafinefs, a piece of thin linen fpread with adhefive
plafter will be better.    I have never known the appli-
cation  of a  bandage after  this operation produaive of
good effeas, but have often feen  it occafion  troublefome
inflammation.
  In general, the pins fhould be fuffered to remain from
five to feven days, according to the depth of  the wound.
But when  the patient is unhealthy, a longer time may be
neceffary*.

                                                    As

  * In  young healthy fubjecls the union is often completed in half
the time; but perhaps the fafeft  way is to leave the pins in the parts till
a fmall degree of digeftion appears. 
                      C  79  3
  As foon as they are removed, a bandage may be ufed
with advantage, to fupport the newly-united parts.   But
perhaps ftrips of leather fpread with glue,  applied to each
fide of the cicatrix, and conneaed by ligatures, would be
preferable.
  Of the dry future we fhall  treat hereafter.
                CHAP.   V.

Of the Ligature of Arteries,  and other artifi-
     cial means offopping Hemorrhagies.
  IN every wound,  the  firft circumftance to be attended
   to is the hemorrhagy.  This is  either produced from
the large arteries, or by  a general oozing from the fmaller
veffels.   In the  firft cafe,  a temporary ftoppage of the
difcharge  fhould be  immediately  attempted  by  com-
preffion,  until the  permanent fecurity of ligatures can
be obtained.  In the head  and trunk, the eafieft method
of preffure is formed by lint or foft linen retained firmly on
the mouths of the veffels by the hand or a bandage; or if
the fuperior part of the veffels can be compreffed it anfwers
better,  as ligatures can then be applied with more eafe.
  When the wound is in the extremities, and compreffion
can be  made on  the fuperior part of the artery,  it fhould
immediately be done by  means of the tourniquet.   Plate
iii. fig.  5.
' Previous 
                       [  8o  3
   Previous to the application of the tourniquet, a cufhion,
 three inches  in length, and one and  an  half in breadth,
 fhould  be   placed  immediately  above   the   principal
 artery, and well fecured by two turns of a roller.   Over
 this roller the ftrap of the tourniquet  is to be firmly fix-
 ed, the fcrew being on the fide of the limb oppofite  to
 the cufhion:  one turn of the fcrew is generally fufficient.
See plate and explanation.
   As the ancients were ignorant of the ufe of the tourniquet
 and of ligatures, they endeavoured  to  remove hemorrha-
gies by applying aaual cauteries or hot irons to the large
veffels,  and lint covered  with ftyptic  powders, to the
fmaller.  But thefe often failed.  Even lately, agaric, cha-
lybeate folutions, and the  mineral  acids have been much
recommended.  Thefe  in many cafes do not produce the
defired effea.   When ligatures can be  well applied,  they
invariably fucceed;  and in the larger veffels fhould alone
be depended on.
   Various  methods have  been ufed  for  tying arteries.
The common praaice at prefent is,  by means of a curved
needle to pafs a ligature of fufficient  ftrength around the
mouth of the veffel, including a quarter of an inch of the
contiguous parts : but, as tying the nerves and mufcles often
produces not  only partial but general fpafms,  and always
a great deal of pain, it is advifeable to include the artery
only in the ligature, by employing forceps, or rather the te-
naculum, Plate vii. fig.  5.  In very  deep wounds the
needle may be neceffary ; but fuch cafes rarely occur.  Ex-
perience from repeated comparative trials  has  convinced
me, that the mode recommended is, as fecure as that by the
 needle ; and when it is ufed the ligatures come away much
fooner, generally at the third or fourth dreffing ; which is
often  of  very great advantage.  I  have feen  inftanees of
the ligatures  remaining for weeks  when the needle was
employed, and fome cafes in which  they were at laft cut
away  by the furgeon.
                                                  The 
                       C   8i  ]
  The forceps do not anfwer well in tying  fmall arteries;
they  might therefore,  with propriety,  be entirely laid
afide, as the tenaculum or hook is equally applicable to the
large and fmall arteries.  The manner of ufing it is as fol-
lows :
  In order to detea the arteries to be tied, the tourniquet
muft be loofened, and  as foon as the  largeft artery is  dif-
covered, the furgeon fixes his eye upon it,  and immediate-
ly again tightens the tourniquet.  An affillant then forms a
noofe in the ligature, and placing it over the end of thevef-
fel,  the operator pufhes the point  of the tenaculum thro'
the fides of the veffel, and pulls as much of it out as he
thinks fhould be included in the furgeon's knot now to be
made by the affiftant.   For  greater fecurity a fecond knot
fhould alfo be formed.  In  making the knots,  a very fmall
addition to the force  requifite for  reftraining the hemorr-
hagy, is fufficient.
  In this manner all the arteries that can be diftinguifhed
fhould  be fecured:  For fatal  hemorrhagies  have  fome-
times  been produced from  very  inconfiderable veffels,
when the patient has become warm in bed.   Lofs of blood,
fear, or cold,  often occafion fuch a retraaion of the fmal-
ler  arteries,  that  it is difficult to detea  them :—To  ef-
fea this, the tourniquet fhould be loofened, and the wound
well wafhed with a fponge  and warm water ; and  if the
patient is faintifh,  a  glafs of wine or  fome other cordial
fhould be given.
  As in fome inftanees we  are unable to  tie  arteries  by
means of the tenaculum, we fhould be provided with nee-
dles of various  forms and  fizes.   Thofe ufed in forming
the interrupted  future are  very well  adapted to the tying
of arteries.  In  ufing the needle,  it  fhould be introduced,
armed with a ligature, at the diftance of a fixth or  eighth
of an inch from the artery,  pufhed to a depth fufficient for
retaining the thread, and carried one half round the veffel.
                           L                        It 
                      [  82  3
It muft now be withdrawn,  and being again pufhed  for-
ward till it has encircled the  mouth of the artery, is then
to be pulled out, and  a knot formed on the ligature as al-
ready direaed.
  Hemorrhagies to an alarming degree are frequently pro-
duced in extenfive  wounds by a general oozing  from the
furface of the fore  ; and fometimes it is with difficulty they
are  fupprcffed.  They feem to proceed from two very dif-
ferent circumftances :  ift. In robuft habits, either from too
great a  quantity of blood, an excefs of tone in the veffels,
or  a combination  of both; or 2dly. And  more frequent-
ly,  in relaxed debilitated habits, from a diffolved ftate of the
blood, a want of tone in the veffels,  or a  concurrence  of
both thefe.
  In healthy conftitutions, the difcharge of blood from the
fmaller veffels  of wounded parts is commonly foon remo-
ved by the contraaion of thefe veffels, and the  difcharge
of a glutinous  fluid from them, which is diffufed over the
furface of the  wound  : But when it continues in fuch de-
gree as  to fhew a morbid ftate, it is to be attributed to one
of the caufes  abovementioned.  In robuft habits relief is
to  be obtained by opening  a vein; or  perhaps  more  ef-
feaually by untying  one of the  principal arteries of the
part and fuffering  it to difcharge freely ; by keeping  the
patient cool ; giving him cold acidulated drinks ;  obliging
him to  avoid motion, particularly of the  part;  covering
the wound with  lint;  and by applying  a bandage over
it.   In all thefe cafes, and particularly when violent  fpaf-
modic affeaions fupervene, a large dofe of opium is one of
the moft effeaual remedies, and fhould  be exhibited as
foon as the  patient has been bled and put to bed.  When
we have reafon to fuppofe the difeafe  is fupported by the
fecond  fet of caufes mentioned, a generous diet, and a free
 ufe of Port, Madeira, or other good  wines, fhould be al-
                                               lowed i 
                       C   83   1
lowed; the  patient fhould be  kept cool;  mineral  acids,
particularly the vitriolic,  muft be given ; reft of body en-
joined ; and  opiates, to obviate pain or fpafm, liberally ad-
miniftered.
   Together  with thefe general  remedies,  particular dref-
fings, adapted to the ftate of the fyftem, fhould be applied.
Dufting the parts with ftarch or wheat flour, or gum  arabic
in fine powder, has been ufeful in all flates of the body, but
particularly in that of debility.   In this cafe,  lint moiften-
ed with tinaure of myrrh, traumatic balfam, and other fti-
mulating  applications,  are  very ferviceable.   When thefe
do not  prove effeaual, an equable preffure by a bandage,
or the hand  applied ever the dreffing, will feldom fail*.

   * This laft mode of preffure is much the beft, and has fucceeded  in
fome aneurifms, where it could be made immediately upon the orifice of
the wounded artery.
CHAP. 
[  84  3
CHAP.    VI.

   Of  Blood-letting.
                    SECT.   I.

              Of Blood-letting in general.

   IN all general affeaions where blood-letting is confider-
    ed neceffary, the blood is difcharged by an opening
made in an artery or vein.   The former operation is^ cal-   ?
led arteriotomy;  the latter  phlebotomy.   In local affeaions,  ^
particular benefit is often afforded by dividing a  number    ■
of the fmaller veffels of the  part difeafed; this is termed  .
topical bleeding.                                           i
   We fhall firft confider phlebotomy.  The choice of a vein   |
in this  operation, muft  be determined by  the  particular
circumftances of the  patient.    The veins from  which
blood  is  ufually  drawn,  are thofe of  the arm  at the
flexure of &e cubitus or fore arm, the jugular veins, and
thofe of the ankles and feet.   On certain occafions, blood
is alfo  taken from the veins  of  the hands, tongue, and
other parts.
   In blood-letting in  general, as the pofition of the pati-
ent has fome influence on the effeas of the operation, it
fhould  be precifely fixed.  When fainting is likely to be
induced,  and we do not wifh to rifk  it, an  horizontal pof-
ture is  to be preferred;  but if we expea advantages from
the fainting, the patient fhould be placed erea.   The part
                                                      to 
                           C   85  3
    to be  operated upon fhould- be  fo fituated, as that the
    principal  light of  the  apartment  may fall  direaiy  up-
    on it:  and the furgeon ought always to be feated ;  as he
    will then bleed with much more fleadinefs and nicety than
    if he ftands*.  When the patient is properly fixed, a ban-
    dage fhould be applied to the member to be operated upon,
    to produce an accumulation of blood in the veins ; but not
    fo tight as to obftrua its  paffage in the correfponding ar-
    teries.
       Various inftruments have been invented to bleed  with ;
    but there are only two now in ufe : the  lancet  and  the
    phleme.
       The  phleme is  placed immediately  on the part to be
    cut, and by means of a fpring is ftruck fuddenly into the
    vein.   Its inconveniencies are,  that we muft regulate the
    depth to which it is to go, before we apply it;. on  which
    account, if  the  vein  lies deeper than  fuppofed,  we  may
    not reach it; and  there is danger of its wounding arteries,
\    qr other parts beneath the  vein,  if it fhould  go  too farf.
j    Thefe difadvantages do  not attend the ufe of  the  lancet,
/    and therefore it certainly ought to be preferred.
       The  lancet fhould  be  fpear-pointed—it  then  enters
    the integuments  with little pain •, and forms an opening in
    , them  very little larger than  the orifice ia-the vein,  which
     readers it an jafy  matter to flop the difcharge.—Thefe ad-
    vantages are not derived  from the broad-fhouldered  lan-
    cet in common ufe.
       The ligature having been  made for a fhort time to pro-
     duce fome fwelling in the veins, that vein is to be fefeaed
                                                       which

       * This  depends upon habit—thofe accuftomed to operate  ftanding
     will perform with more eafe to themfelves, than if they were feated.
       f Notwithftanding thefe obvious objections, the phleme is very uni-
     verfally ufed here, among the bleeders, in  preference to the  lancet; and
     even fome medical practitioners employ it.  I have very feldom heard of
     any material bad effects from itj  ufe—never but of one cafe of aneu-
     rifm. 
                       C  86  }
 which rolls lefs than the others on being preffed with the
 finger, even if it fhould  be fomewhat deeper than thofe
 near it—Veins that lie contiguous to arteries  and tendons
 fhould, if poffible, be avoided ; although a dextrous  ope-
 rator may often open  them with perfect fafety.
   When a vein is made choice of, the furgeon, if he  is to
 ufe the right hand, grafps firmly the member,  an  inch and
 an half below the part to be  operated upon with his left,
 and  makes fuch a preffure on the vein, with the thumb,  as
 will interrupt the communication between the  inferior part
 of it, and the part  above the  thumb, and  will render the
 teguments  fomewhat tenfe.  The lancet being bent to ra-
 ther more than right angles, is then to  be taken  between
 the thumb and fore-finger of the right-hand of the opera-
 tor,  and leaving one half of the blade uncovered,   he refts
 his hand on the remaining fingers, and  then pufhes the
 point of the lancet into the vein, and carries it forward in an
 oblique direaion, until the orifice is fufficiently  large.   The
 point ought neither to  be raifed nor depreffed, left it fhould
 wound parts unneceffarily.  The  inftrument is now to be
 withdrawn, and the left hand removed as foon as the cup
 for receiving  the  blood is  applied.  While the  blood  is
 flowing,  the member  fhould be kept in the pofition it had
 when the incifion was made;  otherwife the fkin may flip
 over the orifice in the vein, obftrua  the  difcharge,  and
 produce ecchymofis.
   If the  wound is  made longitudinally, it does not admit
 of a  free difcharge ; and if acrofs the vein, it is difficult to
heal.   The fize of the orifice muft depend on the  circum-
ftances of the difeafe for which the bleeding was ordered.
In general,  when  the fpear-pointed  lancet  is ufed,  an
eighth of an inch will  be  fufficiently large;  but when we
employ the common lancet, a quarter of an inch  will not
be too  much.
                                                    It 
                      C  87   3
  It fometimes happens that the blood is not freely dif-
charged,  either from faintifhnefs, or from the opening in
the fkin receding from that in the vein.   In the firft cafe,
it will be proper to admit a ftream of air into the apart-
ment, to give  fome wine  or other cordial, and have the
patient placed  in a horizontal pofture.  If the blood does
not then  flow  as we wifh it, the part fhould be put into a
variety of pofitions, the mufcles fhould be thrown into ac-
tion by moving fomething in the hand, if the  arm is ope-
rated upon; and  if the  pulfe is feeble in the inferior part
of the member, we fhould loofen the ligature.
   As foon as  a fufficiency of blood is drawn, the com-
preffion fhould be taken  off,  and if the difcharge does not
then  ceafe, the thumb fhould be  applied above, and the
fore-finger below the orifice, and it being well wafhed and
cleared of blood, its fides fhould be brought exaaiy  to-
gether, and there retained by a ft rip of adhefive plafter.
This will generally be fufficient;  if it is not, it will be pro-
per to apply a linen comprefs over the plafter, and fecurc
both with a roller.
   The wound will commonly heal by the firft intention,
or  without the formation  of pus; but troublefome confe-
quences fometimes enfue.  Of thefe  the  moft material are
thrombus or ecchymofis;  wounds of arteries, nerves, or
tendons contiguous to the vein;  and inflammation  of  the
internal coat of the vein operated upon.


                   SECT.   II.

             Of a Thrombus or  Ecchymofis.

   A  thrombus is a fmall round tumor produced by extra-
vafated blood  infinuating itfelf into the cellular membrane.
When this fwelling is more diffufed it is  termed an ecchy-
                                                 mofis. 
                      C  88   3
mofis.   In bleeding, it is commonly induced by the orifice
in the  fkin receding from  that in the vein.  Immediately
on the  appearance of fuch  fweUings the ligature fhould be
removed, and again applied, as foon as the limb is brought
into the pofition it had  during the operation.  Should not
this fucceed  in difperfing  the tumor, or at leaft  in pro-
curing  a free difcharge of blood, the ligature muft again
be taken off; and if the neceffary quantity of blood has
not been drawn,  another vein fhould  be opened.
  Thefe fweUings in general go off of themfelves ; but if
they do  not, they  may often be difperfed by the applica-
tion of compreffes wet with brandy, or a folution of fal
ammoniac in vinegar.   If thefe have not the defired effea,
the tumor fhould be laid open,  the blood  taken out, and
the wound then healed in the ufual mode.
                   SECT.   III.

              Of Wounds of the Arteries.

  The only certain method of knowing whether an ar-
tery is wounded through the vein, in bleeding, is to com-
prefs the vein above and below the orifice; if the artery is
wounded, the difcharge will then continue, or be increafed;
if it is not,  it will  ceafe.   The flow of blood being  per
fal turn, is a fallacious criterion, becaufe it may happen from
a vein lying immediately above an artery.
  As foon as we are certain of an artery being thus wound-
ed,  as  much blood  fhould be fuffered to flow as the ftate
of the body will admit of, and  the wound fhould then be
clofed by adhefive  plafter;  reft fhould be enjoined,  and
the body kept cool; gentle purgatives muft be given,  and
blood-letting repeated occafionally.   By thefe means,  the
fyftem will be relaxed, and  we  fhall have fome chance of
                                               healing 
                      [   89  3
healing the wound.  If this is not accomplished, the  effufi-
on of blood forms a fpecies of aneurifm.
  It has been the common  praaice  in wounds of the ar-
teries,  to apply immediate and  flrong compreffion, by
means of compreffes and bandages ;  but  it is evident that
this, from the obftruaion  it gives  to the paffage of the
blood, according to its degree, muft either increafe the he-
morrhagy by producing an increafed aaion in the artery,
or caufe a gangrene in the parts below.

                    SECT.   IV.

                                               t
    Of Wounds in the Nerves and Tendons from  Bleeding.

   These accidents arife from carrying the lancet through
the back part of the vein; and  may be avoided by keep-
ing the point of the inftrument in a ftraight direaion*,  in-
flead of depreffing it after it  has  entered the cavity of the
vein.
   If immediately on the introduaion of the lancet the pa-
tient complains of exquifite pain, we may reft affured that
either a nerve or tendon has been wounded.
   In fome cafes,  by proper management, the pain will gradu-
ally go off entirely without any bad  confequence whatever.
At other times,  however,  the pain  foon increafes,  a fmall
degree of fwelling takes place ; the lips of the fore become
fomewhat hard  and  inflamed ;  and  in the courfe of about
twenty-four hours from the operation, a thin watery ferum
begins to be difcharged at the orifice.
   If relief is not foon obtained,  thefe fymptoms generally
 continue nearly  in the fame flate for two or three  days
 longer.  At this time, the pain becomes  greater, and  in-
                            M                   ftead
* See Se<ftion I. 
                     [  90   3
Head of being acute as before, is now attended with a burn-
ing heat, which gradually augmenting proves, during the
whole courfe of the difeafe,  exceedingly diftreffing.   The
fulnefs and hardnefs in the lips of the wound begin to in-
creafe, and the fwelling by degrees extends over the whole
member ; from the foot, if the operation has been perform-
ed there, over the whole  lower extremity ;  and from the
elbow, if the bleeding  has been done in  the arm, down
the fore-arm, and  along  the humerus over the peaoral
mufcle and other contiguous parts.
  The parts at laft become exceedingly  hard and tenfe/,
an eryfipelas frequently appears over the whole member;
the pulfe becomes  generally  very  hard  and quick;  the
pain intenfe, and the patient very  reftlefs ;  twitchings of
the tendons occur,  on fome  occafions, a locked jaw and
ether convul five affeaions fupervene ; and all thefe fymp-
toms  continuing to increafe,  it moft frequently happens
that the fufferings of the patient are only terminated  by
death-—All the inftanees of accidents of this  kind that
I have feen have ended fatally.
   By  fome,  the  fymptoms  we  have  enumerated  have
been attributed  to  wounds of the  tendons; others fup-
pofing  tendons  to be deftitute  of  fenfibility, have im-
puted them, in all cafes,  to wounds of the nerves : And
Mr  Hunter of London,  is  entirely  convinced that they
are the  confequence of  an  inflammation of the internal
coat  of the vein  operated  upon—He  has  traced this
inflammation in horfes,  and even  in  the human  fub-
jea,  to a confiderable extent in the vein,  and in fome in-
ftanees,  even to the heart.   The matter formed in confe-
quence, Mr Hunter fuppofes to produce death, by  being
 carried to the heart in the courfe  of the circulation.  But
 although  there  can  be no doubt  that  this  inflamed
 ftate of the vein may often occur, yet we are clearly of opi-
 nion,  that the violent pain  experienced immediately af-
                                                   t<_r 
                        r  91  3
  ter the puncture, cannot be occafioned by the wound of
  the vein;  and that the inflammation of its internal furface
  ought rather to be confidered as fymptomatic of the pre-
  vious affeaion of a nerve or tendon, than as the fole and
  primary caufe  of the fymptoms which we have above de-
  fcribed as  confequent to bleeding.
    In  order  to obviate the ufual confequences of  this acci-
  dent, a confiderable quantity of blood fhould be immedi-
  ately  difcharged at the orifice, the limb  fhould be kept
  perfeaiy at reft,  for  fome days, care being at  the fame
  time taken that the mufcles of the part be all preferved in
  as relaxed  a flate as poffible;  the  patient  fhould be kept
  cool,  and on a low diet; and if neceffary, laxatives fhould
  be adminiftered.
    By this treatment, we may frequently prevent all bad
 fymptoms;  and when  thefe do occur, from injudicious
 management, they  prove fatal  as much from negligence
 in  the fubfequent treatment,  as from any thiag peculiarly
 bad in the  nature of the accident.
   When,  however, notwithftanding  the  employment of
 the means  recommended, the  lips  of the wound  grow
 hard and inflamed, the pain increafes, and  efpecially if the
 fwelling becomes more  confiderable, we  muft  have  re-
 courfe to other remedies.  Topical  bleeding, by leeches
 applied as near  as poffible to  the lips of the wound, fre-
 quently affords  much relief: and when the pulfe is full and
 quick, it is neceffary to employ general bleeding to a very
 confiderable extent.
  As  applications to the part, warm emollient poultices
 and fomentations have  been  ftrongly recommended.   I
 have ufed them;  but never  with good effea—And it is
probable, that  as the membranous parts affeaed are in-
 capable of  yielding  a good pus, to  produce  which, has
been the objea of their ufe, they prove hurtful by the
heat they communicate.
                                                  By 
                      C   9*  3
  By Heifter and others, inftead of emollients, oil of tur-
pentine, tinaure of myrrh, and other heating applications
are advifed.  But fufpeaing that they would increafe the
fymptoms,  by irritating parts rendered already exquifitely
fenfible by  difeafe, I have never employed them.
   I can, however,  from  repeated experience affert, that
cooling aftringents, and  particularly  the faturnine pre-
parations,  afford much more eafe and effeaual relief than
warm emollients.  In all fuch cafes, therefore, immediately
after bleeding, the  fwelling ought to be covered with foft   <
linen moiftened with the faturnine folution;  and this being
kept conftantly  wet for a few hours,  the part fhould then
be covered by pledgits fpread with  the  faturnine  or Gou-
lard's  cerate.    Thefe preparations fhould  be  alternately
ufed till the tumor  entirely fubfides.
   The febrile fymptoms muft be moderated  by keeping the
patient cool;  on a  low diet;  preferving a lax ftate of the
bowels; and if neceffary, by repeating blood-letting.
   For the violence of  the pain,  which often prevents the
 patient altogether  from fleeping, opiates fhould be freely
 exhibited; and when twitches of the tendons  and other
 convulfive fymptoms occur,  medicines of this kind become
 ftill more neceffary;  but it  is  to  be obferved that unlefs
 they are given in large dofes, they certainly aggravate in-
 ftead  of leffening the difeafe.
    When  every thing we have  advifed  proves ineffeaual,
 and the life of the patient appears to be in imminent danger,
 the only remedy from which much advantage is to be ex-
 peaed, is a free and extenfive divifton of the parts in which
 the orifice producing the mifchief  was at firft made.
    In performing this operation, in order to prevent an in-
 convenient difcharge of  blood from the fmaller veffels, or
 a dangerous hemorrhagy from the larger, it will be neceffa-
 ry to have a tourniquet applied on the fuperior part of the
 limb.  When this is done, a large tranfyerfe incifion fhould
                                                      be 
                       C  93   3
be  made through  the teguments of the parts  chiefly af-
feaed,  and carried acrofs  the original orifice in the vein.
The furgeon muft  then, by cautious diffeaion, wiping the
blood away frequently with a fponge, and avoiding the ten-
dons, larger  arteries,  and veins, endeavour  to difeover
the wounded nerve; if  he cannot  accomplifh  this, he
fhould  ftill continue the incifions till he gets to  the  periof-
teum.  The tourniquet fhould then be loofened;  and if the
 wounded part has been divided, the pain will ceafe.  If the
 pain continues,  the adjacent tendons, and particularly that
 which  lies beneath the vein, fhould be accurately examined;
 and the one in  which a wound or  inflammation is difco-
 vered  fhould be  entirely divided.   If neither wound  or
* inflammation appears, the tendon  which lies  moft conti-
 guous  to  the vein fhould be cut through;  and if  one  or
 two others fhould be liable to  fufpicion from  their  fitua-
 tion, we  fhould  not hefitate to divide them  all.   When
 this is done, it  feldom happens that relief is not immediate-
  ly derived from it.
    The tourniquet muft now  be  flackened  as much  as
  poffible,  and fuch arteries as have been  wounded  muft be
  fecured.   The parts are then to be covered with foft eafy
  dreffings, and the wound is to be treated as in other cafes.
     The mode of treatment here recommended, I have feen
  praaifed with the greateft fuccefs.


                      SECT.  V.

                 Of Blood-letting in the Arm.

      It appears  to me, that the fixing on the fore part of the
   arm at the elbow, as the nfual place for blood-letting,  is a
   very capital error, on account of the rifk we run of wound-
   ing the  nerves, tendons,  and arteries  contiguous to the
                                                   veins; 
                        C  94   3
 veins; and efpecially as  it can be performed with equal
 eafe, and with much lefs danger, in  the  neck, the lower
 part of the legs, the ankle, and the feet.  The only rea-
 fon that can be given for  the praaice is, that the veins ap-
 pear here more confpicuous than in other places.
   In applying the ligature previous to bleeding in the arm,
 we  fhould  place it about an inch  or an inch and a half
 above the joint of the elbow, and the knots fhould be made
 on the outfide of the arm, that they may not interfere with
 the lancer.
   As the median bafilic vein appears in general more con-
 fpicuous than any of the reft,  and is lefs covered with cel-
 lular fubftance and  the tendinous expanfion of the biceps
 mufcle, it fhould be preferred.   The incifion alfo gives
 lefs pain on account of thefe circumftances.
   The operation is more neatly performed, if the right
 hand is ufed in bleedirtg in the right arm,  and the left in
 the left arm of the patient, than if the right hand is ufed
 in both cafes.
   In very corpulent people,  it  fometimes happens that
 the larger veins cannot be  feen; but  when  they can  be
 fenfibly felt, they may be  opened with perfea fafety.  In
 fome cafes again, the veins  of the arm  can neither  be
 feen nor felt.   The ligature may then  be  applied to the
 middle of the fore-arm,  and a vein of the wrift or back of
 the hand, may generally be opened with eafe.


                   SECT.   VI.

          Of Blood-letting in the  Jugular Vein.

   This operation is fometimes judged neceffary in inflam-
mations of the throat, diforders of the eyes, and other af-
feaions of the head.
There 
                      [  95  3
  There is no branch of the external jugular vein  that
can be opened with propriety, but its principal pofterior-
ramification ;  and even this lies fo deep, that a confi-
derable degree of preffure is neceffary to bring it  well
into view.  In order to produce this,  it is commonly ad-
vifed to place the thumb upon the vein, about an inch or
an inch and an  half below  where the opening is to be
made.   This, however, is feldom fufficient;  for the blood
on being flopped in this branch, paffes off by others  com-
municating with it :  fo that unlefs the vein on the other
fide of the neck is alfo compreffed, the vein to be  opened
can never be fully diftended.  In order to do this,  a  com-
prefs  fhould be applied over it, and a ligature carried above
this, and knotted under the oppofite arm-pit.
   The patient's  head being fupported, the operator fhould
then make a firm preffure on the vein with his  thumb, and
with a lancet penetrate at  once into the veffel, making an
opening fomewhat larger than that advifed in bleeding in
the arm, on account of the  greater difficulty of  procuring
a  fufficient quantity of blood.   Adhefive plafter  alone
commonly reftrains the difcharge.
   It has  been direaed to make an incifion down to the
vein with a fcalpel, and to ufe the lancet merely for opening
the vein: but this precaution  is entirely unneceffary, and
fometimes may injure the operator in the opinion of the pa-
tient.

                   SECT.   VII.

          Of Blood-letting in the Ankles and Feet.

   In thefe cafes,  the ligature being  applied juft above the
 ankle joint, all the  branches  of  the  vena faphena, both
in the infide and outfide of  the foot, generally  come into
view; and  wherever a  proper vein  appears, it  may  be
opened with fafety.
                                                   The 
                      [   96  3
  The ufe  of warm  water prevents  us from afcertaining
the quantity of blood difcharged, and  is perfeaiy unne-
ceffary.
  The bleeding generally ceafes immediately on the remo-
val of the ligature, fo that nothing more than  a  ftrip of
adhefive plafter is neceffary to be applied to  the wound.
  When  it is found  neceffary to difcharge blood  from
the penis,  the veins can eafily be brought into view by the
application of a ligature ;  but in the tongue, in the exter-
nal hemorrhoidal  veins, and other parts where compref-
fion cannot be applied, all that the furgeon can do,  is to
make an orifice in the moft evident  part of the vein, and
if a fufficient  difcharge is  not thus produced, to immerfc
the parts  in warm water, where this is praaicable.

                  SECT.    VIII.

                     Of Arteriotomy.

   Arteriotomy feems hardly in any cafe, to have better
effeas than opening a vein ; and  is  always attended with
much  hazard, notwithftanding what has  been  faid by
theorifts  to the  contrary,  when praaifed on  the  larger
veffels.  The different  branches of the temporal  artery
are thofe  only  from  which  blood is taken in ordinary
praaice ; but any of the fmall arteries  that lie  fuperficial,
or contiguous to bones,  and admit eafily of compreffion,
might be  opened with perfea fafety ; as thofe of the fin-
gers at the middle of the laft  phalanx.  The opening may
be made  as  in common phlebotomy;  but if the  artery  is
 deeply covered with cellular fubftance, it will be neceffary to
                                                 expofe 
                       C  97  3
 expofe it to view by the fcalpel, before making the orifice
 with the lancet; for if the veffel  fhould  be entirely  divi-
 ded, it would retraa and put a flop to the evacuation.
   If the blood fhould not  flow freely, it will  be  pro-
 per to comprefs the artery immediately above the orifice ;
 And when a fufficient quantity is  obtained,  we  may com-
 monly reftrain the evacuation by applying a comprefs and
 roller as direaed in vensefeaion.
   If this does not  flop the difcharge, it may with tolera-
 ble  certainty be fuppreffed,  either by cutting  the artery
 entirely acrofs at the orifice ;  by taking it up with a needle
 and ligature ; or by obliterating its cavity by a gradual and
 conftant compreffion.  For this laft purpofe, a fmall femi-
 circular ftrip of fteel covered with leather,  to reach from
 temple to temple, with a comprefs of linen,  anfwers much
 better than a common  bandage.

                   SECT.   IX.

                 Of Topical Blood-letting.

   Topical bleeding  is performed  either  by  means  of
 leeches  ; by  flight fcarifications with the fiioulder  or edge
 of a lancet;  or  by the inftrument termed  a fcarificator.
 When the laft mode is employed, it is neceffary, in order to
 produce a fufficient difcharge of blood, to apply cupping
 glaffes over the  divided parts.  Thefe  promote the evacu-
 ation  by having the air contained in them rarified immedi-
 ately previous to their  application.
  With a view to produce this rarefaaion and confequent
 fuaion, heat is  now ufually applied to the  cavity of the
glafs, either  by fupporting the  mouth  of it  for  a  few
 feconds above the  flame of a taper, or  by throwing in-
 to it a piece of bibulous paper impregnated with fpirits  of
                           N                   wine, 
                      [   98  3
wine, and fet on  fire.  The  laft  is  the  eafieft and beft
mode—by the former we are very apt to crack the glafs if
the flame be fuffeted to touch it.   The cup fhoUld be ap-
plied  direaiy upon  the  part, when  the  paper is  nearly
extinguifhed.
   As foon as this is done,  the fcarifications, if well made,
begin to difcharge freely; and as foon as the glafs is near-
 ly full of blood,  it fnould be taken away ; which  may be
 eafily done by raifing one fide of  it.   When  more blood
 is wiflied to  be taken, the  parts fhould be bathed in warm
 water,  then dried, and  another  glafs exaaiy of the fize
 of the former, inftantly applied—and  thus, if the fcarifica-
 tions have been fufficiently deep,  almoft  any neceffary
 quantity of blood may be  drawn ;  but when  this cannot
 be obtained from one operation, the trial  fhould be repeat-
 ed, as near as poffible to  the parts  already cut.
   When it is wifhed  to difcharge the blood as quickly
 as poffible, two  or more  cups 'may be applied  at once,
 and previous to the fcarifications, for a few feconds, as well
 as afterwards.—The wounds made by  the fcarificator
 fhould  be well  cleared of blood, and  dreffed with  foft
 linen or lint dipped in milk or cream.
    Dry  cupping  confifts in  the  mere application of the
 glaffes,  without any fcarification.   This  may be very ufeful
 where we wifh.  to  determine a quantity of blood to a  par-
 ticular fpot.
    When cupping  cannot  be ufed, we generally  have re-
 courfe to leeches for the topical evacuation of blood.   In
  order to make thefe animals fix on  a particular fpot,  they
  fhould be fuffered to creep  upon a dry  cloth or board for
  a few  minutes  previous to their  application;—the part
  fhould  be mo'utened with milk, cream or blood :—and they
  fhould  be confined to it by a fmall wine glafs.  As foon as
  the leeches have feparated,  the bleeding is in  common
                                                promoted 
                       C  99   3
 promoted  by covering  the  parts  with linen  wet  with
 warm water; but the  application of cupping glaffes an-
 fwers the purpofe much better.
   Scarification with the edge or fhoulders of a lancet is
 fometimes  neceffary, and particularly in inflammations of
 the eye-ball,  where it often proves a very effeaual remedy.
   In  performing this operation,  the upper eye-lid being
 fupported by an affiftant, and the lower by the left hand of
 the furgeon,  a number of flight fcarifications fhould be
 made through the veffels that feem moft turgid on the tu-
 nica conjunaiva.    The  eye fhould  then  be bathed  in
 warm water to encourage the difcharge.
   It has been recommended to ufe a fpeculum in order
 to keep  the  eye  fleady;  but this is totally unneceffary,
 and by its preffure it  may perhaps be injurious.
   The beards of barley, drawn over the furface of the eye
in a direaion contrary to their fpiculae, have been much
extolled to produce a difcharge of blood—but this gives
fuch exquifite pain that it is now going out of  ufe.
CHAP. 
C   ioo  3
             CHAP.    VII.


                  Of  Aneurifms.

                 . »m^T_g_afs^taawnww-.-------

                    SECT.   I.

            General Remarks on Aneurifms.

     ANEURISMS  are  tumors formed either by the dila-
       tation of the coats of arteries ; or by blood effufed
from arteries into the contiguous  parts.   The firft fpecies
has ufually been denominated the  true aneurifm; but  it
may with greater propriety be called  the encyfled.  The lat-
ter fpecies has been  generally termed the falfe; but  from
its appearances, I think  it Ought to have the appellation of
the dijfufed aneurifm.
  In the true or encyfled aneurifm,  when externally fitu-
ated, the  tumor,  when  firft  obferved, is  commonly very
fmall and circumfcribed ;  the fkin  retains its natural ap-
pearance ; when  preifed  with  the fingers, a pulfation
correfponding with  that of the artery  below is evidently
diftinguifhed; and  with very little  force, the tumor may
be made to difappear entirely.  If it is not removed  when
in this  ftate,  after  fome time the  fwelling gradually  in-
creafes, and  becomes more prominent;  but the fkin for
a confiderable time retains  its natural appearance.  The
tumor  is  not painful, even on preffure; continues  of an
equal foftnefs;  and its contents may  generally  flill  be
made to  difappear  by  preifure.    At length,  when the
                                               fwelling 
                     C   ioi  3
fwelling becomes very large,  the fkin  grows pale, and in
the more advanced flage of the difeafe, cedematous ; the
pulfation ftill continues; but the tumor, now in fome parts
foft, in others  hard, does not yield much to preffure.
  The fwelling continuing to increafe, becomes  gradually
exceedingly painful; the fkin turns livid, apparently verg-
ing to a gangrenous ftate;  at  laft  a  bloody ferum oozes
from the teguments ;  and if a mortification does not take
place,  the fkin cracks in  different parts,  and the blood
burfts  forth from the artery.  In the  large veffels of the
trunk,  this generally  produces almoft inftant death; but
in the extremities,  the hemorrhagy may be reftrained  by
the tourniquet.
  In aneurifms of the  larger arteries,  the contiguous parts
fuffer confiderably.   The bones appear to  be particularly
affeaed: and  in different cafes are much  deranged, and
fometimes entirely  diffolved.  Thefe confequences have
even occurred  in the thigh and arm.
  Various caufes may be fuppofed neceffary to the pro-
duaion of encyfled aneurifms.
   i. As we know of  no reafon why partial debility fhould
not occur  in  arteries as well as  in other parts, we
may confider this as one of the moft frequent caufes of the
difeafe, when it cannot be traced to any external accident;
as is commonly the cafe in aneurifms of  the aorta, and
other internal arteries.   And when weaknefs is produced in
the fmalleft  degree, a dilatation muft neceffarily  follow,
and be conftantly increafed,  from the aaion of the  blood.
  2. The external coat of an artery being deftroyed by a
wound, the  inner tunic will be incapable  of refifting the  ^p*.
impulfe of the  blood ;  and thus an aneurifm will  be rea-
dily induced.  Such cafes  are moft frequently  produced
by blood-letting in the arm.
  3. The external coat of an artery is fometimes  deftroy-
                                                   ed 
                       [  102   3
 cd by the matter of abfceffes  and ulcers,  and occafions
 aneurifmal fweUings in the manner jufl explained above.
   4. As arteries receive, in many fituations, confiderable
 fupport from the adjoining parts,  aneurifms  may be  pro-
 duced from a removal of thefe  parts.  This appeared  to
 be the  only caufe of feveral aneurifmatic tumors that oc-
 curred  in a cafe of gangrene which  deftroyed a part  of
 the thigh.
   5. In blood-letting in  the arm, it fometimes happens
 that the artery is wounded through  the vein when it lies.
 in contaa with it: a communication  being thus formed,
 the arterial blood, by its impetus, produces a dilatation  of
 the coats  of the vein, and thus forms what has been term-
 ed the  varicofe aneurifm.  This  may with propriety be
 confidered as encyfled, becaufe the  blood is confined  to
 the cavity  of the vein.  Soon after the injury,  the  vein
 communicating with the wounded artery,  begins to fwell,
 and gradually acquires a large fize: and when any  confi-
 derable anaftomofis occurs  near  to the part affeaed,  be-
 tween it  and the  contiguous  veins, thefe alfo become
 much enlarged.  By preffing upon the fwelling, it may be
 made to difappear entirely;  and if it is  of confiderable
 fize,  the blood on being forced out of  it, makes a  very
fingular, hiffmg kind of noife.  This,  when it occurs, is a
 very charaaeriftic fymptom;  but it is not always met with.
   There is a very fingular tremulous motion difcovered in
 the dilated vein,  attended with a perpetual hiffing noife,
 as if air was paffing into it through a fmall aperture.  If
 a ligature be applied immediately below  the fwelling,  and
 made fo tight as even to flop the pulfation in the  limb, the
 fwelling in the  veins does not feem  affeaed, and  when
 removed by preffure, inftantaneoufly returns on the preffure
 being taken off.   If the fwelling is removed, and a  flight
 preffure be made on the orifice in the artery by  the point
 of the finger, the veins will remain perfeaiy flaccid,  until
                                                   the 
                      C   103  3
the removal of the compreffion from the orifice;  and thi$
happens even  if the circulation in the artery is not entire-
ly obftruaed  below.
   In the fame manner,  if the artery be compreffed  above
the orifice, fo as to flop the paffage of the blood,  that tre-
mulous motion and hiffing  noife in the fwelling ceafes in-
ftantly; and  if  the veins are now emptied as before, they
will remain fo until the preffure upon the artery is remov-
ed.   In fome inftanees, it happens that if a ligature be
applied an inch or two  above the fwelling, and another as
much below it,  fo tight as  to prevent the circulation in the
tumor, by compreffion, all the blood  contained in it may
be made to pafs into the  artery; from whence  it imme-
diately returns on the preffure being removed.
   When  this difeafe  has  continued  for  any length of
time, and the fwelling  has become confiderable, the trunk
of the artery above the orifice geuerally grows preterna-
turally large, while the branches below become propor-
tionably fmall.   Hence the pulfe in the inferior part of
the member is always  more feeble than that in the found
limb.
   The diminution of  the  branches of the artery may be
readily accounted for from  the direa paflage of fo great a
part of the arterial blood  from the trunk into the corre-
fponding vein; but no fatisfaaory reafon has yet been given
for the enlargement of  the artery above the fwelling.
   The diffufed or falfe aneurifm  occurs in various  parts
of the body; but we fliall here confine our defcription to
that fpecies which we  know to be moft  frequently occa-
fioned by  a  wound made  direaiy into an  artery, and
which it is commonly in the power of art to relieve.
   This  difeafe is frequently produced by a wound  of the
artery in blood-letting in  the arm;  and indeed  when
the artery is  thus wounded, an aneurifm is almoft always
                                                   the 
                      [  '°4   3
the confequence.   The following is the ufual progrefs of
the complaint.
   A fmall tumor, about the fize of a horfe-bean, gene-
rally rifes juft at the orifice in the artery,  foon after the
difcharge  of  blood has  been flopped : at  firft it is foft,
lias a flrong pulfation, and yields a little upon preffure;
but it foon acquires a firm confiftence by the coagulation
of the contained blood.
   If the fwelling is not  now improperly treated by com-
preffion, it generally remains nearly  of  the fame fize for
feveral weeks, when it begins gradually to increafe; and if
feated in the ufual  place of blood-letting in the arm, it pro-
ceeds rather farther up than the  orifice, and extends more
inwardly than towards the outer part of the arm, probably
on account of the expanfion of the biceps mufcle being there
lefs firm than  in the external and under part.  The enlarge-
ment of  the tumor proceeds with much more quicknefs,
and  is  much more  diffufed  in  fome  inftanees  than in
others;  this feems to depend chiefly on the degree of lax-
ity of the parts into which  the blood is effufed.   Thus, in
fome inftanees, fwellings  of  this kind  have  been many-
months,  and  even years in  arriving  at  any confiderable
fize; whilft in others the blood has been diffufed over the
whole arm, from the elbow to the fhoulder,  in the courfe
of a few hours  after the artery was wounded.
   I am  convinced that the compreffion commonly advifed
in wounds of the arteries, has alfo  a confiderable influ-
ence in producing a diffufion of the blood.  If the preffure
could be applied over the orifice alone, it might be advan-
tageous ; but  by every mode yet recommended, the refluent
blood is much  obftruaed in its  paffage;  and  this  muft
evidently diftend  the wounded artery in an equal  propor-
tion, and increafe the quantity of blood  which efcapes by
the orifice.
                                               When 
                      C   io5   3
  When compreffion has not been applied to fuch tumors,
unl'efs there is a very unuf ml degree of laxity in the fur-
rounding parts, the fwelling increafes in  a gradual man-
ner ;  but  it  does not  become  much more prominent,
rather diffufing itfelf among the adjacent  parts ;  by  de-
grees it acquires  a very firm confiftence;  and  the pulfa-
tion,  which was at firft confiderable, always diminifhes in
proportion to the har-.'nefs and fize  of the tumor, info-
much that it is fometimes fcarcely perceptible.
   In the  firft ftages, if the blood  thrown out lies very
 deep, the fkin preferves  its natural appearance,  and does
not  change its colour  till the diforder is much advanced.
It frequently happens  however, that the blood  is thrown
out  at firft  with fuch  violence, as  to get into  immediate
contaa with the  fkin,  and change  it to a livid  colour ;
and in fome inftanees,  either from the quantity extrava-
fated, improper treatment, or  negligence,  a mortification
has  been  induced.
   As the tumor increafes, the patient, who in  the  firft
 ftage did  not complain of  much  uneafinefs, is diftreffed
•with fevere pains, ftiffnefs,  want of feeling,  and immobi-
 lity of the whole member; and thefe fymptoms continuing
 to augment, if the tumor is not  previoufly operated upon,
 the teguments at laft burft ; and when the artery is of con-
 fiderable  fize,  and we do not  have immediate recourfe  to
 means to prevent it,  death  muft  certainly be the confe-
 quence.
    A variety of  caufes may  be produaive of the diffufed
 aneurifm.
    i. Violent bodily exertions may be confidered as the
 moft frequent origin of  the rupture  of arteries internally
 fituated; but  thefe cafes  do not  come  properly under
 our confideration in this place.
    2. The corrofive  matter  of fores  and  abfceffes by en-
                         O                        tirely 
                       I   106*  3
 tirely deftroying the coats  of arteries, may occafion this
 fpecies of the difeafe.
   3. The fharp fplinters of a fraaured  bone being pufh-
 ed into a neighbouring artery, have produced aneurifms.
   4. Violent blows have been known to bring on aneu-
 rifms.   This can  fcarcely  happen in any  other  fituation
 than on the head;  on account of the arteries being there fo
 particularly expofed, and lying fonear a firm bony fubftance.
   5. It has  been  affirmed  by  refpeaable authority, that
 diffufed aneurifms  have been produced, although  rarely,
 by the arterial coats burfting before  the teguments with
 which they are covered in cafes of the encyfled fpecies.
   6. The moft frequent caufes are punftures with  fharp
 inftruments, as fwords and cutlaffes,   but particularly the
 lancet: which laft  may be  confidered as having been pro-
 duaive of nine-tenths of all the aneurifms that ever have
 occurred.
   It has happened, in many inftanees, that aneurifms have
 been miftaken for abfceffes and other colfeaions of matter; j
 have been opened ;  and  death has  been the confequence.
 Swellings of this kind are fometimes with much difficulty
 diftinguifhed from  fome others.  In the beginning  of the
 difeafe, the pulfation and other  circumftances charaaerife
 it fufficiently; but in an advanced ftage, when the tumor
 is very confiderable, and has loft its pulfation entirely, no-
 thing but a very  minute attention to the previous hiftory
 of the cafe,  can enable us to form a judgment  of its na-
 ture.
  Thofe fweUings with which  aneurifms are  moft likely
 to be confounded,  are  foft  encyfled  or  fcrophulous tu-
mors  and abfceffes, fituated either immediately  above, or
 fo nearly in contaa with an artery, as to receive the influ-
ence of its  pulfation; which is often  communicated in  a
very confiderable degree when the artery is large.  But
there  is  one  fymptom, which, when it occurs,  and  is
                                             conneaed 
                      [  io7   3
conneaed with a  flrong pulfation in the tumor, may cer-
tainly determine  the  difeafe to be an  aneurifm;  viz. the
contents of the tumor being made  to  difappear with eafe
upon  preffure, at the fame time that they return  inftanta-
neoufly on the compreffion being removed.   This fymp-
tom,  however, cannot attend  when the contents of the
fwelling have  become hard and firm.   Upon the whole,
therefore, as in  many inftanees the nature of the difeafe
cannot be with  certdnty afcertained, the  praaitioner
fhould always, in fuch  doubtful cafes, proceed upon the
fuppofition of  its  being aneurifmatic.
  It is only in the trunk of the body,  in the neck,  axilla,
upper part of the thigh, or groin, that fo much caution is
neceffary;  for when tumors of  this nature  are feated on
the lower part of the extremities, or on the head, we may
with fafety open  them; becaufe if they fhould chance to
be aneurifms,  there will  be no danger in removing them
in the mode hereafter recommended.
  In  forming  a  prognofis in aneurifms, we muft chiefly
attend i. To the manner in which  the difeafe appears to
have  been  produced.   2. The part of the body  in which
it is fituated;  and, 3. The age, and habit of body of the
patient.
   1.  If an aneurifm  has  come on  in  a gradual  manner,
without any apparent injury  having  been  done to the
part,  and  without any violent  bodily exertion having im-
mediately preceded it, there will be great reafon to fup-
pofe that the difeafe depends upon fome paralytic or other
general affeaion,  either of the  trunk of the veffel  in which
it occurs, or perhaps of the whole arterial fyftem; fo that
no great fuccefs is to be expeaed from any means attempt-
ed for the  patient's relief: whereas, there  will  be  room
to fuppofe, if the tumor  has evidently fucceeded to a
bruife or other external accident,  that the operation will
be attended with complete fuccefs,  provided the ligature
                                                    to 
                      C  108   ]
to be made, does not entirely deftroy the circulation in the
part.
   In  the varicofe  aneurifm, we may generally venture to
make a more favourable prognofis than in any other fpe-
cies of the  difeafe: for it has  been found in different in-
ftanees, that this does not make fo rapid a progrefs as the
others; that after  acquiring a certain fize, it does not af-
terwards grow much larger ;  and that any  inconvenience
produced  by it, may be fuftained with tolerable  eafe for
many years.  Drs. Hunter, Cleghorn,  Pott, and  others,
relate  inftanees  that  confirm  thefe circumftances, and
prove that the operation can very feldom be neceffary to
remove this  variety of the difeafe.
   2. When an aneurifmal fwelling is fo fituated,  that no
ligature or compreffion  can be  applied  for putting  a flop
to the circulation in the  part,  if the artery is large, there
would be the utmoft hazard  in  opening it; as the patient
would probably lofe more blood than  his ftrength could
bear,  before the artery could be fecured.  Hence  in aneu-
rifms fituated on the trunk, neck, axilla or groin,  we can
never make a favourable prognofis;  for the tumor will
certainly at  laft burft,  and  the moft  fatal  confequences
will probably enfue.   And in the humeral or femoral ar-
teries  before their divifion,  the fuccefs  of  the operation
will always  be doubtful;  although there are well attefted
inftanees of the limbs  preferving nearly all their  powers
after the deftruaion of the  principal  trunk.   In thofe
cafes, the circulation  muft be  carried  on by the fmaller
branches,  from their anaftomofing with each other.
   In  aneurifms  of the  extremities, as the fuccefs  of the
operations depend, in  a great  meafure, on  the probable
chance there is  for the circulation going on in the under
part of the  limb,  our prognofis fhould,  all other circum-
ftances being  alike, be more or lefs favourable according
to the lower or higher fituation of the  difeafe—But when
                                                  they 
                      L   109  ]
they arife from an external caufe,  other circumftances be-
ing favourable, it may be eftablifhed as a general rule, that
they fhould be always  removed when the life of the pa-
tient might be endangered by the burfting of the tumor.
   3. The  age and habit of body of the  patient, in every
inftance, fhould have confiderable influence in determining
the opinion of praaitioners as to the effeas to be expeaed
from the  operation : for in no inftance does health and
youth give'greater advantages,  than in the operation for
the removal of aneurifms.—In  the earlier periods  of life,
the veffels can eafily accommodate themfelves to the  chan-
 ges thereby produced ; but, in old age, we may readily fup-
 pofe the fmaller arteries to be altogether incapable of that
 degree of diftention which  is neceffary  for fupplying the
 v/ant of the principal artery of a part.
   A difference  in thefe circumftances  may account for the
 various fuccefs that  has attended the operation in  many
 inftanees where  the caufes  and appearances  were  nearly
 alike; and more particularly for  the bad  fuccefs  that has
 followed the  removal of aneurifms  in  the  popliteal ar-
 tery.

                     SECT.   II.

              Of the Treatment of Aneurifms.

    The  ufe of preffure has been indifcriminately  recom-
  mended  in every fpecies of aneurifm, and in all their ftages;
  but it fhould never be employed in any period of the dif-
  fufed aneurifm.  In  the early ftages of the encyfled, in-
  deed, while the blood can be preffed entirely out of  the
  fac into the artery,  it  often happens, by the ufe of a ban-
  dage of foft and fomewhat elaftic  materials,  properly fit-
  ted to the part, that  much may be done in preventing the
  fwelling from increafing; and on  fome occafions, by the
                                                continued 
                         [   "o   3
  continued fupport thus given to the weakened veffel, com-
  plete cures have been  obtained.   In the varicofe  aneurifm
  more particularly, preffure is very ufeful*.
    It  is to be obferved that the preffure fhould  never  be
  greater than to afford an eafy fupport to the parts  affeaed ;
  for if it is, by the  reaaion  which  will  be excited,  it will
  do more harm than good.   During the ufe of compreffion,
  the patient fhould  be kept  on a low diet; when neceffary,
  blood fhould be drawn ; the  bowels fhould be kept lax ;
  and all  violent exercife,  particularly of the part  affeaed,
"fhould be  carefully avoided.   When there is  much pain,
 opiates  fhould be freely exhibited.
    This  treatment will apply to  every aneurifm not intended
 to be  operated upon ; but is  particularly  proper  in  all
 fweUings of this kind,  fituated  on parts where the opera-
 tion is inadmiffible.
    When the operation for the aneurifm is judged neceffary,
 the firft ftep to be taken in   ir,  is to apply a tourniquet to
 the fuperior part  of the member  difeafed.  The patient
 fhould be  fixed on a table  of fuch  a height as will allow
 the furgeon to be feated.  The  limb  being properly fecu-
 red by an affiftant, the operator  is now with a fcalpel to
 make an incifion  through the teguments,  beginning about
 half an inch above  or below the fwelling, and carrying  it
                                                     along

  * Aneurifms of the leg  may fometimes be cured by comprefiion—two
 inftanees have occurred, where the pofterior tibial artery was opened, and
 a large aneurifmal fac formed in the ufual way—the operator having fully
 dilated the. fac, and cleared it of coagulated blood, applied a fmall bit of
 fpongc fixed to the extremity of a ligature, to the orifice in the artery;
 then filling the wound completely  with dry lint, continued a compreffion
 with the hand during twenty-four hours, after which, compreffion by a
pretty clofe bandage, prevented any further hemorrhagy, and the eighth
day the lint was removed : the fponge adhering two or three days longer,
and coming away with fome difficulty,  induced the operator, in a fecond
inftance, to make ufe of lint alone. The wound was filled  up in thre«
weeks, and the man preferved the  perfeft ufe of his limb. 
                        [   in   3
 along the whole courfe of it, and about a half an inch be-
 yond it.   The blood fhould then be wiped away, and the
 foftefl  part of  the  tumor  being difcovered, an  opening
 ought to  be made into it with a  lancet large enough  for
 admitting the operator's finger ;  which being introduced
 into the orifice, the whole tumor is to be  laid open  by
 running a blunt-pointed biftouri  along the finger,  firft
 from below upwards, and then from above downwards.
    All  the coagulated blood  and tough membranous  fila-
 ments that are commonly found here,  being now removed
 by the fingers of the operator, the cavity is to be well dri-
 ed ;  the tourniquet  muft then be entirely loofened, in or-
 der to  difeover the orifice from which the blood has flow-
 ed.  This being done, we  muft next prevent  any farther
 effufion.   Various means  have been propofed  to  accom-
 plifh this.  In order more effeaually to preferve a free cir-
 culation of blood in  the inferior part  of the member, it has
 been recommended,  i. To apply a piece of agaric,  vitriol,
 alum, or other aftringent, to the orifice, in order if poffible
 to produce a re-union of  its fides ;  and 2.  To  make ufe
 of the  twifted future,  with  the fame  intention*.
   To the firft of thefe  methods  it may be  objeaed,  that
 no aftringent  with which  we are acquainted, is poffeffed
                                                       of

  * Mr. Ic Comte,  in wounds of the arteries, inftead of the ufual modes,
 from experiments on fheep and dogs, recommends the introduction of
 a quill fplit and covered with ribband, in fuch a manner as to include the
 whole artery ; and to fecure it by tying the ends of the ribband.—Mr.
 Vicq d'Azyr made fome  experiments in  prefence of  his pupils on the
 crural arteries of dogs,  to afcertain the effects  of this treatment.   A good
 deal of inflammation and difcharge was produced—the apparatus was
 removed with fome difficulty in about three days; and the wounds healed
 in about fifteen—In three inftanees the cavity  of the artery was entirely
 obliterated, yet the animals  did very well. In fome others, the circula-
 tion was well carried on afterwards through the arteries.
  In every cafe,  the  hemorrhagy was entirely reftrained,  immediately
on tying the ribbands.  Hift. de la Soc. Roy. de Med. torn. I- page 302. 
                      [  "2  3
of fuch powers  as to deferve much confidence; for al-
though they have often put  a  temporary flop to fuch he-
morrhagies, yet  there are  very  few well  authenticated
inftanees  of their having  produced any permanent advan-
tage ; and  when trufted  to, they have generally given a
great deal of diftrefs to the patient and trouble to the fur-
geon.
  With refpea to Mr. Lambert's ingenious propofal of
ftitching  the orifice in the artery, it  would probably  fuc-
ceed in reftraining  the bleeding ; but it  is evident that it
could not be employed when  the artery lies at  the back
part of the tumor, which is the cafe almoft in every in-
ftance.   And by the diminution of the cavity of the artery
which it muft neceffarily produce, there is every  reafon to
fear that it muft tend very  much to  the produaion  of a
dilatation immediately above the ftriaure.
   This mode has yet been employed but in one cafe, that I
know of:  the above objeaions arife merely from reafon-
ingon the fubjea ; its utility muft therefore be decided by
future obfervation.
   Neither  of the abovementioned   methods being found
eligible,  we now proceed to defcribe the ordinary manner
of fecuring the orifice in  the artery by means of ligatures.
   A fmall probe  being  introduced at the opening in the
veffel, and the artery thus raifed from the adjacent parts in
order to avoid the nerves*,  a firm, broad, waxed  ligature  ?
muft then  be paffed  round, about the  eighth of an inch
above the orifice,  and another  at the fame  diftance be- '
low it by  means of a blunt curved needle, plate viii. and
tied in the mode formerly direaed in chapter V.
   We direa the ligatures to be made as near as poffible to
 the orifice, for fear of lofing the benefit of anaftomofing
 branches.   And we advife a blunt needle,  becaufe  when
                                                     the
   * It will facilitate this part of the operation, when the difeafe is on a
 joint, to bend the limb.   B.
 t 
                      C  "3   3
the fharp-pointed needle is ufed, there is a rifle of injuring
parts  unneceflarily, and the operation  is performed with
more  difficulty.
  After the upper  ligature is made, the tourniquet fhould
be loofened, in order to fee whether any blood will be dif-
charged by the wound in the artery.   If it  flows  in any
confiderable quantity,  it affords a proof that the circula-
tion will be tolerably well carried on, by the fmaller bran-
ches,  in the inferior part of the limb.   But we  are not to
defpair of fuccefs if this fhould not be the cafe.
  The ligatures  fhould be left long enough to hang out at
the edges of  the  wound, that they may be eafily with-
drawn when neceffary.
  It has been advifed  to infert two other ligatures very
near to thofe firft made, and leave them untied, in order to
guard more effeaually  againft hemorrhagy; but the tour-
niquet is  a  fufficient and  better fecurity,  and  fhould
always  be left on the member for feveral  days  after the
operation.
  When the ligatures  are formed, the tourniquet fhould
be loofened  entirely;  and if no blood is  then difcharged
at the orifice in  the artery, we  may be fatisfied that they
have  been properly made.   The wound is to be now co-
vered with foft lint, with a pledgit of fome emollient over
it;  and  a comprefs being  applied,  the  whole  is  to  be
fupported by a bandage, juft'tight enough to keep  on the
other applications.
  The  patient is  then to be put to bed, and the member
laid in a relaxed pofture upon a pillow;  and as the ope-
ration is always tedious and painful, a full dofe of lauda-
num fhould be given, and repeated occafionally according
to the degrees of pain and reftleffnefs.
  In  fome cafes, the pulfe in the inferior part of the mem-
ber has been  perceptible immediately after  the operation:
This, however, is a rare occurrence;  for as the difeafe is
feldom met with but in the joint of the elbow, as a confe-
                        . p                     quence 
                      C   "4  3
 quence of bleeding, and as the  brachial artery before its
 bifurcation, is moft commonly the fubjea of the operation,
 it can but rarely happen.
  Immediately after the  operation,  the  patient complains
 of want of feeling in the whole member;  and as it is gene-
 rally cold for a few hours afterwards, it  will be proper to
 keep it covered with  flannel,  and  have  it  gently  rubbed
 now and then.   In the fpace of ten or  twelve hours,  al-
 though the numbnefs  flill continues, the  heat of the parts
 generally begins  to return ;  and  it  often  happens  that in
 the courfe of a few hours more, all the inferior part of the
 limb becomes preternaturally warm.
  In the mean time, the patient being properly attended to
 as to regimen, by giving him cordials and nourifhing diet
 when low, and confining him to a low diet,  if his conftitu-
 tion is  plethoric, the  limb being kept in an eafy  pofture,
 towards the end of the fourth or fifth day, and fometimes
 fooner, a very feeble pulfe  is difcovered in  the lower part
 of the  member; which  becoming gradually ftronger,  the
 patient in the fame proportion recovers the feeling and ufe
 of the  parts.
  As foon as matter forms freely about the fore, which is
 generally about the fifth or fixth day, an emollient poul«
 tice fhould be applied over it for  a few hours, to foften
 the dreffings, which may then be removed.   The ligatures
fhould  net be taken away before  the fecond  or third dreff-
ing.    The dreffings  being  renewed every  fecond  or
 third day, according to  the quantity of the difcharge,  the
 fore commonly heals  eafily;  and although the limb may
remain fome time numb  and weak,  yet it generally at laft
 recovers its powers.
  We  have hitherto defcribed the  moft favourable termi-
nation  of  the operation—In fome inftanees,  inftead of a
return  of  circulation,  and  of  the feeling and ufe of  the
 parts,  they continue  cold  and  infenfible.    From mere
                                                 want 
[  "5   3
want of blood,  therefore, a mortification commences, and
proceeds to its laft ftages, notwithftanding every thing that
can be  done to prevent it.   If the patient furvives the ef-
feas of the gangrene until a feparation  occurs  between
the difeafed and healthy parts, amputation of the member
will then be the only refource.
C   H   A   P.     VIII.

       Of  Hernise.
                    SECT.   I.

                 Of Hernia  in general.

      THE term  Hernia,  in  its general  acceptation, im-
      plies a tumor produced by the  protrufion of fome
part or parts from the cavity of the  abdomen.
  The fituations in which thefe fweUings ufually appear, are
the groin, fcrotum,  labia pudendi,  the  upper and fore-
part of the thigh, the umbilicus,  and the different points
between the interftices of the abdominal mufcles.
  Part of the inteftinal canal or omentum,  are the moft
common  contents of herniae; but there  are  inftanees  of
ruptures  of  the  ftomach,   uterus,  liver,   fpleen,  and
bladder.
  From thefe circumftances of fituation, and contents,  all
the different appellations  are derived by which herniae are
diftinguilhed.   Thus they are termed inguinal,  ferotal,
                                              femoral, 
                      [  IKS   3
femoral,  umbilical,  or ventral,  from the part in which
they make their appearance.  When the tumor is confin-
ed to the groin,  the hernia is faid to be incomplete, and is
termed bubonocele;  but when  it reaches to  the bottom
of the fcrotum,  it is  faid to be complete, and  receives the
name of  ofcheocele.    When a  portion of inteftine  alone
forms the tumor, it is called  an enterocele or inteftinal her-
nia; when a  piece of omentum only  is protruded, it is
termed epiplocele, or omental hernia ; and if both inteftine
and omentum are down, it is called an entero-epiplocele, or
compound rupture.
   The term  rupture arofe from a fuppofition  that in mofl
cafes of hernia there was a laceration  of the  peritonaeum,
or membrane furrounding the abdominal vifcera ;  and this
feemed to be confirmed by thefe vifcera being, in fome cafes
of fcrotal hernia, found in contaa with the tefticle;  but it
is now well afcertained, that in hernia the peritonaeum is
never  ruptured except from external  violence;  and that
in common cafes it is merely carried before  the protruded
part, and only fuffers from dilatation.   When  the part
difplaced is found in contaa with the  teftis, it always paf-
fes down along with the teftis, or before the opening by
 which that defcends is at all or  firmly clofed.  This fpecies
 is ufually termed the hernia congenita,  and hardly ever is
 produced except in the early months of infancy.
   The produaion of hernia in the ufual form, is to be
 explained  from 'one  or  more  of the following circum<
 fiances:
    i. Whatever tends to produce a diminution of capacity
 in the cavity cf the abdomen, muft occafion a proportional
 rifk of fome of :he contained parts being pufhed  from their
 natural f tu-irions.   Violent coughing, crying, laughing, or
 great bodily exertion, frequently operate in this  manner in
 producing herniae.
    2.  Falls,  in  confequence of the violent  derangement
                                                    they 
                      [  "7   3
they produce in the abdominal  vifcera,  are  often the im-
mediate caufes of ruptures.
  3. Perfons  of a preternatural laxity of frame,  are very
liable to hernia, on the application of the abovementioned
caufes ; from the  containing parts not  being fufficiently
firm to refill the weight of the different vifcera.
  4. Sprains induce a laxity of the part  injured,  and ope-
rate  in the manner of  general weaknefs in occafioning
hernia;.
  5.  It has been  obferved,  that the inhabitants  of thofe
countries in which oil is  much  ufed as  an article of diet,
are particularly liable to herniae.
  Thefe various caufes,  it  is evident,  muft  moft readily
operate in inducing hernise,v in thofe parts of the parietes
of the abdomen that are weakeft.  Hence we find them to
occur moft commonly at  the openings of the external  ob-
lique mufcles, under the arch formed  by Poupart's liga-
ment, and at the  umbilicus.  They happen  alfo  in the in-
terftices of the mufcles, but not frequently.
  Whenever an  hernia  is  formed, except in the cafe of
the hernia congenita,  a portion of the peritonaeum muft
go  along with the protruded vifcus, and forms  what  has
been  termed the hernial fac.
  On the firft  appearance  of the  difeafe,  the fac is com-
monly fmall,  as fuch fweUings feldom acquire any great
bulk at once;  but by repeated  defcents of the bowels, it
often  becomes very large;  and  then  frequently gets a
very confiderable degree  of firmnefs and thicknefs.
  Hernial fweUings frequently arife and  continue a length
of  time, without occafioning any bad fymptoms; but as
troublefome  confequences often fucceed to  them, when
their reduaion  can be  accomplifhed with  propriety, it
fhould always be effeaed as quickly as poffible.
   All the bad fymptoms  occurring in hernias, proceed ei-
ther from obftruaion to the paffage of the  fseces, when
                                                    the 
                       [   »8  3
 the inteftinal canal  forms  the tumor, or from a ftoppage
 of circulation, by ftriaure on the  prolapfed parts •  hence
 they will always be more  or  lefs hazardous according to
 the nature of  the  parts  protruded.   Thus  an  omental
 hernia is not fo dangerous  as  a rupture  of an inteftine, or
 other part more eflential to life; but even this may occa-
 fion the moft fatal effeas.
   The  following are generally the fymptoms of a ftric-
 ture on the protruded vifcera fufficient  to produce either
 a ftoppage of the circulation, or of the  fecal contents of
 the alimentary canal, when this is affeaed.
   An elaftic colourlefs fwelling is obferved on the part af-
 feaed ; a flight pain is  felt not only in  the fwelling itfelf,
 but if part of the inteftines is down, an uneafinefs is  felt
 over the whole abdomen ; and this  is always increaled by
 coughing, fneezing, or  any other violent exertion.   The
 patient  complains of  naufea; frequent  retching;  can get
 no difcharge by  flool; becomes hot and reftlefs; and his
 pulfe is  commonly quick and hard.
   If the fwelling is  entirely formed by  inteftine, and no
 feces are contained in it, it has a fmooth equal furface, is
 eafily compreffible, and immediately returns to its former
 fize on  the preffure being  removed ; but when feces are
 colleaed  in the gut,  as  they are apt  to be when the
 difeafe is of long ftanding,  it has confiderable  inequalities.
When  the  tumor is  compofed both of omentum  and
 gut, its appearance is always unequal, and it feels foft and
 fomewhat like dough, and of  courfe not  fo elaftic as when
 inteftine alcne  is down.  If omentum  alone forms  the
 fwelling, no obftruaion to the difcharge of  feces  ever
 occurs,  and of courfe the fymptoms are never fo alarming
 as when  the  inteftine  is  concerned, and the tumor is
 weighty in proportion to its fize.
   But although in fimple  hernke the  contents may be in
general diftinguifhed ;  yet, when they are complicated, it
can never be done with any certainty.
                                              Should 
   Should not the fymptoms  we  have defcribed be now
 removed,  the  naufea and  retching terminate in  frequent
 vomitings,  firft of a bilious, and afterwards of a more
 foetid matter; the belly becomes tenfe;  the pain grows
 more violent;  a diftreffing convulfive hiccup comes on;
 the  fever, which before was trifling, now becomes con-
 fiderable ; and a total want  of  reft,  and great anxiety
 continue through the whole complaint.  Thefe fymptoms,
 after fome  duration,  are fucceeded by a  hidden  ceffation
 of pain:  languid and interrupted pulfe ; cold fweats ; lan-
 guor of the eyes; and fubfidence of the tenfion  of the
 belly.  The fwelling of the affeaed parts difappears; the
 teguments covering them change  from a reddifh  inflamed
 caft to a livid hue; and a crepitous  windy feel is diftin-
 guifhable all over the fwelling.
   If the  protruded parts have not of themfelves  entirely
 gone up,  their return is now generally with eafe produced
 by flight  preffure, and  the patient then difcharges freely
 by ftool;  but  the cold  fweats increafing,  the hiccup be-
 comes more violent, and death is at laft ufhered  in by its
 ufual forerunners, fubfultus tendinum,  and other convul-
 five  affeaions.
   As the ftriaure which prevents the return of the pro-
 truded parts is the caufe of all the morbid fymptoms, the
 indication of  cure  is to effea  its removal.   This  is  to
 be accomplished  either  by  a  reduction of the  difplaced
 parts without  a divifion of the  ftrangulating part, or by
 an incifion into or through  the  part  producing  the ftric-
 ture,  fo as  to  admit  of a replacement  of the fubftances
 deranged.
  In  the treatment of hernia, the firft circumftance to be
 attended to, is  the  placing the  patient  in fuch a pofture as
 will  probably  favour  the return  of the protruded parts.
Thus when the fwelling is in the groin or  forepart of the
thigh, the  thighs  and legs  fhould be raifed  confiderably
                                                higher 
                       C  120  3
 higher than the head and  trunk;  and, in fome inftanees,
 it has been found  neceffary to have the patient placed per-
 pendicularly upon his head, and there well fhook about.
 In exomphalos, or umbilical rupture, the body fhould be
 erea ;  and in cafes of ventral hernia, a horizontal pofture
 is to be chofen.
   While the patient is thus  fixed,  the furgeon fhould
 endeavour to produce a return of the  parts,  by  gentle
 preffure with the fingers.   In the inguinal  and fcrotal
 hernia?,  this fhould  be made  obliquely upwards  towards
 the os ileum ; in the femoral,  it fhould  be made direaiy
 backwards ;  in the umbilical, downwards and backwards ;
 and in the ventral hernia, direaiy backwards.
   When the hernia is of confiderable fize, the preffure is
 moft conveniently  and effeaually  made,  by grafping the
 fwelling with one hand from the bottom upwards, while
 with the fore and middle fingers  of the other  hand, we
 endeavour to pufli up the contents of the tumor.   This
 operation has been termed taxis.
   If a  very moderate degree of preffure, for none other
 ftiould ever be applied, does not reduce the fwelling, other
 means  fhould immediately be employed.   Blood-letting ac-
 cording to the ftrength of the patient, is  here particularly
 ferviceable, and may fafely be carried to very great extent;
 and it has fometimes been found ufeful to manage it fo as
 to induce fainting.
  To remove the obftinate coftivenefs  that fo commonly
 attends,  it has been a general praaice to order ftimulating
 purgatives; but thefe, in almoft every cafe, do much inju-
 ry by increafing the naufea, and by adding to the tenfion
 and pain of the fwelling.  The  beft mode of opening the
body, is by iiijeaing clyfters of tobacco fmoke, by means of
the machine,  plate v. fig. 8. until it has the defired effea,
or until  much  naufea  is produced, or fome  fwelling of
the abdomen.
                                             Although 
                      [   121   3
  Although this remedy  frequently fails, yet it is much
preferable to purgatives given  by the mouth; and if it
fhould not be laxative, it may always be ferviceable by the
anodyne  quality which it  poffeffes.   Acrid fuppofitories
have  been ufed at the fame time with purgatives,  but no
great  dependance fhould be placed on them.
  Opiates are often of great ufe, not only by eafing pain,
but by tending to relax the  ftriaure*.  As their  exhibi-
tion by the mouth is commonly prevented by the  naufea,
they may be given clyflerwife,  alternately with the tobac-
co  fmoke.    General warm  bathing is a very  ferviceable
remedy; but warm applications to the fwelling do injury
by  rarefying the contents of the hernia, and thus increaf-
ing its fize.
  The applications on which  I  place moft  dependance
are the cold faturnine folutions, and  vinegar  and water;
with  thefe  cloths  are  wet,  and  kept conftantly  on  the
fwelling.  In feveral inftanees  I have ufed  ice and fnow
with  evident advantage.
   By thefe  feveral means hernia, are often entirely remov-
ed ; but it  alfo frequently happens that they  produce no
relief; and the  fymptoms  inftead of leffening  become
more  violent.   In this fituation, the  divifion of the parts
producing the ftriaure is our only refource.
   It is one  of  the moft difficult points in furgery to afcer-
tain when this operation  fhould be put in practice.   If it
fhould be too long delayed,  the patient will infallibly die -7
and  if performed too early,  we  may  be  fobjected  to
blame.  There are  many inftanees of  ftrangulated hernias
continuing for eight or ten days,  and  being then replaced,
the patient  has done very well: whilft, on the other hand,
                          Q_                       they

  * Several cafes of ftrangulated hernia, attended with  great pain and
tenfion, have  been happily reduced by a ftrong opiate, without any ma-
nual afliftance, the protruded parts retiring themfelves as foon  as the.
 opiate had produced fleep. 
                      C  122   3
they have proved fatal,  and when apparently in the fame
•degree, within forty-eight hours.
   From  hencey although  the  operation  is attended with
fome rifk, it may with propriety  be eftablifhed as a general
rule always to proceed to it, if a ftrangulated hernia is not
otherwife relieved in two or three hours at fartheft.
   The French furgeons feem  to be more fuccefsful than
the German  or  Britifli, entirely from the circumftance of
their having more early recourfe to the operation.
   Although  in  general  it is proper to reduce herniae as
foon as poffible; yet there are fome inftanees in which it
would be improper  toe attempt it.   Thus, hernia, fome-
times continue a long time without  producing any bad
fymptoms whatever,  and  contraa adhefions  to the fur-
rounding parts,  which can only be removed by the opera-
tion.   In fuch  cafes, unlefs fymptoms  of ftrangulation
come on, nothing more fhould be done than to keep the
bowels lax,  and apply a fufpenfory bandage to the fwel-
ling.
   Where a  hernia has been reduced  either by taxis  or
divifion,  its  return can  only be effeaually prevented  by
the proper application of a  fleel trufs, (plate vi. fig.  i.) and
by avoiding violent  exercife, and particularly fudden ex-
ertions.
   Many  years fince,  there were a variety of methods ufed
to cure herniae radically,  fuch  as ligatures applied fo as to
clofe the  fac,  and cauftics  to deftroy it;  but all of  thefe
have been found ineffeaual to  accomplifh the end pro-
pofed,  and many of  them have been fatal to the unhappy
patients.
SECT. 
C  123   3
                  SECT.   II.

                   Of the Bubonocele.

  Ik the bubonocele the fwelling begins in the groin, and
gradually defcends into the fcrotum in men,  and into the
labia pudendi in women.
  The  difeafes with which  inguinal and fcrotal hernise
are moft likely to be confounded, are  glandular fweUings
in the  groin, hernia  humoralis or inflamed tefticle, and
the different kinds of hydrocele.
  Buboes are readily diftitiguifhed from hernise by their
hardnefs in the firft ftage, and the fluauation of fluid  in
their fuppurated ftate, and by the abfence of the  general
fymptoms of hernise.
  In hernia humoralis the hardened ftate of the tefticle
and epidydimis ; their exquifite painfulnefs to the touch ;
the want of fwelling in the fpermatic  procefs and of the
general fymptoms of hernia, afford fufficient  means of dif-
crimination.
  In hydrocele the  fwelling is more equal than  in hernia,
and ufually begins below ;  but in hydrocele of the fper-
matic procefs,  it fometimes  happens that the tumor com-
mences  even  within  the  opening of the abdominal muf-
cle, and by degrees falls downwards : in this cafe, the
abfence of the  general  fymptoms  of hernia will generally
eftablifh the nature of the cafe.  But in fome inftanees, it
feems impoffible to afcertain with certainty the real ftate  of
the difeafe.  In thefe circumftances we  can only proceed
with fafety upon the fuppofition of its being hernial.
  When every other  means  recommended for  the  re-
moval  of hernia in general has failed in bubonocele,  we
muft then have recourfe to  the operation ; which is  thus
to be performed :
                                                    A 
                       [   124  3
   A table of convenient  height being  placed  in a  good
 light, the patient  muft be laid upon it, having the head
 and body almoft horizontal, and the buttocks fomewhat
 raifed by pillows.  The  legs  hanging over the edge of
 the  table, ought to be fo far feparated as to admit the ope-
 rator between them;  and  ftiould be fecured by an affiftant
 on each fide, who fhould keep the thighs  fo  much raifed
 as to relax all the abdominal mufcles-
   The patient fhould empty the bladder; and the parts hav-
 ing  previoufly been fhaved, an incifion fhould now be made
 with a  fcalpel  through the fkin,  beginning  at  leaft  an
 inch above the fuperior end  of the tumor, and continuing it  ^
 down to the bottom of the fcrotum.   This fhould always
 be done: it enables us to  finifh the operation more  conve-  1
 niently, and. prevents a  lodgement of the matter  after-
 wards formed.                                           i
   The operator  then goes on to divide ilowly  the  cellu-,  i
 Jar fubftance  and the tendinous-like  bands, which,  Unlefs  ,
 the  difeafe is very recent,  are univerfally met  with, either
" loofe upon the furface of  the hernial fac, or on fome occa-
 fions, palling as it were  into its fubftance.  Even this in-
 cifion  fhould be  made very cautioufly, becaufe there are  \
 fome inftanees upon record, in which the fpermatic veffels
 have been found on the anterior part of the fwelling, al-  '
 though they are almoft always behind  it;  and we  would
 run a rifk of wounding them, fhould this be the cafe, by a
 hafty incifion.
   Before making the divifion of the fkin and  cellular fub-
 ftance, the tumor fhould  be grafped with the  left hand, fo
 as to render  it fomewhat tenfe on  the anterior part,  and
 kept fo while the incifion is made with the right hand.
    The hernial  fac fhould now be very cautioufly diffeaed
 through, as near the lower part as poffible, becaufe that is
 generally filled with bloody  ferum, and we  confequently
  there  have the leaft chance  of  wounding the inteftine.
                                                    Ws 
                      [  '2S   3
We may tell when the fac is cut through by a blunt probe
paffing eafily in.  The fac in recent cafes,  and particular-
ly of bubonocele,  is  thin, but  in long  continued herniae,
it often  acquires an aftonifhing thicknefs.
   The  opening firft made being  enlarged  fo as to admit
the fore-finger, a narrow blunt-pointed biftoury,  (plate
vii. fig.  9.} flipuld be  introduced,  to which  the finger ferv-
ing as a dire&or, the hernial fac is to be divided its  whole
length,  from below quite up to the opening in the mufcle.
   The  protruded  pa:ts*  now come fully into  view;  and
fhould  be very carefully  examined; if  they are not gan-
grened, even although  they fhould feem confiderably in-
flamed, they fhould, if  poffible, be immediately returned
into the abdomen.
   In making the  reduaion, whether inteftine, omentum,
or both have  been  found, thofe parts which appear  to
have come out laft fhould be firft  pufhed back; and the
finger  fhould  be  applied to that  part  of the gut with
which  the mefentery  is conneaed;  as by thefe  precautions
we are  lefs liable to do mifchief, and accomplifh. the reducr
tion with more facility.   During the reduaion, the thighs
fhould  be fomewhat more elevated than during the pre-
vious part of  the operation.   When the difeafe is  recent,
and has not often occurred, it  fometimes happens that by
pulling out a  little  more of the gut than was before in
the fac, the obftruaion to its  replacement will be  remov-
ed ; however, when we cannot do this  with great  eafe, it
fnould  not be attempted.
   If our attempts for reduaion of the  part fail, we muft
 proceed then  to  the enlargement  of the opening in  the
 tendon.   This is to be performed by entering the finger
 at the opening  above  the protruded  parts,  introducing
                                                     the

   * In enterocele, late obfervations have taught  us, that the coecum, ap-
 pendix vermiformis, and  part of the colon, have as frequently  been con-
 tained in herniary facs as the ileum or any other  part of the tube. 
                      C   126  3
the blunt biftouri, and the finger ferving as a direaor, and
being kept a little beyond the point of the inftrument, a
free  incifion fhould be made obliquely upwards,  fo as
merely to continue the feparation in the fibres of the ten-
don, without dividing them.
  It  often happens in long continued cafes, that adhefi-
ons not only of the protruded  parts to thofe adjacent to
them take place, and to  each other, but alfo  that they
are difcovered by the introduaion  of  the  finger,  internal-
ly.   The  opening fliould  therefore  be  large enough, to
admit a feparation of the latter.   When adhefions of  the
parts deplaced to each other occur, if flight, they fhould
be feparated by the fingers or the fcalpel; but if confider-
able, the parts fhould be returned as they are.  When ad-
hefions of the inteftines to the fac or omentum are found,
and  are very firm, parts of the latter two  may be with
fafety  diffeaed off;  or when there  is a firm conneaion
between the gut and fac, or omentum and fac, part of the
fac may be  fafcly ddfeaed off,  and returned into the ab-
domen.
   When  the  omentum protruded  is  gangrened,  or by
the  preffure it has fuftained  in the  fac  any confiderable
portion of it  becomes much hardened,  fuch part fhould
be expanded on the hand, and cut off with  a pair of  fcif-
fars  ;  and if any confiderable veffel  is divided,  it fhould
be tied.   It has been obferved that ligatures on the  omen-
tum, as  formerly recommended, have been  produaive of
bad confequences;—none fuch have fucceeded the  return
of it without them.
   When  a  part of  the inteftine is difcovered to be  morti-
fied, it fliould be cut out;  and if this does not extend the
 whole circumference of the  gut, the part above it  fhould
immediately be conneaed by ligature to  the wound in the
 abdomen.  By this means,  the feces will  be difcharged
 externally,  and in fome inftanees the wound in tile intef-
                                                   tine 
                       [   i27   3
 tine has gradually healed.  Where the mortified part is
 confiderable, the found ends of the gut fhould if poffible
 be brought into contaa, united as direaed in  the chapter
 on gaftroraphy, and  both conneaed to the wound.  In
 fome inftanees where a very  confiderable portion, a foot
 e. g. has been gangrened, by this mode the ends of the in-
 teftine have coalefced, and the patient has done very well.
 But fhould not  this  fortunately happen, a  paffage is fe-
 cured to the feces by the groin : the confequence of their
 being voided internally would inevitably be death.
   When the found inteftine is conneaed to the wound, and
 not till then, the opening iu the tendon fhould  be  enlaro-ed
 as much as is neceffary ; if it is done before, the mortified
 portion may flip up together  with the found part.  When
 the fac is found to be thick, hard, and much enlarged, as
 its prefervation can anfwer no good purpofe,  all the late-
 ral and fore parts of it may be cut off with fafety; but the
 pofterior part fhould  be fuffered to remain, becaufe it is
 commonly  conneaed to the fpermatic veffels.
   The operation being now  finifhed, the wound is  to be
 dreffed  with foft lint,  retained by a fufpenfory bag fluffed
 with lint, and the patient  put to bed ; taking care that his
 loins be fomewhat higher  than the reft of the body.   An
 opiate fhould then be given ; he fhould be kept cool; if ple-
 thoric, in order to remove the fever which fucceeds, he
 fhould be bled ;  a low diet fhould be direaed ; and a fre-
 quent ufe of laxatives. When,  however,  the body has been
 previoufly much debilitated, a nourifliing diet fhould be
 advifed.
   The fore having eafy  dreffings applied to it as often as
 feems neceffary, and the proper diet, &c.  being  attended
 to, if the patient furvives the firft three or four days, he
 will in general recover.   And as foon  as the wound is
 well cicatrized, a trufs ought  to be properly fitted to the
parts, and worn conftantly afterwards.
                                                    It 
                      C   128  3
   It has been recommended to flitch the external wound ;
but as this may prevent the difcovery of protrufions of the
inteftine, which are apt to occur during the cure, it ought
never to be done.
   It has been advifed by many  French furgeons to endea-
vour to reduce the inteftine, &c. without dividing the fac;
but although,  if this is praaicable, we might in fome in-
ftanees  do right,  in  many others  we fhould probably
return mortified parts,  which would certainly be  follow-
ed by death.   And befides, there are fome cafes in which
the ftrangulation has been produced by one part of the in-
teftine being wound  around another, as the appendicula
vermiformis  around the  ileum ;  when  it is obvious no
good effeas could refult from the operation.
   By fome authors again, it is recommended to  reduce not
only the bowels, as juft defcribed, but even the  hernial fac
itfelf, without opening it: by  others,  among  whom  is
Mr. Pott, this is deemed  impoffible.   But I have feen a
hernia of five or fix days  duration in which it certainly oc-
curred ; the patient died, and diffeaion  put  it  beyond  a
doubt.  Mr. le Dran  relates inftanees  of the fame  kind.
The fame objeaions  occur to this praaice  that  operate
againft returning the inteftines without examination of them.
   Although bubonocele happens moft frequently in males,
yet it fometimes alfo  takes place in females ;  and  in fome
cafes, the protruded part has defcended  to the bottom al-
moft of the labia pudendi.  The general method of treat-
ment is the fame in both fexea.
   In modeft women, this difeafe fometimes occurs to confi-
derable  degree  without our being made acquainted with
it;—it fhould always be fufpeaed when the fymptoms of
colic  occur to a very alarming degree, and examination
fhould be made to afcertain it.

                                             SECT- 
C  129  3
                   SEC  T.   III.

                Of the Hernia Congenita.

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

                   SECT.   IV.

             Of the Crural or Femoral Hernia.

   The feat of this fpecies of hernia is the upper and an-
terior part of the thigh, under the firm  tendinous aponeu-
rofis of the fafcia lata; the parts being protruded through
the opening by  which* the  femoral artery and vein pafs
out.  In fome inftanees they  are found immediately over
thefe veffels ; in others on the outfide of them ; but more
frequently they lie on the infide, between them  and the
os pubis.
   The fame  general treatment that was recommended in
inguinal hernia is applicable here ;  but it muft be obferved
that the preffure in reduaion fhould be made direaiy  up-
wards,                          r,
   In performing the operation, the external incifion fhould
extend from an inch above to an inch below the tumor: and
when  all  the parts  above  the  ligament  are  divided, if
thofe  protruded  are  to be returned, their reduaion may
                         R                       here 
                     £   i3°  3
here be often accomplished without cutting the ligament,
by  placing the patient in  a favourable pofture.   This
fliould therefore be  always attempted; for it  is almoft
impoffible to make  a free divifion of the ligament in any
direaion, without wounding the fpermatic veffels and epi-
gaftric artery;  and it is by no means fo eafy a matter to
fecure the latter as has been reprefented.   On this account
an inftrument, (pi. v.  fig. 7.) has been invented for dilating
the opening;  but  this probably would feldom be of any
ufe, becaufe the ligament, it is to be fuppofed, is ftretched
nearly as much as poffible by the protruded parts.
  I have once ufed a method which anfwered very effec-
tually, and was without  the rifle of the mode commonly
advifed.  It confifted in gradually diffeaing the  ligament
until a very thin lamella only was left; which then admitted
of a fufficient diftention to fuffer the return of the deplaced
parts.  I guarded the parts below by infinuating  my  fore-
finger into the opening between the gut and ligament, and
then made my incifion, which was about an inch long.
  In this as well as every other cafe of hernia, except bu-
bonocele,  it is better to ufe an  adhefive plafter to retain
the dreffings than any bandage.
  Women ard moft fubjea to femoral rupture;—they are
relieved in the manner above direaed.


                    SECT.  V.

          Of Exomphalos, or Umbilical Rupture.

  The  parts in this  rupture pafs out at the navel; its
contents  are very various ;  moft commonly they  confift of
omentum; fometimes of inteftine;  and in fome inftanees of
part of the ftomach,  the liver, and even the fpleen.   The
fac becomes fometimes fo conneaed with thefe parts, that
                                               doubts 
                      t   131  3
 doubts have been Entertained of its exiftence; but it is al-
 ways very evident in recent cafes.  The fac  and integu-
 ments have been in fome inftanees burfted by the contents.
   Umbilical hernia occurs moft frequently in infancy, foon
 after birth ;  of adults,  the corpulent are moft liable to it,
 from the greater pervioufnefs of the umbilicus in them, pro-
 duced by the conftant diftention of the abdominal mufcles;
 and for  the  fame reafon pregnant women, in  the latter
 months,  are particularly fubjea to it.
   A proper bandage or  trufs will generally be effeaual
 in preventing returns of this hernia: and pregnant women
 fhould be particularly attentive to it on its firft appearance,
 as their  particular fituation has  a tendency  to  render it
 worfe.
   As omentum  commonly forms hernise  of this kind,
 they are  feldom produaive of dangerous fymptoms: but
 when thefe occur, and cannot be removed  without, the
 operation muft be had recourfe to as in other cafes.  The
 divifion of the part producing the ftriaure may be fafely
 made in any  direaion;  but  thofe  who  wifh  to avoid
 wounding the  umbilical ligament or former  veffels, may
 make it on the left fide,  a little upwards  and outwards.
 In other circumftances  we muft proceed as in other cafes
 of hernia.


                   SECT.  VI.

                  Of Ventral Hernia.

   In this fpecies of  hernia  the  parts are  protruded
 into the interftices of the abdominal mufcles.   It occurs
 in every  part of the abdomen, but  moft frequently near
the linea alba;  and when  the ftomach forms the fwelling
                                                    it 
                      C   '32   1
it appears juft under, or by the fide of the xiphoid carti-
lage.
  The treatment recommended  for the exomphalos is ap-
plicable to all ventral hernise.


                  SE  C T.  VII.

           Of the Hernia of the Foramen Ovale.

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


                   SECT.   VIII.

           Of the Hernia of the Urinary Bladder.

    The hernia cyftica occurs  in  the groin  or ferotum
 through the  opening in Poupart's ligament; in the fore
                                                   part 
                      C  133   3
part of the thigh, under this ligament; in the perinseum
through the mufcular  interftices; or in the vagina.   The
part of the bladder  protruded,  is never covered  by  the
peritonseum.   It fometimes is protruded by itfelf, and at
other  times is  accompanied by  inteftines  and omentum.
When complicated  with bubonocele, it is found behind
the hernial fac, and  between that and the fpermatic procefs.
   This hernia is ufually known  by  a tumor attended with
fluauation, which  fubfidcs when the patient voids  urine.
When the fwelling is fmall, water is made without preffure ;
but if large, it is neceffary not only to prefs it, but often to
lift it up.
   A fimple hernia cyftica  is commonly  produced by  a fup-
preffion of urine.   In the treatment therefore, this fliould
be guarded againfl  as much as poffible; and when  no ad-
hefions take place, and the bladder can be reduced,  a trufs
fhould then be worn for  a confiderable time.  When the
parts cannot  be returned, a fufpenfory bag is  the only
probable means of relief.  When  the bladder falls  into
the vagina, after reducing the  parts by laying the  patient
on her back with the loins elevated and preffing with the
fingers from, the vagina, future defcents may  be prevented
by the ufe  of  a proper peffary :  and the fame  means may
be ufed when the inteftine protrudes into the vagina.
   When the operation is neceffary to remove cyftic hernia?,
the diffeaion fliould be very cautious, on account of there
being no fac.
   It fometimes is  thought proper to cut into the bladder
in order  to remove  ftoncs  from the  protruded part;  in this
cafe, as well as when it is accidentally wounded in the ope-
 ration, or part of it has gangrened, it  will be advifable to
preferve its prolapfed fituation until the wound is  healed,
in order to prevent the evacuation of the  urine internally,
which would probably have bad effeas.
                                             C FI A P. 
C  134  1
CHAP.     IX.

   Of the Hydrocele.
                   SECT.   I.

              General Remarks on Hydrocele.

    THE  term Hydrocele  is applied  to watery fweUings
     fituated in the fcrotum or fpermatic cord.
  Thefe, as well as every other fpecies of tumor in the
fcrotum or groin not immediately produced by the pro-
trufion of parts from the abdomen, are by ancient writers,
termed falfe or fpurious hernise, in oppofition to thofe de-
fcribed in the laft chapter, which they diftinguifhed by the
appellation  of  true hernias.   This diftinaion is  of no kind
of ufe;  and indeed nothing written on the fubjea of her-
nise until within a ceutury  paft,  is of much ufeful applica-
tion : the difcoveries of late  anatomifts  and  furgeons have
now, however, made it intelligible and  fatisfaaory.
   All the varieties  of hydrocele may  be comprehended
under the two following fpecies, viz. the anafarcous and
the encyfled.   In the former, the water is diffufed all over
the part affeaed; and in the latter, it is confined to one
or more diftina bags,  and a fluauation of  fluid is  gene-
rally perceptible to the touch.   The  fcrotum and  its con-
tents, as well as  the fpermatic procefs, are  liable to both
fpecies of the  difeafe.
                                             SECT. 
C  '35  3
                   SECT.   II.

       Of the  Anafarcous Hydrocele of the  Scrotum.

  This difeafe is ufually fymptomatic of general dropfy;
but in fome few  inftanees, it is merely a local affeaion.
Thus it has been the confequence of  the preffure of a tu-
mor on the lymphatics of the part; of external injury;
and  of the effufion  of  urine  from  a  rupture  of  the
urethra.
  As foon as water is  colfeaed in any  confiderable quan-
tity in the fcrotum,  a foft, inelaftic,  and colourlefs tumor
is obferved over the whole of it; this gradually increafes,
and often extends up into the groin  and penis; and  dif-
tends the parts fo much as at  length,  in fome inftanees, to
burft them.  After fome  continuance the  flvin acquires a
whitifh fhining appearance; and the largenefs  of the fwel-
ling is frequently produaive of a great deal of inconveni-
ence and diftrefs.
  This difeafe is fo well charaaerifed, that there can be no
danger of confounding it with any other.   As it common-
ly depends  on  a general caufe, its radical cure muft be ac-
complifhed by  the general remedies  of dropfy; but  we
are often under the  neceffity  of affording a temporary re-
lief,  by evacuating the fluid of the particular part.   This
has been done in four different ways ; by feton, by  the
trocar, by incifions, and by punaures.   All thefe, except
the trocar,  evacuate the water very effeaually;  but punc-
tures have  the  leaft troublefome confequences, and there-
fore fhould be preferred.
  The trocar,  feton, and fcarifications, often  produce, ia
a little time after their ufe, eryfipelatous inflammation  and
confequent gangrene; and even punaures have had fuch
effea s,  but much more feldom.
                                          Scarifications 
                      [   ^6  3
   Scarifications are ufually m»de  about  an inch in length,
to the depth of the cutis vera, and about two or three in
number, with the flioulder of a  lancet.  Punaures are
made to the fame depth with the point of the lancet, and
about five or fix generally fuffice.   They may be repeated
in a few days if  the firft feem infufficient; and the parts
fhould be kept as dry as poffible after the operation.
   When inflammation fucceeds, a cold folution of faccha-
rum faturni, or aqua calcis, are the beft applications to re-
move it.  Should thefe fail, and  gangrene come on, the;
remedies for gangrene in general fliould be had recourfe to.
   Although in thefe cafes, mortification often terminates
fatally;  yet very unexpeaed cures are  fometimes obtain-'
ed.  There is an inftance  of the whole fcrotum feparating
and leaving the teftes bare; but  thefe were foon covered
by a cellular fubftance, and the patient recovered.
   When this  difeafe is induced by fweUings in  the abdo-
men or  groin, obftruaing the  return of the  lymph,  they
fhould,  if poffible, be removed ;  if this cannot be done,
punaures muft be made as palliatives.
   It fometimes happens that fuppreffion of urine, produc-
ing a burftiug  of the urethra,  induces this complaint in a
very fudden manner. In order to prevent the  formation
of finufes,  which will be apt  to occur in thefe cafes, an
incifion  fhould be made into the  moft depending part of
the fcrotum, and carried deep enough to reach the wound
in the urethra.  By this means a  free vent  will be niven
to the urine which  has been colleaed, or will be difcharg-
ed.  If  a ftone in  the urethra produces this  fuppreffion,
it  fliould be cut out; if it  originates from a colfeaion of
matter,  this fhould be difcharged; and  if the obftruaion
arifes from caruncles in the urethra, they fhould be re-
moved by bougies.
   The caufe being thus removed,  if there is no conftitu-
tional affeaion, and  the wound is dreffed with foft appli-
                                              cations, 
                       C   137  3
 cations, the opening into the urethra will commonly heal;
 but where there are general complaints, and particularly if
 the patient is fyphilitic, it often happens that  it baffles all
 the powers of medicine.
   Local fcrotal anafarca has been  alfo produced  from the
 rupture of a hydrocele of the tunica vaginalis  teftis, when
 large, by jumping from a great height, or a violent blow;
 and alfo in the operation of tapping in that  difeafe, from
 fuffering  the orifice in the  teguments to recede from that
 in the vaginal coat before the water is all difcharged.
   In both thefe cafes,  the cure fhould confift in laying open
 the tumor; not only for the evacuation of the diffufed wa-
 ter, but alfo for producing a radical cure of the hydrocele
 of  the vaginal coat.
   Of the encyfled  hydrocele there  are  two  varieties:  1.
 When the water is contained in the tunica vaginalis : and,
 2. When it is contained in the fac of a hernia.


                    SECT.  III.

      Of the Hydrocele of the  Vaginal Coat of the Tejlis.

  This difeafe is induced  either by a too abundant depo-
 fition of the fluid ufually exhaled  into the cavity  of  the
 vaginal tunic, or a defeaive abforption of it.
 . In the commencement of the complaint,  a fulnefs is ob-
 ferved at the lower part of one of the tefticles, which gra-
 dually increafes,  and produces a tumor often  of confider-
 able fize.   This although compreffible at  firft, can never
 be made to difappear by preffure; and as  it  increafes the
fkin becomes more tenfe.  The tumor is at firft  globular,
but  gradually becomes  pyramidal,  being larger  below
than  above;  and  after fome  continuance it  often rifes
quite  up to the opening in the abdominal mufcles; Co that
                         S                          if 
                      [  133   3
if it is not combined with hernia, or hydrocele of the cord
itfelf, the fpermatic procefs  may always be  diftinaiy felt
in  the early ftage of the difeafe.   The weight of  the fwel-
ling being uow very confiderable, the fkin of the  parts ad-
jacent is dragged along with it in fuch a manner, that the
penis fhrinks confiderably,  and femetimes  almoft difap-
pears; and the tefticle,  which commonly lies  at the  back
part of the tumor, cannot  now  be  evidently  difcovered.
On a minute examination, however, a hardnefs may be felt
where the teftis is conneaed to the fcrotum ; and a fluftu-
aaon of  fluid may in general be diftinguifhed.
   It fometimes happens when the tumor is very tenfe, that
the fluid cannot be evidently  difcovered ;  neither this, how-
ever, nor the want of tranfparency in it when expofed to
the light of a candle,  fhould determine  againft  its exift-
ence;  for the laft  mentioned circumftance may be occafi-
oned by  a difcolouration of the fluid, or a  thickening of
the tunic.  When the fwelling, however,  appears  trans-
parent, as it frequently does,  it affords a  corroborating
proof  of the exiftence of water.
   The tumor itfelf is not painful, but its weight always
produces fome uneafinefs in the back; this  may however
be prevented or alleviated  by the ufe of  a fufpenfory ban-
dage.
   Thefe  are the common  fymptoms when  the  difeafe is
confined to one fide of the  fcrfttum,  which is ufually  the
cafe;  but in fome inftanees both fides are equally affeaed.
   The difeafes with which  this  is moft likely to be con-
founded  are, fcrotal hernise; the anafarcous hydrocele of
 the fcrotum ; the encyfled hydrocele  of the fpermatic  cord;
 the farcocele or fchirrous tefticle; and the hernia humora-
 lis, or inflamed tefticle.
   But if we attend  to the charaaeriftic marks of each
 of thefe affeaions, there can in general be little danger of
 miflake: thefe have been already given, or will be  taken
                                                  notice 
                       [   139   3
notice of hereafter.   In fome cafes of farcocele combined
with an effufion of water into the vaginal coat, there will
be fome difficulty,  and it is even fometimes impoffible to
afcertain  the complaint:  however,  no  danger will arife
from  the  mi flake,  if we  proceed in the cautious manner
hereafter pointed out.
   In  forming a prognofis in  this difeafe,  we muft  be di-
reaed almoft entirely by the habit of body of the patient.
The affection is in  general local, and in a healthy conftitu-
tion it may almoft always be removed,  and that  with little
or no rift:; but  in conflitutions other wife difeafed;  in old
people;  and in infirm habits, although the complaint may
often be  cured,  yet there  is always fome danger  to be
feared from the  confequent inflammation, fever, and fup-
puration.
   As long as  a  fwelling of  this kind keeps  within mode-
rate  bounds,  which  often  happens for  a  confiderable
time, patients  generally fubmit to the inconvenience it oc-
cafions,  rather than have an operation performed to relieve
them: and this is  the  only means to be depended  on ; for
 notwithstanding what  has  been faid of the beneficial ef-
fects of purgatives in  thefe cafes, I have never feen them
 of any kind of fervice*.
   The methods of treatment propofed  are either intended
 to produce permanent relief,  or only  a  temporary eafe.
 The laft is termed the palliative, the  former the radical cure.
    When the tumor has acquired fuch a fize as  to  become
 inconvenient, if the patient either refufes to fubmit to the
 operation  for the  radical cure, or  his ftate of health ren-
 ders that improper,  the palliative treatment,  or  a mere
                                               evacuation
   * Dr. Shippen, profeflbr  of anatomy and furgery in this city, has in
 more inftanees than one, removed this difeafe by the free  ufe of draftic
 purges, and anointing the part with mercurial ointment. But the Doflor
 is _f opinion with Mr. Bell, that they will generally be ineffe&ual; and
 in his leclures ftrongly recommends the ufe of  the knife  if the patient
 will fuffer it to be employed. 
                       [  HO   3
 evacution of the water by punaure, 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 ufe of the lancet  it may be objeaed,
 that it does not produce a free evacuation of the water; for
 as the opening in  the fkin recedes from that in the vaginal
 coat, the water is either entirely ftopt or  infinuates itfelf
 into the cellular fubftance of the  fcrotum.—The difficulty
 of introducing the common trocar, renders it  a dangerous
 inftrument on  account of the contiguity of the tefticle;
 and many inftanees have occurred wherein the teftis has
 thus been materially injured, even in the hands  of expert
 operators.  The objeaions to thefe inftruments do not,
 however, apply to the trocar with a lancet point, (plate vii.
 %• 3- 4-) which I fome time fince recommended : it ought
 therefore to be preferred to both of them.
   In performing this operation, the patient fhould be feat-
 ed on a chair, with the tumor hanging over the edge of it;
 the operator with his left hand grafping the fwelling on the
 back part, fo as to pufh the water as much as poffible in-
 to the anterior and under part where the punaure is  to be
 made; he then  makes an  opening through the fkin and
 cellular fubftance,  of half  an inch in length,  with the
 flioulder of a  lancet.   This enfures an eafy paffage to the
 trocar, gives but very little pain, and divefts the operation
 of all hazard.
   The trocar  is  now  to  be taken in  the  right hand of
 the operator, the head of it being fixed in the palm, and
 the fore-finger  placed  along the courfe of the inftrument,
 fo as  to leave  as much uncovered as it is thought proper
 fhould enter the vaginal  coat; and this being introduced
 in a gradual eafy manner, the ftiUette is to  be withdrawn
 immediately on the  end of the canula having entered the
 cyft.  If the.tumor is  not very large, all the water ma- be
evacuated at once; but if it is of confiderable  fize/the
                                               fudden 
                     [   Mi   3
fudden difcharge of the  fluid might,  by taking away too
quickly the fupport  it afforded to the veffels of the teftis
and its coat, endanger a  rupture of fome of them ;  it  will
therefore be better  to flop the difcharge now and then
for a few feconds ; and  when the whole is evacuated, the
wound may be clofed by adhefive  plafter, a foft comprefs
applied above this, and both fecured by the T bandage.
   The patient being laid in bed, it commonly happens  that
in a.few  hours all uneafinefs  goes off, and he  may go
about  his ordinary bufinefs ;  in fome inftanees, however,
the  wound inflames and  fuppurates ; and  there are not
wanting  cafes in which a permanent cure has thus  been
obtained.
   This operation is eafily  performed, and feldom produc-
tive of mifchief; but when the patient has been allowed
to go about immediately after  the operation, or the tap-
ping has  been  incautioufly  performed,  it  has fometimes
been fucceeded by very  troublefome  fymptoms.   And
 even when properly managed,  if the patient is very infirm,
 this may happen.   Mr. Pott relates two inftanees of this
kind that  terminated fatally.   Hence it  fliould not be
 rifked in very difeafed habits.
   The intention of every means at prefent  in praaice for
 the  radical  cure  of  this fpecies of  hydrocele, is either
 to admit of a union between the  cellular fubftance of the
 fcrotum and the tunica  albuginea,  by a deftruaion of the
 tunica vaginalis, or by exciting fuch a degree of inflamma-
 tion on the parts as may obliterate the cavity of the tunica
 vaginalis, by making it  adhere to the tunica albuginea.
   The feveral modes of effeaing thefe intentions,  are ex-
 cifion of  the tunica vaginalis; the application of cauftic;
 the ufe of a feton ;  and a  fimple incifion of the fac.
   The three laft are almoft the only methods now in ufe;
 and the cauftic is  the only one of them by which the fac
 has been fuppofed  to be  deftroyed ; but it is exceedingly
                                              doubtful 
                       [   142   3
 doubtful, notwithftanding what Mr. Elfe fays to the con-
 trary, whether this ever takes place.
   By Mr. Douglafs we are recommended  to deftroy the
 vaginal coat entirely ; he direas us, firft to diffea out an
 oval piece of the fcrotum, and having then laid the vaginal
 coat open, to cut it away by a pair of fciffa; s; but if any
 one is inclined to follow this mode, he will feldom find it
 neceffary  to cut off any part of the fcrotum, and will per-
 form the  operation more eafily  with a  fcalpel than  with
 feiflars.
   The  method of  cure by cauftic is thus  conduaed at
 prefent;  the fcrotum  being fhaved, a piece of common
 cauftic pafte, of the fize of an Englifh fix-pence, is  to be
 applied upon the anterior and lower part of the  fcrotum,
 and to be  there well fecured by adhefive plafter,  in  order
 to prevent it from  fpreading.   It  is  to remain five  or fix
 hours, and then be removed.   An emollient poultice,  or
 fome  digeftivc,  muft afterwards be applied over .the   fcro-
 tum, and the whole fufpended by a bandage.
   Inflammation we are told, is foon induced over the whole
 tunica vaginalis ; and the febrile fymptoms  which fucceed
 are to be moderated by blood-letting, clyfters, &c.   In a
few days  the efcar feparates and  comes away ; and  in a
 gradual manner, in the  courfe of four, five,  or  fix weeks,
 the whole tunica  vaginalis  comes off; when the wound
immediately  cicatrizes, and a complete cure is obtained.
   When the feton  is to be ufed, the following is the me-
thod  direaed by  Mr.  Pott.  He ufes a trocar ; a  filver
canula,  five inches  in length, and of fuch a diameter as to
pafs eafily through the  canula of the trocar ; and a probe,
fix inches  and an half long, having at one end a fine tro-
car fleel point,  and at  the  other  an. eye which  carries a
cord of coarfe white fewing filk,  of fuch a thicknefs  as
will pafs eaffty  through the  long canula.   With the tro-
car, the inferior and anterior part of the  tumor is  to be
                                              pierced; 
pierced; and as foon as the perforator is withdrawn,  and
the water difcharged, the feton canula is paffed through
that of the trocar,  till it  reaches the upper  part of the
tunica  vaginalis, and can be felt in the very fuperior part
of the fcrotum.  This being done, the probe armed with
its feton is to  be conveyed through trie  latter canula, the
vaginal coat and  teguments to be pierced, and the feton
drawn through the canula  till  a  fufficient  quantity  is
brought out at the  upper  orifice, when  the canulas are to
be withdrawn.
   About  the  end of the third day, the parts begin to in-
flame;  fomentations,  poultices, a  fufpenfory bandage,
temperate regimen, and laxatives, are ordered to keep the
fymptoms moderate: as foon as the inflammation fubfides,
which is generally about the tenth or twelfth  day, the fe-
ton is to be diminiflied at every fubfequent  dreffing, by
withdrawing fix or  eight threads: the dreffings confift  of
a  fmall pledgit on  the wounds, and a plafter of ceratum
faturninum over the fcrotum.
   This mode of performing the operation I approve of,
except in the circumftance of introducing the  feton, which
I  think is more  eafily executed,  and with  lefs  danger of
injuring the tefticle, in  the manner direaed in the feaion
on abfceffes.
   The operation by the fimple incifion is thus performed.
The patient being placed on a table of convenient height,
and  being properly fecured by two affiftants, with the
fcrotum lying  nearly upon the edge of the table, the ope-
 rator fhould grafp  the tumor  with one hand fo as to hold
 it firmly, and make it fomewhat tenfe on its anterior part;
 and  with a common fcalpel in the other, he  fliould  now
 divide the teguments from the fuperior part of the tumor,
 along its  anterior  furface  down to the moft  depending
 part.
                                                  The 
                       L  M4  ]
   The fcrotum retraaing a little, the vaginal  coat  is laid
 bare, and the operator is to make an opening into it with
 a lancet large enough to receive his fore-finger, at the fu-
 perior part where the firft incifion began;  the finger  be--
 ing inferred, the probe pointed biftouri is  to  be carried
 along it  until the fac is divided quite to its lower extre-
 mity.
  The incifion is direaed to be made from above, on  ac-
 count of its being thus moft eafily performed ; and to be
 carried the whole length of the tumor, becaufe the forma-
 tion of finufes is then prevented.
  When the fac appears much  thickened, it will facilitate
 the cure to remove part of it on each fide:  but when this
 is not the cafe, the dreffing fliould be immediately finithed,
 in order to prevent any bad effea from  the  air coming in
 contaa with, and irritating the teftis.
  The tefticle is generally found to be of a foft texture,
 and pale;  in fome inftanees it is confiderably enlarged;
 and in others it  is reduced to a very  fmall fize:  as the
 cure advances, however, it generally regains its former
 bulk.   .
  It fometimes  happens that  both  fides  of the fcrotum
 are affeaed  with hydrocele;  in fuch  cafes,  we are  by
 fome direaed to lay  both open at the feme time by a dou-
 ble incifion;  but it has been  more common,  on account of
 the inflammation  thus  induced,  to  fubjea  the patient to
 two diftina  operations, by delaying one until a recovery
 from the effeas of the other.  But it is  much  more ad-
 vifable, inftead  of either of thefe modes, to lay open the
 feptum fcroti, after operating on one fide,  and thus effea-
ing the cure of both difeafes at once.   The partition of the
fcrotum is  entirely cellular,  confequently we run  no rifk-
 of doing injury by dividing it.   I  have done  this in two
 inftancer.  with complete fuccefs.
                                                  The 
                       C   M5  1
    The fuccefs of this operation  depends very much on a
  proper dreffing of the wound.  If the tefticle has been pufil-
  ed out of the fcrotum, it fhould be immediately replaced
  and a thin piece of foft lint inferted between it and  the
  edges of the Wound, the whole  length  of the tumor, fo
  much being left out as will cover the lips of the fore,  and
  the remainder pufhed about  half way  to the bottom of
  the fac.  A comprefs of  foft linen is  then to be applied
  over the tumor,  and the whole fupported by  a fefpenfory
  or T bandage.  The patient being now carried to bed, an
  anodyne fhould be given to him ;  and he fliould be direa-
  ed to avoid motion  as much as poffible.
   The lint  is introduced  in order to excite an Inflamma-
  tion over the whole furface of the tunics, and thus prevent
  partial adhefions and confequent finufes.
   When  the inflammatory fymptoms which  fucceed  to
 this operation do not run high, it is not neceffary  to  do
 any thing for fome days;  but when they are confiderable,
 we muft employ blood-letting, laxatives, and a cooling diet;
 and apply fomentations and poultices to the part, In order to
 induce  a plentiful fuppuration,  which tends more  effeau-
 ally than any thing  elfe to take off bad fymptoms.
   In general, about  the fourth day  the  parts fhould be
 fomented  and  poulticed ; and by the fifth or fixth  the
 dreffings come off.   The  edges of the fore now appear
 hard and fwelled, and the matter difcharged is thin and
 difcoloured ;  the lint fliould then  be  all removed  as foon
 as it will come away eafily,  which is  ufually at the  third
 or fourth dreffing.  The fore fhould be dreffed every day
 or two, according to the  quantity of the  difcharge; and
 the poultices fhould be continued till a plentiful fuppuration
comes on, which generally happens by the twelfth or  four-
teenth day.
  The fwelling and fore now gradually leffening, the only
dreffing nece.Tary, is lint covered with a pledgit of cerate ;
                           f                     and 
                      C  146  3
and  in  four,  five, or  fix weeks,  according to circum-
ftances, the cure is completed.
   From an attentive obfervation of the effeas of the three
modes of operation laft defcribed, in a very  great variety
of cafes, in different places, I am induced to conclude that
they are all equally capable of producing  a radical cure;
but that the  fimple incifion effeas this with lefs trouble to
the operator and rifle to the patient than either of the other
two ; and that of the others,  the cauftic is to be preferred
to the feton.                         '
   I have feen all thefe methods produce troublefome fymp-
toms ;  fuch  as great pain and tenfion of the abdomen, in-
flammation and fever;  but the feton, from  the irritation it
gives to the tefticle, more frequently occafions  them  than
either of  the  others.   The  feton  induces  fuch a  plenti-
ful fuppuration alfo, in many cafes, that the matter cannot
be evacuated at the openings, and in confequence forms
troublefome  finufes.
   Another important objeaion is, that it  does not admit
of a  free examination of the teftis, or of the fluid contained
in the fac.   In fimple  hydrocele this would be of no  con-
fequence; but if the tefticle  fliould be much  difeafed, the
irritation of  the cord on it might produce very troublefome
and alarming fymptoms: And there are feveral inftanees
upon record in  which  the  firft  furgeons have miftaken
hydro-farcocele for fimple hydrocele, and vice verfa; indeed
in fome cafes,  there is no certain  means of difcrimination.'
In fuch, the furgeon fhould  always proceed upon the fup-
pofition of the difeafe being   hydrocele; and if on laying
open the fwelling, the tefticle fhould be in fuch a  ftate as
to require extirpation,  it fhould be immediately removed.
   The fluid in  hydrocele is  frequently contained  in "hy-
datids :  This forms another  objeaion to the feton ; which
is obvioufly  ill calculated for its removal in that cafe.
i 
                                               i

                         [   M7   3

    The treatment by  cauftic is liable to  one very  material
 objeaion, viz.  that  of being  produaive  of finufes and
 abfceffes in the  fcrotum and cellular fubftance  conneaing
 this to the tunica vaginalis.  This is never the confequence
 of the fimple incifion; and  on  this account,  becaufe it
 brings the ftate  of the tefticle more evidently into view;
 and  becaufe experience has taught me that it  produces the
 leaft troublefome fymptoms, I am clearly of  opinion that
 it ought to be chofen in preference to the cure by feton or
 cauftic*.



                     SECT.    IV.

            Of the Hydrocele cf a  Hernial Sac.

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

  * The lateft experience feems to juftify this opinion; and inftead of
applying warm poultices and fomentations, if foft compreffes,  dipped in
a folutiun of the faccharum faturni, are immediately laid on the fimple
dreffings, and kept  conftantly wet, no more fwelling or  inflammation
will attend the operation, in moft cafes,  than is  neceffary to induce  a
union of the tunica vaginalis with the tefticle.
  Thefe tumors are  fometimes of a moft enormous fize.—A man who
had laboured under one for nine  years,  and worn  a fufpenfory  trufs for
it as a rupture, had the operation performed by incifion,  and  two gal-
lons of a brown' turbid fluid, with a large quantity of a fubftance like
that of the meliceris,  was difcharged.  The veins of the fcrotum were en-
larged like thofe of  the gravid uterus in  the laft month of pregnancy.
Warm fpirituous fomentations and dreffings were employed in this cafe
to reftore the loft  tone of  the parts,  and in about fix months the wound
was clofed, the fcrotum and tunica vaginalis contracting to a very mo-
derate fire. 
                      r   143  3
   In this fpecies the tefticle is ufually more evident at the
lower part of the tumor than in  fimple  hydrocele;  but
when the difeafe is  combined with hernia  congenita, as it
frequently has been, this will not be the cafe.   When the
parts forming the hernia are down, the fulnefs they pro-
duce along the fpermatic cord, ferves in fome meafure to
denote the complaint.  And if the water can be made to pafs
into the abdomen by preffure, this affords a certain charac-
teriftic:  But  where it happens that the neck of the fac has
been clofed by the preffure of a trufs, or any other caufe,
this mark cannot appear.   In fuch a cafe, the only means of
diftinaion will  be,  an acquaintance with the previous hif-
tory of the diforder :—no bad confequence could however
enfue from a miftake, as  the treatment  adapted to fimple
hydrocele applies equally to this variety.
   When  the protruded  parts  flill remain down,  unlefs
the operation for bubonocele is fubmitted  to  at the fame
time, no other fliould be attempted than that of difcharg-
ing the water by means of a fmall trocar, when  the fize
of the fwelling renders  it neceffary:  becaufe the expofure
of  the  inteftines to the air might be produaive of mate-
rial injury.
   The  fimple incifion fhould  always be ufed for the ra-
dical cure of  this difeafe, on account of the rifk of  injur-
ing parts that might be  protruded, by the employment of
(the feton, or  of cauftic,


                    SEC T.   V.

     Of the Anafarcous Hydrocele of the Spermatic Cord.

   This difeafe is  feated in the cellular membrane  which
envelopes the fpermatic procefs of  the peritonaeum.
   It is, in fome inftanees, fymptomatic of afcites or anafarca;
                                                    in 
                     L   M9  3
in other cafes, it is a local affeaion, and is produced from
an obftruaion in the lymphatic veffels of the part, by fchir-
rous abdominal vifcera, or by the preffure of a trufs.
  When the difeafe is  fymptomatic, it is clearly marked;
when it is merely local, it appears as a colouriefs tumor in
the  courfe of the fpermatic  cord, foft  and inelaftic, and
not  attended with fluauation.  In an erea pofture it is ob-
long, but in a recumbent fituation it is more flat, and fome-
what round.  It does  not in common  extend lower than
the inferior part of the groin; but in fome cafes,  it goes
quite to the  bottom of  the tefticle, and  ftretches the fcro-
tum to a great fize.  By preffure the fwelling can be made
to recede entirely,  or at leaft in great part, into the cavity
of the abdomen; but it inftantly returns to its former fitu-
ation  on removing the preffure.
  When this difeafe depends on a general affeaion, it com-
monly difappears  with the removal of that affeaion; but
when it is local,  and has become inconvenient, an  incifion
is to be made  into it, the whole length of the tumor, fo as
to evacuate  all its contents;  and the wound is then to be
dreffed with lint,  and  treated as a fimple-lore from any
ether caufe.


                   SECT.   VI.

      Of the Encyfled Hydrocele of the Spermatic Cord.

  In this difeafe the water is contained in one or more dif-
tina  cyfts, or cells.  It  commonly begins  by a fmall  tu-
mor in the  fpermatic procefs, juft above the epidydimis;
although, in fome  inftanees, it  begins in its fuperior part.
By  degrees it extends upwards,  and on fome occafions fo
far  downwards,  as  to  reach from the abdominal  mufcles
to the bottom of the fcrotum.    The  teftis can  always
                                                    be 
                      C  150   3
be diftinguifhed at the back part of this fwelling, and quite
unconneaed with it; and a fluauation of fluid is always
perceived on preffure.  The tumor is commonly of a pyra- •
midal form, and is not at all altered in fize by preffure.
  When the water is contained in two cells, the line of
divifion is  commonly evident, by the tumor being there
fomewhat  puckered, or fometimes diminiflied in its  diame-
ter.   A fimilar appearance takes  place when  this fpecies is
combined with  a real  hydrocele of the tunica vaginalis at
the upper extremity of the tunic.
  The difeafes  with which this  is  moft  likely to be  con-
founded, are the hydrocele of the  vaginal tunic, the ana-
farcous hydrocele of the fpermatic cord, and  a hernia of
the inteftines or omentum.   But  an attentive confideration
of the phenomena of thefe complaints, and of thofe attend-   \
ing the one we are treating of, will in general effeaually
prevent the miftaking one for any other of them.
  This, as well as the anafarcous hydrocele of the cord, and
the cedematous tumor of the fcrotum, are all  frequent in
infancy.  They are  then, in common, foon removed by the
application of fpirit of wine, or infufion of rofe  leaves  with
alum.   Dr. Monro recommends the fumes of benzoin.
But in adults,  thefe applications are feldom effeaual; and
we are under the necemty of employing an  operation, as
in hydrocele of the  vaginal tunic, when it arrives at an in-
convenient  fize.
  In accomplifhing  a radical cure,  the incifion is particu-
larly proper on account of the water being fometimes con-
tained in more than one cyft; and becaufe there is a poffi-
bility of confounding this difeafe with hydrocele accompa-
nied by hernia.
  In  the defcription we have given of the five fpecies of
hydrocele,  We  have neceflarily  enumerated the  particu-
lar fymptoms  of each uncombined  with  thofe of  any
other ; but it fometimes happens that  two, three, or even
                                                  four 
                     C  151   3
four, occur at the fame time in the fame perfon.  In fuch
cafes there will fometimes be confiderable difficulty in afcer-
taining the precife ftate of the complaints ; we  can only
form a judgment of this, however, from an attention to the
fymptoms  which ufually  happen in the  feparate ftate  of
each variety.
CHAP.     X.

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

Of the  Varicocele,  Cirfocele, Spermatocele,
              and Pneumatocele.
    BY the firft of thefe terms  is meant,  a varicofe diften-
     fion of the  veins of the fcrotum; which form a tu-
mor of hard  knotty inequalities,  feldom attended  with
pain, and only inconvenient from its fize.
  The cirfocele is a tumor of the feme nature, feated in the
fpermatic vein, and extending  from the fuperior part of
the  fcrotum to the abdominal mufcles.
  Both  thefe  affeaions are fometimes produced  by tu-
mors, the preffure of a trufs, or  other caufes of obflruc-
tion to  the return of the venous  blood:—In  fuch  cafes
the  removal of thefe caufes  fhould  therefore be the firft
ftep towards a cure.
  But when a general relaxed  ftate of the veins gives rife
to them, and this is the moft common caufe,  remedies to
recover  their loft tone fhould be employed.  For this pur-
pofe, we fhould direa the ufe of a fufpenfory bandage; a
horizontal pofture; the cold bath;  and the application of a
folution  of alum and other aftringents to the parts affected.
  By thefe means every affeaion  of this kind may  be pre-
vented from increafing,  and fo far relieved as to render the
harfh modes of cure by the knife, the cautery and ligature,
recommended by ancient writers, unneccffary.
  By the term fpermatocele is meant a morbid diftenfion
of the epidydimis and vas deferens, produced by a flagna-
                                                  tioQ 
                      t   *SS  3
tion of femen.   This may be occafioned  by tumors, ftric-
ture, or inflammation about the caput gallinaginis, or in
the courfe of the vas deferens :  the  laft is probably  the
moft frequent caufe.
   Inflammation is to be removed by the common remedies.
In general tumors  fliould be either extirpated or brought
to fuppuration ; if they are venereal, a mercurial  courfe
fhould be  direaed.   Caftration has fometimes  been em-
ployed as a dernier refort; but  we cannot fuppofe  it ever
to be very neceffary.
   The appellation of pneumatocele has been applied to tu-
mors of the fcrotum produced by  air.  This difeafe  has
been defcribed by the ancients as a frequent occurrence;
but it is extremely doubtful whether  it ever exifts as a lo-
cal affeaion: and it  is moft probable that  hernia or hy-
drocele have been ufually miftaken for  it.  As a part of
general difeafe,  it  may  happen either from a wound of
the lungs,  or from a putrefcent ftate of the fluids.   In  the
former cafe, punaures with a lancet will be  an effeaual
mode of cure ; but in the latter, nothing will probably be
of any advantage.
CHAP. 
C  is*  3
          CHAP.     XII.

Of the  Sarcocele, or Schirrous  Tefticle.
    BY farcocele is underflood  a  firm  fiefhy kind of en-
     largement of the tefticle;  much more hard than that
occafioned by inflammation.
  An unufual degree of hardnefs, attended with a trifling
enlargement, and inconfiderable pain of the tefticle, are the
ufual  indications of the  commencement  of this difeafe:
thefe  fymptoms  gradually  increafe for fome  time;  and
then often remain ftationary for a  great length of  time.
In a very few inftanees they have been prevented from iu-
creafing, or even removed, by a  moderate  diet, keeping
the belly open, a proper  fufpenfion  of the tumor, and
avoiding violent  exercife.   Such  inftanees  are however
very rare;  and generally in more or lefs time,  the tumor
becomes larger;  grows ragged and unequal on its furface;
and the pain becomes  more fevere,  frequently darting fed-
denly through the fubflance of the fwelling.
   The inequalities on the furface of the tumor increafe by
degrees:—on fome occafions, a confiderable  quantity of
ferum is extravafated  into  the tunica vaginalis, and gives
the appearance of a  common hydrocele; at other times,
partial  colfeaions of matter  are formed throughout the
body of the  tumor;  which increafing, at length the fcro-
tum burfts, and a thin foetid bloody matter is difcharged.
   The fpermatic cord, after the tumor has acquired a con.
 fiderable fize, becomes hard and enlarged, but feldom be,
                                                 ferej 
                     [   *57  3
fore;  and often not till matter  has been formed.  By de-
grees  it  grows very knotty and painful throughout  its
whole extent.
  Although the  difcharge of matter increafes in quantity,
the  tumor  inftead  of leffening continues to increafe; the
edges of the fores  become hard, livid,  and retorted; and
fungous  excrefcences  fhoot  out from  different parts of
them.
  The patient now becomes emaciated and pale;  and the
difeafe, which in this flage is a moft malignant cancer, con-
ftantly increafing,  at length carries him off in the  greateft
mifery.
  This  is the general progrefs of the complaint, unlefs it
is interrupted by a timely extirpation.   But as it affumes a
great variety of appearances, it is impoffible to convey a clear
idea of them in defcription.  In fome  inftanees  the tumor
remains almoft  indolent for a number of years; while in
other cafes, it goes through all the ftages we have  defcrib-
ed in  the courfe of a few months.
  In the greateft number of cafes, the  difeafe begins  in the
teftis; but it now and then makes its appearance firft in
the epidydimis, and fometimes even in  the fpermatic cord.
  Hernia humoralis  feldom terminates in farcocele, but
there  are indifputable evidences of its ending, in fome in-
ftanees, in  that difeafe.
  Schirrous affeaions of the  tefticle  have been  attri-
buted to  the water fometimes met with in the tunica vagi-
nalis at the fame time; but there can  be little doubt but
that  this colfeaion of  fluid is  produced by the  difeafe of
the  teflis, and ought not to be confidered as the  primary
affeaion.   The difeafe  formed by this  combination has
been termed hydro farcocele; and it is often with difficulty
diftinguiflied from fimple hydrocele.   In fome inftanees
there  is no  poffibility of determining the real nature of the 
                       C  158   3
 cafe, but from expofure of the parts by an incifion.  The
 previous hiftory of the difeafe muft give the chief light in
 thefe doubtful inftanees.
   In forming a prognofis in farcocele, we are to be direa-
 ed by the age and habit of the patient, the duration of the
 difeafe, and its ftate at the time.
   Thus,  we  may have  more hopes of fuccefs in young
 healthy fubjeas,  particularly if extirpation  is to  be  ad-
 vifed, than in thofe of an advanced  age  and infirm habit •
 and  indeed when the fyftem  is otherwife much  difeafed,
 there can be little  or  no advantage expeaed from any
 thing.
   If the  complaint  has  proceeded very flowly,  there is
 reafon to think that  it is of a mild nature,  and  that  the
 habit is not  fo much affeaed as if  its  progrefs has been
 very rapid.
   And, as long as the tefticle is only fomewhat hard and
 enlarged, without the formation of matter, and without any
 difeafe of the cord, if the conftitution is otherwife healthy,
 there is a probability of fuccefs from any operation that
 ought to take place; but when the oppofites  of thefe cir-
 cumftances occur,  and particularly if there is  an ulceration
 of the teftis,  there will be little reafon to expea a favour-
 able  event.
  With refpea  to the  fpermatic cord,  whenever  this is
 merely enlarged by the weight of the tefticle producing a
 varicofe ftate  of its veffels, or a watery depofition in its
 cellular fubftance,  and is not painful in itfelf, the extirpa-
 tion of the tefticle  may be admitted,  if no circumftance of
general difeafe forbids it; but if the cord has become en-
larged, hard, knotty,  painful to the touch, adherent to the
neighbouring  parts,  and ulcerated, and  the  affeaion ex-
 tends quite up to the abdominal mufcles, caftration fliould
 always be forbid.
  No remedy but extirpation can be depended on for the
                                               removal 
removal of farcocele.   The moft important circumftance
to be determined then,  is the period at which  the opera-
tion is moft advifable.
  Although this difeafe, in fome inftanees, remains ftation-
ary for a long time, or proceeds very flowly,  yet in  the
greater number of cafes, its progrefs is very rapid.  When
therefore, bleeding,  laxatives,  a fufpenfory bandage,  or
mercury, when it has  probably originated from a venereal
fource and other occafional remedies, have been ineffec-
tual, and  the tumor  daily increafes in  fize, and becomes
more  painful, the operation fhould be inftituted  without
delay ; but while the difeafe remains ftationary and indo-
lent, it can never be confidered as abfolutely neceffary.
  The method of performing caftration is  as  follows:—
The patient muft be placed horizontally on a table of con-
venient height, with his legs hanging down, to be fecured
by an affiftant on each fide.  The parts being previoufly
fhaved,  an affiftant muft hold the tumor,  if very large, if
it is not, the furgeon fhould manage it himfelf.  Grafping
it firmly  with one hand, he fhould make an incifion with
a fcalpel in  the other, along the whole extent of it,  be-
ginning at leaft an inch above the part where  the cord is
to be cut, and  carrying it  through  the fkin  and  cellu-
lar fubftance quite  down to the end of the fcrotum, by
one cut of the knife.
  The vas deferens fliould then be feparated from the blood-
veffels ;  and a firm waxed ligature being carried around the
artery and vein, avoiding the nerve, by means  of the cur-
ved blunt  needle, (plate vii. fig. 2.) a  running knot fhould
be made on them, a quarter of an inch above  where the
cord is to  be divided.
  The cord being here cut acrofs, the lower part  of it and
the tefticle, are then to be  diffeaed out with the fcalpel.
When this is effeaed,  the ligature is to be untied, and the
artery and vein, if poffible, feparated from the nerve by the
                                            tenaculum, 
                      [   160  3
tenaculum, and fecured.  The  ligature above may be left
loofe, and is to ferve as a  fecurity againft hemorrhagy.
  When it is neceffary  to divide  the cord  near  to the
opening in the abdominal  mufcle, it wUl be proper to leave
the ligatures a few inches long, left  a retraction  of the
cord  within  the abdomen,  which  fometimes  happens
when it has been much feparated from the parts beneath,
fhonld take place.  If the fcrotal artery fhould be divided
during the operation, it fhould be immediately tied.
  The wound is now to  be dreffed with foft  lint, fecured
by a comprefs, and the T bandage, or a fufpenfory  bag.
  The patient being then laid to reft,  and an  opiate admi-
niftered, the fore fhould  not be dreffed till a free fuppura-
tion takes place -, which  will generally  happen about the
fifth or fixth day; and the dreffings may afterwards be re-
newed once in two days,  or oftener,  according to circum-
ftances.
   Sometimes, after this operation the patient complains of
much pain in the fore, and of tenfion and uneafinefs over
the abdomen : in  thefe  cafes, warm fomentations fliould
be applied to the  abdomen, and an emollient  poultice to
the fore.
   In performing caftration, no portion of the fkin fhould
be removed, unlefs from the fize of the tumor it  has be-
come very thin, or it  is  inflamed  or  ulcerated ; in which
eafes, after making the firft incifion to the extremity of the
fpermatic cord,  two femilunar incifions fhould be conti-
nued to the end of  the  fcrotum,  fo as to include all the
 difeafed fkin;  and this  is  to be  afterwards diffeaed off
 with the tefticle.
CHAP. 
[  i6i   3
      CHAP.    XIII.
           ■3
Of the  Difeafes of the  Penis.
                   SECT.   I.

                   Of the Phymofis.

     THE  difeafe called phymofis is formed when the pre-
      puce has  got forward over the glans penis,  and
cannot be drawn back.
  It is produced by whatever tends to fwell the glans, or
to excite inflammation and ftriaure of the preputium:  and
in fome people, the prepuce i3 fo tight, as to render them
liable to  this difeafe from very trifling caufes.   It origi-
nates frequently from  allowing  a colfeaion  of the  mu-
cus  behind the glans to take  place, and continue till it be-
comes acrid ; but the moft frequent carae  of it is the ap-
plication of the venereal virus to thefe parts.
  In flight and recent cafes,  warm emollient  fomentations
and poultices are commonly effeaual remedies.  At the fame
time it will be proper to injea  part  of the  fomentation
between the prepuce and  glans frequently,  in  order to re-
move any matter that may  be there accumulated from
chancres or other caufes.
  When  the  inflammation is very confiderable,  blood-let-
ting may be neceffary;  and this will  be more effeaual  if
the blood can be taken from the  penis by the  lancet;  if
this cannot be accomplifhed, it may  be drawn from the
arm.  Topical bleeding by leeches might be very ufeful; 
                                                      1
                      £  i6z  3
but when  the  difeafe  originates from  a venereal caufe,
the wounds thus caufed are apt to terminate in troublefome
fores.   Laxatives, reft, and  low diet, fliould alfo be di.
retted.
  When all  thefe  remedies  fail,  and efpecially if chan-
cres are confined under  the  prepuce, the difcharge from
which might  injure the prepuce and glans,  it will be ne-
ceffary  to  remove  the ftriaure by cutting through the
prepuce  its  whole  length.   This will be  moft eafily
and effeaually accomplifhed by a  very fmall biflouri,
concealed  in  the groove  of a direaor,  and  fomewhat
curved  at its  extremity.  Thefe  being introduced between
the glans and prepuce, to the upper part of the latter, the
operator is to  keep the direaor firm with one hand, arid
with  the other is to pufh the point of  the  knife through
the membrane; the direaor being then withdrawn, the
biftouri is  to be  drawn forward fo as to divide the  pre-
puce entirely.
  The  operation fhould be performed on the fide of uw
penis, in order more effeaually to avoid the large veins.
   The  parts beneath  fhould now be cleaned with warm
water; and the fore being covered by lint, and a comprefs.
of  linen laid over it, the whole may  be  fecured by a fmall
linen bag conneaed to a circular band around the body.
   In the fubfequent treatment,  care fhould be taken to
infert a piece  of lint between the divided  prepuce and
glans, otherwife troublefome adhefions may take place;
and if the venereal difeafe exifts in the  habit, a mercurial
courfe will be abfolutely neceffary to the  healing of the
fore.
   In cafes where  the prepuce  is  found exceflively long,
inftead of dividing  it longitudinally, it will  be better  to
take off a  part of its whole  circumference*.
                                               SECT.
   * This will  be moft eafily and effectually  performed  by making
 lateral incifions firft. 
I   «*3  1
                   SECT.   II.

                 Of the Paraphymofis.

  By the term paraphymofis is meant a morbid retraaion
of the preputium, producing a ftriaure behind the  glans
penis.  This  difeafe is produced moft frequently by a ve-
nereal taint;  but it may originate from whatever tends to
occafion a preternatural fulnefs of the glans, or a conftric-
tion of the prepuce, or both.
  In the  commencement of this complaint, the prepuce
may  be fometimes brought over the glans  by pufhing the
nut gently back  with the thumbs, while  the fingers are
employed in moving the prepuce  forward ; but this fhould
never be attempted in an advanced ftage,  as it is then not
only unfuccefsful, but often injurious.
  As paraphymofis ufually arifes  from an  enlargement of
the glans, warm fomentations inftead of proving fervicea-
ble often do  mifchief.  Nothing anfwers fo well as  fatur-
nine  applications; and immerfing the fwelling frequently
in a cold folution of faccharum faturni, will often remove
it when all other remedies fail.  When the penis is  much
fwelled and inflamed, the patient fhould be kept cool, and
on a Jow  diet, gentle laxatives fliould be exhibited, and
fome blood may be difcharged from a vein  of the penis.
  Thefe remedies will often fucceed;  but when they are
ineffeaual, the fwelling and  ftriaure increafing, an  cede-
matous fwelling  appears in  the  prepuce, and  often ac-
quires a confiderable  fize; and unlefs the  ftriaure is re-
moved, a mortification of the glans will  be very apt to
occur.
  When therefore, the means above advifed do not remove
the complaint, and the fymptoms juft mentioned begin to
come on, the ftriaure fhould  be removed by making a deep
                                           fcarification 
                      I  164  3
fcarification  on each fide of the penis, direaiy behind the
glans, about half an inch in length, and of fuch a depth as
to divide the prepuce juft at its termination.
   As foon as the hemorrhagy flops, the wound fhould be
dreffed with lint,  and a plafter of cerate, and a foft poul-
tice fhould be applied over the whole jumor.   The parts
fhould afterwards be dreffed in the ordinary way.  If the
ftriaure fhould not have  been completely relieved by the
firft incifion, a fecond fhould be made.
   Mercury will be neceffary, if the caufe of the difeafe has <
been venereal.


                   SECT.   III.

            Of Amputation of the Penis, &c.

   A necessity for amputation of the penis is  moft com-
monly  induced by gangrene from paraphymofis and other
caufes, and by cancerous fores affeaing it.
   In performing this operation, a circular incifion is to be
firft made through  the found  fkin on the verge of the fore,
and the fkin being then drawn back, all the difeiffed parts
are to be removed by one ftroke of the knife.   All the ar-
teries that bleed freely, which are generally two or three
in number, ought then to be  fecured by ligature; and the
oozing of blood, that afterwards occurs from  the furface
of the wound, may fometimes be commanded by fprinkling \
the fore with ftarch, or finely powdered gum arabic: but
wsen thefe do not fucceed, a fmall  filver canula being in-
troduced into the urethra, and there fecured by bandage,
the difcharge may be reftrained by paffing a narrow roller,
moderately tight, upon the remaining parts.
    It has been recommended  by fome, in order to avoid
 hemorrhagy,  to remove the  penis  by making  a ligature
                                                around
_ 
                      [   i*5  3
around it; but it is  taken off with, much more eafe and
certainty by the  fcalpel.  Others are fo little apprehenfive
of hemorrhagy, that they advife  us to truft  entirely  to
compreffion for  reftraining it.   I  once faw  a patient lofe
his life by following this plan*.
   The wound fhould be  dreffed with lint, covered with
ftarch, or powdered gum  arabic,  and a comprefs of linen,
with a hole in it large enough to pafs over the canula, be-
ing applied,  the whole fhould be  fecured by the T band-
age.   The fubfequent  treatment  muft be fimilar to that
of wounds in other parts.
   Before proceeding to this operation, it  fhould be known
with certainty,  whether the glans penis is really difeafed;
and when there is any doubt, the prepuce fliould be taken
off to afcertain it.
   When the frenum of the penis  is fo fhort as to produce
uneafinefs or pain  on  ereaion, it may  with the utmofl
fafety be  divided by a pair  of feiffars;  and after this is
 done, a piece of lint fhould be inferted between the lips  of
 the wound to prevent their re-union.
   It fometimes  happens,  that the uretha in male children
 terminates before it reaches the end  of the penis.   Some-
 times there is no external opening ; at other times, there is
 a fmall orifice  at fome diftance from the extremity of the
 yard.
   When  there is  no opening externally, if the urine is
found to  ftop at a  particular part, the introduaion of a
 fmall trocar from the point of  the yard, along the courfe
 that the urethra ought to take, until it meets with the urine,
 will  always afford  immediate relief; and  by the ufe  of
 fmall bougies the fides of the paffage may be rendered  cal-
 lous,  and an opening thus preferved.   But when any open-
                                                     ing

   * In two cafes of amputation of the penis in the Pennfylvania hofpital,
 a very trifling hemorrhage was eafily retrained by dry lint, and mode-
 rate comprefllon. 
                      C  i*6  3
ing is difcovered, whatever be its fituation,  if It affords a
paffage to the urine, the operation had better be delayed to
a more advanced age, when a piece of flexible catheter can
be  introduced to preferve the opening made by  the  tro-
car.
P
               CHAP.   XIV.


                   Of the Stone.




                   SECT.  I.

           General Remarks on urinary Calculi.

    ARTICLES  of ftone have  been formed in almoft
     every cavity of the body, but they are moft frequent-
ly met with in the urinary  organs.   A  variety of cau-
fes  may  concur  in producing this depofition of earthy
matter from the blood or fecretions.
  i. If a greater quantity of earthy fubftance be taken into
the circulating fluids than can be fufpended  by them, the
fuperabundance muft neceffarily  be  feparated;  and the
depofition will  moft readily take place in  the bladder and
kidneys, from the urine containing a greater proportion of
earth than any  of the other fecretions.
  2. There is reafon to fuppofe that  a long continued ufe
of water,  or of wines which contain a great  quantity of
earth, has a tendency to overcharge the circulating fluids
with earthy matter.
                                                  3. A 
                      C  i«7  3
  3. A conftant ufe of a great proportion of folid food
feems to have a confiderable effea in producing an accu-
mulation of earthy matter in the fluids; and hence, in fuch
cafes, probably arifes the benefit from direaing a large ufe
of diluting drinks.
  4. A fuperabundance of  earthy matter being once pro-
duced in the blood, various circumftances may concur to
form depofitions  of it in  the different cavities;  of thefe,
a fedentary life is one of the principal; and hence thofe
who ufe leaft bodily exertion are moft fubjea to calculous
complaints.  When they  occur in poor labouring people,
as they frequently do, they may with probability be attri-
buted to their diet; the effeas of which are too powerful
to be obviated by exercife.
   5. Whatever effeas  predifpofition may have  in occa-
fioning calculi, the introduaion of any fubftance that can
ferve as a nucleus, will almoft certainly produce a ftone,
in whatever cavity it is lodged.  Thus,  a particle of fand,
of blood  or coagulable lymph, may, in confequence of
fpafm  or  inflammation, be  confined  in the pelvis of the
kidney or bladder, and there acquire fuch a fize, from the
conftant depofition of earthy matter, that it cannot be car-
ried off by the urine; and afterwards,  in a longer or fliorter
time, acquire a confiderable  fize, according to the quantity
of earth with which the urine is impregnated.
   It is very doubtful,  whether a ftone is  ever formed in
the urinary paffages without the intervention of a nucleus.
Nuclei of various kinds, fuch as hairs, needles, mufket and
piflol bullets, pieces of bougies, and a variety of other ar-
ticles,  have been met with in the centre of urinary calculi;
but particles of blood, or coagulable lymph, moft frequent-
ly produce them.
   By a difference of food at different periods of the difeafe;
by the ftone being formed  flowly or more quickly; and
perhaps by other caufes not known, or not eafily expli-
                                                  cable 
                      [   168  3
cable when known, it commonly happens that the differ-
ent lamellae of which calculi are compofed vary confider-
ably in colour  and confidence;  thus  the  external layer is
frequently foft  and friable, the next hard as marble, and
the internal lameUa as foft as dough.
  Calculi thai are hard, covered with fpiculse, or large, are
ufually produaive of more bad fymptoms than thofe that
are foft, fmooth, or fmall.
  One of the firft fymptoms of urinary calculus, is an uneafy
fenfation at the end of  the urethra, which, for fome time,
is only difcovered on taking violent exercife, or immediate-
ly after voiding  urine.   This  becomes by degrees more
fevere and frequent.  There is a flrong propenfity  to make
urine frequently; and it is commonly voided in fmall quan-
tities,  perhaps  drop by  drop.   When flowing in a  full
ftream, it often  flops fuddenly, and particularly  when
there is much  colfeaed.  Nor do the efforts of the patient
anfwer any  good purpofe, unlefs he changes his  pofture:
For as the  obftruaion proceeds from the ftone  bearing
againft the neck of the bladder and orifice of the  urethra,
nothing elfe but its removal from that fituation will afford
 relief;  and  this is beft effeaed by elevating the pelvis.
   The urine is fometimes clear; but it is ufually thick, and
 depofits a mucous fediment; and when the  difeafe is in
 violent degree, it is fometimes tinged with blood.  When
 the ftone is large, a dull  uneafy fenfation is always expe-
 rienced about the neck of the bladder;  and  the irritation
 produced by  it frequently induces a very troublefome te-
 nefmus.
   All thefe fymptoms  are uniformly increafed  by exer-
 cife, particularly by riding  on horfeback:—from  a  long
 continuance of pain,  and the want of reft which  conftant-
 ly is  induced,  the patient's  general health becomes much
 impaired;  and unlefs the caufe  of the  difeafe is now re-
  moved, his mifery is, in general, only terminated by death.
                                                   The 
                      [   169  3
  The exiftence of  calculus can only be rendered certain
by the  patient's paffing fmall ftones or fragments of ftones
with the urine, or by feeling the ftone in the bladder by
the intervention of a found : becaufe all the abovemention-
ed fymptoms may originate from a tumor  or ulcer  in the
bladder, or from tumors preffing on the neck of the blad-
der.  However there will, in general, be  great  reafon to
fuppofe it when all or moft  of the  phenomena defcribed
occur.
   The found  alfo affords us,  in many inftanees, the only
means of determining whether the calculus be feated in the
bladder, ureter, or  kidney.   For although  a ftone in the
pelvis  renis ufually produces fymptoms which do not in com-
mon attend vefical calculus, fuch as pain in the back, frequent
naufea, retching and vomiting, yet thefe are not  fuch inva-
riable  concomitants as to afford any certain charaaeriftic.


                     SECT.  II.

           Of founding or fearching for the Stone*.

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

    * The inftrument termed a catheter, and by means of which it is fome-
 times neceffary  to evacuate the urine, is ufed exactly in the mode here
 directed for the introduction of the found. 
                      [  170  3
fome difficulty is experienced in paffing through that part
of the urethra which is furrounded by the proftate gland;
when the inftrument flops here,  we fhould not attempt to
force it forward, as it may thus be made to penetrate thro'
the urethra; but  the fore finger of the left  hand, well
oiled, fhould  be introduced into the reaum, which by ele-
vating the flaff at the fame time that it is gently pufhed on-
ward,  will commonly procure its eafy entrance into the
bladder-   Depreffing the handle  of the found  will fome-
times anfwer the purpofe, but the above defcribed mode is
ufually more effeaual.
 .  This is  fometimes  a difficult operatioo, and it requires
frequent performance to execute  it with dexterity:  an ex-
pert furgeon  however will feldom fail in it, if the parts are
not much affeaed  with inflammation, fwelling, or ulcera-
tion.
   The flaff, when  entered into the bladder, is  to be gently
moved about with one hand, in order to make it touch  the
ftone.   When  the calculus  is fmall, it may lie near  the
neck of the bladder in fuch a manner as to fuffer the found.
to pafs over  it; when this is fufpeaed,  a finger fhould be
introduced  into the reaum  to  alter its fituation.  If this
fhould not fucceed, the patient fhould be put into a  variety
of poftures until the ftone can be felt. The beft pofition, in
general, is to have the pelvis elevated above the trunk and
head :  by this, if the ftone is not contained in a cyft, which
rarely happens, it may commonly be moved to the  fundus
veficae.
   The  operation  fhould  be repeated feveral  times when
there is room to fufpea a calculus, and it is not difcovered
by the firft attempt.
   The fenfation communicated to the operator when a ftone
ftrikes the flaff is  fo peculiar, that an attentive and expe-
rienced furgeon can never be  deceived in  it; but, in fome
                                               inftanees, 
                      C   171  3
inftanees, a hardened ftate of the bladder has unfortunately
been miftaken for a ftone.


                   SECT.  III.

      General Remarks on the Operation of Lithotomy.

   The prefence of a ftone in the bladder being afcertain-
ed, the means to be employed for the patient's relief is the
next objea of confideration.
   Although  lime-water, diluted  cauftic  alkali,  and  fome
other  articles have, in  particular inftanees, mitigated the
pain, and leffened the frequency of paroxyfms ; yet  there
has  not been one cafe  well  authenticated,  in which the
ftone in the bladder has been diffolved by  the ufe of any
remedy whatever.
   As  all  lithontriptics  are liable  to material changes in
their paffage  from the ftomach to the bladder, it has been
propofed  to  injea fuch fubftances  into the bladder, and
thus bring them into immediate contaa with  the ftone.
But it has been found by various experiments,  that no fub-
ftance  powerful enough to have any effea upon a ftone,
can be thus injeaed,  without the greateft hazard of injur-
ing the bladder very materially.
   From what has been  faid,  it appears that no  hopes can
be ref^bnably entertained of the removal of  a calculus, but
by a chirurgical operation.
   Although  a great  proportion of thofe who are cut for
the ftone recover, yet a confiderable degree  of danger al-
ways attends  the operation.   Children  appear to  recover
more readily from its  effeas than adults ; and it  is likewife
obferved,  that old people  from the fifty-fifth to  the  fe-
ventieth year, whofe conftitutions  have not  been much
broken, run lefs rifk than men in the  full  vigour of life.
                                                  This 
                      C  172   3
This feems  to arife from inflammatory  fymptoms  being
then lefs apt to fupervene; for from thefe the chief danger
of the operation  is produced.  But at whatever period of
life the  patient  may be, the  event will be  favourable or
otherwife according to the general health, and degree or
continuance of the topical affeaion.
  If the bladder has even  become  ulcerated, and the pa-
tient is young, and his general  health is  fo  good that we
need not be apprehenfive of the effeas of the hemorrhagy,
the operation may be tried; but if,  on the contrary, toge-
ther with  an ulcer in the bladder, the patient is advanced
in life and  infirm, we fhould advife  the  palliatives, a free
ufe of mucilaginous  drinks, the warm-bath  and opium,
and avoid  the operation;  as it would moft probably, in
fuch circumftances, be fatal.
   There have been various modes of performing the ope-
ration of lithotomy ufed at different times, and in different
places.   In performing it by the leffer apparatus, or cutting
on the gripe, the finger is introduced into the reaum, and
the ftone pufhed by it towards the perinseum; an incifion
is  then made  immediately on  the  tumor  formed by it
into  the  bladder,  and  the ftone  removed.   This  was
the only mode in ufe from the time of Hippocrates to the
beginning  of the fifteenth century;  when Johannes de
Romanis  propofed the operation by the greater apparatus^
which was performed nearly in the  manner  of the lateral
 operation, except that a blunt gorget, or fome other inftru-
 ment was  ufed, by which the  parts  were  diredted to be
 dilated for  the paffage of the ftone; but it always happen-
 ed that they were much  torn.  The inconveniences that
 were found to  attend  this method, fuggefted the idea of
 putting into the bladder immediately above the  os pubis.
 This was firft praaifed by Franco, a French furgeon, who
 pnblilhed  an account of it  in 1561.  It has been termed
 r'                                                the 
                '    "t   «7f*.
the /j/£<6  operation:  and was much ufed in many parts of
Europe till near  1730.
   As all  thefe methods  of operation have been by expe-
rience found much more  objeaionable than the lateral ope-
ration, they have  for  many years paft given place to it
almoft univerfally*.


                    SECT.   IV.

                Of the Lateral  Operation.

   This operation was invented by Frere Jaques, a French
 ecclefiaftic, about the year 1697.   Since that time it has
 undergone various alterations.—We fhall deferibe it in its
 moft improved form.
   In order to prevent the patient from going to flool foon
 after the operation, the  bowels ought to be well  emptied
 by a laxative given the preceding day; and a clyfter fhould
 be exhibited  a few hours before  the operation,  with a
 view to evacuate entirely the contents  of the reaum.—As
 the bladder, when in  a collapfed ftate,  is liable to be cut in
 different places, the patient ought  to  drink  plentifully of
 fome  diluting  liquor, and to  retain  his urine for  fome
 hours  before he  is laid upon  the table;  and when the
 urine cannot be retained voluntarily,  it will be proper to
 ufe a flight compreffion  on the penis.
    The  perineum  and parts  about  the anus being fhaved,
 the patient is now to be laid upon a table of convenient
 height firmly fixed, and there well fecured in the follow-
 ing manner: Let a noofe be formed in the double  of a
 piece of broad flrong  tape  about three feec  in  length;
 the  patient's  wrift  being introduced  at  this noofe,  he
                                                  ought
    * For this reafon,  it is thought  unneccflary to enter into a particular
 detail refpefting them in this wcri. 
                      C  174   3
ought then to take a firm hold of the outfide of the ancle
of the fame fide,  when,  by different  turns of the  tape
around the hand, ancle and foot, they  are  to be well fe-
cured together;  and the hand and foot of  the other fide
are afterwards to be tied in the fame manner.
  The operator muft now introduce a grooved flaff, (plate
iii. fig. 2.) of a proper fize;  and the ftone being again dif-
tinaiy felt,  not  only by the furgeon, but by the affiftants
alfo, the patient muft then be  put  into the  pofture in
which he is to be kept during the remainder of the opera-
tion.  A pillow, for  convenience, may be placed under
his head; and in order to  elevate  the pelvis confiderably
above the abdomen, two pillows at leaft,  fhould be laid
under the buttocks, which  ought  to  projea an inch or
two over the end of the table.   By obferving this direaion,
we give lefs chance of injuring the bladder in feveral places,
and more particularly if it  fhould not be diftended during/
the operation.                                         *
  There fhould  be an affiftant on each fide, to fecure the
arms and legs  of the patient; one  muft prevent him from
moving  the  upper  part of his body,  another muft  ma-
nage the flaff,  and a fifth will be neceffary to hand the in-
ftruments to the  operator.
  The furgeon,  after  having again felt the ftone with
the flaff, is now to make the handle of it pafs over the
right groin of the patient, fo  that the inftrument may be
felt on the left fide  of the perinseum; and  in this pofition
it ought to  be preferved by the affiftant,  who with his
right hand fhould hold the handle of the flaff,  while with
his left he elevates  and fupports the fcrotum.
  The thighs  of the patient being fufficiently feparated /*
by the affiftants;  and the furgeon being feated between
the patient and the window, in  fuch a manner as to make
the light fall direaiy upon the parts to be cut, an  inci-'*
fion is now to  be made through  the fkin and cellular  fub-
                                               ftance, 
                     C   i"7S  3
ftance, at  leaft  four inches in length in a full grown per-
fon, and proportionably lefs in fmaller people;  beginning
a little to  the left fide of  the rapha,  about  an  inch from
the termination  of the fcrotum,  and proceeding  in an  ob-
lique  direaion  along the  perineum, between the tubero-
fity of the ifchium and the anus, until it  is extended at
leaft an inch beyond the latter.   This fhould be  done by
one ftroke of the fcalpel:  by  a continuation of  the inci-
fion,  the  ereaor penis, accelerator urinse, the  tranfverfa-
lis perinaei,  and levator ani, are alfo to  be divided.  If
in making  this incifion  any confiderable  veffel fhould
be cut, and efpecially if the patient is much weakened, it
fhould be immediately tied.
   It is  to be particularly obferved, that the eafy extraaion
of the ftone, and tying of arteries that may be cut, depends
very  much on thefe incifions being very freely made.
   The operator is now to  fearch  for the  flaff  with  the
fore-finger of the left hand; and  having found it, he is to
pufh  his finger along the  courfe of it till he paffes the bulb
of the  urethra, when,  with the  edge of  his knife turned
 towards the groove of the flaff,  he is to  divide the mem-
branous part in its whole courfe,  from  the bulb  to the
proftate gland, by one cut of the fcalpel;  and  as the fin-
ger is made ufe of  as a direaor, and kept between  the
 reaum and the knife, the gut  is thus preferved from in-
jury, and the incifion made  with perfea  fafety.  A divi-
fion of the bulb of the urethra,  as  commonly direaed, is
 never neceffary, and  is almoft  always fucceeded by  con-
 fiderable  hemorrhagy, and the formation of finufes.
  'The proftate gland, which may  be evidently difcovered
 by the  finger,  is next to  be divided.   This may be done
 by an expert furgeon  with a lateral ftroke of the fcalpel;
 but  as in the  hands of common  operators,  the rectum
 might be frequently wounded by the knife, it will be beft
 to employ the  cutting gorget (pi. iv. fig.  3.) as  commonly
                                               direaed 
                        [   i76   3
direaed, or what I confider as fuperior to this, a cutting
direaor*, (pi. v.  fig. 4, 5.)  In ufing thefe, the nail of the'
index of the left hand  ought to  ferve  as  a conductor to
the beak of the gorget or  direaor ;  which being introdu-
ced into the  groove of the flaff,  the furgeon is now to rife
from his  feat, take that  inftrument from the  affiftant;
and having  raifed it fo as to form  nearly a  right angle
with the body of the patient, he muft, with his  left hand,
hold it  firm in this fituation ;  while, with his  right,  he
pufhes  on the direaor,  taking great care that  the point
be kept in the  groove of the flaff, till it has  paffed freely
into the bladder; a circumftance which is evidenced by the
urine ruffling freely out at the wound.
  The  flaff is now  to be  withdrawn, and the  finger to be
introduced, in order, if poffible, to difeover the fituation of
the ftone; a pair of forceps (pi. iv. fig. 1, 4.)  is then to be
carried  along the gorget  or direaor into the bladder,  and
the latter is then to be taken out  flowly,  and in  the fame
direaion in  which it was entered, left  any part might be
cut unneceffarily.
  If the ftone has been previoufly difcovered by the finger,
it is commonly eafily laid hold of with the forceps; but
when its  fituation  is not known, it is often difficult to
meet with it.   The forceps muft neceffarily be introduced
fhut; but as foon as they have  entered the bladder, they
                                                    fhould

  *  Mr.  Bell fays, that his cutting direBor, from expanding more in the cut-
ting part, divides the proftate gland, &c. much better and more freely
than  the gorget •, and from  being more contracted in  the  blunt part,
gives lefs chance of injuring the urethra,  by bruifmg or lacerating it—
But  the contufion or laceration of the urethra or bladder is not  occafion-
ed by the blunt part  of the gorget, but by the extraction of the ftone,
particularly when it is large;  in which cafe, an enlargement of the wound
with the  fcalpel, upon the ftone, is perhaps preferable to breaking it with
the forceps.  Mr. Bell's cutting director does not apricr.r to poffefs as muck
certainty  in its direction and management as Mr. Hawkin's cutting gor* <
get; and ftill wants the tell: of more general experience to recommend it. 
[   r?7  '3
fliould  be gradually opened,  and  there moved about in
various  direaions,  until  the ftone  can  be laid hold of.
When  the calculus  is fmall and difficult to find,  it is moft
frequently concealed in the lower part of the bladder  near
its neck; in  this cafe it may be brought within reach of the
forceps  by  introducing the  finger  into  the reaum,  and
thus elevating this part of the bladder.*
  When the ftone is got within the forceps, the operator
fhould  introduce his finger, to  difeover whether it is  pro-
perly fixed;  and if  he finds that a ftone of any confider-
able length is laid hold of in fuch a manner as to make its
longeft  diameter  prefs  tranfverfely  with  refpea  to  the
opening in the bladder, it fhould be turned with the finger;
or if this cannot be done,  it fhould be fuffered to  flip out
of the inftrument, and again be laid  hold of, if poffible, in
a more favourable   pofition.    The  furgeon  fhould  then
gradually  extraa it; having his  right hand  firmly  fixed
on  the extremity of the handles of the  forceps, and the
                           Z                            left

  * Mr. Bell  tells us that when much difficulty occurs in difcovering a
ftone, it has been alledged that it  is often contained  in  a cyft;—he
acknowledges that the  ftone is often covered with coagulable lymph,
which gives the appearance of a cyft or bag,  but fays we are unacquaint-
ed with any procefs by  which an adhefion can be produced between the
ftone and bladder; and that diffection  has never difcovered one well au-
thenticated inftance of this kind.  But the following cafe would feem to
render this opinion fomewhat doubtful.
  A boy about fixteen years of age had fuffered the fevereft fymptoms of
the  ftone for feveral years, has been frequently founded by many gentle-
men of the profeffion, but no ftone could be felt; at length it was nightly
touched  by one of them.  The operation was then determined on, and
when the operator had introduced his forceps into the bladder, no ftone
could be found; upon which he introduced the fore-finger of his left hand
into the bladder, and was enabled to feel a fmall portion of the ftone thro'
an orifice of an apparent cyft in which it was contained;  then carrying
the  cutting gorget upon  his finger as a director, introduced the beak in-
to the orifice, dilated the cyft, and turned the ftone into the  common ca-
rity of the bladder, when it was readily laid hold of, and extracted. 
                      C  178  3
left near to the common axis,  and making the preffure al-
moft downwards, in the courfe of the wound,  becaufe he
will thus meet with  lefs  refiftance,  and do lefs injury, than
by preffing in all direaions as  we arc commonly advifed.
  When there  is confiderable refiftance to  the paffage of
the ftone, the ftate  of the divided  parts fliould be examin-
ed; and if  any part of the mufcles which fhould havd-
been cut are flill found  entire, they fhould be immediately
laid open with the fcalpel, while the forceps is held firm-
ly in the left hand.
  As the rifk of this operation is in a great meafure pro-
portioned to the fize of the ftone,  it  would perhaps be ad-
vifable,  whenever this  is fo great as to endanger much
injury to the parts through which it  is to be extraaed, to
endeavour to break it with the forceps already introduced,
or with a pair  with very large teeth and a fcrew.  When
this is done, all the fragments muft be carefully removed
by the forceps or feoop, or by injeaing large quantities of
warm water.
   When  a  ftone is extraaed with a fmooth polifhecf fur-
face,  it is commonly fuppofed  that  there  are others re-
maining in the  bladder, and e contra; but  no dependance
can be placed on this;  and therefore,  as foon as  one ftone
is extraaed, the operator ought  to fearch  firft with hkf
finger,  and afterwards with the  forceps,  or  what is better,
the fearcher,*  as long as any ftones are  to be difcovered.
   The  hemorrhagy from the urethra and  bladder fhould
not, in general,  be reftrained,  until the ftones are all ex-
traaed, as  it  tends to prevent inflammatory  fymptoms;
when  this is accomplifhed,  ligatures may  commonly be
made on the arteries, but if  this  cannot be accomplifhed,
a large  canula,  (pi. v. fig. 2.)  covered with linen, will ufu-
ally anfwer to comprefs them.  But fometimes it happens,
                                                   that
   * An inftrument in the form of a found, except that it is made gradu-
ally fomewhat larger from the beginning of the curvature to the end. 
                       C  *79  3
 that notwithftanding every precaution,  fome of the deeper
 feated veffels will continue to pour out blood, which colfeas
 in the bladder in great quantities.  In thefe cafes,  as much
 as poffible fhould be taken out with a feoop, (pi. iv. fig. 2.)
 and warm  water then injeaed to remove the remainder.
 In fome inftanees, when this  has not been done, the blad-
 der  has by degrees become  filled by a bloody coagulum,
 which has prevented the fecretion  of urine, and at length
 occafioned death. In order to prevent fuch an  unfortunate
 occurrence as much as poffible, the patient fliould, imme-
 diately after the  operation, be placed with the pelvis low,
 fo as to keep the wound in a depending fituation.
   As 'foon  as the hemorrhagy  has ceafed,  the  patient
 fhould be untied, and a piece of foft  lint being  inferted
 between the lips  of the wound, the thighs fhould be laid
 together,  and the patient carried to bed; when  a large
 dofe of opium fhould be given to him.
   When  the ftone has been  eafily extraaed,  the patient
 remains tolerably free from pain, and frequently procures
 fome fleep during the firft three or four  hours after the
 operation; but  when the ftone has been large, and with
 difficulty extraaed, a fevere pain  in the lower part of the
 abdomen often fupervenes in an hour or two.  This  is fome-
 times eafily removed by fomentations and anodyne clyfters:
 but,  in other cafes, it increafes conftantly,  and  when with
 this, a  hardnefs and fwelling of the abdomen occur, fulnefs
 and quicknefs of pulfe, which go on to be augmented, much
danger is  to  be  apprehended.  As thefe fymptoms origi-
 nate from  inflammation, bleeding, clyfters, warm  flannels
 or bladders of warm water to the abdomen, fliould  be ufed
freely,  according to circumftances; and particular  benefit
is often derived from the femicupium.
  Thefe remedies, together with opiates, low diet,  and di-
luent drinks,  will frequently remove very alarming fymp-
toms :  but in fome inftanees,  notwithftanding every thing
                                                 that 
                      [   i so   3
that is ufed, the pain and tenfion  of the abdomen increafe;
the wound has an unfavourable appearance;  the feverilh
fymptoms augment; and death at length clofes the fcene.
   When the cafe terminates happily, the wound by degrees
acquires a healthy afpea;  the urine in fome inftanees paffes
by the urethra from the beginning;  but in moft cafes, it
comes away by the wound  for the firft two or three weeks;
the pain in the abdomen gradually abates ;  and the feverifh
appearances are in a fhort time entirely  removed.
   The cure is perfeaed in a longer or fhorter period ac-
cording to  the  circumftances of the patient's  health.  In
a  few cafes of young healthy boys, I have  known the
wound cicatrifed in lefs than three weeks; but in others,
this  is not accomplifhed till  the  fixth,  feventh, or eighth
week.  In fome inftanees  again, although a great part of
the wound is healed readily enough, yet a fmall opening is
left, at which the urine continues  to be difcharged, and
which at length becomes fiftulous; this cannot be relieved
but by another operation,   The prevention of  fuch an oc-
currence depends very much on  a  proper dreffing of the
wound.   The dreffings fhould be light, and care fhould be
taken that the fore  heals properly from  the bottom.
   In order to prevent a  troublefome  excoriation of the
buttocks,* which is apt to be occafioned  by the conftant
paffage of the urine over them, they fhould be frequently
wafhed with brandy, or with lime-water.
   In patients  of a weak habit, an incontinence of urine is
apt to fucceed to this operation;  this commonly goes off
upon a recovery of the former ftrength ; which will be much
aided by a ufe of the cold bath, of Peruvian bark, and of a
nourifliing diet.   As palliatives for  incontinence of  urine,
a  jugum for compreffing the urethra, and a receptacle for
                                                    the

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

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


                    SECT.  V.

                    Of Nephrotomy.

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

  * The fame objection appears to be applicable to  Mr. Bell's cutting
director, and will continue unlefs that inftrument acquires a fanction by
future experience. 
                      [  184   3
in the ufual way—it is apt in fome inftanees to become fif-
tulous.
                   SECT.   VI.

                Of Stones in the  Urethra.

   In  calculous complaints  ftones  are often paffed  with
 the urine; and when they are pretty large and rough, they
 frequently lodge in the urethra, and produce pain, inflam-
 mation and fwelling of the parts, and always a partial, and
 often a total fuppreffion of urine.   In fome inftanees, when
 the difeafe is long negfeaed,  this fuppreffion  and confe-
 quent tumor,  terminate in  a rupture of the  urethra;  to
 which fucceeds a diffufion of the urine into the cellular
 fubftance of the penis, fcrotum, and perineum.
   When the fymptoms are not very violent indeed, blood-
 letting, general or topical,  according  to  circumftances
 fhould be  ufed; warm  oil fhould be injeaed frequently
 into  the urethra; the  patient fhould  be immerfed  in a
 warm bath; a full dofe of  laudanum  fhould be  given  to
 him,  in order  to  remove the fpafmodic contraaions  of
 the urethra, which often very much impede the paffage  of
 the ftone:  And the patient fhould carefully avoid taking
 any thing  which  will increafe the quantity of the urine;
 as this will probably in moft cafes augment all the fymp-
toms.
   As foon as  by the ufe of the  above  remedies  there  is
 reafon to  fuppofe a relaxation is produced, the  furgeon
fhould endeavour, by gentle preffure, to pufh the ftone for-
ward  along the courfe of the urethra : But no ihftruments
fhould be ufed to extraa it; for  thefe often do injury by
irritating the membrane of the urethra.
                                                When 
                      [   iBs   3
  When a fuppreffion of urine is induced, it becomes ne-
ceffary to have recourfe to  an operation, as foon as the
means above  recommended are found ineffcaual.   If the
difcharge of urine is praaicable,  from the urethra not be-
ing entirely filled by the ftone, the  patient is fometimes in-
duced to let  it  remain from  dread of the operation.  In
fuch cafes,  the calculus often  acquiies, in a  fhort time, a
great increafe of  (ize by the depofition of earth from the
urine.
   When calculi in the urethra arc to be removed by an
operation,  this is performed by cutting direaiy  upon them,
and taking them out with  a  fcoop, or  forceps;  but  the
method of doing this muft  vary  according to the fituation
of the ftone.
   If the ftone is  fixed in the  canal  near the  bladder, it has
been advifed to pufli it back into the bladder by a ftaff;  but
 as it might  there acquire a  larger fize, and render litho-
 tomy afterwards neceffary, it is much more eligible to ex-
 traa ir.  In doing this, the patient fliould  be fecured  on
 a table in the manner direaed for lithotomy; and an  af-
 fiftant fufpending the fcrotum and  penis, the furgeon, after
 oiling the  firft  and fecond  fingers  of his left hand,  fliould
 introduce  them into the anus, and with them  prefs firmly
 on the parts immediately behind the ftone; an  incifion is
 then to be made through  the teguments and urethra down
 to the  ftone, which fhould be removed by the preffure of
 the fingers behind it, or by the forceps or fcoop.   The af •
 ter treatment muft be fimilar to that of lithotomy.
    When a ftone is fixed  farther  fojv/ard in  the  urethra,
 the fkin fliould  be drawn as  much as poffible pall it; either
 backward or forward ; and  the ftone  being  then fecured
 by preffure, a  longitudinal incifion fliould be made upon it
 through the urethra, fufficiently large to admit of its eafy
 extraction by  the forceps or fcoop.   The edges  of  the
  wound are afterwards to be entirely cleared of fabulous
                            /v a                  matter, 
                      [   186  3
matter, and the fkin allowed to regain its former fituation;
by this means the wound  in  the urethra will  be entirely
covered  by fkin  that  has not been injured,  and it will
ufually heal by the  firft intention.   If, however, any urine
fhould  efeape  into the  cellular  fubftance  through the
fore, it muft be fet out by an incifion.
   When the ftone is fo near the end of the penis as to be
feen, it may often be removed  by a fmall pair of forceps;
and this may be facilitated, when neceffary,  by dilatation
of the urethra  from its extremity.   But when  this fails,
an incifion muft be made,  as before direaed.   Soft dref-
fings  fhould be ufed ; and when the wound is nearly healed,
a hollow bougie, a  fhort filver  tube, or a fmall catheter of
elaftic gum, fhould  be  introduced into  the  urethra, in or-
der to preferve its proper fize.
   The moft unfavourable fituation in the urethra for a cal-
culus  is juft below  the fcrotum; for if it makes  its way
into the fcrotum, or it is neceffary to make  an incifion up-
on it, large and troublefome colfeaions of  urine are very
apt to be produced : as foon, therefore, as1 it  is difcovered
in this fituation, it  fhould, if poffible,  be  pufhed  farther
forward or backward : but if thefe fhould both be imprac-
ticable, we ought  to begin the incifion at  the under part
of the fcrotum, immediately on one fide of the feptum, and
continue it upwards till the ftone  is diftinaiy felt, when it
is to be laid bare, and extraaed in the  manner  already di-
reaed.  This  manner of making the incifion gives  a free
paffage to the urine  that efcapes from the urethra, and ren-
ders the extraaion of the  calculus eafy.  During the ope-
ration an affiftant fhould  keep the  teftis out  of the way;
and care fhould be afterwards taken that the  wound heals
from the bottom.        ,
  When urine continues to be difcharged by  a preternatu-
ral opening of the urethra, for any  length  of time,  if the
calculous diathefis remains, ftones of a large  fize will fre-
                                               quently 
                      [  i87   3
quently form in the  cellular fubftance contiguous  to the
opening; they  fhould  be removed by incifion,  the  for-
ceps, and fcoop, and the wound then carefully healed from
the bottom.
  In females, ftones feldom become fixed in the urethra;
when they do,  they are commonly eafily removed by infi-
nuating the end of a blunt probe behind them, and then
pulling it forward; or  when this does not fucceed,  it may
be effeaed with fafety by cutting open the extremity of the
urethra,  fo as  to admit a pair  of forceps to extraa the
ftone.
    CHAP.    XV.

Of Incontinence of Urine.*
     THE ufual  caufes of this difeafe may be reduced to
      the following heads.
   i. Irritation about the neck of the bladder, produced by
the friaion  of ftones  contained  in  it.   Hence it is fre-
quently  a fymptom of calculus;  and is entirely relieved
by lithotomy.  When  this is not to be employed, it is often
confiderably alleviated by remedies which dirainifh the ir-
ritability of the bladder;  particularly by a free ufe of mu-
cilaginous drinks, and of opiates.
   2. Paralytic affeaions.  In thefe  cafes it is often  only
a  part  of  general difeafe;  the  fphinaer  appearing to
                                                  lofe
*  Enurefis. 
                        C  188   3                         1
  lofe  its power  of contraaion entirely',  while the detru- * 1
  for urinas or mufeular coat of  the bladder retains its full
  vigour.  The remedies to be here employed are tonics,   I
  particularly  peruvian  bark,  chalybeates,  and  the  cold
  bath.—But the application of cold, by dafhing water on
  the  perinaeum  and  anus,  is the moft  effeaual remedy.
  Cloths wet with vinegar and water, or  folution  of facch.
  faturni, have alfo been of ufe.
     3. Laceration in the operation of lithotomy, and in de-   ]
  livery.  In thefe cafes the fame remedies as were directed
  where the difeafe is the confequence of palfy, are to be em-
  ployed,  and frequently remove  the complaint.             ,
     But, in many inftanees, in all the  varieties of inconti-
  nence of urine, it happens  that no cure can be obtained.
   In fuch,  all we can  do is,  to  prevent the urine from in-
   commoding the patient as much as poffible.
     When  the difeafe originates from  pally or laceration,
   compreffion of the urethra by the jugum or yoke, (pi. xi.
v   fig. 2.; anfwers this  purpofe very effeaually.  For wo-
   men, peffaries of fponge may be employed ;  but if the ir-
   ritability of the parts  do not  admit of thefe,  peffaries of
   ivory or  any  folid wood, made  very fmooth  and  oiled,
   fhould be placed acrofs in the vagina.
     When  the  incontinence proceeds  from irritation  about
   the neck of the bladder, thefe inftruments cannot be ufed:
   In  fuch  cafes,  all that can be  done is  to  f_t*a  convenient
   refervoir  for the urine to the penis in men, (fuch as in pi.
   xi.  fig  k) and to apply fponge and foft linen,  to abforb it
   in women.
CHAP. 
[  i3o  ]
            C   H    A   P.    XVI.


          Of a  Suppreffion of Urine.*

                   -nunrt •IfiHWTifrn.....    —

     AN impediment to  the evacuation  of urine from  the
      bladder,  conftitutes a  very  alarming, and general-
ly very painful difeafe.   It may originate;
  i. In paralyfis,  and particularly paraplegia, from the  bo-
dy of the bladder lofing its  power of  contraaion,  while
that of the fphinaer is  retained.   It is alfo thus frequent-
ly induced from a too  long  continued and voluntary  re-
tention of the urine.  In  thefe cafes, the introduaion of
the  catheter, (pi. v. fig. 3.)  which  is fimilar to  the
operation of foundingf, proves commonly  a  certain  re-
medy; and when the complaint  is produced in the man-
ner  laft defcribed, it will  contribute much to a permanent
cure to  ufe  the catheter conftantly, as foon as  an  incli-
nation is  felt to difcharge the  water colfeaed.
  2. From the  uterus,  in the  laft months of pregnancy,
preffing upoy^the neck of the bladder.   In fuch cafes, as
the  catheter is  very eafily introduced  in females, in  or-
der  to prevent  an over-diftenfion  of its  coats or a rup-
ture of them, it will be  proper  to  ufe it  conftantly  when
any difficulty ia voiding  urine occurs.
  Tumors in the vagina and neighbouring parts, when laroe
often comprefs the urethra likewife in iuch a  manner as to
induce a fuppreffion of  urine; it is alio a frequent confe-
quence  of prolapfus uteri.   Until the removal of thefe
                                               caufe;,

             * Ifchuria.    f Chap. XIV. Sed. If. 
                     C   19°  3
caufes, the catheter  fliould  be employed occafionally  as a
palliative.   When it  is advifable to  let a catheter remain
in the urethra conftantly,  as  thofe of filver give  a  great
deal of irritation,  we  fhould always employ the catheters
made of the elajlic refin or gum.
  3. From fchirrofities of the proftate gland, obftruaions
in the urethra from gonorrhea,  and ftones  impaaed in
the urethra.  The latter cafes have  been already treated
of, and the former will be the fubjeas of a chapter here-
after.
  4. From inflammation about the  neck of the bladder.
When this arrives to  fuch a degree as to prevent the in-
troduaion of the catheter, it cenftitutes  the moft alarming
variety of this complaint.
  This fpecies often arifes from  a  communication of in-
flammation from the urethra, in cafes of gonorrhoea, pro-
duced by  the improper ufe of aftringent  injeaions in that
difeafe.  It may alfo originate from the  general caufes of
inflammation.
   The treatment fhould confift in general bleeding; the
application of  leeches to  the perinasum  ; the large ufe of
opiates;  the  frequent  employment of  clyfters of warm
milk or water; and the general ufe of the warm-bath.
   When  all  thefe remedies fail,  and the introduaion of
the catheter is  impoffible, we have no means of relief left
but punauring the bladder.
   There have been feveral modes of effeaing this propofed.
Mr. Sharpe, and others, advife the bladder to be perforated
 above the os pubis; this may be done with a common tro-
 car, and with moft propriety about an inch or an inch and
a half above the fymphyfis pubis.   As foon as  the ftiUette
 has entered  the bladder, it fliould be withdrawn and the
 canula fhould  be fuffered to remain in the opening, and be
 there fecured by a ribband or tape carried around the bo-
                                                    dv. 
                      C   191  3
dy.  It muft be flopped by a piece'of cork, that the urine
may be evacuated only at proper intervals.
  The length of the canula fhould be particularly attended
to,  left it fhould injure fome  of the contents of the pelvis;
in fat  people it may be  two inches long;  but in others not
more than an inch and  an half.
  The bladder is more eafily punaured from the perine-
um than above  the pubes ;  the urine is  more readily eva-
cuated ; and there is  lefs danger of the  canula  flipping
out of it  and injuring the  parts adjacent:  and hence  I
am perfeaiy of  opinion that this  mode  fhould  be pre-
ferred.
   In  performing this operation, the patient fhould be laid
upon  his back, and his thighs being properly feparated and
fecured by affiftants,  an incifion of an inch and an half in
length, beginning at the commencement of the membra-
nous part  of the urethra,  and continued towards the anus,
parallel to the  raphe,  and half  an inch from  it,  fhould
be  made  through the fkin  and'cellular fubftance.  The
trocar fhould then be pufhed into the bladder, a little above
and to  the left of the proftate gland, and if the point' of
the inftrument is fomewhat  raifed, there will be no dan-
ger of wounding the uterus or vafa deferentia.   In order
to kuow when the trocar  has  reached the bladder, thefe
fhould be a groove in  the ftiUette to admit of an immedi-
ate difcharg»of urine.
   As foon as the urine is evacuated, the canula fhould be
fecured in the  wound by tapes,  or a ribband  conneaed
with  it, and a bandage paffed around the body.
   Whether the  punaure is  made above the pubes, or in
the perinaeum, it will  be  proper to withdraw the canula
once  in two or three days, in  order to clean off the fabu-
lous  matter that will colfea on it,  and which might, if it
was fuffered to be depofited in confiderable quantity, pre-
                                                  vent 
                     [   i92  3
vent the canula from being eafily removed.  The canula
fliould remain  till the urine can be evacuated by the ure-
thra.
  It has been advifed  lately, to  punaure the bladder
through the reaum;  but as this would give confiderable
rifk of wounding the ureters,  vafa deferentia, or  veficulas
feminales, and might  afford a paffage of  faeces  into the
bladder, it fliould certainly never be employed.
  When it becomes neceffary to punaure the bladder in
women, it can be performed always with mofl eafe and cer-
tainty from the  vagina.  In  doing ir, the  fore-finger of
the left hand fliould ferve as a direaor to the trocar,  and
the perforation fliould be made in the  part firft felt, in or-
der to avoid the ureters.  The canula is  to  be left in the
wound as long as the caufe  of the fuppreffion exifts,  and
fhould be long enough to pafs  out of the  vagina, to be
there fecured by tapes conneaed to the T bandage.
       CHAP.   XVII.

Of Obftru&ions  in the  Urethra.
     OBSTPvUC TIONS iii the urethra are moft frequently
      the confequence of gonorrhoea, and confift;
   I. In caruncles or  ficihy excrefcences from the  mem-
brane lining the urethra.  Thefe,  according to my  obfer-
vation, are fimilar to  thofe warty excreieences which fo
often appear on the glans and prepuce as a confequence of
gonorrhea   and   generally   accompany them.—I   have
never found them farther up the canal  than half an inch
                                                 from 
                      [  193   3
from its extremity : Mr. Daran fays he has often feen them
in every part of the  urethra;  but  it is evident  that he
confounds them with the other caufes of  obftruaion.
   2. In ulcers and cicatrices from ulcers.   Ulcers  are
certainly produced in  the urethra in fome cafes of gonor-
rhaza.  Thefe originate, in many inftanees, from inflamma-
tion ; but  in  others merely from the mechanical effeas of
the poifon.  I have feldom found them more than an inch
or two from the end of the penis.                      .,
   3. In a contraaed ftate of the urethra.   Although this
may ufually be the confequence  of ulceration, yet there is
every probability that it may be produced folely from  in-
flammation thickening the  parts it affeas.  Aftringent
injeaions,  improperly ufed, may fometimes be confidered
as the caufe of this fpecies of  ftriaure.
   4. In a  total or partial obliteration of the canal,  from
the preffure of tumors formed either in  the cellular fub-
ftance of the urethra, or in the glands conneaed with it.
This may be the confequence of inflammation from any
caufe; and when inflammation terminates  in fuppuration,
the obftruaion  is ufually removed by  the difcharge of
matter; but when this does not take place, and the fwel-
ling  is of  long continuance, the oppofite fides of the ure-
thra  become conneaed,  and produce a total fuppreffion of
urine, unlefs,  which indeed commonly  happens, preter-
natural openings are formed by the force of the urine.
   5. In an enlargement of the corpus fpongiofum urethras.
This fulnefs or thickening is perhaps the moft frequent
caufe of obftruaion, and it has proceeded to fuch a degree,
in fome cafes, as entirely to  prevent  the paffage of  the
urine.  It fometimes is confined to a  particular  fpot; in
other inftanees it extends a confiderable  diftance; and in
fome others it attacks different parts of the canal.
   When obftruaions of the  urethra arife from  caufes
enumerated under the  fourth head, the treatment muft be
                        B  b                  direaed 
                      C   194   3
direaed by the particular nature of the tumor or tumors
When they are indolent or fchirrous, and do not penetrate
deep, they may be extirpated;  but when  the proftate
gland, or any of the parts about the neck of the bladder
are affeaed with fchirrus or ulceration, we can only at-
tempt a cure by internal remedies.  Of thefe,  cicuta has
been much ufed, but feldom with advantage.
   In  cafes  of ulceration", uva  urfi has been found to give
relief; but a long continued and gentle courfe of mercury
gives the greateft profpea of  benefit.   In the mean time,
mucilaginous drinks and opiates muft be freely ufed as pal-
liatives.  When the tumors are inflammatory, if they can-
not be difcuffed, they fhould be brought to fuppuration as
fpeedily as poffible, and as foon as a fluauation of fluid
is  perceived in them, they fliould be opened.
 * If on difcharging the matter, the obftruaion  is not en-
tirely removed, a bougie or flexible catheter fliould be in-
troduced, and allowed to remain feveral hours  every day
until the paffage is entirely cleared.
   When the urine, from its obftruaed flow by the ure-
thra, forms  openings  from it through the perinseum and
other contiguous parts, it produces a very diftreffing com-
plaint.  This will be confidered in the next  chapter.
   In all the other cafes of ftriaure we have enumerated,
if  the venereal difeafe  fubfifts in the habit,  it muft be re-
moved by mercury, at  the fame time that we pay attention
to the topical affeaion.  As all of them operate by in-
ducing a diminiflied capacity  or contraaed ftate of the
urethra,  bougies, which by their preffure tend to remove
this,  are our principal remedies.   Independent of their
mechanical power,  it is fuppofed by  many  that the good
effeas of thefe are, in a great meafure, to be  attributed to a
fuppuration excited by  their irritation on the difeafed parts;
and  hence  they have been often compofed of ftimulating
ingredients.  But I  am of opinion that this is not the cafe;
                                                becaufe 
                      C  J5>S   3
becaufe caruncles, which are fuppofed to exift commonly
when bougies  are found ferviceable,  do not in fa& occur
in more than  once  in  ten fuch cafes, and when they do
exift, they are commonly of a warty  nature, and confe-
quently not likely to be removed by fuppuration; and  be-
caufe their effeas may  readily be accounted for from their
preffure only.
   It muft be  evident  that  in general  medicated bougies
fhould therefore be  difcarded from ufe; becaufe the irri-
tating ingredients of which they are compofed, muft pro-
bably often do injury to the urethra.
   Bougies fhould be formed of mild ingredients, and made
very fmooth;  and great care fhould be taken to have them
of a proper confiftence.  If made too hard they are apt to
crack, and cannot be introduced or retained with eafe; and
if too foft they do not give a fufficient degree of preffure.
   The beft compofition for bougies, that I know of, is as
follows :
   &. Emplaft. Diachyl. Simpl. §iv.
      Cerse purifs.             §ifs.
      Ol. Olivar. opt.          5iii.
   The diachylon fhould be flowly melted,  and the wax
being melted in the oil in a  different veffel, they  fhould
then be mixed ; and while the mixture  is tolerably  warm,
let pieces of fine old linen be dipt in it; care being taken,
by means  of a  fpatula,  to cover  the whole linen equally,
and to make the plafter as fmooth as poffible.
   As foon as  the cloth is fufficiently cold, it may  be cut
with a fharp pointed knife direaed by a ruler, into pieces
from nine to eleven  inches in length,  and fomewhat wider
at one end than the other, for the formation of the bougies.
They fhould be made of  different widths; the middle-
fized bougies will be formed by  flips of .about five-eighths
of an inch broad at the largeft  end.  On account  of  the
facility of introduaion it will be neceffary to make them
                                                 taper 
                      C   196   3
taper more or lefs, from about two or three inches from the
fmaller extremity.
  The ftrips  of linen are to  be rolled up as  firmly and
neatly  as  poffible by the  fibers;  and in  order to  give
them a fmooth poliffied furface,  they  fhould befoiled for
fome time between a piece  of fmooth hard wood, and a
plate  of finely  polifhed  marble,  and  the  points  bei_g
rounded,  they are then fit for ufe.
  In the application of the bougie, one adapted to the fize
of the  paffage being fefeaed,  it fhould be well oiled, and
the penis being firmly grafped and  extended  with one
hand, the point is to be inferted into the urethra  with the
other,  and pufhed forward with  caution until it meets with
the obftruaion; the bougie fliould be preffed beyond this,if
a moderate force will  accomplifh it;  if not, it fliould be
withdrawn,  and  one with a fmaller point ufed the fol-
lowing day.
   By  repeated cautious  trials,  bougies  may  perhaps, in
every inftance, be paffed ; but in ufing them, whenever the
points yield  in  any degree,  they fhould be  immediately
withdrawn,  as they will not then  go forward,  and their
extraaion may be rendered painful if they become twifted.
   Catgut alone, fmoothed by rubbing on marble, or with
the compofition  abovementioned, forms  bougies of a fuf-
ficient degree of firmnefs for  common purpofes.
   In order to prevent bougies from flipping into the ure-
thra,  or bladder, they fhould be tied by  a  piece of foft.
thread or tape to the penis, or to a bandage paffed around
the body.
   The length of time they fhould be fuffered  to remain in
the urethra,  muft be entirely regulated  by the  degree of
pain or uneafinefs  they  occafion ; when this is confider-
able, they fhould not be allowed to remain long, nor be em-
ployed oftener perhaps than once in two or three days; in
this cafe they ought not to  be ufed  but when the patient
                                                   can 
                      C  ^97   3
 can confine himfelf to his bed, or at leaft to his apartment:
 but when they give little or no pain, they  fhould be worn
 as conftantly as poffible.  The bougie fhould be gradual-
 ly increafed in fize until it  fills the whole urethra;  and
 they fhould  be ufed for  a confiderable time after the dif-
 ficulty in paffing water goes off entirely. Great care^iould
 be taken that they never pafs into the bladder, as a part of
 them might fall off, and form the bafis of a ftone.   When
 the obftruaion is  feated  very near to the bladder, a cathe-
 ter fliould always be made ufe of inftead of a bougie.
   Various forms  • of flexible catheters to remain  in the
 urethra have been employed; the  moft convenient that I
 have feen confifts  in a tube formed of flexible filver wire,
 wrapped fpirally round a fleel probe; and this being cover-
 ed with a piece of bougie plafter,  and the probe being then
 withdrawn,  the inftrument is thus completed.  Thefe ca-
 theters are not fo ferviceable, however, as has been ex-
 peaed: and they fhould never be fuffered to  remain long
 in the bladder, on account of the plafter on them.  When-
 ever it is neceffary to leave a flexible catheter  in the blad-
 der,  thofe compofed of  the  elaftic refin or gum, fhould
 be employed in preference to them.
  Although in general the bougies,  compofed as above di-
 refted, are to be made ufe of; yet when there is reafon to
 fuppofe there  is  a  venereal  ulcer in  the urethra,  about
two ounces of quickfilver, extinguifhed by honey, fhould
be added to every fix ounces of  the plafter when melted.
  In women, bougies fhould always be employed for the
fame purpofes as in men ; but it often happens that tumors
of fuch a fize  form in the urethras  of females,  that it is
neceffary to  employ a ligature,  or the fcalpel, to remove
them.  By thefe,  even tumors that are conneaed with the
bladder,  may  be  taken off.   In fuch cafes,  the urethra
 fhould be laid open on one  fide,  and  the  vagina need not
 be at all injured.    But  they fliould not be meddled with,
                                                unlefs 
                      [  198   3
unlefs they give a great deal of uneafinefs, or obftruft the
paffage of the urine very much.
  Inftruments for the application of cauftic to carnofities
in the urethra, have been invented and ufed; but it is evi-
dent,  that there muft be great rifk  of injuring the found
parts from this praaice.
      CHAP.    XVIII.

Of the  Fiftula in  the Perinseurn.
    BY the term fiftula in perinaeo is underftood a fmuous
     ulcer in this part, extending moft frequently to the
nrethra, fometimes to the bladder, and in other inftanees
terminating in the fcrotum or penis.
   In fome cafes there is but a fingle opening, and the con-
tiguous parts remain  nearly in their natural ftate: but in
others,  together with one or more external openings, there
is a hardnefs,  enlargement, or inflammation of the parts
adjacent,  extending, in  fome inftanees,  from the anus to
the fcrotum and fore-part of the penis.  And as the urine
is more or lefs  evacuated at the orifices  in moft  inftanees,
they are often produaive of much diftrefs.
   The caufes of fiftula in perinaeo are;
   i. Wounds and other injuries of the  urethra and blad-
der from external violence.  Thus it is now and then  the
confequence of lithotomy, or of cutting into the  urethra for
the extraaion of ftones.
                                                2.  In- 
                      C   »99  3
   2. Inflammation in the urethra terminating in fuppura-
 tion, and difcharge of matter through the perinseurn.  This
 is moft  frequently the confequence  of  gonorrhsea.   Ab-
 fceffes formed  in the foft  parts about the anus, and  ex-
 tending to the urethra, alfo occafion perinseal fiftulse.
   3. The feveral circumftances produaive of obftruaion
 in the urethra,  and enumerated in the laft chapter.  Thefe
 by impeding the flow of urine through its natural channel,
 frequently induce this complaint.       t
   All thefe caufes tend to produce fiftula;  1. By the for-
 mation of a paffage direaiy into the urethra or bladder, by
 external violence, or ulcers and abfceffes feated internally;
 which may occur independent of any obftruaion to  the
 paffage of  the urine.
   2. By the fole influence  of obftruaions in the urethra;
 in confequence of which the urine occafions a rupture of
 the urethra.
   In the treatment of the difeafe, it is of the utmofl con-
 fequence that we attend to  the mode of its produaion as
 thus explained; and as it is fometimes conneaed with fy-
 philis, fcrophula, or fcurvy, it is evident  that in fuch cafes
 general remedies muft be conjoined with the topical appli-
 cations.
   When the difeafe is local,  and  proceeds  from obftruc-
 tions in  the urethra, and  the parts  through which the
 opening runs are not much  affeaed, the bougie, applied in
 the manner direaed  in the preceding chapter,  is almoft
 the only remedy neceffary, and it is commonly effeaual.
 When the obftruaion is removed, which may be known
 by the inftrument paffing  in without  impediment, and  by
 the urine flowing in a full ftream when the orifice at the
fore is compreffed ; if the ulcer does not  foon heal, it will
generally be found owing to the edges having become
callous.  Thefe muft therefore be removed in the follow-
ing manner.  The patient muft be laid upon a table, near- 
                     [   200  ]
ly in the pofture  recommended in lithotomy, and  a ftaff
being introduced into  the urethra,  fo as to pafs the open-
ing,  it  is to be held firmly by an affiftant,  while  the fur-
geon introducing a fmall probe  at  the external orifice of
the fore, and cutting upon it in the direaion of the finus,
is thus  to lay it open its whole length, even if it extends
to the bladder.  All the finufes,  in whatever direaion they
run,  muft be  treated in the fame way.
  When any of the parts through which the finufes run,
have become extenfively  hard,  a fmall  portion  of thofe
that  lie moft contiguous  to the fores may be removed,
and  the remainder  will commonly be  taken off by the
fubfequent fuppuration.   The ftaff fhould be now with-
drawn, and the divided parts gently feparated by the intro-
duaion of lint, fpread with fome  emollient ointment; a
pledgit of ointment is then to be  placed over the fores, and
fecured by compreffes  and the T bandage.
   About twenty-four  hours after the operation, an emol-
lient poultice fhould be applied over the  dreffings  ;  and as
foon as a free fuppuration comes on, the whole is  to be re-
moved, and light eafy  dreffings fhould be continued  till the
fores are healed from  the bottom. The fuccefs of the ope-
ration  chiefly depends  on a regular and careful application
of dreffings.
   It has ufually been  the praaice to keep a bougie or  ca-
theter  in the urethra  as  conftantly as poffible after this
operation, in order to  prevent, it is faid,  an  improper con-
traaion of the urethra, and the  paffage of the urine out at
the wound.   But, from much experience, I can pronounce
that the wounds heal perfeaiy well without them; and that
when  they are employed, they  keep the urethra  fo much
diftended, that they prevent the  ready healing of the fores ;
are not effeaual in hindering the urine from paffing off by
the  orifices,  if not  paffed to the bladder,  and if they are
                                                paffed 
                      C   201   ]
paffed  fo far,  almoft conftantly excite pain, ^inflammation,
and fwelling about its neck.
  The paffage of the urine feems to be a very trifling im-
pediment to the  healing of the fores; after the operation
of lithotomy, it always paffes off by the wound ; a cure is
then in common foon obtained,  and the ufe of a catheter is
never thought of.   When indeed  fome ftriaure occurs in
the urethra after lithotomy,  or the  cutting the fiftulse, it
will be ufeful to employ bougies, as in other cafes,  but ne-
ver otherwife.
   When the  parts in the perinaeum have become much
 hardened and otherwife difeafed,  before  the operation is
 put in praaice,  we are commonly  direaed to  ufe poultices,
 mercurial  friaions, and gum  plafters; but  I have never
 feen any material  advantage derived from their  employ-
 ment.
   If the hardened  parts  are very extenfive, and the above-
 mentioned difcutients are ineffeaual, we are  ufually advif-
 ed to cut them entirely away:  but although it will be pro-
 per to remove  the callous edges of fores here, yet fuch a
 painful  operation as that muft be can rarely, if ever, be
 advifable.
    When  an  opening is  formed in the urethra by  abfceffes
 feated internally or externally,  or by external violence, in-
 flammation muft be moderated, or fuppuration promoted,
 &c. according to circumftances; and if the wounds do not
  readily heal, the  operation above defcribed  muft be infti-
 tuted.
    By the treatment recommended,  moft of the  affeaions
  we have juft  defcribed may  be removed; but where the
  difeafe  is very extenfive, and there is fome general com-
  plaint joined with the topical  affeaion,  we  are in fome in-
  ftanees baffled in all our attempts for a cure.
C c
C H A P. 
             [  202   3                       W


      CHAP.    XIX.

Of the  Hemorrhoids, or Piles.
      THE  term hemorrhois or piles is applied to tumors
       in the  reaum or its vicinity, produced either by a
 diftention of  the veins, or  of the cellular  fubftance, or
 both.
   When thefe tumors do not  difcharge any matter,  they
 receive the appellation of the hemorrhoides csecae or blind
 piles;  but  when a  difcharge  of blood or ferous  matter
 takes place from them, they are termed the apertae, open
 or bleeding piles.
   Hemorrhoidal tumors that  difcharge freely are ufually
 fmall; but when they do not  bleed much, or at all,  they  .
 have arrived fometimes to the fize of a pullet's egg.  In
 the firft cafe  they give little uneafinefs, but in the latter
 they produce  a great deal of  pain and irritation, and fre-
 quent tenefmus.
   Thefe fweUings have generally a dark livid appearance; •
 are at  firft foft, and can ufually be  much diminiflied by
 preffure; twhen they become  open,  they  acquire a firm
 confiftence,  and their fize is not leffened by preffure or by
 the difcharge from them.  When blind they are generally
 moft painful.
  While the tumors are fmall  and compreffible, it is pro-
bable they depend entirely on an enlargement of the veins;
but when they become  large,  and of a firm flefhy con-
fiftence, they are probably chiefly occafioned by the effu-
 fion of blood into the cellular fubftance.
                                                 The 
                      C  203   3
  The piles are ufually induced by a compreffion on the
hemorrhoidal veins.  This  compreffion is  moft frequent-
ly occafioned by hardened  faeces in the reaum; by  the
gravid uterus ; and by tumors  of the reaum, bladder,
mefenteric glands, &c.
  In the  cure, tumors muft, if poffible, be removed :—A
frequent  recumbent pofture muft be advifed during preg-
nancy ; and to obviate or remove coftivenefs gentle laxa-
tives, as  cream of tartar, and  caftor oil,  fhould  be  oc-
cafionally advifed.   If there is much  fever, blood muft be
taken, and particularly by leeches  applied to  the  tumid
veins—The fwelled parts fhould be bathed with a folution
of faccharum faturni;  and the patient fhould be kept upon
a low, cooling regimen.  An ointment of equal parts of
powdered galls and lard or butter, is a very ufeful applica-
tion ; and an infufion of galls injeaed in  internal piles  is
very ferviceable.   Balfam capivi is alfo very beneficial  as a
laxative and anodyne.
   When the difcharge  of blood in hemorrhois is fo great
as to debilitate the fyftem much, and the above means do
not reftrain it, it becomes neceffary either to comprefs  the
bleeding veffel or  veffels,  or  to  tie them.  In flight cafes,
 compreffion may  be  made by introducing a  filver tube,
wrapped round with foft linen ;  or perhaps better, by in-
troducing a  piece  of fheep's gut, tied at one end, into the
anus, filling this  by the other  extremity with water or
fome other fluid, and then tying the lower  end.
   If the  veffels are fo large as  not to  admit of effeaual
 compreffion, and are within reach of the tenaculum,  they
fhould be tied.
   When hemorrhoidal tumors  become fo  large as to ob-
flrua the paffage of  the  faeces,  but  never before,  they
fhould be removed.  If they  are feated externally, or not
much more  than  an inch from the end  of  the reaum,
                                                when 
                     C  204  3
when they can  be brought fufficiently  low, by bearing
down,  they may be eafily taken off.
  If the fwelling is fmall, and  there is  no reafon to fear
hemorrhagy, it  fhould always be removed by the fcalpel;
but when it is large, and we are apprehenfive  of a confi-
derable difcharge of blood, ligatures  fhould always  be
preferred to the knife.
  Tumors with a broad bafis may be fafely and eafily  re-
moved in the following  manner: a needle,  armed with
two firm waxed threads, being introduced through  the
middle of the bafis of the tumor, the ends of one of the
threads are to be  firmly tied round one  half of the fwel-
ling, and the other is then to be fecured in the fame man-
ner by the other ligature.  The  tumor  fometimes drops
off in  eight and  forty hours,  but  not  commonly  in  lefs
than three  days.  When the fcalpel is ufed,  the wound
is to be dreffed  with lint and foft ointment.
               CHAP.   XX.

Of Condylomata, and other fimilar Excrefcen-
               ces about the Anus.
     THE parts about the anus are liable to be affeaed by
      tumors which have received the various names of
condylomata,  fici, criftae, &c.  Thefe are all of the fame
nature, and require fimilar remedies.
  They are fometimes  met with in the cavity of the rec-
tum, but they moft frequently affea the external parts.
                                               They 
                      [  2°5   3
They are of various degrees of hardnefs,  being fometimes
quite foft, and at other times as firm as a fchirrus.  They
are differently coloured; fome being white,  and others of
different  fhades of red.  Sometimes there is  but a fingle
excrefcence or  two;  but moft  frequently all  the  parts
about the anus are at laft covered by them. They are often
not larger than warts;  in many inftanees, however, they
are about the fhape and fize of fplit garden beans.  They
feem at  firft  to be mere produaions  of  the cuticle; but
by long continuance  they extend  to the cutis,  or even to
the mufcles.
   Tumors of this kind fhould not be  touched unlefs they
become troublefome.   When they are to be removed, the
fofter kinds will often yield to friaion with fal ammoniac,
or wafhing with a folution of it, or to the ufe of finely pow-
dered favin.  But when the excrefcences are hard, the fcal-
pel, or lunar  cauftic, muft be employed.   The former is to
be preferred; and after the operation,  the wounds fhould
be treated with lint, &o as in other cafes.   When we em-
ploy cauftic, great care muft be taken that it does not fpread
to the reaum.
CHAP*. 
                      [  2o<5   3


               CHAP.    XXL


               Of a  Prolapfus  Ani.

                  ■»cM_fci«_%ti>»r* *•»»?-««-—--------■-

       AProtrufion of any part of the inteftinum reaum be-
       yond its ufual limits, is  termed  a  prolapfus ani.
This varies very much in degree in different cafes.
  Whatever tends to debilitate the fphinaer ani and adja-
cent parts, will probably contribute to the produaion of
this difeafe;  but its moft common caufe is frequent and
violent exertions excited in the reaum itfelf, by a frequent
ufe of  aloetics; by afcarides ; by habitual coftivenefs ; he-
morrhoidal fweUings, &c.
  The reaum has often remained in a prolapfed ftate for
a confiderable time without injury; but it  fhould always be
reduced as early as poffible.  This  is beft  effeaed by the
fingers, in the following manner: The patient being put
into bed, on his face, with his buttocks fomewhat elevated,
the furgeon fhould prefs firmly and equally upon  the pro-
truded part.  When this method fails, which is feldom the
cafe, a proper  application of the fingers of one hand to the
fuperior part,  while the palm of the other hand  fupports
the lower part, will always fucceed.
   We are to obferve that this operation  is only to be em-
ployed when there is no inflammation and fwelling of the
gut;  for when  thefe  occur, which  happens fometimes,
bleeding,  and  bathing the part with folution cf faccharum
faturni a little warmed  to remove them,  fhould be previ-
oufly ufed.
                                                    In 
                      [  207  3
  In order to  retain the  reaum in its fituation after re-
duaion, it will be commonly neceffary to employ a thick
comprefs  and  the T  bandage, or  Mr.  Gooch's  trafs.
The patient  fhould  always  reduce the  gut immediately
after going to flool,  and apply his bandage: And to- re-
move the debility of the parts affeaed,  he muft be di-
reaed to the ufe of fleel, bark, and the cold bath : throw-
ing water on the  buttocks and under part  of the back, is
particularly  ferviceable.   Injeaions of flrong aftringents,
as galls, oak-bark, &c. have alfo been ufeful:  and opium
may be advantageoufly added to remove irritability of the
reaum.   I have  ufed alum  and facch. faturni with bene-
fit ; but in general all falines fhould be avoided.

    nfi■!_■!! jinnmfTTOTrTma_r-ra_-ri-T'm-11 ■ mi n-sririT^nri-ii 1 'iniirriTP~l-r,_rT~if-fmTrrii-»-ii ■ m i inn mm
    CHAP.   XXII.

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

 Of the Fiftula in Ano.
    EVERY  finuous ulcer in the neighbourhood  of the
     reaum is termed a fiftula  in ano.  When the fore
has no communication with the reaum, it is faid to form
an incomplete fiftula;  when the ulcer  has two openings,
one into the reaum,  and another  externally,  it is called
complete: and when the fore opens into the gut only, it
is termed an internal or occult fiftula.
  This difeafe has alfo been diftinguiftied into  fimple  and
compound.  In the fimple  fiftula there is one or more
finufes conneaed merely with the internal ulcer, and the
adjacent  parts are  all found: but in the  complicated or
compound, the parts  through which  the finus ruus are
hard and fwelled ;  or there is a communication with the
bladder, vagina, os facrum, and other parts.
  In the beginning of the difeafe  the contiguous parts are
ufually found ; but after a long continuance of it, and the
difeafe has fpread  not only over the parts about the anus,
but even to the perinaeum and buttocks, thefe become hard
and much fwelled.
  When the  matter in the finufes  acquires a confiderable
degree of acrimony, inftanees have occurred in  which
the facrum  has  become carious,  and  the   vagina  and
bla"dder  have been corroded and had the contents  of  the
reaum emptied into them ; but fuch terrible cafes are very
feldom met with.
                        tj J                Whatever 
                      E  210  3
   Whatever tends to produce  the formation of matter
 about  the  anus,  may  occafion this  difeafe;  fuch as the
 piles;  condylomatous tumors ; hardened faeces in the rec-
 tum ;  and fevers.
   On  account of the  languid circulation in thefe parts,
 inflammatory fweUings are very apt to terminate in fuppu-
 ration ; and fores  thus induced heal with difficulty.
   As foon as fuppuration  appears to be coming on, there-
 fore,  we fliould employ every means to haften the forma-
 tion of matter; fuch as warm poultices, fomentations, and
 the fleams of water ;  and as foon  as pus is  produced, it
 fhould be evacuated by a very free incifion.
   The wound fhould be very lightly dreffed with  fome
 emollient ointment fpread upon  lint,  and a  foft poultice
 ought  to be applied  conftantly over the whole.   By this
 means  the hardnefs will be removed, and a cure will often
 be eafily accomplifhed.
   A furgeon is,  however, feldom  called until a fiftula is
 fully formed ; his firft objea fhould then be, to afcertaiih-
 the courfe of the finus or finufes.  When the  fores are
 external, this can eafily be done by the probe alone ; but
 when they run up by the reaum, the finger fliould be
oiled and introduced into the gut, at the fame time that the
 probe is paffed in  at the ulcer, in order to determine  whe-
 ther it  communicates with the inteftine, which is  a  point
of confequence.   When this will not afcertain it,  the paf-
 fing of the feces  or air at the fore, or water injeaed at
 the fore coming out by  the inteftine, will fometimes direft
us.
   Aftringent injeaions, paftes and  ointments,  have at dif-
ferent times  been ufed  for the cure of  fiftula  in ano j but
experience has proved them to be not only  ufelefs,  but of-
ten injurious.  The  real indication  is to excite  fuch a
degree of inflammation on the fides of the finus as will
produce a union of them.  This  in fiftulae of other parts
                                                    is 
                      _   211  3
is  accomplifhed either  by the introduaion of a cord of
cotton or filk, along the  courfe of the fore, or by laying
the whole finus  open,  fo as to reduce it as nearly as pof-
fible to the ftate of a recent wound: but as the feton here
gives too  much  irritation, the latter mode is to be pre-
ferred.
  The  day before the operation, the bowels fhould be well
emptied by a laxative,  and the reaum fhould be cleared
by a clyfter given a few hours previous to it.
  The patient may be either allowed to Hand up with his
back expofed to the light of a window, and leaning for-
ward on a chair, table, or bed ; or he may be laid on a
table in the pofture  direaed  for lithotomy.   Which-
ever is  chofen, the patient muft be firmly  held in it;  and
the furgeon, after dipping the fore-finger of his left hand
in oil, muft introduce it as far as poffible into the reaum,
and with his right hand muft then enter the probe pointed
biftouri, and carry it forward until he feels the point of
it through the opening in  the gut, for we fuppofe this to be
a complete fiftula; he  is  then to bring the point, guarded
and  fupported by the finger, out of the reaum, by which
means  the finus will be  entirely laid  open.   If there are
more finufes than one, they fhould all be opened.  It fel-
dom happens that more  than one communicate with  the
reaum, but they generally communicate with each other.
   When the fiftula  is  incomplete, the only difference be-
tween the operation  for  it and the one juft defcribed, is
that the biftouri muft  be pufhed  through  the  reaum at
the fuperior part of  the finus.
   When the finus extends very far up the  reanm, all that
can be fafely done is to divide the finus as high as the fin-
ger  will reach.
   The  hemorrhage  from this operation is  very  trifling;
and therefore the method of cure by introducing a flexible
piece of lead or filver at the orifice,  bringing it  back by
                                                   the. 
                      C   212  3
 the gut, and then twilling it,  is totally unneceffary on ac-
 count of the difcharge of blood.   The pain attending this
 mode by ligature, and its tedioufnefs will probably prevent
 it from being received into general ufe.
   The  wound being cleaned,  a piece of foft lint or linen,
 covered with a liniment of wax and oil, fhould be infinu-
 ated between its edges, but not fo far as to give uneafinefs.
 A comprefs  and the T  bandage being then applied, the
 patient  fhould be carried to bed; and the dreffings being
 renewed after every ftool, or about  once in  twenty-four
 hours,  the fores will generally heal very well.
   By this method,  diarrhaea  and tenefmus, which often
 prove very troublefome when dreffings  at all  irritating,
 even dry lint, are employed, are entirely prevented.
   Injeaions are often advifed to clean the fores, but they al-
 ways do injury.   Nothing more is in general neceffary than
 to remove any faeces which may lodge in the wound.
   In fome inftanees, inftead of a favourable appearance,
the fore acquires a  foft unhealthy afpea,  and the matter
difcharged from it is thin, foetid, and perhaps mixed with
blood.    A hitherto  undifcovered finus is in thefe  cafes
 fometimes found upon examination;  this  fhould be imme-
diately laid open: but it more  frequently happens that this
ftate of the  fore depends  upon fome general  affeaion,
 which till then had not manifefted itfelf.  In this cafe, re-
medies adapted to the difeafe fhould be employed.   It may,
in fome  inftanees, be the confequence of mere debility from
fever or difcharge of matter.   Tonics, and a generous diet,
will then effea a cure.
  When the difeafe has  continued long,  experience has
taught me the propriety, and indeed neceffity, of forming
an iffue; making it difcharge freely for fome time previous
to the operation.
 ^ By thefe feveral means, the difeafe, when confined to the
Vicinity  of the reclum, may almoft always be removed.
                                                    In
« 
                      _  213   3
   In an advanced  ftage,  the  matter fometimes  not only
 feparates the fkin from the mufcles in all the parts adjacent
 to the reaum,  but  even detaches  the  reaum itfelf from
 the cellular fubftance,  with which in health it is fo firm]y
 conneaed.   In fuch inftanees,  all that fhould be done, is
 to lay open the inteftine as far as it is feparated; and if this
 is not fufficient to make it apply equally to the furrounding
 parts, another incifion fhould  be made on  the  oppofite
 fide of it:  by this means,  if the conftitution is pretty good,
 an adhefion will take place between the gut and the parts
 contiguous, and  a  complete  cure will  be obtained.  Si-
 nufes feated externally  fhould  be treated in the fame way.
 The dreffings in both fhould be mild, and applied over the
 fores only, and not  infinuated between their edges.
   The occult fiftula, or that in which there is no external
 opening, is to be diftinguifhed by a difcharge of matter un-
 mixed with the faeces ; by fdftie degree of hardnefs,  fwell-
 ing or difcolouration in the vicinity of the fundament; and
 by pain from preffure on it.
   In this fpecies, a fcalpel or lancet is to be  plunged into
 the part where we have reafon  to fuppofe the abfcefs feat-
 ed ;  and the difeafe being then reduced to the ftate of a
 fimple, complete fiftula, the operation is to be finifhed as
 was  direaed for that variety of the difeafe.   The  fubfe-
 quent treatment muft be fimilar to that ufed in other cafes
 of fiftula.
   We have hitherto fuppofed  the  parts affeaed to be  no
 otherwife  difeafed  than by  haviug an   abfcefs  feated in
 them,  and  finufes conneaed with it; but when by ne-
 gfea or improper treatment the matter  colfeaed  does not
 find  a free vent, the parts  contiguous to it become inflamed
 and painful, and gradually acquire a confiderable and dif-
 treffing hardnefs  or callofity.  In fuch circumflances, ex-
 perience  has taught us  that poultices, mercurials, &c. as
advifed by fome,  are perfeaiy inadequate to the difcuffion
                                                    of 
                      C  214   3
 of any fuch callofities as are confiderable and of long da-
 ration ;  and that it is entirely  unneceffary to deftroy them
 by cauftic, or extirpate them with the knife,  except they
 cannot be preferved but at the hazard of the patient's life.
   In inftanees  where  thefe callofities occur, the finufes
 fhould not only be laid  open as direaed  in  fimple fiftulae,
 but incifions  fliould be made along the whole  extent of
 the hardnefs ; and if a free fuppuration does not fponta-
 neoufly fucceed to the  inflammation  which is commonly   -*M
 produced, it fhould be encouraged by  warm  poultices, and
 fupported till the  greater part of the  callofity is  removed;
 which will commonly happen  after fome time,  if the habit
 is healthy.   When fuppuration cannot be readily induced,
 and the edges of  the fores become inflamed and painful,
 and a foetid thin matter is difcharged, fome general difeafe
may  be fufpeaed.
  If the edges of  the fores ale very hard and reverfed,  it
may  be ufeful to take off a  part of them ; and if the cal-
lous  parts are fo  feparated  from thofe beneath,  that  they
will probably never adhere to them again,  they  muft be
removed ; but in no other circumftances can  extirpation, in
any degree, be with propriety  advifed.
  It  fometimes happens that the matter colfeaed in fiftula
in ano penetrates to the bones; but-it oftener happens that
the bones  are  the parts  primarily  affeaed.  Thus the
matter may  be formed in confequence  of  caries of the
lumbar vertebrae,  os  facrum or coccyx,  and find its  way
down to the vicinity of  the anus.
  But the moft  diftreffing fymptom attendant on fiftuke in
ano,  is the formation of a paffage between the reaum and
bladder.   This  is known moft certainly by an  offenfive
dark fediment in the urine, obftruaions to the paffage of
the water, and the difcharge of air by the  urethra either     j
before or  after making  water.  In fuch cafes the patient
                                               lingers     j 
                     t   215  1
lingers for fome time, and at length falls a viaim to the
difeafe.
  When the bones have become carious  from the matter
penetrating to them in this difeafe, all that art can do is to
preferve a free vent to the matter; to keep the parts clean;
to extraa  pieces of loofe bone; and to ftrengthen and fup-
port the conftitution during the long continued difcharge
which will probably enfue, by tonics and nutritious diet.
Some few have  recovered  by this management; but  all
that can in general be expeaed, is a mere palliation of the
moft diftreffing fymptoms.
             CHAP.   XXIV.


     Of the  Paracentefis of the Abdomen.




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

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


                   SECT.   I.

           Of Serum colleBed in the Thorax.*

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

                    SECT.   II.

             Of Blood colleBed in the Thorax.

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

                    SECT.   III.

    Of an Empyema, or a Codec!ion of Pus in the Thorax.

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

           Of Air Extravafated in the Thorax.

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

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

 Of CEfophagotomy.
       WHEN fubftances  lodged in the oefophagus can be
         feen, they may commonly be removed by a pair
of forceps; but when they are out of fight, we are re-
duced  to the neceffity either of allowing them to remain
where  they are fixed, of pufhing them into the ftomach,
or of extraaing them by laying the cefophagus open.
  If the fubftance is of a foft texture, fuch as bread, cheefe,
or flefh,  the  beft method is to pufli it into the ftomach by
the probang.   But when  a pin,  a  piece of fharp bone, or
other firm fubftance is lodged in the paffage, we fhould not
attempt to pufli it down; for if this docs not fucceed, it
may be fixed  in the cefophagus.  If the pain, and obftruc-
tion to breathing are not confiderable, and if aliment can
ftill be fwallowed,no effort fhould be made to diflodge if,
for it will probably be at length carried down,  either from
the effeas  of fome degree of diffolvTtion in the fubftance
itfelf, or of a fuppuration in that part of the gullet in which
it is fixed.   But  when  the  paffage of nutriment to the
ftomach is entirely prevented, or refpiration is impeded to
                                                   a 
                     C   23»   3
a dangerous degree, an incifion into the  cefophagus, for
the removal of the offending caufe, is our only remedy.
  Oefophagotomy may be alfo  rendered  neceffary by tn*
mors and ftriaures in the fuperior part of the cefophagus j
but in fuch cafes, the  relief it gives is  in general merely
temporary, as  the difeafes which give  occafion to it are
ofually incurable.
  In performing this operation, the patient being fecured
as direaed for bronchotomy, an incifion fhould be made
with a fcalpel,  at leaft two inches in  length, through th«
fkin  and cellular  fubftance, on  the left fide of the neck,
keeping clofe by the fide of the trachea, and commencing
about half an inch above the part  where the obftruaing
fubftance  is fixed, when  this  is praaicable; and where
this is found impoffible, on account  of the obftruaion be-
ing within the cavity of the thorax,  the incifion muft begin
about an inch and an half above the fternum.
  The fterno-thyroidasi,  and fterno-hyoidad mufcles,  and
a part of  the thyroid gland being now cxpofed, an affift-
ant fhould pull the mufcles gently  to  the left fide with a
blunt flat  hook, while another draws the trachea to the
right, fo as  to admit of the cefophagus being brought into
view.  If any large blood-veffel fhould be unavoidably di-
vided it fhould now be fecured.   The cefophagus being
next opened longitudinally, the fubftance is to be extraaed
with a pair of forceps.   If the  obftruaing matter is above
the fternum, and its feat  can  be difcovered, the incifion
fhould be made immediately upon  it, and  of a fufficient
fize  for its removal by a pair of fmall forceps ; but when
the fubftance is in the cheft,  the gullet is to be opened for
about  two  inches, and immediately above the fternum;
a blunt probe  being then  introduced to difeover the feat
of the  complain^ the fubftance is afterwards to be ex-
traaed by  a pair of  ftraight forceps,  when it is near  at
hand, or by crooked forceps, if farther down the tube.
                                                When 
                       C  232   ]
   When the operation is performed on account of fome
 difeafe, till this can be removed, our principal objea is
 the  conveyance of  nourifhment  to  the ftomach, and  the
 opening fliould then be preferved  ; but when it is employ-
 ed for the purpofe of removing a  foreign fubftance fixed in
 the  paffage,  as  foon as this  is  accomplifhed,  the  parts
 fhould  be reunited as  fpeedily as poffible.  It will there-
 fore be prudent to recommend total abftinence from folid
 food for feveral days, and to convey nourifhment  by injea-
 ing broth by the anus, and allowing  very fmall  quantities
 of milk or foup to be now and then  fwallowed.   The pa-
 tient fhould keep his neck quiet, and  the wound  fhould be
 treated as fimilar cafes in other parts.
   There is by no means that degree of danger  attending
 cefophagotomy that has been  fuppofed.  By proper cau-
 tion  the larger blood-veffels will be eafily avoided, and if
 the thyroideal arteries fliould be divided, they may in com-
 mon be readily fecured.  The  recurrent  nerve will be  in
little danger,  although it runs clofe  by the cefophagus, if
 proper care is obferved, and even if  fome of its branches
fhould be divided, the  only bad  confequence would  be a
weaknefs of voice.
  The operation has been more than  once fuccefsfully per-
formed :—and there are many  inftanees of  large wounds
of the gullet healing very well; and if they fhould become
fiftulous and not heal, the patient  will have had  the only
chance of relief, when they are  induced by the operation.
CHAP. 
t  233   3
            CHAP,   xxvnr.

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

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

                   General Remarks.

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


                   SECT.   II.

     Of Compreffion of the Brain from external Violence.

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

 § I.  Of Compreffion of the  Brain from FraElures with De-
                       preffion.

  The only general and ufeful  diftinaion of  fraaures  is,
into thofe  which are  attended  with depreffion, and  thofe
which are not: thefe laft we term fiffures, and fhall con-
 fider them in a feparate feaion.
  Fraaures of the fkull may  be produced by  falls  from
 a height;  by  blows   with fharp or blunt  inftruments;
 and by miffile weapons fuch as ftones, &c. thrown  from
 a diftance—Little  advantage is  derived from  a  knowledge
 of the meaus  by which a fraaure  is produced—For al-
 though in many inftanees when occafioned  by a blunt in-
 ftrument, or a fall from a confiderable height, it is frequent-
ly attended by more  alarming confequences than when it
is produced by a fharp  inftrument, this  is not univer-
fally the cafe.  It is  however proper to  enquire into the
nature of the caufe.
  The indications in  this affeaion are,
                                                i. To 
                     L"   239  3
   r. To difeover, as exaaiy as poffible, the  fite,  the
courfe, and the full extent of the fraaure.
   2. To obviate the effeas.of the injury,  by elevating or
removing the depreffed parts of the bone.
   3. To endeavour to complete the cure,  by the applica-
tion of  proper dreffings,  and attention to  the after treat-
ment.—When  circumftances admit the accomplifliment of
thefe objeas, we can often afford more certain relief than
in any other difeafe.
   If the integuments are torn away, or cut, the ftate of the
bone is immediately difcovered; but when they are entire,
it is difficult to afcertain  ir.   In this cafe,  if any mark of
external injury is perceived, particularly a tumor on any
part of  the head,  with evident appearances of its proceed-
ing from a recent  contufion,  the other fymptoms  will pro-
bably, on incifion into it,  be found to originate from frac-
ture direaiy underneath.   But,  as frequently  happens,
when affeaions of the brain,  and fraaures of the fkull,
fucceed  injuries which do not produce any external mark,
the whole head fhould be fhaved,  and then fometimes  a
rednefs  of a particular fpot will be perceived, and indicate
the part affeaed.   When no tumor, inflammation, or other
mark of injury occurs, we may fometimes be led to the feat
of the accident by preffing firmly all over the head: and if
we find the patient  to  moan on preffing  one particular
part,  or he  puts up his hand,  or draws away his head on
this trial being repeated,  we may conclude this the feat of
the injury.  If the patient applies his  hand frequently to
the fame part of the head, it will merit our attention.
   When the fymptoms of a compreffed brain are evidently
marked, we ought to proceed immediately to the exami-
nation of the  cranium,  wherever the injury appears to be
feated,  by laying the bone  bare by an incifion.   When
the bone appears to  be much injured, which may happen
without a laceration of the fcalp,  this fliould be done with
                                               caution, 
                       C  240   3
 caution, for fear of hurting the  brain.  But  when  this'is
 not the cafe, the incifion may be made at once through the
 fcalp.  In order to expofe the bone more completely, it has
 been propofed to make  a  crucial  incifion, or one  in the
 form of a T,  and by fome to remove  a  circular or oval
 piece of the fcalp ; but when either of thefe modes are ufed,
 a  painful wound is produced, difficult to heal; tedious
 exfoliations are  fometimes induced;  and  the  covering
 formed afterwards never anfwers fo well as the teguments
 removed.  A fimple incifion appears to be amply fufficient •
 on this being made,  the parts retraa fo as to admit of a
 free examination of the bone, and if a fraaure is difcover-
 ed,  the courfe of it may be traced as well by continuing
 the courfe of the incifion along it,  as by removing part of
 the fcalp;  and this will generally give room for the  appli-
 cation of the trepan.   In  fome few cafes indeed, where the
 bone is fraaured in different direaions,  it  may be neceffa-
 ry to remove a fmall corner of the divided  integuments.
   Upon making the incifion, if there is a fraaure and  de-
 preffion of the fkull, the means hereafter  to be  recommend-
 ed  fhould be  immediately  employed; but where no ex-
 ternal mark of  fraaure is met with,  or any injury what-
 ever, and the patient  continues to labour under the fymp-
 toms of a compreffed brain ; if the pericranium has been
 feparated;  and efpecially if the bone has become of a
 pale white  or dufky hue;  the trepan  fliould be  applied
 where thefe appearances  occur.   We fhall hereafter en-
 deavour to fliew,  that by this means alone, effufed blood,
 or ferum, which may produce the compreffion, can be  re-
 moved ; and that it would be highly improper to truft to
 abforption of the extravafated fluids, as advifed by fome.
  For although no mark of difeafe fhould appear on the
 external table of the bone, yet there is a poffibility that the
 internal table may be broken and depreffed, and this may
produce as  bad confequences as  if the  whole bone was
                                                 beat 
                      L   241  3
 beat in.   Of this I have met with fome inftanees, and au-
 thors tell us of many.
   It will often  happen that no relief is afforded  by the
 trepan in the cafes mentioned : This may arife from various
 circumftances, but the moft fatal is what is termed a contra-
 fiffure,  by which the cranium is fraaured, and perhaps
 depreffed,  or  effufion occafioned,  at  a part diftant from
 that which received the  blow,  and  where alone there
 are marks of injury.
   The exiftence of fuch a cafe has  been called in qneftion
 by theorifts,  but  every praaitioner  of  experience muft
 have feen inftanees of this kind.   It does not happen that
 injuries  are neceffarily produced immediately oppofite to
 the parts receiving  the impreffion, but it frequently hap-
 pens  that the  fkull is fraaured in a part not immediately
 contiguous to thofe on which the blow was infliaed ; and
 this often occurs when no  external mark can be difcovered
 on the   teguments  correfpondent to  the  part fraaured,
 and  when the bone remains entire on  the part which im-
 mediately received the injury.
   Many of the older writers apprehended confiderable ha-
 zard  from expofing the brain to the air,  by the  operation
 of the trepan ; while fome of the  moderns  Confider the
 danger fo trifling, as to  direa the operation as a  preventa-
 tive of bad  fymptoms.  But I am clearly of opinion,  that
 the trepan fhould never  be ufed but where there are fymp-
 toms  of  a compreffed brain,  and which would  probably
 foon prove  fatal if their caufe was  not removed; becaufe
 it appears by  no means an  innocent remedy, and  is fre-
 quently of itfelf produaive  of dangerous fymptoms.
   We now  proceed to the fecond general indication, to re-
 move or elevate the depreffed portion of bone:—
   If  the teguments  are not feparated  at all, or  not fuffi-
■ ciently,  by the accident, to admit of an examination of the
 bone injured, the head  fhould be fhaved, and an incifion
                         H h "                  mads 
                      [   242   3
 made  by a fcalpel through the teguments, and continued
 along  the  courfe of the fraaure.  By this it frequently
 happens that  fome blood-veffels  are  divided,  which dif-
 charge very freely:  if the patient  is  very  weak,  thefe
 fhould be immediately fecured by ligature, lint, and com-
 preffion ;  but  when this is not the cafe, they fliould be fuf-
 fered to bleed  in proportion to the patient's ftrength.   They
 will in common foon retraa and reftrain the hemorrhagy;
 and if  they do not, they may be eafily fecured as above di-
 reaed.
   In performing the  operation  of perforating  the  fkuU,
 the  patient fliould be laid  on a  firm  table, and his  head
 there fecured  by a pillow.  The inftrument now ufually
 employed for  removing a  part of the  cranium, in  order
 to admit of the raifing of the portion depreffed,  is termed
 a trephine; but  the trepan, (pi. i. fig. 5.) is much prefer-
 able, as  it perforates the bones in half the time, and  is
equally fafe.   It  differs from  the trephine  only in the
handle being worked like a carpenter's wimble.
  In cafes of  depreffion of the fkull in children, we have
been advifed to try the effeas of  adhefive plafters laid up-
on the  cranial  integuments, and conneaed with ligatures;
by pulling  the firings, it was propofed to elevate the de-
 preffed part; but this mods is evidently inadequate.
  We  have by  fome  been  direaed to introduce a fcrew
nearly  through the cranium, and  then by puliing it, to en-
deavour to raife  the depreffion; but as  by this  method we
could neither  remove any fplinters of the bones, if  their
internal table fhould  be broken,  or take out extravafated
blood,  if lodged on the brain, it v/ould obvioufly be of no
fervice  in moft cafes.
  When any portion of the bones injured can be removed
by the  hand, or  forceps, it  fhould be done; and if by this
means  the  depreffed  part cannot be elevated to its proper
fituation, the ufe of the trepan becomes neceffary.
                                                  The 
                       £  243  3
   The operation of trepanning may  be performed on any
 part of the cranium : but on account of hemorrhagy, and
 the  difficulty  of the operation when performed in thefe
 places, it will, if poffible, be proper to avoid the under part
 of the parietal and temporal bones, the inferior part of the
 frontal bones, the whole courfe of the longitudinal finus,
 and  the under part of the os occipitis.
   In proceeding to this operation, as  much of the peri-
 cranium fliould  be taken off by the fcalpel  or rafpatory,
 (pi.  i. fig. 3.) as will admit  a free application of the trepan ;
 and  this fhould be done at the point where the greateft re-
 fiftance feems  to occur to the elevation of the bone.   The
 perforation ought to  be formed fo as to include not only
 the frafture or fiffure, but if poffible a finall portion of the
 depreffed piece.
   A fmall hole is to be  made in  a proper part  of the
 undeprefTed bone with the perforator, (pi. i. fig. 7.)  to re-
 ceive the pin of the trepan  few.   By this  the faw  is
 kept in its fituation until it is  carried fufficiently deep  to
 render fuch fupport unneceffary, when the pin is to  be re-
 moved,  left it might injure the membranes of the brain.
   The furgeon is now to prefs equably and firmly upon
 the  inftrument until he makes the  perforation.  If the
 trephine is ufed, the faw is made to cut by forming  about
 half  a circle with the hand alone, turned firft forwards and
 then  backwards; but when the trepan  is employed, all
 the neceffary preffure is to be applied on the head  of the
 inftrument with one hand, while the  handle of it is turned
 with the other.   The inftrument fhonld be frequently re-
moved, and  the depth of the perforation afcertained by a
pointed piece of quill or a probe : and if it is deeper  in one
place than another, the faw fhould be made to bear more
on the part leaft cut,  fo as to preferve the perforation of an
equal depth all  around.   While  the  furgeon examines
and cleans  the cut,  an affiftant fhould  brufh the fee; or
                                                  there 
                      [  244  3
there fhonld be two faws of  an equal fize,  that no inter-
ruption may be given to the  operation.  A cylindrical
form of the inftrument will contribute confiderably to ex-
pedite the fawing.
   When the bone is probably  nearly fawed  through, as
may be judged in fome cafes from our  having met  with
the diploe, the perforation fhould be very frequently exa-
mined, and as  foon as it is found to go through the bone,
the preffure fhould then be removed from this, and equally
applied over the remaining^ uncut  part.   As  foon as it is
praaicable,  from the bone being  loofened in one or two
points, it fhould be taken out by the forceps, (pi. ii. fig. i.)
or the levator, without waiting for its entire feparation by
the faw, for by this praaice I have feen very expert opera-
tors injure the dura mater.   If any fplinters are left, they
may be removed by  the forceps,  or by the lenticular,
(pi. i. fig. 2.)
   That the intention  of this operation  may  be fully an-
fwered, the piece of bone removed  fhould never in  an adult
be lefs than an inch in diameter.  If the depreffed part can-
not be raifed by the levator,  (pi. i. fig. i.) after one perfo-
ration, as many more as may feem neceffary fhould be made.
The levator fhould always be  fixed upon a fmall Hand,
(pi. i. fig. 4.) as the force ufed for elevating the bone does
not then materially  affea the parts to which  it is applied.
Great  attention  fliould  be paid to the  entire removal of
the depreffion, of  extravafated blood  or ferum  on  the
brain, and of all extraneous bodies ; and when this is done,
the  wound  fhould be  lightly  covered  with lint fpread
with cerate, a  comprefe of foft linen applied over this,  and
a night-cap fhould fecure the whole.
   When the patient is removed  to bed, the head fhould be
placed in fuch  a manner  that the difcharge from the
wound may have free vent.
   If the compreffion of the brain has  been completely
taken off by the operation,  it fometimes  happens  that the
                                             fymptoms 
                      [  245  3
 fymptoms are mitigated  immediately,  or at leaft in the
 courfe of a few hours; but when no favourable  change is
 perceived in  a fhort time,  we may attribute the continu-
 ance of the bad  fymptoms, either to a concuffion of the
 brain itfelf, or to an inflammation of its membranes ; and
 the remedies  hereafter  direaed muft be then applied, ac-
 cording to the circumftances of the cafe.
   In all cafes after the operation of trepanning, the patient
 fhould be kept quiet; little or no light  fliould be admitted
 to his apartment; his food fhould be of the  mildeft kind;
 and his drink fhould be whey, or fome other mild diluent
 liquor.
   As the membranes  of  the brain are very apt to become
 inflamed  in thefe cafes, it  will be proper, both as a preven-
 tative and a curative of inflammation, to produce a plenti-
 ful fuppuration  from the wound by  the application  of
 warm emollient poultices  and  fomentations over the dreff-
 ings—the matter colfeaed in the fore may be removed by
 lint or a fponge.
   After the floughs formed are caft off, the  wound com-
 monly fills up, and cicatrizes in the ufual  way;  but  in
 fome  cafes,  excrefcences  of confiderable magnitude fhoot
 out from  the perforations.   Thefe are,  in  general,  pro-
 duaions  of the dura mater,  and fhould feldom be med-
 dled with until the different perforations are filled up with
 bone;  when, if they do not drop off fpontaneoufly, they
 fhould be removed by excifion, cauftic,  or ligature: Com-
 preffion can never be fafely employed either  to prevent or
 remove them.
   When the fcalp has been  removed to any confiderable
 extent, as the bone will  afterwards be  covered only  by
 cuticle and cellular fubftance, a piece of tin or lead, lined
 with flannel,  fliould be fitted to the part, with a view  to
protea it from the cold and other external injuries.
§ 2. 
I  246  3
    § 2. Of Compreffion of the Brain from Extravafation.

   The fymptoms  of a  compreffed brain from extravafa-
 tion of blood or ferum, or from the formation of pus, are
 exaaiy fimilar to  thofe produced by a depreffion of the
 cranium and other  caufes, and therefore need not be here
 repeated.
   Extravafation of blood  or ferum is a frequent concomi-
 tant of a fraaure or fiffure of the fkull; but it alfo occurs
 in cafes where no mark  of either is to be perceived, or
 even  the  fmalleft  fign of external injury.  In every in-
 ftance, however,  the trepan affords the only mode of re-
 lief  with  which  we  are  at  prefent  acquainted.  When
 there is any external injury the perforation fhould be made
 on the part difeafed : but when there is no fuch guide, we
fhould make repeated openings, beginning as near the bafe
of the fkull as poffible, until the feat of the extravafation
is difcovered.
  When the removal of  the  blood or ferum, lying upon
the dura mater, does not  take off the fymptoms of com-
preffion, and when this membrane appears dark  coloured
and tenfe,  as there will be reafon to  fuppofe there is ex-
travafated  blood beneath it, it fhould be cautioufly open-
ed by the flioulder  of a lancet, and the orifice enlarged by
crooked feiffars fufficiently for  the  removal  of the effufed
matter.  And in like manner, when we have reafon to be-
lieve there is a colfeaion of pus, an  opening  fhould  cer-
tainly be made to admit of its difcharge.  In either of thefe
cafes we give the patient the only chance of relief.
SECT. 
C  247  3
                   SECT.   III.

         Of Concuffion or Commotion of the Brain,

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

                      SECT.   IV.

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

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

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

   Contufions of the head are produced, as in other parts,
 by  blows or falls;  and are  fometimes accompanied with
 wounds, at other times they are not.
  The immediate and moft frequent effea  produced from
 them, when they afterwards prove troublefome, is to de-
 prive the patient of his  fenfes, and leave  fome degree of
 giddinefs.  In a gradual manner, however,  he recovers,
 fo that after a night's reft he appears  perfeaiy well,  un-
 lefs a wound was produced at the fame time with the con-
 tufion, until fome days, weeks, or even months after the
 accident, according to circumftances,  when the fymptoms
 above defcribed make their appearance.
  Hence it  is evident,  that accidents of this kind, which
at firft appear trifling may be produaive of very danger-
ous confequences, and  therefore that  all injuries done to
the  head merit a great deal of attention.
  In  the treatment of contufions of the head,  the indica-
tions are;
  1. To employ every means preventative of infferrinn-
tu;n. 
                      [   252  3
 tion.   2. To produce refolution of the inflammation when
 it has aaually come on.   3.  If this  cannot be done, and
 fuppuration takes place, to procure a free vent to the mat-
 ter : And,  4. If a gangrene  fupervenes, to remove it or
 obviate its effeas.
   1. Patients  recover  fo  fpeedily from the immediate ef-
 fea.s of  contufion,  in moft inftanees, that we feldom have
 an opportunity of employing the  prophylaaic remedies of
 inflammation.   But when  this is afforded,  we would re-
 commend blood-letting, general and topical—laxatives—
 the application of  folution of faccharum fiiturni  to the
 part affeaed—a low  diet, and total abftinence from ex-
 ercife.
   2. For the removal of inflammation it will be neceffary
 to employ, 1. Blood-letting—When a fufficient quantity
 of blood can  be  obtained by  topical bleeding this  fhould
 be preferred;  hence leeches or cupping fhould,  if poffible,
be ufed near to the affeaed part.  Deep fcarifications with
a lancet  or  fcalpel,  when  the  parts have not been divided
but merely bruifed  and inflamed,  are very ferviceable for
this purpofe.  When general bleeding  is neceffary,  it will
be beft to  open the jugular vein  or  temporal artery, and
draw off blood until the pulfe begins  to flag, if poffible, to
the quantity of 20 or 25 ounces : this  will be much more
ufeful than repeated fmall  bleedings.   It will be proper to
repeat  the  bleeding in a few hours if the fymptoms conti-
nue violent, to an extent to be determined by the circum-
ftances of the  cafe.
   2. Strong purgatives, or ftimulating glyfters-fhefe are
very ufeful and fhould never be omitted.
   3. Gentle diaphoretics.   It is a matter of confequence to
keep a gentle moifture on the fkin.  If this cannot be effeaed
by warm fomentations  to the feet and legs,  and by laying
the patient in blankets,  we muft employ internal fudorifics
Dover s powder is apt to excite vomiting; on this account
                                                     I 
                      C  253   3
I prefer a  combination of  an antimonial with opium—fif-
teen or twenty drops of antimonial wine, with four or five
of laudanum may be given every two hours until a fweat is
brought on, when a lefs quantity will ferve to fupport it.
  4. Opiates.  A prejudice againft the ufe of opium in dif-
eafes of this kind has hitherto prevailed ; but experience
has convinced me that this is unfounded, and that it may
always  be employed with advantage  to  remove  pain or
reftleffnefs.
   5. Suitable applications  to the injured part.   Experi-
ence has evinced to me the utility of producing a plentiful
fuppuration from the part affeaed in all contufions of the
head.   For this purpofe,  when  the accident is attended
with a wound, it fhould  be covered  with pledgits of lint
fpread with fome emollient ointment, and foft warm cata-
plafms fhould be applied over thefe, and frequently renew-
ed.  The fymptoms are  thus  generally mitigated,  and
fometimes entirely removed.  When there  is no wound,
and when from the fwelling and  pain of  the injured part,
fome time after the accident, there will  be reafon to expea
the coming on of bad fymptoms,  the tumor  fhould be im-
mediately laid open down to the pericranium; and  if this is
feparated,  it ought likewife to be divided, any matter that
may be colfeaed  taken away, and the wound treated as
juft above direaed.
   By the  contrary  treatment of fuffering the fwelling to
remain unopened  until a fluauation is perceived, I have
reafon to  believe that the matter  colfeaed, which is gene-
 rally thin and acrid, is the moft frequent caufe of the fuc-
ceeding inflammation of  the dura mater which often takes
place.  It  produces this effea by firft exciting inflammation
of the parts externally,  which is extended to the  internal
 parts  by  the communicant veffels.  Injuries of  the head
 very probably, in moft inftanees, operate  by  inducing an ef-
fufion between the ficull and pericranium; this being ofeen
                                                   very 
                      _   *54  3
 rery fmall,  does  not  occafion any evident tumor until its
 acrimony excites an inflammation of the furrounding parts;
 and hence we may  readily account for the effeas of  thefe
 injuries not  appearing until fome time has elapfed after the
 accident.
   It is  to be obferved, however,  that  the treatment we
 have juft  recommended is not applicable to tumors recently
 formed from external injuries.  Thefe are to be removed
 in common by folution of lead,  or of crude fal ammoniac,
 or by the application of brandy, or fome other aftringent.
 Such fweUings give a fenfation like that afforded by  frac-
 tured cranium ; but we can never be deceived if we attend
 to the concomitant fymptoms.
   3. When we have reafon to fuppofe pus is formed with-
 in the cranium, the  only  probable  means  of  relief is af-
 forded by the application of the trepan, in the manner for-
 merly direaed in  feaions 1 and 2.
   4. When on perforating the fkull, it  is found that the
 dura mater  has become floughy,  with  fome  tendency to
 gangrene, the utmofl danger is to be dreaded.   There are,
 however,  fome inftanees of recovery, in fuch cafes, upon re-
 cord : all  that can be done is to keep the fores clean ; dif-
 charge any matter that may colfea; apply foft light dref-
 fings, and give Peruvian bark and vitriolic  acid in as large
 quantities  as the ftomach will  bear them.  If there remains
 any  tendency to inflammation, the  diet fhould be low and
 coding, and the  bowels fliould be  kept  moderately open;
but if the  fyftem is low, and the pulfe feeble, wine, and a
generous diet fhould be allowed.
  The operation of  trepanning has  been recommended  in
inflammation of the brain, and in fome cafes of epilepfy  ; but
it muft evidently be injurious  in the former cafe, from the
irritation it gives to the difeafed parts ; and in two cafes of
epilepfy in which  I have feen it employed, there was every
                                           probability 
                       C  255  3
  probability that it occafioned the death of the patients by
t exciting inflammation and a confequent fuppuration.

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

   By a fiffure  we underftand a mere divifion of the fkull,
 not  attended with depreffion: This may either penetrate
 the whole thickncfs  of the bone, or  be confined to one la-
 mella of it: it may alfo either be attended with a divifion of
 the correfponding teguments, or thefe may be left entire.
   Fiffures always require a great deal of attention;  for al-
 though there are many inftanees of  thofe of great  exteut
 healing without the  occurrence of bad fymptoms, yet there
 are alfo inftanees of very fmall fiffures terminating fatally.
   Fiffures are often accompanied by original affeaions of
 the brain,  and  they are produaive  of  danger themfelves
 by  inducing effufions of blood or ferum upon the brain,
 or by tending to excite inflammation of its membranes.
   When effufion  takes  place, as  it muft immediately be
 attended with fymptoms of compreffion,  the remedies for-
  merly recommended muft  be employed.  The trepan af-
 fords the only effeaual relief: the fiffures fhould be traced
 through their whole extent,  and a perforation being made
 in the moft depending part of each of them, if this does not
 prove entirely fuccefsful, the operation fhould be repeated
 along the courfe of the fraaures, as  long as the fymptoms
 of  compreffion remain, care being  taken  to  include the
  fiffure in every perforation.
    It  often happens  that the  fiffure is fo exceedingly fmall
 that it is difficult  to diftinguifh it  from the furrows  pro-
 duced by the blood-veffels, or from the futures.  This is,
 however,  a matter  of little confequence  with regard  to
  praaice.
    When the pericranium is  not feparated from the cranium
  by  the accident, but is  found feparated  in a particular part
                                                     on 
                      C   255  3
 on cutting down to it, it affords a pretty  certain mark of
 a fraaure beneath.  When the bone is bared by the acci-
 dent, it has been propofed to afcertain it by various means.
 By pouring ink over the bone it has been faid, that  it will
 fink into the crack and there remain,  even  if we attempt
 to wafh it off with water.   But it  is  to be obferved, that
 unlefs  the bones  be very firmly offified indeed,  the ink
 will always  fink into the futures, and hence this method
 can  feldom be of any ufe  in difcovering a  fiffure.   Some
 other modes recommended, as by holding a  firing between
 the teeth and ftriking it; and chewing  fome  hard fubftance
 to excite pain in the part injured, have no effea  unlefs the
 injury be extenfive, and then they are unneceflary.
  It often happens that blood continues to  ooze out con-
ftantly from  the  fiffure; this, when it occurs,  is  a very
 certain charaaeriftic.
  It has been by fome advifed in all  cafes of fiffure to ap-
ply the trepan, chiefly with a view to evacuate any colfeaion
of fluid more freely than  it  could be  donj2 by the fiffure;
 but, if the fiffure is wide, there can occur no neceffity for,
it;  and we know  from experience,  that thofe of fmall ex-
tent frequently do well without the formation of any mat-
ter ; and it would certainly  not be prudent to advife a ha-
zardous operation merely for the chance of its becoming
neceffary.  And befides, inftanees  are often  met with in
which fiffures penetrate no  deeper than the  external table
of the fkull; this  cannot be previoufly known, and  could
never need the operation.
  I  am of opinion, that unlefs fymptoms of compreffion
come on, the trepan can never be neceffary, and that fiffures
while unattended by  bad  fymptoms,  fhould be treated
merely as a caufe that  may give rife to inflammation.  The
 patient  fhould be bled according  to  circumftances ; the
 bowels  fhould be kept open; the fore fliould be treated
                                                 with 
                        [  257  3
mild dreffings;  and violent exertions of every kind fhould
be avoided.*
  By thefe means a cure will frequently be obtained; but
when inflammation is  induced,  and fuppuration is  con-
fequent  to it, the trepan is to be ufed as in other cafes.
     CHAP.    XXX.

Of the Difeafes  of the Eyes.
                     SECT.    I.


       Of Ophthalmia, or Inflammation of the Eyes.


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

  * In all thefe cafes, the experience and judgment of the furgeon muft
govern his conduct, as no precifc pofitive directions can be laid down for
that variety of cafes and circumftances which occur in practice: the young
furgeon ihould always have recourfe to the advice and afliftan.ce of thofe
more experienced, whenever he can  procure  it; they will not only re-
lieve his own mind, but fecure  his character from the imputation of rafh-
fiefa or ignorance. 
                         [  258  3
   pofure to light.  When the pain produced by light is coa-
   fiderable, we have reafon to conclude, that the parts at the
   bottom of the eye, particularly the retina,  are chiefly af-
   feaed ; but  when the pain thus  occafioned  is not great,
   the inflammation is probably  confined to the external co-
   verings of the eye.   In fuperficial affeaions, the fymptoms
   are  ufually  entirely local;  but whenever they  are deep
   feated, there are fevcre fhooting pains through the head
   and commonly fever to a greater or left degree.
     The tears  difcharged are frequently fo hot and acrid
  as to excoriate the  cheeks; and after fome continuance of
  the difeafe, together with  the tears, there is often a confi-
  derable  quantity  of a  yellow  purulent  like  matter dif-
  charged.   When the  inflammation has  extended to, or   \
  has originated in the tarfij  a difcharge of vifcid fluid takes
  place from them, which adds  greatly to the patient's dif-
  trefs, by cementing the eye-lids fo firmly  together, as to    '
  render it very difficult to feparate them.                    ']
    Ophthalmia fometimes, though not very frequently, ter-
  minates in  fuppuration,  oftener In  obftruaion  or  indura-    [>
  tion of fome part  of the membranes of the eye, but very    \
 rarely in gangrene.
   This difeafe may be induced by whatever occafions in-    ''
 flammation in any other  part of  the body.  It fa alf0 pro-    '<
 duced by fmoke;  by much light,  and  particularly W   \
 much expofure  to  the rays  of the fun;  expofure to fire-     <
 to foowj and by the introduaion  of fend, lirae, or any   <\
 other extraneous body beneath the eye-lids.  It fa alfo in-    5
 duced by fcrophula, or lues venerea.                        '■'
   When ophthalmy  depends on the two latter caufes
 the employment of the  remedies adapted  to the general  '
diathefis  becomes neceffary.   We  Pr,pofe in  this  place

Tufes7 t0      ^  thC ^^  WhCn Pr°duCcd  by l0caI

                                                  The 
                        C  259   3
    The indications of cure are, to remove extraneous irri-
  tating fubftances; to diminifh pain and irritability induced;
  to remove the tUrgefcence of the blood-veffels' of the eyes;
  and to prevent a  return of the difeafe.
    When inflammation is produced by extraneous  fub-
  ftances between the eye-lids and eyes, they  fliould, if pof>
  fible, be removed.  The eye may be opened fufficiently to
  admit of this by the  fingers; but it  is more effeaually
  done, if  while an affiftant lifts up the fuperior eye-lid with
  a blunt hook,  the furgeon depreffes  the inferior  eye-lid.
  The  fubftance may  by this means be difcovered, and  if
  loofe, may be taken out with the end of a blunt probe, co-
  vered with a bit of foft linen, or filk; or if it is  fixed
  in the eye, it may be removed by a pair of fmall forceps.
    It often happens that we cannot difeover  the  offending
  matter; in thefe  cafes tepid water, or  milk and  water,
  fhould be frequently injeaed under the eye-lids, and the
  eyes  fhould be  frequently  dipped and bathed  in warm
  water.—When the inflammation  has  fubfifted  for  fome
^  time, it often continues even  after its exciting caufe has
  been  removed.
    Whenever the  topical  fymptoms  are  confiderable,  and
  there is  much fever^t will be neceffary to ufe general
  bleeding,  brifk purgatives, and  a low cooling regimen.
  The light fhould be  excluded  from  both  the   eyes;
  and the difeafed eye fliould be kept conftantly covered, ei-
  ther with foft linen foaked in a watery folution of lead, or
  with cold poultices compofed of this folution and crumb of
  bread.
   By thefe means very  violent ophthalmias may often be
 removed ; but inftanees frequently occur in which they are
 not effeaual.  In fuch, blood may  be difcharged by cupping
 the temples, or by the application of leeches to them; but
 it will fometimes  happen, that even thefe give  no  relief:
 the veffels of  the eye itfelf  fhould then  be°dividcd.
   This may be done either with  the flioulder of a  lancet,
                                                     or 
                      I   260  3
 or with a fmall knife.   An affiftant fupporting the head
 of the patient behind, and  another  fecuring  his  hands,
 the furgeon with the fore and middle fingers of one hand,
 is to fepante  the  eye-lids, while with the inftrument he
 makes  repeated fmall  fcarifications  on the turgid  veffels,
. avoiding thofe of the cornea, without they feem very much
 diftended with  blood.  In order  to  produce  a free dif-
 charge from the veffels, the eye fhould be frequently dip-   j
 pedin warm water, or foft linen immerfed in warm water,   j
 ihould be conftantly applied to it.                         1
   This operation  is very  eafily and  fafely performed by   I
 any furgeon of a tolerable  degree of fteadinefs; and a few   j
 drops of blood evacuated by it is frequently of more fer-   1
 vice than any other remedy.
   When fearification does not remove the pain, or when
 it is not admitted, a little laudanum, dropped into the eye,   \
 will fometimes  be effeaual in taking it off.   The  pain as   •]
 well  as every other fymptom produced by ophthalmia, i»  ;S
 Otten  relieved by fhaving the head  and  wafhing it  fre-  fl
 quently in  cold  water.  Blifters applied  to the head, be-
 hind the ears, or on  the neck, are likewife advantageous
 as well as iffues and fetons in the back of the neck.       .i
    To obviate that gluing together of the  eye-lids which is   1
 apt to take  place, particularly at night, it  will be proper to   ]
 infinuate a fmall  quantity of fome emollient ointment be-
 tween them,  every evening.  There are often flight ulce-   \
 rations of  the tarfi,  which  contribute to  produce  this ad-
 hefion : when thefe  are  difcovered,  and are unconneaed   J
 with any general difeafe, they are moft effeaually removed  '
 by the application  of  mild mercurial  ointment, by means
 of a pencil, night  and morning, and the  ufe of a weak fa-  <
 turnine or  vitriolic lotion, once or twice  a-day.
    It is of great importance to prevent  the admiffion of
 light  to the eye as long as it is produaive  of pain; and  ;
 even when one eye only is inflamed,  both of  them fhould
                                                     be 
                      [  26-1   3
be lightly covered with a loofe  bandage*of filk or  linen; -
and when the patient  is able to go abroad, the bandage
(pi. vi. fig. 2.) will be found very ufeful.   The quantity of
light admitted can be eafily regulated, and  the eyes by it
are neither compreffed  nor kept too warm.
   To prevent a return  of ophthalmia nothing is fo certainly
ufeful as cold bathing, general and  topical.   Shaving the
head, and bathing it daily,  has been found of  confiderable
fervice.  Peruvian bark is alfo very ufeful, and wdien the
difeafe is  periodical, it is the moft effeaual  remedy: all
exciting caufes are carefully to be avoided.


                    SECT.   II.

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

   When the eye-lids  are wounded in a longitudinal direc-
tion,  all that is  neceffary is to bring the lips of the cut to-
gether, and retain them by ftrips of adhefive plafter, un-
til a re-union takes place: but when the wound is tranf-
verfe, and particularly if the  tarfus is divided, the parts
fhould  be kept  together by one or more futures.   The
interrupted future  is  ufually employed, but  I  prefer  the
twifted future.   The  pins ufed fhould be fhort and very
thin, that they may not injure the contiguous parts ; and in
the introduaion of them, care  fliould  be taken to' make
them pafs through the fibres of the orbicularis mufcle,  or
little advantage  will be gained by the operation, and that
they do not pafs through the internal membrane of  the eye-
lid, or they will injure the globe of the eye.
   In performing this  operation,  we fhould be careful that
 the parts are not fo clofely drawn together,  as to impede
 the aaion of the  eye afterwards; and as foon as it is fi-
 nifhed, as it  is of confequence to prevent the  motion of the
                                                     eyes 
                       [  262  3
 eyes during the  cure, the eye-lids fhould be clofed,  and
 covered with a piece of foft linen fpread with  faturnine
 cerate • and a comprefs of lint being laid over the affeaed
 as well as the found eye, the whole fhould be retained by
 a napkin.   Inflammation fliould be guarded againft, or re-
 moved if prefent, and in three days the futures may be re-
 moved, as a union will then probably have taken place.
   When fo much of the eye-lid is taken off, that the re-
 maining parts cannot be brought into contaa without im-
 peding the motion of the eye-ball,  it will be  beft to leave
 them apart, ufe light eafy dreffings, and truft to nature for
 fupplying the deficiency with cellular fubftance.
   Wounds  of the eye-ball which  penetrate deep,  are fre-
 quently dangerous from  the  contiguity of the brain ;   but
 thofe which go no farther than the anterior part of the eye,
 although they  may deftroy the beauty and  utility of the
 organ, are not in other refpeas hazardous.
   Wounds  of the cornea,  particularly  if direaiy oppofite
 to the pupil, are moft frequently produaive of lofs of lighf.
 in greater or lefs degree, from the cicatrix confequent to
 them ; but they do not ufually occafion fo much inflamma-
 tion as thofe of the fame extent in the felerotica.
   Thefe affeaions are attended with rifk in proportion to
 their extent;  the larger the wound is the greater danger
 will there be of inflammation, and of deftruaion of fight,
 from evacuation of the humors of the  eye,  or from ci-
 catrices.
   The circumftance which requires our  chief attention in
 wounds of the eye, is the prevention or removal of inflam-
 mation ; for if a large opening is made in the eye, a great
 portion of  the  humors will certainly be evacuated.    All
that art can do  is,  together with a ftria antiphlogiftic
 courfe, to keep the eye lightly covered with fome emollient
application of the  faturnine kind, and to bathe  it now and
then with a watery folution of lead.  When   pain to  any
                                           confiderable 
                       r  26-3  3
 confiderable degree occurs,  opium  may be given in pro-
 portion to its violence.
   By thefe means, fymptoms of a very formidable appear-
 ance will often be entirely removed.

                     SECT.  III.

                Of Tumors of the Eye-lids.

   The eye-'ids are frequently infefted with fmall, trouble-
 fome tumors  of various kinds.
   Towards the internal angle of the eye,  and moft  fre-
 quently on the under eye-lid, near the punautn iachryrnale,
 many people are  liable to frequent  returns of a fmall en-
 cyfled tumor of  the inflammatory kind,  by nofologifts
 termed hordeolum, but commonly known by the appella-
 tion of a flye.  This begins with a fenfation of fulnefs, fliff-
 nef?, and  uneafinefs  of the  internal canthus  of the eye.
 At firft the fkin is  fearcely if at all difcoloured, but if fup-
 puration follows,  which will always be the cafe if the tu-
 mor is left to itfelf, it becomes  firft of a pale red,  and af-
 terwards of a yellow colour towards the upper part, where
 it commonly  burfts, and difcharges  a fmall quantity of a
 thick purulent matter.  This tumor is very flow  in its
 progrefs, and the peculiar appearance .of it may be readily
accounted for from its particular fituation.
  Styes are more frequently met with than any other tu-
 mors of the eye-lids,  and are ufually feated near the nofe;
but the other fpecies  are fituated indifcriminately in eve-
ry part of them.  Thefe are of three kinds.
  The firft we fhall  mention is commonly of a roundifh
form ; is fomewhat foft;  it feems to, move when  preffed
upon ; the fkin  retains its  natural appearance ; and from
the contents of it being always of a white and fat<like na-
                                                  ture, 
                      [  264   3
 ture, it is termed fteatoma.  The matter of which thefe tu-
 mors are compofed, is always furrounded by a firm mem-
 branous cyft.
   From different parts of the eye-lids, we frequently ob-
 ferve fmall  pendulous excrefeences  to  hang by  very nar-<
 row necks:  on other occafions  they are conneaed to the
 fkin by means of thin broad bafes.  Some of thefe tumors
 being of a  foft flefhy confiftence  are termed farcomata:
 others being hard,  are termed verrucse, or  warts.
   In the treatment of flyes, we are  by fome direaed to en-
 deavour to difcufs them by aftringent applications ; but by
 this mode we fometimes produce tumors  of a hard and in-
 veterate nature, and may injure the eye-lids by the appli-
 cations themfelves.  I think it the  beft praaice to endea-
 vour by poultices  to bring them to a fpeedy fuppuration,
 and then to difcharge the  matter ;  the fore ufually heals
 very fpeedily, and  the  parts foon  recover  their tone,  if
bathed with fome mild aftringent.
   Excifion  alone fliould be depended on for the removal
 of the farcomata and verrucse; if cauftic or ligature are em-
 ployed,  they are  always tedious in their  operation,  and   j
 often produce troublefome  inflammatory affeaions.
   The patient being feated oppofite to a  window,  and his
head being fecured by an affiftan/, if the tumor is not large
 enough to be laid hold of by the fingers, a  ligature ought
 either to be  paffed  through it or around it, by a needle,
 that  it may be raifed  from the parts beneath : if the bafis
 of the fwelling is narrow, it may be  feparated by one ftroke
 of the fcalpel, but if its attachment to the fubjacent parts
 is of any confiderable extent,  it is  better to remove  it by
 cautious diffeaion.   The only dreffing in common necef-
fary is lint retained by adhefive plafter.
   When we have  to  remove a fteatomatous  or encyfled
 tumor, inftead of diffeaing off the  fwelling covered with
 the fkin, it is better merely to divide the fkin  and  cellular
                                             fubftance 
                       C  265  3
fubftance  by a fimple incifion entirely acrofs the moft pro*
minent part of the tumor with a fcalpel, a  ftrong waxed
thread being then paffed through the centre of the cyft, an
affiftant fliould by means of it  raife the tumor fufficiently,
while the furgeon diffeas it entirely out.
  If the internal membrane of the eye-lid is divided in the
operation, the lips of the wound in it muft be laid as nearly
together as poffible, and any fuperfluous matter that forms
muft be frequently removed; but nothing more fliould be
attempted.  When, however, the external fkin of the eye-
lid  is cut,  the wound fhould be clofed by ftrips  of adhe-
five plafter.
  In extirpating thefe tumors,  whenever the cyft is pretty
firm,  and  the contents are fteatomatous,  they are more ea-
fily and effeaually removed by preferving the cyft entire;
but when the cyft is thin, and efpecially if its contents are
fluid, from fuppuration of fome part of it, which is fre-
quently the cafe, it will conduce to the facility and expedi-
tion of  the operation, to punaure the cyft, and difcharge
its contents as foon as it is laid  bare.*
                   SECT.   IV.

         Of Inverfton of the Cilia, or Eye-lafhes.

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

  * This fpecies of tumor is frequently  fo fituated as to admit of re-
moval  by turning the  ciliary ligament outwards, then laying hold of it
with a fmall hook and diflis&ing it out,  without wounding the internal
flcin of the eye-lid. 
  This  difeafe is  ufually termed Trichiafis or Entropium,
and may depend entirely upon a derangement of the hairs
themfelves, which leaving their ufual direaion, turn in to-
wards the eye-ball;  but it more frequently originates from
an inverfion of the tarfus, induced either by fome unequal
fpafmodic affeaion of  the orbicularis mufcle in the under
eye-lid,  for it feldom occurs in the upper  palpebra, or by
a cicatrix in the fkin of this part.  It is alfo fometimes the
effea of tumors; and  it has likewife been attributed to a
relaxation of the teguments of the eye-lid.
  When the complaint is induced merely by a derange-
ment of the hairs themfelves, if the hairs have acquired*.
their full ftrength,  as  it will be impoffible to bring them'
back into a proper direaion,  they fliould be pulled out by
a fmall pair of forceps, which ufually gives immediate re-
lief; and to prevent a return  of  the difeafe, as foon as the
fucceeding hairs have  acquired about half their full fize,
they fhould be turned down upon the eye-lid  with the end
of a blunt probe,  and there retained for one, two, or three
weeks,  by covering them with narrow  flips of adhefive
plafter,  or with ftrong mucilage or glue by means of a pen-
cil.  This method  will almoft always fucceed in the re-
moval" of this troublefome and painful complaint.
  If trichiafis arifes from partial fpafms #of the Orbicular
mufcle, the only effeaual mode  of cure confifts in making
an incifion through  the internal part of the palpebra, fo as
to divide the  affeaed  fibres.   No dreffing is neceffary to
be applied to the wound.
   When a tumor or cicatrix appears  to be the caufe of the
inverfion, it fhould be diffeaed out.   When, in the latter
cafe, the difeafe is not immediately removed by the opera-
tion, the edges of the wound fhould be united by adhefive
plafter, or, if neceffary, by  the twifted or interrupted fu-
ture.  When  the operation fucceeds there  will be nothing
more than foft eafy dreffings  requifite.
                                                     It 
                      L  267   ]
  It is not very probable that entropium is  ever occafion-
ed by a relaxation of the teguments of the palpebra ; when
it appears to be the cafe, however, a folution of alum in
infufion of oak bark will probably remove it; but if this
doe8 not fucceed, there is no remedy but the removal of
the  relaxed fkin by the fcalpel, and afterwards uniting the
edges of the wound by future.
  Inflammation of the eye is a very conftant attendant of
this difeafe;  when  it is not removed  by taking away the
hairs, the remedies  formerly direaed for ophthalmy muft
b*e employed.
  The upper lid is fubjea  to a dropfical fwelling which
fometimes may be produaive of trichiafis:   This may be
often cured by making  two or three fmall punaures in  it
with the point of a  lancet;  but  when this  does  not  fuc-
ceed, it will be neceffary to cut off a part  of the fkin with a
fcalpel,  and  clofe the wound afterwards by adhefive plaf-
ter  or future.


                    S E  C T.   V.

       Of the Turning Outwards of the Eye-lids.

  When the internal  furface of either  of the eye-lids  is
turned outwards, fo as to fold over any  part of  the  cilia
or of the contiguous fkin, the difeafe is termed earopium ;
when the upper eye-lid only is affeaed,  it has been called
Lagophthalmus.
  This complaint is not only produaive of  deformity, but
alfo,  in many  inftanees, of  confiderable pain.   It may  be
induced by  an enlargement of  any  part of the eye,  or
other tumors within the orbit; by dropfical fweUings  of
the  palpebra;  by  violent  inflammations   of the tunica
conjunaiva  lining the  eye-lids;  by mere relaxation of the
                                              palpebra; 
                     C   26S   ]
palpebra;  and by cicatrices of wounds or abfceffes, pro-
ducing a corrugation of the fkin of the eye-lid.
  When the  difeafe is induced by tumors, thefe  muft be
removed;  when  topical  dropfy  is  the caufe, it  muft be
treated  as direaed in  the laft feaion.   If  inflammation
has  given rife  to it, and it continues after that  has  fub-
fided,  deep fcarifications into  the  affeaed  part  will be
particularly  beneficial:   And if the complaint originates
in relaxation,  as  will be  particularly the  cafe in  old age,
cold water, brandy, and aftringent lotions fhould be fre-
quently employed; but in aged perfons no operation fhould
be advifed.
   Cicatrices, from confluent fmall-pox,  and other  caufes,
fometimes  induce this difeafe.   When the  contraaion is
only in one point, it may be  removed merely by an inci-
fion through the fkin and cellular fubftance ;  but when
there is an adhefion the whole  length of the cicatrix, af-
ter making an  incifion,  the fkin fhould be raifed  by a pair
 of fmall  forceps,  and  the whole  of it  feparated by the
 knife  from the parts  with which  it adheres.  The cilium
 then being reftored to  its natural  place, the fkin is to be
 kept in a proper fituation by adhefive plafter, if poffible,  if
 not, by a bandage, until the wound fills up and heals.


                    S  E  C  T.   VI.

                Of  Concretion  of the Eye-lids.

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

                  SECT.   VII.

           Of Flefhy Excrefcences on the Cornea.

   This difeafe is denominated from its appearance, Ptery-
gium, or Onyx, by different writers.  It is moft frequently
met with at the internal angle of the eye, but it attacks other
parts in various inftanees.  In fome cafes it is  fmall, but
in others, it gradually extends over the whole cornea.
   This affeaion feems to confift in an organic membranous
fubftance formed by a protrufion of fome of the blood-
veffels of the  tunica  conjunaiva from  external violence,
inflammation,  or other caufes; and its increafe is probably
owing to  fubfequent inflammations.   Ophthalmia is  its
moft frequent caufe ;  and it  feldom appears until the dif-
eafe begins to fubfide, or  has entirely gone off.   During
the  inflammatory  flate,  this fwelling  is  generally of a
deep red colour, and very painful; but  afterwards, and
when it arifes without any previous inflammation, it is  of
 a pale  yellow, and  unattended  with much pain, unlefs
irritated.
   When the inflammation has gone  off, as  long as this
 complaint  does not impede the motion of the eye-lids, we
                                                 fliould 
                      [   270  3
 fhould truft chiefly to aftringent applications, fuch as fo-
 lutions of alum and white vitriol, as ftrong as the patient
 can bear them, perhaps 3fs of the former, and ty. of the lat-
 ter to §iv. of water, and ufed three or four times a-day—
 A weak  folution of corrofive fublimate, as gr. i. to |iv. or
 verdegris, may alfo be employed with benefit.
   Efeharotic powders, as calcined alum, white vitriol, or
 verdegris, mixed  with  loaf fugar, and fprinkled  on the
 part once or twice a day,  have been ufed.   But we fhould
 be very  cautious  in  the  application  of remedies of  this
 kind.   They may  be  ufed alone,  or  alternated with  the
 aftringents abovementioned.
   When thefe remedies  fail in preventing  the tumor from
 acquiring an inconvenient fize, if it is  attached to the eye
 by a fmall pedicle  only, it may be removed by one  ftroke
 of the fcalpel; but whenever it is conneaed to the whole,
 or a large part of  the furface  of the eye, it has  ufually
 been recommended to diffea off the whole;  but this  is a
 tedious   and  hazardous  operation :  The  following  an-
 fwers every purpofe of it without danger.  The  patient
 being placed upon a pillow on  the floor, the furgeon fitting
 behind him on  a chair, fhould  have the head  of the  pa-
 tient reclined on his knees, with the face fo raifed,  that a
 fufficient degree  of light  may fall on the eyes.  The pati-
 ent's hands  then  being fecured, the  under eye-lid fliould
 be drawn down  as far  as poffible by an  affiftant, while
 the upper palpebra is  fupported in fuch a manner  by  the
 furgeon with his left hand, as to expofe to  view the whole
 of the difeafed part.   A fmall knife* is now to be employ-
 ed in making fcarifications through the excrefcence near
 to and all  around its outer circumference, fo as  to cut  •■>
 off all  communication between  the roots and  ex'tremities
                                                     of
  * The knife beft adapted to this purpofe, is made about the fize and
fhape of that ufed for extracting the cataract, except that it is  fomewhat
more rounded at the point,  and has a back like a common fcalpel. 
                      C   271  2
 of thofe veffels of which it is formed.  And in order to
 render the operation more certainly  fuccefsful, after th«
 difcharge of  blood induced by the firft incifions is fome-
 what abated, one,   two,  or more circular  fcarifications
 may be made within  each other.
   Thefe  incifions had better be made by repeated ftrokes
 of the knife through the excrefcence,  for fear of injuring
 the eye-ball;  and they may  be done  with equal fafety,
and  with more eafe, in the manner  above recommended
 than by lifting the excrefcence by a ligature  paffed through
 itj as advifed by fome operators.
   The incifions  fhould be allowed  to bleed freely,  and
 may afterwards be bathed  two or three times a-day with
 a weak folution of faccharum  faturni.   If the excrefcences
 do not feem to decreafe in a few days, the operation may
 be repeated, and again renewed from time to time, as long
 as any part of the difeafe remains; and whenever any part
 of the tumor  becomes loofe, it may  be cut off, but  not
 without.
   Although this operation very commonly proves fuccefs-
ful,  yet  there are fome inftanees in which no advantage is
derived from it,  and the difeafe uniformly  increafes after
its performance:  In  thefe  cafes, we muft truft to pallia-
tives. The eye fhould be frequently bathed with a weak
faturnine folution, and be covered with pledgits  of Gou-
lard's cerate.    When  thefe applications have no  effea,
and the tumor increafes to fuch a fize as to  deftroy vifion,
and becomes very painful, it will be neceffary, left it fhould
degenerate into a  cancer, to remove it at once, by extir-
pating the whole eye-ball.
SECT. 
C  272  3
                  SECT.    VIII.

           Of Abfceffes in the Globe of the Eye.

  When inflammation of  the eye terminates in fuppura-
tion,  which is  feldom the cafe, it commonly originates
from  negligence, or from  a fcrophulous or  fome other
general affeaion.
  The effufion of puriform matter into the ball of the eye,
is commonly produced from the  internal  part of its mem-
branes ; by  mixing with the aqueous humors it  produces
an enlargement of the eye, a lofs of vifion, and fuch an
opacity, that, in  general, neither  the iris,  pupil, or cryftal-
line lens can be diftinguifhed.   In fome few cafes, how-
ever,  the iris  is pufhed forward,  and  can be obferved
in clofe contaa with the cornea ; and the coats of  the eye
being here weaker than in any other part, a protrufion
commonly takes place, which, if not opened foon, burfls of
itfelf, and difcharges part, or perhaps all of the contents of
the eye; and at  this opening the  iris, in a thickened difeaf-
ed ftate,  is very generally  pufhed out.   In  fome cafes,
partial fweUings occur likewife in the fclerotica.
  During the formation of this  difeafe the  patient fuf-
fers not only a lofs  of fight, but fevere pains in the eyes,
{hooting backwards into the head,  are  generally attend-
ant, accompanied  by conftant reftleffnefs, heat,  and other
fymptoms of  fever ; and  thefe continue very commonly
until  the  contents  of the eye are evacuated.  In fome in-
ftanees there is no  pain ;  but the matter formed is then
fmall in quantity, and the  fwelling is chiefly of a watery
nature, probably originating from an increafe of the aqu&r
ous humor.
   All the varieties  of this difeafe we comprehend  under
the  name of ftaphyloma.   Small, partial abfceffes  feated
                                                    on 
                       L"   273  3
 on different parts of the cornea or fclerotica, and In which
 there is no general affeaion of the eye, are included under
 the title of Hypopyon.  In both thefe difeafes, the motion
 of the eye-lids is more or lefs impeded.
   All the varieties  of  the  ftaphyloma require  the  fame
 treatment.   As  it rarely  happens that the ufe of the eye
 can be preferved, our chief objea in general is, to abate
 the violence of the pain, and to remove the deformity pro-
 duced.   For the accomplifhment of the  firft intention,
 the difeafe is to be treated by the remedies of ophthalmia:
 And if, notwithftanding the  employment of thefe,  fuppu-
 ration is induced, and the pain produced by the confequent
 increafed diftention of the eye is  very great, nothing but
 an incifion through its coats fo as to evacuate the effufed
 matter and  the  thinner  humors,  will  give relief.   The
 patient's  head  being fecured  by an affiftant,  and the
 operator ftanding before him,  the eye-lids may be fuffici-
 ently feparated by one hand,  while the  knife recommend-
 ed in feaioti vii. being  introduced into the moft promi-
 nent part of the tumor,  or into the  moft  depending part
 of the tranfparent  cornea, is to be carried forward hori-
 zontally until an opening of a fufficient fize is formed.
   It has  been recommended  inftead of the above defcribed
 operation, either to  diffea  off the  protuberant part of
 the eye, or  to  remove  it  by a  ligature;  but  neither of
 thefe painful modes are in common neceffary, nor  are they
 more effeaual than the method we have advifed.  In feme
 very long continued cafes of ftaphyloma, indeed, where the
 humors of the eye feem  to be entirely abforbed or deftroy-
 ed, and in which the tumor  is altogether formed by a thick-
 ening of the coats of the eye, and particularly of the iris,
 the only effeaual remedy is  the removal of all  the promi-
 nent part of the eye ; but in common, the difeafe fhould be
confidered merely as an abfcefs, and treated as abfceffes in
other parts of the body.
                        M m                    After 
                      [  274  3
   After the contents of the eye have been evacuated, the
parts fliould be gently covered with aToft comprefs moift-
ened with weak lead water,  and the patient fhould be kept
upon a low, cooling regimen, until the wound is  healed,
or there is no rilk of inflammation.
   The hypopyon is to be treated upon the fame plan ; the
pain is to be moderated by opiates, &c. and as foon as mat-
ter is formed,  it  fhould be  evacuated  by  an incifion, in
order to prevent a  chance  of its being difcharged into the
globe of the eye, and deftroy vifion entirely.
   The fungous excrefcences that occur after  operations
in thefe difeafes, may be kept down by  the occafional ap-,
plication  of burnt alum  finely powdered,  or  of lunar
cauftic.

                    SECT.   IX.

          Of Dropfcal Swellings of the Eye-Ball.

   A  dropsy of the eye-ball  is produced folely by an in-
 creafed quantity of the aqueous humor.  The firft fymp-
tom of the difeafe  is, a fenfe  of fulnefs  in the eye, which
produces a good deal of diftrefs,  long before any increafe
of fize in the eye-ball is perceptible : This at length makes
its appearance; the motion of the  eye-lids begins to be im-
peded ; and vifion gradually becomes more imperfea, until
at length the patient is juft able to diftinguifh light from
darknefs.   At this period too, fome part of the eye, moll
frequently the tranfparent cornea, generally begins to pro-
trude, fo as to form a fmall tumor.  If the contents of the
eye are not now difcharged  by an operation, the  tumor
foon burfts.
In 
                      C   275   3
  In the early ftage of this difeafe there is no difficulty in
diftinguifhing it from ftaphyloma;  but in the advanced
ftate this is not always eafy to be done.  The external ap-
pearances of thefe difeafes are fometimes exaaiy  fimilar;
but in the  dropfy  of the eye, the patient is always fenfible
to the effeas of light; and if the pupil can be diftinguiflicd,
light will  commonly produce fome  degree of contraaion.
in it.  It is, however, of no confequence to difcriminate
between them, for the treatment adapted to one is equally
proper for the other.  See the laft feaion.
  In the earlier ftages of this complaint, as the confequent
lofs of vifion feems to originate often merely from diften-
tion,  would it not be better to evacuate the fluid, by an
incifion of perhaps three-tenths of an inch long with the
knife (pi. vii. fig.  8.) into the moft depending part of the
tranfparent cornea;  or by introducing a flat trocar  with
a lancet point,  of the fize of a crow quill, about the tenth
of an inch from the cornea tranfparens, behind the iris, and
at the moft depending part of the eye ?  This might be re-
peated occafionally, if the difeafe fhould return.   It is an
operation  perfeaiy fafe;  and after its  performance, with a
view to ftrengthen the eye, and  prevent a  return of the
complaint, the parts might be bathed frequently with fome
aftringent lotion.
   Inftead  of difcharging the humor by an incifion, in an
advanced ftage of the difeafe,  when vifion is deftroyed, it
has been propofed to employ a feton; but it is probable
this would give too much irritation.
SECT. 
[  276  1
                   SECT.   X.

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

  Blood may be effufed into one or other of the  cham-
bers of the eye by various  caufes.    It has  occurred in
fome inftanees of putrid difeafes,  and in inflammations of
the eye; but it is more frequently  the confequence of a
rupture of fome  blood  veffel, from a blow,  or from a
wound penetrating into the pofterior  chamber.   When the
wound does not extend  farther than the anterior chamber
of the  eye,  as the veffels furrounding that do  not in com-
mon convey red blood, it feldom occurs as an  effea.
  Whenever blood is mixed in  fuch  quantity with the
aqueous humor as to obftrua  vifion, it fhould be remov-
ed by  an operation ; but when it  finks below the  axis of
vifion,  and produces no inconvenience, it may be fuffered
to remain.
  The operation  for the removal of blood from the eye-
ball  is  fimilar to that defcribed in the laft feaion.  An
opening fhould be made  in the moft  depending part of the
tranfparent cornea, with the  knife, about a fixteenth part
of an  inch from  the junaion  of  the  iris  with the other
coats of the eye; and thence carrying the point of it ho-
rizontally forward to the diftance of about three-tenths of
an inch, it ought at this part to be pufhed through the cor-
nea :—by proceeding flowly  and  fteadily, all that  part of
this  membrane fhould then be divided which lies between
the two openings made by the inftrument at its entrance
into, and its paffage from the cavity  of the eye, care being
taken to make the incifion at  an equal diftance from  the
iris through its whole length.
  The aqueous humor, together with the commixed blood,
will now be difcharged,  particularly if the patient turn his
                                                  face 
                     [   277  3
face  downwards,  and the fides of the divided cornea be
feparated by a blunt probe, or a fmall fcoop.   The cornea
will then collapfe,  and a  comprefs  of  lint moiftened with
lead  water being applied, the wound will foon clofe,  and
the aqueous humor be quickly regenerated.


                   SECT.  XI.

          Of the Ulcers on the Globe of the Eye.

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

            Of Specks or Films  upon the Eye.

  The difeafe termed leucoma,  albugo, or nubecula, con-
fifts  in an opake fpot formed on  fome part  of  the eye.
When it occurs on the fclerotica,  it feldom requires the
affiftance  of the furgeon;  but  when  it is  feated on the
cornea,  it always merits great  attention, as a very fmall
degree of it frequently  induces a partial and fometimes a
total lofs of vifion.
  Thefe  fpecks or films are generally of a whitifh colour,
and feem to originate,  in every inftance, from that effufion
which is fo frequent a confequence of inflammation.  When
an abfcefs is thus produced,  the burfting or opening of it
very commonly, leaves an opaque fpot,  attended with fome
degree of prominency of the parts in which it was feated;
but where the effufion inftead of being near the furface of
the cornea is difperfed among the different lamellae of which
that membrane is compofed ; or when the degree of inflam-
mation has not been fufficient for carrying it on to fuppu-
ration, the opacity induced, does not,  as in the cafe of an
abfcefs, form a protuberance, but rather appears to con-
ftitute a part of the cornea itfelf.
  Thefe fpots on the eye are of various forms, and of dif-
ferent degrees  of magnitude. Whenever they affea the
fight -materially, they fhould certainly if  poffible be re-
moved.   In the cure,  it is of the greateft confequence to
afcertain  which of  the two  varieties  above defcribed the
cafe belongs to.  When the effufed matter feems to be
fpread through the whole  fubftance of that  part of the
cornea in  which it is feated, without elevating it in any
degree, no advantage can be expeaed from any  external
applications, becaufe we cannot by thefe remove  the dif-
                                                  eafe 
                       [   280  ]
eafe without deftroying the cornea itfelf.   In fuch cafes,
as the opacity is fometimes removed by an exertion of the
fyftem alone, probably by means of abforption,  it will be
proper to employ fuch remedied  as  we know excite this
operation, fuch as a gentle courfe of mercury,  now and
then  brifk purgatives,  and iffues.   But we feldom derive
much advantage from them.*
   When there is an evident prominency in the difeafed fpot,
produced  from an elevation  and opacity of  the external
lamina alone,  we can  often  cure  the complaint entirely,
and almoft in every cafe produce an alleviation of it.   This
variety of leucoma may be removed either by the knife, or
by efcharotics ; but in general the former is preferable. The
eye being fixed with a fpeculum,  (pi. vi. fig. 6.) the furgeon
fhould feat  himfelf  between  the patient and a clear light;
and then  with repeated  ftrokes of  the fmall knife,  (re-
commended in fea. vii.) he fhould endeavour to cut away
all that portion of the cornea which is in any degree fepa-
rated from  the reft.  This may be done with the greatefl
fafety by an operator with a fteady hand.
   As patients will not  always fubmit  to this operation, we
are fometimes under the neceffity of employing efcharotics.
Thefe may  be ufed  fufficiently ftrong to remove leucoma,
in many inftanees, without injuring the found parts conti-
guous to thofe difeafed.   When  efcharotic  powders  are
employed alone, or mixed with emollient ointments, they
fhould be very finely  levigated.   The moft  effeaual of
thefe are red precipitate, or verdegris, mixed with three or
                                                     four

   * When the opacity is confined to the middle of the  cornea, and the
other parts of the eye are found, Mr. Pellier fays he has derived confider-
able advantage from  enlarging the pupil, by means of a fmall pair of
curved fciiV.irs 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 fliould be
complicated with a cataract, the cataract is to be extracted. 
                       [  28i   3
 four parts of fine fugar.   Calcined alum, and white vitriol,
 combined  with egg-fnells in fine pov/dcr, have frequently
 proved ufeful.  A lotion, or w#afh, feems to be the beft form
 in which efcharotics can be applied to the eye :  to make
 thefe, verdegris, white vitriol, or corrofive fublimate, may
 be diffolved in water.
   As it is impoffible to confine any of thefe applications
 to the difeafed  part; all that can  be done is to infert them
 within the eye-lid ; by the motion  of which they  are foon
 conveyed over  the whole  furface of the eye.  In  order to
 reap advantage from them, it will be advifable to  em-
 ploy two or  more at the fame time; thus a fmall quantity
 of the powders  or ointments may be ufed  evening and
 morning, and a wafh may be employed twice or  thrice in
 the day.


                   SECT.   XIII.

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

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

                   SECT.    XIV.
Of Cancerous AffeBions of the Eye, and Extirpation of the e;
                       Eye-Ball.

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

                     SECT.   XV.

                    Of Artificial Eyes.

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

                    SECT.   XVI.

                       Of CataraBs.

            §.  I. General Remarks on CataraBs.

   A  cataract  is a deprivation of fight,  induced by an
opacity of the cryftalline lens,  or of  its  capfule.f
                                                  Inftanees
   * Though the hemorrhage confequent upon this operation, may be eafily
reftrained by preffure with the fponge and lint as dire&ed, yet a violent one
has enfued the fourth day after in  confequence of a fevere cough which
forced out the plug of lint from the focket in the night, and the patient loft
about forty ounces of blood before any affiftance could ariive.  This ought
to put young furgeons upon their guard in fuch cafes.
   f M. Pellier, a very able and fuccefsful French  oculilt, tells us, that
cataract is fometimes  induced by an opacity in the fluid, with which the
                                                    fubftance 
                        C   285   ]

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

fubftance of the lens is  immediately  furrounded.  That it is in fome cafes
complicated with a  diffolution,  and in others with an opacity of  the vi-
treous humor, originating from very violent inflammation,  and which
are both incurable; and fometimes with adhefions of the lens to the cap-
fule of  the vitreous humor ; which  is probably the moft common caufe
of a failure in couching.
   He alfo informs us,  that  when a cataract is of a firm confiftence, it is
almoft 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 cafe, appears full, and fomewhat larger than ufual, and
the capfule is confiderably thickened:  This if it is of a yellow colour, a
fmall portion  of the lens is commonly hard, and the reft  fluid: And
that  he has  feen  inftanees of a  black  cataract; which is to  be dif-
tinguifhed  from a gutta fcrena, by  the pupil retaining its contractile
power.  Mr. Bell appears to be well convinced,  that Mr. Pellier  is ca-
pable of diftinguifhing thefe varieties of cataract by the marks here laid
down.
   Mr. Pellier prefers extraction to depreffion of the cataract in every cafe,
except the pupil is very fmall.  He always fixes  the patient wkh his fide
towards the light, during the  operation  ; but the eye oppofite to th_t
operated upon,  previoufly covered, is placed near the light.   He fepar;it-._
adhefions of the lens,  or replaces the iris v.hen it is thrown  forward,  by
means of a fnull inftrument which he t-.m'.s a curette.  When there is
                                                          reafon 
                         [   28*  3

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

reafon to fuppofe the cataract fluid, he merely introduces a  knife  through
the cornea and pupil, and  makes an opening in the capfule.   When the
membrane is  difeafed, he always advifes us to avoid tearing it, and to ex-
trail it together with the lens. That Mr. Pellier ever takes out the cap-
fule together  with the lens, by preflure, as he directs, Mr. Bell  from fe-
veral facts, and for very fubftantial reafons, very confidently denies.   Mr,
Bell advifes the blunt probe to open the capfule, as  lefs dangerous than
the knife.
  If the 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 propofes to enlarge the pupil.  See Note to  Sect, on Leucoma.
  Mr.  Pellier advifes repeated fmall dofes of  opiates a few hours after
the operation.  Befides other  remedies,  he ufes  a liniment of powdered
alum, or of  white  vitriol and  faccharum faturni beat up with white
°f egg, and applied between folds of foft linen, and a  little of  the latter
infinuated between the eye-lid*, three or four times a-day, to remove the
confequent inflammation and pain.  When the iris, after the operation, is
 forced out at  the incifion by any  caufe, he fays it may be touched  fre-
 quently with gentle  cauftics, fuch  as Goulard's extract of lead concen-
 trated by long boiling, or  any mild  antimonial cauftic;  immerfing the
 whole eye immediately afterwards in warm milk, or  fome emollient de-
 coction, and  then covering it  with a comprefs wet with lead water, &c. 
                     [  287  3
lens, Induced in fome inftanees by external violence, but
in others by fome internal caufe with which we are unac-
quainted.  This is rendered probable from the  difeafe of-
ten happening to women about the period of the ceffation
of the menfes,  when obftruaions  in many parts  of the
body are more particularly apt to be induced.
  The indications of cure in this difeafe are,  i. To re-
move the opacity of the lens; or when this cannot be ac-
complifhed,  2.  To remove the lens itfelf from the axis of
vifion.
  In the incipient ftate of cataraa, mercurial preparations,
and particularly  calomel, are fometimes ferviceable.  When
inflammation occurs, it muft be treated as in other cafes.
The extraaum  hyofcyami, the flammula jovis,  and other
vegetable preparations, are much recommended by fome;
but I cannot fay any thing of them from my own experi-
ence.
  In confirmed cataraas of long duration, we  feldom de-
rive advantage from  any  internal medicines; and we are
confequently reduced to the neceffity of removing the dif-
eafed lens from  the axis of vifion.  This  is accomplifhed,
either by preffing it to the bottom of the eye,  by an ope-
ration termed couching,  or  by removing it entirely from
the eye, by  the operation of extraaion.

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

  By the operation of couching,  the opaque lens is fepa-
rated from its capfule, and being preffed down  behind the
iris,  below the axis of vifion, if the operation fucceeds, it
either remains  there during life,  or is  diffolved  in the
aqueous  humor.  And although the fight will never  be
fo perfea afterwards, as it was before the lens became dif-
eafed, if the eye be otherwife found, it will be quite fuffi-
cient for the common purpofes of life.
                                                    As 
                      I  238   ]
   As this operation as well as extraaion, is always fucceed-
ed by inflammation to a greater or lefs extent,  it fhould ne-
ver be rifked unlefs the patient is blind  to fuch a degree as
to prevent him from following his  ordinary bufinefs; and
never then, when the cataraa is complicated with gutta fe-
rena, or with an opacity of the cornea.  Although the lens
is  frequently harder than natural,  and in  fome inftanees
fofter,  this, were it always known,  fhould not influence us
in  determining upon the operation.
   In order  to  obviate the  inflammation  confequent  to
couching, it will be proper to confine the patient to a low
regimen a few days previous  to the operation, and to give
him  two or three dofes of fome cooling laxative at proper
intervals.
   It will  be  beft to have the patient  placed in an apart-
ment expofed to the north,  during the operation; for  al-
though it may be neceffary to have a good light,  the fun- -i
fliine fhould not be admitted, as it will, by  irritating the J
eye, prevent it  from being fleadily fixed.   The patient  ?
fliould be placed upon a  low feat,  with  his face  towards -J
the  window;  and the furgeon upon a chair confiderably
higher, fliould be feated direaiy before him.   An affiftant
ftanding behind muft be direaed to place the patient's
head upon his breaft, while he fecures it iu this  fituation by
his right hand under the chin, and his  left placed upon the
forehead; and the  patient's  hands fhould be properly fe-
cured  by aii affiftant on each fide.
   The affiftant is now to raife the upper eye-lid with the
fingers of his left hand  ; and  the furgeon applying  the
groove in the fpeculeim, in fuch a manner that it may receive
the  edge of the  eye-lid, the opening or circle formed by the
brim of the fpeculum  is tovbe preffed upon the ball of the
eye  till the cornea,  and nearly the eighth of an inch of the
fclerotica, is protruded.   A fteady and equal preffure being
made  on the inftrument by the left hand of  the  operator,
                                                    and 
                      C   289  3
and he having the elbow of t'.ie right leaning on a table,
or on his knee, in order  to preferve the arm fteady, muft
take a couching needle (pi. vi. fig. 3.) be;ween the thumb
and fore and middle fingers, while the ring n.v.i little fin-
gers are made to reft upon the  cheek of the patfent: the
point of the  inftrument is  to  be carried forward beyond
the external canthus of the eye,  and being brought nearly
into contaa with the fclerotic?, it muft be fuddenly piung-
ed through this coat  fomewhat  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  fide of the
needle is to be introduced towards it;  and it is thus to be
carried forward in a horizontal direaion, until the point o£
it is  difcovered behind the pupil.  The flat furface of  the
needle is then to be turned downwards;  and the point be-
ing pufhed into the upper  part of the lens, we endeavour to
deprefs it to the bottom of the eye by railing the handle of
the inftrument:  It will be  inftantly known that.this is ef-
feaed by the difappearance  of the lens, and by the patient
difeoveriag more light than he had been lately accuftomed
to.   In order to give the  operation a better chance of fuc-
cefs, it veill be advifable  to carry the  lens flowly on  the
point of the inftrument towards the outer and back part of
the eye.   By this means,  the cryftaiine will be partly
lodged in the vitreous  humor, and there will be lefs rifk
of its rifing again to its  former fituation, an  occurrence
which has fometimes taken place.
  The needle fhould now  be  withdrawn, and the fpecu-
lum  taken off; and there will be no  harm  in making a
cautious trial of the good effeas of the operation,  by pre-
fenting fome  objedl  before  the eye.  A comprefs of  foft
lint wet with a weak faturnine  folution  fhould then be
lightly applied over the eye,  and this being fecured by a
triangular napkin, the patient fhould be confined in a dark
                        O o                    room, 
                      C  290   3
room, and kept upon a low regimen  for  fome time.  As
additional preventative remedies of inflammation,  a pur-
gative or two may  be given, and when  neceffary, blood
fliould be taken from the temporal artery,  or jugular vein,
or from the vicinity of the eye by leeches.
   In  the courfe of  three  or four days, the dreffings may
be removed from the eye.  It may then generally be afcer-
tained whether the  operation has fucceeded or not.  The
power of vifion does not always immediately return; and
there  are inftanees in which the  fight, very imperfea  at  .
firft,  has gradually  become betler for  feveral months after  |
the operation, which probably happens from the flow fub-
fidence of inflammation excited in the capfule of the lens.
   When the firft operation is unfuccefsful, as foon as the
inflammation produced has gone off,  the trial may be re-
peated ; and again if this fecond attempt fhould not be ef-
feaual,  A failure,  I am difpofed to think, generally arifes
from  not pufliing the  lens beneath the vitreous  humor,
which by its preffure may probably prevent it from rifing.
Experience proves that no bad  effea is  produced from
doing this,  and much  harm may enfue from negfeaing it.
   Couching, as above defcribed, is fuppofed to have been
performed  on the left  eye;  but  in operating on the right
eye, if the needle is to be  entered in the  ufual  way at
the external canthus,  it muft either be done with the left
hand,  or if the furgeon wifhes to ufe the right hand, he
muft  fland  or fit behind the patient, having  the head fup-
ported on his breaft.   As there are few furgeons who can
ufe the left hand with fufficient dexterity,  and we  cannot
have a good  command of the  eye when  ftanding behind ,
the patient, it will be better to ufe the needle (pi.  vi.  fig. 4.)
with  which the  operator  may  couch  the  right eye with
the right hand very well; the only difference between this
and the method  already defcribed, confifting in entering
                                                  the 
                        C  2or   2
  the needle at the internal canthus, and drawing the cataraa
  toward the nofe.
    Inftead of couching  in  the  manner  we have defcribed,
  it has been propofed to pafs the needle through the tranf-
  parent cornea and pupil; but befides that the cataraa can-
  not thus be fo eafily depreffed, there muft be  a very great
  rifk of injuring the iris.

             §.  3. Of ExtraBing the CataraB.

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


                  SECT.   XVII.

              Of the Fifiula Lachrymalis.

  Every obftruaion to the paffage of the tears  from the
 eye to the nofe, is ufually comprehended under the term of
 Fiftula Lachrymalis.
  This  difeafe affumes a variety of appearances, accord-
 ing to the feat of the obftruaion, and  to  the effeas pro-
 duced by it  upon  the neighbouring parts.  When the la-
 chrymal punaa,  and the fmall duaS conneaed with them,
 are obliged in confequence of burns,  wounds, or vio-
lent inflammatory affeaions, the  tears  neceffarily fall over
 the cheek;  and  this,  together  with  a  confequent dry-
 nefs  in  the  correfponding  noftril,  conflitutes that varie-
                                                   ty 
                       [  295  3
  ty of  the  difeafe, which  alone  fhjpuld be termed Epi-
  phora; for when the obftruaion is5 feated in any other
  part of the lachrymal paffages, the complaint is attended
  with fymptoms of a much more perplexing and painful
  nature.
   When the lachrymal punaa and duas remain open, if
  obftruaion takes place in the under part of the lachrymal
  fac,  or in the  dua leading from this to the nofe, the firft
  fymptom is a fmall tumor in the internal canthus of the eye,
  which  is made to difappear upon preffure being applied to
 it, by a plentiful flow of tears paffing into the eye, and from
 thence  over the cheek, and perhaps a greater or lefs quan-
 tity paffing into the nofe.  If the tears are now regularly
 preffed out before the fwelling acquires any confiderable
 fize,  and before they  have become  acrid by  ftagnation,
 they  are, in general, found to be perfeaiy of a natural ap-
 pearance.  This ftate of the difeafe  has been  termed a
 dropfy  of the lachrymal fac; and by a proper  application
 of preffure may be often cured.
   It  moft frequently happens however,  either  from inat-
 tention  in the  patient,  admitting  of the fac being  over-
 ftretched, or from fome other caufe, that the difeafe gra-
 dually grows worfe—the paffage into  the nofe becomes •
 entirely obftruacd—the fwelling in the canthus increafes,
 but flill is unaltered in colour—the tears are  then  pref-
 fed out  with more difficulty; and are mixed with a pro-
 portion  of thick, opake, white mucus—But the patient
 feldom fuffers much pain, or any other inconvenience than
 what  arifes  from the  tears and mucus paffing over the
 cheek.
   At  length the tumor begins to become tenfe, red, and
 painful to the touch, and the matter preffed out has much
 the appearance of pus.  The parts gradually become  more
 inflamed,  until the teguments at laft  burft, and form  an
opening  in the  moft  prominent part of the  fwelling,  at
                                               whjch 
                     C   296  3
which  the tears and  matter are now entirely difcharged.
This opening being  ufually fmall, heals  again  in  a  few
days; but it burfts as foon as any confiderable  colfeaion
is again formed in it: and it continues  thus to  form  and
difcharge alternately, until the opening  becomes  fuffici-
ently large to prevent any further colfeaion.   This forms
a finuous, callous ulcer,  fometimes with  retorted edges;
and the difeafe is now properly termed  a fiftula lachry-
malis.
  It happens in many cafes,  particularly when the habit
is tainted with fyphilis or fcrophula, an occurrence by no
means unfrequent,  that the contiguous bones become cari-
ous : in fuch circumftances the difcharge is thin, foetid,
and commonly  fo acrid as to corrode the adjacent integu-
ments ; and the fore affumes a different appearance accord-
ing to the general affeaion with which it is conneaed.
  The prognofis as  well as the method  of  cure in  this
difeafe,  muft depend entirely upon the nature of the ob-.
ftruaion in  the lachrymal paifages,  and the  particular
ftage of the affeaion.   When the difeafe is  recent,  and
proceeds from inflammation  of the lachrymal  paffages,
which is the moft  frequent caufe, and is induced by mea-
fles, ophthalmia, catarrh, &c. our prognoftic may gene-
rally be favourable;  but  when the complaint is  of  long
ftanding, and  the bones  have  become  carious from fcro-
phula, or the venereal difeafe, the cure  will chiefly depend
on  the removal of the general  affeaion, and  is  feldom
completely obtained.
   When the difeafe is a confequence of tumors in the con-
tiguous parts,  e. g. of polypi in the nofe which prefs on the
lower  part  of  the nafal  dua, the prognofis muft almoft
entirely  depend on  the  praaicability of  removing  the
fwelling.
   If the difeafe originates from inflammation, the common
remedies of inflammation in general muft be  ufed—gene-
                                                   ral 
                      [  297   3
ral of local bleeding—laxatives—a low diet—and fatur-
nine applications to the parts.   In fome inftanees, thefe
remove  the complaint;  but in  many others,  the fides of
the duas are united by the  inflammation, and thus conti-
nue the complaint after the  inflammation has entirely fub-
fided.
  When the obftruaion thus  produced is feated in the
punaa lachrymalia, or in the duas leading from thefe to
the fac, we are to  attempt its removal by inferting a fmall
probe  (pi.  vi.)  into each punaum, fo  as to pafs it along
the courfe of the duas into the lachrymal fac.   The open-
ings thus formed, may be preferved by afterwards injeaing,
twice or thrice daily with a  fmall fyringe,  a weak iulution
of alum, or of  faccharum faturni, and by keeping at other
times fmall  leaden probes conftantly inferted, till the fides
of the duas are rendered perfeaiy callous; the tears will
then pafs as formerly into the nofe.  This  is a nice,  but
not a difficult operation.
  Inftead of the method we have advifed, it has been pro-
pofed to introduce a feton into the duas,  and fuffer it to
remain until their cavities become  callous.  Independent,
however, of the  difficulty of doing this, it would proba-
bly excite fo muc 1  pain and  inflammation, that it would do
more harm  than  good.
  But  the  obftruaion producing this difeafe  is moft fre-
quently fituated in the dua leading from  the lachrymal
fac to the nofe.   While  this produces no farther inconve-
nience  than a frequent difcharge  of tears over the cheek,
with perhaps a  flight fwelling forming now and then in
the corner of the eye, nothing more fhould  be  direaed
than to prefs out the tears from the fac by the finger, fo
frequently as to prevent them from becoming acrid by flag-
nation, and to avoid expofure to cold,  or any other caufe
that might excite inflammation of the eye,  or  other conti-
guous parts.
                        Pp                       We 
                      [  298   3
  We are indeed advifed to attempt the removal  of the
obftruaion,  by  inferting probes into  the  lachrymal  or
nafal duas, or by injeaing fluids into thefe paffages.  But
befides  the difficulty, and fometimes impoffibility  of per-
forming  thefe  operations,  the  pain and inflammation ex-
cited  by them often does  a great deal  of injury.  The
praaice of introducing quickfilver into the fac for  the re-
moval  of the obftruaion, will  probably feldom be found
ferviceable,  but is lefs exceptionable than the others.  A
continued application of preffure, as advifed by fome* does
not appear to  have the leaft chance of removing the  dif-
eafe.
   Although the palliatives above defcribed fhould be truft-
ed to in the fimple ftate of the complaint,  whenever the
tumor in the angle of the eye becomes larger, inflamed, and
painful, and there is danger of  the bones being injured by
the  acrid matter colfeaed in the part affeaed,  we are un-
der the neceffity of having recourfe to a different  method
of treatment.   In fuch circumftances, our views muft be,
to difcharge the contents of the fwelling; to procure a free
 difcharge in future  for the tears  from the lachrymal fac
 into the nofe; and to prevent the paffage from  being again
 obliterated: And this  being  done, to heal the  external
 opening.
   While the  fwelling continues hard,  it would be impro-
 per to open it,  as  this would  give a  great deal  of pain,
 and  the parts below  could not  then  be freely  examin-
 ed.  But a warm emollient poultice fhould be kept con-
 ftantly over  the tumOr until  it becomes  quite foft; the
 point of a  lancet fhould then  be pufhed  into the fupe-
 rior part of it fairly  into  the fac, and  fhould be carried
 downwards in a ftraight  direaion to  the moft  depend-
 ing  part.  When  there  is already  an opening  formed,
 it fhould be  fufficiently enlarged by a  fcalpel introduced
 upon a direaor.   A  few  fibres  of the orbicularis mufcle
                                                    will 
                      t   299  3
 will thus be cut, but this will produce no inconvenience.
 The contents  of the fwelling are now to be gently forced
 out;  a fmall doffil of lint fpread with emollient ointment
 fhould be inferted between the lips  of the wound, and a
 flip of adhefive plafter placed above to retain it.   As a
 plentiful difcharge commonly takes place,  it is  neceffary
 in general to renew the dreffings every day; and in order
 to  preferve the opening of a proper fize for admitting a
 free examination of the parts beneath, a piece of prepared
 fponge, of fuch a fize as  not to irritate the parts, may be
 introduced inftead of  the  Hot every fecond  or third  day;
 and the more  effeaually  to prevent its irritation, a  piece
 of foft oiled linen fliould be put around it.  A piece of
 waxed  thread may alfo be tied to it,  that it may be eafily
 withdrawn when neceffary.
   It was formerly the praaice, inftead of the  dreffings
 we have recommended, to employ the aaual cautery or
 efcharotics for the purpofe of deftroying the hard edges
 of the  fore—This  produced a great deal of  pain, deformi-
 ty, and fometimes an obliteration of the cavity of the dif-
 ferent  duas,  the confequence of which, was a conftant
 difcharge of tears over the cheek.   In many cafes, how-
 ever,  the lachrymal duas  continued open,  and a frequent
 recurrence  of the complaint then fucceeded.
  By the management we have advifed, any  degree of
 hardnefs remaining in  the wound will foon be removed;
 and the fore being cleared of a tough vifcid kind of mu-
 cus with which it is always covered for a few days  after
 the operation, we are now to attempt the formation of a
 free paffage for the tears from the fac into the nofe.   This
-is effeaed by removing the obftruaion in the nafal  dua j
 or when this is impraaicable, by forming an  artificial open-
 ing direaiy through the os unguis, from the under  and
 back part of the lachrymal fac.
                                                 With 
1
                      C  30°  3
   With a view to accomplifh the firft of thefe objefts, _
firm round pointed probe, vfuch as in pi. vi. fig. 7.) ffiould
be inferted into the  bottom of  the fac,  and pufhed  for-
ward with a  moderate force  in the direaion of the nafal
dua; if it enters the beginning of the canal we may then:
go on with fafety, and a probability of fuccefs,  but if the
inftrument cannot be entered into the canal  we  fliould de-
fift,  as it  is then probably rendered impervious by an ad-
hefion of  its fides.  When  the probe  can  be paffed, the;
opening may be preferved by  keeping a piece of  cat-gut,
or of lead wire conftantly in it, until it becomes fufficient-    j
ly large.                                                  1
   Should every trial for difcovering the natural conduit of   I
the tears  be  ineffeaual, we are  reduced  to the neceffity   1
of forming an artificial  paffage for them.   This has been
accomplifhed till very lately by the aaual cautery.  But the    '
cautery fhould never be had recourfe to in thefe cafes, be-
caufe it is always produaive of confiderable injury to the
parts contiguous to thofe which alone ought to be operated
upon ; and  becaufe every good purpofe which it  anfwers
can be obtained with equal  certainty, and  with more eafe'
and  fefety, by forcing any  firm fharp inftrument from the
back part of the fac through  the os unguis :  This is beft   j
performed by a fmall round trocar.
   In proceeding to  this part  of the  operation,  the pa-
tient's head fhould  be fupported by an affiftant;  and the
furgeon, fitting or ftanding between him and the window,  'j
muft introduce the canula of the trocar into the under and   j
back part of the fac : it muft be kept firmly in this fituation   j
with one  hand,  while the ftiUette is inferted into it with   i
the other; and the point of it fhould then be carried for-
ward obliquely downwards,  through  the  os  unguis jull
where the fac terminates and the  nafal dua begins, and
into the nofe,  taking care  to  avoid following the natural
paffage,  for fear of  injuring  the  os  maxillare.   The
                                               entrance   * 
                     [  joi   3
entrance of the inftrument into the nofe will be followed
immediately by the difcharge of a fmall quantity of bloody
mucus from the noftril.   The ftiUette fliould now be turn-
ed round until the opening is made fufficiently free,  and
then  it may be withdrawn.    A leaden  probe equal in
fize to the ftiUette, being introduced  through  the open-
ing, the canula may likewife  be taken out, and the exter-
nal end of the probe  fhould  then be fomewhat curved to
prevent it from flipping into  the nofe.   The fore muft be
covered with a fmall pledgit of lint, fpread with emollient
ointment, and the whole may be retained with a  ftrip of
adhefive plafter.
   The leaden  probe  fhould  be kept in the fore until the
fides of the paffage become perfeaiy callous, which will
ufually happen in about eight or nine weeks.  It ffiould be
taken out every day or two, that the matter adhering to it,
and that colfeaed in the fore  may be removed : and at each
dreffing,  infufion of  oak bark, folution of alum,  or fome
other aftringent  fhould be injeaed with  a fmall  fyringe
from the external opening into the nofe.   On withdraw-
ing the leaden probe,  the external opening fhould be well
cleaned; and  as it has  then  become very fmall, it will
foon heal by bringing the-fides of it together and retaining
them by adhefive plafter, or  when this does not fucceed in
a few days, touching  the edges with lunar  cauftic will com-
monly complete the cure very quickly.  In the mean time,
moderate preffure by the finger,  frequently applied,  or by
a  machine,  fhould be ufed,  and ought  to be continued
until  there is  reafon  to  fuppofe  the fac  and contiguous
parts have recovered their loft tone.
   What we have faid  refpeaing the propriety of  continu-
ing the leaden probe for a confiderable time, and of apply-
ing  preffure afterwards  on  the  fee, is entirely applicable
when  the natural paffage of the tears is difcovered.  In-
                                                  ftead 
                      [  3°*  3
ftead of a probe of lead fome advife a piece of cat.gut, or
of bougie; but thefe are more difficult to introduce—ab-
forb too eafily the mucus of  the part—are apt to be en-
tangled in the bone—and are not fo effeaual in  rendering
the paffage callous.
  When the difeafe  returns, which is fometimes the cafe,
after  the performance of this  operation, it  may originate
from fome general affeaion, as  fcrophula, or fyphilis; from
a mere caries  of the bone;  or from too fmall an opening
being made.
  When the bones are difcovered to be carious, the tumor
muft again be laid open ; an exfoliation of the bones produc-
ed if poffible; and then the os unguis muft be perforated
as before, if the exfoliation does not form a fufficient open-
ing.   If this fecond operation  fhould be unfuccefsful from
the fore again  filling  up, we will have reafon to fufpea a
general affeaion of the habit,  which muft be removed be-
fore a permanent cure can be expeaed.  When the taint
of the habit is venereal, large and tedious exfoliations ufur
ally take place, and a perfea cure is not often obtained.
  In  order  to obviate the uncertainty  of this operation,
it has been propofed in every  cafe to introduce a filver or
gold  canula,  either  through  the  natural paffage of the
tears, or through the artificial opening; and by leaving it
there,  and healing the fkin over it, thus to form a paffage
which no difeafe of  the conftitution  can  have any effea
upon.  But as the operation when well performed, is ge-
nerally fuccefsful,  -nd it is a very difagreeable and formi-
dable circumftance to moft people to  have any extraneous
body remaining for a long time in a wound, I would never
advife it until the ufual operation is found to be ineffeaual:
It would then be  proper  to  ufe the  canula:  In pi. vi.
fig. 9. is one of the  beft forms of it;  it fhould always be
made of gold,  and fo long as  that the lower part may juft
                                                   pafs 
                        C   3<>3   1
pafs through theos unguis, while the upper part is covered
by the integuments.*
  It has been  advifed, in order  to  prevent  the imaginary
bad  confequences of fplintering the os unguis by the ufe
of the trocar,  to employ  an inftrument  made in the form
of the cantrla of a trocar,  with a handle like that of the ftil-
lette, but  with  a fharp edge.  By this a piece of the bone
is eafily cut out;  but as  the operation  is more effeaually
done with the trocar, and  experience fhews  that there  is
no danger from its ufe, it fhould certainly be preferred.
CHAP.
  * M. Pellier  conftantly employs this method, and generally accom-
plifhes a cure  in  three weeks, and fomctime* in two.  He fays he ne-
ver fails in finding the end of the lachrymal  du&; and always makes
an opening in the courfe of it.  The tube  (fig. 9.) is  introduced on
the perforator,  (pi. vi.  fig. i'o.)  and preffed into  the  orifice made,
by the compreffor (fig. 10.)   In order  to afcertain whether the tuba
is of  a proper length, a little milk  and  water mould  be inje<fted af-
ter its introduction, and  if this paffes readily into  the nofe  i: will do;
if  it  does  not,  the tube muft be  withdrawn  and, fhort encd.  The
wound muft  be dreffed  with  lint  and  cerate for eight or ten  days,
or as long as it  affords much matter,  and  then  healed by adhefive
plafter ;  and milk and  water fliould be daily mjefted through the
canula. 
[  3°4   3
       CHAP.    XXXI.

Of Difeafes of the Nofe and Fauces.
                    SECT.   I.

           Of Hemorrhagies from the Nofirils.

      HEMORRHAGIES from the  nofirils are  in gene-
      ral of little importance; but as they fometimes are
dangerous, and have even proved fatal, they always merit
attention.
  Cold, in moft cafes, is an effeaual remedy—It fhould be
applied in a variety of ways : The patient fhould  be plac-
ed in a large  apartment, through which a current  of  air
paffes ; his food and drink  ought to be cold ; his  face fre-
quently bathed or immerfed in cold water,  or vinegar and
water; a ftrong folution of alum, or fome other aftringent,
fhould be ufed as a gargle, and compreffes  wet  with it ap-
plied over the nofe :—When  in bed he fhould be lightly co-
vered, and have his head high.
  If thefe means fail, the uncertain remedy of compreffion
muft be tried.   Compreffion may be made by a doffil of lint
introduced into the noftril; but a piece of hog's gut that has
been dried and moiftened again,  tied at one  end, and intro-
duced by  means of a probe  or  direaor along  the noftril
as far as  the  upper part of the  pharynx, and then filled
with fome cold liquid, as water, vinegar, &c. and tied at the
                                                  end 
                      C   3°5   3
 end hanging out at the noftril, is more effeaual in reftrain-
 ing the hemorrhage.
   When  both thefe are ineffeaual, we  muft introduce  a
 ftrong ligature into each  noftril, by means of a crooked
 tube, take hold of the ends in the fauces  with a  pair of
 forceps, and draw them out;  then tie a bolfter of foft lint
 to  each, large enough to fill  the pofterior nares,  and by
 pulling the ends of  the  ligatures that hang out  of the
 nofirils, firmly fix the cufhions of lint in  the upper part of
 the pharynx; and afterwards apply a comprefs of lint to
 each noftril,  and fecure them by tying the ligatures over
 them.    By this  means, if the cufhions are  well  adapt-
 ed,  and firmly fixed,  no blood can efeape from the nares,
 and what  is  effufed will coagulate.  The doffils  of lint
 fhould remain until the re-union  of the veffels has taken
 place.   By ufing two ligatures, &c. a more  firm and equal
 preffure is applied than by the employment of one only,
 as commonly advifed.  Reft ffiould be enjoined after the
 operation.
   Future returns of the difeafe may be prevented by bleed-
 ing, cooling laxatives, and a low diet.

                   SECT.   II.

                    Of the Ozana.

  An ozsena,  or ulceration in  the nofirils,  is  often a con-
fequence of catarrh, and  is ufually attended  by a fwel-
ling of the adjacent parts.  Its moft common caufe is cold;
but external violence of every kind that  terminates in an
inflamed ftate of the membrane of the nofe,  fuch as  the ap-
plication of acrid irritating fubftances, blows,  bruifes, &c.
may alfo produce it.
  In this  ftate  of the  difeafe, aftringent applications are
chiefly to  be   depended  on,   fuch as  a  decoaion  of
                        Qj.]                  Peruvian 
                      C   306   3
Peruvian or  oak bark,  mixed  with  folution of  alum,
brandy  or  other ardent fpirits, diluted with water; lime-
water, &c.
  Doffils of lint, wet with fome of thefe, fhould be intro-
duced to the affeaed part three or four times a day; and
at night, lint  fpread with  an ointment prepared with a
confiderable proportion of lap. calam. or zinc. calc.
  A colfeaion of matter in the  antrum  highmorianum
may be miftaken for an ozsena, as the matter is fometimes in
fuch cafes difcharged through the nofe:  Confiderable at-
tention  is  therefore  requifite to  diferiminate thefe com-
plaints.
  When the matter difcharged in an ozsena is thin,  foetid,
and of  a brown or blackiffi colour, we hftve caufe to fuf-
pea a caries of  the  contiguous bones, which muft be re-
hioved before a cure can be expeaed.   This feems to origi-
nate commonly from a lues venerea; but whatever be its
caufe, mercury feems to be the beft remedy  for it.  The
local applications abovementioned are alfo to be employed;
and as fungous excrefeences are frequently produced, oint-
ments with corrofive fubftances may  be  occafionally uled
with  the greateft fafety, particularly  red  precipitate and
verdegris,  in the proportion of an eighth or ninth part of
the firft,  and a fmaller quantity of  the  latter, to one of
wax and oil.
   When the carious bones have exfoliated, a continuation
of  the aftringents already mentioned will commonly effea
a cure.
   Ozaena is often difficult and tedious of cure when a ca-
ries is attendant; in this cafe we have no remedy that can
with  certainty be depended on.  The mode of cure above
recommended will however commonly fucceed.
SECT. 
C  3°7  3
                   SECT.  III.

                Of Imperforated Nofirils.

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

                   SECT.  IV.

            Of Polypi in the Nofe and Throat.

  The whole of the nafal  cavity, and of the back part of
the throat is  liable to  excrefcences, which from their fup-
pofed refemblance  to the infeas of this name,  have been
commonly termed  polypi.  Thefe moft  frequently origi-
nate from that part of the membrane  of the nofe which co-
vers or lines the offa fpongiofa, and  in general are confi-
ned to one fide of the nofe.  In fome inftanees, however,
they occupy both nofirils;  and now  and  then  become fo
large as  to  be perceptible on  looking  into  the fauces.
Cafes have occurred in which they  originated from the
pharynx.
  The firft fymptom of  this difeafe is commonly  a partial
lofs of fmell, attended with a fenfation of fulnefs or ob-
ftruaion in fome part of the nofe.    This  increafes  till a
fmall tumor or excrefcence is perceived in one or  both no-
firils, which, in fome inftanees, defcends no farther than to
be merely perceptible when the head  is fomewhat raifed;
in others, it  falls down upon the  upper lip before, and
perhaps puffies back into the throat.
  In fome, this elongation  of the tumor is permanent, but
in moft cafes  the fwelling retraas within the nares in dry,
and protrudes only in rainy or hazy weather.  In fome in-
ftanees, the fwelling appears very confiderable in the leaft
tendency to a damp atmofphere, and even  in thofe who, in
dry weather, were not known to labour under the difeafe.
  Polypi  are of various  degrees of firmnefs;  moft of
them are foft and compreffible; but fome acquire almoft the
                                              hardnefs 
                      [   309   3
hardnefs  of cartilages.  Both kinds  are  apt to bleed  on
being fretted,  or roughly handled;  but  thofe of a foft
fpongy nature only are fo remarkably affeaed  by the wea-
ther.
   The colour of polypi is likewife variable; in common
tbey are  pale and tranfparent, and thefe according to my
obfervation, are ufually foft and compreffible,  while the
more firm are generally of a deep red colour.
   In the commencement of the diforder the pain is incon-
fiderable, and in the fofter kind, it is feldom at any time
confiderable;  but  the harder polypi are generally painful
in proportion  to the increafe  of their fize, particularly
when irritated.   Polypi alfo become in fome inftanees une-
qual and ulcerated;  a large, thin,  and foetid difcharge
takes place from them ; and if they are not then extirpated,
are apt to degenerate into  cancers, but more particularly
thofe of  a firm texture.
   The fofter kinds of thefe fweUings when of confiderable
fize, produce a great deal  of diftrefs,  by falling on the lip,
and by paffing into the fauces, and obftruaing deglutition
and  refpiration.   In fome inftanees,  not only the  nofirils
are much diftended, but the bones of the nofe are feparat-
ed and raifed.
  Polypi are_faid moft frequently to depend on a fcrophu-
lous or venereal taint.  They  may be fymptoms of  thefe
difeafes,  but in fuch cafes we would confider the general
difeafe merely as an occafional caufe of the local affeaion;
for in almoft every cafe, a local injury may be traced as the
caufe of  polypus;  and upon the whole we conclude it is
always of a local and  circumfcribed  nature.  Even when
it originates from fyphilis, it remains after the general af-
feaion is completely removed.
  The  harder  polypi  probably may  arife from  the  fame
caufes that produce fimilar tumors in other parts ; but they
generally feem  to be conneaed with  a  caries of the bone
beneath: and this renders them more hazardous and diffi-
                                                   cult 
                       [  310   3
 cult of cure than thofe of a fofter nature, which we ima-
 gine are commonly produced by a mere diftention and  re-
 laxation of  the membrana fchneideriana.  When any por-
 tion of  this membrane becomes inflamed from cold,  &c.
 or is ruptured or eroded, as frequently happens from blow-
 ing or picking the nofe, a weaknefs is produced,  which is
 apt to terminate in a prominency; and this being increafed
 by every fucceeding cold, a polypus comes to take place.
   The further progrefs of the difeafe may depend on vari-
 ous caufes ;  but generally it will advance more or lefs  ra-
 pidly,  according as the parts are more or lefs liable to in-
 flammation.  Thus we have inftanees of polypi remaining
 fmall and ftationary for  a number of years, when the pa-
 tients were not much expofed to the open air :  while among
 poor people who  are expofed to every inclemency of wea-
 ther, and confequently more liable to frequent catarrh, the
 difeafe advances with great  rapidity.
   The rifle with which polypi are attended is, according to
 my experience, nearly in proportion to their firmnefs. The
 removal  of the fofter kinds may always be undertaken with
 a probability of fuccefs; but in  polypi of a flefhy, or flill
 firmer texture, it  is always  attended with  confiderable ha-
 zard, for they often cannot be entirely removed;  and even
 when their removal is praaicable, they are very apt to  be
 regenerated, or to become cancerous.
   As long as  the hard polypi remain ftationary,  and  are
 not attended with  pain,  if the breathing or deglutition are
 not obftruaed by them, they fliould not be touched: but
 when  the reverfe  of thefe  circumftances takes  place, we
 fhould always endeavour to extraa  them, provided they
do not adhere throughout their whole extent to the bones,
or thefe bones are  not carious.—A caries  of  the  adjacent
bones is very apt to take place in an advanced ftage.
  In  the foft polypous tumors, aftringent  applications,
 fuch as folution of alum, decoaion of oak bark,  vinegar,
                                                    or 
                     C   3"  3
or fpirits,  frequently prevent  them from acquiring an in-
creafe of bulk, and  will fometimes  dirninifh, but  never
remove them.   Thefe applications  fhould always be ufed
on their firft appearance.
  The methods employed for the removal of  polypi have
been, the ufe of caifiics, aaual and potential; the paffing
of * feton or cord through  the noftril, with fome corrofive
unguent on the part in contaa with the tumor; exdfion with
the fcalpel or feiffars; the  application of a ligature around
the neck of the tumor; and evulfion or extraaion by the
forceps.
   Cauftics are not employed at prefent, becaufe they can-
not be prevented from injuring the found as well as the
difeafed parts.  The feton is inadequate to the removal of
polypi, and feems only ufeful when fmall portions are left   t„
after the extirpation of the  greater by other means.   When
the  tumor originates low enough  to  admit  of  excifion,
the fcalpel fhould be employed; but this is rarely the cafe:
and the noftril is often fo filled, that we have no room for
the introduaion of a knife.
   The ligature is the beft remedy; it  is lefs  painful than
tearing or twilling off  the polypus by the forceps, and
equally praaicable.   It is thus to be applied when the
tumor is in the throat.
   Take a pliable piece  of filver wire, which when dou-
bled, is long  enough to pafs through the nofe into the
pharynx:  let the doubled  extremity be flowly and gently
infinuated through  one  of the nofirils, and  when  it ap-
pears in the throat,  let the operator with his fingers open
the doubled extremity fufficiently  for  pafiing it over the
pendulous end of the tumor; and having preffed it down
to the root of  it,  pafs the  ends of the ligature hanging out    •
of  the noftril, through the pipes of a double  canula, fimi-
lar to ^hat reprefented in (pi. iv.  fig.  5.) except that  the
end is a little  crooked; the canula is to be inferted into
                                                    the 
                       [  3J2   3
 the fame noftril, and pufhed back along the courfe of the
 wire,  till it comes in contaa with the root of the polypus.
 The fingers being ftill continued in  the throat to preferve
 the ligature in a proper fituation, the wire muft now be
 drawn  tolerably tight,  and  the  ends being fixed on the
 handle  of the canula, it muft be left fo till the  next day,
 when it ffiould be drawn fomewhat tighter; and this be-
 ing daily repeated, the tumor will foon drop off—If fmall,
 in two  days,  if large, frequently in three:  But we muft
 be  careful not to draw the ligature fo tight as to cut the
 tumor and induce hemorrhagy.
   All polypi which originate in the throat, or which pro-
 ceed back from the noftril into the fauces, and even thofe"
 which are deeply feated in the pharynx,  if the ligature can
 be applied over  them  with the fingers,  or with  a  forked
 or  flit  crooked probe,  may  thus be  removed.—Thofe
 which are feated few down in the cefophagus,  might pro-
 bably be treated in the fame  way.
  When the polypus  is fixed deep in the cefophagus,  and
 on  all occafions in which the application of the ligature
 is tedious and difficult,  it is proper to fecure a free refpi- "
 ration, by  previoufly  performing Bronchotomy:   In  fuch
 cafes a fpeculum oris ffiould  alfo  be ufed.
  To apply the ligature to a polypus  feated in the anteri-
 or part  of the nofe, and which proceeds towards the up-
 per lip; let the double of it  be paffed over the  moft de-
pending part of the polypus, and be flowly  pufhed up
to  the  root of it with a  flit probe:  the  probe being
given to an affiftant to  keep the ligature in its  fituation,
the  ends of the thread muft  be paffed through the double
canula, (pi. iv. fig. 5.)  which being inferted into the noftril
on the oppofite fide of the polypus, and pufhed along till it
reaches the root of it, the ligature fliould now be drawn fo
right as to make fome  impreffion on the tumor, and  the
                                                 ends 
                      [  3r3   3
ends of it muft then be tied to the wings of the inftrument,
and daily tightened till the tumor drops off.
  Mr.  Chefelden  recommends to pafs a ligature through
the noftril into the throat, in fuch a manner that the dou-
bling may include the root of the polypus, and  the  oppo-
fite ends may be taken out of the mouth and twifted fo as
to remove the tumor—this mode would  often fail.
  For  the  extraaion of polypi by  the  anterior  nares,
ftraight forceps with eyes  have been commonly  employ-
ed—and thofe who choofe to ufe forceps for the removal of
polypi which pafs into the throat behind the uvula have ufed
crooked forceps.   Dr. Richter, of  Gottingen, has  inven-
ted a pair of crooked  forceps, (pi. ii. fig.  2.) by which pref-
fure may be applied  equally to every part of the  tumor
included  in  them—the blades  being feparately  intro-
duced,  where  the polypus  is large.  In this refpea, and
on account of  their  facility  of introduaion, they are the
beft yet invented.   The blades  are  conneaed and  intro-
duced like thofe of the midwifery forceps.  The part intro-
duced  ffiould always be made fmall, on  account of the
ftraitnefs of the paffage.
  In proceeding to extraa  a polypus by  the forceps, the
patient fhould  be firmly   feated with his  head leaning
back,  and fupported  by an  affiftant behind; and  in order
to difeover  the origin of the tumor, it will  be ufeful to
place the face fo that  the light of a  clear fun may fall into
the noftril.  The furgeon is now to take the forceps and in-
fert one blade on each fide  of the polypus,  and bringing
the points as near as poffible,  or quite to the root or neck
of it, and grafping it firmly,  endeavour to extraa it  entire,
by pulling downwards, or from  fide to fide,  or more pro-
perly perhaps by twifting the polypus round till it is com-
pletely feparated.  By turning it round, the attachment may
be more readily loofened, probably, than by any other way,
and the membrane is not fo  liable to be torn—and if. the
                       R  r                    polypus 
                      [  3*4   3
polypus is firm,  it may frequently be  brought uway Rt
once;  but if foft, it  will be  extraaed  piecemeal—as
much as poffible fliould  be removed.
  A hemorrhagy in confiderable degree often attends the
firft attempt to remove the tumor ; but this ffiould  not be
regarded, unlefs  it be  very profufe;  and in patients of a
robuft habit, even after the operation,  it will be proper to
fuffer a moderate difcharge, as  this will tend to prevent
the inflammation  which otherwife would be apt to occur.
The means formerly recommended are proper to reflrain
the bleeding  when it feems proceeding too far.   If any  I
part of the polypus remains and we can bring it into view,,  J
it may be touched with lunar cauftic  covered with a canu-
la, the day after the operation,  and every fecond or third  ]
day  afterwards, till it is  removed—when  any remaining
part cannot be feen, the feton might be employed to re-
move it;  but a bougie, probably, would anfwer better-—:
this  might alfo be ferviceable in diffipating  an incipient
polypus.   I have  feen  very beneficial effeas from  it in
one cafe:  A hollow filver tube covered with  plafter, was
ufed during part  of the time, through which  the  patient
breathed freely, and which was fecured by flrips of adhefive
plafter,  conneaing it  with the lip—a piece of tape paffed  J
round the head might be employed for the fame purpofe.   I
   When polypi are fo large that forceps cannot be intro-  j
duced, it  will be proper to lay the noftril open,  by divid-  ]
ing  the  cartilaginous parts by  means of  a longitudinal
incifion; and  after extraaing the tumor, to re-unite the
wound by an  adhefive plafter or by future.   There is no  j
rifk in cutting the ala  nafi; for  if we  find,  on laying open  ,
the parts,  that the tumor cannot with propriety, be taken
away, the wound will foon heal  again.
   When a firm polypus has ulcerated, and the  cartilages  <
and bones  of the nofe are affeaed, this treatment would be
imprudent; but  in the  fofter kinds  which fearcely ever
                                                become 
                      C   3^5  3
 become cancerous, and where the cartilages and bones are
 not affeaed, it fhould be ufed without hefitation.
   In a cafe of firm flefhy polypus, which filled the noftril
 fo that the forceps could  not be introduced, Dr. Richter
 pufhed a red  hot  trocar covered by a canula, through the
 centre of  the tumor, and  thus  formed a paffage through
 which the patient breathed eafily, and by which the tumor
 was much leffened.


                   SECT.  V.

             Of Extirpation  of the  Tonfils.

   Enlargements of the tonfils feem to  originate com-
 monly from inflammation, and are but feldom if ever fchir-
 rous ;  independent of inflammation  they are never pain-
 ful ; they never terminate as far as we know in cancer;  and
 when the  difeafed part  is extirpated, the complaint  never
 returns.
   Whenever  thefe tumors become fo large as to produce
 much interruption to the paffage of the aliment and  air,
 they ffiould be removed.
  For this purpofe, the cauteries, aaual and  potential, have
 been advifed; but the impoffibility of confining their effeas
 to the  difeafed parts  fhould always prevent their employ-
 ment.   Excifion with  the fcalpel, or crooked fciffars is alfo
 inadmiffiblc, on account of the confequent hemorrhagy.—
 The method by ligature is the only proper  mode.  Silver
 wire,  or catgut may  be introduced  through the nofe, as
 in operating on a polypus in  the throat, and fixed on the
amygdala,  a ftraight  or fomewhat  crooked canula  being
employed  in the manner the canula is ufed  in that opera-
tion, and the procefs conduaed exaaiy in  the fame way.
                                                 The 
                     C  3»*  3
The more pendulous the tumor, the more eafily will the
ligature be fixed, but in any cafe the difficulty is inconfi-
derable.
  The ligature, if  carried through the mouth,  would be
very inconvenient;  but fhould any difficulty occur in the
employment of the  mode recommended, this may be ufed.
  If it be neceffary to remove both almonds, it will be
proper to allow any inflammation that may occur from the
firft operation to fubfide, previous to the removal of the
remaining gland.
  The mode above defcribed I conceive to be the beft; but
the operation  may often be done differently.   Let a fuffi-
ciently ftrong ligature  be formed of waxed  thread, and
carried round the tumor, either with the fingers or a fplit
probe.  A  noofe is then to be formed  on it and  drawn
round the almond by fixing one end of the thread at its fide,
with a fmall  fleel  inftrument which is ftraight, except at
the ends, where it is formed into rings,  while the other is
drawn out of the mouth by the other hand of the furgeon.
When the tumor is of  a pyramidal form, and broad at the
bafe, a double ligature being put into the eye of a long nee-
dle, fixed in a handle, with the eye near the point, the nee-
dle is  to be  pufhed  through the middle of  the fwelling
near its bafe, and  the thread being difengaged by forceps,
the needle  muft be  withdrawn.  By the affiftance of the
ringed inftrument, a knot muft then be formed on each
half of the tumor.
   Both thefe operations  are recommended by Mr. Chefel-
den: Mr.  Sharpe concurs with me in  thinking them un-
neceffary, and properly fuperfeded by  the mode firft de-
 fcribed.
SECT. 
        ■> * m m m m mwW^^m • m

                     C   3'7  J


                  SECT.   VI.

             Of Extirpation of the Uvula.

  When the uvula, in confequence of frequent inflamma-
tion, &c. becomes relaxed to fuch a degree as by irritating
the throat, to induce cough, retching, and vomiting, and
to obftrua deglutition; and when this cannot be remedied
by aftringent gargles, extirpation  can alone be  depended
on for a cure.
   This  may  be effeaed  by excifion  or ligature:—when
the uvula is merely elongated, the firft  fliould be employed ;
but where it  is much  enlarged, as there would be danger
of confiderable hemorrhage from the  ufe of the knife,
the ligature fliould be  preferred.
   The crooked, probe-pointed biftouri, is the beft inftru-
ment for cutting off the uvula; but it may be done with a
pair  of common  or  curved fciffars.    In both  cafes the
mouth fhould previoufly be fecured with  a fpeculum oris,
and the uvula fhould be taken hold of with a pair  of fmall
forceps,  or a fharp hook.   If much blood is difcharged
after the operation,  we muft ufe an  aftringent gargle, or
touch the veffel with lunar cauftic.
   When a ligature is employed, the mode  of fixing it
defcribed in the laft chapter but  one,  may  be adopted;
and  the canula may be introduced either  through  the
mouth or nofe: or it may be done by Mr. Chefelden's me-
thod of tying the tonfils.   After paffing the ligature, it
fhould be tied as  direaed in the cafe of polypus,  by Mr.
Chefelden.   See Ch. penult.
SECT. 
[  318  3
                  SECT.   vn.

         Of Scarifying  and Fomenting the Throat.

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

Of the  Difeafes  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 fiffures in one of them, but particularly
in the upper lip.   In fome there is a confiderable  deficien-
cy of parts, and in others two fiffures with an intermediate
fpace.   Thefe affeaions  are all included under the name of
                                                  hare- 
nr-—            t  3-."pyi
    hare-Hp, from a fuppofed refemblance in them to the lip of
    that animal.
      The opening is commonly confined to the lip, but fome-
    times it extends along the palate and uvula into the throat;
    and in many inftanees the bones of the palate are feparated,
    in part, or altogether wanting.
      Deformity is a conftant  confequence of this difeafe.  It
    fometimes prevents fucking, and when in  the under lip, is
    commonly attended with inability to retain the faliva : and
    it is always produaive of impediment in the fpeech.   When
    the divifion extends along the bones, chewing and fwal-
    lowing are obftruaed by the food paffing up to the nofe.
      Thefe  are  reafons for  attempting the cure as early as
    poffible.   I have effeaed this,  in healthy children, in the
    third  month  of their  age; and the  operation may be
    performed thus  early with as much probability of fuccefs
    as at  any time of life—Young  children  are more eafily
    managed than thofe at a more advanced age.
      The intention of this operation is to cut off the fides of
    the fiffure, in order to reduce it to the ftate of a frelli wound;
    and then to bring the divided parts into contaa, and to re-
    tain them  there till a firm adhefion takes place between
    them.
      Some contend that  adhefive plafters or bandages,  are
    fully adequate to the retention of the parts after they  are
    properly cut; thefe may  fucceed  in fome cafes, but they
    will frequently fail, and induce a ncceffity for a fecond ope-
    ration;—when futures  are  properly employed they  ne-
    ver fail.
      In performing  the operation, if the patient is an adult,
    he fliould be feated  with  his head  to the light, properly
    fupported by an affiftant  behind ; but  if a child,  he will
    be more firmly fecured by being laid on a table, and kept
    in a  proper pofture by  an affiftant ftanding on each
     de.   The operator is  now  to make an  attentive exami-
                                                   nation 
                     [   3^0  ]
nation of the difeafed parts, and of thofe contiguous to them.
The upper lip is to be feparated from the gums beneath ;
and if  a tooth projeas it  fhould be removed, as it would
irritate the lip.  If there  is  a projeaion from the angles
of the divided palate bones, it  muft be taken off by cut-
ting pliers, (pi. ix. fig. i.) or forceps.   One fide of the
lip is now to be taken between the thumb and fore-finger
of the left hand, and an affiftant doing the fame, and
ftretching it pretty tightly, an incifion muft be made  from
the under border  of the  lip to the fuperior part, with a
fcalpel, in which a  fmall  portion of the found parts  muft
be included ;  the fame muft be performed on the oppofite
fide, terminating in the fame  point in the upper part of the
lip; by this means, a piece  including the fiffure, will be
cut out refembling an  inverted j±.
   The  veffels fhould be  fuffered to  bleed  freely if  the
patient  is plethoric;  and then the fides of the wound
ihould be united.   To effea  this the cheeks ffiould be
pufhed forward fo as to  bring the edges of the wound
nearly into contaa, and an affiftant behind fhould fupport
them in this fituation.  Pins are then to  be introduced in
the manner defcribed, when treating of the twifted future.
The firft  fhould be near the under edge of the lip, leaving
merely fpace  enough to fupport  it.  Another  ffiould  be
inferted in the centre of the  cut, and a third very near the
fuperior angle of it.—In infants two pins will fuffice.
   In paffing the pins, they fhould be entered nearly half an
inch from the edge of the wound; and being  carried almoft
to the bottom, they muft be again paffed outward in a fimilar
direaion, and to an equal diftance  on the oppofite fide of the
fiffure. The affiftant fliould now  prefs forward the cheeks
fo as to bring the  parts  into clofe contaa,  and  a waxed
ligature muft be applied over the  pins, beginning with the
 under one,  and having made three or four turns, deferr-
                                                   ing 
                      C  321   3
ing the figure of 8: it fhould then be carried to the conti-
guous pin, and being in a fimilar manner carried round that,
the operation muft be finifhed by paffing it to the other;
taking care to draw it fo tight as to retain the parts well in
clofe contaa,  but not  fo  ftrait  as to irritate  them.   A
piece of lint covered with mucilage  fhould now be put
over the cut—it fhould alfo cover the ends of the pins,
that they may not be entangled by the bed-clothes, &c.
  When there is  a  great deficiency  of parts,  and the
edges of the wound are with difficulty brought together,
an oblong  piece of leather fpread with  common glue,  or
with a ftrong mucilage, being applied over each cheek, and
reaching  from the angle of the  jaw to within  an inch of
the pins  on each fide,  each piece of leather ffiould have
three firm ligatures fixed  to the end next the lip,  which
fhould be made  to pafs between  the pins, and be tied  fo
as to retain the parts together.                                   1
  The  pins fhould  remain five or fix days, and during
this time the  patient  ffiould be  fed  on fpoon-meats, and
be prevented  from laughing, crying, or  ftretching  the
mouth in any way.
  When the hare-lip is double, there is a neceffity for per-
forming the operation  twice:  But we ffiould complete the
cure of  one lip before attempting to operate on the other.
The iucifion ffiould always  be extended to the upper part of
the lip : the fides of it fhould be exaaiy of an equal length,
and to infure  this, it  will be proper previoufly  to  mark
the length and direaion of the  cut with ink—and the lip
fhould be equally and tightly ftretched during the incifions:
for this  purpofe, curved forceps may be ufed to lay hold
of the lip,  and the incifions made along the fide of them
in the proper direaion.
  Some writers  direa us to introduce  a piece of pafte-
board,  lead, or tin beneath the lip, and cut upon it;  but
the incifion is more eafily  made  as above direaed.   Scif-
                         S s                       fars 
                      [  3*2  3
fars may be employed with as much fafety and eafe as the"
fcalpel.
  Flexible needles are ufed by fome  inftead  of the pins
we  have recommended, but they are not fo proper.   In
paffing the pins, particular care fhould be taken that they
go nearly through to the oppofite fide of the lip;  other-
wife a fiffure may remain in the inner  part of the lip, and
a troublefome oozing  of blood may take place behind.
Death has enfued from this difcharge, in confequence of
ignorance of its quantity, from the patient's being direa-
ed to fwallow his faliva.  This fliould induce us to forbid
fwallowing the faliva, while it is  tinaured wdth blood—   -
Befides  this dangerous inconvenience, fometimes  a fmall
quantity pf blood  taken into  the ftomach, excites  naufea
and vomiting, which ftretch the lip and feparate the clof-
ed parts.
  Fiffures of the lip, from whatever caufe, are to be treat-
ed in this way; except that in a recent wound, all  that is
neceffary  is to infert  the pins and  apply  the  ligatures.
While any  inflammation continues  in wounds where fup-
puration  has  commenced, we fhould avoid  the  applica-   :
tion of the ligatures; but as foon as  this  fubfides,  the
operation may be ufed with as much fuccefs as when  the
wound  is recent.
  In  cafes  where  the bones of the  palate  are  feparated,
after  uniting the  foft  parts,  fome  advantage may  be  ob-
tained from a thin  plate of  gold  or filver  fitted to  the
arch of the palate,  inferted in the fiffure, and fixed by a
piece of fponge flitched to the convex  fide:  The  fponge
fhould be dry when inferted, and  the moiflure it imbibes
will retain  it.  By this means the fpeech and fwallowing
will be  much aided.   When,  however,  the fiffure is wider
externally  than within,  fponge  cannot  be  applied.—A
plate with gold fprings to fix on the  contiguous parts has
been propofed, but it  does not fucceed.
                                              SECT. 
C  323  3
                    SECT.   II.

           Of the Extirpation of Cancerous Lips.

   The under lip is more fubjea to cancer than any other
 part of the body ; and the fcalpel alone can be trufted to
 for relief.  When the whole lip or  a confiderable part is
 affeaed, the  difeafed parts muft be removed,  the arteries
 tied,  and the fore dreffed as a  recent  wound.   This un-
 covers  the teeth and gums,  and produces an incapacity of
 retaining the  faliva, and a difficulty of fwallowing liquids;
 but there is no alternative—When an inconfiderable por-
 tion of  the lip only is affeaed, the  edges of the  wound
 fhould be united  by the twifted future as already defcri-
 bed :  By this means much deformity and  inconvenience
 will be prevented; and  the difeafe will be  lefs  apt  to re-
 turn, than when it is treated without employing future.—
 If a third of the lip remains, the  future may be  ufed : It
 fucceeded in  a cafe in which  mere extirpation had been
 twice tried.
   When the  difeafe extends  to  the cheek, a tranfverfe in-
 cifion of the cheek as well as  a  longitudinal one of the lip
will be neceffary,  and both are to be  afterwards clofed by
pins and ligatures.
CHAP. 
C  324  3
 C H A  P.   XXXIIr.

Of Difeafes of the Mouth.
                     SECT.  I.

                     Of Dentition.

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


                   SECT.    II.

             Of Derangement of the Teeth.

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

                    Of Gum-Boils.


   The gums  are very frequently fubjea to abfceffes, be-
 caufe they are much expofed to  the  caufes produaive of
 them.  Gum-boils may originate from cold, and other com-
 mon caufes of inflammation ;  but they more commonly are
 produced from tooth-ach.  They occur  not only from ca-
 ries, but alfo from inflammation at the roots of the teeth.
   A gum-boil commonly appears after a fit of  tooth-ach
 has continued for fome time: It  begins with pain, and a
 fmall tumor in the part; the cheek foon after fwells, and
 frequently the whole face.  When fuppuration takes place,
 the fwelling  becomes  pointed, and  if  not  opened foon
 burfts on  the fide of the gum, or between the  gum and
 teeth.  Effeaual  relief  is  afforded  by  the difcharge of
 matter ; but as the caufe commonly remains,  the difcharge
 continues till this is  removed ; or if the opening clofes, the
 difeafe  is commonly foon renewed.   When indeed inflam-
 mation at the root of a tooth is  the caufe,  and  the peri-
 ofteum is not feparated, a cure may be produced, after the
 difcharge of the matter, by the union  of the fides of the
 abfcefs: But when  the  tooth is  carious, its root denu-
 ded, or when a part  of the jaw is carious, removal of the
 difeafed parts will alone accomplifli a cure.
  "VV here inflammation at the root of the tooth is the caufe,
 the abfcefs  fliould  be laid  completely open, a  doffil of
 lint introduced,- and the wound healed from the bottom.
 But when incifirm will not be admitted,  we fliould injecl:
 tina. myrrh*, lime-water, fpirits,  and tina. of bark diluted
to remove  the difcharge.  If  the affeaion is feated very
 deep, fo that there is danger of a caries of the jaw from the
                                               impoft- 
                      I   328   3
impofthumation, we fhould ufe warm fomentations to the
part, and warm ftimulating fubftances, fuch as a roafted
onion,  to that part of the gum mofl affeaed, in  order to
excite a fuppuration, that may point into the mouth; and
as foon as matter is formed, we fhould open the abfcefs. A
free depending orifice fhould afterwards be preferved,  till
exfoliation takes place,  and a cure is completed.   Where
there is  a fcrophulous or other conftitutional  affeaion,
the ulceration is  commonly very troublefome, and only
yields to remedies for the general affeaion.

                   SECT.   IV.

           Of Abfceffes in the Antrum Maxillare.

   Whatever tends to produce inflammation in the mem-
brane  lining the  antrum highmorianum  may produce ab-
fceffes  in it; fuch  as blows on the cheeks ; inflammations of
the membrane lining the nares,  and even long continued
inflammations of the  eyes  fpreading  into the  antrum.
Much expofure  to cold has frequently produced them;
but repeated violent tooth-ach is their moft common caufe.
Mr. Hunter  confiders the obliteration  of the dua leading
from the antrum  to  the nofe as a frequent fource of thefe
colfeaions ;  but this appears to me to be merely a confe-
quence of fome of the other caufes,  and to be occafioned
in common by adhefive inflammation.
   The firft  fymptom of this complaint is  fome  degree of
pain over the cheek;  which frequently  continues a confi-
derable time before any fwelling comes on. This increafes,
and extends  perhaps to the  eye, nofe, or  ear ; at length
a hard fwelling appears over the whole cheek,  which af-
ter fome continuance points,  moft frequently in  the centre
of the cheek, a little above the  roots of the pofterior mo-
                                                 lares. 
                       [  329  3
  lares.  In fome  inftanees, the matter burfts out between
  the roots of thefe teeth and the gums,  and prevents the
  difcharge externally;  this probably  takes place in com-
  mon,  when the roots  of the teeth penetrate the antrum.
  For the moft part too,  as foon as matter is formed, fome
  of it is difcharged by the noftril when the patient lies on the
  oppofite fide with the  head low.  In judging of the ori-
  gin of a difcharge by the noftril,  we muft confider that it
  may be produced from  inflammation of  the  membrana
  fchneideriana;  from an ozsena;  from affeaions  of  the
  frontal finufes; and from abfceffes in the lachrymal fac, as
  well as from matter in the antrum maxillare.
   As  foon as we  have evidence of the difeafe, if a perfora-
  tion is not made to difcharge the matter,  the bones of the
  cheek  will be elevated,  and at laft rendered carious.   The
  opening may either be made into the fide of the antrum,
 where it projeas over  the two great molares,  or  one of
 thefe teeth may be taken out,  and a perforation made di-
 reaiy upwards in the courfe of one of the fangs.  The laft:
 is the only effeaual mode.  If either of the large molares
 is difeafed that fliould  be removed;  but  if they are both
 found,  the one next the  dens fapientiae  fliould  be taken
 away,  becaufe the antrum is thinneft beneath it.
   Sometimes the  matter  is  difcharged  immediately  on
 drawing the  tooth,  either from  having  penetrated  the
 focket, or from the os maxillare being corroded by its con-
 tents.  If the opening thus formed, is infufficient to admit
 of a free difcharge, it fhould be enlarged; but if no open-
 ing occurs, one is  to be made by pufhing a trocar, or fome
 other proper fharp inftrument,  into the antrum, in the di-
 reaion of one of  the fangs.   In performing this, the  pa-
 tient fhould be feated on  the floor oppofite to a clear  light,
 and his head laid  on the knee  of  the operator, who may
either ftand or  fit  behind him.   The inftrument fhould be
                        T t                withdrawn 
                      [   330   ]
withdrawn as foon as by the non-refiftance to its point we
find it has entered the cavity.
  As foon as  the  matter is difcharged,  a  wooden plug,
with a knob at its head, fhould be introduced into the ori-
fice,  to prevent the air and food from entering it.  This
plug fhould be removed twice or thrice a day, to admit of
a free and quick evacuation of the colfeaed matter;  and a
cure will commonly foon be obtained.  But in fome cafes,
either from relaxation of the membrane of the antrum, or
other caufes, the difcharge continues confiderable a long |
time.  In this cafe, liquids  moderately aftringent fhould be
frequently injeaed; but nothing fliould be ufed which con-
tains any folid  matter, that might be depofited in the an-
trum : I  commonly ufe a folution of alum, brandy diluted, ^
or lime-water.   When the bones are carious, of which  1
we may be fatisfied by  the appearance and fmell of the dif-
charge, or by the probe, we canuot expea a cure till ex-
foliation  has taken place.
   Blood may be effufed into the antrum,  from blows, &c.
and  require this operation.—Worms fometimes are pro-
duced in it; they are  indicated  by violent  pains in the re-
gion of the cavity, not induced  by any obvious caufe.  In
this  cafe an opening fliould be made immediately above the
roots of the large molares, and  after extraaing all the
worms we can find, oil, a filtrated folution of affafcetida,
or a weak infufion of tobacco, fhould be injeaed from time
to time,  to deftroy any that may remain.
   It has been propofed by Mr. Hunter, to  perforate the
 antrum through the noftril; and with equal propriety it
 might be perforated through the roof of the mouth; but it
 muft be obvious, that the mode above recommended is in-
 finitely preferable to either.
   By the means we  have advifed,  almoft  every  difeafe
 from colfeaions in the antrum maxiUare,  may be remov-
                                                   ed; 
                      C  331   3
cd; but there are complaints,  apparently originating from
an enlargement of the bones of the cheek, which frequent-
ly terminate in the death of the patient.  In abfceffes of the
antrum, the  cheek feldom fwells  very much;  and when
the  difeafe has been of long  duration,  if the matter does
not find an opening into the noftril,  or  along the  root  of
the  teeth, it commonly points towards the prominent part
of the  cheek; but  when  no  matter is  colfeaed,  and the
difeafe  proceeds from an affeaion of the bones, although
the  fwelling  gradually arrives  to a confiderable  fize, it
fpreads equally over the cheek,  without pointing at any par-
ticular  part, except in the laft  ftages when fuppuration oc-
curs in fome of the foft parts.   Till the fkin is inflamed,
which  only happens in an advanced period, the fwelling
remains colourlefs.   But the  moft charaaeriftic mark  of
this fpecies of fwelling, is the  remarkable degree of elafti-
city which it acquires : The bones yield  to preffure, and on
its removal inftantly return to their former  fituation.   If
an incifion  is now made into them, they appear foft and
cartilaginous, and fometimes fomewhat gelatinous.
  In the inftanees of this  difeafe, where carious teeth ap-
peared  to have fome effea in  producing it, their  removal
has produced a temporary ftop to its progrefs  ; and in fome
others,  long  continued gentle courfes  of mercury, with
decoaion of mezereon, have  had the fame effea; but  no
permanent benefit arifes either from internal  medicines  or
external applications.
SECT. 
C  332  3
                    SECT.   V.

             Of Excrefcences on the Gums.

  The gums are liable to excrefcences of different degrees   j
of firmnefs, from the hardnefs of a wart to the fofrnefs of
fundus, nearly of the colour of themfelves.—Thefe excref-
cences impede maftication and the fpeech, but are feldom   ]
painful—they occur moft frequently in the under jaw  and
infide of the teeth, and commonly adhere throughout their
whole extent.   They frequently  originate from  carious
teeth, and fometimes from caries of the alveoli.            \
   Removal of the _ifeafed bone will commonly be followed   {
in rhcfe inftanees, by difappearance of the excrefcence; but
if it is not, the tumor fhould be extirpated.  I never knew
either a  hemorrhagy of any confequence, or  a cancer to   j
fucceed the extirpation.  When the excrefcence is attached   J
by a narrow neck, a ligature fhould be applied to  it; but   *]
when it has a broad bafe, we muft ufe the fcalpel.   In  pro-
ceeding  to the  extirpation,  the patient  fhould be firmly   .]
feated oppofite  to a  clear  light, and  the  head fhould be   j
fupported by an affiftant behind;  and  unlefs the patient
has  a  good  deal of  refolution,  a fpeculum  oris fhould be    |
ufed.   A common fcalpel will frequently ferve for the dif-
feaion,  but  a curved knife and crooked fciffars will fome-
times be better, and fhould be at hand.   The tumor  mull
be elevated  with  a diffeaing hook  that  has two fangs,
which is here much preferable to the common hook. Great   j
care  ffiould  be taken not  to injure  the parts  conneaed    j
with the tumor unneceffarily; but  if it  is  firmly connect-
 ed to the gums, a part  of them fhould be  removed,  even
 to the  depth of the focket; although this may induce a
 danger  of injuring  the  teeth.   A  moderate  difcharge of
 blood  may  be  fuffered;  but if it tends  to profufenefs,
                                                    the   | 
                     [  333   3
the patient fliould take fome brandy or tinaure of myrrh,
into the  mouth; and if this does not reftrain it,  lunar
cauftic  fhould  be applied  to  the wound.  Dreffings  to
the fore,  are, from  its fituation, inadmiffible.   For fome
days after the operation, it ffiould be waffied with a warm
emollient decoaion;  and if a cicatrix does not then readi-
ly form, lime-water,  port-wine, or  any  mild  aftringent,
fliould  be applied to it.

                   SECT.   VI.

                    Of Loofe Teeth.

   The teeth are frequently loofened  by external violence ;
as falls  and blows ; and often  by  improper force   in
pulling thofe contiguous to them.  In thefe cafes, they
ffiould  be fixed as-firmly as poffible  in their former fitua-
tions, by preffing them as  far as they will  go into the fock-
ets, and there fecuring them by ligatures of Indian weed,
cat-gut,  or waxed  filk,  carried round the  adjoining
teeth;  and the  patient ffiould live on fpoon-meat till they
become faft.  In youth this praaice  will commonly fuc-
ceed ; but in old age, loofe  teeth from any  caufe can feldom
be again firmly  fixed, and in very advanced periods of life,
it ought not perhaps to be attempted.   The teeth alfo be-
come loofened by depofition of tartar, between the roots and
the gums; and in fome cafes between the roots and fockets.
In thefe cafes, fealing off the tartar will commonly remove
the complaint—this ffiould be done as  early as poffible.
   Sponginefs of the gums, and  their feparation from the
teeth,  frequently produce loofenefs of the  teeth.  This
fometimes  occurs from the ufe of mercury;  and often
happens- in fcurvy.   When it originates  from fcurvy, a
removal of the  general difeafe is the remedy.   But it of-
                                                   ten 
1
                      C   334  3
 ten occurs as a local affeaion ; and then deep fcarifications
 of the gums, occafionally repeated, is the beft and moft ef-
 feaual mode of cure—This often produces an adhefion of
 the gums to the teeth : and then, aftringent gargles made
 of tinaures of Peruvian  and oak barks, and  of myrrh,
 and a ftrong folution of alum, with cold  water, fhould be
 employed frequently, and the  teeth fhould not  be  ufed
 till they  have been  for fome  time firm.   Aftringents ufed
 before an adhefion  of the gums to the teeth takes place,    (
 often renders  them hard and incapable of forming a con-
 neaion with the teeth.   When  the teeth have long been   |
 loofe, there is but little chance of making them fall again.
   This difeafe is fometimes produced by abfceffes  between   ,\
 the roots and alveoli of the teeth—(vide  chapter on gum-
 boils.)  It alfo  occurs in old age, from a  new removal of    j
 the alveoli; probably in confequence of the offeous matter   |
being abforbed,  when nature cannot afford a fupply of it—  ;«
 this cafe is  irremediable.

                   SECT.   VII.

                Of Cleaning the Teeth.

  The teeth fometimes  lofe their colour, and acquire ei-
ther a dufky yellow hue, or become black to a certain de-    ]
 gree, without  any  adventitious  matter being perceptible    j
on them.   2. They, on fome occafions become foul, and    |
give a  difagreeable  taint to the breath, from a long remo*
ra of the mucus of the mouth.   But, 3. The moft fre-    ,
quent  caufe of foul teeth, is the depofition of a calcare-  , j
 ous kind of matter from  the  faliva.   Some will have the
teeth thickly incrufted with this fubftance a few weeks after
having them cleaned : and moft  people are fubjea to fuch
 a depofition in greater or  lefs degree.  It firft appears 00
                                                   the    I 
                     C   335  3
 the fore-teeth, in the angles between two of them,  where
 they are leaft rubbed by the tongue or lips; but the effeas
 of maftication commonly prevent it from fpreading to the
 points  of them.  In many cafes  it is confined to one or
 two  teeth; but in  others a continued cruft feems  formed
 all over the whole jaw;  and this fometimes to fo great a
 degree, as to disfigure the cheek externally, and to have
 been miftaken for an exoftofis of the jaw-bone.
  Slight ulcerations of the gums are often produced when
 any confiderable quantity of this tartar is colfeaed,  which
 frequently infinuates itfelf between the  gums and  alveoli
 fo as to feparate  them a good deal from each other.
  Acids will diffolve and remove  the tartar, but  at the
 fame time they injure the enamel, and many have loft their
 teeth from the ufe  of them.   Scaling inftruments  afford
 a certain relief,  and from a proper application of them no
 harm can enfue.   When the teeth are once well cleaned,
 frequent wafhing with cold water, and rubbing them every
 fecond  or third morning with burnt bread, Peruvian bark,
 cream  of  tartar, chalk,  or any other mild application, in
 fine powders will generally keep them clean and white.
  The inftruments  employed (fuch as in pi. ix. fig. 5. 6.)
 fhould  be moderately fliarp;  but their  edges ffiould not
 be very fine, or they will turn or break.    In  perform-
 ing  the operation,  the patient  fhould be feated on  a  low
 chair, with his  face to the light, and his head fupported
 by an affiftant: the furgeon ffiould fit oppofite to him,  and
 wrapping  the fore-finger of  his left hand in a wet cloth,
 fhould  prefs firmly on the point of the  tooth, while  the
 back part of the inftrument  will form a point of refift-
 ance  for  the thumb of the fame  hand.  The fharp edge
 of the inftrument is now to be infinuated beneath the under
 part of  the incruftation, avoiding the neck of the tooth
 for fear of loofening it: it muft then be pufhed with firm-
nefs to the fup.rior part of the tooth,  and repeatedly ap-
                                            :   . piled. 
                      I  336  3                         1
 plied till the incruftation is removed.  When the teeth are
 all cleaned, they fhould be rubbed well with a piece of
 fponge in the form of a brufh, covered with a fine powder
 prepared of equal parts  of  cream of tartar  and Peruvian
 bark.
   The teeth fometimes acquire a kind of foulnefs and lofe
 their  colour,  when  there is  no apparent  depofition on
 them.  Moderate friaion with  a  fcaling inftrument  will
frequently remove this.   But the  worft kind of foulnefs   ;
is  when they become  black, and feem  perforated  with a
number of fmall holes.  Alkaline applications are the  beft
in thefe cafes; they often render the teeth clean, and never
injure  them.  A lather of common foap, or a folution of   \
fait of tartar applied over the teeth wirh  a pencil brufh  will
often anfwer.  When the difeafe is thus removed, frequent
waffiing with cold water, and rubbing them with the above-
mentioned powders,  are the moft effeaual preventatives
of a return ; but they are often unfuccefsful.   This variety   M
of the affeaion feems to depend on a putrefcent caufe,  for »
it is evidently attended with a mortification of the teeth;
and hence antifeptics would  probably prove ufeful.
   Lucerne and alkanet roots dried and beat at one end  into
the form of  a brufh,  are very proper to rub the interftices
between the teeth; but no  kind of brufh fhould be  em-
ployed to rub the roots of the teeth, or  the upper parts of
the gums; becaufe they  may feparate the gums from the
teeth.  For  this reafon I  always make  ufe of a piece of    ,
fponge, fixed on  a ftnall handle, which may be ufed with
the greateft fafety.
SECT. 
SECT.   VIII.
                    Of the  Tooth-ach.

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

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

   from whatever caufe the nerve of a tooth becomes ex-
 pofed, pain, and many other of the fymptoms abovemen-
 tioned, will be the inevitable confequence.   This does not
 feem fo much to be produced from  the  mere expofure of
 the nerve to the  aaion of the aliment and  air,  as from a
 certain degree of irritability induced by the  expofure; for
 we frequently fee the cavity  of  the tooth laid open by ex-
 ternal violence,  and nothing more than  a temporary pain
 lomewhat proportioned to the  accident  induced:   and  it
 often happens, that teeth gradually moulder  away with-
out any  pain  or uneafinefs whatever  being produced.
Thefe occurrences could not  take place if a mere denuda-
                        U»                      tion 
                      [  338   3
tion  of the nerve was  the  ultimate caufe of  the  tooth-
ach.
   An irritable  ftate  of  the  nerve may be brought  on by
various caufes;  and  more particularly by faccharine acid,
and  other  ftimulating  fubftances contained  in the food,
being frequently applied  to it—by a  too frequent ufe of
tooth picks—and by much expofure to a flieam of cold air,
and  efpecially if this is  at the fame time moift.
   The  operation of thefe  caufes in inducing  tooth-ach
when the  nerve is already  expofed, by  the  deftruaion of
the enamel from  external violence, or from caries and a
confequent decay of the offeous part of the tooth, is eafily .
underftood : but the produaion of a caries of  the enamel,
 when no external violence  has been applied, the mofl fre-
 quent caufe of the complaint, has not been fo fatisfaclorily
 explained.
   It has  been placed in the large ufe of acids,  and in the
 lodgement of putrefcent particles of the aliment on the
 teeth,  from want  of  waffiing  the  mouth  after  meals.
 With refpea to the  firft  of  thefe, there is  no doubt
 that they  prove injurious to the enamel,  and ffiould there-
 fore be avoided : And the fecond fhould certainly alfo be
 guarded  againft ; becaufe  it not only gives a difagreeable
 foetor  to  the breath,  but  alfo  contributes  to the forma-
 tion of an inconvenient incruftation on the  teeth.  It does
 not, however, appear that caries of the teeth is the con-
 fequence  of either of them.    If acids occafioned it,  k
 fliould affecl all the.teeth, or at leaft a confiderable part
 of them, at the fame time,  and.in an equal degree;  where-
 as ir almoft always begins in a fmall point,  and extends
 itfelf very  gradually.   And if  it was the  confequence of
 the lodgement  of  putrefcent  particles,  it  ffiould always
 appear in thofe parts of  the teeth  which are nearefl to
  each other; but we  know this is  not  the cafe.   And it
  does not  appear, from experiment, that the immerfion of
  teeth extraaed from the body,  when they would proba-
                                                     bly 
                       C  339  3
 bly  be much more readily affeaed  with putrefeency than
 while  they retain the  living principle,  for a confiderable
 time in putrid  matter,  has the leaft effea in producing a
 carious ftate of them.
   Upon the whole, I  am of opinion  that  caries of the
 teeth is generally an effea  of fome conftitutional caufe.
 It often begins in one tooth, and is afterwards extended  to
 a lefs or greater number of others: And I have feen inftanees
 in which the whole of the teeth were  extraaed one after
 another  as  the difeafe extended itfelf,  and  the patient  at
 laft  received no permanent benefit, from the pain  fixing
 upon the jaw.
   This view of the fubjea fhews the impropriety of re-
 moving teeth fo  frequently  as is  ufually done.  For if,
 upon extraaing the firft or fecond tooth  that becomes
 carious, as foon as the violence of the pain  renders it ne-
 ceffary, a third or a fourth fliould be affeaed, the  patient
 ffiould  always be advifed to fubmit to the pain rather than
 to have it removed, as the difeafe is then probably  fefte-
 matical,  and will foon affea more—and it will often hap-
 pen, that if one  fit of  the tooth-ach is borne, the  fame
 tooth will never again be feized by it.
   In cafes of carious teeth, it has been   a prevailing prac-
 tice to  remove the affeaed part with a file, in order to pre-
 vent the difeafe from fpfeading; but I have almoft univer-
 fally feen this detrimental.   It cannot have  the effea ex-
 peaed  from it;  and it becomes injurious by  expofing the
 found parts to the air, and whatever is taken into the mouth.
   When fo much of the enamel is removed,  either by ca-
 ries or  external violence, as to form a hollow of any mag-
 nitude, we may frequently prevent the tooth-ach, and pre-
ferve the teeth, by filling up the opening.  If this is  large,
and particularly if narrow at the bottom and wider exter-
nally, maftick and gum-lac, or even bees-wax,  will be
very proper  for the purpofe;  but  when  the  opening is
                                                 fmall 
I
                      [  340  3
fmall, and the tooth is much hollowed internally, feme of
the metals are preferable.   Gold-leaf is then frequently
made ufe of; but nothing anfwers fo well as common tin-
foil.  As much of this as appears neceffary being cut off,
it ffiould be pufhed in gradually (by the inftrument deline-
ated pi. viii. fig. 1.) beginning at one end, until the cavity
is completely filled; any portion which may be left fhould
then be cut off, and the furface of the whole made perfectly
fmooth by  a fmall  burniflier.  Before the cavity is flopped,
the nerve ffiould always if poffible be rendered infenfible,
either by delaying  the operation for a few weeks  after the
nerve is laid bare, or by daily dropping into  the opening a
fmall  quantity of oil of thyme, origanum, or fome other  j
effential oil.
  When the  fize of the opening prevents  hard fubftances
from  being retained, inftead of  ufing  wax and  the other
foft bodies  above  recommended, it has been propofed to
fluff the tooth  with tin-foil  or  gold-leaf, and  retain it by
means of a fmall peg driven through a hole drilled in the  '
tooth.  But this will not anfwer either when the external
opening is very wide, or when  the  fides of  the tooth are
very thin.
  Befides this  means of preventing the return of tooth-  j
ach, the patient fhould as much as poffible avoid  expofure
to cold;  his head fliould be kept warm; and it will be of  ]
great  importance,  and  fometimes  indifpenfible,  that  he
ffiould live  in a dry fituation.
  For the removal of tooth-ach from expofure of the  j
nerve, the only remeclies I have found ufeful, are anodyne
and corrofive applications to the part itfelf, and extraaion  j
of the tooth.   Slight cafes are fometimes relieved, or even
altogether removed, by applying opium or laudanum to the
nerve: camphor alone, or joined with thefe, is alfo in fome  3
cafes of benefit; and either is now and then of ufe : but as
thefe, and other applications of a milder nature, are often'*  1
                                                unfuc- 
                      C  34i   3
 unfuccefsful, we are then under the neceffity of employing
 thofe which will deftroy the nerve entirely. A long continu-
 ed ufe of any of the ftrong eflential oils will in fome cafes
 render the nerve fomewhat infenfible, but will not deftroy
 it fo effeaually as to prevent a rifle of future returns of the
 tooth-ach.  This may be accompliffied by the ufe of any
 of the concentrated mineral acids, by lunar cauftic, or by
 the ufe of the aaual cautery.   In making ufe of the cauftic
 or acids, however,  we ffiould be very careful to prevent
 them from  fipreading to the contiguous parts.   The  ac-
 tual cautery may be employed widiout a rifle of this, but
 it gives fo much pain, and is fo tedious in its operation, that
 few patients will fubmit to an effeaual application of it.
 A piece of pointed fmall wire may be made ufe of as a cau-
 tery, when the inftrument (pi. viii. fig.  i.) cannot  be had.
   When all thefe remedies fail,  or are not employed to a
 fufficient extent, we are under the neceffity of  deftroying
 the nerve by the extraaion of the tooth ; and  this being
 done, if the tooth is not much decayed, or is not broken,
 particularly if it be one of the incifores  or canini, after the
 focket is  cleared of  blood, it may  be replaced,  and will in
 time prove as ufeful as  ever.   See feaion on tranfplanting
 teeth.
   Teeth  may be extraaed either  in a perpendicular or la-
 teral direaion,  or by making them turn upon their axes,
 by depreffing the coronas or upper parts of them.
   As the removal of teeth in a  perpendicular direaion,
 would neceffarily be attended with lefs violence to the con-
 tiguous foft  parts, than  by taking them out  laterally, it
 fhould undoubtedly be  preferred wherever it  is  praai-
 cable.  This  however can only be the cafe in the extrac-
 tion of the incifores and canini,  unlefs  fome of  the others
 are loofe;  becaufe  we  have not fufficient  room  to  ap-
ply  the  inftruments  for  effeaing it   in  the  molares.
Thefe laft  muft therefore always  be drawn laterally, not-
                                          withftanding 
                       C   342  3
 wlthftanding that not only the  foft parts muft thus  be
 bruifed or lacerated, but the alveolar proceffes broken.
    The beft inftrument yet  invented for drawing teeth in
 a lateral direaion,  is the common key inftrument. In ope-
 rating with  this,  if the  tooth  is in the  lower  jaw, the
 patient fhould be  feated in a chair, in a clear light,  with
 his head fupported by an affiftant ftanding behind;  but if
 it be in the under jaw, he fliJuld be feated upon a pillow,
 with his head turned back,  and fupported upon the knees
 of the operator ftanding behind him.  In order to prevent :
 the gums from being torn, and to admit of a proper ap-
 plication of the key, the gums fhould  be feparated from
 the teeth by  the fcarificator or  gum-lancet.   The patient
 having cleared his mouth of blood, the point of the claw of
 the key muft then be preffed as far down between the gum
 and tooth as poffible, and retained there by the fore-finger
 of the left hand, while the fulcrum  or  heel of the inftru-
 ment, previoufly covered  with foft linen, being placed as
 far down as it will go upon the gums on the oppofite  fide
 of the tooth, the operator muft now with his right hand
 apply gradually fuch a force as he may find neceffary for
 moving it; and by turning the hand fufficiently, any tooth
 may  generally be  drawn  at one pull: where one effort
 however is not fufficient,  and particularly in the  molares,
 it will be better, as foon as the tooth is loofened, to turn the
 claw  to  the  oppofite fide,  and  thus render it fufficiently *
 loofe  to be taken out by the  forceps.
   With a view to prevent the loofening of teeth  contigu-
 ous to the one drawn, the edges of the latter may be taken
 off by a thin file, fmooth on one fide.
   By this method  the incifores and canini may likewife be
 pulled, as well as in the manner hereafter defcribed.
   The alveoli of the teeth feem to be  fo  nearly of an equal
degree of ftrength on each fide, that  in the extraaion this
merits no attention.   Neither is it a  matter of any confe- *
                                               quence 
                      C  343   3
quence to regard the direaion of  the  roots of moft  of
the molares, for thefe  run equally divergent  on either
fide, and except in  the two laft, which  ffiould  always  be
drawn to the infide, on account of the fituation  of the co-
ronoid procefs of the lower jaw,  it is perfeaiy indifferent
with refpea  to both thefe circumftances,  whether the ex-
traaion is made towards  the infide or outfide of the jaw.
Even if the tooth is particularly decayed on one fide, if the
gums are properly feparated,  it is of  little importance
to which  fide the tooth  is pulled:—whatever direaion is
ufed, the focket muft neceffarily be broken on both fides.
   The heel of the inftrument fliould always be made long,
as it will  then injure  any particular part of the gums by
its preffure much lefs than if it is fhort.
   Even when  a tooth  has  been  cautioufly extraaed,
troublefome  circumftances fometimes occur from the ope-
ration :—thefe are,  bruifing of  the gum, feparation  of
fplinters of  bone from the jaw, and alarming hemorr-
hage.  In the firft cafe, if any part of the gum is nearly
feparated, it fliould be cut off  with a pair of fciffars; the
mouth fliould then be fomented with warm milk,  or any
emollient decoaion ; and if there is a probability of a fup-
puration taking place, this ffiould be promoted by the ap-
plication  of  roafted figs, and the abfcefs afterwards open-
ed if neceffary.
   When the alveolar procefs only is broken, it will be of
little confequence;  but if the folid part of the bone is
fplintered, as will more  particularly be  apt to  happen in
children,  a  tedious fore  will very probably enfue  if it is
not treated with great care.  All loofe pieces of bone fliould
be immediately  removed,  and the  reft  will either  come
away afterwards, during the  formation  of matter, or be
eafily taken  out; and if the conftitution is found, the ulcer
wiU then  heal, but not before.
                                              Hemorr- 
                      [  344   3
   Hemorrhagies of any importance feldom occur;  but in
cafes, where any of the larger arteries of  the parts con-
tiguous  to the tooth are divided by the force ufed in the
operation,  very alarming  hemorrhagies fometimes  take
place.   Taking a  mouthful of  cold  water, red  wine,
brandy, vinegar, or alcohol will fometimes reftrain them;
if thefe  fail, compreffion may be tried, by putting a dofiil
of lint into  the opening, and making a conftant preffure
on it by keeping the  mouth fhut.  This  will almoft al-
ways ftop the bleeding; fhould  it, however, be unfuccefs-
ful,  the aaual cautery is alone to be depended on.
   For the purpofe  of extraaing teeth in a perpendicular;
direaion,  the common  teeth  forceps  will generally  an-
fwer.  In applying this, it fhould be preffed as far down
upon the tooth as poffible, otherwife it will be apt to break
off the upper part of  it; and the tooth ffiould not be pul-
led direaiy upwards, but fhould be  twifted alternately
from one fide to the other until it becomes loofe.   If the
forceps are found to give in fufficient force  for the extrac-
tion,  the key fhould be employed.
   When the upper part of a tooth is entirely deftroyed,
leaving nothing but the  fang or root, or what is common-
ly termed  a  flump,  it may be removed very readily by the
ufe of a fimple or crooked lever, ufually called a punch,
previoufly feparating  the gums,  as in  extraaing  whole
teeth.   In ufing  this, it  fliould  never  be puffied lower
down than is juft fufficient to  give a firm reft upon the
fang; for  if it is carried  very low, the force employed is
in a great meafure loft againft the ftrong part of the alve-
olus on the oppofite fide.  When the tooth is  merely
loofened by the punch,  it may  be removed with the for-
ceps.
§.2. 
E  345  3
          § 2.  Of Tooth-ach from  Inflammation.

  Tooth-ach fometimes originates entirely from an inflam-
mation, either of  the  membrane furrounding the  root, or
of the parts within the body of the tooth.   This fpecies is
indicated by a fevere and permanent pain of a tooth which
is to appearance found ;  and efpecially when  the affeaion
has evidently been induced by expofure to cold, or when it
is conneaed with other  fymptoms of inflammation, fuch
as an inflamed ftate  of the contiguous cheek,  fwelling and
fuppuration in the adjoining gums, &c.
  Although in moft inftanees we  may trace this variety of
tooth-ach to cold, yet it may alfo be induced by any  other
caufe of inflammation in general.  It is alfo in fome cafes
the confequence of a fwelling of the fang of the tooth.
But whatever be  the caufe of  the  inflammation, it is al-
ways attended by a  very great  degree of pain; probably
on  account of  the  bone with which the  membrane is
furrounded, preventing it from readily yielding to diften-
tion.
  In the cure  of tooth-ach  from inflammation, the gene-
ral remedies of  affeaions of this  kind  in other parts are
found the moft ufeful.  Local blood-letting,  either  by
fcarifying the  contiguous gums, or  by the  application of
leeches, often gives relief.  I have known a blifter applied
direaiy oppofite  to  the affeaed parts remove the  pain en-
tirely ;  and a  large dofe of  laudanum is often very ufeful,
by leffening the  irritation.  The head ffiould be kept  warm
by covering it with flannel; and fomenting it with  the
fleams  of a decoaion of emollient herbs,  or  even  with
warm water, will often  procure relief when  every  other
remedy has failed.   In fome cafes, cold water, vinegar, or
fpirits, taken into the mouth prove ferviceable ; but  warm
applications are generally beft.
                      X x                       When 
                      C   346   ]                      I
   When this  complaint cannot  be removed by the reme- 1
dies already recommended, we are reduced to the neceffity  \
ofadvifing  the extraaion of the tooth :  but in this cafe
we ffiould be particularly careful to avoid  a hafty extrac- \
tion, more efpecially  if we have reafon to believe there is
an enlargement of  the fang  or fangs.  After the tooth is
removed, if it is uninjured, We  are commonly advifed  to  i
replace it: but in this variety of tooth-ach, and even when  j
none but  the parts  contiguous to the tooth are inflamed, I
have feldom or ever feen  the praaice fuccefsful.

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

   We  judge  that  this variety of tooth-ach occurs  when
there are  no fymptoms  of either of the fpecies defcribed
in § 1  and 2.   It  may  originate  from rheumatifm, from
an  arthritic diathefis,  from hyfteria,  from  pregnancy,
and from a  foul ftate of the ftomach.
   In this laft cafe,  which is  indicated by the ftate of the
tongue and  other circumftances, emetics often give imme-
diate relief; and then the exhibition of Peruvian bark, par-
ticularly if the fits of the  difeafe have returned periodically,
will be the beft means  of  preventing returns.  Opiates
never are of 'fervice, but often do injury  by  producing  !
naufea, &c.—and even  increafe the pain.   But  when the
complaint originates from gout,  rheumatifm, or hyfteria,
opiates will generally  remove  it entirely : and a  return
may be obviated by keeping the parts warm.  In hyfleri-
cal tooth-ach,  ether,  combined  with opium, has fucceed- \
ed when every thing elfe had failed.  Opiates are never of
permanent benefit  in tooth-ach from pregnancy :  general
blood-letting is  often the only  effeaual remedy—Apply-
ing leeches to  the  gums  will fometimes  anfwer the pur-
pofe.
                                               SECT. 
C  347   3
                    SECT.   IX.

                Of Tranfplanting Teeth.

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


                    SECT.   X.

                     Of the Ranula.

   Tumors are frequently met with beneath the tongue, on
 one or both fides of the frenum; thefe are all known by
 the term ranula.  They are feldom attended with much
 pain;  but they become in fome inftanees fo large as very
 much to impede  the  fucking of infants,  and the maftica-
 tion, and even the fpeech  of adults.   In fome cafes  they
 contain a  fatty matter; but in  nineteen  cafes of  twenty,
 they are filled almoft  entirely with  a thin limpid liquor,
 refembiing the faliva;  and  we find, on cutting into them,
 that they  are often produced by a ftoppage of the falivary
 duas, from  calculous concretions forming in them.   The
 tumor generally burfts when it arrives at the fize of a large
 nut, leaving  an ulcer which  is  difficult to heal, unlefs the
 caufe be difcovered.  The concretions are of various  fizes;
 I have in  feveral inftanees found them as large as a kidney-
 bean.
    Whenever thefe fweUings are not of a firm confiftence,
 the moft  effeaual mode of treatment is to lay them open
 with  a fcalpel from  one  end to the other; the calcareous
 particles  will then eafily be  difcovered;  and thefe being
 removed, and the fore wafhed with warm water,  or fome
 other emollient, it generally foon heals.   But  if there is af-
 terwards  any  difficulty  in  curing  the  ulcer, it  may be
 bathed with  tinaure of bark,  or  fome other  aftringent.
  Oid fiftulous fores of  thefe parts will be commonly found
 to depend on a  calcareous matter; and by making an inci- 
                      L"  35°  3
fion down to  this,  and removing it by a fcoop or forceps,
they will foon be cured.
   When tumors  in this fituation  are of a fatty or firmer
confiftence,  they ffiould be totally extirpated ; and  this
may be eafily done unlefs they  lie deep, and are very large.
They may ufually be removed without any danger of divid-
ing the larger arteries :  and  the hemorrhagy may then be
eafily reftrained by fpirit of wine, or tinaure of myrrh.  But
if any large veffels fhould be cut, as ligatures cannot poffibly
be applied to them, it will be neceffary  to have recourfe to
the potential or even the aaual  cautery.   If  the tumor
cannot be held by the fingers during the operation, a fmall
hook will  anfwer th'13 purpofe better than the forceps
which  are ufually employed.


                   SECT.   XI.

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

   The tongue, and other parts within the mouth, are li-
able to all the variety of ulcers incident to other parts of
the body, and the treatment they require is nearly fimilar.
When  they originate from the lues venerea, fcrophula, or
fcurvy, the general remedies  of thefe difeafes become necef-
fary ;  but when the affeaion is local,  topical remedies are
alone to be employed.
   Local  ulcers of  the  mouth  appear to be moft  fre-
quently occafioned by the fliarp points of broken or ca-
rious teeth,  which irritate or deftroy part of the  infide of
the cheeks, or of the fide of the tongue;  when this is the
cafe, the teeth fliould  be fmoothed with a fmall file.  If
fores appear to be induced by  the formation of tartar up-
on the  teeth, this  muft be removed  as formerly direaed.
                                                   The 
                      I  35i   3
   The removal of the original caufe is ufually foon followed
 by the cure of the fore; but when this is not the cafe,  we
 may frequently derive advantage from wafhing the month
 with  decoaion of bark, a  folution of  alum, and other
 aftringents.   Notwithftanding the ufe of thefe, mercury,
 and of every other remedy, the fores,  in fome cafes, con-
 ftantly  become worfe:  They grow ragged  and unequal
 about  the edges; difcharge  a thin foetid fanies ; and then
 become very painful.
   As long as a fore of this kind continues fmall, and (hews
 no tendency to fpread, there will be a chance of its heal-
 ing.   But whenever it conftantly grows larger, and more
 painful, notwithftanding the employment of the remedies
 above recommended, we will have reafon to  fuppofe it of
 a cancerous nature, and fliould certainly advife its removal
 by immediate extirpation.
   When the  ulcer is fmall and fuperficial, it may be remo-
 ved with eafe and fafety; but when it is large, this is attend-
 ed with difficulty and danger.  However, whenever the
 whole of the parts affeaed can be taken away, as the ope-
 ration  affords the only remedy, it  fhould  certainly  be
 rifked.
   The eafieft and moft effeaual method of removing a
 deep feated cancer in  the cheek, is  to make  an incifion
 through  the  whole  fubftance of the cheek, beginning at
 the contiguous angle of the  mouth, and ending at the fame
 part, after carrying it  round the fore.  The difeafed parts
 being thus  entirely  removed, the fides  of the  cut muft
 be brought into contaa, and fecured  by  the twifted fu-
ture.
   In removing any confiderable portion of the  tongue by
 the knife, the hemorrhagy  is the only occurrence  pro-
 duaive  of  danger.   To remove this  the furgeon  ffiould
 provide himfelf with  all the ordinary remedies.  When
ligatures can  be paffed  round  the veffels,  which may  be
                                                done 
                      C  352  3
done farther  back in the mouth  than is  commonly  fup-
pofed, they  ffiould  undoubtedly be  employed.  If the
tenaculum or crooked needle cannot be ufed for this pur-
pofe,  the apparatus  defcribed for tying  fchirrous tonfils,
muft  be had recourfe  to.   But when the veffels cannot
be fecured by either of thefe methods, keeping the mouth
filled  with  aftringent infufions or folutions,  and particu-
larly a folution of alum or diluted vitriolic acid, will fome-
times  be effeaual in reftraining the  difcharge; if thefe
do not fucceed,  the  potential or even the aaual cautery
muft be employed as the laft refource.
  As this is a formidable  operation,  it has  feldom been
performed ; and indeed it fhould not be attempted but by a
furgeon of great firmnefs and experience.

                  SECT.    XII.

          Of the Divifion of the Frenum Lingua.

  This operation becomes  neceffary when the frenum of
the. tongue is either  fo  fhort,  or  continued fo near to the
point of it that  it impedes  the fucking of children.   It is
ufually  performed by  a fcalpel  or  pair of  fciffars; the
child  being  laid acrofs  the nurfe's knees,  and  the furgeon
elevating the tongue with the middle finger of the left
hand,' while he makes  the  incifion with the right,  taking
care to avoid the larger blood-veffels of the tongue.
SECT. 
t  353  3'
                    SECT.   XIII.

           Of the Divifion  of the *Parotid DuB.

    The dua of the parotid gland is  fometimes  divided
  in extirpating cancerous fores from the cheek; fometimes
  by accident;  and if the divided parts  are not retained in
e. Cbntaa until they heal, it often happens that the internal
  part of the^wound clofes, and a conftant difcharge of fa-
  liva takes place over the cheek,  which  at length produces
  a tedious fiftulous fore.
    In cafe of a recent divifion of this dua, the ends fhould
  be brought together,  and retained  by adhefive plafter,
  or the  twifted future, as may feem moft proper; but when
  this has been negfeaed, or fails of fuccefs, as the inner part
  of the  dua becomes clofed, it will be neceffary,, for a cure,
  to make an artificial opening into tlie mouth, and endeavour
  to form a union between this part and the upper portion
  of the  dua which  leads from the parotid gland.   For this
  purpofe, a fharp pointed perforator, fomewhat larger than
  the dua, fhould be entered on the fide  of the  fore op-
  pofite  and contiguous  to  the under extremity of the  fu-
  perior  part of the dua, and carried obliquely, in the na-
  tural direaion  of the  canal, into  the  mouth.  A leaden
  probe  exactly  the fize of  the perforator,  fhould then
  be introduced  along the  courfe of the opening, and  re-
  tained there until the fides of it become callous ; the probe
  ffiould afterwards  be  withdrawn, and the  extremity of
  the dua  drawn  into  contaa  with the fuperior part of
  the artificial opening by  means of adhefive plafter,  and
  retained until  a firm union  has  taken  place.    It  will
  facilitate  the union between the  parts,-if the  edges of
  each   are  made  raw  with a  lancet  or fcalpel,  before
   they are brought  together.   The  patient fliould live upon
                           y y                    ipoon- 
                     C  354  3
fpoon-meat till a cure is effeaed;  fliould  fpeak little or
none;  and  make  as  little  exertion with his  jaws as
poffible.
           CHAP.    XXXIV.

Of Difeafes  of the  Ears,   and  Operations
             pra&ifed upon them.
                    SECT.  I.

                     Of Deafnefs.

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

        $ I. Of an Imperforated Meatus Auditorius.

   This difeafe  feldom  occurs.   It  may  be  formed either
 by a thin membrane fpread over the mouth  of the paffage,
 or by a fleffiy kind of fubftance  occupying more or lefs  of
 the cavity.   In both thefe cafes, the only  remedy  is af-
 forded by an operation.
   The patient's  head being fecured in a proper light, the
 operator with a fmall (harp-pointed biftoury fhould make
 an incifion of a  proper  length,  exaaiy on the fpot where
 the external paffage ffiould terminate, and carry it  gradu-
 ally through the obftruaing fubftances, either till the re-
 fiftance is entirely removed, or till there is  reafon  to fear
 that the tympanum would be  hurt if  it  were carried
 deeper: the  inftrument fhould then be  withdrawn; and
 in order to  prevent the parts from adhering  together,  a
 bit of oiled bougie fhould be introduced and retained un-
 til the cure Is completed,  removing it  daily to wipe off
 any matter produced.
   In  this manner deafnefs may often be  removed, when
 the obftruaion does not extend quite to  the tympanum ;
 and it fliould always for obvious reafons  be attempted
 about the time when the child begins to fpeak. At a more
 early period the  child could not bear it; and if longer de-
layed it might produce dumbnefs.
§2. 
[  35*  3
       i. 2. Of Extraneous Bodies lodged in the Ear.

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

       §. 3.  Of Excrefcences in the Meatus Auditorius.

   The auditory paffage is as  liable  to  polypous excref-
cences as the nofe and throat; but they feldom arrive to
a  large fize,  and  are   generally of  a  firm  confiftence.
They are fometimes pendulous by one pedicle; but in other
cafes they feem to confift merely  in a general  thickening
of the  membrane of the conduit.
                                                  Thefe 
                     I  357  3
  Thefe  fubftances  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 diffeaing hook, they may
be eafily cut out with a probe  pointed biftouri; and  with-
out any  danger from hemorrhagy;  but when they lie
deep, it will be moft convenient  to remove them by liga-
tures.  This may be done by  means of a fplit probe and
a double canula, as advifed in  polypi of the nofe.
   But in  cafes  where the excrefcence extends a  confi-
derable way along the membrane, inftead of being pendu-
lous by a fmall neck, neither of thefe methods is  appli-
cable.   Bougies will here generally fucceed as well  as in
obftruaions in the urethra.   In the introduaion of them
however, we  muft  be careful not  to pa& them to the
depth of the tympanum, or they  may do more harm than
good.   Efcharotics have been  recommended in  thefe  cafes;
but they muft always give fome  rifle of  injuring the tym-
panum.

      §. 4. Of Deafnefs from Wax colleBedin the Ears.

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

          Of Perforating the Lobes of the Ears.

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

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

  * In the London Medical Journal for 1790, there are related two
cafes  of wry  neck,  from an affe&ion of the mufcles, which were
cured by  electricity  applied to the  antagonifts  of the mufcles  con-
tracted. 
[  36i   3
            CHAP.    XXXVI,


        Of the  Difeafes of the Nipples.




       HEN  the nipple is fo far funk into the breaft that
        the child cannot  take hold of it, it becomes ne-
ceffary to draw it out by means of nipple glaffes.   Thefe
may be ufed either by the patient herfelf, or by an affiftant.
They are made of glafs alone, or of a glafs cup conneaed
to a bag of gum elaftic.
  The beft remedies for cracks or ulcerations of the nip-
ples, are mild, aftringent, and  drying applications.  The
parts may be bathed with  lime-water, port wine, or bran-
dy  and  water, and afterwards  covered with unguentum
nutritum,  or Goulard's  cerate.   The firft is the beft; but
whichever  of  thefe ointments is ufed,  they ffiould be en-
tirely wafhed off before the child is allowed to fuck, on ac-
count of the lead  contained in them.  The child ffiould
not be permitted to fuck oftener than  is abfolutely necef-
fary ; and when one nipple only is fore, he ffiould if pof-
fible be confined to the  well breaft, and the other fhould
be  drawn occafionally.    The nipples  fhould be  covered
with fmall wooden cups, perforated to let the milk through;
in order to prevent the clothes from retarding the cure.
w
Z  z                 CHAP. 
•   I   362  3
            CHAP.    XXXVII.


                     Of IlTues.

                    -_-a-__aaa_a__aT~—

   ISSUES  are fmall artificial ulcers formed in different
    parts cf the body for procuring a difcharge of pus.
It is now very well eftabliffied, that thefe are only ufeful in
proportion to the quantity of the matter they afford: (See
Chapter on Ulcers).   And as this is the cafe, they may be
placed in any fituation moft convenient to the patient.
  In the formation of iffues however, it is to be obferved,
that they ffiould never be placed immediately above a bone
thinly covered, direaiy above a tendon, very  contiguous
to a large blood-veffel or nerve, or upon  the belly of a
mufcle.   The beft fituations for iffues are, the fpace be-
tween the tendons on the back of the neck, the middle of
the upper fide of the humerus,  and the hollow on the in-
fide of the knee above the flexor tendons.   They may like-
wife be inferted between two of  the ribs, and on each fide
of  the vertebrae of the back; or wherever there is a fuffi-
cient  quantity of cellular fubftance  for  the proteaion of
the parts beneath.
   Iffues are formed,, by removing the fkin  by  epifpaf-
tics;  by making  an incifion with a fcalpel or lancet; by
the application of cauftic;  and by  the introduaion of a
cord.
   If  a blifler is ufed, it muft be exaaly of the fize of the
intended  fore;  and  after its  operation,  a difcharge  of
 matter may be kept up by dreffing daily with cerate mixed
                                                   with 
                      C  363   3
with cantharides.   If incifion or cauftic is to be employed,
an opening muft be made of a fufficient fize, and preferved
by inferting daily fome extraneous  body  covered  with
ointment,  and  fecured by a comprefs and bandage.—Peas
are commonly  employed: but kidney beans,  gentian root,
or aurantia curaflavantia cut into a proper form, will alfo
anfwer very well.
   When the opening  is to be made-by incifion, the fkin
fliould be  fupported on one fide by an affiftant, and on the
other by the furgeon,  who fliould then make a cut of a
fufficient length and  depth for  receiving the number of
peas intended  to be put into it.   The common lapis  infer-
nalis anfwers beft for making an iffue by cauftic.  It fliould
be firft reduced to powder, and made into a pafle with
water  or  foft  foap; a piece of leather fpread with Bur-
gundy pitch,  or any  adhefive plafter,  with a fmall hole
cut in the  centre of it,  fhould then be placed upon the parr.
The cauftic being put into this opening, the whole fhould
be covered with another adhefive plafter.   Thefe precau-
tions  are  neceffary to prevent the cauftic from fpreading
farther than the  part upon which it is wiflied to  operate.
In the courfe of ten or twelve hours  the cauftic may  be re-
moved, as by  this time it will have produced an efehar of
a fufficient depth.  In three or four days the efehar will
feparate, and  the opening muft then be filled with peas as
above  direaed.
   When  we  wiffi to difcharge  a very large  quantity of
matter by iffue, and  particularly from deep-feated  parts,
we effea  it by the introduaion of a cord of cotton or filk,
forming what  is termed a feton.   The  parts at which the
cord is to  enter ffiould always be marked with ink; and this
being put into the flat needle  (pi. ix. fig.  3.) and the parts
fupported by an affiftant, the needle fliould be pufhed in at
one of'the fpots marked,  and carried out at the  other,
leaving'-two or three  inches of  the cord hanging  out at,
                                                  each' 
                     C   364  3
each orifice.  The irritation which the feton  gives foon
produces a plentiful difcharge  of  matter; which  may be
increafed or diminiflied, 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 reafon to fuppofe that almoft all eruptive
       difeafes, as  well as fome others, may be communi-
cated by inoculation; but the operation is feldom praaifed
but for the communication of the fmall-pox.  The plague
and  meaflcs have been given in this way.   The latter has
been tried in Scotland,  but without  advantage.
  The fmall-pox can only be communicated  with certainty,
in inoculation, by means of the matter taken from  fome of
the puftules, and  applied  to a wound made in fome part
of the body.  This is now commonly done in a very fim-
ple manner : The point of a lancet, previoufly moiftened in
the matter, is infinuated through the cuticle, fo as flightly
to injure the cutis vera.  If the matter has become hard it
fhould be foftened  by warm water or fleam.
   The operation may  be  done in any part of the body;
but the arm is generally preferred.   In ordet the more
certainly to enfure  fuccefs, it  may be performed in tv/o or
more places; but always at fuch  a diftance apart that the
inflammation produced may not extend from  one to the
                                                 other 
                     C  3<*5   3
other—on each leg or thigh for inftance.  No dreffing is
employed;  and about the end of the fecond or third day,
if the operation has fucceeded, the wounds will have be-
come red, fwelled, and painful.
CHAP.    XXXIX.

      Of  Wounds.
                   SECT.  I.

                Of Wounds in General.

A WOUND may be  defined,  a recent folution of
      continuity in any of the fofter parts of  the body,
attended by a correfponding divifion of the integuments.
  Wounds muft neceffarily exhibit great 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 mufeular parts are very different in
their appearances and nature, from thofe which  affea ten-
dinous  parts; thofe made with a cutting inftrument  are
materially different from  contufed  or lacerated wounds;
and punaured wounds are generally produaive of very
different effeas from thofe which are mofe  extenfive.
  We ffiail at prefent confine ourfelves to the  defcription
of the  phenomena which ufually take place in the moft
                                             frequent 
                      C  366   3
frequent form of this  affeaion, what we  term a fimple-
incifed wound.
  The firft appearance we obferve  in a wound of this
kind, is a feparation of the divided  parts; the degree of
this depends on the depth and length of  the  wound, and
on the direaion of it with regard to the fibres of the part.
This laft circumftance has a very confiderable influence in
this  refpea,  for  when the fibres of a mufcle  have been
cut tranfverfely,  they will feparate fometimes to fuch a de-
cree, as to give reafon for fuppofing that a part of them
has been removed ; and it often happens  that a wound of
fome depth in the direaion of  the fibres, will produce fo
little retraaion of the fkin that it appears almoft as a line.
  The next appearance is the  hemorrhagy,  which takes
place to  a  greater or lfcfs extent, according to the fize of
the cut,  and the  fize and number of the blood-veffels di-
vided.  If this is  negfeaed, or  is not worth attention,  the
irritation produced  by the injury, as well as by the  exter-
nal air, excites the veffels to contraaion, and  thus flops
the  difcharge.   The  difcharge of  red  blood gradually
ceafing, a ferous fluid oozes out for  a few hours, and the
whole furface of the fore  then foon becomes more' or  lefs
dried, or covered over with coagulated blood.
  The pain in thefe wounds is at firft commonly inconfi-
derable,  unlefs a  nerve or tendon has been  partially divid-
ed, in which cafes it is ufually fevere.-  But in a few hours
it becomes more  confiderable and more or  lefs of inflam-
mation fucceeds; and  if  the wound is large,  a propor-
tionate degree of fever.   Thefe  fymptoms increafing, mor*
tification is at length produced  in fome inftanees; but for
the mod part,  the furface of the wound, which for fome
time  remained perfeaiy dry, is gradually  rendered moift
and foft, by  a thin  ferum oozing into  it, which being al-
lowed to colfea,  is at length changed into purulent mat-
ter; and in general, the general and topical  fymptoms of
                                           inflammation 
                      [  '3*7  3
                                     *
inflammation abate more  or lefs quickly according as this
formation of  matter  is more or lefs plentiful; and go off
entirely when a free fuppuration takes place.
  From  this  view of the progrefs .of the fymptoms  of a
wound, it  is  evident,  that in  its treatment,  it fhould  be
chiefly attended to as an exciting caufe of inflammation.
  When no organ of  importance to life is wounded, and
when the cut is feated in  a fleffiy parr,, if nature be not im-
peded in her operation, the whole furface of  the fore be-
comes covered with granulations, when a  proper fuppura-
tion has taken place;  and a cure is gradually accomplifhed
in the manner defcribed in the chapter on ulcers.
   This favourable termination may be prevented  by  a va-
riety of caufes; but thofe which arife folely from the na-
ture of the wound are, too great or too fmall a degree of
inflammation,  and a want of a free difcharge of the matter
that is produced :*  Thus punaured wounds are  very apt
to be  accompanied by  too much inflammation ; and lodge-
ments of matter frequently occur in them.   In contufed
wounds the texture of the parts is fometimes fo much  in-
jured, that the  circulation is  ftopped, and a mortification
is occafioned.   And  wounds  attended with  much lacera-
tion are particularly liable to produce gangrene, ultimately
from exciting too much inflammation.
   In forming a prognofis in wounds, befides the circum-
 ftances juft defcribed, it will  be neceffary to pay  attention
 to the age and  habit of  body of the patient; the texture
 of the wounded part; the part of the body injured; and
 the rifle of a communication  of the effeas  of the wound
 to the adjacent parts.
   Thus it is well eftabliffied by experience, that wounds
 are much  lefs hazardous, and heal  more readily in youth
 and middle-age than in very advanced periods of life;  but
 it does not appear that  healthy old age is any obftruaion
                                                     in
     * Thefe are circumftances that require particular attention.   B. 
                        _  3*8  3
in a great many cafes,  particularly in the operations of li-
thotomy and amputation,  to the healing of wounds;  on
the contrary it is often advantageous,  by giving lefs ten-
dency to inflammation.
   It is well known alfo, that wounds are much lefs painful,
and heal more eafily in fome parts than in others, in muf-
cles, e. g. than in tendons,  or glands.
   With refpea to the  fituation  of a wound, it is obvious
that wounds in the extremities,  when confined to parts
lying above any of the hard bones, are not fo hazardous as
thofe which pafs into any of the joints; and in other parts,
wounds which penetrate any of the larger cavities muft be
more dangerous than thofe which do not run fo deep. This
may be occafioned by the chance  of fome organ being di-
reaiy  injured, either by  air  or  other extraneous bodies
finding accefs to the expofed cavities, or by the lodgement
of matter.
   It is alfo to be confidered that wounds, which at firft did
not appear to be attended  with  any rifk, may eventually
prove mortal;  thus the lungs,  ftomach, aorta, or recep-
taculum  chyli  may be wounded flightly,  and at length
prove a very unexpeaed caufe of the patient's death.
   Wounds alfo prove fatal in fome inftanees, from a com-
munication of inflammation to parts which were not pri-
marily injured in any degree;  and they may likewife ter-
minate in death from  mifmanagement in diet,  dreffmgs,
and other circumftances.
SECT. 
C  369   3
                   SECT.   II.

         Of the Cure of Simple Incifed Wounds.

  Our  firft attention, in wounds, is to be direaed to the
hemorrhagy; both on account of the fafety of the patient,
and of afcertaining the extent and nature of the injury.
  Hemorrhagies are to be reftrained by the tourniquet, or
by preffure with the hand, according as the wound is feat-
ed on the extremities, or on the trunk,  or head, until the
veffels can  be tied, either by means of the tenaculum or
needle.   If neceffary, the wound ffiould be enlarged in or-
der  to admit of the application of the  ligature; and  this
praaice  if properly attended to, would we  believe  have
faved many limbs which have been amputated, from the
fuppofed impoffibility of otherwife  reftraining  the bleed-
ing.
  When the injured arteries run in the fubftance of a bone,
as they  cannot then be tied,  they fliould  be cut entirely
acrofs, and their confequent contraaion will, perhaps al-
ways, remove the hemorrhagy.
  If the difcharge proceeds from the very fmall veffels on
the furface of the fore, remedies of a different kind  from
thofe juft mentioned muft be employed.  See chap, on the
means of removing hemorrhagies.
  The bleeding being ftopped, we  are then to examine the
wound carefully, and remove all extraneous fubftances that
can  be taken away without giving much pain, or danger of
injuring  parts of importance;  any  others that may be pre-
fent muft be left to be thrown  off by the confequent fup-
puration.  This  praaice will often  prevent  very trouble-
fome  inflammation.   But it is to be  obferved, that we are
to be in  fome meafure guided in our  condua  here, by the
nature of the fubftance lodged in the wound; for inftance,
                        3 A                      lead 
                      I   37o   3
lead has often lain a confiderable time in the body without
being produaive of injury; but  almoft  every other fub-
ftance feems  to produce  bad effeas to a greater or lefs
degree.
  Where  the fingers will effea the purpofe, they fliould
be preferred to forceps, or any  other inftrument, for the
removal of fubftances from  wounds.  Sand, duft, or fmall
pieces of glafs, &c. are beft removed by bathing the parts
in warm water, either by means of a fponge, or of a fyringe,
or by pouring it upon them:  And in doing this,  as well as
in ufing the fingers or forceps, much of our fuccefs will de-
pend  on putting the patient in fuch  a pofition as will mofl
effeaually relax the injured parts, and  produce as wide a
feparation  of  the lips of the wound as poffible.
  We are in the third place, to proceed to the employment
of thofe means which will probably heal the wound in the
moft eafy  and expeditious manner.   Wherever the nature
of the injury  will admit of it, the divided parts  ffiould be
brought into  contaa:  the irritation  excited by the wound
itfelf will  then generally be produaive  of a certain de-
gree of inflammation, which will accompliffi a union In the
courfe of  a few  days, by the intervention of a glutinous
fluid exhaled from the veffels.  This  conneaion is, in many
inftanees,  foon confiderably ftrengthened  by the  formation
of blood veffels.  The wound is then faid to be  healed by
the firft intention ; and this mode of cure fliould always,
when it appears  praaicable, be  attempted. ' If the parts
cannot be brought  into contaa,  they fliould be made to
approximate as much as poffible, as this will, in every in-
ftance, expedite the cure.
  The advantages of  this  method of treatment are, that
very extenfive wounds are  very quickly  cured,  the  parts
being ufually united in the courfe  of five days;  a large
and  often  materially  injurious  difcharge is  prevented;
the free motion of parts  that would otherwife be loft is
                                                  often 
                      C  371   3
often preferved ; the fear produced is very fmall;  and the
wounded parts are well covered by found fkin.
  The means of drawing and preferving divided parts in
contaa, are, bandages, adhefive plafters, and futures.  With
refpea to the firft, although  the uniting bandage  may be
ufed in longitudinal wounds in  the  extremities and  head,
yet it feldom keeps the parts fmooth and even,  when ufed
alone, and in tranfverfe wourjds it can be of no benefit at
all.  It may, however,  be often  ferviceable in aiding the
effeas of adhefive plafters : Thefe ffiould  always be pre-
ferred to any other  remedies  in wounds that do not pene-
trate much deeper than the cellular membrane; and where
the lofs of fubftance  prevents the edges from coming to-
gether, the  plafters  are to  be applied in  fuch  a man-
ner as* to  bring them as clofe as  poffible.*  But  in  all
wounds that penetrate  to any confiderable depth,  when
their lips can be brought into contaa, the twifted future is
the beft means of retaining them.—(See chapter on Sutures.)
The interrupted future which  is moft frequently employed,
does not fupport the parts fo well; the ligatures are apt to
tear or cut the parts;  and they frequently  leave difagree-
able marks.
   It is of confequence to obferve, that where the ufe of fu-
tures or adhefive plafters has been negfeaed  at the firft,
they may be employed with advantage during any ftage of
the fore,  as the parts will unite at any time very readily;
and it will expedite the cure very much to bring the edges
of the ulcer  into contaa whenever it can be done.
   The good effeas of futures and plafters  will be much
aided by  a proper pofture of the patient; and indeed with-
out this be attended to, they will be of little advantage.
   When the parts are brought together in  the manner di-
reaed, in  order to prevent the accefs of air,  it  will be bet-
                                                    ter

  * The form and fize of the plafters muft be regulated by the judg-
merc of the furgeon. 
                      [  372   3
ter to cover them  with lint fpread either with  mucilage of
fome mild gum or fome unauous fubftance.
   If the patient is low and emaciated,  it will be proper to
allow him a light nouriffiing diet; but if he is plethoric,  or
liable to inflammatory complaints, he fliould be confined to
a ftria antiphlogiftic courfe, in order to prevent too great a
degree of fubfequent inflammation.
   Should the fymptoms of pain and inflammation continue
moderate,  the dreffings ffiould never  be  removed till  the
cure be completed; but whenever  the pain in the wound
becomes  fevere, as  it  will, if not properly attended to, be
produaive of fo much inflammation as to fruftrate our in-
tention, the dreffings  ffiould  be removed, and the parts
gently, and for  fome time,  rubbed or bathed with fome
emollient oil.  If this proves inefficient, general and topi-
cal bleeding, and  opiates, muft be employed, according  to
the circumftances of  the  cafe.  Thefe will generally  re-
move the inflammation ; but if they fhould not have this
effea, it will be neceffary to  take away  the  ligatures or
plafters entirely,  and accompliffi a cure in the ordinary
way.
   In general,  even  in very large wounds, the futures or
>lafters may be removed about the fifth or fixth day, as a
union will by that time  have been produced, and they may
then be difadvantageous.
   It has  been objeaed to the method we  have  advifed,
that where arteries are tied,  the ligatures will prevent  the
union of the divided parts, and that finufes are very apt to
be formed, and produce the fame effea : buscwhen the cure
has been properly conduaed, I have never found thefe cir-
cumftances to occur in fuch degree as to afford any valid
ground of objeaion.
   When wounds do  not admit of a union by the firft io-
tention, the moft effeaual method of preventing the occur-
rence of bad fymptoms, is to promote  a fpeedy and plenti-
                                                   ful 
                      C  373   3
ful  fuppuration, by the remedies formerly  recommended
for  this purpofe, viz. poultices and  fomentations.   Thefe
ffiould be applied immediately when the pain is very great;
but when this is moderate, we  had better  defer  the  ufe
of them until the effufion neceffary for  the formation of
pus has taken place, which will probably be in the courfe
of a day or two,  left the inflammation ffiould be  prevent-
ed  from arifing  to  the neceffary  degree.   The ufe of
thefe  remedies  fhould  be omitted  as foon as the  pain
and inflammation have fubfided, and a  free fuppuration
has taken  place ; becaufe  a  longer  continuance of them
would do injury by relaxing the parts to too great a de-
gree ;  and the fore is then to be treated in the manner for-
merly advifed, in  the chapter on Ulcers.
  The immediate applications to recent wounds  fhould
always be mild;  dry lint or fponge are very commonly re-
commended, but lint  fpreacl with a mild ointment is  lefs
irritating, and in my opinion, of confequence more  proper.
  The  firft  dreffings  of  wounds ffiould be removed as
foon as they appear to be covered with matter: this  will
generally happen about the fourth or fifth day; but it muft
neceffarily depend on the health of  the patient, and other
circumftances.   The  application of  poultices above the
dreffings after  the fecond day,  puts it into our power to
remove them fooner than we otherwife could, by foftening
them, and  promoting the fuppuration.   The nature of the
fubfequent dreffings muft depend upon the particular nature
and appearances of the fore.  See chapter on Ulcers.
   The fymptoms which  more particularly require atten-
tion in wounds, are,  pain, inflammation,  and convulfive af-
feaions.   The firft of thefe ufually  goes  off in a fhort
time ; but when  it continues  very violent and for  a longer
time than ufual, it will be neceffary,  in the firft place, to try
the effeas of  opiates : Should not thefe give permanent
relief, we fhould  carefully fearch for the caufe.  This will
                                             fometimes 
                      C  374   3
fometimes be  found to  confift in  extraneous fubftances
lodged in  the wound;  thefe fhould therefore be fearched
for, and removed, either by the fingers, injeaions of warm
water, or by immerfing the parts in warm water or milk
for a  confiderable time, by which they may be diffolved
and waffied out.
  If thefe trials do not remove the pain,  it will often be
found to originate from inflammation.  This  is to be re-
moved in the ufual way;  but particularly by  the applica-
tion of leeches to the edges  of the  wound,  and by feari-
fying the periofteum,  if the  inflammation appears  to be
feated there.   There is  not fo much danger of inducing
exfoliation of the bone by this proceeding, as  by fuffering
the inflammation to continue, and perhaps  terminate in
the formation of matter.
   When the pain appears to be deep feated,  and does not
feem to originate from either of the caufes already mention-
ed, it may with  fome reafon be attributed to a partial divifion
of a nerve or  tendon.   In this cafe, although putting the
part in a  relaxed pofition may afford fome eafe, no effec-
tual relief will be given by any remedy,  but an entire divi-
fion of the injured  nerve or tendon.   This being made,
the limb fhould be relaxed, and the part affeaed covered
by an emollient poultice.  If this fhould fail, either from
the divifion  being made incompletely, or from its having
been  too long  deferred, there will  be great reafon to fear
the patient will die convulfed,  notwithftanding the ufe of
opiates, and every other remedy.
   In  fome inftanees, the pain inftead of being  deep feated,
is found to originate from a peculiar degree  of irritability
of the nerves on the furface of the injured parts.  It is not
then ufually fevere, but it often  prevents the  patient from
fleeping, and occafions a  thin acrid  difcharge.  In thefe
cafes,  large dofes of opium  give the moft  certain relief;
and a weak folution of opium, or of faccharum  faturni,
                                                    are 
                      C   375  3
are the beft external applications.  Poultices often increafe
inftead of relieving the complaint.
   Subfultus tendinum, and  other flight fpafmodic affec-
tions are frequent confequences of wounds; thefe are par-
ticularly apt to occur after amputation, and then produce
very difagreeable and fometimes dangerous confequences.
They are evidently the effea of pain and irritation from the
wound, and are often relieved confiderably or entirely, by
putting the whole body, and particularly the part wound-
ed, into an eafy relaxed pofture.  If this fails, opiates will
commonly fucceed :  and thefe ffiould always be given in
fmall quantities, frequently  repeated; for large dofes are
very apt to naufeate  or puke,  and to be produaive of an
increafe of the  fpafms after their  immediate  effeas are
 over.
   The moft  alarming  convulfive affeaions confequent to
 wounds, are  the locked-jaw and tetanus.  Thefe are moft
 apt to  occur in warm countries, but occafionally are met
 with in every variety of climate.  They  are  frequently the
 effeas of trifling injuries;  a fmall  feratch, for  inftance,
 which does not penetrate to a greater depth than the fkin
 will fometimes induce them : and  when they happen  as
 the confequences of large wounds,  they do not commonly
 make their appearance until the fore feems nearly healed.
   Upon the firft fymptoms of thefe affeaions, the patient
 ffiould be immerfedin a bath of warm water as long as he can
 bear it, or what will pel haps be preferable, a bath of warm
 milk, or of water impregnated with oil; in fat broth, e. g.
    As the  warm bath  has often failed, fome praaition-
 ers have had recourfe to cold bathing;  but although this
 has proved frequently ufeful in tetanus, it is ftill doubtful
 whether it can be equally ferviceable in triimus, or locked
 jaw, the moft dangerous fpecies of thefe affeaions.
    Opium appears to be the moft ufeful internal  medicine,
 and it feems more  proper  to give it iij moderate dofes, as
                                                  above 
                         C   376   3

 above direaed, fo as to keep the fyftem conftantly under its
 effeas, than to exhibit it in  very large quantities at a time j
 as this laft method appears  to induce that ftate of the body
 which  it was meant to prevent, when the immediate effeas
 of the  medicine are gone off,  viz. a  great degree of irrita-
 bility.   ./Ether and mufk have been joined with opium, but
 they have not been  produaive of any important  benefit.
    A s  external applications, emollient animal oils  feem to
 be thofe that we may  expea  to be moft ferviceable; fuch
 as the  oil obtained  by boiling recent bones in water, and
 that afforded by fowls,  Mercurial  ointment feems chiefly
 ufeful  as an emollient.  Opium  moiftened with fpirit or
 water,  or in  the form of laudanum,  has been rubbed or ap-
 plied on the contraaed parts with benefit.*
   At the fame  time that thefe remedies  are employed, the
 patient ffiould be fupported by mild  nourifhment given by
 the mouth,  when this can  be done ; and  by  clyfters of
 ftrong  broths,  if the contraaion of the  jaws prevents the
 exhibition of food by  the  mouth.   In order to avoid this
                                                        laft

   " Dr. Ruth, profeflbr of the theory and practice  of medicine in the
college of Philadelphia,  in wounds  of  nervous  and tendinous parts,
as preventatives of thefe fpafmodic affections,  advifes dilatation,  and
drefling  with  fpirits  of turpentine,  or fome  other  ftimulant fub-
ftance ; and tells  us,  that where this plan has  been  properly fol-
lowed, fo as to excite an inflammation of the part, he has never feen
them produced.  The  Dojftor  believes  tetanus  to  be founded  in re-
laxation,  and  that in order to  remove the affection, it is  neceffary
not only  to reftore  the natural  vigour, but to  excite fomething like
inflammatory  diathefis  in the  fyftem.   Agreeably   to this idea, be-
fides the  cold  bath, oleum fuccini,  Barbadoes  tar, mercury, and the
other tonics and  ftimulants which  have heretofore  been recommend-
ed, he employs wine, bark,  and blifters,  together with the  topical
remedies   above mentioned. Electricity, as fuggefted by the Doclor
has lately been  ufed with fuccefs in New-England, as we learn from
a publication 01 the Medical Society at New-Haven.
  The happy effects of Dr. Rulh's  method, in feveral inftanees, feems
much  in  confirmation  of his opinion.  See Med. Obf.  and Inq. by
Benj. Rufh, M.  D. 
                      L*   377  3
laft circumftance, it will be advifable to remove a tooth  or
two, when the fymptoms of trifmus feem approaching;  or
if this is then negfeaed, to extraa them afterwards. .
  When a locked jaw is the confequence of a wound in the
extremities, if it does not yield to the remedies above re-
commended, it has been advifed to  amputate the member;
but experience has  (hewn this praaice  to be not only in-
effeaual, but in many inftanees to have increafed the dif-
eafe.


                  SECT.   III.

                Of PunBured Wounds.

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

                     SECT.   IV.

             Of Lacerated and Contufed Wounds.

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

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


                     SECT.   V.

                Of Wounds in the Veins.

   Wounds in the veins heal with much more  eafe,  and
 are attended by much lefs danger than wounds of the arte-
 ries, both  on account of their having lefs mufeular fub-
 ftance on them, and the lefs degree of force with which
 the blood is moved in  them, and becaufe the  obliteration
 even of the largeft external  veins, is of little confequence,
 the anaftomofing branches readily fupplying  the want of
 them.
   A longitudinal  wound  will generally  heal  if covered
 by a piece  of lint, or foft linen;  or at any rate if dried
 fponge or agaric is applied  to  it,  and fecured by mode-
 rate preffure.   But in tranfverfe cuts,  when  compreffion
 cannot be ufed, or is infufficient to reftrain  the hemor-
rhagy, the veffel ffiould be tied by the tenaculum or needle,
as direaed in the cafe of wounded arteries.
SECT. 
[  383   3
                   SECT.  VI.

              Of Wounds in the Lymphatics.


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


                   SECT.   VII.

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


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

             Of Wounds in the Ligaments.

  Our obfervations on this fubjea are chiefly applicable to
wounds of the capfular ligaments'; as the ligaments fitu-
ated far  from the furface  of the body are not much ex-
pofed to  external violence, and are  out  of the  reach of
applications.
  The ligaments  are rendered  extremely  fenfible by dif-
eafe, and wounds of them are  often  produaive of very
alarming confequences.   For  although, in fome inftanees,
lacerations,  by  the heads of  bones being pufhed through
them, and wounds of them, have readily healed ; yet in ge-
neral, the fymptoms which enfue from injuries to them are
very fevere and  hazardous.   Nothing  alarming appears
perhaps at firft, or for feveral days after the accident; but
at length the patient feels an uneafinefs and ftiffnefs of the
joint; thefe gradually increafe;  and the parts foon become
fwelled, tenfe, and inflamed.—The pain now grows excef-
five; a fenfe of tightnefs around the articulation comes on j
and the inflammation fpreads  all over the limb.
   If the wound in the ligament is large, the fynovia is often
immediately difcharged in confiderable quantities ; but the
fubfequent fwelling gradually flops the flow of it, and the
fore becomes dry and floughy.   In a few days, however,
extenfive fuppurations  begin  to form in the joint; and if
thefe are laid open, fynovia is  difcharged  with the  pus.
 This relieves the tenfion and pain ; but  a fucceffion of ab-
 fceffes is apt to take place, which at length materially injure
the patient's health.
   Thefe effeas almoft always  refult from  wounds in the
large joints, if they are not healed very quickly, and  al-
 moft without the formation of matter.   They feem  to be
                         3 C                    chiefly 
                     [   3^'  3
chiefly the  refult  of the  admiffion of  air to the internal
parts of the joints;  and on this account, in incifed wounds,
where it is  praaicable, as foon as extraneous ■ fubftances
that may have been carried into the cavity have been re-
moved, the fkin fliould be pulled over the wound, fo that
the cut in that and in the ligament may not correfpond, and
the divided parts of it conneaed  by adhefive plafter, or
futures.  As futures are too apt to excite  inflammation, the
plafters ffiould in general be preferred :  Thefe ffiould be
aided  by the application of  a flannel roller  around  the
joint.  The  patient fhould be in  bed when the dreffings
are applied, that he may  not  be obliged to move the limb
foon ; and the limb fhould be placed on a pillow in fuch
 a fituation, as wiii moft effeaually relax  the  integuments:
 If the wound is  on the anterior  part of the joint of the
 knee, for inftance, the leg muft be extended,  and if on the
 back part, it muft be bent.
    In  order  to prevent  inflammation, the patient ffiould
 be put on  a low  diet; laxatives fhould be ufed ;  moderate
 perfpiration fliould be excited; and he  fliould lefe fome
 blood.
    By this treatment I have known many of  thefe wounds
 to heal  very readily;  but  when  it has  been  neglect-
 ed, or is not effeaual, and inflammation has taken place,
 local blood-letting is the  mofl  beneficial  remedy.  In
 robuft habits, eighteen  or twenty  leeches  fhould be ap-
 plied as near to the  parts affeaed as  poffible; and  this
  ihould be daily repeated  as long as  the  continuance of the
  inflammation may  render it proper.   The wound may be
  dreffed with fome  fimple ointment;  but  one  of the beft ap-
  plications to the joint is  the  fleam of warm vinegar.   Fo-
  menting  the  part with  decoaion of white  poppy heads
  will be fometimes  very  ufeful in leffening the pain:  but in
  general it will be neceffary  to employ  large dofes of opi-
  ates.
                                                   Theft 
                      r  387.3
  Thefe  means properly employed will often remove the -'•
inflammation ;  but when they do not, it terminates in large
abfceffes, partly within the joint, partly in the fubftance of
the ligament, and in  part in  the cellular fubftance conti-
guous.  All that can be done then, is to promote the for-
mation of thefe when they have begun, and to difcharge
the matter as  foon as fuppuration is  completed, by open-
ings  in the moft dependant parts of  the tumors.  If not-
withftanding this  treatment, the difeafe continues until the
patient becomes heaic, and much debilitated, as any far-
ther attempt to fave the limb will be hazardous, amputa-
tion  fhould be had recourfe to.   See chapter on Amputa-
tion.

                   SECT.  IX.

                 Of Wounds in the Face.

   In injuries of this kind,  it is an  objea of importance to
 prevent deformity.   To effea this, the divided parts fhould
 be laid as exaaiy together as poffible; and if the wound
 i* in the direaion of the fibres of the injured part, or is fu-
 perficial in any direaion, they may  be kept in contaa  by
 adhefive plafters; but wheiever the wounded parts retraa
 much, it will  be neceffary to employ futures. The twifted
 future, particularly  for the lip, is  to be preferred to any
 other.   See feaion on  Hare-lip.
   When wounds penetrate the falivary duas, the treatment
 direaed in  chapter xxxiii.  muft be employed.
   In the fore-head, wounds are apt to be attended with trou-
 blefome hemorrhagy;  and when this cannot be reftrained
 by compreffion, or  the artery cannot be readily  tied, which
 will happen fometimes, if it lies in the bone, a  part of the
 external lamella,- or if neceffary of the whole fubftance of
                                                    the 
                      [   388   3
the bone, may be removed, in order to enable us to apply
a ligature to the veffel.

                    SECT.   X.

        Of Wounds in the Trachea and Oefophagus.

   These wounds are moft frequently the confequence of
an attempt to effea fuicide.
   When  the  trachea  is  divided longitudinally,  adhefive
plafters will be found  adequate to the retention of the fe-
parated parts in contaa.  They will alfo be fufficient in
flight tranfverfe wounds,  if aided by a proper  pofture of
the head:  Indeed  in all  wounds of  this kind, it is abfo-
lutely neceffiiry to the  cure, that the head be kept bent as
much as poffible down upon the breaft ; this will be moft
certainly effeaed by conneaing  a night-cap placed  on the
head, with a roller carried round the body.
   In all deep tranfverfe wounds of the trachea, it will be
neceffary to employ the interrupted future.   But as the li-
gatures, if carried into the trachea, are apt to excite cough-
ing, which has in fome  inftanees torn out  the flitches, I
have in  different inftanees fucceeded very well by paffing
them merely  through the integuments,  in  the following
manner;  a flat needle  with a flight curvature, and thread-
 ed with a  broad flat ligature, being inferted at the wound,
 and paffed flowly up for the fpace  of an inch as clofe as
 poffible  to the trachea, it is then to  be puffied  out  with
 the ligature;  and the other end  of the thread being armed
 with a needle, muft in like manner be paffed through the
 teguments  of the oppofite fide.  After a  fufficient num-
 ber of ligatures are paffed,  they  ffiould be fecured  with
 running knots, that they may be eafily untied if neceffary;
 adhefive plafters fhould then be  applied over the whole. 
                      [   3«9  1
  I have not yet had an opportunity of afcertaining whe-
ther this method will  fucceed,  when  the wind-pipe is en-
tirely  cut through ; but it is probable it  will.   If how-
ever, it is thought neceffary to ftitch the trachea itfelf, we
fliould carry the needle from within outwards,  for fear of
doing mifchief.  Three ligatures will generally be found
fufficient;  one anteriorly,  and the others at the fides.
  Wounds in  the cefophagus are to be  managed nearly in
the fame manner with thofe of the trachea, but they are
more dangerous ; as well on account of the greater difficulty
of reaching the part injured, from its  depth, and the lower
pait of it being apt to be drawn below the fternum ; as from
the difficulty  of conveying nourifliment to the ftomach
which they produce; and from the  vicinity of the recurrent
nerve?, the carotid arteries, and jugular veins.
   Our firft objea  in divifions  of the trachea and cefopha-
gus muft be to ftop the hemorrhagy ; not only on  account
of the lofs of  blood, but to obviate the cough and naufea,
which are very injurious,  and  which are the confequences
of the blood getting into the lungs and ftomach.  All the
divided arteries and veins ffiould therefore be fecured im-
mediately.  A wound of the carotid artery is ufually imme-
diately fatal:  if the furgeon is called in time he fhould how-
ever make a ligature on both ends of it.  Should the jugular
vein be partially divided, we may attempt to effea a cure by
compreffion, made either  by a common  bandage, or where
much  preffure is required, by a machine which does not
interrupt the refpiration ;  but if it be cut through,  it muft
be tied.
   As foon as  the bleeding is ftopped, the cefophagus muft
be ftitched in the manner  advifed for the  rc-union of the
trachea;  and  in order to effea this more readily,  the ex-
ternal wound  ffiould be enlarged without hefitation when
it is judged neceffary.
   Longitudinal wounds in the gullet might very probably
be cured merely by adhefive plafters.
                                             SECT. 
C  390  3
                  SECT.   XI.

              Of Wounds in the Thorax.

                 § I.  General Remarks.

  Wounds in the thorax are in general dangerous in pro-
portion to their  depth: Thofe which  affea  the  integu-
ments only,  if properly treated,  are feldom produaive of
any important confequences ;  but the fmalleft  wounds pe-
netrating the cavity of the cheft, will, in fome inftanees, be
attended by  the  moft alarming fymptoms, particularly if
the contained vifcera  are injured.
  The firft objea in  thefe  wounds is to afcertain whether
they have entered the thorax: This may be generally done;
by putting the patient into a proper pofition, and then care-
fully examining the wound by means of the fingers, or a
probe;  by afcertaining  the  form of the inftrument with
which the wound was infliaed, and  the length to which it
feemed to be pufhed; by liquids injeaed returning imme-
diately, or lodging in the wound; by air being difcharged
from:  the wound ; by an emphyfematous fwelling  of the
contiguous teguments ; by the quantity of blood difcharged
from  the wound; by the appearance  of the blood;  by
blood being difcharged from the mouth ;  and by the ftate
of the pulfe and refpiration.
   1. The patient  fhould always be placed as nearly as pof-
fible in the pofture he was when he received  the  wound,
during the examination ; for it muft be obvious, that in
feme poftures, from  the mobility of the mufcles and ribs,
a wound, in reality deep, may be made to appear very fu-
perficial.
   2. The depth of the wound may, in fome inftanees, be
afcertained  by the eye; but when  this cannot be done,
                                                   nor 
                     C   39*  3
nor the fingers employed to  difeover it, on  account  of
the opening being very fmall,  a bougie ffiould be employ-
ed : This gives lefs pain, and is lefs apt to do injury than a
metallic probe.  But the examination ffiould be very cauti-
oufly made, and foon defifted from, if we cannot afcertain
the extent of the injury  very readily ; becaufe the patient
may fuffer from the attempt, and the fymptoms which fol-
low will foon determine the matter.
   3. The  fize and  form  of the inftrument, the direaion
it appeared to take,  and the depth to which it was pufhed,
fhould always be afcertained  with as much exaanefs as
poffible, as  thefe circumftances  may undoubtedly affift us
in forming a judgment of the depth  of the wound.
   4. "When thefe means  do not  enable us to form an opi-
nion, the injeaion of fome mild liquid, as warm water, may
be  tried.  If this returns immediately,  the wound is pro-
bably not deep;  if it remain*  altogether, or in great part,
without producing any external fwelling, we cannot doubt
of its having penetrated the cheft.                >
   5. If air paffes out at  the wound during infpiratlon,
there will  be reafon to fufpea that the lungs are injured.
However, in cafes where there is no adhefion between  the
lungs and the pleura, this appearance  may be  produced
from  the admiffion of air, by the wound, into the cavity :
The patient fliould therefore be direaed to make feveral full
infpirations, in order to difcharge the air that may thus be
colfeaed; and at the end of each, the fkin fhould be drawn
over the wound to prevent  more from  getting  in: The
whole will thus foon be evacuated; and then if air ftill
rufhes out during infpiration,. we may conclude  with cer-
tainty that the lungs are wounded.
   6. Emphyfematous fweUings,  produced by  the air from
the lungs infinuating itfelf into the  cellular membrane, are
more apt to be the  confequence of punaured than  of ex-
tenfive wounds, and efpecially of thofe which run oblique-
                                                    ly 
                      t  392   3
ly.   It is to be obferved however, that emphyfema may al-
fo be produced from the admiffion of external air  by the
wound.
  7. When the quantity of blood difcharged is very con-
fiderable,  and particularly if it is not ftopped by compref-
fing the iutercoftal  artery, we may with  certainty  con-
clude that fome of the thoracic vifcera are wounded.  That
the  lungs  are injured may be inferred from the frothy and
very red appearance of  the blood ;  and particularly if the
patient difcharges blood by the mouth.
  Laftly,  When  wounds  do  not penetrate deeper  than
the  teguments, the pulfe and breathing are not at all af-
feaed at firft ; but when they enter  the  thorax, and parti-
cularly  if they affea the lungs, or  any other part of its
contents,  an immediate change in the ftate of the pulfe and
refpiration is produced.  The wound may,  however, pafs
to a confiderable depth,  if it is infliaed  where there is an
adhefion between the lungs and pleura, without producing
any extravafation, and  confequently without injuring the
ftate of the pulfe or breathing; but when either blood or
air gets into the cavity of the cheft, the breathing immedi-
ately becomes difficult, and  the puffe feeble,  oppreffed,
and intermitting.

  §  2. Of J Founds in the external Teguments of the Thorax.

  Wounds which  do  not  go  deeper than the cellular
membrane, heal as  readily in thefe parts as  in  any other
fituation ; but thofe that reach the iutercoftal mufcles, and
particularly punaured wounds of confiderable extent, are
very apt to penetrate the cavity  of the thorax at length,
if great attention is not paid to the timely evacuation of
the  matter formed.   When thefe kinds  of wounds  are not
very extenfive, the beft method of treatment is to lay  them
entirely open with a fcalpel  and direaor, and  then heal
                                                  them 
                      [   393  3
 them carefully from the bottom ; but when the punaure
 is of confiderable length, the cure by feton is to be prefer-
 red.  Some advife, inftead of a feton, to employ compref-
 fion ; but this cannot be ufed to a fufficient degree with-
 out impeding the refpiration ; and befides this bad effea,
 it would endanger an  infinuation of the matter produced
 into the cavity of the thorax.
   It is  particularly neceffary in wounds of this  kind  to
 avoid exercife, efpecially  of the  cheft; hence  coughing,
 laughing, and even talking,  fliould as much as poffible  be
 avoided.  The patient ffiould be kept on a low cooling re-
 gimen ; the bowels ffiould be gently opened; and, if necef-
 fary, bleeding fliould be employed.

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

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

              § 4. Of Wounds of the Lungs.

   Wounds  in the lungs require the lame general treat-
ment with thofe  which merely  penetrate the cavity of the
cheft ; but  as they are more hazardous, they demand a
more particular  attention.  The  danger of them arifes
from the hemorrhagy,  or a  fubfequent fuppuration in the
lungs.
   The hemorrhagy is mofl effeaually checked by copious
bleeding, fo  as  to induce fainting; by keeping the patient
in a cool apartment,  and  perfeaiy  at  reft;  by cooling
laxatives; and by a  low diet.   It is alfo of the greateft
confequence to keep the lungs as free from aaion as  pof-
fible : Hence coughing,  laughing, much  fpeaking,  and
even  the making  deep infpirations, fhould be  carefully
avoided.
  Notwithftanding all our  efforts, however,  the  patient
will fometimes die from  the hemorrhagy; or the extra-
vafation of blood will  obftrua  the breathing  materially;
or abfceffes  will be formed  in the fubftance of the lungs.
The latter circumftance only remains to be confidered^
                                            Colleaions 
                      [  395  3
   Colfeaions  of matter in the lungs may be difcharged
either by the mouth,  by the wound, or into the cavity of
the cheft.  We are in this place to pay attention only to
thofe cafes in  which the abfcefs formed  burfts into  the
wound, or at leaft is difcovered pointing towards it.   As
foon as this is  known by an oozing of pus, or by intro-
ducing the finger between the ribs, an opening fliould be
made into the abfcefs as in other cafes.  By doing this, we
avoid the hazard of immediate  death, which often happens
from the matter being difcharged  in great quantities into
the bronchise,  and at the fame time prevent the pus from
paffing into the cheft,  which might render another opera-
tion neceffary.  In cafes of this dangerous  kind, when the
ftoppage of a previous difcharge of matter has taken place,
and all the ufual fymptoms of a freffi colfeaion have come
on, I would  even advife  the  external wound to be  en-
larged  to the extent  of two or three inches,  in order  to
difeover the feat of the abfcefs, and when this is afcertain-
ed, to  make an opening into it,  by the careful introduc-
tion of a biftouri along the finger, at whatever depth it be
feated.   I have ufed this praaice in two inftanees;  and in
both of them was obliged to go nearly the length  of  my
finger into the fubftance of the lungs:  the patients were
inftantaneoufly relieved, and are now in good health.
   In the fubfequent treatment of thefe abfceffes, we muft
be careful that the fore heals from the bottom; and .this
will be moft effeaually accomplifhed  by the ufe of  a hol-
low oval tent.   See feaion on Punaured Wounds.
   When any part of  the lungs protrudes  from a  wound
in  the cheft, it fhould be immediately replaced ; but if this '
is negfeaed until a part of them becomes gangrenous,  this
fhould  be  cautioufly removed,  and the  reft replaced.   If
the incifion be confined to the mortified part,  no hemorr-
hagy, or other bad confequence will arife from it.
§. 5. 
C  396  3
§.  5.  Of Wounds of the Heart,  of the large Veffels conneBed
           with it, and of the  Thoracic DuB.

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

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

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


                   SECT.   XII.


               Of Wounds of the Abdomen..


§.1.0/* Wounds of the Teguments and Mufcles of the Ab-
                        domen.

   Wounds of this  kind  merit particular attention, on ac-
count of the danger there is  of their effeas  being commu-
nicated to the contiguous vifcera.
   It muft be  our firft objea  in all wounds in the region of
the abdomen, to determine whether or not  they penetrate
the cavity.  When their extent is not evident to the fight,
it may commonly be afcertained; by  a proper examination
with  the fingers or probe, after putting the patient into
the pofture in which  he received  the  wound; by  afcer-
taining the form and fize of  the inftrument, the depth to
which it  went,  and the direaion it appeared to  take;
by  the  quantity of blood difcharged; by the attending
fympfoms ; and by  the matter difcharged by the wound.
   When the  wound will admit the  finger, we may always
determine with  certainty the extent of it; but probes
ffiould not be depended on in thefe cafes, becaufe they
readily  pafs  among the parts,  in almoft  any direaion,
with a very  little force.   Injeaions  are of no fervice#to
determine this matter, becaufe they are fo very  apt to
fpread among the mufcles and cellular fubftance.
  The fize of the inftrument,  its direaion and the  appa-
                                                  rent 
                      [   399  3
rent depth to which it entered, fhould alfo be confidered,
and may affift us in our judgment.
  When the quantity of blood difcharged is very great, we
may conclude almoft with certainty, that fome of the large
internal veffels are injured, for there is no external artery
but the epigaftric that can afford much difcharge, and it
may be foon afcertained whether this is wounded.  It is to
be obferved however,  that even the largeft internal artery
may be cut, and ftill no external difcharge of blood take
place.  The internal hemorrhagy will, however,  foon be
evidenced ; by the patient becoming v/eak and faint; by a
weaknefs of pulfe, and cold fweats; and if the difcharge
does not foon ftop, by every other fymptom of approach-
ing death.
  A difcharge of faeces, of bile,  of the pancreatic juice,
and even of chyle, fometimes appear, and determine with
certainty that fome of  the abdominal contents are wound-
ed.   This is alfo afcertained,  if large quantities of  blood
are  thrown up  from the ftomach,  or difcharged by flool.
Urine  may be difcharged by a wound which does not pe-
netrate the cavity of the abdomen, becaufe the kidneys  and
ureters are fituated behind the peritonseum.
  When none of the fymptoms which we have defcribed
as indicative of  wounded vifcera appear, and the pain is
not in  violent degree,  we may conclude it very probable,
that the wound has not reached the cavity of  the belly.
  Our principal  view in that cafe,  as in fimilar wounds of
the thorax, is to prevent inflammation, and the lodgement
of matter, by bleeding, low diet, laxatives, reft, and a pro-
per attention to the wound,  as recommended in  the laft
featon.  It will  however, be neceffary to obferve, that ss
any weaknefs of a part of the abdominal parietes, will be
apt to  induce a protrufion of fome of the vifcera, it will be
proper, in order to prevent this, that the patient be kept as
much as poffible in a horizontal pofition,  and  when  he at-
                                                tempt. 
                      [   4°°   3
tempts to fit or walk, that the debilitated part be fupported
by a flannel bandage, paffed two or three times around the
body: And it  will be advifable to continue the ufe of
this  roller  for  a confiderable time after the  wound is
healed.

§ 2.   Of Wounds which penetrate  the Cavity of the Abdomen
              without injuring its Contents.

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

             § 4. Of Wounds of the Intefiines.

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

  * In the common method of performing this operation, both  fides
fii the gut are perforated at the fame time.  B. 
                     C   4°5  3
lightly, keep the wound clean, and truft to nature to effea
a cure.  The fseces  muft neceffarily for fome time be dif-
charged by  the fore, but  there are inftanees of the ends
of the inteftine  becoming firmly  united in a very little
time.
   Another method of treatment, is to infert a tube of thin
parchment or of paper, or rather  a piece of tallow  made
of the diameter of the inteftine, into the  upper end of it,
and afterwards to carry this, with the fubftance ufed with
it,  into the lower portion of the gut about an inch; and
then connea them with a  fine needle and thread all round,
either at the end of the inferior part only, or there, and
likewife juft above  the extremity  of the fuperior  portion
of the inteftine.  Tallow fhould be preferred to  parch-
 ment or paper, becaufe it  will foon melt and come off with
 the fseces.   The upper  part of the gut  may be  diftin-
 guifhed from  the  lower by the  periftaltic motion in  it
 being more remarkable,  and by the  difcharge of chyle
 inftead of feces from it.
   When only one end of a divided inteftine hangs-out at the
 wound, we are ufually advifed  to  connea  it to the perito-
 nseum  and other parts  contiguous  to the wound, and if
 this happens to be the fuperior portion, and not to be near
 to the  upper part of the  fmall guts, it is  faid the  patient
 may  live, under the inconvenience of an artificial anus ; but I
 am clearly of opinion that as the other end of the inteftine
 is probably  not  far from the wound, the incifion fhould
  always be enlarged fo as to admit of  the  introduaion  of
 the fingers to fearch for it;  for this will not  add much to
  the danger ; and fliould  the  protruded part be the lower
  end, the patient will inevitably  die in a fhort time, if the
  other is not found and connected in the manner above di-
  reaed.
    In cafe  of gangrene  of the  gut, whether complicated
                                                   with 
                       I   400  3
 with  a wound  or not, the treatment fliould be the fame.
 Vide  § 3.
    Wounds of the inteftines are  always  hazardous: but it
 does not appear, from experience,  that the  difference of
 the part injured makes any difference  in the degree of
 danger.

              §. 5. Of Wounds of the Stomach.

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

     § 6. Of Wounds of the Omentum and Mcfcntery.

  When any part  of the omentum is nearly  feparated
from the reft, or  has become cold,  fo as to induce a dan-
ger of gangrene,  it ffiould be immediately taken off;  but
when thefe circumftances  do not occur, it fhould be re-
turned as foon as poffible into*1 the  abdomen.   See chap.
on Herniae.
  In wounds of the mefentery, when any of its veffels are
divided they fhould be tied, in order to prevent the effufion
of blood or chyle into the cavity of the abdomen ; and the
ends of the ligatures fhould be left hanging out at the
wound,  that thefe may be removed as  foon as they fepa-
rate.

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

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

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

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

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

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

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

             §.  10.  Of Wounds of the Bladder.

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

    {.n. Of Wounds of the Uterus, and its appendages.

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


                  SECT.   XIII.

                  Of Poifoned Wounds.

  The flings of wafps, bees, and  other  infeas, of this
climate, although fometimes produaive of  a good  deal of
pain, feldom induce any other bad confequence.   The ap-
plication of vinegar or fpirit of wine immediately after the
injury,  often  prevents  the   inflammation which would
otherwife follow ;  but when  this  aaually comes on, cold
water feems the beft remedy.  For the fling of a feorpion,
as well  as of the wafp and other infeas in warm climates,
the fame remedies have fucceeded.
  The bite of a viper always merits great attention; for
although it does not appear that  the poifon is in  general
thrown out unlefs the animal  is much irritated, yet as this
cannot be  certainly  determined  immediately, we fhould
conftantly proceed upon the fuppofiticn  of  the wound
being poifoned.
  This  poifon  generally operates on the fyftem in the
courfe  of twelve or fourteen  hours.   The patient at  firft
complains of a violent burning pain in  the injured part;
this foon begins to fwell;  inflammation fucceeds, and  is
often  extended over the whole  body:  The patient be-
comes  languid  and faint,  and the pulfe low  and feeble;
he complains of giddinefs, naufea and vomiting; and of a
                                                 fixed 
                     [   4*2  3
fixed pain in the region of the heart:  The whole furface
of the body becomes yellow; and this as well as the yel-
lownefs of the urine which occurs,  is evidently the confe-
quence of the diffufion of bile; cold fweats, and convulfive
twitches come on;  and if  relief is  not obtained, death is
fpeedily the confequence.
  In order to prevent thefe fymptoms, the only certain me-
thod is,  either to cut out the injured part immediately,  or
to deftroy it with  the  aaual or potential cautery:  And
this may probably be done with good  effea while no bad
fymptom has come on ;  but the fooner  it is put in praaice,
the greater chance  will  there be of its proving effeaual.
Suaion, either by the mouth,  or  by inftruments, ffiould
never be trufted to.
   After  the operation,  a plentiful  fuppuration fhould  be
excited, either  by ftimulating ointments, or by emollient
poultices, according to  the ftate of the wound, with  re-
fpea to inflammation.
   When  the  poifon has entered the fyftem, the rubbing
the body  all over with  warm olive oil,  and giving about
an ounce of it every hour,  has been faid  to obviate its bad
effeas in  many inftanees.   But  the  efficacy of this remedy
is rendered very doubtful by  late obfervations;  and it
would feem that the fupporting a plentiful perfpiration is
more to  be depended on.  For this purpofe, eau de luce
has been particularly recommended;  but it is probable,
that the common form of  volatile alkali  would be equally
ufeful.   Theriaca,  and  many other remedies, have been
highly extolled, but none  of thefe  appear to merit  confi-
dence.
   With refpea to  the bites of mad animals, when their
effeas are extended to the  fyftem, fo as to produce hydro-
phobia, we cannot depend  on any remedy with which  we
are at  prefent acquainted for their removal.  As a preven-
tative of  thefe, the moft probable means is to remove the
injured part by cutting it out, or cjeftroying it, by means of
                                                    the 
                      L  413   3
the aaual or potential cautery, and exciting a plentiful fup-
puration  afterwards.  As the effeas  of the bite are  fel-
dom communicated to the fyftem  for feveral weeks,  and
fometimes not for fix  months, this treatment would pro-
bably fucceed,  if employed  at  any  period before thefe
come on.   The fore fhould afterwards be kept running for
a confiderable length of time.
   Sea-bathing and  friaions, with mercurial ointment, to-
gether with its  application to  the fore, have been  much
depended on by fome  as  preventatives.  When the  hy-
drophobia aaually makes its appearance, it will almoft al-
ways be fatal; the treatment proper  to be then direaed,
belongs to the province of medicine.
   When wounds are poifoned by the matter of difeafes, as
fometimes happens to furgeons  in  dreffing cancerous  and
venereal  ulcers, the moft effeaual remedy is, to cut out or
deftroy the part.  This muft alfo be the beft praaice when
fores are infeaed with vegetable poifons.  With refpea
to metallic poifons,  they feem only hurtful by irritating or
corroding the edges of fores;  and require no  peculiarity
of treatment.

                  SECT.   XIV.

                 Of Gun-fhot  Wounds.

   As gun-fhot wounds exhibit the fame appearances, ex-
cept that they are ufually in more violent degree, and re-
quire the fame  general  treatment with contufed wounds
from other caufes,* it  is not neceffary here to  enter  very
particularly into the confideration of them.
   Our firft objea in thefe cafes fhould be to prevent in-
flammation ; for from the fupervention of this, gangrene, or
                                              extenfive
* See Se&ion on Contufed Wounds. 
                       C   4^4  3
 extenfive fuppurations, which are the confequences moft
 to be dreaded, almoft always originate.   Hence, above all
 other remedies, blood-letting fhould be freely employed.
    The very beneficial effeas of bleeding in  general, but
 more particularly of  the abftraaion of blood from the in-
 jured parts  themfelves,* in wounds of this  kind  is very
 clearly evidenced by this faa,  that  fome of the moft re-
 markable cures have occurred among thofe patients who
 after an engagement, are left fome time upon the field; by
 which means they always lofe a great quantity of blood.
   With  refpea  to  the extraaion of  extraneous fub-
 ftances, which is next to be attended to, the fame general
 direaions are to be  obferved as in  the cafe of  punctured
 wounds.
   When a ball cannot readily be extraaed by the wound,
 or by a counter opening, it  fhould  be fuffered to remain,
 unlefs it is lodged within a bone, when it fhould  always be
 removed, if  this  can be done without danger to the pa-
 tient ; becaufe in  fuch a fituation it is produaive generally
 of great inflammation, fwelling,  and pain, of all the conti-
 guous parts.   In taking out  balls, or other fubftances, we
 fhould  be  very cautious in the introduaion of forceps
 and other inftruments.   Where they can be feen, forceps
 may be ufed; but unlefs this be the cafe,  it will be gene-
 rally better to effea their removal  by making  a counter
 opening, fo as to admit of their  being laid hold  of by the
 fingers.
  When  the wound is  of little extent,  inftead of this
 praaice, whether the ball is lodged or no, if it can be done
 fafely, it will be better to lay the wound entirely open; by
 this the ball is more eafily extraaed,  and the cure will be
expedited.  The  dreffings ffiould be fome emollient oint-
ment fpread on lint, and over this a poultice of bread and
milk.   To thefe applications  the lead ointments may  fome-
                                                 times
* See Section on Contufed Wounds. 
                      C  415   3
times be fubftituted with advantage. An opiate ffiould then
be given,  and the patient  laid to reft in an eafy  relaxed
pofture.
  The general treatment afterwards coincides very exaa-
ly with that formerly recommended  in  wounds attended
with  contufion: Suppuration fhould be promoted, and
the matter which forms, difcharged  by a proper  pofition
of the patient, and by opening every  colfeaion  which ap-
pears ; while  at the  fame time the patient's  ftrength is
kept up by tonics and a nutritious diet.
  When a long continued  and exceffive difcharge affords
room for  fuppofing that fome extraneous body, or pieces
of bone may ftUl remain in the fore, a careful examination
ffiould be made, and they  ffiould be  removed.  When
none of thefe can be difcovered, as fome fubftance,  fuch
as cloth, may ftill be there, though it cannot be felt,  if a
feton can be ufed, it fhould be immediately introduced; and
often after a confiderable length of time, the drawing of
the cord has brought out fuch fubftances,  and a cure in
confequence has been foon effeaed.
   Opium  is particularly ferviceable  to abate pain and ir-
ritation in every ftage of thefe complaints, and fhould be
given liberally.
   Hemorrhagies are fometimes apt to  take  place upon
 the feparation of the floughs which are  produced in gun-
 fhot wounds ;  and  as they are often preceded by heat and
 throbbing pain in the parts,  they  may frequently be pre-
 vented by copious bleeding, particularly from the contigu-
 ous parts by leeches; but when the bleeding aaually comes
 on, if the veffels are of  any confiderable fize, they muft be
 tied in the ufual way.   When there is any danger of con-
 fiderable  hemorrhagy in thefe cafes,  the patient fhould al-
 ways be provided with a tourniquet, that he may reftrain
 the  difcharge until  affiftance can be procured.
   ocarification of gun-fhot wounds, and even dilatation of
                                                  thera 
                          [  4i<5  3

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

  * The  following  facts  reflecting  gun-fhot wounds are inferted in
the  Medical  Journal for  1790.   They are communicated by  a Dr.
Jackfon, and tend to fhew, that the practice of dilating gun-fhot wounds
in the firft inftance  fo  generally recommended  hitherto, except  where
it is abfolutely neceffary for the removal of pieces of bone,  or extraneous
fubftances, inftead of expediting their cure,  often  tends to retard it by the
additional pain and inflammation it generally excites.
  In  1779,   a  number  of  militia-men  were  wounded  in  Georgia,
where  they  could receive no  furgical afliftance.  Their wounds were
merely bound up  with  rags; and they appeared  to heal much more
readily than  thofe in fimilar circumftances that were treated  by fur-
geons in  the ufual mode.   After another engagement, a part of the
wounded  were conveyed to  hofpitals; fome remained  in  the  woods
without   any medical  aid.   The  latter, /the  circumftances  of the
wounds being alike3 healed with  nearly twice  the rapidity with which
the others did.  Irr 1781, after the  battle of  the  Cowpens, in South-
Carolina,  thofe who received furgical afliftance, neither  got  well fo
foon, nor  with fo little trouble as thofe  who  cured themfelves.  The
whole were lodged in country huts.
  Dr.  Jackfon further tells  us, that  in the warm climates of 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  fpirituous liquors, and more particularly from
pouring cold  water on the wounded limbs.              >
   From  the  Doctor's obfervation  it  would alfo feem  to appear, that
reft, in  flefh wounds,  is not  only  unneceflary, 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 horfebuch: while they were in motion  the progrefs 10 healing was
rapid ; when they halted for  a few days,  this was retarded; and when
they ftopped  altogether,  it  was in fome degree  retrograde.   The ktter
circumftance  was probably  owing to the  more free accefs to  fpirituous
liquors, which was then obtained. 
                      C  417   3
cers from this caufe, compreffion fhould be employed as in
other fimilar cafes.
  With refpea to the treatment of  gangrene from gun-
fhot wounds, and to the propriety  of amputation in them
from that and  other caufes,  we muft refer to the feaion
on mortification, and chapter on amputation.
CHAP.   XL.

     Of Burns,
    BURNS vary in appearance, according to their degree
    of  violence, and to the manner in which  they  are
 produced.   Thofe which  do not deftroy the cuticle, and
 which merely irritate the fkin, operate like cantharides, by
 exciting an increafed aaion in the exhaling veffels of  the
 part, by which  vefications  are formed, in extent and num-
 ber proportioned to the violence of the caufe : but when
 the fkin or fubjacent parts are  deftroyed,  no veficles  are
 produced; a black  gangrenous flough  is firft obferved,
 and when this feparates, an  ulcer is  left of a depth pro-
 portioned to the extent of the burnt part.
   The pain in burns is generally confiderable ;  but it is in
 common greater where the fkin has  been merely  irritated,
 than when  it  has  been entirely  deftroyed.  The irrita-
 tion and pain are indeed in fome cafes of extenfive burns,
 fo violent as to induce a very  high inflammation and fever ;
tnd fuch a degree of torpor fometimes comes on,  that it at
                         3 G                       laft 
                      i  418  ]
laft ends in death.   This fatal termination is,  in fome in-
ftanees, induced by an extenfive mortification taking place
foon after the accident.
 '  In the treatment of burns,  our firft objea is to procure
eafe as fpeedily as  poffible.   Where  the  fkin is  not de-
ftroyed this can be accompliflied by immerfing the  part
in cold water,  or fuddenly plunging it into boiling water,
or any other fluid, nearly of the fame heat.   Emollients
fometimes procure immediate relief; but in general, aftrin-
gents are more beneficial, fuch as brandy or other ardent
fpirits.   In  thefe the parts  may be immerfed; or when
this  cannot be done, they  may  be  covered with  linen
foaked in them.  Thefe applications give a momentary in-
creafe of pain at firft; but this is foon fucceeded by a very
agreeable toothing fenfation.   Strong lead water, a ftrong
folution of alum, or  common ink, are  alfo  very effeaual
remedies.  None of thefe applications feem chiefly ufeful
by preventing vefications, which they  do when  early em-
ployed,  becaufe they are more effeaual in  abating  pain
after  thefe are formed.   Whatever is made ufe of ffiould
be continued until the pain goes off.
   Together  with  the external applications, opium fhould
be liberally taken  internally, according to the degree of
pain and irritation.   Befides removing thefe, it feems to
be the beft  remedy for that drowfinefs which often oc-
curs.
   I  am of  opinion, that the vefications which occur in
burns, fhould not  be opened until the pain has gone  off;
becaufe the adrrliffion of air always gives an increafe of this;
but as foon as the  irritation induced has fubfided, they may
be opened with advantage ;   as the lodgment of the ferum
upon the fkin may  probably  render it tender,  and perhaps
even  produce ulcerations.  In order to prevent any bad ef-
feas from the admiffion of  air, fmall punaures fliould be
made in preference to incifions.   A liniment  cf wax, oil,
                                                   and 
                       r  4*9  3
and faccharum  faturni is the eafieft  application after the
difcharge of the ferum.
  When the inflammatory  fymptoms run high, bleeding,
laxativesj  and other  remedies fuited to inflammation in
general  become  neceffary;  and the ulcerations which
fucceed  muft be treated  in the ufual way.   See Chapter
on Ulcers.
  When burns occafion  a lofs of  fubftance, it will perhaps
be better to expofe them to the  air  for a day or two, as
the flighteft covering produces pain, and to apply either a
liniment compofed of equal parts of lime  water and lin-
feed oil, Goulard's cerate, the unguentum nutritum, or
weak lead  water.   The firft  is generally to be preferred.
As  foon as  the pain and irritation have thus been remov-
ed,  the fore is to be dreffed as in  other cafes.
  In burns from the explofion of gun-powder, fome of
the grains of the powder are apt to be forced into the flrih.
If thefe are not  removed they will increafe the  irritation,
and perhaps produce permanent  marks.   They may moft
readily be  removed by  a needle  or fome other fmall in-
ftrument; if thefe do not take them all away, an emollient
poultice will complete their removal; this indeed is the
beft application in injuries of this  kind, for a few day?, not
only for this purpofe, but  to prevent fubfequent inflam-
mation.   There  are fome parts,  fuch as the fingers,  toe„,
nofirils, and  palpebral,  which will  be apt to adhere toge-
ther when  burnt,  if attention is  not given to prevent it.
This will be effectually done  by  the interpofition of  fome
parts of the dreffings.
  Ulcers from  burns are very apt to  become fungous:
when this  is obferved,  the fungus  is to be removed by
leaving off the  ufe of emollients,  and employing gentle
aftringents, and compreffion; and if thefe do not fucceed,
by the ufe of cauftics.
                                            CHAP. 
C  420  ]
CHAP.    XLL

    Of  Tumors.
                    SECT.   I.

                 Of Tumors in general.

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


                   SECT.   II.

           Of Acute or  Inflammatory  Tumors.

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

                  §i.O/* Eryfipelas.

  Eryfipelas is a variety of  external inflammation diftin-
guifhed from  phlegmon, (See chap. i. fea. i.) by the co-
lour of the inflamed  part not being of fo bright a red,
but having a more dark copper-like appearance ; and by the
fwelling being not very evident in any particular place, but
rather  diffufed, and ending as  it were imperceptibly, upon
the furrounding parts.
   Eryfipelas feldom penetrates deeper than the fkin;  and
any effufion with which  it is  attended, is commonly thin
and acrid, and not often convertible into pus. As the ulce-
rations which  this effufion fometimes produces are always
difficult to heal, it fliould be our firft objea to prevent it
from taking place.  The fuppofed rifk attending this prac-
tice, and of attempting the difcuffion of eryfipelatous affec-
tions,  appears from experience to  be totally  founded in
prejudice.
   The moft common applications in the firft ftage of eryfi-
pelas, and perhaps the beft, are fine flour, ftarch, and hair-
powder.   Thefe  commonly  give confiderable  relief;  but
I believe they effea this rather by foothing that uneafy fen-
fation which ufually accompanies eryfipelas, and leffening
the increafed aaion of the veffels which occafions the effu-
fion, than by abforbing the matter when poured out. Unc-
tuous  and moift  applications  of every kind are  generally
fuppofed to be injurious ; neverthelefs, in fome cafes which
were not benefited by the remedies abovementioned, I have
experienced immediate relief from expofure of  the part af-
feaed  to the air, and wetting it now  and then with a weak
folution of faccharum faturni,  without any fubfequent dis-
advantage being occafioned by the praaice.
                                            Experience 
                       C  422   3
   Experience alfo eftablifhes the utility of bleeding accord-
 ing to the circumftances  of the  cafe.  Topical blood-let-
 ting, however,  being  apt to be produaive of troublefome
 fores, muft not be ufed.   Gentle  laxatives, and mild fudo-
 rifics, ffiould alfo be employed, and a cooling regimen ob-
 ferved.
   By thefe means, moft eryfipelatous affeaions may be dif-
 cuffed ;  when  however,  they terminate in effufion to any
 confiderable degree, an opening fhould be made in the moft
 depending part of the colfeaion, and fome of the faturnine
 ointments ufed as a dreffing to the fore.

             §  2. Of Inflammation of the Ear.

   Inflammation feated  in the  membrane of the meatus
 auditorius, is commonly very painful, from the part affeaed
 not readily yielding to the increafed quantity of  fluid pro-
 pelled into it.
   The treatment muft be determined by the ftage  of the
 complaint.   If  the inflammation has continued fo long
 as  to give  reafon  for  fuppofing  it will  terminate in
 fuppuration,  the ear  fhould be  frequently  bathed with
 warm emollient fleams,  and warm poultices  fliould be
 applied over it.  But in the beginning of the affeaiop., wc
 fhould generally try to prevent fuppuration ;  becaufe the
 difcharge of matter which enfues  will be  apt  to continue
 a confiderable  time, and  perhaps  terminate in  deafnefs.
 Refolution will be moft effeaually promoted by the appli-
 cation of a blifter behind the ear;  and by dropping a
little  laudanum, or fpirit of lavender,  mixed with  oil,
into the  paffage, we  may generally  abate  the  pain and
irritation, and confequently promote  the  refolution very
 much.
 . We will often be unable  to  prevent the formation of
matter;  and when this  has taken place, we fliould  endea-
                                                 vovw 
                      C   423   3
vour to affift its evacuation  by bathing the ear in warm
water, or  by injeaing warm water  into it.  Thefe will
often ftop  the difcharge ; but when they do not, lime wa-
ter, or a weak folution of facch. faturni, may be employed,
and will feldom fail, if the  foft parts  alone are affeaed.
When the bones are difeafed, which will be known by the
foetor, and black or brown colour of the difcharge, all that
fhould be  done, is to keep the paffage clear by injeaions.

                    §•3-  Of Angina.

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

            §. 4. Of Inflammation of the Liver.

   When notwithftending the  employment of the reme-
dies of internal inflammation in general, and of mercury,
which has been found fo particularly beneficial in hepatitis,
the difeafe terminates in fuppuration, the aid of furgery of-
ten becomes neceffary.
   When  the abfcefs is feated on the convex part of the li-
ver, and  is of confiderable fize, it  will readily be difco-
vered by  the touch.  But  when  this is  not the cafe, a
continuance of the pain  in the right  flioulder and neck;
an appearance  of fwelling in the  region of the liver; an
                                            cede.matcu3 
                      C  424  3
cedematous affeaion of the integuments in this part;  but
particularly  the occurrence  of frequent lhivering fits,
will  pretty certainly denote  that  fuppuration  has  taken
place.
  Abfceffes of the liver have been known to burft through
the diaphragm, fo as to  be emptied into the thorax: in
fome few cafes, the matter has been carried into the  duo-
denum, by the  duaus  communis,  choledochus;  and
fometimes by the great arch of the colon adhering to the
liver, a communication has been  formed between them,
by which  the pus has been  evacuated ; but for the moft
part,  when  it  is  not  difcharged  by  an external  open-
ing,  it burfts  into the cavity of the abdomen.  In or-
der to prevent fuch a fatal termination, as foon as we have
reafon to fuppofe that matter is colfeaed, even if it ffiould
not probably have yet been converted into pus,  an incifion
ffiould be  made with a fcalpel through the teguments, in
the moft  depending  part of the tumor, and  on reaching
the abfcefs, it  may either be opened with the  fcalpel or
with a lancet; but a trocar would perhaps be  preferable
to either,  as by means of that we have it in our power to
evacuate the  matter gradually, which is a point of confe-
quence in  all  large colfeaions.  With a view  to prevent
this opening from clofing before the cyft collapfes  fuffi-u
ciently to hinder a farther colfeaion of matter, it fliould bel
afterwards fomewhat enlarged.  A pledgit of lint, dipped
in oil, or fpread  with  fome  emollient ointment, ffiould
then be infinuated between the edges of the wound, fo as
to prevent them from uniting until the ulcer heals from the
bottom; a procefs which will be much haftened by  the
ufe of  compreffion, applied by means  of  a roller carried
round the body.
  Ulcers in the liver heal fooner, and with lefs trouble
than  in any other part of the body.   But when they do
not readily fill up, which  will very feldom  be the cafe,
                                                    it 
                      C   425  3
it will  be proper  to introduce a canula, in order to pre-
ferve a free difcharge of the matter which  forms.
  A free ufe of bark, and a nutritious regimen will always
be very neceffary and  ufeful  in the  fuppuratory ftage of
this difeafe.
  Praaitioners are  generally of opinion,  that unlefs the
colfeaion of  matter takes place in the convex part of the
liver,  no attempt to difcharge  it by  an external opening
can with propriety  be  made;  but wherever it is fituated
a vent fhould certainly  be procured for the matter;  for if
it is not evacuated  externally,  it will  moft probably  be
emptied into  the abdomen, and  inevitably occafion death.
When  the  matter is poured  into the abdomen or  cheft,
the only chance of faving the patient will be by drawing it
off by the operation of the paracentefis, as foon as poffible.

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

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

         §  6.  Of the  Inflammation  of  the Tefles.

   Inflammation  of  the tefles may be induced by cold,
external  violence, or by any other caufe of inflammation
in general: but  it is moft frequently occafioned  by violent
gonorrhoea.  In  this cafe it  appears to be produced by an
extenfion of the  inflammation from the  urethra along the
vafa  deferentia;  and is  commonly  the confequence of  a
ftoppage of the running from the ufe of irritating injeaions,
or other caufes.   This circumftance  is  very generally at-
tended by an increafe of  inflammation; to abate which
nothing  is more  effeaual than  a return of the  difcharge.
This is  the moft probable  manner of accounting for the
 relief which a return of the running, in  fuch inftanees,
 gives to  the tefles.
                                                  This 
                      [  427   3
  This  difeafe  rarely  terminates in  fuppuration.   The
moft effeaual remedy  for its  removal is blood-letting;
and particularly by means of leeches applied to the part
affeaed.  The  fwelling fhould  afterwards  be kept con-
ftantly wet with a folution of facchar. faturni;  the fcro-
tum and teftes fhould be  fufpended;  the  bowels  fliould
be kept  moderately open ; a low  diet fhonld be ordered ;
and the  patient fhould be confined  to a horizontal pof-
ture.  If the cafe is venereal, it will be abfolutely  necef-
fary to  employ mercury  ; and  when the  difeafe  is the
confequence of a  fudden  ftoppage of  the difcharge,  we
ffiould endeavour to  produce a return of this by bathing
the penis in  warm water;  by injeaing warm oil into the
urethra ; or by the ufe of bougies.
   If  the  fwelling  fhould  fuppurate,  which  will very
rarely happen, an opening  ffiould be made in  the moft
depending part of the  colfeaion, and the fore afterwards
dreffed in the manner advifed in other cafes of abfcefs.

                §. 7. Of  Venereal Buboes.

   Swellings in  the lymphatic glands  from the abforp-
tion of the venereal virus, are termed Venereal Buboes.
They may appear  in any gland feated  between a venereal
fore  and  the heart; but  they  are  moft frequent  in  the
groin, in confequence of  chancres on the penis. In fome
inftanees they  occur from the matter  of a gonorrhoea;
and in fome others they arife without any  previous ulce-
ration or difcharge from the penis, the matter appearing to
be abforbed without  any erofion of the fkin.
   As it is now very  well  known, that the quantity of ve-
nereal matter  is increafed by  buboes  being brought  to
fuppuration, and  that  the  fores produced  by  them  are
often very difficult to heal, few doubt of the propriety of
 endeavouring to remove them by  refolution. 
                      [   428   ]
  In order to effea this,  the  patient fhould be put upon
an antiphlogiftic regimen; his bowels fhould be kept open
by purgatives; leeches ffiould  be  applied  to  the  gland;
and it ffiould be kept conftantly  wet with a ftrong folution
of faccharum  faturni.   And along  with  thefe, mercury
ffiould be employed in as large quantities as may  appear
neceffary ;  and it will be moft  beneficial if made to pafs
through the difeafed gland, by rubbing the  mercurial oint-
ment  into  fome part where  it may be  abforbed by  the
lymphatics that  go to the part  affeaed; thus  in inguinal
buboes, it fhould be applied on the leg or thigh.
  By  thefe  remedies,  buboes, if taken  in  time, may
generally be difcuffed; but  when  this cannot be done,
either  from the difeafe having fubfifted  too long, or from
a  complication  with fcrophula, fcurvy,  eryfipelas,  or
phlegmon,  the ufe of the mercury ffiould  be intermitted
for fome time, until^by a change of diet  and other circum-
ftances, we  may give a chance of making a fecond trial of
it more fuccefsful.
  When a  bubo  feems  proceeding  to  fuppuration,  this
ffiould be promoted by the ufe of  fomentations and poul-
tices as in other cafes;  and as foon as matter is formed it
fhould be difcharged.   There have been various methods
of effeaing this.  Some advife a  fmall punaure with a
lancet; others an incifion, the whole length of the fwelling:
fome again, recommend it to be atcomplifhed by the applica-
tion of a cauftic ; while others are advocates for leaving the
bubo  to  form  an opening cf itfelf.  Either of thefe  me-
thods may fucceed in fimple  venereal buboes, provided a
fufficient quantity of mercury is given ;  and each of them
may occafionally be followed by fores difficult  to heal.
  The local treatment here  ffiould be nearly fimilar to
that advifed in colfeaions  of matter in other  parts.  In
general,  an  opening  fhould  be  made  merely fufficient for
giving vent  to the matter.   In  very  large buboes indeed,
                                                   the 
                      [   429   3
the teguments are often rendered fo lax, and their texture
is  fo much deftroyed, that it will be  advifable to remove
part of them by cauftic -? but in common it will be fufficient
to make an opening from the middle of the tumor, where
it  ufually points, to the  mofl depending  pare.   In fmall
buboes a mere punaure will often anfwer the purpofe; or
they may even be allowed to burft;  but this ffiould never
be depended on  in  large colfeaions.  When ti. integu-
ments  remain  unufually firm, I have fometimes  fucceeded
by the introduaion of a fmall  cord.   And laftly, from
having obferved  buboes  which difcharged the matter con-
tained  in them by a number of fmall openings to heal very
readily in general, I have in feveral inftanees imitated the
procefs by making feveral fmall punaures with a lancet,
and with very good effeas.  I attribute the fuccefs in fuch
inftanees to  the exclufion of the external air, which  muft
 be the confequence of this method.
   The patient ffiould continue the ufe of mercury conftant-
 ly, for if he intermits it, the fore will not heal fo readily.
 The ulcer, however, often proves tedious,  even  where we
 are convinced that a fufficient quantity of mercury has been
 given  to eradicate the fyphilitic virus.  The edges become
 hard and thin ;  the matter difcharged, thin, acrid, and foe-
 tid; and the fore gradually becomes more extenfive; or if
 it heals in fome parts it breaks out in others, giving a honey-
 comb appearance to all the under part of the abdomen,
 and upper parts  of  the thigh.   The patient fuffers a great
 deal of pain ; becomes heaical; lofes his reft and appetite;
 and becomes  very much emaciated.
    In  fuch cafes, we muft  firft be certain that  the patient
 has taken a fufficiency of mercury, and that no  finufes are
 left in which matter can be lodged.   In thefe inftanees, I
 have known cicuta very beneficial: I have feen ulcers healed
 by mixing the juice of the frefli herb with a common poul-
  tice  which had refilled all the common applications; when
                                                  given 
                       C  430  3
 given  internally, the frefli juice has been  more effeaual
 than any other form of it.  The  belladonna and hyofcya-
 mus, have never appeared to  me  to produce any  material
 advantage.   And neither farfaparilla  nor guaiacum have
 been ufeful; but mezereon has alone evidently cured fome
 patients  in whom all  the ufual  remedies  had failed.  A
 drachm  and an half may be  boiled with 5'ij of liquorice-
 root, in three pints of  water to a quart; and that quantity
 of  the decoaion drank daily.
   But the moft effeaual courfe that I have tried  is, the
 application  of  cauftic  all rou'id  the edges and hardened
 parts of the fore,  at the fame time that opium in confider-
 able quantity is  given internally.   On thofe days in which
 the cauftic is not applied, red precipitate fhould be ufed to
 the fores, either fprinkled over them, or applied in an oint-
 ment.   The  firft few applications of thefe commonly give
 pain, but this foon fubfides, and the difcharge feldom fails
 to alter  from a thin fliarp fanies  to a thick well digefted
 pus.
   Opium alone  has  been lately given  in very large quan-
 tities for the cure of the venereal difeafe;—to the extent of
 half a  drachm or more three times a day.   I have feen no
 proof of its curing any venereal affeaion;  but I have feen
 feveral inftanees of fuch fores  as we have above defcribed,
 completely cured by the ufe of it.  It  does not however
 appear that it is more  effeaual when  given in very large
 quantities, than when fo much only is exhibited as is necef-
 fary to alleviate or remove the  pain.  Its utility feems to me
 to depend entirely on its narcotic or anodyne powers; by
thefe it removes that ftate of  irritability with which thefe
fores are affeaed,  and  thus deftroys the difpofition of the
veffels  to form that kind of matter, which by its acrimony
feems to  perpetuate itfelf; and this being done, and  other
circumftances being  favourable, nature alone will feldom
fail in accomplifliing  a cure.
                                                   § 8. 
C  431   3
              §  8.   Of Lumbar Abfceffes.

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

           §. 9. Of the Paronychia or Whitlow.

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

                  § io. Of Chilblains.

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

            §n.   Of Sprains and Contufions.

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

             Of Chronic or Indolent Tumors.*

               §.  I. Of Encyfled Tumors.

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

  * Although chronic  tumors, as has already been mentioned, are not
primarily and neceffarily attended by inflammation, yet it is to  be ob-
ferved, that any variety cf them, by the diftention they give the Jkia;
may eventually produce it.  13. 
                       C  440   3
 parts of them that have  been  abforbed.   And we think
 it probable, that  the  atheromatous and melicerous tumors
 are originally formed by a depofition of ferum,  with per-
 haps a confiderable proportion of coagulable lymph ; and
 that their degrees of confiftence will depend upon the quan-
 tity of lymph contained in  them, their duration, and parti-
 cularly upon their having been inflamed, and the degree of
 the inflammation.
   In general, an experienced praaitioner will be able to
 diftinguiffi the nature of thefejpmors before they are open-
 ed : thus the fteatoma is ufually of a firm confiftence, loofe,
 and rolls under the fkin more readily than the others; and
 its furface is apt to be unequal: the atheroma is foft and
 compreffible, but no  fluauation  is obferved in it; and in
 the meliceris, the  fluauation of a fluid  is in general very
 diftinaiy perceived.  But, in fome inftanees, from the cir-
 cumftances  mentioned in the laft paragraph but one, it
 muft be evident, that we  may be fometimes miftaken in
 our judgment  of the nature of  thefe tumors; and  their
 combination will contribute likewife to  deceive us.   The
 fteatoma is  very  rarely joined with either of the  others;
 but the atheroma and meliceris  are more frequently com-
 bined.  It is to be obferved  alfo, that  the firft fpecies is
 rarely found  where fat is  not ufually depofited in a ftate
 of  health;  thus  I  have never met with it on the head,
 where the other  fpecies frequeutly occur.  None of them
 are often feated on the abdomen  ;  probably  owing to  the
 parietes of the abdomen being foft and yielding, and con-
 fequently  not fo  liable to ill effeas from preffure, as the
 foft  parts  which lie  contiguous to bone.
  Thefe tumors  appear fmall at  firft, and increafe in fize
 very  flowly.   They  are  of  very different fliapes  and
 fizes: On  the  head  they  are   commonly round  and
 fmooth,. and feldom grow  larger  than an  egg, probably
from the teguments  not being  fo capable  of much diftenti-
                                                   on 
                      C  441   3
on as in other parts, where they have arrived fometimes to
fuch an enormous fize as to weigh forty pounds.
  They are never painful at firft ; and the (kin for  a con-
fiderable  time retains its natural colour.   But when they
become large, the veins of the fkin, as well as thofe of the
fac,  become  large  and varicofe ; and the prominent part
of the fwelling acquires a clear fhining red colour.   Even
now the tumor is not painful, unlefs it be injured by  ex-
ternal violence,  which will very readily  excite inflamma-
tion in the  fkin.  It then becomes tender  and painful, and
foon burfts, if not prevented by an artificial opening.
  From the fame caufe  which influences  the fize of thefe
affeaions, their progrefs feems rendered more or lefs rapid :
hence they fooner terminate on the head than in any other
fituation.
  The firmnefs with which they are attached to the conti-
guous parts feems to depend on  the parts  with  which they
are covered,  and their having been inflamed or not, and
the degree to  which the inflammation, when they have been
feized with it, has extended.   They are fometimes quite
loofe and moveable, particularly while they continue fmall;
and  at other  times  they are firmly fixed,  and in fome in-
ftanees from  the beginning.
  It was formerly the praaice to attempt the difcuffion of
encyfled tumors  by the application of mercurial ointment,
mercurial and gum plafters, and a variety of other things;
but experience has now proved, that nothing but a chirur-
gical operation can be depended on for their removal.
  The meliceris ffiould be treated as a common abfcefs. If
fmall, its contents may be difcharged by an incifion with a
lancet, and then it may be dreffed in the ordinary way un-
til it fills up or adheres from  the bottom.   But if it is large,
to prevent  the admiffion of air  which would be injurious,
a feton fhould be  employed in the manner direaed in the
                       3 K                      feaion 
                      C  442  3
feaion on fuppuration.  This  is the moft effeaual mode
of treatment I have ever feen employed.
   When the contents of the tumor are too firm to be dif-
charged in this manner, it becomes neceffary either to emp-
ty the cyft by an  extenfive incifion,  or to diffea it, with
its contents,  entirely out.  If the  bag adheres very firmly
to the contiguous parts,  it will be better to lay it entirely
open, and only take away thofe parts of it which are loofe.
By this, we may effeaually remove its contents ; and the
cure may be afterwards accomplifhed with equal certainty,
by preferving the wound open  until it heals from the  bot-
tom, or by drawing  the edges together, and trufting to
moderate preffure, and  the common effeas of inflamma-
tion for  producing a re-union.  It is ufually thought ne-
ceffary  to remove the whole of the cyft;  but experience
difproves this.   When it is to  be done,  however,  it will
contribute much to the facility of the operation, to make a
longitudinal  incifion  through  the  tumor, and  remove its
contents before we begin to diffea it out.  After its remo-
val the teguments ffiould be laid together, and fecured by
 adhefive plafters  or  futures,  and  an equable  compreffion
then made over them,  in order to produce a  cure  by the
firft intention.*
   If any arteries  of confiderable fize are cut in the opera-
 tion, they ffiould  be immediately fecured by means of the
 tenaculum ; and the ligatures  ffiould be left hanging out at
 the wound.   The  trifling impediment  that this will give
 to the cure,  will  be much more  than compenfated by the
 fecurity from hemorrhagy,  that is derived from the prac-
                   1                                 tice;

   * Though many of the  encyfted tumors, which Mr. Bell defcribes as
 fuccefsfuUy treated by a fimple dilatation, or the ufe of the feton, may
have been radically cured, yet inftanees enough occur of their filling again,
 where the whole or greater part of the fac  has been left, to put young
furgeons on their  guard in tumors of any confiderable  fize, where the
fafeft way is to remove the fac entirely. 
                      L  443   3
tice; for ffiould the bleeding be even very trifling, it might
confiderably retard the cure.   The  ligatures  may gene-
rally be taken away readily  and with fafety at the fecond
or third dreffing.
   In common  cafes it is not neceffary to remove any por-
tion of the fkin, for although it may appear too extenfive
at firft,  it ufually contraas fo much in a little time as mere-
ly to cover the parts beneath.  But in large tumors,  where
the fkin is in very large quantity, or where it has become
exceffively thin, or ulcerated, it will be proper to remove a
part of it.  This will be beft  effeaed by  two femilunar
incifions, including as much of the  fkin as ought to  be
taken away, and then diffeaing it off with the cyft.   The
fubfequent treatment is to be the fame as if no part of it
was removed.  In  fuch cafes we are advifed  by fome to
employ cauftic for  the removal of the fkin; this fhould,
 however, never be  done except the patient will not admit
 the ufe  of the fcalpel.

                  § 2.  Of Ganglions.

   By the term ganglion, we mean an indolent, moveable
 tumor,  formed upon the tendons in different parts of  the
 body, but moft frequently on the back part of the hand,
 and joint of the wrift.
   Thefe fweUings  are  diftinguifhed  from the encyfled by
 their elafticity.   They feldom become large, or painful;
 and for the moft part the fkin above them retains its natu-
 ral afpea.  If laid  open, they are found to contain a tough,
 vifcid,  tranfparent  fluid, refembling  the white of an egg.
   Ganglia may be  generally removed,  if early attended to,
 either by moderate and frequent friaion,  or by compref-
 fing them by means of thin plates of lead, or any other
 ductile metal.   We  ffiould be careful not  to ufe thefe
                                               remedies 
                      C  444   3
 remedies in fuch a manner as to inflame the parts;  as
 troublefome fores may be the confequence.
   If  thefe means fail,  and the tumors  become trouble-
 fome  by impeding the  motion of  the joint or in any other
 way,  but not otherwife, they may be removed, either by a
 mere  incifion into them, or if they do not adhere firmly to
 the tendons, by cutting  them entirely out, in the manner ad-
 vifed  in the cafe of encyfled tumors.  The fore thus pro-
 duced is to be kept open until it  heals from  the bottom;
 which will commonly happen without much difficulty.

        $ 3.   Of Swellings of the Burfa  Mucofie.

   The burfa; mucofse  are fmall membranous bags, feated
 upon, or contiguous to all the larger joints,  containing a
 thin,  tranfparent and gelatinous fluid, which feems intend-
 ed to lubricate the parts upon which  the tendons  move
 that pafs over  the joints.  A preternatural  accumulation
 of this  fluid, produced more particularly by fprains, con-
 tulion, and rheumatifm, conftitutes the difeafe we are now
 to treat of.
   This fpecies  of fwelling  is feldom attended with much
 pain; it yields to preffure, but is much more elaftic than a
 tumor from pus ; at firft it is always confined to one part
 of a joint, but in fome cafes it at length  extends almoft
 round it; and the fkin always retains its  colour, unlefs it
 becomes inflamed.  When rheumatifm produces the  fwel-
 ling,  its contents are  commonly very like  the  fynovia;
 but when it is the confequence of fprains, together  with
 this fluid there  is ufually a confiderable quantity of pretty
firm concretions.  In fome  few inftanees,  however,  thefe
concretions are  foft.—Their  confiftency may generally be
afcertained  by the touch.
  When thefe tumors are the effeas of rheumatifm,  they
 may perhaps  be always difperfed  in time,  by keeping the
                                                parts 
                          C   445   3
parts warm with flannel; by frequent friaions ; by fre-
quently pumping warm water upon them ; or by the appli-
cation of blifters.   But if they  originate from  fprains, al-
though they may long remain ftationary, they can feldom
be difeuffed.   An operation then  becomes  neceffary  for
their removal whenever they become troublefome.
  This confifts in forming an opening to difcharge the con-
tents of the tumor,  and preferving the wound open until
it fills  with  granulations  from below.*  When the fac
cannot be opened through its whole length, on account of
the  contiguity  of tendons,  it will be  beft to lay it open
at each end, and after preffing out the contents,  to pafs a
fmall feton through it.
  Thefe operations  ffiould  be done with a great deal  of
care;  and when the feton is ufed, it  fliould be introduced
with a blunt probe,  and  fuffered to  remain no longer than
till  a flight degree of inflammation is  excited,  on  account
of the contiguity of the joint; and when  it is withdrawn,
the cure is to  be  completed by gentle  preffure with a
roller.f
                                                         A

  *  A great deal of  difficulty  has  fometimes  happened in confequence
of a dilatation or  removal of thefe  tumors,  particularly where they
do not heal  by  the firft intention.  The  moft fuccefsful mode  of
opening  them is  by drawing up the external ikin, then  puncturing
the  tumor with a lancet, and when the  fluid is entirely difcharged
fuffering the  external to  pafs beyond the internal  orifice. A com-
prefs, dipped in lead water, is then to  be applied, and retained  with a
moderately tight bandage, enjoining perfect  reft and quiet for feveral
days.
  f  Dr. A. Monro, of Edinburgh,  has lately publilhed a valuable work
on the fubject of the bur/a mucof#,  or as he is difpofed to term them, the
ve/ias unguinof<z;  and as it is very probable, that collections in thefe have
often been miftaken for affections of a  very different nature,  it may per-
haps be ufeful to add fome obfervations from this trcatife, to what Mx.
Bell has faid on the fubject.
  The Doctor tell* us,  that  he has difcovered one hundred and forty
                                                       burfce 
                         C   440"   ]

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

      §. 4.  Of ColleBions within the Capfular Ligaments.


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

burfse mucofae in all;  thirty-three  in each of the fuperior, and thirty-
feven in each of the inferior  extremities.  Many  of  theiu are placed
on the inner fides of the tendons, between thefe  and the  bones.  Many
others  cover not only the inner,  but  the outer fide  of the tendons, or
are interpofed  between the tendons and  external parts, as well as be-
tween thofe and the  bones.   Some are  fituated between  the  tendons
and the external parts  only, or chiefly; fome between contiguous ten-
dons, or  between the tendons  and the  ligaments of the joints.  A
few are  interpofed where  the  proceffes of  bones play upon  the liga-
ments, or  where one  bone plays upon another.  Some  of the burfa
communicate with  each  other"; fome  with the cavities  of  the joints*
In the latter cafe  the communication feems fometimes  to  be formed
by long friction; and  particularly occurs in the  joints of the  fhoulder
and knee ; and efpecially juft below the inferior part of the firft, and
immediately  above  the fuperior   part  of the laft.   This connection
does not feem to be productive of bad effects, even when it is not formed
originally.
  The Dr. has proved very  fatisfa6torily the  fimilarity between the
ftructure  of thef? facs  and that of the  capfular hgaments, as well froro
an examination of their ftructure  and  ufes  in a healthy  ftate, as from
the  effects  of difeafes upon  them.   With  refpect  to  the latter,  he
finds that  they are  rendered  exquifitely  fenfible  by  inflammation;
and  that either depofitions of fluid matters, or the  formation of fo-
lid fubftances  'of different kinds, occur not  only  from rheumatifm,
                                                             but 
                       C   447   3
the whole of it;  and  by  being generally  painful:  and
from abfceffes in the cellular membrane, by the matter in
the latter  being  fuperficial,  and  extending  beyond  the
boundaries of the capfular ligaments.
   The nature of  the fluid colfeaed in thefe fweUings  may
be afcertained by the circumftances preceding them,  and
by the  fymptoms  with   which  they  are  accompanied.
Thus when a violent  bruife of  a joint is immediately  fuc-
ceeded  by a  large  effufion within the capfular ligament,
it will probably be  found to confift chiefly of blood.   Of
 this I have feen a remarkable cafe. ' When inflammation of
 a joint terminates in effufion, it will probably confift  of a
 ferous matter, with fome tendency to purulency.   And if
 the tumor fucceeds  to  rheumatic affeaions,  there  will
 be reafon to fuppofe,  that it  is  produced  entirely from
 ferum.
   The fpecies  of  this affeaion which is confequent to
 rheumatifm,  may generally be difcuffed by the remedies of
 fimilar colfeaions in the burfie mucofae ; or, if thefe fail, by
 the ufe of a laced flocking or roller,  applied  as tight as
 can be borne.   But if this ffiould be  unfuccefsful, the pa-
 tient had better fubmit  to the  inconveniency occafioned
 by the difeafe,  than run the rifk of the  inflammation fo
 apt to  follow an opening made in the  ligament for its dif-
 charge.  When, however,  any matter is  colfeaed in the
 joint, which may do mifchief by remaining in it, or which
                                                      can-
  but alfo from gout and fcrophula.  In  one inftance, the Dr. has found
  not lefs than fifty  cartilaginous bodies within the burfa fituated be-
  hind the tendon of the flexor pollicis longus.  He is of opinion, from
  fome fads, that all folid fubftances in thefe facs confift in cxcrefcen-
  cies from them, and that they are always nourilhed by peduncles con-
  necting them to the facs; and hence, if thefe peduncles are any how
  broken, the excrefcencies never afterwards increafe in fize.
    Dr. Monro  feems to be of opinion, that when an operation becomes
  neceffary in thefe  affeaions, it fliould be either fimilar to that advifed
  in § 4. or to  the one recommended in §5. of this fection,  according
  as the fubftance to be removed is fluid or folid. 
                       C  448  3
 cannot be readily abforbed, an opening ffiould be made to
 remove it.   This is the cafe when blood, or matter form-
 ed by inflammation, is effufed.
   As the danger which  attends  this operation, feems to
 depend greatly  on  the admiffion of air  into  the  joint;
 it ffiould be conduaed in fuch a manner as to prevent this
 as much as poffible.  For  which purpofe a trocar fhould
 be employed, and the fkin being previoufly drawn tightly
 to the  upper part  of the  fwelling  as  foon as all  the
 fluid is evacuated, it ffiould be returned to its place.  The
 wound ffiould then  be  clofed by adhefive plafter, and  the
 joint moderately compreffed by a roller, or a laced  flock-
 ing:  And  in order to guard more  effeaually againft  in-
 flammation,  if the patient is plethoric, he ffiould be bled;
 and  a ftria antiphlogiftic regimen ffiould be obferved.*

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

   These affeaions  induce a great deal of pain in fome  in-
 ftanees,  and always  impede more or  lefs the motion of the
joint.   In  fome cafes,  the offending fubftances are  fmall
 and  loofe, and as firm  as cartilage; and in  others, they
 are of a foft membranous nature, fprouting from an eroded
 furface  of one of the bones forming the joint, or from the
inner furface of  the  capfular ligament.
   In  the latter, which remain fixed nearly in the fame fitu-
 ation, the pain is conftant,  but it is feldom fevere; but in
the former, it is only felt in particular fituations, perhaps
when the conneaing membrane gets between the ends of
the bones, but  it is then  often  exceffively  violent, and'
fometimes fo excruciating as to produce fainting.
  Thefe fubftances can only be removed by an operation; but
as this,  altho' fometimes followed by  no bad confequences,
                                                  has
  * All thefe remedies will fail, if the patient does not obferve the mofl
pcrfe-i reft and quiet. 
                     I  449   3
has in many inftanees produced fuch a violent inflamma-
tion in the ligament and adjacent parts, and other bad ef-
feas, as to render the  amputation of the limb  ultimately
neceffary, it fliould be advifed with great caution.   From a
good deal of  experience, I am of opinion, that where
the concretions appear,  on examination,  to  be perfeaiy
loofe and detached,  if the pain which  they excite is very
fevere, rather than fubmit to  a long continuance of it,  we
fhould venture to take them  out; but whenever there is
reafon to fuppofe they are conneaed with any  part of the
joint, the patient ffiould be advifed to fuffer the pain, which
may in general be rendered  moderate by avoiding exer-
cife, rather than  to  run  the rifk attending the extirpation
of them.  If, indeed, the  pain,  notwithftanding every means
employed to mitigate it, becomes infupportable, amputation
of the limb ffiould be recommended, as lefs hazardous than
the excifion of the tumor when attached to the capfular li-
gaments.
   The operation for the  removal of loofe  bodies may thus
be performed : If the joint of  the knee or  ankle  is affeaed,
the patient  ffiould be laid upon a table or bed; but if  the
joints of the arm are to be opened, he may  fit; and the limb
fhould be  firmly  fecured in the moft convenient pofture.
The furgeon ffiould then endeavour to fix the fubftance with
the left hand towards the upper part of the joint, that the
fynovia may not efeape by the wound to be made, the fkin
being previoufly  drawn  up as much as poffible from the
part to be divided.  An  incifion is now to be made with a
fcalpel through the teguments and ligament, direaiy upon
the fubftance,  of fuch a  fize as will admit of its being ea-
fily taken out; which may be done either with  the finger,
or with a blunt probe paffed beneath it. If it is found Co be
conneaed by fmall filaments either to the ligaments or  car-
tilages of the joint, thefe ffiould be cautioufly divided with
a  probe-pointed  biftouri, or  probe-pointed fciffars, after
drawing out  the fubftance itfelf as  far  as poffible wij£
                          3  L                    ■&»»&
                                                   •  _i 
                     t  450  J"
fmall forceps, or a fmall hook, when the texture of it will
admit of the ufe of this.  If there are feveral concretions,
they ffiould, if poffible, be all removed at the fame opening;
but where this is not praaicable, on account of their lying
on oppofite fides of the joints, after allowing the firft inci-
fion to heal, a fecond opening muft  be made.
  After the concretion is removed, the fkin fliould be im-
mediately drawn over the wound in the ligament,  and the
incifion of  the fkin fliould  be clofed by adhefive plafter.
The limb fhould be kept as much  as poffible in one pof-
ture until  the wound  is healed; and a ftria  antiphlogif-
tic regimen ffiould be obferved.  For the farther treatment
of fuch cafes, we muft refer to  the feaion on wounds of
the ligaments.

             §. 6. Of Anafarca or  Oedema.

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

               §  7.   Of the Spina  Bifida.

  The  term fpina bifida is applied  to thofe foft fmall fwel-
lings which fometimes appear on  the fpine, in new-born
children, moft frequently between the two laft lumbar ver-
tebrae.   A fluauation is perceived  in them,  and the fluid
they contain can in  part be preffed  into an opening which
occurs  between the fpinous  proceffes of  the two vertebrae
in which they are feated.   This opening is found to depend
either on a deficiency of bone, or merely on a feparation of
the proceffes.   The difeafe  always proceeds from ferum
depofited within the coverings of the fpinal marrow;  and
is for the moft part local; though  in a few inftanees it has
been found conneaed with hydrocephalus.
  In fome cafes children  have lived under this difeafe for
two or three years;  but in general they die in the fpace of
a few months.  All the afliftance that art  has hitherto been
able to  afford,  has  been to fupport the tumor by a band-
age ; and  thus to retard  its increafe.  Opening it has al-
ways been followed by death,  either immediately, or with-
in a few hours.
  Proceeding upon the fuppofition, that  the want of the
neceffary fupport to the membranes of the fpinal marrow
                                                  from
  * We  are commonly advifed, as one means of leffening the chance
of gangrene in thefe cafes, not to make the punctures in the mojl de-
pending part of the limb. 
                      C  452   3
from the deficiency of bone, may be the  caufe of this dif-
eafe, and not  the  effeB,  as has  been generally fuppofed,
might not fome advantage be derived from a ligature ap-
plied round the bafe of the tumor fo as not only to remove
it, but to draw the bottom of the cyft together, and thus
give a  proper  fupport to the  parts beneath ?   And  as an
additional help,  as foon as the  tumor drops off,  a firm
fluffed pad might be applied over the opening in the  verte-
bras, and fecured by a proper bandage.
   A fwelling  of the fame  appearance, in fimilar circum-
ftances, and probably of the fame nature with fpina bifida,
appears  fometimes on  the head; death  is alfo  the  confe-
quence of opening it.

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

                §. o. Of the Bronchocele.

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

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

                  §  n.   Of Warts.

  Warts appear to be produced from the cutis and cuti-
cle :  If left to themfelves they generally wafte away, or fall
off;  and it is only when they  grow fo large, or in fuch fitu-
ations as  to become very troublefome, that they fliould be
                                             removed 
                      C   4?7  3
removed by art.   When they  have a narrow bafe, they
may be taken off by a ligature; but if their befe be broad,
it will be neceffary to employ cauftics, or the fcaloeU for**
their removal.  The former .we ufually preferred.    ^^^.
   As cauftics, the lapis infernalis, the lunar cauftic, a folu-
tion of quickfilver in an  equal quantity of  nitrous acid,
pulvi  fabinae,  oleum tartar! per deiiquium,  or fpirits of
* artffiorn, will either of them be effeaual; but as moft of
them are apt to excite too much inflanimation, they  ffiould
be ufed very cautioufly.  The beft remedy I have tried,  is
 rubbirig them with fal ammoniac crud. moiftened,  two or
 three  times a  day.   It excites neither  inflammation" nor
 pain,  and feldom fails,  except  in the very hard fpecies.
    Warts frequently appear upon the penis in the venereal
 difeafe, and often continue long after the virus is eradicated.
 Mercury in fuch cafes is of no benefit; and if the parts are
 kept clean, or when they produce matter, waffied with fome
 gentle aftringent,  fuch  as  lime water, they will generally
 difappear of themfelves after lbme time.  When, however,
 it  is  determined to remove them, either  the fcalpel  or cau-
 ftic may be employed. After the uie of the former, in order
 the more effeaually to  pwevent their return,  the parts may
 be touched with lunar  cauftic.
    It  muft  be  particulaljobferved, that  no application
 fhould  be  repeated which produces  inflammation;  and
 when the fcalpel is  ufed,  we ffiould rather take off fome
 of the found fkin, than run the rifk of injuring the wart
 itfelf, or of leaving any part of it; for, from want of at-
 tention to thefe circumftances, a great deal of mifchief may
 be produced : a neceffity for the amputation of a limb has
  been the confequence of a negfea of the laft.
3M
§ 12. 
C  458   3
                § 12.  Of Fleffiy Excrefcencies.

;;  ,^ ^ No 'part of the body is exempted from the formation of
    flefhy excrefcencies.  They arc of various fizes ; are gene-
    rally fomewhat more red than the healthy fkin; have about
    the fame degree of firmnefs that the lips poffefs; and are
    feldom painful.   They have the appearance of mufcle,1
    when laid open;  but,  on  a clofe examination, appear to
    confift  chiefly of cellular  fubftance,  in which are a great
  *  number of blood-veffels, very much ramified.
      Efcharotics are feldom effeaual in removing thefe tu-
    mors, and are very apt to irritate and excite inflammation
    in  them.  We ffiould, therefore, never truft to remedies
    of this kind,  and always make ufe of the fcalpel, or a li-
    gature.  The latter ffiould be employed when the excref-
    cence is^pendulous by a fmall neck: and the fcalpel, when
    the bafe of the tumor is broad.   After carefully diffeceting
    out the tumor,  the fkin ffiould be brought to cover the
    wound, and the cure conduaed as in other  cafes.

                      § 13.   Of Corns.

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

^14.   Of a fimple  Exofiofis, Venereal  Nodes,  pnd Spina
                        Ventofa.

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

     Of Fra&ures.
                   SECT.   I.

                 General Obfervations.

A FRACTURE may be defined a folution of conti-
      nuity in a bone, produced by external violence.
  This  affeaion  receives various  appellations,  derived
either from its  direaion, or  from  the  fymptoms  with
which it is accompanied:  Thus it may be tranfverfe, ob-
lique, longitudinal,  or fimple,  if there  is a  mere divi-
fion of a bone;  or compound,  when  there is an external
wound of  the  foft  parts, leading  to  the  injured  bone.
                                                 This 
                      C  465   3
This is the only  diftinaion of fraaures, that is  ufeful or
neceffary.
  The exiftence of a fraaure is in general eafily difcovered
by manual examination.  It  is only in fimple fraaures that
a difficulty can occur ;  and more particularly, if the conti-
guous parts have become  inflamed  and painful.   In fuch
cafes we muft be direaed in our opinion,  by a careful at-
tention to the age and habit  of the patient;  the fite of the
fuppofed fraaure ;  the fituation of  the limb when the in-
jury was received ; and to the attending fymptoms.
   1. Thus the bones are much more brittle in old age than
early in life, and  confequently  are  much more readily
broken.   In  infancy the bones bend very much  inftead of
breaking, upon the application of a moderate force.
   Different difeafes alfo induce a brittlenefs of the bones.
 Lues venerea has this effea  to fuch a degree, that the bones
 are fometimes broken by the aaion of the  mufcles alone.
 Scurvy has the fame effea  ; and likewife what  is termed
 mollities offium.
   2. Bones are  more apt  to be fraaured in thofe parts of
 them which  are firmeft, and confequently leaft  flexible as
 in the middle ; and, thofe which are thickly covered with
 foft  parts are much lefs liable to  be  broken, than thofe
 which lie  near the furface; thus the  thigh-bone is not fo
 frequently fraaured as the  bones of the arm and leg.
   3. With refpea to the fituation of the  part  injured, it
 is evident, that a bone lying on an unequal furface may rea-
 dily be fraaured by  an inconfiderable  force, while, if
 equally fupported, it will bear a very heavy weight with-
 out injury.
   And laftly, The concomitant fymptoms are to be attend-
 ed to. Thofe of fraaure are generally, pain, fwelling, and
 tenfion  of the contiguous  parts ; a  more or lefs crooked
 and diftorted ftate of the limb ; a crackling or grating noife
                         3N                         on 
                     [  466  ]
on the parts being handled ; and lofs of power to a certain
extent in the injured limb.
  Pain in fraaures chiefly arifes from the ends of the dif-
placed portions of bone irritating the foft parts, and from
the injury to the latter by the accident.   It is feldom very
great; but in fome cafes it is fo violent, as to be produaive
of fpafmodic affeaions of the mufcles of the limb, great
degree of  inflammation  and fever,  fubfultus  tendinum,
general convulfions, and delirium ; and if the caufe is not
foon removed,  death very  commonly fucceeds.  This  is
ufually preceded by gangrene of the  parts contiguous to
the fraaure; but in fome inftanees it  feems  to be occa-
fioned merely by  the  violence of  the fever.  It muft be
obvious,  that  thefe fymptoms  will be moft readily induc-
ed by an  oblique fraaure.
   A grating noife on handling the part,  and diflortion and
lofs of power in the limb, almoft always attend fraaures:
When they are longitudinal,  which feldom happens, they
cannot indeed occur.
   But befides thefe leading fymptoms  which immediately
take place, there is often a great degree of ecchymofis pro-
duced by the ends of the bone wounding an artery or vein;
and a wound of the teguments in compound fraaures.
   The moft important confequences of fraaures  are, ftiff-
nefs and  immobility of the  injured  limb; diflortion of the
parts chiefly affeaed, either from a fu.lnefs or thicknefs re-
maining  in  the contiguous mufcles or ligaments ; an exu-
berancy  of  callus ;  a  contraaed flate  of the contiguous
joints ; or a marafmus  or wafting  of  the limb itfelf.  All
thefe will be confidered hereafter.
   In judging of the event of a fraaure, we are to confider,
 i. The age  and habit of body of the patient; thus bones
unite much fooner in youth,  and  particularly  in infancy,
than in old age.   Indeed it  has been faid, that it is often
impoffible  to  procure the re-union  of bones in advanced
age ; but I never have met with an inftance of  this kind.
                                                 Lues 
                      C  467   3
Lues venerea and  fcurvy, are often confiderable obftacles
to the cure of fraaures, and  fometimes  prevent it en-
tirely.
   2. The fituation  and part of a bone that is injured.
Thus we know that fraaures of the fmall bones of the
arms, hands, legs,  and feet,  and of the cheft,  heal much
more readily than thofe of the humerus and thigh-bone.
The difficulty in the thigh often arifes chiefly from our not
being able to retain the ends of the bone in contaa.   And
 when any of the larger bones are fraaured near to their
 extremities, we find the danger to be greater, and the pro-
 fpea of a complete cure much lefs than when they are
 broken near the middle; for here the fhortnefs of one end of
 the bone makes the retention difficult; and the fymptoms
 which enfue are  apt to be fevere, on account of the conti-
 guity of the capfular ligaments, and tendons,  which may
 be more or lefs injured.  And as the ends of the bones are
 more fpongy, they do not unite equably and foon ; and col-
 feaions of matter and exfoliations  are very  apt to take
 place.   Thefe fraaures are frequently produaive of ftiff
 joints,  pains and fweUings,  which often  continue  a long
  time, and  fometimes  during life.  Such troublefome cir-
  cumftances feem to originate more from the nature of the
  injury  in moft cafes, than from the  mifmanagement either
  of the patient or furgeon.
    3. The degree of the fymptoms :  for the prognofis muft
  obvioufly be^favourable, or otherwife, according  as thefe
  are mild or violent.
    4. The concomitant circumftances: thus the fraaure
  may be accompanied by contufion,  laceration, or  difloca-
  tion of the contiguous parts;  according to  the degree of
  which  will be the danger.
     5  The kind  of fraaure.  It  very  commonly  happens
  that fimple fraaures are unattended by bad fymptoms, and
  are foon cured; but in general,  although there are many
                                               inftanees 
                      C   468  3
inftanees to the contrary, the fmalleft external wound
communicating with the  injury in the bone, will be  pro-
duaive of danger.
  The indications in the cure of fraaures  are,  1. To re-
place the deranged parts of the bone.   2.  To retain them
in this  fituation as long as neceffary.   And, 3. To obviate
fymptoms which occur during the cure.
  When bones  are fraaured  direaiy  acrofs,  they  are
either not moved out of their natural fituation, or the de-
placement is fo inconfiderable that they are eafily reduced;
but when the  fraaure is oblique, the ends of the broken
bones  are apt to pafs each other  fo as to produce much
deformity and  pain.
  Previous to  attempting the reduaion of a fraaure,  the
limb or part ffiould be put into fuch a pofition that all its
mufcles will be as much as poffible relaxed.  When this is
done, the furgeon  may commonly replace the bones him-
felf; but when afliftance is neceffary, the upper part of. the
limb ffiould be held firm, while the  lower part is gently
extended, ftill keeping the mufcles relaxed  as much as. pof-
fible.  The difplaced portions of bone ffiould then be gen-
tly reduced, fo as to render the limb as fimilar as poffible to
the  found one, in order to afcertain which, they ffiould be
brought as near together as convenient.
  The bones are to be retained in their proper fituation by
compreffes and bandages, and by keeping the limb in an
eafy pofture, and as much fixed as poffible.  The appli-
cations ffiould be made with  no  greater degree of  tight-
nefs  than is abfolutely neceffary for retaining the bones in
their fituation.
  The time required for rendering the re-union of bones
fufficiently firm,  muft depend upon  the  age  and habit
of body, the violence of the injury, attention of the pati-
ent,  and other circumftances; but in  general, in healthy
middle aged people,  and in  favourable circumftances,  a
                                              fraaure 
                      [  469   3
fraaure of the femur, or bones  of the leg will get well in
two months ; an os humeri, or bone of the fore-arm in fix
weeks;  and any of the  bones of the  hands, fingers, feet
and toes, in three weeks.   In infancy and childhood, frac-
tures heal more quickly ;  and  in old age  they require a
much longer time.
  In  fimple fraaures, to which  thefe obfervations more
particularly  apply, the inflammation  and other attending
fymptoms ufually  fubfide in a few days, if the bones are
kept in their places ; but in fome cafes they conftantly in-
creafe from their firft appearance.  To obviate thefe, it will
be always advifable to make ufe of fome aftringent appli-
cation, fuch as a folution of facchar. faturni, offal ammon.
cr. or fp. mind, and  when this has not the defired effea,
to employ topical bleeding, by leeches.  Thefe have a moft
happy effea in removing the inflammation, and thus pre-
venting  greater part of the bad confequences of fraaures,
formerly enumerated.  If the fwelling and pain in a frac-
tured limb have continued long, the moft effeaual relief is
obtained from friaions with emollient oils, and from warm
bathing, particularly in the medicinal  waters.
  To check an overgrowth of callus, the application of
aftringents, and of moderate compreffion with a thin plate
of lead, retained by a roller, are ufeful;  but thefe will not
be always fuccefsful.
  The  ends of fraaured bones  fometimes remain loofe
and unconneaed long after they fliould, according to the
common progrefs of cures in fuch cafes, have been united ;
this  may originate : from  fome conftitutional difeafe, as
lues venerea, fcurvy or rickets ; from the ends of the bones
not having been conftantly in contaa; from  a portion of
a mufcle, a  tendon, or ligament falling in between the di-
vided parts ; and  from the bone being broken in different
parts, and in  fmall pieces.  This circumftance has alfo
                                                  been 
                      C   470  3
been obferved to happen more  peculiarly  during preg-
nancy.
  When the want of re-union depends on fome  general
difeafe, the proper  remedy of fuch difeafe becomes necef-
fary to a cure ; and indeed it will be always prudent to at-
tend to this when the fraaure is firft produced.
  If the defea of union arifes from the bones not being in
contaa, it will accompllfli a cure, in recent cafes, to appofe
them : But when the offeous  matter  which ffiould have
joined the bones has  become fmooth and hard, as in long
continued  inftanees of this kind,  and they move freely on
each other without giving pain,  it will anfwer no  good
purpofe to bring them together ; and  the only mode of
relief will  be to lay their ends  bare by an incifion, and by
removing  a fmall  portion  of each,  with a  trepan or
a common faw, reduce them to the ftate of a fimple frac-
ture.  This operation fliould always be advifed  when the
injury affeas the large bones  of  the  extremities; but in
the bones of the  fingers and toes,  of the metacarpus and
metatarfus, the clavicles and ribs, where no great difad-
vantage is  experienced from it,  it will be advifable rather
to fubmit to the inconveniency.
  This  operation is  painful and tedious ;  as the  incifion
muft be pretty  extenfive, and  muft be made with  great
caution in  order to  avoid  the large blood-veffels ; but it is
perfeaiy fafe, and has  been  followed with  complete fuc-
cefs, nature fupplying fully the place of the removed  por-
tion of bone.
  In  compound fraaures, all detached portions of the
bone  that  will  not  probably  unite with the larger  parts
fhould be  immediately removed ;  but  in fimple fraaures
where the fkin remains entire, as we cannot judge of the
nature of the injury  to the  bone  with  any  exaanefs, we
muft always proceed  as  formerly direaed,  at firft; and
when the union feems to be prevented in the ufual  time by
                                                  any 
                     C  471  3
any detached pieces of bone, an incifion ffiould be made
down to them, and they ffiould then be removed by the
fingers or forceps.
  Another  caufe  preventing the re-union of  bones, is a
portion of mufcle,  or fome other foft part paffing between
them.   This is to be fuppofed when the pain and tenfion
of the injured part have been more fevere than ufual from
the firft; when particular motions  of  the  limb give  fe-
vere pain and twitchings of the mufcles that move it; and
when the ends of the bone do not unite at the ufual time.
In this cafe we ffiould endeavour to remove the interpofed
fubftance, by putting the limb into a variety of pofitions.
As this, however, will feldom fucceed, it will be commonly
neceffary to make an incifion down to  the affeaed parts:
If the callus is found foft, a cure may be effeaed merely
 by bringing the bones into contaa ; but if  it  has become
 hard, it will be abfelutely neceffary to remove a fmall por-
 tion of it as above direaed.   -
   Effufion  of blood  around the injured bone fometimes
 prevents a re-union of it.  When a large veffel is wounded
 by the bone,  the extravafation of blood is in fome cafes fo
 confiderable, and the limb becomes fo much fwelled,  that
 it will be neceffary to lay it open, and tie  the veffel; but
 when the fwelling does not arrive to  an alarming height,
 we are rather to truft to the contraaility of the artery for
 flopping the hemorrhagy,  and to the abforbents for re-
 moving the blood already  effufed.   In fome fuch cafes,
 where the  blood has remained long in contaa  with the
 bone,  the periofteum becomes feparated for a confiderable
 fpace, no callus  is produced, no union takes place, and a
 foetid  fanies  is commonly  difcharged from  the fore: A
 cure cannot  then be effeaed  until the denuded parts of
 the bone  exfoliate.  As the exfoliation is a  very tedious
  procefs, it will render the cure more fpeedy and certain to
                                                remove 
                      [  472   3
remove thofe parts of the bone from which the periofteum
is feparated, by means of a faw.


                   SECT.   II.

               Of FraBures of the Nofe.

  Fractures in the bones of the nofe require very parti-
cular attention, becaufe they are apt to impede refpiration,
to affea fpeaking,  and the fenfe of fmelling; and in fome
cafes, to produce  polypi, and tedious ulcers; and becaufe
of the contiguity of the brain.
  When any part of the bones  have been raifed above the
reft, it muft be preffed into its  place by the fingers; and
fuch parts as are forced into the nofirils muft be elevated
with the end of a fpatula, or fome fuch inftrument.   If any
portion is either very nearly or entirely feparated from the
reft, it fhould be removed.
  When the reduaion is properly made, the bones wiU ge-
nerally remain in their fituations of themfelves—If there
is a wound it muft be dreffed in the ufual way: And in-
flammation muft be obviated by faturnine applications, or
if neceffary by local bleeding.
  If, however, the bones will  not remain firmly in their
places of themfelves, it will either be neceffary to introduce
fmall tubes adapted to the fize  of the nofirils,  previoufly
covered with  cerate fpread on  lint, and  fecured by tape
paffed around the head, or to apply a comprefs and roller
over the nofe,  according as the bones fall into the nares, or
are  raifed too high.  By this treatment we may commonly
accompliffi a cure,  unlefs the bones have been very much
broken, when if they cannot be re-united, all the detached
pieces muft be removed,  and the wound healed as  well as
poffible.
                                             SECT^ 
[  473   3
                   SECT.   III.

  Of FraBures of the fuperior Maxillary, and Cheek Bones.

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

                   SECT.  IV.

       Of FraBures of the inferior Maxillary Bones.

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

                   SECT.  V.

         Of FraBures  of the Clavicles and Ribs.

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


                   SECT.   VI.

              Of FraBures of the Sternum.

  A simple fraaure of the fternum requires a treatment
fimilar to that of a fraaured rib.  More danger, however,
may arife  from a part of this bone being forced  into the
cheft, on account of the  vicinity of large blood-veffels; but
the pain of the part, and other fymptoms induced are the
fame.
  When the  pain,  cough, oppreffed breathing, and other
fymptoms  do not yield  to bleeding and an antiphlogiftic
courfe, the only effeaual method of affording relief will
be, to make an incifion upon the injured part large enough
to admit a free examination of the bone, and then to raife
the depreffed piece, either by means  of a fcalpel or levator,
if the  opening will admit them,  or when  this is not the
cafe, with  a trepan, in the manner advifed in a fraaured
fkull;  and  the fore produced may afterwards be treated in
the ufual way.
                                                  This 
                      C  477  3
  This operation may be done with fafety, and fliould un-
 doubtedly be tried:  No other mode of cure yet propofed,
 gives any chance of  fuccefs.


                   SECT.  VII.

 Of FraBures of the  Vertebra, os Sacrum, Coccyx, and offix
                      Innominata.

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


                  SECT.   VIII.

              Of FraBures of the  Scapula.

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

                   SEC  T,  IX.

              Of FraBures of the Humerus.

   Fractures of the humerus are in  general very eafily
deteaed, by the feat of the pain, inability to move the part,
and the other general fymptoms of fraaure.
   By bending the  elbow moderately and raifing the arm
nearly to a horizontal direaion, in a line with the body, we
relax all the mufcles of the arm, and  the furgeon may then
commonly  reduce  this  fraaure  without  affiftance;  but
when this becomes neceffary,  an extenfion  may be made
by one perfon grafping the arm near  the flioulder, and an-
other juft above the elbow.
   When the bone is reduced, it is to be fecured in its fitu-
ation by a fplint,  of the kind reprefented (pi. xii. fig. i.)
laid along the whole outfide of the arm, and another along      4
the infide, both covered with foft thin  flannel,  to prevent
them from galling the psrts ;  and while thefe are fecured
by one affiftant, and the fore-arm fupported by another, a
flannel roller fhould be  applied moderately  tight over the
whole.
   The fore-arm ffiould be fupported by a  fling, (pi. xn.
fig. 3.) but it will  be better, even in  bed, that it ffiould be
                                                    in 
                      [   43o  3
 in a hanging pofition,  fo that it may have fome  effea in
 pulling the lower part  of the humerus gently downwards,
 and thus  prevent the ends  of the bone from  overlapping
 each other, than to have it laid on a pillow horizontally.
   Unlefs the arm becomes much fwelled and' painful, the   #
 bandage ffiould not be  removed until the feventh or eighth
 day, when we may cautioufly examine whether the bone is
 perfeaiy in place or not;  and any accidental difplacement
 may then be eafily  remedied.
   Fraaures of the humerus heal more  readily than thofe
 of any other part;  all  circumftances being favourable, ge-
 nerally in lefs than four weeeks; and, if well managed, are
 feldom produaive either of lamenefs or diflortion.

                    SECT.   X.

         Of FraBureS of the Bones of the Fore-Arm.

  These fraaures  very frequently occur.   When both
 bones are broken,  there is  feldom any  difficulty in difco-
vering the ftate  of the injury ; but when one only is frac-
 tured, efpecially if  it be the radius,  as the  firmnefs of the
other prevents its difplacement, it requires fome attention
 to difeover it.   The feat of the pain, however,  points out
the part injured.
  If a great deal of attention is not given to thefe frac-
 tures, they are very apt to induce  a permanent ftiffnefs
in the arm, and more  particularly when the radius alone
is broken ; probably from  the difficulty of keeping it in
its fituation, owing to its having a  rotatory motion inde-
pendent of the ulna.
  In order to reduce a fraaure in the  fore-arm, the pa-
tient being feated,  and the mufcles of the  arm relaxed by
bending the elbow and wrift, the limb ffiould be extend-
ed  to fuch a degree,  by  one •affiftant  grafping it above
                                                  the 
                      [   481  J
the fraaure, and  another benea_h  it,  as  will  allow  the
furgeon to replace  the bones with exaanefs.   This being
done, fuch  a fplint  as  reprefented plate  xii.  fig.  _.  co-
vered with  foft flannel, and fo long as to reach from the
elbow to the tops of the fingers, and of fuch a breadth as
to go round more  than half the arm and hand,  ffiould  be
placed  along the ulna.  Another fplint not quite fo broad
muft be placed along the  courfe of the  radius, and both
may be fecured either with  a flannel  roller or a twelve-
tailed bandage.
   The palm of the hand fliould always be turned towards
the breaft, as this is not only the moft convenient pofition,
but it  moft  effeaually prevents the motion of  the radius.
The arm after being drfffed as above direaed, fliould be
hung in the fling,  plate xii. fig. 3. and  allowed to remain
in it during  the night.
   We  have din^ted the fplints to be very long,  becaufe
it is of great  confequence to prevent  the motion  of  the
fingers; for if this  is  permitted, it  not only tends to
 fupport inflammation and pain,  but  alfo to  difplace  the
bones.
   A partial diflocation of the bones of the wrift is a fre-
 quent  concomitant of a fraaure of the  radius ; by which
 the rifk of  a ftiff  joint, or of a  painful permanent fwel-
 ling of the arm   becomes   confiderable.   This  ffiould
 therefore be  particularly attended to  in  the treatment.
 See chap, on Diflocations, and fea. on Fraaures  in Ge-
 neral.
   The olecranon is fometimes fraaured without any inju-
 ry being  done to  the reft of the ulna, particularly from
 falls or  bruifes on the elbow.   In this cafe,  in order to
 keep the fraaured parts  in  contaa,. the fore-arm muft be
 kept extended by  means of a long fplint laid  along the in-
 terior  part of it, from the middle of the humerus to the tops
 of the fingers, fecured  by  a roller.   The arm ffiould be
                             - p                 allowed 
                      C  482   ]
 allowed to hang by the patient's fide,  to. which it fhould
 be fixed with one or two ftraps.
   But left a ftiffnefs of the elbow might be the confequence
 of keeping the arm conftantly extended during the  cure,
 the dreffings fliould be removed about the eighth or tenth
 day,  and daily afterwards ;  and the fore-arm being for
 fome time moved flowly backward and forward, and the
 joint  rubbed with any emollient oil, the arm may then be
 fecured as before.

                   SECT.   XI.

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

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


                   SEC T.   XII.

            Of FraBures of the Thigh-Bone.

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

               Of FraBures of the Patella.

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

  * In  tranfverfe fractures  of the patella, Mr.  Sabatier,  from much
experience, is of opinion that  no fplints or  bandages are at  all  necef-
fary or ufeful.  He advifes  tbe  thigh to be  moderately bent,  and the
knee  to be in  a  flight degree  of flexion alfo •  and both to  be  laid
upon  pillows.   Wherever  he  has employed fplints or bandages, or
feen  them employed,  they have  been  neceffarily  foon removed, on
account of the inflammation  and  fwelling induced  by them:  It is to
obviate thefe fymptoms that he has found the propriety  of keeping
the knee  flightly  bent.   See  Hiftoire de Acad. Roy. des Sciences,
pour 1' am 1783. 
                       [  489   3
 a fufficiently long continued extenfion  of the  limb, toge-
 ther with the general treatment recommended in fraaured
 patella, will remove this complaint.


                  SECT.   XIV.

          Of FraBures of the  Bones of the Leg.

  When one bone  of the leg only  is  broken, there is
 fometimes  a difficulty  in afcertaining the fraaure,  but
 when both are broken,  which  is more commonly the cafe,
 it  is  readily difcovered.' In  the former cafe, however,
 as the found bone generally fupports the other in its  place,
 this  is of no great confequence;  nothing more than con-
 finement,  till an union is effeaed, being neceffiiry.
  The  leg  is moft  frequently fraaured juft above  the
 ankle; and  particularly when  the fibula is the feat of  the
 injury.
  In  the management of this  fraaure, the general prin-
 ciples apply which were laid down in  the treatment of a
 fraaured thigh.   During the reduaion, the mufcles ffiould
 be relaxed  by bending the knee and flightly extending the
 foot; and an affiftant at the upper end of the limb and one
 below, will eafily  extend the  leg fufficiently.   The limb
 being laid upon its outfide, and the knee flightly bent, the
 fplints, plate xn. fig. 2—7.  or thofe made in the manner
 of fig. 1.  ffiould be applied, and retained by the twelve-
 tailed bandage:  the  fplint  on  the outfide ffiould  always
 reach from a little above the knee, below the  ankle, with
 a view to prevent the motion of  either of thefe joints, by
which the bones are apt to be difplaced.  If the patient is
very reftlefs, or  troubled with fpafmodic  affeaions of  the
mufcles of the leg, it  will be better, as an additional fecu-
rity, to apply a fplint of wood of the form, plate xn. fig. 2.
                        3  Q^                    a°4 
                     I"   49°  3
and filled with foft  wool,  to the outfide  of the leg, and
faften it by means of a couple of ftraps.   The foot fhould
alfo be always fupported by a ftrip of linen, conneaed on
each fide of the leg  to the  bandage.
  If it is thought proper, inftead of lying on his fide, the
patient may have the leg  placed on the  frame,  plate x.
fisr. 6. and  lie on his back; and this  or the fide, may
be occafionally ufed in the fame patient during the cure,
for the fake of eafe and variety: No change  of pofture
ffiould however  be  permitted for the firft  ten or twelve
days.  And when the pofition  is altered, the leg fhould
always be kept in the fame degree of curvature.
  In making the appofition of thefe bones, our fole objea
ffiould be to raife the inferior part of the bone; for this
is  almoft always drawn beneath the  upper,  by  the weight
of the foot, and the contraaion of the  mufcles on the
back part of the leg.

                   SECT.   XV.

      Of FraBures of the Bones of the Foot and Toes.

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

                  SECT.  XVI.

                 Of Compound FraBures.

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

   * In order  to preferve the bandage clean, and thus prevent a necef-
 fity 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 cafel
 of fracture, inftead of placing  the fplints beneath the bandage,  many
 practitioners apply the  bandage firft, and  fix the fplints  above  thefe,
 either by means of ftraps, or pieces of tape.  See Jones on  Wounds and
 Fractures. 
                      C  493  3
plentiful  fuppuration, as this  is the beft  preventative  of
gangrene; but  as foon as the inflammation  has fubfided,
they fhould be omitted.
  When the difcharge of matter becomes  very great,  the
fore fliould be dreffed with gentle aftringentSj  fuch as lint
dipped in a folution of facchar. faturni;  and  the  patient
ffiould be fupported  by a nouriffiing diet,  a  free ufe of
wine, Peruvian bark, and elixir of vitriol.   If the matter
cannot be freely difcharged by a  proper  pofition  of the
limb, or cannot be fufficiently abforbed  by lint or  fponge
applied to  the  fore, a counter opening muft  be made to
give it vent.   This  exceffive difcharge  will fometimes be
occafioned by loofe  pieces of bone: Thefe fliould there-
fore be fearched for, by the finger  if poffible, if not,  by
the^ probe,  and extraaed.
   If  the inflammation fliould terminate in gangrene, the
treatment formerly  recommended, or hereafter to be ad-
vifed, is to be employed.  See feaion  on Gangrene,  and
chapter on Amputation.
   Various machines  have been recommended  by different
authors, for  forcibly retaining fraaured limbs  in their
proper fituations, but they are in general unneceffary.  In
particular circumftances, that mentioned  in feaion xi. of
this chapter, may be ufeful for keeping the fraaured bones
extended; and confiderable  advantage may be  derived
from it  in keeping  the  bones fleady, when it is neceffary
to remove the patient from one place to  another; but in
common praaice I  have never derived  any advantage from
any inftrument ufed for this purpofe.
CHAP. 
I  494  3
CHAP.   XL1II.

    Of Luxations.
                   SECT.   I.

             General Remarks  on  Luxations.

A BONE is faid  to be  luxated when that part of it
      forming a joipt is difplaced. If the end of the bone
is forced entirely out  of the cavity in which it is lodged,
the diflocation is faid to be complete;  but where any part
of the bone refts upon the edge of the focket,  incomplete.
  Luxations may be either fimple, i. e. unaccompanied by
any other affection; compound,  when accompanied by a
wound,  laying open the cavity of a joint; or complicated,
when joined with a fraaure.
  Luxations are ufually produced by external violence, ap-
plied either in leaping or  falling, by  blows,  and violent
twifts and diftraaions of the different bones of a part; but
they are alfo produced by a morbid weaknefs  or relaxation
of the mufcles and ligaments of a joint, from palfy or rheu-
matifm; and  by the preffure of matter colfeaed in a joint,
and of farcomatous tumors and exoftofes.   Thofe produc-
ed by external violence are chiefly the objeas of furgery.
  The general fymptoms of fuch diflocations are, inabili-
ty to move the limb;  pain, tenfion,  and deformity  of the
part injured; and  in fome cafes,  inflammation, fubfultus
tendinum, and fever.   In general, the motion of  the limb
                                                   is 
                       t  495  "3
 is impaired in proportion to the extent of the luxation ; but
 in fome cafes, particularly in the larger joints, the moft par-
 tial affeaion renders the joint ftiff,  and immoveable, and
 gives the moft exquifite pain on every attempt to move it.
 The deformity muft always be proportioned to the extent
 of the injury; but the inflammation and  fubfultus are of-
 tener excited to a greater degree by a partial than by a com-
 plete di (location.
   The fwelling that firft takes place in  cafes of diflocation
 is always inflammatory, and neceffarily confequent to the
 violence done the parts;  and  ffiould be  carefully diftin-
 guiflied from a  fecondary fwelling, that, in  fome cafes,
 fpreads over all the inferior part of a limb, which is pale
t and cedematous,  and feems to  originate from a compreffion
 of the lymphatics.  This is moft commonly an attendant of
 diflocations of the humerus and thigh :Tn thefe a numbnefs,
 from compreffion of the nerves, is alfo very apt to occur.
   There  is  feldom any  difficulty in diftinguifhing complete
 diflocations;  but it is not always eafy  to difcriminate be-
 tween  contufions or fprains,  and fubluxations, or incom-
 plete diflocations.
   In forming a prognofis in diflocations, we are to confider,
 the form and flruaure of the joints ;  the nature and extent
 of the affeaion,  together with the  degree of violence by
 which  it  was produced, and the circumftances with which>
 it may  be complicated ; and the duration of the injury.
   It is chiefly in joints which admit of much motion  that'
 diflocations are met with, viz. where the articulations are
 by ball and focket, and by ginglymus.
   It has  been fuppofed that the capfular ligament is always
 ruptured in  luxations: I  am, however,  of opinion  that
 partial  diflocations may happen  without any rupture of
 the ligament; but I believe this is always torn in complete
 luxations, and fometimes almoft entirely from  its infertion.
 Where the difeafe proceeds from  the  gradual formation
                                                    of 
                       [  49*  3*
 of a-tumor within the joint, and where the ligament is per-
 haps much relaxed from any caufe, no rupture may take
 place; but when  the  luxation  is  produced by  external
 violence, it cannot be fuppofed that  the bone can be forced
 feveral inches  from its  natural fituation without lacerating
 the capfular ligament.
   The pain which more particularly attends partial difloca-
 tions, probably proceeds from the ftretching of the ligament,
 by the preffure of the difplaced bone.
   In forming a prognofis in  luxation, the diftance to which
 the head of the bone is forced, and the degree of violence
 producing the affeaion, are  to be particularly attended to.
 A partial diflocation will be more eafily and certainly re-
 duced  than where the difplacement  is  complete—And
 where the violence has  not been very confiderable, the in-
 flammation, and  other  fymptoms, will  not be in great de-
 gree, and vice verfa.
   The complication of  fraaure with luxation is very un-
 favourable.  When the luxated bone only is broken, and
 particularly if the fraaure is near its neck, it is  difficult to
 reduce it; but  when the receiving bone is  broken,  not on-
 ly a great degree of inflammation, and its confequences, are
 apt to  follow, but if the injury extends to the focket, there
 is always a confiderable rifle of a ftiff joint fucceeding.
  The difficulty of reducing a diflocation is, cseteris paribus,
 proportioned to the duration of the  difplacement.   For in
 a little time, the head of the bone will form a focket for it-
 felf among the mufcles, and be firmly grafped  by them,
 and the natural focket will at length be more or  lefs filled
 by the  contiguous foft parts,  and perhaps  have part of its
brim worn off by the aaion of the mufeular fibres paffing
 over it.  It does not appear from diffeaion, that an infpif-
 fation of the fynovia, which has been faid  often to take
place, ever occurs in thefe cafes.
  It is  alfo to be obferved, that the patient's age and health
                                              influence 
                      C  497  3
influence the reduaion of a bone.  Thus, in advanced life,
and in delicate conftitutions, it is accompliffied with much
more eafe than in the vigour of youth, and in robuft habits
of body, where the fuperior ftrength of the mufcles has a
confiderable influence in counteraaing it.
  The indications in diflocations are ; to reduce the difplac-
ed bone into  its  natural fituation, with as much eafe and
expedition as  poffible; to retain it in this fituation until the
injured  parts  have  recovered  their tone; and to obviate
pain, inflammation,  and other  fymptoms that fupervene.
  If the foft parts  are  much  contufed and inflamed, we
fhould not attempt the reduaion,  until, by the application
of leeches, and of faturnine preparations, by a low regimen,
and putting the limb in  a  relaxed pofture, thefe effeas of
the injury have fubfided.   But where the contiguous parts
have not fuffered in  this manner, the fooner we attempt to
put the  bone  into its proper fituation the better.
  In almoft every cafe of luxation, it is the bone forming the
lower part of the joint only that is difplaced ;  hence the on-
ly attention we have to give to the upper part, is to keep it
firm and fteady,  while we endeavour to replace the under
part of  it.  In effeaing the latter, our  chief obftacle con-
fifts in the aaion of the mufcles conneaed with the joint;
thefe not only refill our attempts for reduaion,  by keep-
ing the bone  in the place to which it is puffied, but often
draw it out of its natural direaion, and  fix it firmly in fome
adjacent cavity;  and the  trials  we make are very apt to
ftimulate the  mufcles to ftronger aaion,  and  thus increafe
the difficulty of  the reduaion.   Hence the neceffity of
putting  all thefe mufcles as much as poffible into a ftate of
relaxation,  in order to remove a luxation.
   When this is done, we may commonly fucceed by the aid
of affiftants alone;  but in feme cafes,  fuch force is requi-
fite that we are obliged to have recourfe to machinery.  It
ffiould however be very particularly obferved, that no more
                         3 R                     force 
                     [   498  3
force ought to be employed, in any cafe, than is juft fuffi-
cient to bring the end of the diflodged bone on a line with
the end of that to which it  is to be appofed; that this
force be applied only to the bone difplaced ; and that it be
applied in a very gradual manner,  and in fuch a direaion
as appears  beft adapted to that  in which  the diflocation
was made.   As foon as the ends of the bones are brought
on a line, the ordinary  aaion of the  mufcles will com-
monly bring them  into their natural fituation; but if this
is infufficient,  a gentle preffure muft be employed for the
purpofe.
   There is feldom  any difficulty in retaining the bone in its
proper fituation, after ieduaion, unlefs  it has been fre-
quently difplaced; the fureft method is, to put the limb
into a relaxed  pofture, and fupport the bone with a band-
age, until the furrounding  foft, parts have recovered their
tone.
   The fymptoms that require the greateft attention, both
before  and after reduaion, are, pain, inflammation, and
fwelling.  Thefe commonly abate  after the replacement:
but while any degree of inflammation continues, it ffiould
be carefully attended to, as being the moft common fource
of the  other fymptoms, as well as of the chronic pains
which frequently fucceed.   See chapter on Contufions.
   When luxations are complicated with  fraaures of the
difplaced bones, if the fraaure is at fome diftance from the
luxated part,  it will be no impediment to the reduaion;
the fraaure may then be treated in  the  ufual way; but
when it is fo  near the end of a bone that this cannot be
taken hold of,  it renders the cafe difficult and uncertain.
In the fmaller joints, as thofe of the  fingers and toes, the
reduaion may fometimes be  made;  but  in the larger, as
the hip-joint, and that of the  ffioulder, we muft allow the
fraaure to be  cured before we remove the luxation.
   In compound luxations,  where there is a wound of the
                                                 joint, 
                       C  499   3
joint, the treatment recommended in compound fraaures
will  be  applicable after the replacement of the bone  our
objea being to obviate inflammation, and its confequences.
  What we  have hitherto faid,  relates  in general to lux-
ations produced by external violence; when they are the
confequence of tumors or colfeaions  of matter, they are
almoft always incurable.   If the difeafed parts can be tak-
en off, it fhould always be advifed; but when this cannot
be done, all that art ffiould attempt is,  to  give as free a
difcharge as poffible to any  matter that may form, and to
fupport  the body  by a proper diet.
  When diflocations proceed from a relaxation of the li-
gaments  and  tendons  which connea the bones, a perfea
cure is feldom obtained;  all that can be done is to fupport
the limb with a bandage, and to brace the relaxed parts by
cold bathing, efearicity, and other tonics.

                   SECT.    II.

         Of Luxations of the Bones of the Cranium.

  The  bones of the  cranium are frequently feparated at
the futures, in cafes of hydrocephalus : If the colfeaion is
removed, all that we  can do is to fupport the parts by a
bandage.
  Openings are alfo produced by external violence, parti-
cularly by falls from  great heights.  Such accidents are
almoft always fatal.  The only affiftance furgery can afford
is to fupport the  parts by gentle preffure with a bandage;
to direa blood letting, and other remedies, according to
the violence of the fymptoms ; and to keep the patient quiet,
and in a  proper pofture during the cure.
SECT. 
[  5°o   3
                  SECT.   III.

         Of Luxations of the Bones of the Nofe.

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

                   SECT.   IV.

            Of Luxations of the Lower Jaw.

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

                      SECT.  V.

                  Of Luxations of the Head.

     These luxations  are produced by the head being for-
  ced with fuch violence forward, as to ftretch or rupture
  the ligaments by which the tooth-like procefs of the fecond
                                                vertebra 
                       C  5°2   3
 vertebra is conneaed to the occiput: And this commonly
 happens from falls  from great heights, or  from horfe-
 back.
   When the head is luxated, it always falls forward on the
 breaft; the patient  is deprived  of fenfibility inftantane-
 oufly, and  lies as if dead ; and foon dies, unlefs  the luxa-
 tion is fpcedily reduced.
   Diflocations of the head  commonly  terminate fatally;
 but as  recoveries have fometimes  happened from them,
 there is reafon to fuppofe, that death is frequently the con-
 fequence of the want of timely affiftance.  An attempt for
 the  reduaion ffiould always be made, if poffible, inftanta-
 neoufly after the accident.
   The patient being feated upon the ground,  and fupport-
 ed by an affiftant, the furgeon ftanding behind, ffiould  raife
 the  head from the breaft; and the affiftant being defired to
 prefs down the  ffioulders, the head fliould  be gradually
 pulled ftraight up till the diflocation is reduced ; and if this
 is not accompliffied  by moderate extenfion, the head  may
 be  gently moved from fide to fide.  A fudden  crack  is
 heard on the reduaion taking place; and if the patient be
 not dead, it is immediately afcertained by a partial, and in
 fome cafes,  by  an  entire  recovery of all  his faculties.
 Thefe, however, in fome  inftanees,  always remain im-
 paired.
  The patient fliould be laid in bed immediately  after the
 reduaion;  the head  ffiould be  kept  raifed,  and for a
 confiderable time in one  pofture, by means  of a proper
bandage; venaefeaion and laxatives  fhould be employed ;
and a low regimen advifed.
SECT. 
t  5°3   3
                   SECT.   VI.

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

  A complete luxation of any of the vertebrse probably
never happens without a concomitant fraaure ; and is, per-
haps, always immediately fatal, from the  effeas it  muft
neceffarily produce on the fpinal marrow, and the contents
of the thorax or abdomen:  It can, therefore,  never be an
objea of furgery.
  Partial diflocations may however occur,  and the patient
may live a long time afterwards; but he will probably fel-
dom entirely recover.   Thefe are ufually the confequence,
of falls from great heights,  of violent blows,  or of heavy
weights paffing over the body.
  They are diftinguiffied by diftortion of the part; by the
touch ;  and by the fymptoms they ufually induce, fuch as
palfy of the parts  below the injury,  and either a total fup-
preffion of urine,  or an involuntary difcharge of urine and
feces.
  The vertebrae are,  in  common, luxated either direaiy
forward, or to one fide; and hence it is very difficult to
accompliffi  their  reduaion.   The  moft certain method
perhaps, is to  bend the body  flowly forward,  as far as
poffible, over a cafk, or any other cylindrical large fub-
ftance, and if the luxation  is  to one fide,  towards the fide
affeaed :  No  machinery by which  much  force is em-
ployed  fhould  ever be  ufed.   Whatever  means is  made
ufe of, however,  will be feldom fuccefsful when '.he bont
is much difplaced.
   When any part of the facrum is diflocated, ail t^at can
be done is, to replace it as well as poffible by external pref-
fure, and by bending the body forward in the manner we
have mentioned.
                                                  The 
                      [  5°4   3
  The coccyx is more frequently luxated than any of thefe
bones, from  being more expofed to injuries.   It may be
thrown either forward or backward.  It is apt to be forc-
ed  outwards in laborious  births; and fometimes from
Large colfeaions of hardened faeces in the reaum.
  This injury is known, by pain all over the loins, parti-
cularly about the junaion of the coccyx with the facrum,
and from aaual examination with the fingers.
  In luxations inwardly,  from falls or blows, the patient
complains of pain, and a fenfation of fome hard body com-
preffing the under part of the reaum ; tenefmus comes on,
and difficulty in paffing the fceces ; and, in fome inftanees,
a fuppreffion of urine  takes place.   Thefe luxations are
readily deteaed, by introducing the finger into the anus;
and by paffing it as far as poffible up the reaum, and fup-
porting the external parts with  the other hand, they may
be eafily reduced.
  Outward luxations of the coccyx are  in common reduc-
ed,  without much  difficulty, merely by external  preffure
with the fingers; buj: it is often  difficult to retain the bone
in its  place.   This is moft effeaually done by a comprefs,
and the T bandage.
  As  diflocations of any of thefe bones,  and particularly
thofe of the coccyx, are very apt to produce inflammation,
which  often  terminates  in abfceffes  difficult to heal,  we
ffiould employ general and topical bleeding,  and laxatives,
and direa an eafy pofture for the patient, and a low regi-
men, in order, if poffible, to prevent ir.
SECT. 
t  SOS  3
                    SECT.  VII.

               Of Luxations of the Clavicles.

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

                  SECT.   VIII.

                Of Luxations of the Ribs.

   It has been generally fuppofed that  the ribs cannot be
diflocated;  but it has been proved by diffeaions that they
are fometimes  luxated inwards.
                            3S                       A 
                      [  $o6  2
   A luxated  rib will produce nearly the fame fymptoms
 that occur from a fraaure ; but it may be diftinguifhed, by
 the  pain being moft fevere at the articulation, and by no
 part of the bone yielding to preffure except this fpot.
   In genera], a luxated rib will probably return to its na-
 tural fituation from its own elafticity, when the caufe of
 the injury  is  removed; but if it does not, the beft method
 of reducing it will  be, to bend the body forward over a
 cafk, or fome other cylindrical fubftance, while the vertebrae
 immediately above  and below the rib are preffed inwards
 with as much force as can with fafety be applied  to them.
 After this, a  thick  comprefs of linen fhould be laid over
 the vertebras mentioned, and another  along the moft pro-
 minent part of the diflocated rib, and the two immediately
 contiguous ;  and a broad roller  fliould then be  paffed
 over them, and two or three  times  around  the body, in
 order to retain the replaced rib and the vertebra; in  their
 fituations : And to prevent the roller  from moving, a fea-
 pulary bandage,  a  ftrap conneaed  with it  behind, car-
 ried  between  the thighs and fixed to  it before, fhould be
 employed.
   For the prevention  of inflammation, and other difagree-
 able  effeas, which are very apt to  enfue from this luxa-
 tion, bleeding, a low and cooling regimen, and opiates are
 the beft remedies.

                   SECT.  IX.

       Of Diflocations of the Humerus at the Shoulder.

   From the conftruaion of the joint at the ffioulder, dif-
locations oftener happen there than in all the  other joints
of the body together.   The os humeri is moft frequently
luxated downwards, from  its  meeting with leaft refiftance
                                                    in 
                      C  507   3
 in that direaion.  It is fometimes puffied downwards and
 forwards, beneath the peaoral mufcle, and between the
 coracoid  procefs of the fcapula,  and the middle of the cla-
 vicle and lodged on the ribs.  In a few cafes, it is diflocated
 downwards and backwards; but  it can never be thrown
 upwards without being accompanied by a fraaure of the
 acromion, of the coracoid procefs, or  of both.  But al-
 though the direaion the bone takes depends in  fome mea-
 fure on the refiftance it meets with, it  alfo is  influenced
 by the part which is the immediate feat of the injury.
   A diflocation of the humerus is evidenced, by inability
 to move the arm ; by fevere pain being excited on attempt-
 ing to bring it near the  fide; by its being ffiorter or longer
 than the other arm ; by feeling the head of the bone;  and
 by difcovering a vacancy beneath the acromion.   In  order
 to afcertain thefe circumftances, the found arm  ffiould be
 compared with  the other.
  In long continued cafes,  the whole arm is  apt  to become
 cedematous, and fomewhat infenfible from the preffure of
 the bone on the lymphatics and nerves.
  In fimple and recent luxations of the  humerus,  we may
 in almoft  every inftance accompliffi a reduaion,  without
 much difficulty; but in  long continued  cafes, all our at-
 tempts are frequently rendered abortive, either from the
 head of the bone having formed a focket among,  and be-
 coming firmly conneaed to, the contiguous parts,  or from
 a diminution of the cavity  of the natural focket.   In fuch
 cafes, therefore, no great degree of force ffiould be much
 perfifted in to accompliffi a reduaion;  for befides giving
 a great deal of  pain,  it is apt to render  the motion of the
 head of the bone in the artificial focket more ftiff than it
 was before.
  It is generally faid, that  a reduaion is more eafily effea-
ed when  the bone is in the axilla, than  when it is puffied
forward beneath the peaoral  mufcle;  and more eafily
                                               when 
                      [  5^8  3
 when in this  fituation,  than  if it is  lodged backward be-
 neath the fpine of the fcapula.  The latter appears to be
 the cafe; but in the others,  I have found no difference.
   I have often reduced a diflocated  humerus  by preffing
 back  the fcapula  with one  hand, while  I extended the
 arm gently with the other, bending the elbow  moderately,
 and raifing the arm nearly to a right angle with the body
 in fuch a direaion as to prevent either the peaoral or ex-
-tenfor mufcles of the arm from being ftretched.  A great-
 er degree of  force than can  thus be applied is, hov/ever,
 fometimes neceffary.   The  following is  the  method by
 which I have always fucceeded in recent cafes:  The pa-
 tient is feated on a chair, and his body fecured by a long
 broad belt paffed  round it,  and given to affiftants, or tied
 round a poft; a firm band of leather, four or five inches
 broad, and lined  with flannel, as reprefented in pi. xi.
 fig.  4. is now to be tied round the arm immediately above
 the  elbow.   The three  ftraps  or cords  conneaed  with
 this band being given to affiftants, they muft be defired to
 extend the arm in the relaxed pofition we  have mentioned,
 and  in  a flow, equable  manner, while another affiftant
 Handing behind is employed in preffing the fcapula back-
 wards.   The furgeon himfelf  ftands  moft conveniently
 on the outfide of the  arm : he is to direa the degree of
 force to be employed, and  to point out  the  direaion ia
 which the arm is to be extended ; he may alfo fupport the
 fore-arm,  and retain it  bent at  the elbow,  as  already
 mentioned.   As foon as  the head of the  bone is drawn
 paft  the brim of the focket,  the extending force ffiould be
 leffened, and  the reduaion will then in common be accom-
 pliffied by the aaion of the mufcles of the joint; or it may
 be effeaed by moving the  arm gently in  different direc-
 tions.  A crack is ufually heard on the bone  flipping in;
 immediate relief is afforded;  and the ffioulder refumes its
 prominency.
                                                   The 
                     C  509   1
  The arm  muft always be extended  in that direaion
which gives  the  leaft  refiftance : when the  head of the
bone is puffied forward beneath the  peaoral mufcle, or
thrown backward, the arm ffiould be raifed to a right angle
with the body ; but in the moft  frequent kind of luxation
in this part,  where the bone is  fixed  in  the  arm-pit, the
arm  fliould be drawn fomewhat obliquely downward.   It
is to be obferved, however, that we ffiould always vary the
direaion of the extenfion as foon as  ever we meet with
any confiderable refiftance.
  The mode of treatment I have juft  recommended will
fucceed generally, even in cafes  of long ftanding,  where a
reduaion is  praaicable ; but when  a greater force is re-
quired than  can  be applied in this manner, the inftrument,
reprefented plate iii. fig. 1. invented by Mr. Freke, anfwers
the purpofe  with more  eafe and fafety than any  other  I
have feen employed.  By this machine we can make a gra-
dual extenfion in any direaion.   For the mode of applying
it, fee the plate and explanation.
   A great  variety of methods, all  however much more
objeaionable  than  the one we  have  advifed, have  been
praaifed in  the reduaion of a diflocated humerus.   1. The
arm being  forcibly extended  by laying hold of the fore-
arm, the heel of the furgeon is by  fome direaed to  be
applied to the head of the bone in order to pufli it up;
and fometimes a ball, or fome  other  round fubftance,  is
piaced  between the  heel and bone.  By this method the
elbow  and  fore-arm may  be unneceffarily  injured;  the
mufcles which may, and ought to be  relaxed, are  kept ex-
tended ; and  the  head of the  humerus muft  be often
forced up againft the neck of the fcapula, or other  con-
tiguous parts, and thus tend  effeaually to counteraa the
extenfion.   2. Others  attempt to reduce the bone, by ap-
plying a rolling-pin covered with cloth  or flannel, to the head
of the bone  while an extenfion is made.   This is liable to a
                                              material 
                     C  5*°  3
material objection juft mentioned.  And neither this mode
nor the firft can be applicable when the  bone is luxated
backward or forward, becaufe they  can at any  rate only
aa in raifing the bones.  3.  It has been a praaice with
fome to have a towel or girth paffed  round the os  humeri
near its head, and over the head of the furgeon, in order
to raife the bone while the extenfion  is made.   This is ob-
jeftionable  for the third reafon mentioned in defcribing the
firft mode.
   In  order to increafe  the powers of extenfion, when
thefe methods  have been fruitlefs ; 4. The ambe of Hippo-
crates  has been ufed ; but this is liable in a very great de-
gree  to  the objeaion  to the 3d  method.   5. The pa-
tient has been  fuddenly fufpended, by the diflocated arm,
from  a ladder  or high door.  We are told this has often fuc-
ceeded.  6. The  patient has been  fufpended by  two or
three men ftanding on a table; and the bone thus reduced
in fome inftanees.  7. The patient has been raifed by the
arm by  means of pullies fixed in  the  deling of  a room.
This  has alfo  fucceeded in  cafes where other means have
failed.
   All thefe modes are, however, liable to great objections;
the extenfion is made in fo  forcible,  fudden, and irregular
a manner, that more mifchief is often done to  the foft
parts, although defended by flannel or feather, than can be
compenfated by the reduaion of the bone ; and as the arm
muft   always  be  extended  in the fame  direaion, it muft
cbvioufly in fome  cafes give  a great chance of  fraauring
a rib, the fcapula, or the humerus itfelf.
   8.  A machine has been invented for conjoining  the
power of  the ambe with  the mode juft defcribed ; this
muft neceffarily be more dangerous than either  of thofe
 methods  feparately.   And,  9. Ropes  and  pullies  have
been employed to diflodge  the  difplaced bone;  by which
                                                    as 
                      t  511   3
as much force  as ever  can be  neceffary may be  readily
applied.
  Swelling, inflammation, and pain, when concomitants of
luxation, are  to be  removed  by the ufual  remedies, but
chiefly by the application of leeches.
  The  round  head of  the  biceps cubiti  which  paffes
through  the  fhoulder-joint, is apt to be feparated  from
the humerus,  and induces pain, ftiffnefs,  and unwieldinefs
of the arm.  The moft certain method of reducing it is, to
move the arm in a variety of direaions from time to time;
and we know that  it is replaced, by an inftahtaneous re-
moval of the diftrefs.
   In order to  prevent  the humerus from  falling out of
its place  after  reduaion, the  beft method is to fupport  it
by the fling reprefented plate xn. fig. 3. until  the  parts
recover their tone:  Bliflers and the  cold bath, have alfo
been ufeful to reftore this.


                    SECT.   X.

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

   These luxations  occur more frequently upwards and
backwards than in  any other direaion; they can hardly
be produced forward or laterally, without an  accompany-
ing fraaure of the upper part of the ulna.
   Luxations  of the fore-arm  are  readily  diftinguiffied,
unlefs  the  foft parts have  become fwelled  and inflamed.
When the luxation  is backward, the olecranon is felt on
the back part of the arm, and the condyles of the humerus
are puffied forward.  When  the olecranon  is broke, and
the ulna and radius  thrown forward, they are alfo apt to
be drawn  upward  on the  anterior part of the  humerus,
and the  condyles of that bone are difcovered  behind. ^  A
                                             comolef: 
                       .  5™   3
 complete lateral  luxation can never occur unlefs the foft
 parts are much lacerated. In whatever way the difplacement
 is made, the joint becomes immediately immoveable.
   In the reduaion of thefe diflocations, the patient ffiould
 be feated, and the arm firmly fecured by an affiftant: When
 the  bones are luxated  backward, the fore-arm ffiould be
 moderately bent,  in order to  relax  the flexor  mufcles;  it
 ffiould  then be gradually extended, and  if while this  is
 done,  the  curvature of the elbow is proportionably in-
 creafed, we will  feldom fail in the reduaion.  Where the
 olecranon is broken, and the ends of  the ulna and radius
 puffied forward and drawn up upon the humerus, we muft
 extend  the arm while in a ftraight pofition ; and the exten-
 fion muft be continued  until  the  ends of  both bones are
 pulled  fomewhat lower than the moft depending part of
 the humerus, when they will foon regain their fituation by
 the aaion of the  mufcles, or be eafily forced into it.
   In lateral diflocations of thefe bones, the extenfion  muft
 alfo  be  continued  till they have paffed  the end  of the hu-
 merus,  and  then  they  may be puffied laterally into  their
 places.   In  every variety, the extenfion  fliould  be made
 by affiftants grafping the arm juft above the wrift;  and
 while this  is done, the furgeon  ffiould  prefs down the
 heads of the bones.
  After the  reduaion,  the  elbow ffiould be kept  mode-
 rately bent,  and the arm as much  as poffible at reft, until
 the parts have recovered their tone.
  Inftanees  have  occurred of the feparation of the bones
 of the arm  from each other  at both their points of.  con-
 neaion; but this has  happened  more frequently  at the
 wrift than at the  elbow.  It is  known by the  motion of
the joint being impaired, and the other ufual fymptoms of
diflocation.
  In general, the luxated bone is eafily reduced, but it is diffi-
cult to retain it in its place. The beft method of effeaing this.
                                                   is 
                      [   513  3
is by  means of fplints, extending  from the elbow to the
ends of the fingers,  and fecured by a roller, and by after-
wards putting the arm in the fling,  reprefented plate xn.



                    SECT.  XI.

         Of Luxations of the Bones  of the Wrifl.

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



                           r, T                  SECT. 
[  5^4  3
                  SECT.   XII.

Of Luxations of the Bones of the Metacarpus and Fingers.

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


                    SECT.  XIII.

       Of  Luxations of the Femur at the  Hip-Joint.

   It has been doubtedLwhether a luxation of the femur at
 the hip-joint has ever taken place: But I have feen inftanees
 in which its exiftence has been proved by the patient's be-
 ing inftantaneoufly relieved by the efforts of the furgeon.
   The os  femoris, it is faid, may be luxated either upward 
                      C  s-<s   3
and backward, upward and forward, downward and back-
ward,  downward  and forward, or direaiy downward.
The firft and third of  thefe have very feldom been met
with ;  and the moft common variety, and  the only one  I
have feen, is that in which the bone is thrown downward
and forward, and lodged in the foramen ovale.   The rea-
fon why this is moft freequntly met with is, that  there is
a vacancy in the  os innominatum forming the focket on the
interior part, which is covered only by a ligament.
   When the  luxation is upward and  backward,  the leg
 will be confiderably fhorter than the other ; the great
 trochanter will be higher ;  the knee and foot will be turn-
 ed inward, and it will give a good deal  of pain to  attempt
 to alter their direaion.
   If the femur  is thrown  upward  and forward,  the leg
 will be fhortened ; the head of the bone will be felt refting
 upon the os pubis in the groin ;  the great trochanter wiU
 be on  the  upper and anterior part of the thigh,  and a va-
 cancy  will be found in its  proper fituation ;  the knee and
 toes will be  turned outwards;  and if the diflocation be
 not foon reduced, pain and inflammation will probably af-
 fea the fpermatic cord and teftis.
   If ever the luxation be downward and backwards, the
 leg will be confiderably lengthened  ; the knee and toes will
 be turned inwards ; and the great trochanter will be lower
 than it ought to be.   When the head of the bone paffes
 direaiy downwards, the  leg will be longer and  the tro-
 chanter lower,  but the knees and toes will retain their na-
 tural fituation.
    In the moft frequent fpecies of luxation, the leg appears
 confiderably longer than  the other ;  the knees  and toes
 turn outwards,  and cannot be moved inward or  outward
 without pain ;  all the mufcles of the internal part of the
 thigh are tenfe  and painful; the femur cannot  be felt  on
 the outfide  farther off than the middle of the thigh; a
                                               vacancy 
                     [  5i6  3
vacancy is felt in  the ufual place of the great trochanter,
which is found  farther down and on  the anterior part  of
the thigh, while the head of the bone is felt a little below
the groin.
   Recent luxations of the os femoris may with proper ma-
nagement be almoft always reduced ; but for the reafons
mentioned when treating  of diflocations in general, thofe
of long  duration often  baffle all our efforts.
   In  reducing this luxation, the extenfion muft vary in  its
direaion according to  the variety of the affeaion; and the
head of the bone ffiould always be completely raifed above
any projeaing part of the  contiguous  bones before any
other attempt is made to reduce it : As this will remove the
principal impediment to the reduaion,  if the mufcles  of
the limb be at the  fame time relaxed, the bone will eafily
be drawn into the focket,  when the diflocation is upward,
or puffied into it, when downward.
   In the moft common luxation of  the thigh,  where the
head of the bone  is  puffied  downward and forward, I
have fucceeded in the following  manner: The patient be-
ing laid upon his back acrofs a bed, and firmly fecured  by
an affiftant or two, a broad  ftrap, or table-cloth  properly
folded,  is  paffed  between his thighs and over the groin,
on the found fide, and given to two  other affiftants;  a  fi-
milar ftrap is  paffed around the luxated thigh as near  as
poffible to its head, the ends of which muft be given to
an affiftant ftanding on the oppofite fide.  The belt, plate
xi. fig. 4. being previoufly fixed upon the  under part  of
the thigh, the ftraps conneaed with it are given to an  af-
fiftant or two, while the knee is fupported  by another  af-
fiftant with the leg moderately bent.   The extenfion ffiould
then be made by the affiftants who have the charge of the
ftraps conneaed to the belt; but it ought not to be carried
farther than is confidered neceffary for drawing the head of
the bone down to the under part of the foramen ovale, which
                                                 may 
                      l   5*7  3
may be effeaed by a moderate force.   The ftrap round the
upper part of the thigh muft be firmly pulled, and the thigh
drawn upward and inward, the affiftants  ftanding fome-
what higher than the patient, until the bone has probably
cleared the foramen ovale.   At this  time, the knee ffiould
be moved fomewhat inward, and the thigh be pufhed up-
ward and obliquely outward, by the affiftant keeping one
hand on the knee, while he holds the foot with  the other,
keeping the leg moderately bent.
   The furgeon  may judge  that the head of the  bone is
 fufficiently raifed  when  it appears  to be about  an  inch
 higher than when the force was firft applied.   If  it yields
 with difficulty,  we may fuppofe that feme part of it has
 become  fixed in the upper  part of the foramen; in which
 cafe  the force in the direaion  recommended muft be dif-
 eontinued,'and  the affiftants at the  knee being  direaed to
 increafe the  extenfion downward, it will afterwards be
 more eafily raifed.
   When this method fails, and it is judged neceffary to
 employ greater force  than can be thus applied,  we  may
 have recourfe to Mr. Freke's machine, plate in. fig.  i. or
 to ropes and pullies.  But it is to be obferved,  that no af-
 fiftance of this kind can be neceffary when  the diflocation
 is downward.
    The  violent diftention of the mufcles and laceration of
 the  ligaments of the  joint with which  this  affection  muft
 be neceffarily attended, render a  great deal  of attention
 neceffary for a long time after the reduaion.    Bloodlet-
  ting, topically, fhould be freely ufed according to circum-
  ftances, and reft  fhould  be enjoined until  the parts have
  recovered their tone.
    I  do not  believe that  a fubluxation  of this joint, as
  mentioned by fome, can poffibly take place, on account of
  the roundnefs of the  head  of the thigh-bone,  and the
  narrownefs of the brim of its focket. 
C  5»8  3
                  SECT.  XIV.

              Of Luxations of the Patella.

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


                  SECT.   XV.

        Of Luxations of the Leg at the Knee-joint.

  The bones of the thigh and leg are fo firmly connea-
ed, that they are lefs frequently feparated  than thofe form-
ing  any other joint of the body:  They cannot be com-
                                               pletely 
                      C  5^9   3
pletely luxated,  unlefs the  teguments, tendons, and liga-
ments which tie them together be ruptured.  When how-
ever a luxation happens, it may be  produced nearly with
equal eafe on either fide;  but it may occur more readily
backward than forward.
   There is no difficulty in  diftinguifhing a luxation of the
knee.   It is to be reduced  by fixing the thigh  firmly,  and
extending the leg in as relaxed a  pofition as poffible, until
the ends of the bones are entirely clear of each other,  and
then puffiing them together.
   As inflammation is  more particularly apt  to  fupervene
 to this luxation, the patient ffiould obferve a ftria antiphlo-
 giftic courfe; local bleeding ffiould be freely ufed, and re-
 peated according to circumftances; and the limb ffiould be
 kept a confiderable time at perfea reft.
    A feparation of the fibula from the tibia, at one or  both
 ends, is very apt to be miftaken for a fprain;  but an atten-
 tive examination will fecure us from this.  It fliould be re-
 placed as foon as poffible,  and retained by a bandage until
 the parts recover their tone.

                   SECT.   XVI.

          Of Luxations of the Foot at the Ankle-Joim.

     The aftragalus may  be luxated either  backward or
   forward, or outward or inward, but it is more frequently
   puffied inward than in any other direaion.  It cannot be
   luxated outwardly without breaking the end of the fibula.
   Diflocations of this joint are in general eafily difcovered by
   the pain and lamenefs they produce, as well as  by the ob-
   vious alteration which they  occafion in the  appearance of
   the foot.   They are to be thus reduced: The  patient be-
   ing placed either on a table or a bed, and the leg with the
                                                    K.QCG 
                      [  520  ]
knee bent, firmly fecured by  an affiftant or two ; the foot
is then to be extended in a relaxed pofture, until the moft
prominent part of the aftragalus  has paffed the end of the
tibia, when it will either flip into its place, or may be eafily
forced into it.
  Befides  the ufual antiphlogiftic courfe which we have re-
commended in luxations of all the larger  joints,  it  is par-
ticularly neceffary here to keep the limb for a confiderable
time perfeaiy at reft, efpecially when the fibula is broken;
becaufe if the bone be not retained exaaiy in its fituation
till  a cure is  effeaed, this important joint may be  kept
weak during  life, or be rendered  ftiff and very painful.
Any weaknefs remaining after  injuries of this kind, is moft
effeaually obviated  by a firm thin iron  plate applied along
the outfide of the leg, and conneaed with the ffioe.   Mr.
Gooch has invented a machine for this purpofe.


                  SECT.   XVII.


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

  The os calcis is fometimes diflocated laterally, by itfelf;
and at other times, together with the aftragalus, is difplaced
at its junaion with  the os naviculare and cuboides down-
ward, outward, or inward ;  but hardly if ever upward.
  Luxations  of thefe bones  are very readily difcovered by
the pain and  lamenefs which they always occafion,  and by
the alteration of fhape in the foor which they induce.
   A diflocation of the os calcis is  more difficult to reduce
than that  of  almoft any other bone of the foot:  This is to
be  effeaed by fixing the leg in a relaxed pofition, and mo-
derately extending the foot,  previous to attempting the co-
aptation of the bones.
                                                   The 
                      C  521  2
  The reft of the bones of the tarfus, as well as thofe of
the metatarfus and toes, are to be replaced when  diflocated
by the fame general treatment that was recommended in
luxations of the hand.
CHAP.    XUV.

Of  Diftorted  Limbs.
D
     ISTORTIONS  of the  limbs  may  originate either
  J from  a difeafed ftate of the bones, or from a con-
traaed ftate of the mufcles, or both.   They may occur ei-
ther from an original mai-conformation, or  as the confe-
quence of fome difeafe  at an early  or later period  after
birth.
  In infancy, as the bones are foft, they may  be rendered
crooked by children being made to walk too early.  There
are alfo fome difeafes which render  them preternaturally
foft,  fo that they readily give way to the ordinary aaion of
the mufcles,  as  well as  to the weight of the body, and
thus  lofe their natural direaion.  But the moft frequent
caufe of diftorted limbs is that contraaion of the flexor
mufcles, particularly in the knee and  elbow, which  is often
induced by an inflamed ftate of the joints, from the patient
keeping them conftantly bent for a  confiderable length of

 '"when the diflortion originates from an adhefion of the
bones forming a joint, nothing can give relief but amputa-
                          - tj                     tion. 
                      C   522  3
 tion. (3ee chap, on Amputation).  But when the contraaed
 ftate of the mufcles and tendons is the caufe of it, which
 is moft frequently the cafe, we may in almoft every inftance
 afford confiderable relief:  And, where a limb is crooked
 from the bone being bent,  whether it may have  happened
 from improper management during childhood,  or from the
 effeas of the rickets,  or any other difeafe,  we  may very
 commonly,  by timely attention,  either remove it entirely,
 or render it much lefs confiderable.
   In diftortions from  contraaed mufcles, by  the ufe  of
 emollients and  gradual  extenfion, 1 have  relieved, and
 fometimes cured, patients who had been lame for feveral
 years, and whofe cafes had been deemed hopelefs.  As
 emollients, the animal fats and oils are the beft; but what-
 ever is ufed muft be employed for a confiderable  length of
 time, and  in a very ample manner to be beneficial. All the
 contraaed mufcles and tendons, from their origins to their
 infertions, muft be well rubbed with the fubftance made ufe
 of at leaft half an hour three times a-day;  and  the limb
 fliould be kept conftantly moift with, or as it were  immerfed
 in the emollient, by being covered with flannel wellfoaked in
 it.  While the friaions are ufed, the limb ffiould be flowly,
 though firmly, extended to as great a degree  as the patient
 can eafily  bear; and an apparatus ffiould afterwards be ap-
 plied to prevent the mufcles from contraaing.
  Even where the extenfion is  not neceffary, as in joints
merely ftiff without any diflortion, emollients  are often
 very ufeful.
  Where  the diflortion  proceeds  from  the curvature  of
 a bone, if  this is not of long duration, and efpecially when
it occurs in childhood, we  may very frequently remove it
by making a conftant preffure, gradually increafed,  on the
convex fide of the limb, until the bone is  brought into
its natural direaion.  This deformity is  moft  frequently
met with in new-born children,  and in ricketty patients;
                                                  and 
                     C   523  3
and commonly affeas the legs.  If the bones of the leg
are bent  outward, it caufes the foot to be turned inward ;
and the foot is turned outward when the leg is bent in-
ward :  In  the latter cafe, patients  are termed Valgi; and
in the former, Vari.
   The diflortion  of the  feet in thefe cafe3,  has  by many
been attributed to a difeafed ftate of the ankle; but who-
ever will take the trouble of examining the complaint with
attention, will be convinced that it is,  at leaft in  common,
a mere confequence of the affeaion of the leg; and therer
fore, that our views in its removal muft be chiefly direaed
to the latter.
   The cure of this variety of diflortion can only be effeaed
 by a proper application of preffure to the leg-bones.  This
 is mofl: eafily and effeaually given by a firm fplint of iron
 fixed on the concave fide of the leg,  and extending from
 the correfponding condyle of the femur to the foot, fecur-
 ed by one or two broad ftraps paffed round  both the leg
 and the fplint.   If the  fplint is covered with foft feather,
 and properly fitted to the parts, it gives  no uneafinefs;
 and by  drawing the ftraps tighter from time to time,  the
 preffure will be gradually increafed as above direaed.
    It is  fometimes fufficient to fix the ends of the fplint in
 the fhoe;  but in other cafes, it is neceffary to  connea it
 with a frame beneath the fhoe, and fixed to it, in order to
 keep the foot in its proper pofition.
    It is  obvious  that the treatment of diftorted limbs muft
  be varied  according to the  particular  nature of the cafe:
  this muft be left to the judgment  of the furgeon.
CHAP. 
C  524  3
     CHAP.   XLV.

Of Diftortions of the Spine.
     THE fpine may be  diftorted in various direaions;
      outwardly, inwardly, "or  laterally; and,  in fome
cafes, we meet  with it in all thefe direaions at the fame
time, and in the fame perfon.
  This  difeafe  arifes  from external  violence;  but it is
more frequently a fymptom of a weakly conftitution.
  Befides the deformity which thefe diftortions produce,
they are very apt to injure  the health by compreffing the
vifcera of the  abdomen and thorax, and by  inducing pa-
ralytic affeaions of the lov/er extremities from the preffure
they make upon the nerves.   They appear at all ages;
but more frequently about  puberty than at any other pe-
riod, and more commonly in girls than in boys.   In gene-
ral, the  effeas refulting from them  are  obferved  before
the caufe is fufpeaed.
    When diftortions of the fpine occur in infancy, the pa-
tient appears to be fuddenly deprived  of the  ufe  of his
limbs;  but  at more advanced periods, he complains for
fome  time of  feeblenefs, and of want of feeling  in the
lower extremities.   By degrees this infenfibility increafes;
and he  is often obferved to ftumble, and drag his  legs in
walking; nor  can he ftand erea for any length of time
but with much  difficulty.   At laft the legs become entire-
ly paralytic; and  when the fpine is thrown much forward,
fo as to comprefs the abdominal, or thoracic  vifcera, diffi-
culty of breathing, and complaints in the bowels to a con-
                                              fiderable 
                      I  525   3
fiderable degree, are induced.  In fome cafes, the paralyfis
takes place in a few days from the firft appearance of the
difeafe; and it fometimes becomes gradually lefs,  though
according to my obfervation, it is never entirely removed.
  When the curvature is firft difcovered, we fometimes
find that only one of the vertebrse is difplaced ;  at other
times,  two or more;  and it  often happens that where one
bone only has been affeaed in the beginning,  that feveral
adjoining are feized in the after progrefs of the complaint;
and, in fome cafes, there is reafon to fuppofe  that the de-
formity is  a confequence of an  affeaion of the vertebral
ligaments alone.   When one bone only  is deranged, the
patient  is always rendered more completely paralytic than
when feveral are affeaed, and the difeafe is more fpeedily
fatal.   For in the firft cafe,  the  patient almoft always dies
within the courfe of a year or two, or lefs;  while in the
latter,  he frequently lives as long as if no fuch difeafe had
fubfifted.  The difference of preffure on the fpinal marrow
neceffarily produced,  will  account for this difference  in
the appearances of the difeafe;  and likewife for the fymp-
toms  becoming in  fome inftanees lefs remarkable in the
courfe of the complaint than they were at firft.
   As this  affection often proceeds from weakly perfons in-
dulging too much in particular poftures, every habit  of
this kind  ffiould be carefully guarded againft  on the firft
appearance of  the  complaint; and if a particular habit is
already contraaed, its oppofite  ffiould be advifed.  That
the body may lie as much  as poffible upon an equal fur-
face, a hair matrafs, laid upon boards, ffiould be ufed in-
ftead of a feather bed.
   By  attention to  thefe circumftances;  by the ufe of  an
invigorating diet-, the cold  bath, bark,  and other tonics,
the difeafe has, in fome cafes, been prevented from advanc-
ing fo  far as it probably would have otherwife gone; but
where  any of the bones have been affeaed,  I have never
                                                   feen 
C   526  3
feen a complete cure obtained.   Mr. Pott fpeaks highly of
the effeas of  drains  placed as near as  poffible to the  tu-
mor.  He advifes an  iffue to  be made with cauftic,  on
each fide of it,  large enough to admit of  a kidney-bean, and
the bottom of the fore  to be fprinkled occafionally with
powdered  cantharides to keep  it running.*   I have em-
ployed this method  with  advantage when  the ligaments
were the feat of the complaint; but when it has appeared
to prove ferviceable  where the bones were affeaed,  I  am
of opinion  that the change was rather induced by the pref-
fure upon the fpinal  marrow being leffened as above  ex-
plained.
   All the advantage  that can be  derived from the ufe of
machinery in  this difeafe, muft be  from  the fupport that
it  can give  to the  head and  ffioulders.    This  indeed
                                                           is

  * It may perhaps  not be  amifs  to  give  a more particular defcrip-
tion  of Mr. Pott's  method: To form the iffue he prefers cauftic.
He tells us, that  the cauftic  to be applied, fhould in  adults,  be large
enough to form an oval efehar of about  an inch in length, and nearly
three quarters of an inch in breadth  at the  broadeft part.  One  fhould
be fo  applied on  each fide of the curvature, that the portion of  flan
covering the fpinal proceffes  of the protruded  bones fhall  be left en-
tire.   In a few days, when the floughs begin to loofen, the middle of
them fhould be cut out, and a large kidney-bean, or fome peas, put
into each:  Upon the entire feparation of the  efchars, the fores  may
be filled  conftantly with  peas or  beans;  and  powdered cantharides,
or fome  other  ftimulant  may  be now  and then applied to  them;
thefe will keep them running,  and may perhaps  produce fome other
good effects.
  The iffues fliould be kept  open until  the patient has recovered his
general health.    This period will vary exceedingly; in fome, cures
have been perfected  in two  months;  in others, in not lefs than  two
years, two-thirds of  which perhaps has paffed without any figns of
amendment.
  Mr. Pott relates many cafes in which  there could be no doubt
of the bones tliemfelves being difeafed, that were perfectly relieved
by the method  above defcribed.   See Pott's Works, vol. hi. 
                     L"   527  3
is an objea  of the firft importance; and it can be very
well attained by  the  ufe  of the machine reprefented  in
plate xn. fig. 6.   If  this point is not attended to, the
weight of the head will conftantly tend  to increafe the
diflortion.
CHAP.   XLVI.

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

                   SECT.  I.

   Of the Caufes which may  render Amputation neceffary.

  Amputation may be  rendered neceffary by the caufes
enumerated under the following heads.
  1. Bad compound fraaures.
  2. Extenfive lacerated and contufed wounds.
  3. A  portion of a limb being carried off by a cannon-
ball, or in any  other manner, if the bones  be  unequally-
broken and not well covered.
                                               4. Ex- 
                      C   528  3
   4. Extenfive mortifications.
   5. White fweUings of the joints.
   6. Large exoftofes,  whether they be confined to joints,
 or fpread over the whole bone, or bones of a limb.
   7. Cafes of extenfive caries accompanied with bad ulcers
 of the contiguous foft parts.
   8. Cancer,  and  fome other  ulcers of an inveterate na-
 ture.
   9, Various  kinds of tumors.
   10. Particular diftortions of a limb.
   We fhall confider each of thefe cafes  in the order men-
 tioned.
   (1.) In cafes of compound  fraaures which occur in
 the army and navy, where the patients cannot be duly at-
 tended, where they muft  be much jolted and moved from
 place  to place, if  the bones  are   fo much  broken  that
 when appofed they  do not fupport each other firmly, and
 the-foft parts are likewife much injured,  I am perfeaiy of
 opinion,  that,  in general, immediate amputation ffiould be
 advifed.
   In private praaice, however, where the patient can
 from the firft  be placed in an eafy  comfortable fituation,
 from which he need not be removed until the cure is com-
 pleted,  where he can have all the advantages of good air,
 a  proper regimen,  and good medical  affiftance,  very few
 cafes  will occur in  which amputation ffiould be recom-
 mended.   The only caufe which,  in  fuch circumftances,
 can render an  immediate performance  of it proper, is the
bones of a limb, together with the foft parts  being fo
 ffiattered and bruifed, that there,will be no chance of the
member being rendered ufeful by any attempt that might
be made to fave it.
   But it is particularly to be  obferved, that unlefs the
operation can be had recourfe to foon after  the accident,
n cannot again be admiffible for a confiderable time ; for
                                             whenever 
                      C   529  3
whenever a limb has become fwelled and inflamed, it  can
in no cafe, but with the utmofl  danger,  be taken off until
thefe fymptoms fubfide.
  And  numerous  obfervat'ons  have afcertained the faa,
that amputation at this period,  i. e. as foon  as the inflam-
matory  fymptoms have gone off, and before the  patient has
been too much weakened by the difcharge,* fucceeds much
better than when it is instituted immediately  after the acci-
dent.   In the latter cafe, death feems to be induced, by the
violence of the fymptomatic fever, which oftentimes induces
fatal hemorrhagies ;  by the great and  fudden change  pro-
duced in the circulating fyftem; and by the violent agita-
tion of mind excited by the operation, and which  feems to
be  more particularly induced at that time.              ,  ^
   Although amputation  is feldom neceffary in private prac-
 tice, yet in the fubfequent treatment of compound fraaures,
 it is fometimes rendered  proper :
    1 ft.  By profufe hemorrhagies,  which cannot otherwife
 be ftopped;  produced  by fome  of  the  arteries being
 wounded by the ends of the fraaured  bones, as well as
 other caufes.
    2dly. By  extenfive mortification.  This  we fhall confi-
  der hereafter.   And,
    3dly. By the ends  of fraaured bones  remaining dif-
  united, attended with  the difcharge of fuch large quan-
  tities of matter that the patient runs a rifk of  finking un-
  der it.
    In every cafe,  when  the laft mentioned  circumftances
  occur,   and  continue, notwithftanding every thing is  done
  which   would probably  tend to  remove them, fuch as the
  taking  away  all loofe pieces of bone,  the preferving the
  Umbfteadily in one pofture,  regular  dreffing of the fore
                           3X

   • The operation feems to fucceed better, whatever may induce a ne-
  ceffity for it, when the patient is fomewhat weakened. 
                      [  53°   3
as often as feems neceffary, allowing a nouriffiing diet, and
a plentiful ufe of bark, nothing  will  fo certainly fave the
patient as the removal of the limb.
  (2.) Wounds not accompanied by  fraaures of the con-
tiguous  bones  feldom  require  amputation:  But  when-
ever a limb is lacerated, or contufed to fuch a degree as  to
have  all the large blood-veffels  deftroyed,  there will then
be no profpea that the circulation can be  preferved in  it,
immediate amputation ffiould  be advifed :  Mortification  is
particularly apt  to occur in  fuch cafes.  It alfo happens,
that amputation,  although it  does not appear neceffary  at
firft,  will become advifable  afterwards, either from he-
morrhagies which cannot be  ftopped,  extenfive gangrene,
or  large difcharges  of matter,  as in  cafes of compound
fraaure.
  (3.) When a portion of a limb has been removed by a
cannon-ball, or fome other means, and the  bones are much
broken  and perhaps fpllntered,  the  mufcles and  tendons
left of unequal lengths, and much  lacerated and  bruifed,
as  the  operation can be performed in the fame time that
the broken and fplintered pieces  of bones,  and the injured
parts of the mufcles  and  tendons can be removed ; as  it
will make a much lefs  fore,  which  confequently will heal
fooner and form a better ftu:np than if the  original wound
is  left, and  no  amputation  employed,  I  have no  doubt
of the propriety  of an immediate performance of the ope-
ration.*
   (4.) In all cafes of mortification by which the whole or
a very great portion of the foft parts of the limb are de-
ftroyed, amputation is the  only refource.   But it  fliould
never be employed until  the  gangrene has fairly ftopped
 its  progrefs; and then I am of opinion we ffiould perform
                                                     it

  * Here the furgeon's judgment and experience can alone determine the
degree of injury which render amputation neceffary. 
                      r  53«   3
it as foon as poffible, and without waiting, as advifed by
fome, for the feparation of the difeafed parts.
  (5.) White fweUings of the joints are only to be remov-
ed, in fome cafes, by amputation.  The particular circum-
ftances  in which  this is  advifable are defcribed chap. in.
The  caufe of the fuccefs of the operation in long continued
inftanees of  Hydarthrus, is probably fimilar to that above
affigned in fome cafes of compound fraaures.
  (6.)  Certain cafes  of exofiofis, in which  the tumor is
productive of much  inconvenience  and  injury to the pa-
tient, and which cannot be otherwife  removed, require
amputation.   See chap. xli.  fea. iii.
  (7.) When an extenfive caries is accompanied by ulcera-
tions which  have deftroyed fo much of the foft parts that
a cure cannot  reafonably  be  expeaed, even if the difeafed
bone was removed,  amputation  is our only remedy.  But
we have inftanees upon record, in which the whole  of
fome of the  larger bones of  the extremities have been re-
moved, in young healthy fubjeas, where the  foft parts
have not  been very much injured,  and  cures  afterwards
obtained: In fuch  cafes there  fias either been  a  repro-
duaion of bone, or at leaft the formation of a fubftance
which fupplied its place.
  (8.) When cancers on the extremities affea the ligaments
or bones, and efpecially if they are  extenfive, nothing but
the removal  of the limb  above  the  parts affeaed can  be
depended on ; and even this fometimes fails.  Every other
fpecies of local ulcer that injures the patient's health, and
which, notwithftanding all the remedies employed, evident-
ly becomes more extenfive, and affords fo large a difcharge
as might  by a longer continuance  endanger the patient's
life,  is likewife indicative  of amputation.
  (9.)  Encyfled  tumors  feldom render amputation necef-
fary ; but in  fome  inftanees where they are deep  feated,
originating  perhaps from the periofteum, they produce
                                                caries 
                     C   532  3
caries or even diffolution of the bones, and fo injure the
foft parts of the extremity, that the operation is the  only
remedy.
  We fometimes find part of a limb confiderably enlarged
with an uniform hardnefs in fome parts, and in others with
a foftnefs, as if a fluid was colfeaed beneath.  This fwel-
ling in the beginning ufually affeas the lower part of the
member, and gradually extends  over the whole of it.  The
fkin at firft has its ufual colour, but at laft it acquires a  li-
vid hue.  There is no pain in  the commencement of the
complaint,  but at laft it becomes not only painful  but ex-
tremely  troublefome from its weight.   It  ufually arifes
without  any evident caufe, and often in people who are
otherwife healthy.
   Swellings of this kind are at firft often miftaken for ana-
farca;  but the effufion into the cellular membrane which
produces them, is tinged with blood, and is  of an acrimo-
nious nature.   When they are opened, the difcharge does
not occafion  much diminution in the fize of them, and a
painful fore is produced which  always  accelerates the dif-
eafe.   Nothing that I have ever feen ufed feems to retard
its progrefs ; and amputation ffiould always  be advifed,  as
foon  as  the tumor becomes materially inconvenient; with
me it has always prevented a return of the complaint, when
performed on a found part of the limb.
   Swellings of the aneurifmal kind, when very large, and
feated in the ham or thigh, if they have continued fo long as
to hurt the texture of the foft  parts,  inducing an oedema-
tous fwelling in them, and fo injure the  bone, and have had
thefe effeas  to fuch a degree as to  preclude all  hope of
the  parts being  reftored  to health, even if the operation
 for  aneurifm ffiould fucceed, admit of no other treatment
 than of removal by amputation of the limb.
   The aneurifm here alluded to,  is that which  proceeds
 from a dilatation of the artery, and in which the coats of the
                                                  veffel 
                       C   533   3
veffel have burft, and a confiderable effufion of blood has »
taken  place  into the  cellular membrane.   In the  latter
ftages of this affeaion, the fwelling becomes fo laro-e, that
the beating of the artery is fcarcely, if at all*  perceptible;
from which it has fometimes been miftaken for a tumor of
a different kind:  The hiftory of the cafe  will, however,
generally lead to a knowledge of its nature.
   (10.) Where a limb is otherwife perfeaiy found,  it fel-
dom happens  that mere diflortion of it can be a fufficient
caufe for  amputation ;  but the diftrefs produced by this  af-
feaion, fometimes induces patients to requsft the perform-.
ance of the operation, when more gentle means fail of  re-
moving the complaint.
   The difficulty of determining the exaa period of the  va-
rious above enumerated complaints,  at which amputation
ffiould be employed, and  the blame which a furpeon is fo
apt to incur if he proceeds  to the  operation  while  the
fmalleft   doubt  remains of  its  propriety,  ffiould induce
every praaitioner previous to a performance  of  it,  to  re-
queft the advice of fome others of his profeffion, in all cafes
where he confiders it neceffary.
                                                SECT.

   * In a cafe of  aneurifm of the arm  from a wound in blood-letting,
 operated upon in  the Pennfylvania Hofpital in the year 1787,  and in
 which part of the limb was exceffively fwelled, there was not the leaji
 degree of pulfation in the tumor :  notwithftanding that it was evident
 to the operator, Dr. Foulke, as well as to moft others prefent, it  was
 the trunk  of the  brachial artery which was wounded,  and that it was
 neceffary to tie a confiderable ramification alfo, which was cut  during
 the operation,  and which was perhaps  two inches higher than  the
 wound of the  arterial  trunk,  the patient  recovered  perfectly in a
 &ort time. 
_  534  3
                   SECT.   II.

   General Remarks on the Method of Amputating Limbs.

  This operation till lately was attended with a great deal
of danger ;  in the prefent improved method of performing
it  however, perhaps  not  more than one death will hap-
pen in twenty cafes, even in hofpital praaice.
  The circumftances which,  in amputation, more particu-
larly require our attention, are, the choice,  when this is in
our power, of the part to be operated upon ; the preven-
tion of hemorrhagy; the divifion of the fkin, mufcles and
bones,  in fuch a manner as to admit of the flump  being
entirely covered with fkin ; the including the arteries alone
in the  ligature;  fecuring the teguments  in a proper fitua-
tion, fo as to prevent them from retraaing after the opera-
tion ;  and a proper fubfequent treatment  of the cafe.
  Next to fecuring. the  patient  from  hemorrhagy,  the
moft material of-thefe is the fav'.ng fuch a proportion  of
the foft parts as will  cover the flump, fo as to heal  the
fore as  nearly as poffible by the firft intention; for  with-
out this, the wound produced by the removal of a large
limb is  always extenfive;  the  cure accordingly proves te-
dious ;  and in many  cafes, the difcharge is fo exceffiVe,
that the patient's health is irreparably hurt by it.  In order
to remedy thefe inconveniences, various attempts have been
made at different times.  At firft,  the f ft parts were cut
down to the bone by one ftroke of the knife, and the bone
afterwards fawed at the edge of the retraaed mufcles.  It
was afterwards  propofed  by Mr. Chefelden to divide the
foft parts by a double incifion ; firft to cut through the fkin
and  cellular  fubftance,  and then  to divide the  mufcles
at the edge of the retraaed fkin; by this  means  the faw
was applied higher in the bone, and the flump was better
                                               covered 
                     C  535   3   *
covered both with mufcles  and fkin.  Still,  however,  an
extenfive fore was left, which in the thigh feldom healed
in lefs than  three months, and often required five or fix;
the flumps were often, from the retraaion of the foft parts,
pyramidal;  and  after they were healed, fometimes an exfo-
liation occurred  at a diftant period.
   To prevent the retraaion of the foft parts from the bone,
 a roller was applied from the upper part of the thigh to the
 end of the ftump ; and Mr. Sharp, as an additional help to
 the cure, propofed to keep  the teguments near together by
 futures : But the laft method was found injurious, and the
 former inadequate.
    In confequence of  the fuppofed impoffibility of  improv-
 ing this method of operaffiig Co as to fliorten the cure,  and
 prevent a pyramidal form of the ftump, about the year 1768,
 different fargeons attempted to revive the  flap operation,
 which had been firft prr.aifed near a century before by an
• Englifli furgeon of the name of Loudham.  See feaion v.
  The objeaionsto this method of operating  were, however,
  fo forcible, that it has never been brought into general ufe.
  And praaitioners by attention to the common mode of am-
  putation have fo improved it, that a fufficient quantity  of
  teguments  is faved to cover the whole end of the ftump;
  and by this means,  unlefs  the patient is of a bad habit of
  body, or the inflammation induced  runs  very  high, the
  whole wound  ufually heals  in the courfe of two or three
  weeks, and the greater  part of it, or perhaps  the  whole,
  by  the firft intention, without the  formation of matter.
  This I confider as one of the moft important improvements
  in the modern  praaice of furgery.  I was induced to em-
  ploy it from obfervation  of  the inconveniencies  refulting
  from the want of attention to the faving of fkin in various
  operations, but particularly in  this; and ever fince 1772,
  I have made if a conftant  rule to five as much integument
  as poffible in ali kinds of operations where I conceived it 
                      C   53*  3
might  expedite the cure.   It was not till  1779,  that Mr.
Allanfon of Liverpool pubiifhed an account of his improve-
ment of the common method of amputation, and which
he recommends from the  experience of nine years.  This
is confidered by many as  the beft mode of operating yet
pubiifhed;  but although by it the wound is chiefly healed
without the formation  of matter,  yet  the  reafons to  be
hereafter mentioned, induce me to give a preference to the
method I make ufe of, and which I fhall now defcribe.

                   SECT.   III.

               Of Amputating the Thigh.

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

  *- A retradlor is ufually formed thus: Take a piece of leather, either
foft or firm, eighteen inches in length, and about fix wide, cut out  a
fmall round or oval piece in the middle, and from the hole thus made
divide the ftrip to one Old.  The  mode  of applying it is too obvious
to need  defcription. 
                      _   538  3
the femoral artery being drawn out with the tenaculum, .1
fufficient ligature ffiould be made upon it before the tour-
niquet is loofened ; all  the arterial branches which can be
difcovered on  loofening the  tourniquet, and waffiing the
wound with a fponge and water, ffiould then be fecured;
taking care to leave the ends  of the ligatures of a fufficient
length to hang without the lips  of  the wound.  The fur-
face of the wound being well cleared of blood, the mufcles
and teguments fhould  be  drawn down  till the fkin com-
pletely covers the ftump, and retained in this  fituation  by
an affiftant, until a flannel or  cotton  roller, previoufly fixed
round the body  to prevent it from  flipping down, be ap-
plied  in fuch a manner as to fupport and fix them; for
which purpofe it ffiould  be paffed  two or  three  times
nearly in a  circular  direaion, round the upper part  of
the thigh, and fliould afterwards be continued in a  fpiral
direaion almoft  to the end  of the  ftump, and moderate-
ly tight.  It ffiould  then be  pinned,  as much of it  bang
left loofe as will pafs two or three times around the ftump.
   The ends  of the  divided mufcles being placed with  as
much equality as poffible over the bone, the edges of the
fkin muft be laid exaaiy together, fo as to form a ftraight
longitudinal line along the centre of the ftump.   When there
are only one or two ligatures, they  fhould be left hanging
out of the inferior angle of the wound ; but when there are
feveral, they ffiould be divided between the two angles, to
prevent the parts from fuffering by a large extraneous body
fixed at any one place.  An affiftant retaining the edges of
the fkin in contaa, two or three flips of adhefive plafter
muft be laid acrofs the ftump to preferve them nearly in
this fituation :  and the whole end of the ftump ffiould now
be covered  with a large pledgit of foft lint fpread with
Goulard's cerate, or the ceratum e lap. calam.  Over this
there  ffiould be placed a foft cufliion of fine  tow,  and a
                                             comprefs 
                      C  539  3
comprefs of old  linen ;  and  for  the  purpofe of retaining
them, as well as to make a gentle preffure on the ftump, a
flip of linen, three inches in  breadth, ffiould be laid over
them acrofs  the ftump.  The remaining part of the roller
is to be  employed to fix this, by paffing it two or three
times  round the ftump ;  and  the preffure formed  by the
crofs ftrap may afterwards be  increafed or diminiffied at
pleafure, by drawing it  with more or  lefs tightnefs,  and
fixing it with pins to the circular roller.
   While we are applying the roller, the tourniquet ffiould
be  taken off;  but  it  muft be  replaced immediately after
the ftump is dreffed.   If let  loofe it gives no  uneafinefs,
and it enables the attendants  to check any hemorrhagy
which may fucceed;  a circumftance which merits attention
for feveral days after  the amputation of any of the extre-
mities.   The patient fhould  now be  carried to bed,  and
the ftump, contrary to the ufual praaice, ought to be laid
fomewhat lower than  the reft of the body; for this purpofe
 the bed ffiould be made with a moderate declivity from
 above downwards, and  nothing ffiould  be put beneath the
 ftump but a little fine tow.
   To prevent the limb from being moved inadvertently, as
 well as to guard in fome degree againft the effea of thofe
 fpafms which often prove troublefome after this operation,
 I commonly fix the ftump  down to the bed, by placing  a
 ftrip of linen or flannel  acrofs  near the end of  the flump,
 and another at the upper part  of the thigh, and  connea-
 ing them by pins to the roller,  and  by pins or pieces of
 tape fewed on them to the matrafs,*  to which  tape is alfo
to be fixed.  A bafket,  or hooped frame,  ffiould  now be
 put over the flump, to protea it from the bed-clothes; and
 an anodyne ought then  always to be given, to prevent or
 remove pain and reftleffnefs.
                                                   As
* A matrafs is much preferable to a feather bed. 
                     C   54«  3
   As hemorrhagies often happen  many hours after the
operation, the attendants fhould be direaed to examine the
ftump frequently; and if any material difcharge takes place,
to tighten the tourniquet fo as to reftrain it till the furgeon
can attend.  This  perplexing circumftance has never taken
place in  any confiderable degree, when  the  method  we
have advifed has been employed ; but in  the old mode  of
operating, the large furface expofed to irritation is very apt
to induce fpafms, which  fometimes  terminate in fatal he-
morrhagies.  When  there is merely a trifling  oozing  of
blood, it need not  be regarded ; but if the difcharge is  fo
great as to lead toafufpicion of its proceeding from a large
artery, the dreffings ffiould be removed, and the veffel tied.
   Troublefome fpafms in the mufcles of the flump fucceed
fometimes  to this operation: If thefe are not taken off by
laying the limb in an eafy pofition, we muft truft to opiates
for their removal.
   In order to remove the inflammation  and tenfion of the
wound, and the  fever, which to a greater or lefs degree, al-
ways fucceed to amputation, it will be proper to confine the
patient to as low a diet as the ftate of his ftrength will per-
mit.  Where there is  much vigour, bleeding ffiould be
ufed as foon as the fymptoms of fever come on, and gentle
feline laxatives ffiould be given.  This treatment is feldom
neceffary but for a few days ; and afterwards would be in-
jurious.
   Where the ftump is not covered with fkin, as in the com-
mon mode of operation, and  a free fuppuration is expeaed,
the dreffings ffiould not be removed  till the fourth or fifth
day; but in the method I recommend, the ftump fliould al-
ways be examined at the end of the third day after the ope-
ration. For this purpofe it ffiould be  fupported by an affift-
ant, while a few turns of the roller are taken off;  and the
dreffings totally removed.  In a  few cafes,  the parts will  be
found to be united  by the firft intention ;  but for the moft
                                                  part 
                      C   54i  3
part there will be a fmall quantity  of matter all over the
furface of the ftump, and chiefly at the lower angle of the
wound ; and the parts will be red, tenfe, and painful to the
touch, with a fmall feparation between the edges of the di-
vided fkin.  The furface of the ftump ffiould now be cover-
ed  with a pledgit of emollient ointment,  and a cufhion  of
foft tow being laid  over this, the crofs ftrips of linen and
roller ffiould be again applied.
   The wound ought to be thus dreffed every other day ;*
 and generally about the  feventh or eighth day, the inflam-
 mation  will be fo  far removed, that the  ligatures may  be
 drawn out; at leaft this ffiould be gently attempted at eve-
 ry dreffing, becaufe they will  now impede the healing of
 the wound. While the roller continues clean, it may remain,
 but as foon as  it becomes fullied with matter, it  ffiould be
 changed.   It  ffiould always be employed for three or four
 weeks, but if  continued longer, it is apt to diminiffi  the
 fize of the limb.
    As foon as the fore becomes clean and begins to granu-
 late, the pain and  tenfion being now gone  off, the cure
 may with propriety be completed by drawing the edges of
 the wound together, by means of ftrips of a moderately ad-
 hefive plafter.  By this management, even the largeft flumps
 will  generally heal  in three or four weeks,  often  in lefs,
 in private praaice, where every defirable advantage can be
 had ; but in hofpitals, where the patient often fuffers more
 from the bad air,  &c. than from the operation,  the fuccefs
 is not  fo great.   In fome inftanees, large finufes form in
 the ftump  between the teguments and mufcles, and retard
 the cure confiderably ; and fometimes a cure cannot be ob-
 tained at all,  without the affiftance of  good air and  diet.
 But for  one inftance of this  kind from the operation we
 have defcribed, there will be twenty from the ufual mode.
                                                     It

    * In moft parts of the United States, during the fummer feafon at leaft,
 it will be generally neceffary to drefs mere frequently. 
                      C  542   3
   It ffiould not be our objea to heal the ftump in the firfl
 inflance, without  the  formation of matter ; when  this is
 done, by the ufe of ftrong adhefive plafters, &c. the tegu-
 ments are apt to be very uneven, and the ligatures are re-
 moved with difficulty; but when the cure is accompliffied
 gradually,  as above direaed, the ligatures may be eafily
 taken out, and the ftump is always left fmooth and equal.
   The  circumftances of confequence, in which Mr. Allan-
 fon's method of amputation differs  from the mode I have
 recommended, confift  chiefly in the manner of dividing the
 mufcles: and the after  pofition of the fkin.  After fepara-
 ting as  much fkin as neceffary,  he direas a double  edged
 knife to be applied to the inner edge of the vaftus  inter-
 nus, and at one ftroke to  cut obliquely through the muf-
 cles, upwards as to the limb, and down to the  bone,  fo as
 to lay the bone bare about two or three fingers  breadth
 higher than is ufually  done by the common perpendicular
 incifion ; the point of  the knife  is then to  reft upon and
 revolve round the bone, while the incifion of  the mufcles
 is continued round the limb  in the direaion that was firft
 given to it.   The  quantity of fkin  faved, and mufeular
 fubftance taken out, muft be in fuch a proportion to each
 other, that by a removal of both, the whole furface of the
 wound will be afterwards  eafily covered, and the length
 of the limb  not more fhortened than is  neceffary to obtain
this end.
   Mr  Allanfon direas the fkin  and mufcles to be placed
over the bone in  fuch  a direaion as that  the wound ffiall
appear  only  as a  line,  with the angles  at each  fide ;  and,
inftead  of fecuring the  dreffings  with a  part  of the roller,
he direas a manifold bandage to be employed.
   I have ufed this  method of operating;  but I find it
much more exceptionable than that I have above  defcribed.
The removal of fuch a  large portion of mufeular fubftance
as is done by  Mr. Allanfon's oblique incifion, produces a
                                              hollow 
                      C  543   3
hollow, which not only retains the matter, but which pre-
vents the ftump from being fo equal and  fmooth  as when
the fkin is fupported by a flat mufeular furface, in the man-
ner we have advifed.   Nor is the bone fo well covered by
mufcle, and the danger of exfoliation fo well avoided, by
his method as by that I have defcribed above.  But if the
ultimate advantages refulting from both were equal,  the
latter mode would claim a preference on account of its
greater facility of performance.  It  is  almoft impoffible
to avoid mangling the fkin in making the oblique incifion
of  the mufcles,  and the affiftants which Mr. Allanfon di-
reas to prevent this,  muft be apt, not only to embarrafs
each other, but the operator.
   Mr. AUanfon's reafon for placing the  lips  of the wound
 tranfverfely is,  that after the  cure,  the cicatrix will be
 drawn near the lower  edge of the extremity by the fupe-
 rior force of the pofterior mufcles, aud  confequently that
 the preffure on the ftump in  walking will be afterwards
 made upon the found (kin.  But I have found no inconve-
 niency from  the cicatrix being oppofite  to the bone, and
 the lodgement of matter which is fo pernicious, and would
 probably  be fo apt to occur from the  method recommend-
 ed by him, is to me  a fufficient  reafon  for preferring the
 perpendicular pofition of the integuments.


                   SECT.   IV.

                 Of Amputating the  Leg.

    Whenever the ftate of the difeafe will admit  of the leg
 being amputated juft above the ankle, it ffiould be always
 done in preference to taking it off at the ufual place about
 four inches  below the patella;  becaufe the operation  is
 there performed with more eafe and fafety  to the patient,
       r                                           en 
                      [  544   3
on account of the fmaller diameter of the leg and the great-
er proportional quantity of foft parts, which enable us to
cover the fore  more completely,  and heal  it fooner; and
becaufe machines may  be fitted to it  which are  much
more pleafing to the eye than the wooden  ones commonly
ufed;  and with which the  patients are rendered capable
of walking very well,  as they preferve the  ufe of  the knee
joint.
   But when this is not admiffible,  as  the cure  of a  leg
amputated  immediately below the knee is  always tedious,
owing to the great extent of bone at this part, and the  de-
ficiency of foft parts,  and as the bone is equally  well  de-
fended from the preffure of an artificial leg when the ope-
ration is performed above the knee,  I would always give a
preference to the latter, when it was optional.
   If, however, the ufual place is chofen, the fame general
direaions that were given for the amputation of the thigh,
will apply to the operation here, except that the tourniquet
need not be placed much above the knee, having the cufhion
on the artery in the ham:  and as the teguments  are clofe-
ly attached to the bone on the fore-part of the  leg, they
muft be rolled up, when a fufficiency of them is feparated,
to keep them out of the way of the knife.  The mufcles
are to be cut juft below the infertion of the flexor tendons
of the leg; and the interoffeous parts muft be divided with
the end  of the amputating  knife, or with a fmaller knife
termed a catline.
   In fawing the bones, the inftrument ffiould be applied
to both at the  fame time, to prevent a  rifk of fplintering
them;  and in the application of the roller, two or three
turns above the knee will be fafficient.
   In operating above the  ankle, the moft convenient part
is about nine inches below the knee, meafuring  from  the
condyles of the femur, both on account of accomplifhing
a fpeedy cure,  and of adapting an artificial extremity to the
                                                ftump. 
                      [   545  3
ftump.  The cure is ufually produced in lefs than three
weeks, and the furface of the ftump will be equal, and co-
vered entirely with found fkin.

                   SECT.   V.

              Of Amputating  with a Flap.

   This operation was invented a century ago, in order to
 obviate the difagreeable confequences of the ufual method
 of amputation.   In performing it,  a flap of fkin and mufcles
 was preferved, fufficiently large to cover the whole ftump.
   The flap operation was never received into general ufe,
 becaufe it was found difficult  to reftrain the  hemorrhagy,
 when it happened to recur after the flap  was applied and
 fixed in its fituation ;  for, in order to difeover the bleeding
 arteries,  it was neceffary to undo the whole; becaufe the
 flap was found not to adhere uniformly  over the furface
 of  the ftump;  and, becaufe the pain and  inflammation
 produced, was more confiderable than that which was con-
 fequent to the ufual mode.
    To remove thefe objeaions, Mr. O'Halloran, about the
 year  1768, propofed to drefs the ftump and flap as fepa-
 rate fores for  the firft twelve days; and  the rifk of he-
 morrhagy, and the inflammation, having then gone off, to
 fecure the flap on the furface of  the ftump by plafters and
 bandages till they united.
    By this improvement, the operation was rendered more
  fafe and certain ; and it is probable that it  would gradually
  have come into general praaice, if the improved method
  which we have already defcribed, had not  in the mean time
  been introduced:  But,  notwithftanding this is generally
  preferable, yet,  wherever  the divided parts cannot  other-
  wife be  properly covered with fkin, the flap  operation
  ought certainly to be employed.  This will be the cafe in
  amputating the arm at the ffioulder,  the thigh  at the hip-
                          3  z                     ^"^ 
                      [  54*  2
joint, and the fingers or toes.  But as fome may perhaps
prefer it when the operation is performed immediately be-
low the knee or above the ankle, or in the arm and fore-
arm, it will be proper to deferibe  the method of doing it
in all thefe places.

                    SECT.  VI.

        Of Amputating the Thigh at the Hip-Joint.

   This has  always been confidered as a very hazardous
 operation, and there are confequently very few inftanees
 of its having been  performed; but,  as in  the method I
 ffiall recommend there is very little hazard  from hemorr-
 hagy, and fo much fkin is faved, that the fore can be en-
 tirely covered by it, and confequently will heal in a few
 weeks, whenever cafes occur which would otherwife ter-
 minate in the death of the patient,  we fhould certainly not
 hefitate to perform it.
    The circumftances  which moft  commonly render this
 operation neceffary, are, gun-fhot wounds, accompanied
 by fraaures of the upper part of the os femoris, and fpina
 venofa, or caries of the head of it: It may alfo be proper
 in all the cafes  formerly noticed, when treating of ampu-
 tation in  general.
    In performing this operation, the patient ffiould be placed
 upon a table, on the found fide, and fecured by affiftants.
 Let the tourniquet be  applied as near as poffible to the top
 of the limb, the femoral artery having the cufhion fixed
 on it juft below Poupart's ligament.   Let the integument.
 and tendinous fafcia of the  thigh be divided by a circular
 incifion,  fix inches from the top of the thigh; that is, at
 leaft three  inches  beneath  the band  of the  tourniquet.
 Let the  retraaed fkin be pulled  an  inch  upwards;  and
 then let  the mufcles  be divided at its edge down to the
 bone.  The arteries  are then to be fecured-  This being
                                                   done 
                      t  547   3
done, take a fcalpel larger than the common fize, and com-
mencing at the upper edge of the circular cut on the pos-
terior part of the thigh, make an incifion down to the bone,
and carry it up of the fame depth to a little above the great
trochanter,  into the joint.   Let a fimilar cut be made on
the oppofite fide of the limb, at a fufficient diftance from
the femoral artery, and completely down to the bone. Let
thefe two portions of flefn be now  diffeaed from the bone,
and the flaps formed by them betaken care of by affiftants,
while any artery divided, is tied as foon  as  it is obferved.
The joint being laid bare, the femur muft be moved m dif-
 ferent direaions, and particularly inwards, where it yields
 moft readily, from the brim of the acetabulum being loweft,
 until it is fo far turned out of the focket as to admit of the
 round ligament being reached with the point of a fcalpel,
 or a firm  probe-pointed biftouri,  and divided,  when the
 limb may be removed.
   If the acetabulum is found, our profpea  of a  cure will
 undoubtedly be more favourable than if  it is carious : But
 in whatever ftate the bones maybe, our treatment of the
 fore muft  be fo direaed as to heal it as much as poffible
 by  the  firft  intention.   After removing  the coagulated
 blood, and placing the mufcles as nearly as poffible in their
 natural fituations,  the  flaps fficuld be drawn together  fo
 as to cover the fore as  completely as may be;  they fliould
 be fecured in this fituation by three or four futures, by ad-
 hefive plafters,  and by compreffes retained by  a broad
 flannel roller paffed feveral times round the body and over
 the ftump; care being taken to leave the ligatures hanging
  out of the wound.
    The patient muft now be put to bed, and treated as in
  other cafes, except that  a more particular attention will
  be requifite to prevent and  remove inflammation and fever:
  And it will be proper  to advife  a very moderate diet for a
  confiderable time afterwards. 
                     C  548  3
  The ligatures may be removed in about ten or  twelve
days.  Colfeaions of matter will probably be very  apt  to
form in the ftump; and if preffure does not remove them,
they muft be difcharged by punaure with a lancet.

                  SECT.   VII.


     Of the Flap Operation immediately above the Knee.

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

         Of the Flap  Operation  below the Knee.

  The method  of operating here, is nearly fimilar to that
direaed to be employed above the knee.   We have hitherto
been advifed to form the flap on  the back part of the leg;
but I would  prefer the outfide,  whether the  operation is
performed immediately below  the knee, or at the diftance
formerly recommended above the  ankle,  on account of
the matter that will be produced finding a more ready dif-
charge,  than when the ufual part is chofen.
SECT. 
[  5S*   3
                   SECT.   IX.

       On Amputating the Foot, Fingers, and Toes.

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

  * A  common fpringfaw (plate ii- fig. 3-) »*  &» he ufcd 5n this
operation. 
                     C   552  3
ffiould be inferted in fuch a manner as to avoid the  flexor
and extenfor tendons.
  Fingers and toes are ufually amputated in the fame man-
ner as the larger extremities, either by  preferving  a flap
fufficient for covering the  ftump, and afterwards dividing
the bone with a fmall fpring faw, or by the double incifion:
But it is much better always to cut them off at the  joints.
A flap being marked with ink, and  diffeaed from the bone
with  a  fcalpel, a  circular incifion ffiould then  be made
through the reft of the  foft  parts,  a little below the joint,
and on a line with the bafe of the flap.  The finger ffiould
then be moved, to afcertain the proper  place in which the
lateral ligament ffiould be cut;  and when this is divided,
the whole  may be readily taken  off.  The flap is then to
be applied, and fecured by adhefive  plafter, a comprefs, and
flannel roller.  If it is neceffary  to  tie an artery,  the tena-
culum ffiould be ufed.

                    SECT.   X.


     Of Amputating the Arm at the Joint of the Shoulder.


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



                           4 A                  *" 
                     C   554  3
preffure above  the clavicle, ffiould any confiderable quan-
tity of blood be difcharged, until the veffel can be tied.
  A cure may foon be expeaed in favourable circum-
ftances ; as the mufcles appear to unite as fpeedily to carti-
lage as  to bone.

                  SECT.   XI.

               Of Amputating the Arm.

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

Of Removing the Ends of Bones in  Difeafes
                 of the Joints.
     THERE are feveral inftanees  upon record of the
      ends of the larger bones being removed when dif-
eafed, and of the deficiency thus produced being fupplied
                                                 by 
                          C   SSS  3
  by nature.   Mr. Park of Liverpool has lately propofed this
» operation as  a general remedy in affeaions  of the joints ;
  fuch as injury to  them from external violence, white fwel-
  lings, and caries.   He  thinks  it will be chiefly applicable
  to affeaions of the knee and elbow, particularly the latter,
  and more efpecially when they proceed from external vio-
  lence.  Mr. Park relates a cafe of white  fwelling of the
  knee in which it was praaifed  with fuccefs.  The fore was
  healed, but not without  much perplexity and diftrefs, in
  about ten weeks, and the patient has fince been  able to do
  duty on board of a fliip, without the aid of a crutch.  The
  operation was thus performed.
    An incifion was made, beginning about two inches above
  the patella, and continued about as far below it; another,
  crofting this  at right angles,  immediately above  the  pa-
  tella, the leg  being extended,  was made through  the ten-
  dons  of  the  extenfor  mufcles,  down  to  the bone, and
  nearly half round  the limb: the lower  angles,  formed
  by thefe incifions, were raifed  fo as to lay bare  the capfu-
  lar ligament; the patella was then taken out, and  the  up-
  per  angles were raifed,  fo as fairly to denude the head of
  the femur, and to admit of paffing a fmall catline acrofs the
  pofterior  flat part of the bone,  immediately above the con-
  dyles, taking care to keep one of the flat fides of the  point
  of the inftrument quite  clofe  to the bone  all  the  way.
  The catline being withdrawn, an elaftic fpatula  was intro-
  duced in  its  place, to guard the  foft parts  while the os
  femoris was  fawed; which  done, the head of the borre
  thus feparated v/as  carefully diffeaed out;  the head of
  the  tibia  was then with eafe turned out and fawed off, and
  as much as  poffible of the  capfular  ligament diffeaed
  away, leaving only the pofterior part covering the veffels.
  More than  two  inches  of the  femur  was  taken  off,
  and above an  inch of the tibia ;  which was juft  enough
  to admit  of the leg being brought into a right line with
                                                    the 
                     C   SS6  3
the thigh, the previous contraaion of the flexor mufcles
being fuch as  to keep the two fawed ends of the bones
in conta^  To  obviate the inconvenience of the  redun-
dancy of teguments,  a few flitches were paffed through
the edges of the tranfverfe wound,  as well as that  part of
the longitudinal incifion that extended up the thigh.  The
lighteft  fuperficial dreffings were  applied, and  the  limb
placed in a  cafe  of tin, from the ankle to the infertion of
the giuteous mufcle.
   Independent of the difficulty of preferving the limb in a
fixed fituation; of the inconvenience of  a great depth  of
wound ; and of the colfeaions of matter which muft ine-
vitably take place,  there are two other very forcible objec-
tions  againft this operation : The firft is, that where the
bones of large joints are fo much difeafed as to render their
removal neceffary, the furrounding foft parts  are in gene-
ral fo much thickened, inflamed,  or ulcerated,  as  to ren-
der any attempt  to fave them  very uncertain, and much
more hazardous than the amputation of the limb ;  and the
fecond is, the high degree of inflammation which common-
ly fucceeds to wounds of the larger joints.
   To the firft objeaion, Mr. Park replies, that he thinks
this operation will be peculiarly ufeful only when the dif-
eafe originates from  external violence:  and to the laft,
that the operation  has been  frequently done  without any
fubfequent violent  fymptoms;  and that  when thefe  have
occurred, they have probably arifen  principally from  a
partial divifion of the capfular ligaments, and may  com-
monly be prevented by their total removal.  But we  muft
obferve, that we  can fee  no more propriety in  taking off
any part of the capfular ligament, than there would be in
the removal of the tunica vaginalis  in the  operation  for the
hydrocele.  Future experience, however,  muft determine
the propriety of this  part of the operation, as well as  of
the merit of the operation in general.
                                            CHAP. 
[  557   3
             C  HA P.    XLVIII.

Of preventing  or diminijhing  Pain in Chirur-
                gical  Operations.
     THE pain induced by operations may be leffened, ci-
      ther by diminifliing the fenfibility of the fyftem, or
by compreffing the nerves  which fupply thofe parts upon
which the operation is to be performed.  Narcotics of every
kind might be employed for the purpofe of leffening gene-
ral fenfibility; but nothing anfwers this purpofe fo well as
opium.  As this, however,  when given in fufficient dofes, is
very apt to induce naufea and vomiting,  I feldom venture to
exhibit it before an operation. In general it  proves moft ufe-
ful when exhibited immediately after, and then it very com-
monly alleviates that pungent forenefs of which  patients
at this time ufually complain; and by continuing to give it
in proper dofes from time to time, we are  often enabled to
keep the patient eafy and comfortable, till relief is obtained
by the formation of matter, or by the removal of the in-
flammatory tenfion which  ufually accompanies every capi-
tal  operation:  And as this  tends very effectually to mo-
derate the  fubfequent febrile fymptoms,  it ffiould never
be omitted.
  The fenfibility of limbs  is always  more  or lefs diminiffi-
ed,  by the  compreffion on  the nerves, produced by the
tourniquet, in amputations and fome other operations; but
as this anfwers the purpofe very incompletely, it has been
                                                lately 
                      C  553  3
lately propofed by Mr. Moore, of London, to comprefs the
principal nerves fo completely  as  to render the parts be-   •
neath altogether infenfible.   This he endeavours to accom-
pliffi by means of a femicircular plate of iron covered with
leather, having a comprefs at one end, which  is to be ap-
plied  immediately above the feat of the nerves,  and by a
fcrew paffed in at one end.
  In  order to obviate the inconveniency which muft ne-
ceffarily arife from the preffure on the veins  by this ma-
chine, Mr. Moore  propofes to open one of them during
the operation ; but as this might be very injurious to weak
patients,  it would be much better to have  the inftrument
formed fo  as to prefs  chiefly upon the nerves; as this,
however, cannot eafily be done, on account of contiguity
of the veins to the nerves, perhaps the fame purpofe may
be anfwered by compreffing the arteries of the limb for a
minute or two before any preffure is applied to the veins,
by which the latter may be previoufly emptied.
C  H  A  P.    XLIX.

    Of Midwifery.
     THE only operations in midwifery which a furgeon is
      called upon to perform, are, the crefarian feaion,
and the figaultian operation or divifion of the fymphyfis
pubis.   The objea of both thefe is the fame,  viz. to ex-
traa the foetus when the delivery of it  cannot be effeaed
                                                either 
                      t  SS9  3
either by means of the exertions of the mother, or by the
aid of the common midwifery inftruments, on account of a
preternatural narrownefs of the pelvis.   By the firft,  an
opening is made into the uterus for the removal of the
child ; and by the latter, the diameter of the pelvis is intend-
ed to be increafed, fo as  to allow the foetus  to pafs in the
ufual way by the vagina.

                     SECT.  I.

               Of the Ceefarean Operation.

   This operation has not only been performed when  the
 pelvis has been fo narrow as not to allow  the child to  pafs
 out, but alfo when the child has been forced into the ca-
 vity of the abdomen, after a rupture of the  uterus, from
 this organ contraaing too forcibly before the os tincse has
 been fufficiently dilated.
   The csefarean feaion is direaed to be  performed, either
 v/ith a view to fave both the mother and child ;  to fave the
 mother only, when we  know that the child is dead; or to
 fave the child immediately after the death of the mother.
   As there are but few  inftanees of the mother being faved
 by this operation, fome have advifed it never to be perform-
 ed, except in the latter cafe ; but if it is proper at all, it cer-
 tainly ffiould be employed, not only then, but  in both the
 other circumftances mentioned, to give fome chance of pre-
 venting death, at leaft to the mother.  The following is the
 method of performing it.
   The patient  ffiould be placed on a table,  and laid upon
 her back, and her hands and legs properly fecured by affift-
 ants ; her head  fhould be moderately  elevated with  pil-
 lows', and  her  thighs  fomewhat  raifed.  The  operator
 ftanding one fide of the table, is to make an incifion with
                                                     a 
                        [   S6o  3
 a fcalpel through  the  teguments of  the  abdomen, begin-
 niue; two inches above  the umbilicus, on the outer edge  of
 the reaus mufcle, and from thence  about fix inches per-
 pendicularly  downwards.   The uterus is  now  to be laid
 bare, by continuing the cut through the tendinous parts  of
 the abdominal  mufcles and  peritonaeum ;  and an opening
 being then made in the uterus large enough to receive the
 finger,  a probe-pointed biftouri  is to be  conduaed upon
 this, in order to make the cut of the womb as long as the
 external opening.  The biftouri is alfo the beft inftrument
 to divide the peritonaeum and tendons.
   If any large blood-veffel is cut in making the incifion,
 either of the  external parts  or of the uterus, it ffiould be
 immediately fecured by the tenaculum ;  and the ligature
 ffiould  be left  long  enough to hang out  at the external
 wound.  The child  muft then be taken out, and the pla-
 centa, and any  blood that may have efcaped, removed as
 fpeedily as poffible ;  the inteftines,  if they have protruded
 being then replaced, the external wound ffiould be fe-
 cured with  three or four futures, as direaed chap, xxxix.
 fea.  xi. § 3.   The wound  being covered with  a  pledgit
 of emollient ointment,  the abdomen  ffiould be fupported
 by a  flannel  roller;  and the patient ffiould then  be put to
 bed,  and ftriaiy enjoined to avoid fpeaking and every kind
 of exertion.   She  fliould be kept cool, and opiates ffiould
 be given to obviate pain.*?
                                               SECT.

  * A new mode  of  performing  the Cafarean operation is recom-
mended by M.  Lawoerjat,  in a volume on that fubjetft, pubiifhed  at
Paris,  in  1788.  His method is, to make a tranfverfe incifion, of about
five inches in length, through the parietes of the abdomen, between
the re6H mufcles and fpira dorfi.  The incifion muft  be made on the
right or left fide, higher  up or lower down, according as the fundus
uteri happens to be  fituated,  after the  membranes have been  ruptured
and the uterus has  had time to contracl:  The incifion of the uterus
ought to be as near as poffible to its fundus, and fimilar in every re-
                                                    fpedk 
C   5*i   3
                       SECT.    II.


          Of the Divifion of the Symphyfis Pubis.


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

fpe<5b to that made in the abdomen,  with which it will, at firft, corre-
fpond.
  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 incifion,  hitherto  in  ufe.  I. In  this  way, there' is  at  leaft
two-thirds  of  the uterus,  towards  its inferior part,  left untouched.
This cavity retains the lochia till difcharged in the natural way.  The
longitudinal fedljon  leaves no  fuch cavity;  hence  extravafations in
the abdomen,  and the death of  at  leaft nine in ten of  all who  have
been operated  on in this manner,   a. The tranfverfe  incifion is  more
favourable to the fpeedy  healing of  the wound.  The  uterus, in preg-
nancy,  is extended longitudinally more than tranfverfely; and as the
contraction, after delivery, muft  be  in  proportion to this previous ex-
tenfion, the lips  of the tranfverfe incifion  are  brought together,  and
foon united; whereas the lips of  the longitudinal incifion have a natu-
ral  tendency to feparate in every  part, except  at the  angles.  3. The
lips of the external wound are  brought together by the  moft  natural
and eafy  fituation  of the patient,  (the head inclined forward, and the
thighs  bent),  and their union is facilitated;  but let  her  lie  in  what
pofition we may, the  lips  of the wound,  if made by a longitudinal in-
cifion, will feparate, and it will  be  impoffible  to bring them  together
without having  recourfe to the uniting  bandage,  which  he thinks a
dangerous expedient.
  M. Lauverjat  performed the operation,  in  this  way,  on three pa-
tients,  with fuccefs.   The names  of  two other furgeons are  given,
who alfo  performed it fuccefsfuUy four times.   No  unfuccsfsful cafe
is mentioned. 
                      C   562   2
  The operation is eafily performed.  The patient muft
be laid  upon her bad. on  a table;  the pelvis ffiould be
raifed by two or three pillows,  and the legs and arms fe-
cured by affiftants.  The bladder ffiould then be emptied
by the catheter, which ffiould be retained in the urethra,
by an affiftant, till the bones are divided, in order to point
out the urethra, and thus prevent it from being wounded.
  After ffiaving the pubes,  the operator, ftanding one fide
of the patient,  fliould, with a fcalpel, make a longitudinal
incifion  through the teguments  of  the fymphyfis of the
pubes, from the upper edge  of thefe bones nearly their
whole breadth:  the cartilage  by which  they  are  joined
ffiould then be flowly and cautioufly divided; which  is
eafily done on account of its foftnefs.
  The bones now recede confiderably from each other;
and to prevent  this from taking  place fuddenly and forci-
bly,  the affiftants fhould be direaed to fupport the  thighs
carefully towards the clofe of the operation; and if a fuffi-
cient opening is not immediately produced,  they may after-
wards be cautioufly feparated.
  The child and placenta are  now  to be delivered  in the
ufual  way;  and the bones ffiould then be put together,
and retained in their fituation by a  flannel or  cotton rol-
ler applied round  the pelvis and thighs.   The patient
ffiould be kept as much as poffible in one pofture until the
bones have united,  which v/ill probably happen in five or
fix weeks:  But fhe ffiould not be allowed to walk,  or ufe
any pofture which might change the fituation of the bones,
in lefs than nine or ten weeks.   The fore in general heals
with light eafy dreffings.
  The only important objeaion to this operation is,  that it
gains  fo fmall a fpace in  that part of the pelvis where an
increafe of  fize is moft required ; between the facrum and
pubes:  For here the difficulty is almoft always met with.
After the divifion, the diameter of the pelvis in this direaion
remains nearly the fame,  although a feparation  of at leaft
                                                  two 
                      [   5*3  3
two inches* is produced, from fide to fide.   However, as
even this  may in many inftanees be of eflential advantage,
and as the operation is attended with  no kind  of danger,
for it has in feveral inftanees, been repeatedly performed
on the fame  woman, it  ffiould always  be advifed in pre-
ference to the csefarian feaion.  And if future experience
ffiould determine that  the child may always be delivered in
this manner, it ffiould even be preferred to the mode of de-
livery by the crotchet.
T
       CHAP.    L.

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

  * Dr Ornc, of Salem, New-England, performed this operation on  a
woman who died in child-bed, and found that »| inches were gained with-
out difficulty : a quarter of an inch more might have been gained.  See an
interefting publication by the Maffachufetts Medical Allocation, entitled
Medical Papers. 
                     t  S64  3
  The body being placed upon a table, and the head firm-
ly fupported, an incifion fliould be made from ear to ear,
acrofs the parietal bones.  The fcalp is now to be diffeaed
from the parts beneath ; and half of it being  turned back-
ward, and the other half over  the face, with a common am-
putating faw, we muft divide the cranium, beginning on the
os frontis juft above the frontal finufes, and  continuing it
all around.   The feparated part may then be  raifed with a
levator.  If we wiffi  merely to know whether any water
be contained in the ventricles, the brain need  not be remo-
ved ; but if our objea  is to afcertain the ftate of the brain,
it muft be taken out and examined at leifure.   The extra-
vafated blood  being afterwards  removed by a fponge, the
parts are to be replaced and  the fcalp fewed by the glover's
ftitch,  or in  any other way  agreeable to the operator:
For this purpofe, narrow tape and  a large curved needle,
with a triangular point, are ufually  employed.
  The cavities of the  thorax  and abdomen are moft effec-
tually expofed  in the  following manner: Let an incifion
be made through the integuments from the top of the fter-
num to  the umbilicus,  and  from thence on each fide and
through the mufcles, to the top of the os ilium ; the tegu-
ments and mufcles muft now be diffeaed from the fternum
and ribs, and the cartilages divided with a ftrong knife as
near as poffible to  the ribs.   The  diaphragm being  then
feparated beneath, the lower part of the fternum and car-
tilages conneaed with  it, being raifed and  turned upward,
the fternum muft cither be feparated from the clavicles, or
cut acrofs near its upper end.
  This will bring the  vifcera fully into view,  and moft of
them  may  then be examined without being removed ;  if,
however, much accuracy is  requifite, all or  any part  of
them may be taken out, as may be judged neceffary.
  To prevent  the effufion of blood or excrement, two
                                               ftrong 
                      C   s6s  3
ftrong ligatures ffiould be paffed, at the diftance of an inch
from each other, round the lower part of the inteftines and
large  contiguous blood-veffels,  and  round the trachea,
cefophagus, and  large blood-veffels  of the neck.  The
parts between the upper and lower ligatures being divided,
all the vifcera may then be  eafily removed by  diffeaing
them from the contiguous parts, and raifing them up as we
go  along.   "When  the neceffary  examination  has been
made, the effufed blood all waffied off with a fponge, and
the vifcera replaced, the teguments  muft  be drawn over
them, and ftitched neatly together.*
   In opening difeafed bodies, the operator ffiould be very
 cautious to avoid wounding his fingers and hands :  Death
has been the confequence of negfeaing this.
CHAP.   LI.

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

   * The glover's ftitch is generally employed  for this purpofe;  and
 in performing  this, either a ftraight or curved needle may be made
l ufe of. 
                      C   566  3
ing removed in the manner mentioned in the laft chapter,
they are all, excepting the heart, put into a leaden box with
a confiderable quantity' of an  aromatic  antifeptic powder,
prepared with, myrrh, frankincenfe, cloves, the leaves of
lavender,  rofemary, mint, and other fimilar articles; and
to thefe are added fome  of  the  odoriferous  oils.   The
blood  being taken out of the different  cavities, and  the
heart replaced, they are all filled with a due proportion of
odoriferous o'ds or fpirits, and the parts afterwards fewed
up.  By fome, the mouth and nofirils are fluffed with
thefe powders and oils ; and incifions are made into all the
fleffiy parts of the body, which are alfo fluffed with them,
and fewed  up : but there is no neceffity for this, urtlefs the
body is to be kept'for  a confiderable length of time,  or
to be carried  a confiderable diftance; in  which cafe, the
trunk and  extremities are firmly rolled up with bandages,
and the whole varniffied.
  The body is afterwards to be covered with cerecloth,*
fecured by tapes  or ligatures ;  and it is then dreffed, and
either laid  in a coffin, or expofed to view, according to cir-
cumftances.

                                             CHAP.
  * The cerecloth is made of linen dipped in a compofition of wax, oil,
and rbfin, and coloured with verdegris, or red lead; 
C  s6i   3
C  H  A   P.   XII.

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

   * In general, the  width of rollers may be from one and an half to
two and  an half  inches, according to circumftajices. 
                      r.   s69  3
which is an oval, hole; and is employed in fraaures of the
lower jaw.  The undivided part is applied to the chin, the
end  of which projeas through the hole.  The two fupe-
rior  heads are then carried backwards over the occiput,
and  returned forward over the os frontis, where they may
•be pinned.  The lower heads of the roller being refleaed
over the chin, are then carried to the top  of the head, and
there fattened.
   6. The napkin and feapulary.  The napkin is about fix or
feven inches broad,  and when ufed for  the retention of
dreffings, ffiould pafs but once around the body, and be tied
before by pieces of  tape;  but when  it is employed for a
fraaured rib,  it ffiould go feveral times around.  It is to
be placd immediately below the arm pits. The feapulary
confifts of a flip about three inches broad, and  of a length
fufficient to reach from the upper part of the  napkin be-
hind,  and pafs over the ffioulders to be conneaed to it
before; and has  the anterior end of it longitudinally di-
vided,  the flips being carried on each fide of the head.
   7. The bandage  for compreffing the abdomen after the
paracentefis.   See pi. xi. fig. 5.  and explanation.
   8. The trufs for herniae.   See  pi. vi. fig. 4. and expla-
nation.
   9. The fufpenfory bandage  for the penis  and fcrotum.
This is formed by  a fmall pouch of linen or  flannel, or
what is perhaps  better than either, of cotton,  conneaed
to a  eircular bandage paffed round the body,  either before
only, or both behind and before.
   10.  The T bandage.  Formed of a ftrap paffing around
the body, to which a broader piece is-conneaed, and  flit
longitudinally for better than half of its length ;  thefe flips
pafs  from behind, on each fide of the penis  and fcrotum,
and  are pinned to the anterior part of the circular ftrap.
   ir.  The manifold bandage.  This is  formed generally
                        4  C                       of 
                        [   5?o   ]

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

  * This  form  of  bandage is thought  by fome to be  improved,  by
having the oppofite tails or flips connected fo as to form a very obtufe
angle :  This makes them apply more neatly to the limb.
THE    END, 
TES.*
 trepan.
ird lefs
le A A,
\ is the
>er part
rorator,
 it of a
  in the
 is nut,
 awing,
 mecef-
 of the

  n this
 of the
  being
  crof-

   this
  le, is
   ball
  rame

   one
  fide,

   1 ob-
   ibing
    are
   :ric_l 
 
EXPLANATION  of  the   PLATES.*
                       PLATE   I.

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

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

                    PLATE   II.

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

                    PLATE   III.

  Fig. 1. Mr. Freke's  machine for  reducing  luxations.
In order to render thfe inftrument readily portable, it is
divided in the middle, and the two halves are conneaed by
brafs hinges  at  C, and  by two  hooks  and  eyes  on the
other fide of  it.  It thus forms, when ffiut, a box only one
                                                  foot 
 iree inches ■
 Ked on the
 : a fulcrum ■
 ie roller E
 ys,  as well
 an, fo that
 backward,

 ie diameter
 driven two
 he  fides of

 > cut,  and
 to  be con-
 )ok to keep
 Uer G, an
 id covered
 fthe head

 r receiving
 ver part of
 n which is
 s a  rotehet
 is ftopped
 fure it may

 ff leather,
 :> pieces of
 ie of them
 ; the other
 to  receive

lir,  and to
 the lever,
there muft
       be 
26 
A__	
	
~ r__r ~ ~ = -"e - -=-	-7
	
	
	S=™J-=
w&im 
fide, and th<
pieces of bo
   Fig. 4. A
   Fig. 7. A
tion of the \
aaiy of the
handle of tt
   Fig. 8. A
   Fig. 1.  :
of trepannii
fize.
   Fig. 2. A
ferent in foi
Bell: It fen
the catlin t<
length, inch
breadth at t
   Fig. 3. l\
gers or toes
   Fig. 4. F<
This inftrun
polypi in th
   Fig-5-A,
don, for app
in the uteru
  Fig.  1.  1
In order to
divided  in tl
brafs  hinge-
other fide ol 
                      [  ill  2
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 ftands high enough to become a fulcrum
or fupport  to the lever B, which is fixed on the roller E
by a large wooden fcrew, which turning fide-ways, as well
as with the roller,  forms a circumrotatory motion, fo that
it may ferve to reduce a luxation either forward, backward,
or downward.
   The roller on which the lever is fixed, is juft the diameter
of the depth of one of the boxes, and into it are driven two
iron pins,  the ends of  which are received  by the fides of
the box, which are an inch thick.
   The lever is  two feet four inches long, and is  cut, and
 conneaed  again by hinges at C, to fold up fo as to be con-
 tained in the box : On the back part of it is a hook to keep
 it ftraight; one end  of it is to hang over the roller G, an
 inch and an half,  which is  to be excavated and covered
 with buff  leather, for the more eafy reception of the  head
 of the os humeri.
   The iron roller E  has two holes through it, for receiving
 two cords from a brace,  fig. 2. fixed on the lower part of
 the os humeri.  This roller has  a fquare end on which is
 fixed  a wheel D, notched round, which works  as a rotehet
 on  a fpring ketch under the lever,  by which it is ftopped
 as it is wound  up with a winch , fo that at pleafure it may
 be let loofe by difcharging the ketch.
   The brace,  fig. 2-  confifts of a piece of buff feather,
 large enough to embrace the arm, fewed on two pieces of
 ftrong iron, curved plates  rivetted together, one of them
 having an eye  at each end to faften two cords in ; the other
 is bent at the ends into two hooks, which are to receive
  the cords after they have croffed the arm above.
    In order to keep  the  patient  fteady in his chair,  and to
  prevent the fcapula from raifing or depreffing the  lever,
  after the limb is drawn forward by the winch, there muft
                                                    be 
                       C-  iv   3
be fixed over the ffioulder, a girth, with two hooks at the
end of it: This ffiould be long enough to reach the floor
on  the other fide, where it muft  be hooked into a ring
fcrewed into the floor.
   Mr. Bell obferves,  that the ftrap or girth  preffes down
the fcapula,  and thus impedes the reduaion ; he therefore
propofes,  that  it  ffiould either be altogether wanting,  or
made with a flit to pafs over the arm, fo  as to draw back
the fcapula,  and inftead of paffing obliquely downwards,
that it fliould go ftraight acrofs, and  be fixed in  a poft on
a  line with  the flioulder.  The lever of  this inftrument
ffiould, he thinks, be fixed, fo as to ferve only for a fupport
to the arm;  or if it is ever ufed as a lever, it ffiould be ma-
naged with  the utmofl caution ; but  this appears  to him
both dangerous and unneceffary.
   The great advantage of this machine is, that we  by it
are able  to apply any neceffary force in the moft  gradual
manner, and in  any direaion.
   Fig.  3. A fcrew  tourniquet.  Every  part of this  in-
ftrument  is  here reprefented  of the  full  fize; it  may b«
made either  of brafs or fleel;  and the ftrap conneaed with
it  ought to be of very firm materials, at leaft an inch broad,
and of a  length rather more than fufficient to pafs round
the largeft part of the extremities.
   As an  improvement on this inftrument, as here repre-
fented by Mr. Bell, a fmall fcrew has been  made to pafs
through the upper part of the large female fcrew, fo as to
enable the operator himfelf to keep the ftrap fixed to any
degree of tightnefs.
   Fig. 4. An amputating faw.  This ffiould be about  fe-
venteen inches in length, including  the handle, and two
inches and a quarter in breadth, at its broadeft part.
   Fig. 5. A common found or ftaff,  ufed in fearching or
founding for the ftone.
   Fig. 6. A grooved ftaff for the operation for lithotomy.
                                                 The 
 
FLATE  IV.
 
                       [  v  3
The groove is here reprefented on the fide, which is prefer-
red by fome, to having it on the back, in the ufual way.
The termination of the groove fliould always be  perfeaiy
free and open,  otherwife it will  be difficult to  difengage
the gorget from it; and its edges ought to be very fmooth.
If the inftrument has  a greater degree of convexity than
here reprefented, it is not eafily introduced, and always in-
jures  the urethra.
   A ftaff for a full grown fubjea ffiould be twelve inches
long, befides the  handle ;  and for children of feven years
and under,  fhould be from feven to nine inches long.

                   PLATE  IV.

   Fig. 4.  A  gorget  fomewhat  different  from  the ufual
 form which is  reprefented by Mr. Bell.   This  inftrument
 only differs from the  common gorget in the conftruaion
 and direaion  of its handle.  The handle is made of wood,
 and  is in the  fame general direaion  with the blade,  but
 bent downwards", fo as to form a very obtufe angle  with
 it.   In the  common gorget, the handle is made in the man-
 ner of that of the cutting direaor in plate v.
    For adults,  the gorget ffiould meafure from  A to B,
 five inches  and an half; and at its wideft part one inch.
 The beak  ffiould be turned a  little forward, and ffiould
 be carefully adapted to the groove of the ftaff with which
 it is  ufed.
    Fig. 3, 6.  Different forms of forceps for extraaing the
 ftone.   For adults, they ffiould be ten inches long.  Their
 blades ffiould not meet when ffiut, and the teeth ffiould be
 fmall, forming merely a roughnefs, and be confined to with-
 in an inch  of the extremity of the inftrument.  Thefe cir-
  cumftances will fave the bladder from injury, and prevent
  fmall ftones from being fixed near the joint, and thus di-
  lating the inftrument.
                                                 F12. ;. 
                       I  yi  ]
   Fig. 5.  A fcoop for removing fmall pieces of ftone that
 cannot be taken up by the forceps.
   Fig. 1.  A probang, for pufliing fubftances fixed in the
 cefophagus into the ftomach.  It confifts of a piece of foft
 fpong£, firmly tied to a piece of flexible poliffied whale-
 bone, from fifteen to fixteen inches long.
   Fig. 2. A double canula for removing polypi from the .
 nofirils.  When the polypus is  feated in the throat, a ca-
 nula fomewhat curved at the end,  anfwers better than the
 ftraight one here reprefented.

                     PLATE V.

   Fig. i. ' A fide view of Mr. Bell's  cutting-direaor.  It
 ffiould be,  for an adult, five inches from A to B, and three
 inches from B to C.
   Fig. 4. A front view.  This inftrument, in the grooved
 part, fliould be exaaiy three-eighths of an inch broad, viz.
 from D to E;  and the cutting  part  of it from F to G,
 fhould meafure nearly an inch.
   Fig. 7. A view of Frere Cofme's  inftrument  for litho-
 tomy, opened.   If the fpring C is preffed upon, fo as to
 raife  it out of the nitch B, (of which nitches there are fe-
 veral) as the handle A is made  to move upon a pivot, it
 may be turned, and the projeaing part of it D, being turn-
 ed entirely round, and preffure applied to E, it will  raife
 the knife F to the elevation here reprefented.  The point
 G ffiould be made blunt and  round, fo as to run freely in
 the groove  of a ftaff.   The length of this inftrument, in-
 cluding the handle, ffiould be ten inches.
   After  making the  incifion with this  inftrument,  the
 forceps may either be introduced upon the forefinger, or    j
 upon a blunt gorget.   It is afferted that  a wound of any
 determined fize may be formed by this lithotome cachee,
as it is termed : And it is preferred by fome to the gorget, be-
                                                 caufe 
PLATE   V.
 
 
                       _  vii  2
caufe  it makes but one cut, while with the gorget, if the
greateft care is not employed we will be very apt to make
two:  This, however can only arife from inattention.  See
page  175 to 183.
   Fig. 8.  A filver canula of a flat form, for compreffing
the arteries cut in lithotomy which lie too deep to be tied.
   This tube fhould be four  inches in length, and  an inch
broad : The holes in the brim of it are for  the purpofe of
conneaing it,  by pieces of tape, to a circular bandage paffed
around the body.
   Fig. 5.  A  male catheter  of filver.   The holes  near  its
 extremity  anfwer  better than  a flit,  which  is  fometimes
 made, as with thefe it is not fo apt to be entangled  with
 the urethra.   Female  catheters are ufually made ftraight,
 or with a  very fmall degree of curvature;  and rather more
 than half the length of the male.  The female found fhould
 always be curved.   Catheters have been alfo made of lea-
 ther, of flexible wire  rolled into the  form of a tube, and
 covered with bougie  plafter,  and of the caoutchouc  or
 elaftic gum or refin.
    Fig 2.  A  machine  for injeaing tobacco  fmoke by  the
 anus  A is  a brafs box for containing burning tobacco,
 fcrewed on  a fmall brafs  tube, which is conneaed to an
 elaftic leather pipe, wound round with brafs wire B,  and
 which is again fitted to a common glyftcr-pipe C.  In
 both ends of the box  there is a divifion of thin brafs, per-
 forated with fmall holes; one, for the admiffion of air,  and
  the' other, for the tranfmiffion of fmoke.   To the box, a
 pair of double bellows is to be conneaed.
    The bellows ffiould be of the common fize.   lhe  box
  fhould be an inch and an half in diameter, and three inches
   nl noth- the brafs  tube  ffiould be  fix inches in length,
  ^quarter of an  inch in  diameter.  The leather  pipe
  ::11 to  be  nearly of the fame diameter with the  tube  an
D                     ab0Ut 
                       C  viii  ]
 about two  feet and an half in length.  The  glyfler pipe
 ffiould be fomewhat larger than thofe in common ufe.
    Fig. 3. A hook for enlarging the foramen ovale, in her-
 nke of that part.
    Fig. 6. A filver canula, for introducing into the urethra
 after amputating the penis.

                    PLATE   VI.

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

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

                   PLATE  VII.

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

                   PLATE  VIII.

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

                    PLATE   IX.

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

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

  *  This  machine is feldom made ufe of in this place.  Compound
fractures  are  dreffed as lightly as poffible,  with  the  bandage and
fplints ufed in fimple fra-tures.  A third  fplint, applied to the back
of the leg, in  fractures of this part, will enable the patient to he on his
back occafionally, and thus anfwer  in fome  degree the intention of the
fradure box. 
                      C  xiv  2
wool.   G, a hole for receiving the heel, to prevent it from
being hurt when the leg is ftretched out.


                   PLATE   XI.

  FiG. i. A jugum, for compreffing the urethra.   It cori-
fifts of a piece of elaftic fteel, lined with velvet or foft flan-
nel.  By means of the fcrew, A, its width can be regula-
ted;  and  the  cufhion B being placed  Upon the urethra,
any neceffary degree of preffure can be applied to it, with-
out interrupting the circulation in the penis to any Confide-
rable degree.
  Fig. 3. A receptacle for  the urine.   It  may be made of
tin, filver, or any  other metal: It  is convex on one fide",
and concave on the other which  is applied to the thigh..
CD, two tubes for conneaing the  part into which the pe-
nis is put, by tapes, to a bandage  paffed  round the body.
F, a fmall tube for fixing the inftrument to  the thigh.  It
may contain three or four gills.
  Fig. 2. A manifold bandage, of 12 tails.
  Fig. 4. This very ufeful part of the apparatus for extend-
ing diflocated limb., is formed of thick fliamoy or buff lea-
ther.   It  is to be tied firmly around  the limb with the
ftraps at each  end; and the extenfion is made by affiftants
pulling the ftraps  paffed over the hooks :  It  anfwers much
better than towels, which are ufually employed.
  Fig. 5. A bandage for compreffing the  abdomen during
and after the operation of  the paracentefis : It is made of
foft leather lined with flannel. A the body of the bandage,
which ffiould  reach from ilium, to ilium, to  be there fixed
by  the ftraps  BBBB to the buckles CCCC  The ftraps
DD, by paffing over the flioulder?, ferve to fix the buc-
kles EE,  which pafs through between the  thighs.  The
perforation  is  to  be made through the wiodon F, which
                                            afterward0 
PLATE  XI
420132821564 
PLATE  XII
 
                        C  xv  ]
afterwards is ffiut by the  ftraps G, and the buckles H, as
reprefented by the letter I.
   Fig. 6. A peffary  for the prevention of hernise  in  the
vagina.   As fteel is  apt to ruft, this tube ffiould be made
of gold, filver, or ivory, with a cord at one extremity,  for
the purpofe of withdrawing it when neceffary.

                   PLATE  XII.

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

  * To both thefe kinds of  fplints fome prefer thofe made  in the Ihape
of Mr. Sharpe's, but formed of flexible pieces  of whale-bone, conne Jed
by Imen, n-ly in the manner of women's  ftays, and fattened by  thm
leather or girthing ftraps in the mode of Mr. Sharpe's.
 f Cedar is ufually employed in this city. 
                     [  xvi  3
ftraps ffiould be from fifteen to twenty Inches in length,
and one in width, and muft be fewed to the outfide of the
fplint.
  G, a part to fupport the foot; from E to H, it ffiould be
five inches.
  C, The foot-ftrap, twelve inches long, fewed to the end
of the fplint, and paffing under the heel and through the
feather loop B on the upper fplint, to the loweft pin A.
  I, a hole, two inches  long and nearly one wide, to re-
ceive the malleolus externus.
  Fig. 3. A fling, or machine for fupporting the fore-arm.
A A, a cafe of firm leather  properly lined with flannel and
wool, of a fufficient length to  cover the arm, from the el-
bow to the ends of the fingers, for  the left fide.  B, a col-
lar of foft buff leather for paffing over the right arm,  in
order to fupport the fore part of the cafe;  this it does by
means of the ftrap F paffing over the left flioulder and fix-
ed to a buckle at C,  to prevent it from flipping down.
GH, two ftraps and buckles for fixing the arm to the cafe.
  Fig. 6. A machine for  fupporting  the head and ffioul-
ders ; and commonly employed in diftortions of the  fpine.
A, an iron collar, properly covered, for paffing round the
neck. By means of the long iron plate conneaed with this,
it may be raifed or depreffed at pleafure.   BBB,  a broad
iron plate,  fitted to the back and ffioulders.  CC, two
ftraps, to be  carried over the ffioulders, brought beneath
the  arm pits, and fixed to two knobs on the ffioulder plates.
D,  a ftrap for fixing  the  plate going down the back, by
being tied round the body.
  Fig. 4. An artificial leg, made of firm hardened leather.
A,  an oval piece of the fame kind of leather lined  with
fliamoy,  fixed upon a plate of iron C, and moving  upon
an axis  at  the  knee.  The ftrap I, with  the  buckle con-
neaed with it,  ferves to fix it to the thigh.   There muft
alfo  be an oval piece conneaed with a fimilar piece of iron
                                                   on 
                      [  xvii   ]
on the oppofite fide of the thigh : Thefe plates  and pads
fliould reach about nine inches up the thigh.  B,  a ftrap
that comes from the fole of the foot,  and goes up the in-
fide of the leg to the  middle of the thigh,  where it is fixed
by a buckle, to a ftrap coming from the  oppofite  flioul-
der ; this ferves to fupport the leg very effeaually.
  Fig- 5'  A piece of foft fliamoy leather,  which fixes by
a buckle and  ftrap round the condyles at the knee, and
prevents the confequences of the  leg rubbing againft the
knee : The ftump hanging loofe within the leg, the friaion
is entirely fuftained by the  condyles and patella.
  Fig. 8.  An artificial fore-arm and hand, made of the
fame  materials,  to be  fixed to the ffioulder  by the ftraps
DE.
   The  legs abovementioned  are equally ufeful with  the
common wooden legs, and preferable from being  neater,
and not liable to break:  and they anfwer  better than thofe
of copper from being confiderably  lighter, and not apt to
be miffiapen by bruifes.
   Mr. Wilfon, of Edinburgh, who  is the inventor of this
fpecies  of artificial legs  and arms,  makes  three different
 kinds, correfponding to the part at  which the limb is am-
 putated.  When the leg is taken off lower than the ufual
 place below the knee, as recommended in  chap. xlvi. fea.
 4,  the  leg above reprefented  anfwers.   The fecond kind
 is*  intended  for  thofe  cafes  where  the  amputation has
 been performed  at  the  ufual place below the knee ; the
 knee then refts upon a foft cufhion, but has no flexion ; and
 the hollow for  receiving the thigh goes nearly up to the
 hip- It is fixed with ftraps and hooks, and opens behind
 to receive the thigh.  When the  limb is taken off above
 the knee, a joint is  formed in the  artificial leg.   In walk-
 ing, the limb is made fteady by a fteel bolt, running m fta-
 ples, on the  outfide  of the thigh, being puffied down ; the
 Lee is rendered flexible by this  bolt  being  pulled up. 
                     [  xviii  ]
The reft  is obtained  from the leg embracing  the  upper
part of the thigh, and from the hip refting upon the fluf-
fed thigh-box.
   The artificial arms are covered with white lambfkin, co-
loured fo as to refemble  the human  fkin.   The nails are
of  white  horn  coloured.  The  joints are made in the
fhape, and fo as  to have the motions,  of the natural joints.
The fingers and metacarpus are  made up to the proper
form, with foft  fliamoy leather and  baked hair.   In the
palm of the hand there is an iron fcrew, in which a fcrew
nail is occafionally fixed.  The head of this nail is a fpring
plate, fo made as to hold a knife and fork:  And by  means
of a brafs ring on the firft and fecond fingers, a pen may
be ufed for writing.
   The quantity  of parts  to be fupplied,  muft determine
whether the ftraps are to  be conneaed to the arm alone, or
*x> the arm and ffioulder.
INDEX. 
C  xix  3
I     N     D     E     X.
A.
A,
    .BSCESSES in general,       -                  9
               the antrum maxillare,              328
                  breafts of women,              425
                  globe of the eye,               272
                  gums,                        327
                  liver,                         423
              lumbar,                           43l
Affeaions of the brain from external violence,        235
Air extravafated into the thorax,      -       -     226
Albugo,         -                -         -    279
Amputation in general,       -      -       -      527
           of the arm,       -      -       -      554
                   at the ffioulder,       -       552
            cancerous mammae,           -        233
            the foot,       -       -       -      55'
               fingers,       -       -    -      55l
               leg,       -                     543
               penis,       -       -       "     *"4
               thigh,       -       -             S36
                    at the hip,      -           5^6
               toes,       -                     SS1
           with a flap,       -       -             545
                    above the knee,       -      548
                    below the knee,      -      55°
Anafarca,        -       -                      .J*1
                                         Aneurifms, 
XX
INDEX.
Aneurifms,          -
          falfe or diffufed,
          true or encyfled,
          varicofe,
Angina      -
Anus imperforated,
Arteriotomy,

                          B.

Bandages,-
Blood effufed into the eye-ball,
Blood-letting in general,
               the arm,
                  ankles and feet,
                  hemorrhoidal veins,
                 jugular vein,
                  tongue,
          topical,
Bones, removal of the ends of
Bougies,       -
Bronchocele,       -
Bronchotomy,
Buboes, venereal,
Burns,       _       -       -

                          C.

Caefarean feaion,
Calculi urinary,
Cancer of the eye-ball,
             breaft,
             lip,
Carbuncle,         -
Caftration, 
                 I  N E>  E  X.                 xxi
Cataraas,         -        -                      284
         depreffion of                            287
         extraaion of      -       -       -      291
Cerate, common,      -       -       -     -       25
        faturnine,         -        -               26
Chilblains           -          -         -         435
Cirfocele         -         -         -    -      154
Compreffion of the brain from external violence,     237
Concretions of the eye-lids,       -       -    -    268
            within the capfular  ligaments,           448
Concuffion of the brain,        -                  247
Contufions       -         -        -              437
           of the head,       -      -       -     251
 Corns,       -       -      -       -       -     458
Couching,          -       -       -      -    287
Cupping,       -       -       -      -      -      97

                          D.

 Deafnefs,         -       -        -               354
          from imperforated meatus auditorius,       355
              excrefcences in the meat, audit.        35^
              extraneous bodies in the meat, audit.     ib.
              wax in the meatus auditorius,          357
 Dentition,        -                               324
 Diflocations,        -                              494
 Diftortions of the limbs,       -       -       -     521
                 fpine,        -       -            524
 Dua parotid, divifion of the          -       -    353

                           E.

 Ears, difeafes of the       -                      354
      perforating the lobes of the     -              359
 Ecchyrnofis          -                     '     .  .
                                            Embalming 
  x«                INDEX.
 Embalming,         -         _         _        -£-
 Empyema,           -         _         .        224
 Eryfipelas,      -         -         .     .       42I
 Excrefcences on the cornea,        -        _       26o
           condylomatous, about the anus,          204
           within the capfular ligaments,           448
Exofiofis,        -         -        _           4?g
Extirpation of the eye-ball,        -        _     282
teftis,
tumors on the
Fiftula in ano
*S9
Eye, difeafes of the         -         -       -     257
     cancers of the         -         -             282
     dropfical fweUings of the         -       -     274
     films on the        -                        270
     protrufion of the ball of the    -         -     281
Eyes, artificial,      -      -        -            284
Eye-lids, inverfion of the       -       -      -     26 j
263
Fauces, difeafes of the           -         -       304
209
      in perinaeo,       -       -       -         198
      lachrymalis,       -                        294
Fraaures in general,      -                       464
        of the arm,       -      -       -       479
             clavicles,       -       -       -     474
             coccyx,      -       -      -      477
             compound,      -       -          490
             fingers,      -                     482
             foot,        -                      490
             fore-arm,       -      -     -     480
             hand,      -         -             482
             leg,         -      -         -     489
             lower jaw,       -       -     -     473
                                          Fraaures 
INDEX.
xxifl
Fraaures of the nofe,	-	472
patella,	-	487
os femoris,	■i	483
facrum,	-	477
offa innominata,	-	ib.
ribs,	-	474
fcapula,	-	478
flernum,	• _	476
fuperior maxillary an	d cheek bones,	473
toes,	-	490
vertebrae,	-	477
wrift,	-	482
Frenum of the penis, divifion of the,	-	165
G.
Ganglions,      -        -                       443
Gangrene,—dry,    -       -       -       -       *2
Gouetre,       -       -      -       -          453
Gums, excrefcences on the,       -      -         332
       fcarification of the,    -       -       -      324
Gumboils,       -      -        *       "       327
H.
Hare-lip,         -       -       -       *      3»»
Hematocele,       -       -       -              I5I
Hemorrhoids,
Hemorrhagies, means of reftraining,        -         79
Hernise in general,         -                -     J r5
       congenital,       -      -       -     »*-«9
       crural or femoral,
       of the foramen ovale,      -               I32
       umbilical or exomphalos,                   J3°
                       4 f                   Hernia. 
xxiv
INDEX.
Herniae, inguinal, or bubonocele,	123
of the urinary bladder,	132
ventral, - -	I3I
fcrotal, or ofcheocele,	ib.
Herpes, -	49
Hydrocele, -	*34
anafarcous of the fcrotum,	*35
fpermatic cord,	148
encyfted of the fpermatic cord,	149
of the tunica vaginalis,	J37
of a hernial fac,	147
Hydrothorax, -I. Inflammation in general,	219
	1
of the eyes,	257
ear,	422
mamma,	425
membranes of the brain,	249
teftes,	426
eryfipelatous,	421
phlegmonic,	1
Inoculation, -	364
Incontinence of urine,	187
Inverfion of the eye-laffies,	265
Iffues, -	362
L.	
Ligature of arteries, - -	79
Lips, difeafes of the, -	3^
cancerous, extirpation of,	323
Lithotomy, -	171
by the greater apparatus,	172
leffer apparatus,	ib.
lateral method,	■ 173
	Locked
 
                   INDEX.               xxv
Locked jaw,       -                              nne
Luxations in general,         -         -           494
         of the ankle,         -        -     -   519
               cranium,       -                  499
               clavicles,       -                  505
              elbow,         -      -       -    511
               fingers,      -       -      -     514
               foot,        -        -             520
               head,       -       -       -       501
               knee,       -       -       -       518
               lower jaw,      -       -          500
               metacarpus,      -       -        514
               nofe,       -       -       -       500
               os coccyx,      -         -       503
                 femoris,       -         -       514
               patella,      -       -      -  .    518
               ribs,       -                      505
              os facrum,      -       -         503
               fpine,           '»  -      -        ib.
               humerus at the ffioulder,      -     506
               wrift,       -       -      -       513
M.
ivlortihcation,	-	-	12
Mouth, difeafes of the,	N.		324
Naevi materni,	-	-	456
Nephrotomy,	-	-	183
Nipples, difeafes of the,	-	-	361
Node, venereal,	-	-	459
Nofe, difeafes of the,	-	-	3°4
Nofirils, imperforated,	-	-	3°7
hemorrhagies from the,		-	3°4
		Obftruaions,	
 
xxvi               INDEX.

                          O.
Obftruaions in the urethra,
CEdema,
CEfophagotomy,
Opening dead bodies,
Ophthalmia,
Ozaena,

                          P.

Paracentefis of the abdomen,
                 thorax,
Paraphymofis,
Paronychia,
Pain, of obviating, in operations,
Phlegmon,       -       -
Phymofis,       -
Pneumatocele,
Polypi in the nofe and throat,
Prolapfus ani,
Pus, formation of,

                          R.

Ranula,
Ruptures of the tendons,
                capfular ligaments,

                          S.

Sarcocele,
Sarcomata, or flefliy excrefcences,
Setons,
Sounding or fearching for the ftone,
Spermatocele,
Spina ventofa,
     bifida,
Sprains, 
                    INDEX.
 Suppreffion of urine,
 Suppuration,
 Sutures,  ......
 Suture, dry,       -
        glover's       -
        interrupted,
        quilled,
        twifted,
 Stone,  the,       -
 Stones  in the urethra,
 Swelling, white,
                rheumatic,
                fcrophulous,

                           T.

 Teeth,  cleaning the,
        derangement of the,
        extraaing of the,
        loofe,
        tranfplanting of the,
 Tents,          -
 Tetanus,       -
 Throat, fcarifying the
         fomenting the,
Thrombus,
Tongue, extirpation of the,
         divifion of the frenum of the,
         ulcers on the,
Tonfils, extirpation of the
Tooth-ach,          -
           from the nerve being laid bare,
                affeaions of diftant parts,
               inflammation,
Trifmus,         -         -       -
Tumors, in general, 
xxviii
INDEX.
Tumors, acute or inflammatory,       -       -      420
        chronic or indolent,       -      - .'  .     439
        encyfted,         -        -                ib.
        from colfeaions in the burfae mucofae,        444
                             capfular ligaments,    446
        fcrophulous,       -       -      -        452

                         U.
Ulcer, fimple purulent,               -       -       21
             vitiated,       -       -       -        28
       callous,       -       -               -       34
       cancerous,         -         -       _       41
       carious,         -                           36
       cutaneous,       -       -       -       -    49
       fungous,         -                 -         30
       fcorbutic,         -          -         -      62
       fcrophulous,         -         -       -     64
       finuous,         -         -         -       32
       venereal,       -      -       -      -      $6
Ulcers in  general,        -          -                 17
       in  the mouth,           -          -        350
Uvula, extirpation of the,       -       -           317
Urethra, imperforate,       -         -      -     165
                          V.
Varicocele,       -       -       -      - t       ^54
                         W.
Warts, -	- 456
Wounds in general,	365
fimple incifed,	366—369
lacerated and contufed,	380
punaured,	377
poifoned,	411
gun-fhot,	4^3
of the arteries,	88
	Wounds
 
INDEX.
xxix
Wounds of the lymphatics,	-	-	383
nerves,	-	89-	-383
tendons,	-	-	ib.
veins,	-	-	382
capfular ligaments		-	385
face,	-	-	387
eye-balls,	-		261
eye-lids,	-	-	ib.
cefophagus,	-	-	388
trachea,	-	-	388
thorax,	-	-	39°
large thoracic ,	yeffels,	-	396
heart,	-	-	396
lungs,	-	-	394
thoracic dua,	-	-	396
mediaftinum,	-	-	396
pericardium,	-	-	ib.
diaphragm,	-	-	396
abdomen,	-	-	406
omentum,	-	-	407
ftomach,	-	-	406
inteftines,	-	-	4°3
mefentery,	-	-	407
liver,	-	-	ib.
gall-bladder,	-	-	ib.
fpleen,	-	-	408
pancreas,	-	m	408 ib.
receptaculum	chyli,	-	
kidnies,	-	-	409 •r
ureters,	-	-	10. - ib.
bladder,	-	-	
uterus, and it	; appendages		4IO
                                             36a
Wry neck,
\ 


, £ 72
-  > -v_» 
•if      .         •
.  1/       •    /    '
*  <     &