1 - A': <■ v--; •* - 'k>* Jt * .*■ ■$ *. P-A.:*" ^■!^.Q^g.g9gS.ff.^.Lrc^.^ V*.- '*- -*-*------.-^1 PRACTICAL SURGERY, CONTAINING A COMPLETE EXHIBITION OF THE PRESENT STATE OF THE PRINCIPLES AND PRACTICE 4 OF SURGERY, COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF INFORMATION, AND ILLUSTRATED BY CRITICAL REMARKS. BY SAMUELJDOOPER, MEMBER OF THE ROTAL COLLEGE OF SURGEONS, LONDON, AND AUTHOR OF THE " FIRST LINES OF THE PRACTICE OF SURGERY." WITH NOTES AND ADDITIONS, BY JOHN SYNG DORSEY, M. D. ADJUNCT PBOFESSOB OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, &C IN TWO VOLUMES. VOL. I. SECOND AMERICAN, FROM AN ENLARGED LONDON EDITION. - <.rfl"l:]''->... PHILADELPHIA: PUBLISHED BY B. &T. KITE, JOHNSON & WARNER, M CAREY, I.PIERCE, S. W. CONRAD, B. C. BUZBY, E. PARKER, AND A. SMALL. 1816. ****»*»*****»• DISTRICT OF PENNSYLVANIA, TO WIT: BE IT REMEMBERED, That on the first day of January, in the fortieth year of the Independence of the United States of America, A. D. 1816. BENJAMIN AND THOMAS KITE, of the said district, have deposited in thit office the Title of a Book, the right whereof they claim as Proprietors, in the words following, to wit: " A Dictionary pf Pi-actical Surgery, containing a complete Exhibition of the present " State of the Principles and Practice ol Surgery, collected from the best and most original sources of * information, and illustrated by critical remarks. By Samuel Cooper, Member of the Royal College ot " Surgeon*, London, and author of the " First Lines of the Practice of Surgery." With notes and " additions, by John Syng Oorsey, M.D. Adjunct Professor of Surgery in >he University-of Pennsyl- *•* vauia, &c. In two volumes. Vol. I. Second American, from the London second edition." In conformity to the act of the Congress of the United States, entitled " An Act for the Encouragement of learning, by securingthe Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies during the times therein mentioned." And also to the Act, entitled " An Act supplementary to an Act, entitled " An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies during-the time therein mentioned," and extending the Benefits thereof to the Arts of designing, engraving, and etching historical and other Prints." D CALDWELL, Clerk of the District of Pennsylvania ADVERTISEMENT. THE American Editor begs leave to prefix a few remarks to this edition. He was induced to republish the first edition, from a conviction, that he would render an important service to his fellow practitioners throughout the United States, by placing within their reach, a mass of Surgical knowledge, greater than had been ever be- fore, condensed into so small a compass. That he was not greatly mis- taken in his estimate of the work, has been rendered highly probable by the rapid sale of a large edition, and by the concurrent approba- tion of many distinguished Surgeons throughout the extensive territo- ries of the United Stat s. The second London edition, from which this edition is re- printed, has been g.-eatly enlarged by the Author, by copious extracts from most of the recent publications on Surgery. The American Editor has retained, in the present edition, the notes published in the first, and has added others, which he trusts will be found of sufficient interest to justify their insertion. He is conscious that he can hope to derive neither literary nor professional reputation from the task he has undertaken, but in ushering into the world a book, containing the united wisdom of the most eminent writers on Surgery, he has at least one satisfaction, that of promoting the best interests of his profession. January 1, 1816. » A DICTIONARY PRACTICAL SURGERY. >#»»< ABA i BANET. A bandage resembling a j\ girdle. ABAPTISTON, or Abaptista (from it priv.SiRdlZ(C7rTi£et,immergo,to sink under.) Galen, Fabricius ab Aquapendente, and especially Scultetus, in his Armamentarium Cldrurgicum, so denominate the crown of the trepan; or, in other words, the circu- lar saw which makes the perforation in the bone,whentheinstrumentisused. The term came into use, in consequence of this part of the trepan having had, at its first inven- tion, a conical form, which kept it from penetrating the cranium too rapidly, so as to plunge the. teeth of the saw in the dura mater and brain.—Encyclopedic Methodi- qite; Partie Chirurgicale, art. Abaptislon. Whatever suppositious advantages the ancient practitioners of surgery may have imputed to the conical shape of the crowns of their trepans, certain it is, that modern surgeons do not, in general, adopt their no- tions on this subject; but, almost univer- sally, make useof a circular saw, the figure of which is simply" cylindrical. Mr. Samuel Sharp notices the idea of there being the above danger in employing a cylindrical trepan, and remarks, that the great labour of working so slowly and diffi- cultly (with a conical one) is not only very inconvenient to an operator, but by no mean? serviceable to the operation; for, notwithstanding the saw be cylindrical, and work without any other impediment than what lies before the teeth, yet, even with this advantage, the operation goes on so gradually, that, in all the experience which Mr. Sharp has had, he never found the least danger of suddenly passing through to the brain, if care be taken not to lean too hard on the instrument when the bone is almost sawn through. With respect to the impracticableness of inclin- ing the cylindrical saw on any particular Vol. It ABD part of the circle, when sawn unevenly, (which was formerly alleged) whoever will try the experiment, will, in a moment, discover the falseness of the assertion. The very instance stated overthrows this rea- soning ; for, if the circle has already been made more deeply in one part than ano- ther, it must imply, that we have leaned with more ibrce on one part than another, and, consequently, may at pleasure do the same thing again. Mr. Sharp next takes notice of the supposed advantage, which the conical saw had in receiving and re- taining the piece of bone; a circumstance, which he, very properly, calls frivolous. Sharp on the Operations of Surgery. ABDOMEN. The Belly. The term is said to be derived from the Latin verb abdo, to hide, because many of the chief viscera of the body are concealed in the cavity, which it denotes. When a surgeon speaks of the cavity of the abdomen, lie confines his meaning to the space, which is included within the bag of the peritoneum. Hence, neither the kidneys, nor the pelvic viscera, are, strictly speaking, parts of the abdomen. Anatomists have distinguished this large cavity into different regions, and the terms, allotted to these, are so very frequent in the language of surgical books, that some ac- count of them in this Dictionary seems in- dispensable. The middle of the upper part of the ab- domen, from theensiform cartilage, as low down as a line drawn across from the great- est convexity of the cartilages of the ribs, is called the epigastric region. The spaces at the sides of the epigastric. region are termed, the right and left hypo- chondria, or hypochondriac regions. The umbilical region extends upward to the line, forming the lower boundary of the epigastric region, and downwanfl, to a B -) ABDOMEN. ^Kne drawn across from one anterior su- perior spinous process of the ilium to the other. All below the last line, down to the os pubis, is namett the hypogastric region. The abdomen is a part of the body claim- ing the particular attention of every practi- cal surgeon; for, it is the frequent situation of several of the most important surgical diseases. It is also very much exposed to wounds, and various operations are often requisite to be done in different parts of it. One of the most common afflictions, to which mankind are subject, is that in which some of the bowels are protruded, pushing out before them a portion of the peritoneum. This disease is called hernia, and ought to be well understood by every practitioner who, however, can never ac- quire the necessary knowledge,.without being well acquainted with the anatomy of the abdomen, la dropsical cases, it is frequently proper to tap the abdomen, and this operation, named paracentesis, simple as it may seem, requires more considera- tion, and attention to anatomy, than sur- geons often bestow on the subject. But the abdomen is, above all things, exceed- ingly liable to be wounded, to which case We shall confine our present remarks, re- ferring the reader to Hernia and Paracen- tesis for information on these particular subjects. wounds or the audomex. In these cases, we find that the chief cau-e of danger is the tendency ot the peiitoneum to inflame. Every wound of the belly is apt to excite this inflammation, and every inflammation, however slight, is prone ,to spread, to extend itself over all the viscera, and to terminate in gangrene and death. There are (says Mr. John Bell) a thou- sand occasions, on which this delicacy of the peritoneum may be observed; the wound of the (.mall sword, and the stab of the stiletto, explain to us, hi.w quickly the peritoneum, antl all its contained bow- els, inflame from the most minute wound, although it he almost too small to be visi- ble on the outside, and scarcely within j for, often, upon dissection, no intestines are seen to be wounded, arid no frees have escaped into the abdomen. In those, who die after lithotomy, we find the cavity of the peritoneum universally inflamed. The operation of Cesarean section ic fatal, not from any loss of blood, for there is lutle bleeding; nor, from the parts being ex- posed to the air, for, patients als-o die, in whom the womb bursts, and where the air has no possible opportunity of insinuating itself; but, the case proves fatal from the inflammation, which is always disposed to ongiuate from wounds of the peritoneum, small as well as great. (Discourses on the Nature and Cure of Wounds,p 310, edit. 3 ) But, although there can be no doubt, that the wound, abstractedly considered, is the most frequent occasion of this dread- ed inflammation; yet, it sometimes hap- pens, that the inflammatory consequences must be ascribed to another kind of cause. If an intestine be wounded, its contents may, under certain circumstances, be ef- fused in the abdomen ; if the liver, spleen, kidney, or any large vessel be injured, blood may be poured out among the vis- cera; if the gall bladder be wounded, bile may be effused; and, if the bladder be pierced," the urine may escape into the abdomen. Now all these extravasated fluids are extraneous substances, with re- spect to the surfaces, with which the) have come into contact, and usually give rise to inflammation of the peritoneum and vis- cera. I must not, however, prematurely allude to subjects, which will more properly fall under future consideration. Wounds of the abdomen are divided, by almost all-writers, into such as penetrate the cavity of the abdomen, and intoothers, which only interest the skin and muscles. The former differ very much in their na- ture, and degree of danger, according as they do, or do not, injure parts of import- ance, contained in the peritoneum. The latter are not very different from the ge- nerality of other superficial wounds. The chief indications are to lower.inflamma- tion, and to prevent collections of matter. A few particularities, however, in the treatment of superficial wounds of the ab- domen, seem to merit attention. SUPERFICIAL WOUNDS. The most ancient surgeons, and their successors, regularly up to the present day, have recorded, that wounds of tendinous parts are more perilous, than those of fleshy ones. Almost the whole front of the ab- domen is covered with tendinous expan- sions, and, on this account, it is'fiot un- usual to see wounds in this situation fol- lowed by great local inflammations, and the formation of abscesses. The patient is, at the same time, affected with a great deal of the sympathetic inflammatory fe- ver. (Hfte Fever.) When the tension and swelling of the abdomen abate, shivering* sometimes occur, and indicate the occur- rence of suppuration. The matter, which forms in these cases sometimes makes its way into the tendj! noussheath oftherectusmuscle,and, wheti ther^ollection of matter in this situation remains undiscovered until a pointing* ap- ABDOMEN. 3 pears, no sooner does the absces3 burst or is it opened, than an extraordinary quan- tity of matter is discharged. The surgeon should carefully remember the nature of this kind of case, as there is frequently no alteration in the appearance of the inte- guments to denote, either the existence, or the extent, of the suppuration. This kind of abscess tonus one remark- able exception to the excellent general rule of allowing acute phlegmonous abscesses to burst of their own accord. In the pre- sent instance, there is an aponeurotic ex- pansion, intervening between the abscess and the skin, and nothing retards the natu- ral progress of the matter to the surface of the body so powerfully, as the interpo- sition of a tendinous fascia. But, even in this circumstance, the propensity of pus to make its way outward is often seen to have immense influence. Though there is only a thin membrane, (viz. the perito- neum) between matter so situated, and the cavity of the abdomen, yet, in time, the abscess mostly points externally. The proper treatment of this case is to prevent the surprising accumulation of matter, and rapid increase of mischief, b\ • /taking a depending opening, sometimes at the very lowest part of the sheath of the rectus muscle, and thw, as soon as the lodgment of matter is clearly ascertained. The matter sometimes forms between the external and inter*at oblique muscles, and spreads most extensively. The pus may eveji insinuate itself into the abdo- men, and"the case end fatally. Such an example is recorded by Dr. Orowther, of Wakefield. In this instance, however, the disease proceeded from a contusion, not a wound. (See Edinb. Med. and Sur- gical Journal, vol. ii. p. 129.) Superficial wounds of the abdomen are to be treated on the same principles, as similar wounds in other situations. The indications are to prevent inflammation as much aspossiblc, and, if suppuration should be inevitable, to let out the matter by a depending opening, as soon as the abscess is known to exist. The inflammation is to be checked by general and topical bleeding, low diet, emollient clysters, di- luent beverages, quietude, and the mild- est, and most simple dressings. (See In- flammation.) Whenever the abdominal muscles are wounded, it is desirable to relax them; but, this object should not lead us to put the patient out of a horizontal position. A very important point, in the treatment of wounds, which interest the parietes of the abdomen, is to afford a certain degree of support to the wounded part, when there seems the smallest chance of their being too weak to resist the pressure of the *«- cera. The parietes of the abdomen are almost wholly com posed of soft parts, which easily yield. No p-*rt of the front, or sides, of the abdomen, is supported by the sta- bility of a bony structure, and, as the vis- cera are, for the most part, more or less moveable, and closely compressed by the abdom inal muscles, and diaphragm, they are extremely liable to be protruded, when- ever the resistance of the parietes of the abdomen is not sufficiently potent. Thus very perilous cases of hernix may origi- nate. For the above reasons, all wounds of the abdomen, especially those, in which both the integuments and muscles have been cut, demand strict attention to the -pre- caution of supporting the wounded part, and this, though the peritoneum itself should not happen to be divided. The patient ought to keep as much as possible in a horizontal position, while suitable compresses and bandages should be. applied to the situation of the wound. In order to guard against the occurrence of hernia, the part should be supported, in this way, a considerable time after the wound is healed. The peritoneum being connected by means of cellular substance, with the in- ner surface of the abdomiiialmuscles, there is always some risk of the inflammation of these murclesextending to the membranous lining of the abdomen. This occurrence must be averted by the rigorous employ- ment of the antiphlogistic treatment. What renders the event still more dan- gerous is, that when one point of the peritoneum is affected, the inflammation usually spreads with immense rapidity over its whole extent, and too often proves fatal. As superficial wounds of the abdomen are to be treated on.the general princi- ples, applicable to all other wounds of this sort in other situations, it is -hardly necessary to state, that union by the first intention is always, when possible, to be ' attempted. OP WOUNDS PENETRATING THE CAVITV OF THE ABDOMEN. In these cases, the first thing, which the surgeon is generally anxious to know, is, whether the wound penetrates the cavity of the abdomen, and whether any of the viscera are probably injured. When the wound is extensive, and any of the bowels protrude, the first part of the question is at once decided. But, when the wound is narrow, and allows none of the viscera to protrude, it is often exceed- ingly difficult to ascertain, whether the in- jury extends into the abdomen, or not. 4 ABDOMEN. An opinion, however, may usually be form- ed, by carefully examining the wound with one of the fingers, or a probe, after having put the patient, as exactly as pos- sible, in the posture in which he was at the time of receiving the accident; by observ- ing, if possible, the shape and dimensions of the instrument, with which the injury was done; how much of the weapon has entered the flesh; the direction in which it was pushed ; by attending to the quan- tity of blood, which the patient has lost, the state of "his pulse, &c. and, lastly, by observing, whether there is any discharge of bile, feces, or other fluids, known to be naturally contained in some of the abdo- minal viscera. When the wound is sufficiently large to admit the finger, we may always ascertain whether the injury extends into the cavity of the abdomen, because the viscera may then be easily felt. There is only one chance of deception, and that arises from a possibility of the practitioner's mistaking the inside of the sheath of the rectus muscle for the cavity of the peritoneum. When the examination is made with a probe, we should be particularly cautious in forming a judgment; for, the parts are so soft and yielding, that a very little force will make the instrument pass a consider- able way inward. Every examination of this kind should always be undertaken, if possible, when the patient is exactly in the same position, as he was at the time of re- ceiving the wound. Injections have been employed for ascer- taining, whether wounds penetrate the ca- vity of the abdomen. This absurd experi- ment, however, has now been most justly exploded from practice. It is well known to the moderns, that the space termed the cavity of the abdomen, is in fact, com- pletely filled with tlie various viscera, and that a fluid would, in general, not so easily find its way into the bag of the peritone- um, as an unreflecting person might sup- pose. If the injection were propelled with much force, it would be quite as likely to insinuate itself into the cellular substance of the parietes of the abdomen, or, per- haps, into the sheath of the rectus muscle. The feast tortuosity of the wound, or a piece of bowel, or omentum, lying against the internal orifice of the injury, would completely prevent an injection from pass- ing into the abdomen. When a considerable quantity of blood issues from a wound of the abdomen, we may pronounce, almost with certainty, that some large vessel, within its cavity, is in- jured. Excepting the epigastric artery, which runs on the forepart of the abdomen, along the inner surface of the rectus mus- cle, there is not one very considerable ves- sel, distributed to the muscles, and inte- guments. At the same time, it is deserv- ing of particular notice, that a very large artery may be opened in the abdomen, and, yet, not a drop of blood may be dis- charged from the external wound. A co- pious quantity may accumulate in this manner, even without there being any pal- pable swelling of the belly. In such cases, the subsequent symptoms very quickly lead us to suspect what has happened. The patient complains of ex- treme debility and faintness; his pulse faulters ; he has cold sweats; and, if the bleeding should not speedily cease, these symptoms are, in general, soon followed by death. Sometimes, the first glimpse is enough to shew, that the wound extends into the cavity of the abdomen. The event is in- dicated by the escape of chyle, bilious matter, feces, or other fluids,known to be contained in some of the viscera. The same information may also be obtained from seeing a considerable quantity of blood vomited up, or discharged by stool. The urine, however, may flow from a wound, which does not actually penetrate the abdomen, for the kidneys, ureter, mid bladder may be said to be out of the abdo- men, because they are really on the out- side of the cavity of the peritoneum. When no symptoms of the abovedescrip- tion occur, when neither the finger, nor probe, can be introduced; when none of the fluids, known to be contained in the various receptacles in the abdomen, arc emitted from the wound; when the pulse remains natural, and the pain is not exces- sive; there is teason to hope, that the wound has not injured parts of greater consequence than the integuments, and muscles. ( EncyclopedicMethodique,Partie Chirurgicale. Art. Abdomen ) We have now taken a survey of such criteria, as are commonly noticed by sur- gical writers, for the purpose of instruct- ing thereader how to discriminate a wound which has penetrated the abdomen, from one which has not. It is our next place to warn the practitioner, that too much solicitude to determine this point, is very frequently productive of serious harm. It may be set down, as an axiom in surgery, that, whenever the probing of a wound is not renderedabsolutely necessary by some particu- lar object in view, it may, in general, be judici- ously ondtted. A narrow, oblique wound may enter the cavity of the abdomen, with- out there being any particular methodof as- certaining, whether it has done so, or not. This, however, is of no practicul import- ance; for, when there are no urgent symp- toms, evincing the nature of the case, the treatment ought obviously to resemble that ABDOMEN. 5 of a simple wound; and whether the wound is deep, or superficial, the anti- phlogistic treatment is equally indicated. The edges of a wound penetrating the abdomen, but, unattended with any obvi- ous injury of the viscera, are to be brought together with a sticking-plaster, just in the same way as Common wounds. In this situation, sutures are more frequently proper, than in most others. Particular care is also to be taken to keep the bowels from protruding, by the application of a compress, and bandage. All the means of preventing inflammation are to be adopted, (see Inflammation) and quietude is, above all things, to be enjoined. Our good old surgeon Wiseman (ob- serves Mr. Jphn Bell) has said with great simplicity, as a great many have said after him, " Thus it frequently happeneth, that a sword passeth through the body, with- out wounding any considerable part." He means, that a rapier, or ball often passes quite across the belly, in at the navel, and out at the back, and that with- out one bad sign, the patient recovers, and as has very often happened, walks abroad in good health, in eight days; which speedy cure has been supposed to imply a sim- ple wound, in which all the bowels have escaped. But, we see now, how this is to be explained; for, we know, that in a thrust across the abdomen, six turns of in- testine may be wounded,—each wound may adhere ; adhesion, we know, is begun in a few hours, and is perfected in a few days; and, when it is perfect, all danger of inflammation is over; and, when the danger of inflammation is over, the patient may walk abroad; so that we may do, just as old Wiseman did in this case, here alluded to,* " Bleed him, and advise him to keep his bed, and be quiet." In short, a man, thus wounded, if he be kept low, has his chance of escaping bv an adhesion of the internal wounds." (Discourses on the Nature and Cure of Wounds, p. 329, 330, edit. 3.) AVhen a man is stabbed, or shot in the belly, the surgeon can seldom do any good by being very officious; and the wisest conduct, that he can in general adopt, is to keep his patient as quiet as possible, have recourse to bleeding, prescribe ano- dynes, and the lowest fluid diet, and con- tent himself with applying superficial dressings. In the event of severe pain awd swelling of the belly coming on, leeches, fomentations, and emollient poul- tices will be necessary, and nothing will * P. 98. T'ic en e of a man, who was wounded across the belly, an/a well and abroad, in seven days. now avail, except the most rigorous anti- phlogistic means. INFLAMMATORY CONSEQUENCES OF WOUNDS OF THE ABDOMEN. Sometimes, notwithstanding the best treatment, alarming symptoms cannot be prevented. At first, these are commonly of the inflammatory kind ; consequently* repeated bleeding, and redoubled attention to every part of the antiphlogistic treat- ment, are indicated. If the inflammation should not be subdued by such measures, internal mortification and death may fol- low, or abscesses form in the abdomen. SUPPUHATION IN THE ABDOMEN, LN CONSEQ.CENCE OF WOUNDS. Abscesses within the bag of the perito- neum are far from being common occur- rences. As a late writer well observes, " the containing and contained parts of the abdomen present to each other a uni- form and continuous surface of membrane. This membrane is of the serous class, and the species of inflammation, to which it is especially subject, is that, which has been denominated the adhesive. The mem- brane lining1 the intestinal canal,- is of the mucous class, and the ulcerative in- flammation is the species, to which this class is liable. This beneficent provision is an irresistible evidence of the operation of a salutary principle in disease. If the inflamed peritoneum had run directly into suppuration, ulceration of the surrounding parts would have been required for an out- let; and if the internal surface of the irri- tated bowel had tended to form adhesions, the canal would have been in constant danger of obliteration." (Travers on Inju- ries of the Intestines, &c. p. 10.) That collections of matter, however, do sometimes take place in the cavity of the abdomen, in consequence of wounds, is a fact of which there are too many proofs on record, for the possibility of the case to be doubted. At this moment, be it suffi- cient"*for our purpose to refer to two ex- amples of the occurrence, as related fy Mr. Benjamin Bell, in his System of Sur- gery, vol. v. p. 256. If the abscess were in any other part of the body, and did not readily point, the wisest practice would undoubtedly be to make an opening sufficient for the evacua- tion of the matter. But suppuration in the abdomen can seldom be ascertained with certainty, before the collection of matter has existed a- good while; for, the situation of the abscess is so deep^that no fluctuation, nor swelling, becomes perceptible, until a considerable quantity of pus has accumu- 6 ABDOMEN. lkted. Besides, it would not be judicious to expose the patient to the hazard, which might arise from making an opening, into the abdomen, merely for the sake of giv- ing vent to a small collection of matter. Many, indeed,almost all writers, impute a vast deal of th*e danger of wounds of the abdomen to the entrance of air into the cavity of the peritoneumrand they also ad- duce this as an argument against opening abscesses of the abdomen. In inculcating such opinions, however, they betray an in- accuracy of observation, which a very little reflection would have set right. Too much stress has long been laid on the introduc- tion of air into the abdomen, as being a cause of inflammation. The fact is, that the cavity of the belly is always so com- pletely occupied by the various viscera, that the whole inner surface of the perito- neum is constantly in close contact with tfl—ii, and, consequently air cannot so easily diffuse itself from the vicinity of the wound, throughout the abdomen, as has been conceived. After tapping, in drop- sical cases, we seldom see inflammation arise, though air has, in this instance, quite as good an opportunity of entering the abdomen, as in any case of a wound. The peritoneum in animals has been in- flated, without any inflammation being ex- cited. In cases of tympanitis, the perito- neum is distended with air, and yet both this membrane and the bowels are quite uninflamed. In the human subject, it seems probable, that, if a wound were made in a vacuum, the breach of conti- nuity itself would lead to inflammatory consequences. We have also to remark, that collections of matter in the abdomen are almost always completely circumscrib- ed, and separated from the general cavity of the peritoneum, by the adhesion of the viscera to each other, and to the inside of the peritoneum. I am of opinion, that no surgical writer has succeeded so well, as Mr. John Bell, in exposing the absurd apprehensions, not uncommonly entertained by practitioners, respecting the entrance of air into the ab- domen and other cavities of the bod*y\ He Squires: 1st, Whether air can really get into the cavity of the abdomen ? and 2dly, Whether, if it were there, it would pro- duce the dreadful effects ascribed to it i Upon the first question, his arguments "v.n thus: " Suppose a wound of an inch in length;—suppose the bowel to have sunk, in some strange way, into the pel- vis, for example, so as to have left a mere vacuum; what should happen with the flexible parietes of the abdomen? Should they stand rigid, while the air rushed into the cavity to fill it? No, surely. But, on the contrary, the walls of the abdomen would fall together, and the pressure of the outward air, far from making the air rush in by the outward wound, would, at once, lay the belly flat, and close the wound. But, since the walls of the abdo- men are not flaccid, nor the cavity empty, but the abdomen full, and the flat mus- cles, which cover it, acting strongly, the effect must be much more particular; for, the moment that the belly i9 wounded, the action of the muscles will force out part of the bowels: the continuance of that ac- tion is necessary to respiration; the re- spiration continues as regular after the wound, as before; and the continual pres- sure of the abdominal muscles and the diaphragm, against all the viscera of the abdomen, prevents the access of air so effectually, that, though we should hold such a wound open with our fingers, no air could pass into the abdomen, further than to that piece of gut which is first touched with the finger, when we thrust it into the abdomen. Nothing is absolutely exposed tovthe air, except that piece of intestine, which is without the abdome>, or that, which we.see, when we expose a small piece of the bowels, by holding aside the lips of the wound. The pressing forward 9f* that piece, and the protrusion of a por- tion of the gut, proportioned always to the size of the wound; the pressure from be- hind keeping that piece protruded, so that it is with difficulty, we can push it back with our finger ; this incessant pressure, in all directions, is an absolute security against the access of air. The intestine comes out, not like water out of a bottle, the place of which must be supplied bv air entering into the bottle, in proportion as the water comes out; but, the gut is pushed down by the action of the muscu. lar walls of the abdomen, and that action follows the intestine, and keeps it down, and prevents all access of the air whether the gut continue thus protruding, or whe- ther it be reduced; for, if it be reduced, the walls of the abdomen yield, allowing it to be thrust back, but admitting no air. Those, who want to know the effect of air, diffused within the cavity of the abdomen, must make other experiments, than merely cutting open pigs' bellies;—they must give us a fair case, without this unneces- sary wound. We will not allow them to say, when they cut open the belly of any creature, with a long incision, that the inflammation arises from the air: much less shall we allow them to say, when they open the belly with a smaller incision that, by that little incision, the air gets into the abdomen, and that all the bowels are exposed to the air." (Discourses on the Nature and Cure of Wounds, p. 333> 334 v In adverting to the question, whether ABDOMEN. 7 air is so irritating to the cavities of the body, as many have supposed, Mr. John Bell criticises, with much spirit and suc- cess, the opinions, published on this sub- ject, by Dr. A. Monro, in his account of the Bursx Mucosa:, as the annexed quo- tations will shew. " That the vulgar should believe, the first superficial im- pression that strikes them, of air hurting a wound or sore, is by no means surprising; but, it is not natural, that men, bred to philosophy, should allow so strange an assertion as this, without some kind of proof. That the air, which we breathe, and which we.feel upon the surface so bland and delightful, should have so op- posite a relation to the internal parts, that it shou'd there be a stimulus, m**ke acrid and more dangerous, than the urine, is not tb be believed upon slight grounds. I do affirm, (says Mr. John Bell) that it re- mains to be proved, that this fluid, which seems so bland and pleasant to all our senses, and to the outward surface, is yet a horrible stimulus, when admitted, as a celebrated author grandly expresses it, •' into the deep recesses of our body." (Munro's Bursx Mucosa.) With how much reason, Mr. John Bell objects, that this doctrine is founded, will be manifest to every man of any dis- cernment, or impartiality. " The air, for instance, escapes from the lungs, in a fractured rib, and first goes abroad into the thorax; then into the cel- lular substance; then the emphysematous tumour appears; but, often, without any scarifications, with very little care and as- sistance on our part, the air is absorbed, the tumour disappears, and, without in- flammation of the chest, or any particular danger, the man gets well. Here then is the air, within the cavity of a shut sac, filling the thorax, and oppressing the lungs, without any dangerous inflamma- tion ensuing. " That the air n.ay be pushed,under the cellular substance over all the body, without causing inflammation, is very plain from the more desperate cases of emphysema, where the patients, after liv- ing eight or ten days, have died, not from inflammation, but, from oppression mere- ly, the body being so crammed with air, that even the eye-balls have, upon dissec- tion, been found as tense as blown blad- ders. We have also many ludicrous cases of this kind, which prove this to our perfect satisfaction. Soldiers, and sailors, some- times touch the scrotum with a lancet, in- traduce a blow-pipe, and blow it up to an enormous size, imitating hernix, by which they hope to escape from the service. The old story of a man, who was so wicked as to make a hole in h;**- child's head, and blow it up", that he might shew the child in the streets of Paris for a monster, is well authenticated; and, I have little doubt, that a fellow, who knew how to do this, would blow it up every morning, and squeeze it out when he put the child to bed at night. Some viHainous butchers, having a grudge at a soldier, found him lying drunk, under a hedge; they made a little hole in his neck, and blew him up, till he was like a bladder, or, as Dr. Hun- ter describes the disease of emphysema, like a stuffed skin." (P. 338, 339.) After many other pertinent observations, blended with appropriate satyr, on the ex- travagant notions professed by Monro on the bad effects of the air, In lithotomy, operations for hernia, and hydrocele, the Cxsarean section, &c, Mr-John Bell most justly holds up to ridicule the propositions of Dr. Aitken to perform this last operation under the cover of a warm bath in order to exclude tfie air. " This, though it may seem to be a scurvy piece of wit, was really pro- posed in sober serious earnest. But (adds Mr. John Bell), the admission of atmo- spheric air, as a stimulus, when compared with the great incisions of lithotomy, of hernia, of hydrocele, of Cesarean sec- tion, of the trepan, is no more, than the drop of the bucket to the waters of the ocean. And it is just as poor logic to say, that, after such desperate operations, these cavities are inflamed hy the admis- sion of air, as it would be to say, (as Mon- ro did) that when a roan is run through the pericardium with a red hot poker, that the heart and pericardium are inflamed by the admission of the air." (P. 347, edit. 3.) Enough, I conceive, has been said, to dispel all the idle fear and prejudices which have prevailed concerning the bad effects of the air in wounds of the abdo- men, as well as several other cases. When so justly eminent a man as Dr. Alexander Monro, senior, wus disturbed with such apprehensions, it is not wonderful, that many a poor ordinary member of the pro- fession should have been terrified nearly out of his wits upon the subject; and for quieting this alarm, and exposing its absurdities, 1 really think Mr. John Beil deserving of particular praise. In general, it is an excellent rule, in all cases of wounds of the abdomen, never to be officious abcutabscesses, which may take place, nor concerning such viscera, as we may suspect to be injured. It is quite time enough to interfere, when the urgency of the symptoms has confirmed our con- jectures. A great deal of harm is fre- quently done, by handling and disturbing the wounded parts more than is necessary, and, it is well known, that wounds, whicU 8 ABDOMEN. are at first attended with most alarming symptoms, frequently terminate in a fa- vourable . manner. Persons have been known to have swords passed completely through their bodies, without suffering afterwards any threatening symptom, or, indeed, any effects which would authorise one to conclude, that the viscera had been at all injured. We are aware, that se- vere inflammations may not end in suppu- ration, and we also know, that when pus has been formed, the fluid has been often absorbed again. Nothing then indicates the necessity for givir-g vent to purulent matter lodged in the abdomen, except the fluctuation and situation of the abscess be very distinct, and the quantity and pressure of the matter productive of in- conveniences. . For making an opening, some writers recommend a trocar; others, a lancet. The matter must be very copious and dis- tinct, to justify the sudden introduction of such an instrument as a trocar. In other cases, the surgeon should make a Cautious puncture with a lancet. PROTRUSION OF THE VISCERA. Wounds, penetrating the abdomen, sometimes allow considerable portions of the bowels, or omentum, to protrude, and though these viscera may not have re- ceived any injury, yet, their being dis- placed in this way is sometimes productive of fatal consequences. The best mode of preventing such a catastrophe, is to return the viscera into the cavity of the abdomen, as speedily as possible. Almost all authors recommend fomenting the displaced parts, before at- tempting t» reduce them; but, in giving this advice, they seem to forget, that, while time is lost in this preparation, the protruded bowels suffer much more harm from exposure, and other circumstances, than they can possibly receive good from any applications made to them. No kind of fomentation can be half so beneficial, as the natural warmth and moisture of the cavity of the abdomen. In order to faci- litate the return of protruded piece of io- testine, or omentum, the abdominia mus- cle's should be relaxed by placing the pa- tient in a suitable posture, and the large intestines be emptied with a glyster. In mentioning the last measure, it is not meant, that a surgeon should delay the attempt to reduce the part, until the glyster has operated. No, this means is only enumerated as one that may become serviceable, io case the surgeon cannot immediately accomplish the object in view —The mesentery ought always to be reduced before the intestine; the intestine before the omentum; but, the last pro- truded portion of each of these part* ought to be the first one reduced. It is only when the intestine and omen- tum are free from gangrene and mortifica- tion, that they are invariably tu be re- turned into the cavity of the belly, with- out hesitation. Also, when the protruded parts are covered with sand, dust, or other extraneous matter, it is undoubted- ly proper to make them as clean as possi- ble, before putting them back into the abdomen. For this purpose, the parts should be tenderly washed with a little luke-warm milk and water. The two index fingers are the most con- venient for reducing the parts, and, it is a rule to keep the portion, first returned, from protruding again by one finger, until it has been followed by another portion, introduced by the other finger. The second piece is to be kept up, in the same way, by the finger used to retura it; and so on, till the whole of the displaced parts have been put into their natural situation. In attempting to reduce a piece of pro- truded intestine, \h6 patient should be placed in the most favourable posture; the head and chest should be elevated, and the pelvis raised with pillows. Nothing can be more absurd, than the advice to have the thorax rather lower than the pelvis, in order that the weight of the viscera may tend to draw inward the pro- truded parts. This is another erroneous idea, arising from the ridiculous supposi- tion, that a great part of the abdomen is actually an empty cavity. The relaxa- tion of the abdominal muscles is a much more rational and useful object.—When this is properly attended to, and the wound is not exceedingly small, in rela- tion to the bulk of the protruded viscera, the parts may generally be reduced by observing the above directions. But, in addition to what has been already stated, it is necessary to remark, that the pressure should be made in a straight direction into the abdomen; for, when made obliquely, towards the edges of the wound, the parts are liable to suffer contusion, without be- ing reduced, and even to glide between- the layers of the abdominal muscles, and become strangulated. When the wound is in the front of the abdomen, pressure made in this unskilful way, may easilv make the viscera slip into the sheath of the rectus muscle, and cause the same perilous symptoms, as arise from an incar- cerated hernia. (See hernia.) When the reduction seems complete, the surgeon should assure himself of it, by introducing his finger into the cavity of the abdomen, so as to feel, that the parts are all actually reduced, and suffer no con- ABDOMEN. 9 Rtriction between the edges of the wound and the viscera in the abdomen. A difficulty of reduction may arise from the protruded intestines being distended With feces, or air. In this circumstance, the contents of the gut may frequently be made to pass, by little and little, into that portion of the intestinal canal, which is within the abdomen. To accomplish this purpose, the surgeon must press the con- tents of the bowel towards the wound, and, if he succeeds in emptying the part, he will commonly experience equal suc- cess in his next attempt to r. place it in the abdomen. Sometimes, considerable pieces of in- testine are found protruded, through narrow wounds of the abdomen, and the reduction cannot be effected, without do- ing more violence to the bowel, than its delicate structure would bear. In this case, dilating the wound becomes in- dispensable. However, very frequently, when the reduction seems almost a matter of impossibility, on account of the small- ness of the wound, relaxing the abdomi- nal muscles, drawing a little more in- testine out of the wound, and gently press-' ing the contents of the bowels, through the constriction into the abdomen, will render the protruded part sufficiently reducible, without any operation to enlarge the wound. When such operation is unavoidable, the dilatation should be made in a direction, which will not endanger the epigastric ar- tery, and if possible, in the same line as the muscular fibres. It would be unpar- donable to make a more extensive incision than absolutely requisite, as hernix are very much disposed to occur, wher< ver the peritoneum has been divided. The opera- tion may be done with a curved bistoury and a director, much in the same way as is done in cases of strangulated ruptures. (See Hernia.) Instead of enlarging vVounds. of the ab- domen, it has been proposed to let out the air from the~intestines, by making small punctures with the point of a needle, and thus lessen the volume of the protruded part sufficiently to render it easily reduci- ble. This suggest ion first originated with Ambroise Pare, who declares, that he has several times practised the method with success. Rousset, his cotemporary, also in- forms us, that the plan was adopted by another surgeon,. in an instance, where the epigastric region was wounded, and a largi* portion of the intestines was pro- truded and strangulated. Peter Lowe, an English surgeon, likewise assures us, that he has frequently pursued such prac- tice, when other means failed. Garcn- jreot, Sharp, and Van Swieten, are all ad- b Vol. I. vocates for Pare's proposal; but they re- commend employing a round needle, which will merely separate the intestinal canal, without cutting them, as a flat, triangular, sharpedged needle would unavoidably do. These last celebrated writers, however, only sanction the practice, when the quan- tity of protruded intestine is exceedingly great, and when it is so enormously dis- tended with air, that it would be impossi- ble to reduce the part, though the wound were enlarged, and every thing else, •likely to promote the reduction, were put in practice. But, as the judicious Saba- tier has remarked, the punctures must be entirely useless, if made with a fine needle, since they will be immediately stopped up* with tne mucous secretion, with which the inside of the bowels is constantly co- vered; and if the punctures are made with a broad triangular needle, or a very large round one, as Desault and Chopart have advised, they must be highly dangerous, inasmuch as they must be extremely likely to give rise to inflammation, and even to extravasation within the abdomen. (See Mederine Operatoire, Tom. i,p. 10.) It was the circumstance of small punc- tures being unavailing, that led Desault and Chopart to recommend the use of a large round needle, " pour que Pouverture ne soitpointboucheeparies mucosites dont les intestines sont enduits." But, they were also aware of the danger ofemploying such an instrument, since they give us directions how to -proceed, in order to prevent ex- travasation ami inflammation: *" On pre viendra I'epanchement des matieres slercora- les en passant, avant tie reduire I'intestin, une anse tlefil duns la portion de mesentere qid repond d la piqure pour la fixer contre les bords de laplaie exterieure, et Von com- battrapar les remedes generaux Pinf anima- tion que cet piqure pent attirer." (Traite des Maladies Chirurg. 'Torn. 2. p. 135 ) Mr. Travels, one of the latest writers upon this subject, most properly joins in the condemnation of the plan of pricking the protruded bowels. " Blancard and others protested against this practice, on the very sufficient ground of its ineflicacy. La Faye very truly says, it is a useless as well as dangerous practice; for the open- ings, made by a round needle, cannot give issue to the containing air." Mr. Travels then cites two cases, shewing that even small stabs in'a bowel will not pre- vent its becoming distended with air. " A man was brought to St. Thomas's hospital, on Saturday, the 30th of June last (1811,) 'vho had been ■*>tabbed in the direction of the epigastric artery, on the left side of the abdomen, by a case knife. Fie died in eighteen hours, apparently from the sudden and copious hcmorrhagp, 10 ABDOMEN. which had taken place within the belly. About half a yard of'ileon was protruded. The gut was highly discoloured, and so much distended, notwithstanding it was pierced in three places, that the wound of the integuments required to be freely dilated, before it could be returned. The apertures were in fact obliterated by the mu- cous coat." " It appeared upon the trial of Captain Sutherland (Ann. Reg. June 1809) for the murder of his cabin boy, that the intes- tines had been extensively protruded through a wound near the left groin, and had lain exposed for four or five hours— that the dirk had pierced through one fold of intestine, and entered another—that the wound of the intestine was half an inch long, that the reduction could not be ac- complished until the parietal wound was dilated; and that the intestine was then returned, and the integuments sewed up." (Travers on injuries of the Intestines, p. 174, 176.) I must observe, however, with respect to this last case, that it does not satisfac- torily prove what the author intends it to shew, namely, that the bowel was distended with air, though there was a wound in, it half an inch long, for, the evidence does not inform us, that the difficulty of reduction was owing to this cause. I have seen a very small portion of omentum protruded through a wound, and baffle all endea- vours to reduce it for nearly an hour. The first case, adduced by Mr. Travers, however, is more explicit and interesting; and we are to infer from it, and the ob- servations of Hallcr, that tlie punctures, made in an intestine, are not closed by mucus, as Sabatier and Desault have as- serted, but by the mucous coat itself". As the above expedient had been re- commended by writers of some weight, I thought that the subject should not be passed over in silence and without a caution to the reader, never to put any confidence in the method. The plan does not facilitate the business of the operator; there is not even this solitary reason in favour of the practice; and though it may have answered when large needles were used, and some patients, so treated, may have recovered ; yet, every person, who hrs the least knowledge of the animal econo- my, will easily comprehend, hw even the smallest opening, rnude in parts, so irritable and prone to inflammation, as the bowels, must be attended with greater danger than would result from enlarging a wound of the skin and muscles. Besides tlie air may frequently be pressed out of the intestine in a safer way,* as I have al- ready described. A wound of the abdomen, attended with one of the most considerable protru - sions of the viscera, that I have ever read of, is recorded by Mr. Hague, surgeon at Ripon: " August 30th 1808 (says this gentleman,) I went to Norton Mills, about four miles from hence, to see John Brown xt. 12 years, who had received a wound in the abdomen by a wool shears. On my arrival, which was little more than an hour after the accident, I found the poor lad in a very distressing situa- tion ; the great arch of the stomach, and the whole of the intestinal canal, (duodenum excepted) contained within the abdomen, having protruded through the wound. The incision was on the left side of the body, commencing at about two inches below the scrobiculus cordis, and extend- ing in a straight line near four inches in length, distant from the navel two inches, and he was quite sensible, and had vo- mited so as to empty the stomach ; very little blood was lost. I immediately pro- ceeded very carefully to examine the pro- truded viscera, none of which were wounded, and reduced them as quickly as possible, beginning with the stomach, and following the regular course of the intes- tines, in the latter portion of which, I distinctly felt feces, of rather firm con- sistence. He complained of some pain, during the reduction, though not much, and expressed great relief, when the parts were completely returned. I now desired an assistant, to lay the palm of his hand over the wound, and make some pressure upon it; for, 1 found, that, without this, the> parts would soon have protruded again by the action of respiration, which was oppressed and laborious. I brought the sides of the wound together by five sutures, beginning from above down- wards, and passed the needle on each side, quite through the integuments with the peritoneum, &c. The wound was also dressed with adhesive plaster, and co- vered with a bandage." Vide Edinburgh Medical and Surgical Journal, Vol. 5, p. 129, &c. This case is really an interesting one; for, notwithstanding so unlimited a pro- trusion of tlie viscera, and tlie parts had been left unreduced for more than an hour, a recovery ensued, under the judi- cious employment of bleeding, purging, anodynes, &c. When the protruded intestine is wound- ed, the opening is to be closed with a par- ticular suture, before the part is returned into the abdomen. Of this subject, when we speak of the wounds of the intestines. Some of the exposed intestine may have mortified, before the arrival of sur- gical assistance. This event is exceed- ingly rare in cases of wounds, but, is not ABDOMEN. 11 uncommon in those of strangulated liemix. The treatment will be explained in the article Hernia. When the protruded intestine is in a stale of inflammation, its immediate re- duction is, beyond all dispute, the means most likely to set every thing right. Even when the inflammation has risen to a vehe- ment pitch, a timely reduction of the dis- placed part, and the employment of anti- phlogistic means will often prevent gangre- nous mischief. The dull, brown, dark red colour of the intestine may induce the practitioner to suppose, either that the part is already mortified, or must inevi- tably become so, and, consequently, he may delay returning it into its natural si- tuation. But, notwithstanding this sus- picious colour of the intestine, its firm- ness will evince, that it is not in a state of gangrene. The ultimate recovery of a portion of intestine, so circumstanced, is always a matter of uncertainty ; but, the propriety of speedily replacing the part in its natural situation is a thing most cer- tain. In case the bowel should mortify after being reduced, all hopes of the pre- servation of life are not to be abandoned,- as we shall notice again in the subject of hernia, where every thing necessary to be known, concerning the mode of reducing protruded omentum, will also be found. The protruded viscera having been re- duced, the next object is to retain them in the abdomen, until the wound is complete- ly healed. When the wound is small, this is a matter of no difficulty; in this instance, it is enough to put the patient in such a position, as shall relax the fibres of the wounded muscles, while the edges of the wound are maintained in contact with sticking plaster, and supported, in this way, by a compress and bandage. Costiveness is to be removed by the mild- est purgatives, such as the soda phos- phorata and oleum ricini, or by laxative glysters, which are still preferable. But, in cases of extensive wounds, even when the treatment is conducted with all possi- ble judgment, it is occasionally very diffi- cult, and impossible, to hinder the pro- trusion of the bowels by common dressings, and a bandage. In this circumstance the edges of the wound must be sewed to- gether by a particular suture, named Gas- troraphe. (See this article.) It is proper lo remark, however, that, in modern times, this suture is very rarely employed, in comparison with what it was formerly, and, in the description of gastroraphe, some remarks will be offered, for the pur- pose of proving, that even the generality of large wounds of" the abdomen do not require any suture whatsoever. EXTRAVASATION IN THE ABDOME? Wounds of'the abdomen maybeom- plicated with extravasations of bod, chyle, excrement, bile, or urine. lone of these complications, however, arthalf so frequent, as an unreflecting and nex- perienced practitioner might apprcsnd. The employment of the phrase cavity rthe abdomen has paved the way to much to- neous supposition upon this subject, md has induced many absurd notions, wlch even the sensible observations, long ^o published by Petit (le fils,) have scarcly yet dispelled. Asa modern writer has observed," thee is not truly any cavity in the hurnn body, but, all the hollow bowels are fille'. with their contents, all.the cavities fillet with their hollow bowels, and the whole is equally and fairly pressed. Thus, in the abdomen, all the viscera are moved by the diaphragm and the abdominal mus- cles upwards and downwards, with an equable continual pressure, which has no interval; and one would be apt to add, the nUestineshave no repose, being kept thus in continual motion; but, though the action of the diaphragm, and the re- action of tlie abdominal muscles are alter- nate, the pressure is continual; the mo- tion, which it produces, (they produce) is like that which the bowels have, when we move forwards in walking, having a motion, with respect to space, but none with regard to each other, or to the part of the belly, which covers them; the whole mass of the bowels is alternately pressed, to use a coarse illustration, as if betwixt two broad boards, which keep each turn of intestine in its right place, while the whole mass is regularly moved. When the bowels are forced down by the diaphragm, the abdominal muscles re- cede : when the bowels are pushed back again, it is the reaction of the abdominal muscles, that forces them back and fol- lows them; there is never an instant of interruption of this pressure, never a mo- ment, in which the bowels do not press against the peritoneum; nor is there the smallest reason to doubt, that the same points in each are continually opposed. We see, that the intestines do not move, or, at least, do not need to move in per- forming their functions; for, in hernia, where large turns of intestines are cut off'by gangrene, the remaining part of the same intestines is closely fixed to the groin, and yet the bowels are easy, and their functions regular. We find the bowels re- gular, when they lie out of the belly, in hernia, rs when a certain turn of, in- testine lies in the scrotum, or Ihigh, or, in a hernia of the navel; and where yet 12 ABDOMEN. theyre so absolutely fixed, that the piece of irestine is marked by the straitness of the ngs. We find a person, after a woun of the intestine, having free stools for any days ; and what is it that pre- ventthe feces from escaping, but merely this Jgular and universal pressure? We find person, on the fourth or fifth day, Tvitl feces coming from the wound'! a pro-', surely, that the wound of the in- tesne is still opposite, or nearly opposite, to ie external wound. We find the same patent recovering without one bad sign! v\iat better proof than this could we de- sie, that none of tlie feces have exuded iito the abdomen ? "If*, in a wound of the stomach, the pod could get easily out by that wound, die stomach would unload itself that way, there would be no vomiting, the patient must die ; but, so regular and continual is this pressure, that the instant a man is wounded in the stomach, he vomits, he continues vomiting for many days, while not one particle escapes into the cavity of the abdomen. The outward wound is commonly opposite to that of the stomach, and, by that passage, some part of the food comes out; but, when any accident removes the inward wound of the stomach from the outward wound, the abdominal muscles press upon the stomach, and follow it so closely, that if there be not a mere laceration extremely wide, this pres.sure closes the hole, keeps the food in, enables the patient to vomit, and not a particle, even of jellies, or soups, is ever lost, or goes out into the cavity of the belly. " How (proceeds Mr. J. Bell) without this universal and continual pressure, could the viscera be supported ? Could its liga- ments, as we call them, support the weight of the liver ? Or, what could support the weight of the stomach when filled ? Could the ntesentery, or omentum, support the intestines; or could its own ligaments, as we still name them, support the womb ? How, without this uniform pressure, could these viscera fail to give way and burst ? How could the circulation of the abdomen go on ? How could the liver and spleen, so turgid as they are with blood, fail to burst ? Or what possibly could support the loose veins and arteries of the abdomen, since many of them, e. g the splenic vein, is, (are) two feet in length, is (are) of the diameter of the thumb, and has (have) no other, than the common p- llucid and deli- cate coats of the ve.ns ? How could the viscera of the abdomen bear shocks and falls, if not supported by the universal pressure of surrounding parts ? In short, the accident of hernia being forced out by any blow upon the b.-ily, or by any sudden •itrain, explains .to us how perfectly full the abdomen is, and how ill it is able to bear any pressure, even from its own mus- cles, without some point yielding, and some one of its bowels being thrown out. And the sickness and faintness, which im- mediately follow the drawing off of the waters of a dropsy, explain to us, what are the consequences of such pressure being even for a moment relaxed. But, per- haps, one of the strongest proofs is this, that the principle must be acknowledged, in order to explain what happens daily in wounds; for, though in theory we should be inclined to make this distinction, that the hernia, or abscess of the intestines, will adhere and be safe, but, that wounded intestines, not having time to adhere, will become flaccid, as we see them do in dissec- tions, and so, falling away from the ex- ternal wound, will pour out their feces into the abdomen, and prove fatal; though we should settle this, as a fair and good distinction in theory, we find, that it will never answer in practice. Soldiers recover daily from the most desperate wounds ; and the most likely reasons, that we can assign for it, are, the fulness of the abdomen, the universal, equable, and gentle pressure; and the active disposition of the peritoneum, ready to inflame with the slightest touch. The wounded intes- tine is, by the universal pressure, kept close to the external wound, and the pe- ritoneum and the intestine, are equally inclined to adhere. In a few hours, that adhesion is begun, which is to save the patient's life, and the lips of the wounded intestine are glued to the lips of the ex- ternal wound. Thus, is the side of the intestine united to the inner surface of the abdomen; and, though the gut casts out its feces, while the wound is open; though it often casts them out more freely, while the first inflammation lasts; yet, the feces resume their regular course, whenever the wound is disposed to close." (John Bell's Discourses on Wounds, p. 323, 327, edit. 3.) The foregoing extract, though drawn up in a most careless style contains such observations, as are well calculated to make the reader understand, that the ab- domen is in reality not a cavity, but a compact mass of containing and contained parts; that the close manner in which the various surfaces are constantly in con- tact, must powerfully oppose extravasa- tions ; and that, in fact, it often entirely prevents them. The passage cited im- presses us with the utility of that quick propensity to the adhesive inflammation, which prevails throughout every peritoneal surface, and which not only often has the effect of permanently, hindering effusion of the contents of the viscera, by agglutinat- ABDOMEN. 13 ing the parts together, but which, even when an extravasation has happened, be- neficially confines the effused fluid in one mass, and surrounds it with such adhe- sions of the parts to each other, as are rapid in their formation, and effectual for the purposes of limiting the extent of the effusion, and preventing the irritation of the extravasated matter from affecting the rest of the abdomen. It is to M. Petit, that we are indebted for the introduction of more correct modes of thinking upon the foregoing subject, and, as his valuable observations in the Mem. de l'Acad. de Chirurgie, are highly interesting, it is my intention to intro- duce them into this Dictionary, in the article, Extravasation, to which, for the present, I shall be content with referring. But, notwithstanding the influence of the reciprocal pressure of the containing and contained parts against each other, and the useful effect of the quickly arising adhesive inflammation, in all penetrating wounds of the belly, complicated with the injuries of the. viscera, we are not to sup- pose, that extravasation never happens; but, only that it is much less frequent than has been commonly supposed. Mr. Tra- vers, with much laudable industry, has endeavoured to trace more minutely, than any preceding writer, the particular cir- cumstances, under which effusions in the abdomen are likely or unlikely to happen. " It being admitted (says he) that there are cases, in which effusion does take place, it is easy to conceive circumstances, which must considerably influence this event. If, for example, the stomach and bowels be in a state of emptiness, the nausea, which follows the injury, will maintain that state. If the extent of the wound be considerable, the matter will more readily pass through the wound, than along the canal. A wound of the same dimensions in the small and the large intestines, will more readily eva- cuate the former, than the latter, because it bears a larger proportion to the calibre. Incised and punctured wounds admit of the adhesion of the cut edges, or the ever- sion of the internal coat of the gut, so as to be in many instances actually obliterat- ed ; whereas, lacerated, or ulcerated open- ing, do not admit of these salutary pro- cesses. Again, in a transverse section of the bowel, contraction of the circular fibre closes the wound, whereas in a longitudi- nal section, the contraction of this fibre enlarges it. Such (says Mr. Travers) are the circumstances, which combined, in a greater or less degree, increase or diminish the tendency to effusion." (On Injuries of Intestines, SJfc. p. 13—14.) After the details of some experiments and cases, the precedi'ng author makes among other conclusions, the following: 1. That effusion is not an ordinary con- sequence of penetrating wounds. 2. That, if the gut be full and the wound extensive, the surrounding pressure is over- come, by the natural action of the bowel tending to the expulsion of its contents. 3. That, if food has not recently been taken, and the wound amounts to a divi- sion of the gut, or nearly so, the eversion and contraction of the orifice of the tube, prevent effusion. 4. That, if the canal be empty at the time of the wound, no subsequent state of tlie bowel will cause effusion, because •the supervening inflammation agglutinates the surrounding surfaces, and forms a cir- cumscribed sac; nor can effusion take place from a bowel at the moment full, provided it retains a certain portion of its cylinder entire, the wound not amounting nearly to a semidivision of the tube, for then the eversion and contraction are too partial to prevent an extravasation. 5. That, when however air has escaped from the bowel, or blood has been extra- vasated in quantity within the abdomen at the time of the injury, the resistance, op- posed to effusion, will be less effectual, al- though the parietal pressure is the same, as such fluids will yield more readily, than the solids naturally in contact. P. 25— 26, 100. 6. That, though extravasation is not common in penetrating wounds, it follows more generally in cases, where the bowel is ruptured by blows, or falls upon the belly, while the integuments continued un- wounded. P. 36. 7. That when the bowels are perforated by ulceration, there is more tendency to effusion, than in cases of wounds. P. 38, &c. Mr. Travers attempts to explain the reason of the greater tendency to effusion, in cases of intestine burst by violence, and in those^>f ulceration "by the dif- ference in the nature of the injury, which the bowel sustains, when perforated by a sword or bullet, as in the one case, or burst or ulcerated in the other. A rup- ture by concussion could only'take place under a distended state of the bowel, a condition most favourable to effusion, and from the texture of the part, a rupture, so produced would seldom be of limited ex- tent. The process of ulceration, by which an aperture is formed, commences in the internal coat of the bowel, which has al- ways incurred a more extensive lesion, than the peritoneal covering. The puncture, or cut is merely a solution of continuity in a point, or line ; the ulcerated wound is 14 ABDOMEN. an actual loss of substa-nce. The conse- quence of this difference is, that, while the former, if small, is glued up by the ef- fusion from the cut vessels, or, if large, is nearly obliterated, by the full eversion of the villous coat, the latter is a permanent orifice." P. 46. How much Mr. Travers and Mr. John Bell differ in opinion, upon these latter points, will appear from the following passage: after adverting to the adhesion, which takes place between the viscera and the peritoneum, under a variety of circum- stances attending disease, Mr. John Bell observes: " this it is, which makes the chief difference, in point of danger, be-- twixt an ulcerated and a wounded intes- tine; for, in a wound, there is, as we should suppose, no time for adhesion, no- thing to keep the parts in contact, no cause, bv which the adhesion might be produced. But, in an ulcer, there is a slow disease, tedious inflammation, adhe- sion first, and abscess, and bursting after- wards ; sometimes a fistula remains dis- charging feces, and sometimes there is a perfect cure. If a nutshell, a large coin, a bone, or any dangerous thing be swal- lowed, it stops in the stomach, causing swelling and dreadful pain; at last, a hard, firm tumour appears, and then it suppurates, bursts, the bowel opens, the food is discharged at every meal, till the fistula gradually lessens, and heals at last. But, where the stomach is cut with a broad wound of a sabre, the blood from the wounded epiploic vessels, or Uie food itself, too often pours out into the abdo- men, and the patient dies." &c. ( Discourses on Wounds, p. 321, edit. 3.) The author afterwards proceeds to explain how the compact state of the containing and con- tained parts, and the incessant and equa- ble pressure, which the viscera sustain, frequently hinders effusion in cases of pe- netrating wounds. Which of these gentlemen is most cor- rect on the subject, I cannot pretend to say. Mr. Travers has certainly adduced a few cases, in favour of his own state- ment. Whether they are deviations from what is most common, can only be decided by a comparative examination of a greater number of facts. When the intestines ul- cerate, and thus rid themselves of foreign bodies, the general tenor of the cases on record undoubtedly affords us little reason to be apprehensive of extravasation. Yet, with respect to ulceration of the intestines from other causes, circumstances may be very different. Blood is more frequently extravasated in the abdomen, than any other fluid. Extravasations of this kind, however, do not invariably happen, whenever vessels of nota very considerablesize are wounded. The compact state of the abdominal vis- cera, in regard to each other, and their action on each other, oppose this effect. The action, alluded to, which depends on the abdominal muscles and diaphragm, is rendered very manifest by what happens, in consequence of operations for hernix attended with alteration of the intestines, or omentum. If these viscera should burst, or suppurate, after being reduced, the mat- ter which escapes from them, or tlie pus, which they secrete, is not lost in the ab- domen ; but is propelled towards the wound of the skin, and there makes its exit. The intestinal matter, effused from a mortified bowel, has been known to re- main lodged the whole interval, between one time of dressing the wound and ano- ther, in consequence of the surgeon stop- ping up the external wound with a large tent. When the abovementioned action or pressure of the muscles, is not sufficient to keep the -blood from making its escape from the vessels, still it may hinder it from becoming diffused among the convo- lutions of the viscera, and thus the extra- vasation is confined in one mass- The blood, effused and accumulated in this way, is commonly lodged at the inferior and anterior part of the abdomen, above the lateral part of the pubes, and by the side of one of the recti muscles. The weight of the blood may propel it into this situation, or, perhaps, there may be less resistance in this direction than in ano- ther. In opening the bodies of persons, who have died with such extravasations, tilings may put on a different aspect, and the blood seem to be promiscuously extra- vasated over every part of the abdomen. But, when such bodies are examined with care, it will be found, that the blood does not insinuate itself among the viscera, till the moment when the abdomen is opened, and the mass previously lies in a kind of pouch. This pouch is frequently circum- scribed, and bounded by thick membranes, especially when the extravasation has been of some standing. (Sabatier Medecine Operatoire Tom. 1, p. 28—30.) It is of the highest consequence to a practical surgeon to remember well, that all the parts contained in the abdomen are closely in contact with each other, and with the inner surface of the peritoneum. This is one grand reason, why extravasa- tions are seldom so extensively diffused as one might imagine; but, commonly lie in one mass, as Petit, Sabatier and all the best moderns have noticed. The pressure of the elastic bowels, of the diaphragm; and abdominal muscles, not only fre- ABDOMEN. 15 quently presents an obstacle to the diffu- sion of extravasated matter, but often serves to propel it towards the mouth of the wound. The records of surgery make mention of numerous instances, in which persons have been stabbed through the body, without any fatal consequences, and sometimes without the symptoms being even severe. In Mr. Travers's publication many cases, exemplifying this observa- tion, are quoted from a variety of sources; Fab. Hildan Obs. Chirurg. Cent. 5. Obs. 74. CEuvres de Pare, liv. 10. Chap. 35. Wiseman's Surgery, p. 371. La Motte's Traite Complet de Chirurgie, &c. &c. In such cases the bowels have been supposed to have eluded the point of the weapon, and this may perhaps in a few instances, have been actually the fact; but, in almost all such examples, there can be no doubt, that the bowels have been punctured, and an extravasation of intestinal matter has been prevented by the opposite pressure of the adjacent viscera. Such resistance and pressure may, also, have occasionally obliged intestinal matter, or blood, actu- ally extravasated, to pass through the wound of the bowel into its cavity, and thus be speedily removed. Certain it is, such copious evacuations of blood per an- num have followed stabs of tlie abdomen, as could hardly proceed from the arteries of the intestines. This way of getting rid of an extravasation must be rare, how- ever, compared with that by absorption. The pouch, or cyst, including extrava- sated blood, or matter, as mentioned by Sabatier, is formed by the same process, which circumscribes tlie matter of absces- ses. (See Suppuration.) It is in short the adhesive inflammation. All the surfaces in contact with each other, and surrounding the extravasation, and track of the wound, generally soon become so intimately con- nected together by the adhesive inflamma- tion, that the place in which the extrava- sation is lodged, is a cavity entirely desti- tute of all communication with the cavity of the peritoneum. The track of the wound leads to the seat of the effused fluid, but, has no distinct opening into the general cavity of the abdomen. The rapidity with wliich the above adhesions form, is often very great, almost incredible. It should be known, however, that ex- travasations are occasionally diffused in various degrees among the viscera, owing to the patient being subjected to a great deal of motion, or his having violent spas- modic contractions of the intestines, aris- ing from tlie irritation of the extravasated matter. Urine and bile are more frequent- ly dispersed to a great extent among the abdominal viscera, than blood. The latter fluid, indeed, must often coagulate; a circumstance, that must both tend to stop further hemorrhage, and confine the ex- travasation in one mass. SIMPTOMS AND TREATMENT OF EXTRAVA- SATIONS IN THE ABDOMEN. 1. Blood. Wounds of the spleen, and of such veins and arteries, as are above a certain size, almost always prove fatal from internal hemorrhage. Tlie blood generally makes its way downwards,and accumulates at the inferior part of the abdomen, unless the existence «f adhesions happen to oppose tlie descent of the fluid to theniost depend- ing situation. The belly swells, and the fluctuation of afluidis perceptible through the anterior part of the abdominal parietes The patient grows pale, loses his strength, is affected with syncope, and his pulse becomes weaker and weaker. In short, the symptoms, annually attendant on hemor- rhage, are observable. The viscera and vessels in the abdomen being continually compressed on all sides, by the surround- ing parts, the blood cannot be effused, without overcoming a certain degree of resistance ; and unless a vessel of the first magnitude, like the aorta, the vena cava, or one of their principal branches, has been wounded, the blood escapes from the vessel slowly, and several days elapse, be- fore any considerable quantity has accu- mulated in the lesser cavity of the pelvis In these cases of extravasated blood, the symptoms which, perhaps, had disap- peared, under tlie employment of bleeding and anodyne medicines, now come on again. A soft, fluctuating tumour may be felt at the lower part of the abdomen; sometimes on the right side; sometimes on the left; occasionally, on both sides. The pressure, made by the effused blood on the urinary bladder, excites distressing inclinations to make water; while the pres- sure, which the sigmoid flexure of the colon suffers, is tlie cause of obstinate con- stipation. In the mean time, the quantity of extravasated blood increasing, irritation and inflammation of the peritoneum are induced. The pulse grows weaker; debili- ty ensues; the countenance is moistened with cold perspirations; and, unless insti- gated by all the antecedent circumstances, the surgeon practices an incision for the discharge of the fluid, the patient falls a victim to the accident. In the year 1733, Vacher, principal sur- geon of the military hospital at Besancon, successfully adopted this mode of treat- ment, as I shall more particularly notice in the article Extravasation. Petit (the son) afterwards tried the same plan, though it did not answer, (as is alleged) in conse- quenceoftheinflammationhavingadvanced ABDOMEN. too far, before the operation was perform- ed. Long before the time of Vacher and Petit, a successful nstance of similar prac- tice had been recorded by Cabrole, in a work, which this author published, under the title of AA-^*/3jjtov ccvxrofttKov, id est, Anatomes elenchus accuratissimus, omnes humani corporis partes ed quci solent secari methodo, delineans. Accessere osteologia, observationes que Medicis ac Chirurgis perutiles. Geneva 1604. Hence, as Saba- tier has remarked, the method pursued by Vacher, was not so new as Petit imagined. (Medecine Operatoire, Tom. 1, p. 32.) Indeed, when the symptoms leave no doubt of there being a large quantity of blood extravasated in the abdomen ; when the patient's complaints are of a very se- rious nature, and are evidently owing to the irritation and pressure of the blood on the surrounding viscera; and when a local swelling denotes the seat of the extravasa- tion, there cannot be two opinions about the propriety of making an incision for its evacuation. „ Surgeons, however, should recollect, that a small extravasation of the blood may exist, without producing any very consid- erable irritation, provided no opening be made into the cyst, with which it becomes surrounded. On the contrary, when such \ cyst is opened, the air then having free access to the blood contained there, that partofthe fluid, which cannot be discharg- ed, is very apt to putrify, and become so irritating, as to excite inflammation of the surrounding parts.—Even though there may be an evident extravasation of blood, the bad symptoms are also sometimes en- tirely owing to the injury done to the parts within the abdomen, and neithej to the pressure, nor the irritation of the effused blood. But, sometimes as we have already no- ticed,, the accumulated blood at first, nei- ther irritates the adjacent parts by its quantity nor quality. An inflammation, however, of the parts surrounding the ex- travasation at length takes place. The ten- sion, irritation, and pain, which, in the first instance arose from the wound itself, and subsided, seem now to be renewed. When the extravasation is at the lower and ante- rior part of the abdomen, the patient ex- periences pain about the hypogastric re- gion. He is also constipated, and, as he suffers great irritation of the bladder, he feels frequent propensities to make water, but cannot relieve himself. At last, a tu- mour makes its appearance, attended with i fluctuation more or less distinct. In this instance, it seems proper to give vent to the accumulated blood. If this fluid should be found coagulated, injec- tions of warm water would facilitate its discharge. (Sabatier Medecine Operatoire, Tom. 1) 2. Chyle and ftces. These are not so easily extravasated in the abdomen as blood, because they do not require so much resistance, on the outside of the stomach and intestines, to make them continue their natural rout through the ali- mentary canal, as blood requires to keep it in the vessels. Extravasations of this kind, however, sometimes happen, when the wound is large and the bowel distended at the moment of the injury, or when, as Mr. Travers has likewise explained, air is ex- travasated, or blood effused in the abdo- men; these fluids being incapable of making effectual resistance to the escape of the in- testinal matter. (See an Enquiry into tlie Process of Nature in repairing Injuries of the Intestines, &c. p 26.) Nothing is a bet- ter proof of the difficulty with which chyle and feces are extravasated, than the ope- ration of an emetic, when the stomach is wounded and hill of aliment. In this in- stance, if the resistance to the extravasa- tion of the contents of the stomach were not considerable, they would be effused in the abdomen, instead of being vomited up. A peculiarity in wounds of the stomach and intestines is, that the opening, which allows their contents to escape, may also allow them to return into the wounded viscus. Extravasation of intestinal matter in the abdomen is attended with a severe train of febrile symptoms; dryness of the mouth, tongue, and fauces; considerable pain and swelling of the belly; convulsive starlings ; and hiccough and vomiting, with which the patients are generally .a ucked on the day after that, on which tiie wound - as received. (Sabatier de la Medecine Opera- toire, Tom. 1, p. 34.) In these cases, general means are the only ones which can be employed ; vene- section, fomentations, low diet, perfect rest, anodynes, &c. All solid food must be most strictly prohibited. The close state of the viscera m. y also be increased by applying a bandage ound the body. If the symptoms are not speedily as- suaged, the abdominal viscera become affected with general inflammation, and gangrene, and the patients die in the course of a few days. 3. Bile. Bile, on account of its great fluidity, is more easily extravasated extensively in the abdomen, t ban either blood, or the contents of the stomach and intestines. Besides, the gall bladder has the power of contract- ing itself so completely, as to expel the whole of its contents. Notwithstanding ABDOMEN. 17 these circumstances, however, extravasa- tions of this kind are exceedingly uncom- mon, doubtless, on account of the small size of the gall bladder, and its deep guarded situation, between the concave surface of the liver, and upper part of the transverse arch of the colon. Sabatier informs us, that he has only been able to find one example on record. This case, after having been communicated to tlie Royal Society of London, by Dr. Steward, (No. 414, page 341. Abridgm. Tom. 7, page 571—572,) was inserted, as an extract, in the third volume of the Edinburgh Essays, and also in the third volume of Van Swieten's Commentaries on the Aphorisms of Boerhaave, (transl. p. 65, edit. 1754.) An officer received a wound, penetrating the cavity of the abdomen, and entering the fundus of the gall bladder, without doing any material injury to the adjacent parts. The abdomen was imme- diately distended, as if the patient had been afflicted with an ascites, or tympa- nitis; nor, did the swelling either increase, or diminish till the patient's death, which happened a week after the infliction of the wound. There was no rumbling noise in the abdo- men,thoughitwasexceedinglytense.There were no stools, and very little urine was dis- charged, notwithstanding purgatives, and glysters, and a good deal of liquid nourish- ment, were given. The patient never had one instant of sound sleep, but, was always restless, though anodynes were exhibited. There was no appearance of fever, and the pulse was always natural till the last day of the patient's life, when it became inter- mittent. The intestines were found after death, veiy much distended, the gall blad- der quite empty, and a large quantity of bile extravasated in tlie abdomen. Sabatier met with an opportunity of ob- serving the symptoms of an extravasation of bile, in consequence of a wound of the gall bladder. The patient's abdomen swelled very quickly ; his respiration be- came difficult, and he soon afterwards complained of tension and pain in the right hypochondrium. His pulse was small, fre- quent, and contracted; his extremities were cold, and his countenance very pale. The bleedings, which were practised the first day, gave him a little relief; but, the tension of the abdomen, and the difficulty of breathing, still continued. A third bleeding threw the patient into the lowest state of weakness, and he vomited up a greenish matter. On the third day, the lower part of the belly was observed to be more prominent, and there was no doubt of an extravasation. M. Sabatier intro- duced a trocar, and gave vent to a green blackish fluid, which had no smell, and Vol. I. was pure bile, that had escaped from the wound of the gall bladder. After the ope- ration, the patient grew weaker and weaker, and died in a few hours. On opening tlie body, a large quantity of yellow bile was found between the peritoneum and intes- tines ; but, it had not insinuated itself among the convolutions of the viscera. A thickgluten connected the bowelstogether, andthey were prodigiously distended. The gall bladder was shrivelled and almost empty. Towards its fundus, there was a wound, about a line and a half long, cor- responding to a similar wound in the peri- toneum. The wound, which had* occur- red at the middle and lower part of the right hypochondrium, between the third and fourth false ribs, had glided from behind forward, and from above downward,be- tween the cartilages of the ribs, until it reached the fundus of the gall bladder. Sabatier takes notice, that tlie symptoms of the two cases, which have just now been related, were very similar. Both the pa- tients were affected with an exceedingly tense swellingof thebellyunattended with pain, or borborygmus, and they were both obstinately constipated. Their pulse was extremely weak the lajter days of their in- disposition, and they were afflicted with hiccough, nausea, and vomiting. We must not positively infer, however,that such ex- actly would be the symptoms in every in- stance of a wound of the gall bladder, un- accompanied by injury of other viscera: this conclusion only admits of confirmation by attention to more numerous facts. M. Sabatier seems to think one thing certain, viz. that wounds of the gall blad- der attended with effusion of bile, are absolutely mortal, and that no operation can be of any avail. (Medecine Opera- toire, Tom. 1, p. 34—37. 4. Urine. Urine being of a very fluid nature may, like the bile, be easily extravasated in the abdomen, when the bladder is wound- ed at any part, \\ hicl\ is connected with the peritoneum. If the urine, in this kind of case, be not drawn off with a catheter, so as to prevent this fluid issuing by the wound of the bladder, the patient soon perishes. There are many instances re- corded of the bladder being injured even by gun shot wounds, which were not mor- tal. Such wounds, however, might only have injured the sides, or lower part of the bladder. But, in operating for the stone, above the pubes, the bladder has undoubt- edly been occasionally cut at the part of the fundus, which is covered with the pe- ritoneum. However, as the accident was known in the first instance, the right treat- ment was adopted, and such patients have D 18 ABDOMEN. recovered. (Sabatier, Medecine Operatoire, Tom. 1, p. 37.) W0UND6 OF THE INTESTINES. The vomiting of blood, or discharge of it by stool, the escape of fetid air, or of intestinal matter, from the mouth of the wound; an empty collapsed state of" a portion of bowel, protruded at the opening in the skin, are the common symptoms at- tending a wound of this kind. When the wound is situated in the protruded portion, it is obvious to the surgeon's eye; but when it affects a part of the intestinal canal within the abdomen, the nature of the case can only be known by a conside- ration of other symptoms. In addition to such as I have already described, there are some others, which ordinarily accom- pany wounds of the bowels; as, for in- stance, oppression about the prxcardia, accute or griping pain in the belly, cold sweats, syncope, &c. But unless the wounded intestine be protruded, there is no practical good in knowing, whether the bowel is injured or not, since, if it be in the abdomen, the treatment ought not to be materially different from that of a sim- ple penetrating wound of the belly, unat- tended with a wound of any of the viscera. A wounded intestine is said to present some particular appearances, to which the gene- rality of writers have paid no attention: " If a gut be punctured, the elasticity of the peritoneum, and the contraction of the muscular fibres, open the wound, and the villous, or mucous coat forms a sort of hernial protrusion, and obliterates the aperture. If an incised wound be made, the edges are drawn asunder and reverted, so that the mucous coat is elevated in the form of a fleshy lip. If 1he section be transverse, the lip is broad and bulbous, and acquires tumefaction and redness from the contraction of the circular fibres behind it, wh ich produces, relat ively to the everted portion, the appearance of a cervix. If the incision is according to the length of the cylinder, the lip is narrow, and the eontractidn of the adjacent longitudinal, resisting that of the circular fibres, gives the orifice an oval form. This eversion and contraction are produced by that se- ries of motions, which constitutes the pe- ristaltic action of the intestines." (Travers on Injuries of the Intestines, p. 85.) According to this gentleman, some of these appearances were described by II:. I - ler, in Element. Physiol lib. 24, sect. 2, and Opera Minora, torn. 1, sect. 15. Having witnessed the facility,with which considerable injuries of the intestinal tube were repaired, Mr. Travers was desirous of ascertaining more fully the powers of nature in the process of*spontaneous repa- ration, and of determining, under how great a degree of injury, it would com- mence, as well as the mode of its accom- plishment. For ihese purposes,he divided the small intestine of several dogs as far as the mesentery. All these animals died, in consequence of the intestinal matter being extravasated, if they had been lately fed, or if they had been fasting in consequence of inflammation, attended with a separa- tion of the ends of the divided bowel, eversion of the mucous coat, and oblitera- tion of the cavity, partly, by this eversion, and partly by a plug of coagulated chyle. In one particular instance in which Mr. Travers made a division of tlie bowel, half through its diameter, a sort of pouch was formed round the injured intestine. " A pouch, resembling somewhat the diverti- culum in these animals, was formed op- posite to the external wound, on the side of the parietes, by the lining peritoneum, on the other side, by the mesentery of the injured intestine, that intestine itself, and an adjacent fold, which had contracted with it a close adhesion. The pouch, thus formed andinsulated,includedth«.opposed sections of the gut, and had received its contents, &c. The tube, at the orifices, was narrowed by the half eversion, but, offered no impediment to the passage of fluids." (P. 96.) Whether, under these circumstances, the functions of thealimen- tary canal could have been continued, Mr. Travers professes himself incapable of de- ciding. Among the inferences, which this gentleman has drawn from the experiments, detailed in his publication, the tendency of the twp portions of a divided bowel to recede from each other, instead of coalesc- ing to repair the injury, merits notice, in as much as it tends to shew, that the only means of spontaneous reparation consists in the formation of an adventitious canal, by theencirclingbowelsandtheirappendages. Theevertedmucouscoat, which is the part opposed to the surrounding peritoneum, is also indisposed to the adhesive iijflam- mation. When, however, the wound of the in- testine is smaller, the obstacles to repara- tion are not absolutely insurmountable. Here, retraction is prevented, and the pro- cesses of eversion and contraction modi- fied by the limited extent of the injiuy. If, therefore,the adhesive inflammation unite the contiguous surfaces, effusion will be prevented, and the animal escape imme- diate destruction. But, union can only take place through the medium of die sur- rounding parts. According to Mr. Travers, it is the re- traction, immediately followingthe wound that is a chief obstacle to the reparation of* ABDOMEN. 19 "the injury; for, if the division be performed in such a way, as to prevent retraction, the canal will be restored in so short a time, as but slightly to interrupt the digestive function. In confirmation of this state, a ligature was tightly applied round the duo- denum of a dog, which became ill, but entirely recovered, and was killed. " A ligature, fastened around the intestine, divides the interior coats of the gut, in this effect resembling the operation of a liga- ture upon an artery. The peritoneal tunic alone maintains its integrity. The inflam- mation, which the ligature induces on either side of it, is terminated by the de- position of a coat of lymph, which is exte- rior to the ligature, and quickly becomes organized. When the ligature, thus enclos- ed, is liberated by the ulceraive process, it falls of necessity into die canal and pas- ses off with its contents." (P. 103, 104.) It appears also from Mr Travers's ex- periments and observations, that longitu- dinal wounds of the bowels are more easily- repaired, than such as are transverse. In a dog, a longitudinal wound, of the extent of an inch and a half, was repaired by the adhesive inflammation. Here the process of eversion is very limited; the aperture bears a smaller proportion to theiylinder of the bowel, and the entire longitudinal fibres resist the action of the circular.which are divided, and can now only slightly les- sen the area of the canal. (P. 108.) We come now to the consideration of the treatment, which may be proper in cases of wounds of the intestines ; a subject in which much difference of opinion has pre- vailed ; principally, however, concerning the circumsu-uices, in which sutures are necessary, and the most advantageous way of applying them. When the wounded bowel lies within the cavity of the abdomen, no surgeon of the present day would have the rashness to think of attempting to expose the injured intestine, for the purpose of sew ing up the breach of continuity in it. In fact, the surgeon seldom knows at first what has happened; and when the nature of the case is afterwards manifested, by the dis- charge of blood per anum, an extravasa- tion of intestinal matter, &c. it would be impossible to get at the injured part of the bowel, not only because its exact situation is unknown, but, more particularly, on ac- count of the adhesions, which are always formed with surprising rapidity. But, even if the surgeon knew, to a certainty, in the first instance, that one of the bowels was wounded, and the precise situation of the injury, no suture could be applied, without considerably enlarging the external wound, drawing the wounded intes-ine out of the cavity of the abdomen, and handling and , disturbing all the adjacent viscera. No- thing would be more likely, than such proceedings, to render the accident, which may originally be curable, unavoidably fatal. I entirely agree upon this point with Mr. John Bell, who says, " When there is a wounded intestine, which we are warned of only by the passing out of the feces, we must not pretend to search for it, nor put in our finger, nor expect to sew it to the wound; but we may trust, that the uni- versal pressure, which prevents great effu- sion of blood, and collects the blood into one place, that very pressure, which always causes the Wounded bowel and no other to protrude, will make the two wounds, the outward wound and the inward wound of the intestine oppose each other, point to point; and, if all be kept there quiet, though but for one day, so lively is the tendency to inflame, that the adhesion, will be begun, which is to save the patient's life." (Discourses on Wounds, 'p. 361, edit. 3.) When the extravasation.and other symp- toms, a few days after the accident, shew^ the nature of the case, a suture can be of no use whatever, as the adliesive inflam- mation has already fixed the part in its situation, and the space, in which the ex- travasation lies, is completely separated from the general cavity of the abdomen, by the surrounding adhesions. When the- bowel is not protruded, and the opening in it is situated closely behind the wound in the peritoneum, a suture is not requisite, for the contents of the gut not passing onward, will be discharged from the outer wound, and not be diffused among the viscera, if care be taken to keep the external wound open. There is no danger of the wounded bowel changing its situation, and becoming distant from the wound in the peritoneum, for the situation which it now occupies, is its natural one. Nothing, but violent motion, or exertions, could cause so unfavourable an occurrence, and, these should always be avoided. The adhesions, which take place in the course of a day or two, at length render it impos- sible for the bowel to shift its situation. Things, however, are far different when the wounded part of the bowel happens to be protruded. Here we have the authority of all writers, in sanction of the employ- ment of a suture. No enlargement of the outer wound is requisite to enable the? practioner to adopt such practice; there is no disturbance created by the adjacent parts; there is no doubt concerning the actual existence of the injury; no difficulty in immediately finding out its situation. But, though authors are so generally agreed about the propriety of using a su- -ture, in the case of a wounded and pr«« 20 ABDOMEN. truded bowel, they differ exceedingly, both as to the right object of the method, and the most advantageous mode of sewing the injured part of the intestine. Some have little apprehension of extravasation, advise only one stitch to be made, and use the ligature chiefly with a view of confin- ing the injured bowel near the external wound, so that, in the event of an extra- vasation, the effused matter may find its way outward. Other writers wish to re- move the possibility of e xtravasation, by ap- plying numerous stitches, and attach little importance to the plan of using the liga- ture principally for the purpose of keeping the intestine near the superficial wound. When the wound of a bowel is so small, that it is closed by the protrusion of the villous coat, the application of a suture must evidently be altogether needless, and since the ligature would not fail to cause irritation, as an extraneous substance, the employment of it ought unquestionably to be dispensed with. Supposing, however, the breach in the intestine to be small, but yet sufficient to let the feces escape,what method oughtto be adopted? The following practice seems rational. As Mr. Astley Cooper was per- forming the operation for a strangulated hernia, at Guy's hospital, an aperture, giving issue to the intestinal contents, was discovered in a portion of the sound bowel, just when the part was about to be reduced. The operator, including the aperture in his forceps, caused a fine silk ligature to be carried beneath the point of the instru- ment, firmly tied upon the gut, and the ends cut off close to the intestine. The part was then replaced, and the patient did well. Mr. Travers, who has related this fact, approves of the plan of cutting away the extremities of the ligature, instead of leaving them hanging out of the external wound. It appears, that, when the first practice is followed, the remnant always makes its way into the intestine, and is discharged with the stools, without any inconvenience. But, when the long ends are drawn through the outer wound, and left in it, they materially retard the pro- cess of healing. (Sec Travers on Injuries »f the Intestines, &c. p. 112, 113) Let us now enquire into what ought to be tlie conduct of a surgeon, should he be called to a patient, whose bowel is divided through its whole cylinder, and protruded out of the external wound. Various have been the schemes and pro- posals, for the treatment of this sort of ac- cident ; and since experience has furnish- ed few practitioners with an opportunity of seeing such a case in the human subject, a variety of experiments have been made on animals, in order to determine what treat- ment would be the most successful. Ramdohr, indeed, is stated by Moebius, to have had occasion to try, on tlie human subject, a plan, of which a vast deal has been said and written. He cut off a large part of a mortified intestine, and joined tlie two sound ends together, by inserting the upper within the lower one, and fixing them in this position with a suture, the ligature being also employed to keep them at the same tune near the external wound. The patient recovered, and the feces con- tinued to pass entirely by the rectum in the natural way- (See Halleri Disput. Anat. Vol. 6. Obs. Med. Miscellan. 18.) Moebius attempted to repeatRamdohr's operation upon a dog; but, he could not succeed in insinuating the upper part of the divided bowel into the lower one, on account of tlie contraction of the two ends of the intestinal tube, and the smallness of the canal. Moebius, therefore, was obliged to be contentwith merely bringing the ends of the bowel together with a su- ture : the animal died, however, of an ex- travasation of the feces. Dr. Smith, of the Philadelphia Medi- cal Society, also tried to repeat Ramdohr's • method, but could not succeed. He di- vided tltf intestine of a dog transversely, and having inserted a piece of candle into that portion of the bowel, which was sup- posed to be uppermost, he endeavoured to introduce the superior within the inferior; but, the ends became so inverted, that it was found utterly impossible to succeed. The scheme was therefore given up, and only one stitch made, the ligature being then attached to the external wound, in the manner advised by Mr. John Bell. The dog died, and, on examination, there was found a considerable quantity of feces and water in the abdominal cavity. Two other trials were made of Mr. John Bell's plan by Dr. Smith, on tlie intes- tines of dogs : in both instances the ani- mals died, the intestines being much in- flamed, and feces effused in the abdomen. (See Dr. Smith's Thesis.) Mr. Travers likewise tried the same ex- periment. " I divided the small intestine of a dog, which had been for some hours fasting, and carried a fine stitch through the everted edges, at the point opposite to their connexion with the mesentery. The gut was then allowed to slip back, and the wound was closed. The animal survived only a few hours. Examination. The pe- ritoneum appeared highly inflamed. Ad- hesions were formed among the neighbour- ing folds, and lymph was deposited in masses upon the sides of the wounded gut. This presented two large circular orifices. Among the viscera were found a quantity of bilious fluid, and some extraneous sub- ABDOMEN. 21 stances-, and a worm was depending from one of the apertures. By the artificial connexion of the edges in a single point of their circumference, and their natural con- nexion at the mesentery, they could recede only in the intervals, and here they had receded to the utmost." In another ex- periment, Mr. Travers increased the num- ber of points of contact, by placing three single stitches upon a divided intes- tine, cutting away the threads, and re- turning the gut. The animal died on the second day. Examination. Similar marks of inflammation presented themselves. The omentum was partially wrapped about thewound; but, one of the spaces, between the sutures was uncovered, and from this the intestinal fluids had escaped. On cautiously raising the adhering omentum, the remaining stitches came into view. Here again the retraction was considera- ble, and the intervening elliptical aperture proportionally large. On the side, next to the peritoneum, however, the edges were in contact and adhered, so as to unite the sections at an angle. From such experiments, the conclusion, drawn by Mr. Travers, is, that apposi- tion, at a point, or points, is, as respects effusion, more disadvantageous, than no apposition at all; for, it admits of re- traction, and prevents contraction, so that each stitch becomes the extremity of an aperture, the area of which is detfjrmined by the distance of the stitches. (P. 116, 119.) This gentleman, there- fore maintains, that the absolute con- tact of the everted surfaces of a divided intestine, in their entire circumference, is requisite to secure the animal from the danger of abdominal effusion. (P. 121.) The spe- cies of suture employed (says Mr. Travers) is of secondary importance, if it secures this contact. (P. 134.) And among other observations, 1 find "wounds amounting to a direct division of the canal are irrepara- ble,andthereforeinvariablyfatal."(P133.) Without entertaining the least desire to give offence, I confess, I do not know what could induce Mr. Travers to be so positive in these inferences. We are told, that apposition at a point, or powits, is, as respects efrusion,more disadvantageous than no apposition at all, and that the ab- solute contact of the divided surfaces, in their entire circumference, is requisite to secure the animal from the danger of ab- dominal effusion. The foundation of these unqualified conclusions is five expe- riments, made on dogs, in four of which ex- periments, the divided bowel was brought together with one stitch, on Mr. John Bell's plan, while, in another three stitches were made; and, yet, in all these instances, the animals died with tlie con- tents of the bowels effused. So far the inferences seem established. Unfortu- nately, for their stability, however, Mr. Travers immediately afterwards proceeds to relate other experiments, instituted by Mr. Astley Cooper, Dr. Thomson, and. Dr. Smith, which, though Mr. Travers seems unaware of the fact, tend most completely to overturn the conclusions which he had been previously making. " Mr. Cooper repeated the experiments of Duverger, who had succeeded, in uniting by suture, the divided intestine of a dog, including in it a portion of the trachea of a calf. In place of the unin- terrupted suture, .three distinct stitches were inserted. On the sixteenth tlay, the animal was killed, and the union was complete." (P. 123.) Here we have two facts, proving that a wounded intestine may be united, though the suture was not such, as to maintain the divided surfaces in contact, in the whole of their circumference. Mr. Astley Cooper then made the ex- periment, without including the foreign substance. The animal recovered, being a third fact, tending to shew, that the ab- solute contact of every point of the ends of the divided bowel is not essential to the cure. (See A. Cooper on Inguinal and Congenital Hernia. Chap. II) After dividing the small intestine of a dog, Dr. Thomson, Regius professor of Mi- litary Surgery at Edinburgh, applied five interrupted stitches, at equal intervals, the ends of the ligatures, were cut off, and tlie external wound was closed with a suture. This animal did not die of the operation, and, when he was afterwards killed, it appeared, that the threads had madotheir wayinto the interior of the intestinal canal. Dr. Thomson repeated this experiment, and did not kill the animal till six weeks afterwards, when the same tendency of ligatures to pas's into the bowels, and be thus discharged, was exemplified. These two last cases make five, in proof that the absolute contact of every part of the ends of a divided bowel is not essential to prevent effusion, or the consequences of the wound from proving fatal; and several other experiments were made by Dr. Smith, of Philadelphia, who employed four stitches, with similar suc- cess. As far then as the majority of such facts ought to have weight, we are bound to receive the conclusions of Mr. Travers as incorrect, and unestablisbed. I am only surprised, that Mr. Travers him- self, who has cited the particulars of all these last experiments, did not perceive, that they struck directly at his own in- ferences. They are not only irresistible ABDOMEN arguments against Mr. Travers's conclu- sion, that the union of a divided bowel requires tlie contact of the cut extremities in their entire circumference; but, they are a plain denial of another position, advanced by this author, viz. that wounds, amounting to a direct division of the ca- nal are irreparable, and, therefore, inva- riably fatal. With respect to the species of suture being of secondaiy importance, provided it secure the complete contact of every part of the everted ends of the divided bowel, I regret, that Mr. Travers has omitted to institute experiments, in order to shew, that any such suture can be prac- tised, and, if he has the ingenuity to apply it, whether the result would be for, or against, the conclusions, which he has formed. The fact of the sutures always making their way into the cavity of the bowel, and being thus got rid of, appears to me highly interesting, since it shews the safety of cutting away tlie ends, in- stead of leaving them hanging out of the external wound, so as to create the usual irritation and inconveniences of extrane- ous substances. It seems, that Mr. Ben- jamin Bell first recommended cutting the ends of the ligatures away, and reducing the bowel in this state into the abdomen, as he says, a considerable part of the re- mainder of the ligature will fall into the cavity of the gut. (System of Surgery, Vol. II.p. 128, Edit. 7) We have seen, that the experiments of Dr. Thomson confirm the observation, and those, in- stituted by Mr. Travers, tend to the same conclusion. According to the latter writer, the fol- lowing is the process by which a divided intestine is healed, when sutures are em- ployed. " It commences with the agglu- tination of the contiguous mucous sur- faces, probably, by the exudation of a fluid, similar to that, which glues toge- ther the sides of a recent flesh wound, when supported in contact. The adhesive inflammation supervenes, and binds down the everted edges of the peritoneal coat, from the whole circumference of which a layer of coagulable lymph is effused, so as to envelope the wounded bowel. The ac- tion of the longitudinal fibres, being op- posed to the artificial connexion, the sections mutually recede, as the sutures loosen by the process of ulcerative ab- sorption. During this time, the lymph deposited becomes organized, by which further retraction is prevented, and the original cylinder, with the threads attach- ed to it, is encompassed by the new tunic. " The gut ulcerates at the points of the ligatures, and these fall into its canal. The fissures, left by the ligatures, are gradually healed up; but, tlie opposed villous surfaces, so far as my observation foes, neither adhere, nor become conso- dated by granulation, so tliat the inter- stice, marking the division internally is probably never obliterated." ( Travers on Injuries of the Intestine, &c. p. 128.) Notwithstanding I have carefully read all the arguments adduced by Mr Tra- vers in favour of stitching a divided bowel at as many points as possible, I still re- main unconvinced of the advantage of such practice, for reasons already sug- gested. If a case were to present itself to me, in which a bowel was protruded and partly cut tlu-ough, I should apply only a single suture, made with a common sew- ing needle, and a piece of fine silk. If the bowel were completely cut across, I should have no objection to attach hs ends together by means of two or three stitches of the same kind. I coincide with Mr. Travers respecting the advan- tage of cutting off the ends of" tlie liga- ture, instead of leaving them in tlie wound, as I believe he is right, in regard to the little chance there is of the injured intestine receding far from the wound, and if the ends of the ligature are then of no use in keeping the bowel in this posi- tion they must be objectionable, as extra- neous substances. Sometimes, only one end of the divided gut protrudes at the wound, and, the other lies concealed in the cavity of the abdo- men. If the hidden continuation of the intestinal canal, cannot be found without enlargingThe wound, it may be questioned, whether tlie urgency of the case does not justify this practice. If the upper end should happen to be the one concealed in the abdomen, almost certain death must result from its continuance there ; if it be the lower one, and no attempt be made to find it, the patient can only sur- vive with the loathsome affliction of an ar- tificial anus. When the protruded intestine is morti- fied, which must be a very rare occurrence in cases of wounds, the surgeon's conduct should be the same as in a mortified en- terocele. (See Hernia.) With regard to the constitutional treat- ment, in wounds of the intestines, the principal indication is to prerent a dan- gerous degree of inflammation. Hence bleeding and the antiphlogistic treatment are highly indispensable. Let not the surgeon be deterred from putting such practice in execution by the apparent de- bility of the patient, liis small concentrated pulse, and tlie coldness of his extremities, symptoms, common in acute inflammation of the bowels, and, in fact, themselves in- dicating the propriety of repeated vene- ABD section. Wounds of the small intestines arc attended with more vehement inflam- mation, than those of the large ones. All flatulent, stimulating, and solid food, is to be prohibited. The bowels are to be daily emptied with glysters, by which means, no matter will be allowed to accu- mulate in the intestinal canal, so as to create irritation and distention. When excrementitious matter is dis- charged from the outer wound, it is highly necessary to clean and dress it very fre- quently. Gentle pressure should also be made, with the fingers, at the circumfer- ence of the wound, at each time of apply- ing the dressings, for the purpose of pro- moting the escape of any extravasated matter. For the same reason, the patient should always lie, if convenient, in a pos- tui e that wili render the external opening a depending one. After a day or two, the surgeon need not be afraid of letting the outer wound heal up; for the adhesive inflammation, all around the course of the wound, will now prevent any extravasated matter from becoming diffused among the viscera. If the case should end well, the intestine ge- nerally undergoes a diminution in its dia- meter at the place where the wound was situated. When tliis contraction is in- considerable, the patient occasionally ex- periences colic pains at the part, especially after eating such food, as tends to produce flatulence. As these pains usually go en- tirely off after a certain time, and no in- convenience whatsoever remains, the in- testine may possibly regain its wonted capacity again. A more considerable con- striction of the above sort has been known to have occasioned a fatal miserere. Even the intestine itself has been known to burst in this situation, after its contents had ac- cumulated behind the contracted part. Patients, who have recovered from wounds of the intestines, should ever afterwards be particularly careful not to swallow any hard substances, or indigestible, flatu- lent food. In some instances, intestinal matter continues to be discharged from the outer wound, either in part, or entirely, so that either a fistula, or an artificial anus is the consequence. A fistula is more apt to follow, when an intestine has been injured by a ball, has been quite cut through, or has mortified. But, numerous cases have evinced, that this is not invariably the consequence, and that a perfect cure has frequently followed each of these occur- rences. When an intestine is completely cut through, and the lower portion of the canal lies inaccessibly concealed in the ab- domen, there is a necessity for promoting A C C .23 the formation of an artificial anus. In this particular case, the extremity of the intestine is to be attached, with a fine su- ture, to the edges of the outei wound. In order to distinguish the upper end of the intestine from the lower one, some re- commend giving the patient some milk to drink, and to wait a little, to see whether the fluid issues from the mouth of the gut. In the mean while, they content themselves with applying fomentations. If the upper end of the intestine should be in the abdo- men, it certainly seems justifiable, when the accident is quite recent, to dilate the outer wound sufficiently to see, whether the part is near enough to be got at. If the surgeon should succeed in this object, / the two ends of the bowel ought to be sewed together, as above directed. In gun-shot wounds of the abdomen, the treatment is limited to the employ- ment of general means. For information, relative to wounds of the abdomen, see Richter's Anfangsgrunde tier Wundarzney- kunst, Band 5. Kap. 1. Discourses on the Nature and Cure of Wounds, by Jolin Bell, Edit. 3. Encyclopedic Methodique, Partie Chirurgicale, Art. Abdomen, and Intestins. Dr. Smith's Inaugural Thesis. An Enquiry into the Process of Nature in repairing Inju- ries oftlieintestines, &c. by B. 7 'ravers Hun- ter on Gun-shot Wounds. Mr. A. Cooper's , work on Inguinal and Congenital Herrua, Chap. II. Sabatier*s Medecine Operatoire, Tom. 1. Essai sur les Epanchemens, and Sidte de I' Essai sur les l.panchemens par M. Petit, le fils, in Mem. de V Acad, de Chirurgie, Tom. 2 and 4, Edit, in 12mo. ABSCESS. This term signifies a tu- mour containing pus, or a collection of purulent matter. Authors differ about the original derivation of the word. The most common opinion is, that it comes from tlie Latin abscedo, to depart, because parts, which were before contiguous, be- come separated, or depart from each other. Abscesses are divided into two principal kinds, viz. acute and chronic. For every thing, relative to the former, see Suppura- tion; and, for information, concerning the latter, refer to Lumbar Abscess. The Mammary Abscess is a distinct article. See also the articles,Antrum,Anns Abscesses of, Bubo, Empyema, Hypopium, Whitlow, &c. ACANTHA'BOLUS. (from evcou/fa, a thorn, and fictXXm, to cast out.) Art instru- ment for taking thorns out of the flesh, and described by Paulus iEgineta. It is said to be like an instrument called the volsella, used for extracting bones from the oesophagus, and foreign substances from wounds. A'CCIPITER, (a hawk.) The name of a bandage, which was formerly employ- 24 ACHILLES ed by surgeons for covering the nose: it derived its name from its supposed re- semblance to a hawk's claw. ACCRETION. A growing together of parts, as of the toes, or fingers to each other, in consequence of burns, &c. ACETUM. Vinegar. (From aceto, to be acid.) Called in the last Pharmaco- poeia of the London College, AcidumAce- ticum. Vinegar is an article of very con- siderable use in surgery. Mixed with farinaceous substances, it is frequently applied to sprained joints, and, in conjunc- tion with alcohol and water, it makes an eligible lotion for inflammations of the surface of the body. Vinegar has acquired reputation at the Gloucester Infirmary, for quickening the exfoliation of dead bone, which effect may be owing to its property of dissolving the phosphate of lime. The excellent effects of vinegar, when immediately applied to burns and scalds, have been taken particular notice of by Mr. Cleghorn, a brewer in Edin- burgh, who communicated his sentiments to Mr. Hunter. (See Med. Facts and Ob- servations, Vol. II) See the Article, Burns. In chronic inflammations ofthe eyes and eyelids, vinegar has lately been brought into considerable repute. It is also re- commended as an application, in certain instances, in which the eyes are weak and watery. It is said to be an efficacious re- medy even in cases of acute ophtlialmy, after topical and general bleeding. When- ever vinegar is applied to the eye, it is in a diluted state, as may be seen in another part of this work. (See Collyrium Acidi Acetici.) Very strong vinegar may be obtained by freezing and separating the water, which is mixed with the acid. When thus concentrated, it is said to be an excellent styptic for stopping hemorrhage from the nose. With this view, it may be used either as an injection, or a lotion, in which lint is to be dipped, and afterwards intro- duced up the nostril. ACHILLES, Tendon of. So called, be- cause as fable reports, Thetis, the mother of Achilles, held him by that part, when she dipped him in the river Styx, to make him invulnerable. It signifies that great and powerful tendon, which is formed by the junction of the gastrocnemius and so- leus muscles, and which extends along the posterior part of the tibia, from the calf to the heel. When this tendon is unfortu- nately cut, or ruptured, as it may be, in consequence of a violent exertion, or spasm of the muscles, of which it is a continuation, the use of the leg is imme- diately lost, and unless the part be after- wards successfully united, the patient must remain a cripple for life. The ancient surgeons seemjnot to have been well acquainted with tlie rupture of the tendo Achillis, which they probably might mistake for a sprain, or some other complaint. In cases, in which this part had been cut, they recommended approxi- mating the separated portions, and main- taining them in contact bymeans of a suture. When the ruptured tendo Achillis, was afterwards better understood, the plan, just mentioned, was even adopted in this case, the integuments having been previ- ously divided, for the purpose of bringing the tendon into view. But, there is no ne- cessity for having recourse to this painful proceeding. (Encyclopedic Methodique, Partie Chirurgicale, 'Tom. 1, p. 55.) The superficial situation of the tendo Achillis, always renders the diagnosis of its rupture exceedingly obvious, and the accident can only become at all difficult to detect, when there is a considerable degree of swelling, which is very rare. When the tendon has been cut, the division of the skin even allows the accident to be seen. When the tendon has been ruptured, the patient hears a sound, like that of the smack of a whip, at the moment of the occurrence. In whatever way the tendon has been divided, there is a sudden inca- pacity, or, at least, an extreme difficulty, either of standing or walking. Hence, the patient falls down, and cannot get up again. Besides these symptoms, there is a very palpable depression, between the ends of the tendon, which depression is increased when the foot is bent, and di- minished, or even quite removed, when the foot is extended. The patient can spontaneously bend his foot, none of the flexor muscles, being in. terested. The power of extending the foot is still possible, as the peronei mus- cles, the tibialis posticus, and long flexors, remain perfect, and may perform this mo- tion. (OEuvres Chirurgicales de Desault par Bichat, Tom. 1 ) The indications are to bring the ends ofthe divided part together, and to keep them so, until they have become firmly united. The first object is easily fulfilled by putting the foot in a state of complete extension; the second, namely, that of keeping the ends ofthe tendon in contact, is more difficult. In order to have a right comprehension ofthe indications.we should consider what keeps the ends of the tendon from being in contact. The flexion of the foot has this effect on the lower portion; the con- traction ofthe gastrocnemius, and a soleus on the upper one. The indications then are to put the foot in an unalterable state of extension, and to counteract the action of the above muscles. ACHILLES. 23 Tiie action of the muscles may be op- posed : 1. By keeping these powers in a continual state of relaxation. For this purpose, the leg must be kept half bent upon tlie thigh. 2. By applying metho- dical pressure to the muscles; methodical, because it is to operate on the fleshy por- tion ofthe muscles, and not on the tendon, the ends of which being depressed by it, would be separated from each other, and, instead of growing together, would unite to the adjacent parts. The pressure should also operate so as {p prevent the ends of the tendon from inclining either to the right or left. This kind of pressure, which the band- age ought to make, seems to have escaped the attention of all authors. Who cannot see, however, that the action ofthe mus- cles being by tins means resisted, the up- per end of the tendon will not have such a tendency to be drawn upward, and se- parated from the lower one? ((Euvres Chirurgicales de Desault par Bichut, Tom. 1.) The famous Fetit seems entitled to the honour of having first devised the plan of treating the ruptured, or divided tendo Achillis, by keeping the leg and foot in a particular posture, with the aid of an apparatus. Seeing that the extension of the foot brought the ends of the tendon into contact, it occurred to hun that such extension should be maintained during the whole ofthe treatment, in order to bring about a permanent union. This happy idea, the simplicity of which should have rendered it obvious to all practioners, once having originated, became the com- mon basis, on which have been founded all the numerous methods of cure, which have been^iince recommended. (Desault par Bichat.) The celebrated Dr. Alexander Monro, professor of anatomy at Edinburgh, hap- pened to rupture his tendo Achillis. When tlie accident took place, he heard a loud crack, as if he had suddenly broke a nut with his heel, and he experienced a sensa- tion, as if the heel of his shoe had made a hole in the floor. This sensation, he says, has also been observed, by others, though some have complained of a smart stroke, like what would be produced by a stone or cane. Immediately suspecting what had happened, the doctor extended his left foot, in which the occurrence had taken place, as strongly as he could with his right hand, while with his left, he pressed the muscles of the calf downward, so as to bring the ends of tlie broken tendon as near together as possible. In this position he sat, until two surgeons came to his resistance. They applied compresses, and a hent board to the upper part ofthe foot, and forepart of the leg, both which they Vol. I. kept, as nearly as possible, ih a straight line, by a tight bandage, made with a long roller. But, as this mode of dressing soon became very uneasy, it was changed for the following one. A footsock, or1 slipper, was made of double quilted tick- ing, from the heel of which a belt or strap projected, of sufficient length to come up over the calf of the leg. A strong piece, of the same materials, was prepared of sufficient breadth to surround the calf, and this was fastened with lacings. On the back part of this was a buckle, through which the strap of the footsock was pass- ed, so that the foot could be extended, and the calf brought down at pleasure. The leg and loot were wrapt up in soft flannel, fumigated with benzoin, and the bandage was kept on day and night, the belt being made tighter, when the doctor was about to go to sleep, and loosened when he was awake, and on his guard. For a fortnight, he did not move his foot and leg at all, but, was conveyed in a chair on castors from one part of the room to another. After this, he began to move the ankle-joint, but in such a gentle man- ner as not to give any pain. The degree of motion was gradually increased, as the tendon became capable of bearing it, care being taken to stop, when the motion be- gan to create uneasiness. The affected limb was moved in this way, for half an hour at a time. In a few days, the hollow, 1 between the separated ends ofthe tendon, became imperceptible, though the part continued soft much longer. It became, however, gradually thicker and harder until a knot was at last formed in it, appa- rently of a cartilaginous nature. Though this was at first as large as a middling plum, and gradually became softer and smaller, yet it did not disappear entirely. Having occasion to go out six weeks after the accident, the doctor put on a pair of shoes, with heels two inches high, and contrived a steel machine to keep his foot in the proper position. This machine, however, he afterwards changed for ano- ther, made of the same materials as tin*- former. It was not till five months after the accident, that he thought proper to lay aside all assistance, and to put tiie strength of the tendon to a trial. (See Monro's Works, p. 661.) It seems unnecessary to enumerate the various plaRs, devised since the time of Petit. Suffice it to state, that both in a wound and rupture of the tendo Achillis, the ancient method of using a suture, for keeping the ends of the tendon in contact, is at present quite exploded, and position of the limb is the grand agent, by which the cure is now universally accomplished. The following was Desault's method, which, though it was expressly designed 26 ACI ACN to fulfil all the above-mentioned indica- tions, may not after all be a more valua- ble practical plan, than the one adopted by Dr. Monro. Afier the ends of the ten- don had been brought into contact, by moderate flexion of the knee, and com- plete extension of the foot, Desault used to fill up the hollows, on each side of the tendon with soft lint and compresses. The roller, applied to the limb, made as much pressure on these compresses, as on the tendon, and hence this part could not be depi essed too much against the subja- cent parts. Desnult next took a compress, about two inches broad, and long enough to reach from the toes to the middle ofthe thigh,' and placed it under the foot, over the back of the leg, and lower part of the thigh. He then began to apply a few cir- cles of a roller round the end of the foot, so as to fix the lower extremity of the lon- gitudinal compress. After covering the whole foot with the roller, he used to make tlie bandage describe the figure of 8, pass- ing it under the foot, and across the place where the tendon was ruptured, and the method w^s finished by encircling the limb upward, with tlie roller, as far as the upper end of the longitudinal compress. (Desault par Bichnt.). Certainly this plan seems to answer every object, and may be worthy of being adopted in this country. The continued pressure on the muscles of the calf, by which their action is materially resisted, is too much disregarded by the generality of English surgeons. Consult Monro's Works ; Encyclopedic Metltodique, Article Acliille, tendon d', and Memoire sur la divi- sion du tendon d'Actrille, in (Euvre's Chirur- gicales de Desault parBichat, Tom. l,p.306. ACHORES, (from a^-aif £«, bran.) The scald head, so called from the branny scales thrown off* it. (See Tinea Capitis.) ACIDUM NITROSUM, now called by the London College, Acidum Nitiuccm. Dr. Rollo, Mr. Cruikshank, Dr. Beddocs, Mr. Blair, and many others have tried this acid, as a substitute for quicksilver in the cure of the lues venerea. The practice began with Mr. Scott, a surgeon in Bengal, who is said to have caught the idea from Dr. Girtanner, who suggested, that the efficacy of tlie various prepara- tions of quicksilver might arise from the oxygen, which they contained. A multitude of cases have been brought forward in favour of nitric acid, a$> an an- tisyphilitic, but, there are also some others adduced, which seem very decidedly to controvert its claims to that character. It should be carefully remembered, that it is the nitric acid, not the nitrous, wiiich seems to deserve a further trial in syphi- litic cases. Mr. Pearson is of opinion, that the power of this medicine has not yet been ascertained in so satisfactory a way as to preclude all difference of opinion on the subject. Another writer says, that the symptoms of confirmed lues venerea are not removed by nitrous acid; but, that the medicine has been used both liberally and success- fully for removing the debilitating effects of mercury, for giving tone to the sto- mach, improving the appetite, and im- parting a granulating and healthy aspect to certain ulcers remaining after a due course of mercury had been tried, and which were aggravated by persevering in the use of the hitter medicine. The ef- fects of this acid in syphilis, will be more particularly noticed, in the article Venereal Disease. Nitrous acid, given in doses of eight, ten, or fifteen drops, two, or three times a day, is said to have proved particularly efficacious in the cure of some eruptive complaints, especially of the lower extre- mities,and joined with disorder of tlie liver (II ilson's Pliarm. Chirurgica, p. 6.) The common way of giving the nitric*' acid, at first, is to mix gj with a pint of distilled water, the mixture being sweet- ened with simple syrup. This quantity is to be drank, at different times, in the course of 24 hours, through a small glass tube, which is used to keep the teeth from being injured. If no inconvenience is felt, the dose of the acid may be in- creased to ^iss, gij, and even, in certain cases, to ^iij. The acid is said to increase the appe- tite, and secretion of urine; to cause more or less thirst, a white tongue, sizy blood, and an increase in the actions of the whole system, but nothing like mercu- rial salivation is produced. It does not agree, however, equally well with all con- stitutions. The nitric acid is beneficial both in the primary and secondary symptoms of the ve- nereal disease ; more so, however, in the former. But, in the latter, even mercury itself frequently fails, and proves hurtful, so that the nitric acid suffers no dispar- agement from this fact. A change is said to be produced on the disease, by the acid, in six or eight days, and a cure very often m little more than a fortnight. The oxygenated muriate of pot-ash which contains an immense quantity of oxygen, is said by Mr. Cruikshank, to be more efficacious than the nitric acid in relieving venereal symptoms. A'CME. (from ccxf*.*), a point.) The highest pitch of a disease. A'CNA, or A'cxe. (from ecrcvr;, bran, or JEG AIR 27 chaff) A hard, purplish tubercle in the face, covered'with a scale. A'CORES. See Achors. ACOU'STICS. Medicines, or instru- ments to assist the hearing. The term is derived from etrcovu, to hear. ACROMION, (from ot^oi, the top, and 6>f*.«i, the shoulder.) The process of the scapula, articulated with the external end of the clavicle, and formed by the anterior and superior projecting part of the spine of the scapula. It is liable to be broken. (See Fracture.) ACTUAL CAUTERY. A heated iron formerly muth used in surgery for the ex- tirpation and cure of diseases. The in- strument was made in various shapes, adapted to different cases, and it was of- ten applied through a cannula, in order thai no injury might be done to the sur- rounding parts. Actual cauteries were so called in opposition to other applica- tions, which, though they were not really hot, produced the same effect as fire, and, consequently, were named virtual, or po- tential cauteries. ACUPUNCTURE, (from aens, a needle, and pungo, to prick.) The operation of making small punctures in certain parts ofthe body with a needle, for the purpose of relieving diseases, as is practised in Siam, Japan, and other oriental coun- tries, for the cure of headaches, lethargies, convulsions, colics, &c. (See Phil. Trans. No. 148 ) ACUTENACULUM, (from news, a nee- die, and teneo, to hold.) Heister so deno- minates the port aiguille. It is a handle for a needle, to make it penetrate tlie flesh more easily. ADAMITA. Lithiasis, or the stone in the bladder. (See Urinary Calculi and Lithotomy.) ADHESIVE INFLAMMATION. That kind of inflammation, which makes parts of the body adhere, or grow together. It is the process, by which recent incised wounds are often united, without any sup- puration, and it is frequently synonymous with union by the first intention. (Sec Union by the First Intention.) ADYNA'MIA. (from«,neg.andi,ut«ftte, strength.) Extreme debility. JEGIAS. (from «i|, a goat.) A white speck upon the cornea, opposite the pupil, and so named from the supposition, that goats were very subject to such a disorder. JEGI'DES.V (from «i|, a goat.) Small white scars, or opacities, on the cornea. JEGYLOPS. (from«n|, a goat, and wfy, an eye.) A disease, so named from the supposition that goats were very subject to it. The term means a sore just under the inner angle ofthe eye. ^ The best modern surgeons seem to con- sider the xgylops, only as a stage of the fistula lachrymalis. Mr. Pott remarks, when the skin covering the lachrymal sac has been for some time inflamed, or sub- ject to frequently returning inflamma- tions, it most commonly happens, that tlie puncta lachrymalia are affected by it, and the fluid, not having an opportunity of passing off by them, distends the inflamed skin, so that, at last, it becomes sloughy, and bursts externally. This is that state of the disease, which is called perfect aigylops, or xgylops. (Pott in Fistula Lachrymalis.) JEgylops was a very common term with the oid surgical writers, who certainly did not suspect, that obstruction in the ".ichrymal parts ofthe eye, is so frequently the cause of the sore, as it really is. The skin over the lachrymal sac must undoubt- edly be, like that in every other situation, not exempt from inflammation, and ab- scesses ; but, we do not find, that sores, unconnected with disease of the lachry- mal sac, are so frequent, as to merit a distinct appellation. The term, xgylops is therefore going more and more into dis- use, every day. iERUGO, (Subacetas Cupri Impura) pre- pared verdigrease is by some used as an application to incipient chancres. Its acting as a caustic, and completely de- stroying the diseased surface at once, seems to offer a chance of preventing the absorption of the venereal matter, and, consequently, of doing away tlie necessity of making the patient undergo a salivation. However, it is perhaps never safe to rely solely upon this mode of treatment, with- out exhibiting mercury, in some form, or another. Whenever the plan is tried, and it is certainly a very rational one, as long as the chancre is very small and recent, it is better to employ the argentum nitratum, which is a more active caustic, and for this reason, more sure to destroy the whole surface of the sore. AGARIC. A species of fungus, grow- ing. on the oak, and much celebrated for- merly- for its efficacy in stopping bleeding. (See Hemorrhage.) AGGLUTINATION. The union of parts ; the adhesion of parts together, by an effusion of coagulating lymph, follow- ed by a communication of vessels. AGGLUTINANTS. Applications em- ployed with a view of giving an opportu- nity for the opposite surfaces of a wound to adhere and grow together. AGO'MPHIASIS. (from a, neg. and yo^ot;, compact.) A painfull looseness of the teeth. ALR. For an account of the abiurd 28 AL V ALV opinions entertained, concerning its en- trance into several cavitiesof the body, ami its pernicious effects there, see Abdomen. ALBORA. A species of itch, or rather leprosy. ALBUGO, (from albus, white.) A white opacity of the cornea, not of a superficial kind, but affecting the very substance of this membrane. This disease is very simi- lar to the leucoma, with which it will be considered. (See Leucoma.) ALNUS, (tlie Alder Tree.) The leave*;, when cut in small pieces, and applied to the breast, as Warm as can be borne, are much praised by professor Murray, of Got- tingen, for their efficacy in discussing the milk of women, who do not suckle. ALPHONSIN is the name of an instru- ment for extracting balls. It is so called from the name of its inventor Alphonso Ferrier, a Neapolitan physician. It con- sists of three branches, which separate from each other by their elasticity, but are capable of being closed by means of a tube, in which they are included. ALUM, (an Arabic word.) Alum, ei- ther in its simple state, or deprived of its water of crystallization, by being burnt, has long been used in surgery. The inge- nious author ofthe Pharmacopoeia Chirur- gica remarks, that unless for external use, as a dry powder, the virtues of alum are not improved by exposure to fire. Ten grains of alum made into a bolus with con- serve of roses, are given thrice a day at Guy's Hospital, in such cases, as demand powerful tonic, or astringent remedies. In a relaxed state of the urinary passages, or want of power of the sphincter vesicx.small doses of alum have been found of service. It is also recommended by Dr. Percival, to counteract the poison of lead. Burnt alum is a mild caustic, and is a principal ingredient in most stvptic powders. ALVINE CONCRETIONS. Surgical writers have recorded many instances, in which concretions of various sizes, and pro- ducing a series of very bad and even fatal complaints have been formed round plum and cherry stones in the alimentary ca- nal. The knowledge ofthe dangerous con- sequences, which may ensue from swallow- ing such indigestible bodies, cannot be too extensively diffused; for, it is certain, that this pernicious habit of children and thoughtless persons is by no means un- common, and must be a more frequent occasion of ill-health, if not of dea.;h, than is generally supposed. The symptoms induced by thelodgment of concretions of the above kind in the bowels are of a formidable description : severe pains in the stomach and bowels, diarrhoea, violent vomitings of blood and mucus, a discharge of thin fetid matter from the rectum, a diflicu-'.y of voiding the excrement, an afflicting tenesmus, extreme emaciation, and debility. That the foregoing account is not at all exaggerated may be seen by a perusal ofthe cases, and remarks published on the subject by Mr. Charles White, of Man- chester, and Mr. Hey, of Leeds. I shall take the liberty of quoting a case from each of these gentlemen, the first example is one related by Mr. White, shewing the proper mode to be pursued, when practicable. "On March 2, 1762, Dr. Brown de- sired I would visit J. Parkinson, of Man- chester, an out-patient of the infirmary, who had been some time under his car£ for complaints much resembling nephrytic paroxysms, which the medicines, usual in such cases, had frequently relieved. The night before he had perceived a lump in the rectum, which had brought on a con- tinual tenesmus. 1 found him extremely emaciated; the sphincter ani very much dilated, with a continual discharge of thin, excrementitious, and very fetid matter. Upon introducing my finger into the anus, I very distinctly felt a large body moveable in the rectum, which I easily took hold of with a pair of for- ceps, such as are used in lithotomy, and immediately brought away without much difficulty. It was a ball nearly as big as my fist, and, breaking in the extraction, discovered a plum-stone in the centre, which was its nucleus. Upon further examination, I found there was another, which I extracted entire nearly as large as the first. The patient recovered very fast, and in a month's time, was a hearty strong man." (Cases in Surgerywith remarks, &c.) The concretions, which form round fruit stones in the intestinal canal, may become so large as to be incapable of passing onward to the rectum, and, of course, occasion fatal complaints. The annexed case, recorded by Mr. Hey, furnishes us with a proof of this remark. " I was permitted (says this practical writ- er) to examine the body of a boy, whose parents lived at Holbeck, near Leeds, and who had died in an emaciated state, hav- ing had long continued pain in the abdo- men, attended with frequent attacks of the ileus. " 1 found lying in the transverse arch of the colon a concretion which was become of so great bulk, that it could pass no farther along the course of the intestine. Tins seemed to have been the sole cause ofthe boy's death."—Practical Observations in Surgery, p. 492. Sometimes, patients ultimately get well A M A A M A bv voiding the concretions either by vomit- ing, or stool. Mr. Charles White gives us an account of some such instances ; in one fourteen concretions on plum-stones were discharged from the anus; in another, twenty-one similar bodies were ejected from the stomach. The latter gentleman concludes some interesting cases with warning practi- tioners, and mankind in general, of the great danger of swallowing fruit-stones, and he doubts not, that many persons have lost their lives from this cause, when the disorder has not been understood, but been mistaken for the cholic. • The reader may find the principal in- formation on this subject, in Cases in Sur- gery by Charles White, F. R. S. 1770. p. 17. Philos. Trans, abridged, Vol. V. p. 256. et seq. Edinburgh Med. Essays and Obsei^v. Vol. 1. p. 301. Ibid. Vol. 5. p. 431. Essays Phys. and Literary, Vol. II. p. 345. Dr. Leiglis Natural History of Lancashire, Plate I. fig. 4. Practical Observations in Surgery, by W. Hey, F. R. S. p. 490. AMAUROSIS, (from ctfixvpoar, to ob- scure.) Frequently called, Gutta Serena. This is a disease ofthe eye, attended with a diminution, or total loss of sight, and arising from a paralytic affection of the retina and optic nerve. The symptoms of amaurosis are noted for being extremely irregular, and the diag- nosis of the disease is often much more difficult, than is commonly supposed,when there is no visible defect in the eye, and we have nothing more than the patient's assurance, that he has lost the faculty of seeing things. In many cases the pupil is very much dilated, immoveable, and pos- sesses its .natural black colour, and usual transparency. It Aannot be denied, that this is the state of numerous cases; but it is equally true, that there are many excep- tions. Sometimes, in the most complete and incurable cases, the pupil is of its pro- per size, and even capable of very free mo- tion ; and, occasionally, it is actually smal- ler and more contracted, than natural. We have the authority of Richter for asserting, that in particular instances, the iris not only possesses a power of motion, but is capable of moving withuncommon activity, so that, in a very moderate light, it will contract in an unusual degree, and nearly close the pupil. (Anfangsgr-unde tier Wun- tlarzneykuitst, Band. 3. p. 424, Edit. 1795.) Two or three remarkable instances of the active state of the iris, in cases of amaurosis, were some time ago shewn to me by Mr. Albert, surgeon of the York Hospital, Chelsea, and 1 have seen some other similar cases in St. Bartholomew's Hospital Tbo patients alluded U\ had most of them not the least power of distin- guishing the difference, between total darkness, and the vivid light of the sun, or a candle placed just before their eyes. Janin and Richter have seen the pupil ca- pable of motion, in this disease, and Schmucker has twice seen the same fact. From the various conditions of the pu- pil, in different cases of gutta serena, no conclusions, entitled to much confidence, can even be drawn, with regard to the par- ticular nature and character of the com- plaint. For instance, the moveable or im- moveable state of the pupil can neither be considered, as a favourable, or unfavour- able circumstance. Sometimes an amau- rosis may be cured, which is attended with a pupil extraordinarily dilated, and en- tirely motionless. Sometimes, the disorder proves incurable, notwithstanding the pu- pil is of its proper size, and capable of mo- tion. There are likewise examples, in which the pupil recovers its moveableness, in the course of the treatment, although nothing will succeed in re-establishing the sight. (Richter, Op. cit. p. 425.) The pupil of an eye, affected with amau- rosis, (says this experienced surgeon) sel- dom exhibits the clear shining blackness, which is seen in a healthy eye. In gene- ral it is of a dull, glossy, hornlike black- ness, which symptom alone is frequently enough to apprise a well-informed practi- tioner of the nature ofthe disease. Some- times the colour ofthe pupil has an incli- nation to green ; while, in other examples, this aperture seems to be dense, white, and cloudy, so that the complaint might easily be mistaken for the begiiuiing of a cataract. This error, into which inexpe- rienced surgeons are liable to fall, may easily be avoided by attention to the follow- ing circumstances. The misty appear- ance is not situated close behind the pupil, in the place of the crystalline lens; but, frequently, is manifestly deeper in tlie eye. Nor is it in proportion to the impairment of sight, the patient being quite blind, while the misty appearance is so trivial, that, if it arose from the opacity of the crystalline lens, it could at most only oc- casion a slight weakness and obscurity in vision. It must be acknowledged, that it is more difficult to avoid mistake, when a beginning amaurosis is accompanied with this cloudiness in the eye, and consequent- ly, when the degree of blindness seems to bear some proportion to the degree of mis- tiness in the pupil. However, in this case, if we are to credit the observations of Rich- ter, the true nature ofthe disease may ge- nerally be known, by considering, that though the patient's sight is weak, it is not rendered faulty by an appearance of mist before the eyes, which latter circumstance 30 AMAUROSIS. is always complained of by persons, who are beginning to be afflicted with cataracts; not to mention that there are usually pre- sent several other symptoms, which exclu- sively belong to the gutta serena. Sometimes, the interior of the eye, a good way behind tlie pupil, seems quite white, and a concave light coloured surface may be observed, upon which the ramifi- cations of blood-vessels can be plainly seen. In particular instances, this white surface extends over the whole back part of the eye; while in other cases, it only occu- pies a half, or a small portion of it. This peculiar appearance has been ascribed to a loss of transparency in the retina itself, and a consequent reflection of the rays of light. (Holler, Element. Physiol. Tom. 5, p. 409.) There can now be no doubt, that such whitenessbehind the pupil must sometimes have originated from the diseased mass, which, in cases of fungus hxmatodes of the eye, grows from the deeper part of this organ, and gradually makes its way for- ward to the iris, being always attended with total loss of sight. If we put out of consideration the im- pairment of vision, a degree of squinting is, according to Richter, the only one symptom, which is inseparable from amau- rosis. An obliquity of sight, accompany- ing the imperfect state of the disease, has also been particularly adverted to by Mr. Hey, of Leeds. (Med. Observations and In- quiries, Vol. 5.) The patient, says Richter, not only does not turn either eye towards any object, in such a manner, that the ob- ject looked at is in the axis of vision ; but, he also does not turn both his eyes towards tiie same thing. This is alleged to be the only symptom, which we can trust, where implicit confidence should not be put in the mere assurance of the patient, that he cannot see, while all the coats and humours ofthe eye present their natural appearance. Provided this observation be correct, it must be highly interesting to the military surgeon, amaurosis being a common afflic- tion of soldiers, many of whom, however, endeavour to avoid service by pretending to labour under a disease, which they well know does not necessarily produce any very considerable alteration in the natural appearance of the part affected. The gutta serena originates with very various symptoms, and in exceedingly dif- ferent ways. Richter thinks it probable, that this variety, attendant on the begin- ning of the disease, depends upon some difference in the cause of the complaint, and indicates the propriety of having va- riety in the modes of treatment. Some- times, the patient loses his sight quite sud- denly ; while, in other instances, the power of seeing diminishes so slowly, that months*:, and even years elapse, before the disease attains the worst degree. Sometimes, the gutta serena commences with several sym- toms, which seem to betray an increase of sensibility in the eye, or some irritation affecting this organ. In moderately light places, the patient can discern things very well; but, in a great light, he is not able to see at all. The eye is sometimes so sen- sible, that a strong light will make it weep and become painful. Patients of this de- scription ought always to wear a shade, however bad their sight may be. Some- times the gutta serena originates with symptoms of weakness and diminished ir- ritability. The sight is cloudy, and the patient finds that he can see better in a light, than a dark situation. He feels as if some dirt, or dust, were upon his eyes, and is in the habit of frequently wiping them. His power of vision is greater after meals, than at the time of fasting. His sight is always, for a short time, plainer, after the external use of tonic remed'es, such as hartshorn, cold water, &c. Richter informs us of a person, who was nearly quite blind, but, was constantly able to see very well, for the space of an hour, after drinking champagne wine. He also mentions a wo- man, who had entirely lost her sight, who was in the habit of having it restored again, for half an hour, whenever she walked a quick pace up and down her garden. This author likewise acquaints us with the case of a lady, who had been blind for years; but, experienced a short re- covery of her sight, on having a tooth ex- tracted. Sometimes, as Richter observes, the symptoms appear to indicate a preterna- tural accumulation of the humours of the eye. The patients complain of a tension ofthe eye-ball, which is often particularly irksome and distressing. Whenever such sensation is experienced, the eyesight be- comes weak; and, on the subsidence of this feeling, the patient is again able to see better. The eye-hall feels hard, and occasionally is more or less enlarged, so that the state of the affected organ some- what resembles that, which takes place in hydrophthalmia. (Seethis Word) When a cataract is complicated with a gutta se- rena, the vitreous humour is sometimes found, in operating for the first disease, to be preternaturally thin, the eye being, as it were, in a dropsical state. Sometimes, the blood-vessels of the conjunctiva are varicose; the patient sees black specks, net-like appearances, streaks, snake-like figures, &c. It seems as if, in this case, the blood-vessels of the retina and choroide9 were in the same varicose state, as those ofthe conjunctiva, so as to make pressure AMAUROSIS. 31 upon the first of these membranes. That the vessels are in reality thus dilated, says Richter, is rendered probable by the bleed- ing, which is apt to occur in the eye in operating for cataracts, complicated with the gutta serena. In particular examples, the eye seems to be under the influence of some peculiar irritation. The patients see several ob- jects, which are in motion, and of different colours, more especially, shining, fiery spots, flames, and. rays of light. Some- times, amaurosis arises after violent inve- terate ophthalmies, and headachs. Cer- tain patients, before being attacked with the complaint,are repeatedly afflicted with catarrhs, which cease as soon as the gutta sereru is formed. According to Richter, the mucous membrane of the nose then becomes unusually dry and free f. om se- cretion. Some patients, of this kind, have been known to regain their sight, for a short time, on a copious '.scharge of mu- cus spontaneously taking place from the nose. Paying diligent attention to these various circumstances, attending the ori- gin of the disorder, says Richter, will of- ten be of great assistance to the practi- tioner, in enabling him to select a judi- cious method of treatment, when all other indications are absent. The disease commonly makes its attack upon both eyes at once, and even in those occasional instances, in which only one is deprived of sight, the other rarely con- tinues for a long time sound. The disor- der generally extends over the whole eye; but, sometimes only a half ofthe organ is affected, the case being then named amau- rosis dimidiata. In the first example, the patient is quite blind ; in the second, he can discern tlie half of objects. Some- times the malady seems to be confined to a single little spot in the eye, in which case, the patient is conscious of having before the retina an immoveable bluck speck. It is'to this particular instance, that some pathologists apply the term, scotomia. Also patients, who may he said to be entirely blind, sometimes have a small part of the retina, which is still susceptible ofthe im- pression! of light, and is usually situated towards cne side of the eye. (Hey, in Med. Observations and Inquiries, Vol. 5.) Richter mentions, that, in one man, who was in other respects, entirely bereft of vision, this sensible point of the retina was situated obliquely over the nose, and so small, that it was always a considerable time, before its situation could be dis- covered : he adds, that it was so sensible, as not only to discern the light, but even the spire of a distant steeple. Accoiding to this author, it is the centre of the eye, that seems to be the first and most serious- ly affected in the gutta serena. Hence, the generality of patients, who have a begin- ning imperfect amaurosis, can always see objects,laterally situated,better than those which are immediately before them. The gutta serena is sometimes an inter- mittent disorder, making its appearance at regular or irregular intervals. In cer- tain examples, as Richter remarks, the disease prevails at particular times, com- monly all day, till a certain hour; or from one day till the next; or at a stated time every month. The attacks of the complaint sometimes take place at indeterminate pe- riods. In particular cases, another mor- bid affection is associated with the im- pairment of sight. Richter mentions a man, who became blind at twelve o'clock in the day, when the upper eye-lid used also to hang down in consequence of be- ing affected with paralysis. The attack always lasted twenty-four hours. On the following day, at twelve o'clock, the sight used to return, and the patient then sud- denly regained the power of raising the upper eye-lid. He would continue thus able to see for the space ofthe next twen- ty-four hours. Whenever he took bark, the disease was regularly doubled; that is to say, the man then alternately remain- ed blind forty-eight hours, and recovered the power 9! seeing for only twenty-four. In another patient, cited by this experienc- ed surgical writer, t)pe aqueous humour, during the blindness, always became dis- coloured, whitish, and turbid; but, its transparency regularly returned on the ces- sation of the attack. According to Rich- ter, the periodical amaurosis commonly depends upon irritation affecting the di- gestive organs, the stimulus of worms, or irregularity in the menstrual discharge. Sometimes, it is plainly a symptom of a confirmed ague, the patient being attacked with an ordinary intermittent, and blind during each paroxysm; but, always re- gaining his sight as soon as each fit is over. (See Richter's Avfavgsgrunde der Wnndarzneykunst, Band 3, Kup. 14. Before treating of the different causes of the gutta serena, it seems proper to de- scribe the ordinary symptoms of the dis- ease. When the patient is first attacked, his sight gradually grows weaker; he feels, as if a gauze, or cob-web, were drawn over his eyes, and imagines he sees a white sur- face, studded with black specks, which he endeavours to wipe away. By degrees, the pupil of the eye loses its brilliancy, and distends itself much beyond the na- tural size ; and if the patient's eye be closed, the upper eye-lid gently rubbed, and then suddenly opened, in a light place, the pupil will contract very little, or not at all. The sight grows weaker and AMAUROSIS weaker; spectacles and convex glasses are of no service, and the patient, (gene- rally speaking) sees worse in the open day- light, than in a dark situation. While the patient is at all conscious of the im- pression of the rays of light, or while a certain power of seeing still continues, the disease is called the imperfect, or in- complete amaurosis; but, when the patient is wholly insensible of the stimulus of light, the disorder is termed perfect, or complete. Schmucker remarks, that, although the complete gutta serena is generally a gradual disease, there are cases, in wliich it comes on quite suddenly, without being pre- ceded by tiie above-mentioned circum- stances. These cases,, he says, have fre- quently fallen under his observation, and been more easy of cure, than when the af- fliction has taken place in a more gradual way. In such instances, the sight is to- tally lost, the patient can distinguish no object whatever, the pupil of the eye is uncommonly enlarged, and if the eyelid be shut, and then rubbed, and opened in a strong light, tlie aperture in the iris re- mains fixed, and incapable of contraction. A lighted candle may be held to the pa- tient's eyes, without exciting sensation. The pupil now loses its shining black gloss, and grows pale, so that a skilful practitioner can perceive the difference, without being closPto the patient. Per- sons, attacked irt this manner, usually have an unhealthy and timid look. (See Schmucker's Veiinischte Chirurgische Schriften, Band 2.) Acording to Richter, the remote causes of gutta serena may be properly divided into three principal classes.thedifferences of which indicate three general methods of treatment. It is alleged, that the first class of causes seem to depend upon an extraordi- nary plethora and turgidity of the blood- vessels of the brain, or of those of the optic nerves and retinx, upon which last parts a degree of pressure is thereby sup- posed to be occasioned. A considerable plethora, especially, when the patient heats himself, or lets his head hang down, will frequently excite the appearance of" black specks before the eyes, and some- times complete blindness. A plethoric person (says Richter,) who held his breath, and looked at a wlute wall, was conscious of discerning a kind of network, wliich alternately appeared and disap- peared with the diastole and systole ofthe arteries. This phenomenon, it is con- jectured, originated from the plethoric state of the vessels of tlie retina. Boer- haave mentions a man, who, always lost his sight on getting tipsy, and regained it on becoming sober. Richter thinks it likely, that it is m this manner, that the disease is produced, by the suppression of some habitual discharge of blood, by not being bled according to custom, by the stoppage of the menses, and by the cessation of hemorrhage from piles; circumstances, which, if we can give credit to all the accounts of Richter, Scarpa, Schmucker, and other experienced writers on the subject, frequently give rise to the gutta serena. In the same manner, the complaint may be brought on by great bodily exertions, which must de- termine a more rapid current of blood to the head. Richter informs us of a man, who became blind, all on a sudden, while carrying a heavy burden up stairs. He tells us of another man, who laboured ex- cessively hard, for three days in succes- sion, exerting .his strength very much, and who became blind at the end of the third day. Pregnant women, in like manner, are sometimes bereft of their sight during the time of labour. Schmuc- ker has recorded a remarkable instance of this in a strong young woman, thirty years old, and of a full habit. Whenever she was pregnant, she was troubled with violent sickness, till the time of delivery, so that nothing would stop in her sto- mach. She was bled, three or four times, without effect. Towards the ninth month, her sight grew weak, and for eight or ten days before parturition, she was quite blind. Tlie pupil of the eye was greatly enlarged, but, retained its shining black appearance. She recovered her sight im- mediately after delivery, and did not suf- fer any particular complaints. Schmucker assures us, that he has been three times a witness of this extraordinary circumstance. (Vermischte Chir. Schriften, Band 2, p. 6, edit. 1786.) Richter speaks of a person, who lost his sight, during a violent fit of vomiting. Schmucker acquaints us, that it is not uncommon for soldiers, who are performing forced marches in hot wea- ther, to become blind all on a sudden. All great exertions of sirengthjflriien the body is plethoric, or heated, orient for- wards with the head in a low posture, are usually attended with some dangers of bringing on amaurosis. The blindness, which follows external injuries ofthe head, is ranked by Richter among the preceding class of cases. A man, who received a smart box on the ear says this author, lost his sight on the spot. Richter conceives it probable that a concussion of the head may some! times produce an atony of the blood-ves- sels, giving rise to their dilatation, and consequent pressure «ti the adiacent AMAUROSIS. 33 nerves: perhaps, It is more likely, that the blow itself actually ruptures them, and produces an effusion of blood. Richter suspects, that the gutta serena, which originates during a violent ophthalims, or during a severe inflammatory fever, may be ot the same nature. He thinks it pro- bable, that persons, who become blind while exposing themselves to the burning sun with their heads uncovered, have their sight impaired in a similar way. The diagnosis of this first species of the gutta serena is founded on an acquaint- ance with the preceding remote causes, which are for the most part very evident, as the blindness, which is the consequence of them, follows with remarkable quick- ness. The second class of causes are supposed to operate, by weakening either the whole body, or the eye alone, and they indicate the general, or topical use of tonic reme- dies. In the first case, the gutta serena appears as a symptom of considerable uni- versal dehility of the whole system ; in the second case, the disease is altogether local. Every great general weakness of body, let it proceed from any cause what- soever, may be followed by a loss of sight. The gutta serena, if we can give credit to the statement of Richter, has sometimes been the' consequence of a tedious diar- rhxa, a violent cholera morbus, profuse hemorrhage, and immoderate salivations. He informs us of a dropsical woman, who became blind, on the water being let out of her abdomen. According to the same author, no general weakening causes ope- rate upon the eyes, and occasion total blindness, so powerfully and often, as premature and excessive indulgence in venereal pleasures. The causes are various, which operate locally in weakening the eyes. Nothing has a greater tendency to di bilitate these organs, than keeping them fixed very at- tentively, for a long while, upon minute objects. But, however long- and assidu- ously objects are viewed, if they are di- versified, the eye suffers much less, than when they are all of the same kind. A frequJBfchange, in the objects, which we look arenas a material effect in strength- ening and refreshing the eye. The sight is particularly injured by looking at ob- jects with only one eye at a time, as is done with telescopes and magnifying glasses; for when one eye remains shut, the pupil of that, which is open, always becomes dilated beyond its natural diameter, and lets an extraordinary quantity of light into the organ. The eye is generally very much hurt, by bein;? employed ,n the close inspection of bHliant, light-colour- ed, shining objects. They are greatly mis- Voju I. taken, says Richter, who think, that they save their eyes, when they illuminate the object, which they wish to see, in the evening, with more lights, or with a lamp, that intercepts and collects all the rays of light, and reflects them upon the body, which is to be looked at. Richter makes mention of a man, who, in the middle of winter, went a journey on horseback, through a snowy country, while the sun was shining quite bright, and who was at- tacked with amaurosis. He speaks of an- other person, who lost his sight, in con- sequence of the chamber, in which he lay, being suddenly illuminated by a vivid flash of lightning. A man was one night siezed with blindness, while he had his eyes fixed on the moon in a fit of contem- plation. Richter also expresses his belief, that a concussion of the head, from exter- nal violence, may sometimes operate di- rectly on the nerves, so as to weaken and render them completely paralytic. The third class of causes consist of irritations, which, in some inexplicable way, directly, or, probably, for tlie most part, directly, affect the optic nerves, and render them insensible of the impression of the light. Most of these irritations are asserted to lie in the abdominal viscera, whence they sympathetically operate upon the eyes. The observations of Richter, Scarpa, and Schmucker, all tend to con- firm, that amaurosis more frequently arises from irritation in the gastric or- gans, than any other cause whatever. It may often be ascertained that patients with amaurosis have suffered much trou-> ble, and long grief, or been agitated with repeated vexations, anger, and other pas- sions, which are supposed to have a great effect in disordering the bilious secretion, and the digestive functions in general. Richter tells us of a man, who lost his sight, a few hours after being in a violent passion, and recovered it again the next day, upon taking an emetic, by which a considerable quantity of bile was evacu ated. A woman is also cited, who be- came blind, whenever she was troubled with what are termed, acidities in the stomach. (See Anfangsgrunde der Wun- darzneykunst, Band 3, Kap. 14.) The continental surgeons are excessive- ly comprehensive in their ideas of the causes of the gutta serena, and, with many truths, they blend an evident quantity of unestablished conjectures, and palpable absurdities. I believe, it will generally be found, that,'when surgical writers as- sign a multitude of causes for any disease, they deal very much in mere supposition. It would be idle credulity, indeed, to put frith in the assertions concerning the amau- rosis being occasioned by the bad treat- 34 AMAUROSIS. ment of particular fevers, suppressed diar- rhoeas, the repulsion of eruptive com- plaints, &c. There is no reason, why a person should not become blind about the time, when another disorder gives way; but, we ought to have some other ground for the doctrines, to which allusion is made, before we can presume to offer them as entitled to confidence. Worms in the alimentary canal are al- leged to be sometimes the cause of amau- 1 rosis, and, since a disordered state of the gastric organs is universally acknowledged to be frequently concerned in the produc- tion of blindness, we can have no difficulty in conceiving, that worms may likewise have the same effect. Besides gastric irri- tations, there are some others, which class as causes of this disease. A violent fright, which is considered as being a frequent remote cause of the gutta serena, is sup- posed by Richter to operate chiefly by irritating the nerves. The blindness sometimes proceeds from a mechanical kind of irritation. A man received in his right orbit a small shot, which pierced the upper eye-lid,and lodged at the upper part of the socket, between the eye-lid and eye-ball, so that it could be felt externally. Richter adds, th.it this patient shortly afterwards became blind in the left eye; but recovered his signt in it again, upon the excision of the shot. (Anfansg. der Wundarzn. Band 3, p. 439.) Sometimes, says this experienced sur- geon, the irruption, exciting amaurosis, seems to have its seat in the mucous mem- brane of the nose and frontal sinuses. We have already adverted to the unusually dry state ofthe nostril, that has been sus- pected of being occasionally conducive to this species of blindness. The gutta serena is generally difficult of cure. However the degree of difficulty in relieving the disease varies in different cases, according to the way in which the malady originates, and the nature of the cause. Professor Scarpa, of Pavia, has given an excellent account of the prognosis in cases of" amaurosis. Some of"his doctrines, however, founded on the humoral patho- logy, are hypothetical, and, consequently, are purposely omitted in the following account. It also deserves notice that the case supposed to originate from injury of the supra-orbitary nerve, is not always in- curable, as the experience of Hey con- firms. (See Med. Obs. and Inq. Vol. 5.) Amaurosis is divided by Scarpa into the perfect, or imperfect; inveterate or recent ; and continued, or periodical. The perfect, inveterate amaurosis, attend- ed with organic injury of the substance, constituting the immediate organ of sight, says Scarpa, is a disease »absolutcly in- curable. The imperfect, recent amaurosis, particularly that which is periodical, is commonly curable; for, it is mostly sym- pathetic with the state ofthe stomach and primx vix, or dependent on causes, which though they affect the immediate organ of sight, are capable of being dispersed, without leaving any vestige of impaired organization in the optic nerve, or retina. When amaurosis has prevailed several years, in persons of advanced age, whose eyesight has been weak from their youth ; when it has come on slowly, at first with a morbid irritability of the retina, and then with a gradual diminution of sense in this part, till total blindness was Abe conse- quence; when the pupil is motionless, not circular, and not much dilated; when it is widened in such a degree, that the iris seems as if it were wanting, and the margin of\this opening is irregular and jagged ; and, when the bottom of the eye, independently of any opacity of the crys- talline lens, presents an unusual paleness, like that of horn, sometimes partaking of green, and reflected from the thickened retina, the disease may be generally set down as incurable. Cases may be deemed irremediable which are attended with pain all over the head, and a continual sensa- tion of tightness in the eye-ball, which are preceded by a violent, protracted excite- ment of the nervous system, and then by general debility, and languor of the con- stitution, as after masturbation, prema- ture venery, and hard drinking There is no rem -dy for cases, connected with , epileptic fits, or frequent spasmodic hemi- ennia; nor for such as are the conse- quence of violent, long-continued, internal ophthalmia. Cases are incurable, also, when produced by violent concussions of tlie liead, direct blows on the globe ofthe eye, or a violent contusion, or other injury ofthe supra-orbitary nerve, and this, whe- ther the disease take place immediately after the blow, or some weeks subsequent- ly to the healing ofthe wound ofthe eye- brow. Amaurosis is also incurable, when occasioned by foreign bodies inthe eye- ball, lues venerea, or exostosesjiout the orbit. Lastly, amaurosis is absol^e'.y irre- mediable, when conjoined with a manifest change in the figure and dimensions of the eye-ball. On the contrary, all cases of imperfect, recent amaurosis, whether the blindness be total or partial, are mostly curable, when not produced by causes, capable of contusing or destroying the organic struc- ture of the optic nerve, and retina. This is especially true, when the retina is in some degree sensible to the impression of light. Recent, sudden cases, in which the AMAUROSIS. 35 pupil is not excessively dilated, and its disk remains regular, while the bottom of the eye is of a deep black colour; cases, unaccompanied with any acute, continual pain in the head and eye-brow, or'any sense of constriction in the globe of the eye its-It"; cases, which originate from violent anger, deep sorrow, fright, exces- sive fulness of the stomach, a foul state of this viscus, general plethora, or the same part.-ii affection of the head, suppression of the menses, habitual bleedings from the nose, piles, &c. great loss of blood, nervous debility, not too inveterate, and in young subjects, are all, generally speak- ing, curable Amaurosis is also, for the most part, remediable, when produced by convulsions, or the efforts of difficult par- turition ; when it arises during the course, or towards the termination of acute, or intermittent fevers; and when periodical, coming on at intervals, such as every day, every three days, every month, &c. Before entering into the consideration of the treatment of the gutta serena, I shall take this opportunity of noticing a few remarkable circumstances, which are connected with the disease. It sometimes happens, that, when a patient shuts one eye, he can only half dis- tinguish objects; but, that if he opens both eyes, he sees every thing in its natu- ral form. In this case, according to Schmucker, one eye is sound, and only some fibres of the nerve of sight are in- jured in the other. In the gutta serena, which comes on gradually, the patient also sometimes sees double, with both eyes. Some years ago, Schmucker cured a major of hussars, who saw the three lines of his squadron double; and the same surgeon was ordered by the king of Prussia to attend a gentleman, who was afflicted in a similar way. In the opinion of -this eminent surgeon, such cases are brought on by a violent disten- tion of the vessels ofthe choroides, where he thinks, that varices may easily arise, in consequence of tlie weak resistance of that membrane. In iliis manner, the filaments ofthe rj^na suffrr pressure, and the rays of lighflre broken. Under these circum- stancesTu prompt assistance be not afford- ed, total and frequently incurable blind- ness may be the consequence. Schmucker met with an example of such an irreme- diable amaurosis, (the only instance in his practice), in a young man, twenty-six years of age. When the patient'made application for the advice ofthe foregoing surgeon, he had been blind a year. Before he lost his sight, he remarked, that, after any violent emotion, his s.ght at first grew weak, and that obje-sts afterwards appeared double. When his circulation was at all hurried, he saw black spots be- fore his eyes, and, at length, was quite blind. The vessels ofthe choroides were as large, as if they had been injected with wax, and every kind of surgical assistance proved ineffectual. I have already adverted to the occasion- al moveableness of the iris, notwithstand- ing the insensible staU ofthe retina. Let me next take notice of a case, which some- times presents itself, and is quite the reverse of this last. The nerves of the iris may be paralytic, while those of sight continue unimpaired. Schmucker tells us, he was acquainted with a woman, whose pupil was uncommonly distended, and totally incapable of motion. Her sight was very weak, and spectacles were of no use to her. She could scarcely discern any thing by day, or in a strong light; but, she could see rather better at night and in dark places. This infirmity of sight depended upon the dilated, paralytic state of the pupil, by which too many rays of light were admitted into the eye; and the reason, why the patient could see better at night, was, because the pupil, in its natural state, always becomes widened and dilated in a dark situation. (See Ver- mischte Ckirurgische Schriften, Von J. L. Schmucker, Band 2, p. 13, 14.) TREATMENT OF AMAUROSIS, OR THE GUTTA SEREA'A. Here the first endeavour of the practi- tioner should be to find out and remove the cause of the disease. This is the surest and best way of proceeding; but, it is worthy of notice, that sight does not inva- riably return, although the real cause of the blindness has been radically removed. In such cases, the continuation of the loss of sight is ascribed to the torpor of the nerves, wliich have been for a consider- able time without action, and have been impaired by the disease. The practitioner usually prescribes stimulants and tonics, with a view of bringing the nerves into their original state of activity. In other cases, sight returns as soon as the cause ofthe disease is removed. When it is found impossible to make out any thing, respect- ing the cause of the disorder; the surgeon should found the curative indications up- on the symptoms and appearances, which have taken place in the origin and course of the disease, and from wh.cft symptoms some conjectures may be drawn, in regard to the nature ofthe case. When no appear- ances of this kind occur, and nothing can be le«rnt about the cause of the maladv, the surgeon must have recourse to such empirical remedies, as extensive experi- ence has shewn to be sometimes truly ca- pable of removing the affection, although 36 AMAUROSIS. an explanation cannot always be given of the manner, in which they operate. We shall follow Richter, and first treat of that method of cure, wliich is directed against the causes ofthe disease,and which, wiienever circumstances will admit of its adoption, must be regarded as the most proper and scientific. In that species of amaurosis, which arises from the firstclass of causes, namely, from those, which seem to induce the dis- ease, by means of a preternatural fulness and dilation of the blood vessels of the brain, or eye, the indication is evidently to lessen the quantity of blood, and dimi- nish the determination of it to the head. For this purpose, the patient may be bled in the arm, temporal artery, or foot. This evacuation is to be repeated as often as seems necessary, and it will be better to begin with Liking away from twelve to six- teen ounces. We are also advised by Schmucker to apply ten or twelve leeches to the* tcck and temples. The efficacy of bleeding, m the cure of particular cases of the gutta serena, is strikingly exemplified by numerous well authenticated ob.sei\a- tions. Richter informs us of a woman, who, on leaving • if having children, lost her sight; but, recovered, it again by being only once bled it tlie foot. A spontaneous hemorrhage from the nose also cured a young woman, who had been blind for se- veral weeks. (Anfangsgrunde der Wundarz- neykunst. Band 3, p. 442 ) General bkeding sometimes proves inef- fectual, unless assisted by topical. Leeches may be applied to the temples, or cupping glasses to the back part of the neck. "\V hen the disorder seems to be connected with an interruption ofthe menses, or the cessation of bleeding from piles, leeches may be put on the pennxum, the inside of the thigh, or the sacrum. Local bleeding, however, seldom avails, except the whole mass of blood has been previously diminished by a prudent employment of the lancet. Be- sides bleeding, the surgeon may advan- tageously have recourse to other means at the same time, as, for instance, emollient glysters, purgatives, blisters, bathing the feec in warm water, &c. In some cases all the foregoing means fail in producing the desired benefit, even when they have been followed up, as far as the state of the pulse, and strength of the constitution will allow. Here the con- tinuance of the disease may depend, either upon the stoppage of some wopted evacu- ation of blood, or else upon some other cause of the first class. In the first of these cases, (says Richter) experience shews, that the i-sease will sometimes not give way, before the accustomed discharge is re-established, on which the malady de- pends, notwithstanding evacuants may be employed in any way whatsoever. A woman, who (as this author acquaints us) had lost her sight, in consequence of a sudden suppression ofthe menses, did not recover it again till three months after the return ofthe menstrual discharge, notwith- standing every sort of evacuation was tried. He also tells us of another woman, who had been blind half a year, and did not menstruate, and to whose external parts of generation leeches were several times ap- plied. As often as the leeches were put on, (says Richter) the menses in part recom- menced ; and, as long as they made their appearance, which was seldom above two hours, the woman always enjoyed a degree of vision. (Anfangsgruntle der Wundarz- neykunst, Band 3, p. 443.) For the amaurosis, arising from sup. pression of the menses, Scarpa recom- mends leeches to the labia pudendi, bath- ing the feet in warm water, and afterwards exhibiting an emetic, and tlie resolvent pills, of which I shall presently speak. If these means fail in establishing the men- strual discharge, he says, great confidence may be placed in a stream of electricity, conducted from the loins across the pelvis, in every direction, and thence repeatedly to the thighs and feet. He enjoins us not to despair at want of success at first, as the plan frequently succeeds, alter a trial of several weeks. For the amaurosis, proceeding from the" stoppage of an habitual copious bleeding from piles, Scarpa recommends the appli- cation of leeches and fomentations to the hemorrhoidal veins, then giving the patient an emetic, and, afterwards the resolvent pills. ( Saggio di Osservuzicni e d'esperienze sulle principali malattie degli occhi, cap. 19.) When the disease does not appear to originate from the stoppage of any natural or habitual discharge of blood, and does not y ield to the evacuating plan, Richter thinks, that the surgeon is justified in concluding, that the pi-eternaturally dilat- ed vessels have not regained their proper tone and diameter, and that he^oughl to employ topical corroborant remfpies, par- ticularly cold water. Richter, in this kind of ease, is an advocate for washing and bathing the whole head with cold wa- ter, especially, the part about the eyes; a method, he says, wliich may often be prac- tised, after evacuations, with singular and remarkable efficacy. When the return of sight cannot be brought about in this manner, Richter advises us to try such means, as seem calculated to stimulate the nerves, and re- move the torpid affection of the optic nerves in particular. Of these last reine- AMAUROSIS. 37 dies, says he, emetics are the principal and most effectual. Soldiers, who lose their sight in performing forced marshes, in hot weather, very commonly have it re-esta- blished again, by being immediately bled, and taking an emetic the next day. (See Schmucker's Chirurgisch Wahrnehmungen 1. Theil.) We come now to the consideration of that species of the gutta serena, which is regarded as the effect of some unnatural irritation. Here, according'to the pre- cepts delivered by Richter, we should en- deavour to discover what the particular ir- ritation is, and then endeavour to effect.its removal. When it cannot be exactly de- tected, we are recommended generally to employ such remedies, as will lessen the sensibility of the nerves, and render them less apt to be affected by the irritation, of whatever kind it may be. Sometimes the irritation is both dis- coverable and immoveable, and still the ef- fect, that is to say, the blindness continues. In this circumstance, Richter thinks, that tlie surgeon should endeavour to obviate the impression, which the irritation has left upon the nerves, by the use of ano- dynes, or, else, he is of opinion, that the practitioner should try to remove the tor- por of the nerves by the employment of stimulants. But, according to Schmucker, Richter, and Scarpa, the curable imperfect amauro- sis commonly depends on some disease, or irritation, existing in the gastric system, and, in some instances, complicated with general nervous debility, in which tlie eyes participate. Hence, the chief indication, in the majority of cases, is to free the sto- mach and primx vix from all irritating matter, to strengthen the gastric organs, promote digestion, and reanimate the ner- vous system in general, and the neives of the eye in particular. Emetics and internal resolvents answer the first purpose,*and tartar emetic should be preferred to every pharmaceutical pre- paration. When afterwards administered, in small repeated doses, it also acts as a resolvent remedy, which operation may be rendfc-ed stronger by joining it with gummy saponaceous substances. Dissolve three grains of the antimonium tartarizatum, for an adult, in six ounces of water, and give a spoonful of this solution, every half hour, until nausea and copious vomiting are produced. The next day- exhibit some resolvent powders, consisting of an ounce of cream of tartar, and one grain of tartar emetic, divided into six equal parts. The patient must take one of these in the morning, another four hours afterwards, and a third in the evening, for eight or ten days in succession. This remedy will create a little nausea, a few more alvine evacuations, than usual, and, perhaps, in the course of a few days, vo- miting. If the patient, during the use of these resolvent powders, should make vain efforts to vomit, complain of bitterness in his mouth, loss of appetite, and no reno- vation of sight, the emetic, as at first di- rected, is to be prescribed again. This is to be repeated a third, and fourth time, should the morbid state ofthe gastric sys- tem, the bitter taste in the mouth, the ten- sion of the hypochondria, the acid eructa- tions, and the inclination to vomit, make it necessary. The first emetic otten pro- * duces only an evacuation of an aqueous fluid, blended with a little mucus; but, if it be repeated, a few days after the resolv-, ent powders have been administered, it then occasions a discharge of a consider- able quantity of a yellow, greenish, mat- ter, to the infinite relief of the stomach, head, and eyes. The stomach having been thus emptied, Schmucker's, or Richter's, resolvent pills are to be ordered. These are composed as follows : S< Gum. Sagapen. "") Galban. \. an. gj Sap. Venet. j Rhei optim. giss Tart. Emet. gr. xvi. Sue. liquerit £j fiant pilulx gran. quinque. Three of these pills to be taken every morning and evening for a month, or six weeks. 9i Gum. Ammoniac.""! Ass. foetid. Sap. Venet. )-an. gij Rad. Valer. s. p. j Summit. Arnicx. J Tart. Emet. gr. xviij. fiant pilulx gran, quinque. Six to be taken thrice a day for several weeks. The pills are here directed to be made larger, than Schmucker and Richter order, that the number in one dose may be di- minished. To prescribe 15 pills three times a day would seem absurd to the generality of patients in this country. The following are the usual effects. The patient, after having vomited copiously, experiences a general calm, and an easi- ness not felt before. Sometimes, he be- gins to distinguish the outlines of objects the very day on wliich he takes the eme- tic ; at other times, he does not reap this benefit till the fifth, seventh, or tenth day; and, in some instances, not before some weeks have elapsed, after the exhibition 38 AMAUROSIS. ofthe emetic, and the uninterrupted use of the resolvent powders and pills. When the patient begins to recover his sight, the dilated state ofthe pupil diminishes; the iris contracts more on being exposed to the vivid light of a candle; and, in proportion as the power of seeing things increases, the contraction and moveableness of the pupil augments. On the whole, the cure is very seldom completed in less than a month, during which time the employment of such remedies, as are calculated to re- vive the languid action of the nerves of the eye, must not be neglected. When the above plan has rectified the state of the stomach, and partly effected the restoration of sight, such remedies must be employed, as strengthen the di- gestive organs, and excite the vigour of the nervous system in general, and of the nerves ofthe eye in particular. A powder is to be prescribed, composed of an ounce of bark, and half an ounce of valerian, divided into six equal parts, one of which is to be taken in the morning, and another in the evening, in any convenient vehicle, for, at least, five or six weeks. During this time, the patient's nourishment must consist of tender succulent meat, and wholesome broths, with a moderate quan- tity of wine, and proper exercise in a salu- brious air. To excite the action of the nerves of the eye, the vapour of the aqua ammnmx purx; properly directed against the eye, is of the greatest service. This remedy is applied by holding a small ves- sel, containing it, sufficiently near the eye to make this organ feel a smarting, occa- sioned by the very penetrating vapours, with which it is enveloped, and which cause a copious secretion of tears, and a redn ss, in less than half an hour after tlie beginning of the applications. It is now proper to stop, and repeat the ap- plication, three or four hours afterwards. Tiu plan must be thus followed up till the incomplete amaurosis is quite cured. The ammoniacal vapours should be used as soon as the stomach has been freed from all irritating matter, and they should not be discontinued, tilt long after the eye has been cured. The operation of these vapours may be aided by other external stimulants, applied to such other parts X)f the body, as have a great deal of sympathy with the eyes. Of this kind, are blisters to the nape of the neck; friction on the eye-brow with the anodyne liquor; the irritation of the nerves of the nostrils by sternutative powders, like that composed of two grains of tur- bith mineral, and a scruple of powdered betonv leaves; and, lastly, a stream of electricity. The latter has been proposed, as one of the principal means of curing amaurosis; but, experience has shewn, that electricity only merits confidence, as a secondary remedy, and Mr. Hey, one of its most zealous advocates, confesses, that it only succeeds in cases of recent amauro- sis, and, usually, not in these, unless it be combined with proper internal medi- cines, among which resolvents are the chief. (Med. Obs. and Inq. Vol. 5, p. 26.) Many might suppose bark to be a speci- fic for the imperfect periodical amaurosis. This, however, is not the case. Bark, which is efficacious in intermittent fevers, and other periodical diseases, far from curing the periodical amaurosis, seems to, exasperate it, rendering its return more frequent, and of longer duration, than be- fore. On the other hand, this disease is most commonly cured, in a very short time, by exhibiting first emetics, then internal resolvents, and lastly, corroborants, and even hark, which was before useless and , hurtful. The above plan of curing the recent imperfect amaurosis succeeds in the ma- jority of cases, when the disease is only sympathetic, or dependent on the morbid state of" the gastric system. But, there are cases, in the formation of which many other causes operate, besides the most frequent one already stated. These demand the employment of particular cu- rative means, in addition to those which have been already described. Such is, for example, thr imperfect amaurosis, which occurs suddenly, in consequence of the body being excessively heated, or ex- posure to the sun, or violent anger, in ple- thoric subjects. This case requires, in particular, general and topical evacuations of blood, and the application of cold washes to the eyes and whole head. An emetic should next be given, and after- wards a purge of the kali tartarisatum, or small repeated doses of the tartar emetic. Schmucker relates, that, by means of bleeding and an emetic, he has oftentimes restored the eye-sight of soldiers, who had lost it in making forced marches, with very heavy burdens. In amaurosis, suddenly occasioned by violent anger, an emetic is the more strongly indicated afWbleeding, as the blindness, thus arising, is always attended with a bitter taste in the mouth, tension of the hypochondria, and continual nausea. Richter gives an account of a clergyman, who became completely blind, after being in a furious passion, and whose eye-sight was restored the very next day, by means of an emetic, which was given with a view of relieving some obvious marks of bilious disorder in the stomach. The treatment of the imperfect amau- rosis, from fevers badly treated, deep sor- row, great loss of blood, intense study AMAUROSIS. 39 •and forced exertions of the eyes on very minute, or brilliant objects, consists also in removing all irritation from the sto- mach, and afterwards strengthening the nervous system in general, and the nerves of the eye in particular. In the case ori- ginating from fevers, the emetic and resol- vent piUs are to be given ; then bark, steel medicines, and bitters; while the vapours ofthe aqua ammonix purx are applied to the eye itself. When the disorder seems to proceed from grief, or fright, the stomach and in- testines are to be emptied by means of tartar emetic, and the resolvent pills; and the cure is to be completed by giving bark and valerian together ; by applying the vapour of the aqua ammonix purx to the eye; ordering nourishing easily digesti- ble food; diverting the patient's mind, and fixing it on agreeable objects, and recommending moderate exercise. The amaurosis from fright is said to require a longer perseverance in such a plan, than the case from sorrow. (Scarpa's Osservaz. Cap. 19.) The third species of gutta serena, or that which arises from debilitating causes, is of two kinds; in one, the disease is the consequence of a general weakness of the body ; in the other, it is the effect of a de- bility, which is confined to the eye itself", and does not extend to the whole consti- tution. According to Scarpa, the incomplete amaurosis from general nervous debility, copious hemorrhage, convulsions, ab inani- tione, and long continued intense study, especially, by candle light, is less a case of real amaurosis, than a weakness of sight from a fatigued state of the nerves, espe- cially of those constituting the immediate organ of sight. When this complaint is recent, in a young subject, it may be cured, or diminished by emptying the ali- mentary canal with small repeated doses of rhubarb, and then giving tonic cordial remedies. At the same time, the patient must abstain from every thing, that has a tendency to weaken the nervous system, and consequently, the eye-sight. After emptying the stomach, prescribe the de- coction of bark, with valerian, or the infu- sion of quassia, with the addition of a few drops of the xther vltriolicum to each dose, with nourishing, easily digestible food. The aromatic spirituous vapours (mentioned in the article Ophthalmy) may then be topically applied; or if these should prove ineffectual, the vapour of the aqua ammonix purx. The patient must take exercise on foot, horseback, or in a carriage, in a wholesome dry air, in warm weather, and take advantage of sea bath- ing. He must avoid all thoughts of care, and refrain from fixing bis eyes on minute shining objects. In proportion as the en- ergy of the nervous system returns, and the constitution is strengthened, the sight is restored. In order to preserve, and improve this useful sense, the patient must adopt, above all things, every mea- sure, calculated to maintain the tone of the stomach, and moderate the impression of light on the retina. This object can easily be obtained by always wearing flat green glasses before the eyes, in a vivid light. (Saggio di Osservaz. Cap. 19.) When the weakness is confined to the eye alone, Richter thinks the topical em- ployment of corroborant applications alone necessary. Bathing the eye with cold water, says he, is one of the most power- ful means of strengthening the eye. The patient should dip in cold water a com- press, doubled into eight folds, and suffi- ciently large to cover the whole face and forehead, and this he should keep applied, as long as it continues cold. Or, else, he should frequently apply cold water to his eyes and face with his hand, on a piece of rag. In these cases, Richter does not ap- prove of employing eye-glasses; he objects to their smallness, from which the eye soon makes the fluid warm, or presses the greater part of it out. The eye may also be remarkably strength- ened by repeatedly applying blisters of a semi-lunar shape above the eye-brows, only allowing the plaster, however, to re- main just long enough to excite redness. Richter likewise speaks favourably of rub- bing the upper eyelid, several times a day, with a mixture of the tinctura canthari- dum, and spiritus serpilli, great care being taken, that none of the application come into contact with the eye itself. All spi- rituous and aromatic remedies are also proper. The infusum valerianx et salvix, with a proportion of camphorated spirit, and the oleum c. jeput, are likewise enu- merated, as useful and efficacious lini- ments. (Anfangsgrunde der Wunderzney- kunst, Band 3, p. 452.) When no probable cause whatsoever can be assigned for the disease, the sur- geon is justified in employing such reme- dies, as have been proved by experience to be sometimes capable of relieving the affection, although upon what principle is utterly unknown. The chief means of this kind are emetics, given in small doses, so as to excite nausea, and occasionally in larger ones to occasion vomiting. A simple solution of two grains of the an- timonium tartarizatum in-a few ounces of water, taken by spoonfuls, frequently proves productive of remarkable benefit. Experience is also highly in favour of giving a trial to Schmucker's pills, the 40 AMAUROSIS. composition of which has been already described. The operation of these pills may be greatly assisted with the exhibi- tion of arnica and valerian, sixteen grains of which should be taken every morning and evening, and the dose be gradually increased. The leaves and flowers of ar- Hica, in an infusion, or else in powder, have been found efficacious. Of the last, at first ten grains, afterwards gradually increased to half a dram, may be pre- scribed every two, or every four hours. Mercury also deserves trial, and its ad- ministration may be pushed till the patient begins to be salivated. This mineral may be tried either alone, or in conjunc- tion with other medicines, as sarsapai'illa, cicuta, or sulphur auratum antimonii. Valerian alone, in the form of powder, and in the dose of half a dram, two or three times a day, may also be tried. Or this medicine may be joined with the de- coction of bark, containing either some of the ammonia prxparata, or a proper pro- portion of the spiritus xtheris vitriolici compositus. Stork has recommended Pul- satilla, in the form of an extract, of which from half a grain to two grains is to be taken with sugaJT or antimonial wine; or else an infusion of this plant may be given. The extractum hyoscyami albi is said to be often serviceable, either alone, in the dose of from two to eight grains, or to- gether with antimonial wine. A sort of tincture of millepedes is among the em- pirical remedies in repute on the conti- nent. Hemlock is another celebrated re- medy. So is the powder of belladonna, given in the dose of five grains a day. The ammonia prxparata, in the dose of a scruple, once a day, is likewise praised. Externally, the aqua ammonix acetatx, mixed with sage, or setwell tea, has been spoken favourably of, as a collyrium. A mixture of oleum castorei and hartshorn, in equal parts, may be taken inwardly, in the dose of forty drops, and also rubbed upon the upper eyelid and eyebrow. Warner exhibited the oleum animale and musk. The application of sternutative powders to the nostrils, is, perhaps, to be regard- ed as a mode of treatment, established on empirical principles, unless, indeed, we oan place confidence in the statement of Schmucker and Richter, that an unusual dryness of the mucous membrane of the nose, following tedious and severe ca- tarrhs, may have the effect of inducing amaurosis. The snuff, employed by Schmucker, is thus composed: * Mer- cur. viv. :;j. Sacchar. alb. 3*uj, Lill. Alb. Rad. Valerian, a a ,"5J. Misce. Mr. Ware has written in favour of the efficacy of electricity and a mercurial snuff in cases of gutta serena. The snuff is compounded of ten grains of turbith mineral (kydrargyrus mlphuratus) Well mixed, with about a dram of the pulvis sternutatorium, glycirrhiza, .or common . sugar. A small pinch of this snuff, taken up the nose, is found to stimulate it very considerably—sometimes exciting sneez- ing, but, in general producing a very large discharge of mucus. Mr. Ware has observed, that the pupil has been generally dilated, in the cases benefited by electricity. He notices, how- ever, that there are many instances in * which a contraction of the pupil is the only change, which takes place, in the appearance of the eye. In this sort of case, the impairment of sight is usually preceded by severe pain, and the original cause may be an internal ophthalmy of long continuance. The crystalline is sometimes visibly opaque. Here electri- city has been found useful; but, Mr. Ware states, that, in these instances, the sublimate has proved superiorly and more certainly efficacious, and, consequently, he prefers it to all external applications whatever. He recommends 1-fourth of a grain, as a quantity proper for a com- mon dose, and says, that it agrees best with the stomach when first dissolved, as Van Swieten directs, in half an ounce of brandy, and taken in a basin of sago or gruel. For young patients the dose must be diminished in proportion to their youth. The medicine is to be continued, as unin- terruptedly as the constitution will allow, for a month, six weeks, or even longer. Electricity is said to have proved more strikingly useful, in cases of amaurosis, ori- ginating from lightning, than when.the disease has arisen from any other cause. Mr. Ware relates a very interesting in- stance of the success of electricity, in a case, which came on very suddenly, after great pain in the teeth, and a swelling of the face had gone off. The disorder came on more suddenly; the temporary blindness was more entire; the eye-lids were more affected, and the cure more speedy, than in the instances related bv Mr. Hey in the 5th vol. of the Med. Oos. and Inq. (Chirurgical Observationsrelativ to the Eye, by James Ware, Vol. 1.) With the exception of one case related by Valsalva, Scarpa was unacquainted with any instance of amaurosis, arising from a wound of the eye-brow, that was relieved, and he has therefore, set down this species as incurable. The opinion, however, is not perhaps correct, for, the first case related by Mr. Hey arose from this cause, and was cured by giving every night the following dose: * Calomel. pp. Camphor a a iij. Conser-v. Cynosb. q. s. A MA A M B 41 probe misceant et f. Bolus, in conjunction with electricity. The lady, however, had been previously bled twice, had taken some nervous medicines, and had had a blister between the shoulders. The pa- tient was first set upon a stool with glass feet, and had sparks drawn from the eyes, and parts srrrounding the orbits, especi- ally, where the superciliary, and infra orbitary branches of the fifth pair of nerves spread themselves. After this ope- ration hi 1 been continued half .an hour, she was made to receive, for an equal time, slight shocks through the affected parts. In a few days sight began tore- turn, and in less than three months it was quite restored.—In another Case, one grain of calomel, and two of camphor^ given every night, and the employment of electricity, effected a cure. The disease had come on gradually, without any pre- vious accident, or pains in the head. The patient a boy nine years old. There are several other very interesting cases of amaurosis related by Mr. Hey, all of which make electricity appear a most efficacious remedy, though it is true, as Scarpa observes, that, in most of these in- stances, internal medicines, were also given, and bleeding occasionally practised. Mr. Hey attributes the benefit chiefly to the electricity, because, in two of his cases, no medicines were used, yet the progress of the amendment seemed to be as speedy in them, as in the rest, and in two instances, a degree of sight was obtained by the first application of electricity. Mr. Hey makes particular mention of an obliquity of sight, as invariably attendant on amaurosis. It was most remarkable in those, who had totally lost the sight of either eye, for, in them, the most oblique rays of light seemed to make the first sen- sible impression upon the retina ; and in proportion as that nervous coat regained its sensibility, the sight becamemore direct and natural. (Med. Obs. and Inq. Vol. 5.) Many of the causes of amaurosis are of such a nature, as to render the disease to- tally incurable. Bonetus, in his Sepul- chretum Anatomicum, lib. 1. sect. 18. has given us several such cases: after death, the blindness in one was found to be occa- sioned by an encysted tumour weighing fourteen drams, sitt-ltted in the substance ofthe cerebrum, and pressing on the optic nerves near their origin. In a second, the blindness was produced by a cyst, contain- ing water, and lodged on the optic nerves, where they unite. In a third, it arose from a caries of the os frontis, and a consequent alteration in the figure of the optic fora- mina. In a fourth, the cause of the dis- ease was, a malformation of the optic nerves themselves. In some of the in- Voi.. I. stances, in which no apparent alteration can be discovered in the optic nerve,' Mr. Ware conjectures, whether a dilat-oion of the anterior portion of the circulus arteri- osus may not be a cause of the affeck>n. Tlie circulus arteriosus is -an t.rterial orcle, surrounding the sella turcica, formed by the carotid arteries on each s.de, branches passing from t!nm to meet each oilier before, and other branches passing back- wards, to meet branches from the basilary artery behind. The anterior part of the circulus arteriosus lies directly over, crosses, and is in contact, with the optic nerves, just in the same way as the ante- rior branches lie over the optic nerves, the posterior ones lie over the nervi motores oculorum. Hence Mr. Ware attempts to refer the amaurosis itself, and the paralytic affection ofthe eye-lids, and muscles ofthe eye, sometimes attendant on the complaint, to a dilatation of the anterior and posterior branches of the circulus arteriosus. Dr. Baillie has noticed, in his Morbid Ana- tomy, the frequently diseased state of the trunk, or the small branches of the carotid arteries at the side of the sella turcica, and he says the same sort of diseased structure is also found in the basilary artery and its branches. [From an idea that the pressure of an inordinate secretion of the humours of the eye might occasion a paralysis of the retina, Dr. Physick has punctured the cornea, and evacuated the aqueous humour, in some cases of gutta serena, and with temporary advantage.—Mr. Ware has punctured the sclerotica in certain cases of amaurosis. (See "Gutta Serena.") Blisters applied to the eye- lids, have also been found beneficial.] The most valuable information, concern- ing amaurosis, is to be met with in Ver- mischte Chiri/rgische Schriften von J. L. Schmucker, Band 2. Berlin Edit. 2.1786. Remarks on Ophthalmy, &c by James Ware. Inquiry into the causes preventing success in the extraction of tlie Cataract, &c. by the same. Osservazioni sulle Mulattie degli Occhi di A. Scarpa, Venez. 1802. Hey's Practical Observations in Surgery. Medi- cal Observations and Inquiries, Vol. 5. Schmucker's Wahrnehmungen. Richter's Anfangsgrunde der Wuvdarzneykunst. Band 3. Warner's Description ofthe Human Eye, &c. Chandler's Treatise of the Dis- eases of the Eye, chap 24. Some scattered remarks in the posthumous work on the dis- eases of tlie eye ofthe late J. C. Saunders,&c. Some observations connected with the subject of Amaurosis, will be found in the articles Cataract, Hemeralopia, Hemiopia, and Nyctalopia. AM BE. (ttuSn, the edge of a rock: 42 A M M AMP from ctfj.Za.ivu, to ascend.) An old chirurgi- cal machine for reducing dislocations of the shoulder, and so called, because its extremity projects, like the prominence of a rock. Its invention is imputed to Hippocrates. Theambe is the most ancient mechanical contrivance for the ahove pur- pose; but, is not at present employed. Indeed, it is scarcely to be met with in the richest cabinets of surgical apparatus. It is composed of a piece of wood, rising vertically from a pedestal, which is fixed. With the vertical piece is articulated after the manner of a hinge, an horizontal piece, with a gutter formed in it, in which the luxated limb is laid, and secured with leather strings. The patient places himself on one side of the machine; his arm is extended in the gutter, and se- cured ; the angle, formed by the union of the ascending piece, and by the horizontal branch, is lodged in the armpit, and then the horizontal branch is depressed. In this way extension is made, whilst the vertical part makes counter extension, and its superior part tends to force the head ofthe humerus into its cavity. But, thene is nothing to fix the scapula, and the compression made by the superior portion of the vertical piece of the ma- chine, tends to force the head of the hu- merus into its cavity, before it is disen- gaged by the extension. (Boyer on Dis- eases of the Bones, Vol. II.) AMBLYO'GMOS, or Amblto'smos, (from ctfji£xvs, dull.) A dimness of sight. AMBLYOPIA, (from */k£Ai/«, dull, and an}/, the eye.) Hippocrates means by this word, in his Aph. 31. Sect. 3. the dim- ness of sight, to which old people are sub- ject. Paulus, Actuarius, and the best modern writers, seem to think, that am- blyopia means the sane thing as the in- complete amaurosis. ( Encyclopedic Metho. dique; Partie Chirurgicale; Art Amblyopic) A'MMA,(from«a-7*'» to bind.) A truss, or kind of bandage, or machine, for pre- venting a protrusion of the bowels in cases of b'-mia. AMMONL-E MURIAS, AMMONIA MURIATA, or Sal Ammoniac. Its chief U-ae in surgery is as an external discutieut application. See Lotio Amnion. Muriatx cum Aceto. Mr. Jnstamond recommends the follow- ing application for the cure of milk ab- scesses: rn Ammonix Muriatx £j. Spi- ritus Roris marini lbj. Misce. Linen rags are to be wet with the remedy, and kept continually applied to the part affected. AMPHISMI'LA. (from a/*.», I shall now present tlie rcadc: nith the whole of La l-'aye's observations on tliis subj*.ct. In perusing the account, it is to be recollected, that La Faye was a zeal- 60 AMPUTATION. ous advocate for the method, which, though at present thought well of by a few, is not t xtt nsively approved. La Faye's relation, however, is truly inte- resting, for it muk s us at once acquainted with all the principal arguments and rea- sons, which hive been adduced in favor ofthe operation, and it explains to us the different plans of performing it, which were followed by such surgeons, as made tlie earliest trials of it. The description of the new machine for compressing the stump is less interesting now, than for- merly, when a main argument in support of this operation was, that the flap, when applied and pressed upon the stump, stop- ped the bleeding, and rendered ligatures unnecessary*. I have chosen, however, not to omit the account of the instrument, in order that the reader may possess the whole of the memoir. MEMOIR BT M. DE LA FATE ON THE FLAP AMPUTATION. Though surgeons have diligently appli- ed themselves, for more than a century, says La Faye, to bring the ordinary me- thod of amputation to perfection, yet still there are such defects found in it, as the greatest masters have not been able to re- medy. According to this method, a liga- ture is put on the vessels, which produces great pain, and sometimes convulsive mo- tions in the patient: the bones remain bare, and must exfoliate, which requires a considerable time ; it has been some- times necessary to saw tliem .1 second time ; the wound is of a large extent; the suppuration, which is very copious, greatly debilitates the patients, and the cure be- comes exceeding tedious. The reflections, made by several sur- geons at the end of the 17th century, as well as by those of tiie present, on these inconveniences, have induced them to think, that, by preserving a fl *p of fiVsh and skin, for covering the s'ump, the operation would be rendered less painful, more certain, and the cure much quicker. From this portion of flesh, the new me- thod of taking off a limb, has been stiled the flap-amputation. I shall here ex- amine the different notions of those, who have invented or followed this method, and propose such as have occurred to me on this subject. The amputation, with the double inci- sion, is very recent; though it has been surmised l.y .some persons, tn*. ■ Celsus had pointed it out in the followi , and the other end was placed on tlie side with the threads ; after which 1 raised the flap, in order to adjust it to the stump, .and then laid on, not the apparatus used by M. Verduin, but the common sort, or pretty nearly tlie same that is generally employed in the amputation of the leg; by which means, the method of cure becomes more simple, as I make no use of the machines invented by this author and M. La Faye. . I did not take off this apparatus till the fourth day; when I found the flap adhe- rent, with a gentle heat. The longuette or small compress, which hindered the reunion of the flap, in that place alone wliich it possessed, was simply humid. I drew it out with facility, on the eighth day after the operation; and as I found such resistance from the ligature, as made me presume that it would not fall off so soon as I expected, I cut it in the loop with blunt scissars, which were directed into the space of the sinus formed by the presence of the compress. I afterwards joined it together again, by applying an apparatus like that which had been put on, at the instant of the operation. 1 did not remove it till three days after, and saw with pleasure the flap firmly reunited, though a portion of it had been applied on the linen for eight days. The patient was cured on the twentv- seventh day of the operation, and could easily bend and stretch out the extremity which remained of the leg. I am not insensible, that some surgeon- majors of this regiment have performed this operation; but by following Verduin's method too exactly, it has proved unsuc- cessful. I am persuaded that the alter- ations I have already made in it, are of some consequence, and I should still add more, did I see any occasion for making them. What I have experienced in mv third patient, would induce me to make the li&ature, in such a maimer, that it might exactly embrace, if I may use the term, no more than the vessel, in order to its falling oft* more speedily, and sooner re- uniting the flap. I am still of opinion, that if the ligature should not fall off, so soon as we appre- hend it has produced its effect, it would be necessary to cut it; because its too long continuance must naturally obstruct the advantages proposed from this operation, with regard to the speedy re-union. But as it is not vcrv easy to cut the ligature very close, I should make use, m preter- ence to other remedies, of the agaric of oak, whose success is well known. "Iwq pieces of this fungus, each fastened by a string, (to one of which there should be made a knot to distinguish them) being afterwards applied, the one on the other, to the orifice of the vessels, and the two strings covered by the long compress abovementioned, would certainly stop the hemorrhage: the whole being withdrawn in the space of three days, there would need no more than the same space for the whole flap's adhering to the stump, and the cure would be perfectly completed in a short time after. As to what remains to be said on this subject, although I am convinced, says Garengeot, that the method of amputation with a flap, has some advantages, which the others have not; it is not my present design to examine into the reasons of the preference, but only to deliver what has occurred to me on this head, and to pro. pose such alterations as I thought, might render the operation more perfect. (M. de Garengeot, in Memoires de I'Acad, de Chirurgie, Tom. 5, in 12?no.) SUBJECT OF AMPUTATION WITH A FLAP CONCLUDED. __ "We have already spoken of the flap. operation having been done by White and Bromfield above the ankle. In the year 1765, Sylvester O'Halloran, an eminent surgeon, of Limerick in Ireland, published a revival of the flap-amputation, upon a plan entirely new. However, his fruit con- si-.ted in not putting the flap in contact with the wound, till after the inflammation had subsided, about the twelfth day. Messrs. Alanson and Lucas conjectured that the cure might be rendered more safe, easy, and expeditious, by applying the fkp, with a view of uniting it by the first intention. Tlie following case explains Mr. Alan- son s flap-operation. The disease was in the left leg, the patient, therefore, lav on his right side, upon a table of convenient height, so as to turn the part to be first cut fully into view. The intended line, where the knife was to pass in forming the flap, had been previously marked out with ink. A longitudinal incision was made with a common scalpel, about the middle ofthe side of the leg ; first on the outside, then on the inside, and across the tendo Achillis- hence, the intended flap was formed, first by incisions through the skin and adipose membrane, and then completed, by push- ing a catling through the muscular parts in the upper incised point, and afterwards AMPUTATION. 67 carrying it out below, in the direction of the line already mentioned. Thus the whole flap was completed. The flap was thick, containing the whole substance of tlie tendo Achillis. The usual double in- cision was made; the retractor applied to defend the soft parts; and the bone divid- ed, as high as possible, with the saw. The flap was placed in contact with the naked stump, and retained there, at first by three superficial stitches, between which adhesive plasters were used. Not- withstanding the patient caught an infec- tious fever, a few days afterwards, the stump healed in three weeks, except half an inch at the inner angle, where the prin- cipal vent had been. In another week, the wound was reduced to a spongy substance, about the size of a split-pea. This being touched with caustic, healed in a few days. The man was soon able to use an artificial leg, with which he walked remarkably well. He went several voyages to sea, and did his business with great activity. He bore the pressure ofthe machine total- ly upon the end of the stump, and was not troubled with the least excoriation or soreness. In the next instance, in which Mr. Alan- son operated, he formed the flap by push- ing a double-edged knife through the leg, and, passing it downwards and then out- wards, in a line, first marked out for the direction of the knife. In this way, the flap was made more quickly. (Alanson on Amputation.) 1'he leg should be completely extended during the operation ; and kept in that posture, till the wound is perfectly healed. We shall next notice Mr. Hey's method. This gentleman is satisfied, that very near the ankle, is not the most proper place for this kind of amputation. Some cases occurring, in which, from a scrophulous habit, the wound at the stump would not heal completely, nor remain healed, Mr. Hey determined to try, whe- ther amputation in a more muscular part would not secure a complete healing, and give the patient an opportunity of resting his knee on tlie common wooden leg, or using a socket, as he might find most convenient. Mr. Hey now prefers this method, and has reduced it to certain measures. It had been customary, at the Leeds Infirmary, to make the length of the flap equal to one-third of the circumference of the leg. This was determined by the eye of the operator, who usually pushed the catling through the leg,near the posterior part of the fibula. Mr. Hey, finding the flap was not always ofthe proper breadth began to determine this by measure, and uotv operates as follows : to ascertain the place where the bones are to be sawn, to- gether with the length and breadth ofthe flap, he draws upon the limb five lines, three circular, and two longitudinal ones. He first measures the length of tiie leg from the highest part of the tibia to the middle of the inferior protuberance of the fibula. At the midpoint, between the knee and ankle, he makes the first or highest circular mark upon the leg. Here the bones are to be sawn. Here Mr. Hey also measures the circumference of the leg, and thence determines the length and breadth of the flap, each of which is to be equal to one-third of the circumference. In measuring the circumference of the limb, Mr. Hey employs a piece of marked tape, or ribbon, and places one end of it on the front edge ofthe tibia. Supposing the circumference to be twelve inches, he makes a dot in the circular mark on each side of the leg, four inches from the anterior edge of the tibia. These dots must, of course, be four inches apart be- hind. From each of these dots Mr. Hey draws a straight line downwards, four inches in length, and parallel to the front edge of the tibia. These lines shew the direction, which the catling is to take in making the flap. At the termination of these lines, Mr. Hey makes a second mark round the limb, to shew the place where the flap is to end. Lastly, a third circular tnark is to be made an inch below the up- per one, first made, for the purpose of di- recting the circular cut through the inte- guments, in front of the limb. The cat- ling, for making the flap, should be longer than those commonly "employed in ampu- tations. Mr. Hey uses one which is seven inches long in the blade, and blunt at the back, to avoid making any longitudinal wound of the arteries, which is very diffi- cult to close with a ligature, and, for the same reason, he pushes the catling through the leg a little below the place where such muscles are to be" divided, as are not in- cluded in the flap. The limb being nearly horizontal, and tlie fibula upw. rd, he pushes the catling through the leg, where the dot was made, and carries it down- ward along the longitudinal mark, till it approaches the lowest circular mark, a lit- tle below which the instrument is brought out. The flap being held back, Mr. Hey divides the integuments on the front ofthe limb along the course ofthe second circu- lar mark. The muscles not included in the flap, are dien divided a little below the place where the bones are to be sawn. No great quantity of these muscles can be saved, nor is it necessary, as the flap con- tains a sufficient portion of the gastrocne- mius and soleus muscles to make a cushion for tiie end of the bones. After sawing 68 AMPUTATION. the bones, Mr. Hey advises a little of the end ofthe tendon ofthe gastrocnemius to be cut off", as it is apt to project beyond the skin, when the flap is put down; and he recommends the large crural nerve, when found on the inner surface of the flap, to be dissected out, lest it should suffer compression. As strips of adhesive plaster cause great pressure on the end of the stump, Mr. Hey prefers using sutures for keeping the flap applied. Small strips of court plas- ter are to be put between the ligatures. The sutures may be cut out on the eighth or ninth day, and the flap supported by plasters. Mr. Charles Bell describes another sort of flap-amputation. The operation is not to be done so low, as there will not be a sufficiency of muscle to cover the end of the bones. An oblique cut is to be made with the large amputating knife, upward, tlirough the skin of the back part of the leg. The assistant is to draw up the skin, and the knife is to be again applied to the upper margin of the wound, and carried obliquely upward till it reaches the bones. The knife, without being withdrawn, is next to be carried, in a cir- cular direction, over the tibia and fascia, covering the tibialis anticus, until it meets the angle of the first incision on the out- side ofthe limb. The surgeon is then to pierce the interrosseous membrane, &c. The sawing being completed, and the ar- teries secured, the flap is to be laid down, and the integuments of the two sides of tiie wound will be found to meet. (See Bell*s Operative Surgery, Vol. 1.) The flap-amputation is certainly more painful than tlie common method, and, though it has had very able men for its patrons, it is questionable, whether it is productive of the smallest advantage. Nor is there any necessity for adopting this kind of operation, though you may choose Jo amputate near the ankle. Mr. Lucas (Med. Obs. and Inq. Vol. 5.) does indeed endeavour to prove, that the stump will not bear the pres.sure of a machine for walking unless a flap be preserved. However,-as the author ofthe article Am- putation, in the Encyclop. Method, remarks, if care be taken to save muscle, a machine for walking may be worn as conveniently as if a flap had been made. The flap-amputation of the tlngli is now quite abandoned by all the best surgeons in this country, and no description of it seems necessary. Foreign surgeons, how- ever, seem not to have entirely rejected this way of operating. We read in De- sault's works, by Bichat, that the former was in the habit of adopting this kind of amputation; but, it is a justice due to the eminent M. Sabatier, to state his disap probation ofthe practice. (Medecine Ope ratoire, Tom. 3, p- 257.) Some criticisms on the flap-amputation, by the intelligent M. Louis, will be found among the observations, which I have taken from the valuable writings of that eminent surgeon, and inserted at the end of the present article. AMPUTATION OF THE ARM. The structure of the arm is very ana- logous to that of the thigh ; like the lat- ter, it contains only one bone, round which the muscles are arranged. The interior ones are attached to the os brachii, while the more supeificial ones extend along the limb, without being at all adherent. The first consist of the brachialis inter- nus, and the two short heads of the tri- ceps ; the second, of the biceps, and long head of the triceps. Hence, amputation is here to be done in the same way as in the thigh, unless when we are necessitated to amputate very high up, above the in- sertion ofthe deltoid muscle. The patient being properly seated, the arm is to be raised from the side, and, if the disease will allow it, into a horizontal position. The surgeon is to stand on tlie outside of the limb, apply the tourniquet as high as possible, and to have the skin and muscles which he is about to di- vide, made tense, by the hands of an assist- ant. The soft parts are next to be di- vided, as much of the limb being pre- served as possible. The bone is to be sawn with tire usual precautions, and the bleeding stopped in the usual way. The stump is then to be dressed, and the pa- tient put to bed, with the wound a lit- tle elevated from the surface of the bed- ding. If the disease should require the arm to be taken off at its upper part, there would be no room for the application of the tourniquet. A compress might then be put in the axilla, and compressed by any strong bystander. With a straight bistoury, the surgeon is now to make a transverse incision down to the bone, a little above the lower extremity of the deltoid muscle. Two other longitudinal incisions, made along the front and back edge of this muscle, would form a flap, which must be detached and reflected. Lastly, the rest of the soft parts of the limb are to be divided by a circular cut, made on a level with the base of the flap. (Sabatier Medecine Operatoire, Tom. 3, p. With regard to placing a compress on the artery in the axilla, as advised by Sabatier, this is not so eligible, as mak- AMPUTATION. 69 ing pressure on the artery, as it passes over the first rib, and of which method we shall speak when we treat of amputa- tion at the shoulder. AMPUTATION OP THE FOREARM. The wisest maxim, with respect to the place for making the incision, is to cut off as little of the limb as possible. The forearm is to be held by two assistants, one of whom is to take hold ofthe elbow, the other of the wrist. The tourniquet is to be applied to the lower part of the arm, and the assistant,holding the elbow,should draw up the integuments, so as to make them tense. The circular incision is then to be made down to the fascia; from this as much skin js to be detached, reflected, and saved, as is necessary for covering the ends of the bones, and the muscles are to be cut on a level with the reflected skin, at the same time directing the knife obliquely upward, As many of them are deeply situated between the two bones of the forearm, too much attention cannot be paid to dividing all of them, with a double-edged knife introduced between the radius and ulna. The soft parts are to be protected from the saw by a linen retractor. It is gene- rally recommended to saw the two bones together, for which purpose the forearm should be placed in the utmost state of pronation. In any other position, the ulna is situated almost directly under the radius. The ulnar, radial, and two interosseous arteries, are those, which usually require a ligature. AMPUTATIOX AT TIIE HIP-JOINT. The French Academy of Surgery pro- posed the following question in 1756, as the grand prize subject: In the case, i?i which amputation of the hip-joint should ap- pear to be the only resourcefor saving the pa- tient's life, to determine whether this operation ought to be practised, and what would be the best way of performing it? No satisfactory memoirs having been presented, the same subject was proposed in 1759. The ap- probation of the academy was now con- ferred on a paper, in which the possibility' of amputation at the hip-joint was esta- blished The cases/demanding the opera- tion, are also determined by Baibet, the author. If, for instance, a cannon ball, or any other violently contusing cause, should have carried off or crushed the thigh, so as only to leave a few parts to be cut to make the separation complete, we ought not to hesitate about doing it. A sphacelus, extending to the circumfer- ence of the joint, and destroying the greatest part of the surrounding flesh, might render the operation equally ne- cessary and easy. (See Sabatier, Tom. 3, p. 271, &c.) Cases are adduced of the limb being taken off', by the surgeon com- pleting the separation of the dead parts with a knife. However, this cannot be considered as amputation at the hip-joint. Dividing a few dead fibres was a thing of bo importance, in regard to the likelihood of its creating any bad symptoms. The proceeding, in fact, seems to me to have no analogy at all to the bloody operation of taking the thigh bone out of the socket. 1 cannot conceive any case, in which th*! circumstances, however perilous, would be at all improved by this operation. The following are Mr. Pott's sentiments : " M. Bilguer, and M. Tissot, are the only peo- ple whom 1 have met with, or heard of, in the profession, who speak of an ampu- tation in the joint of the hip, as an ad- visable thing, or as being preferable to the same operation in the thigh." After a quotation or two, he continues ; " that amputation in the joint of the hip is not an impracticable operation (although it be a dreadful one) 1 very well know. I cannot say, that 1 have ever done it, but I have seen it done, and am now very sure I shall never do it, unless it-be on a dead body. The parallel, which is drawn be- tween this operation and that in the shoulder will not hold. In the latter it sometimes happens, that the caries is confined to the head of the os humeri, and that the scapula is perfectly sound aud. unaffected. In the case of* a carious hip-joint, this never is the fact; the ace- tabulum iscliii, and parts about, are al- ways, more or less in the same state, or at least in a distempered one, and so indeed most frequently are the parts within the pelvis, a circumstance this ofthe greatest consequence ; for the power of performing the operation beyond tlie seat of the dis- ease, and, consequently, of totally remov- ing all the distempered parts, is the very decisive circumstance in favour of ampu- tation every where, but, in the hip, where (to say nothing of the horridness of the operation itself") the hemorrhage, from a multiplicity of vessels, some of which are of considerable size, and the immense dis- charge which a sore of such dimensions must furnish, the distempered state ofthe parts, wliich cannot by the operation be removed, will render it ineffectual, bold and bloody as it must be." (Pott on Am- putation.) This dreadful operation was performed in this country, some year* ago, by Dr. Kerr, of Northampton. (See Duncan's Med. Commentaries, Vol. 6, p\ 337) M. Larrey informs us, that lie hrJ performed 70 AMPUTATION. it three times ; twice in Egypt, and once, while he was surgeon to the French army on the Rhine. One of his patients sur- vived tiie operation a week, at the end of which he was carried off* by the plague ; and the others died, after being conveyed, .n a very uneasy manner, during a preci- pitate march of the army. (See Relation de l' Expedition de I' Armee d' Orient en Egypte, &c.) For my own part, with all the respect, which I entertain for this ju- dicious surgeon, I cannot conceive any circumstances, in wliich a patient would be benefited by so severe an operation Were the upper portion of the thigh bone the only part diseased, or were it and the adjacent part of the pelvis splintered by a gun-shot injury, I should rather listen to the suggestion of Mr. Charles White, of Manchester, and endeavour to per- form the excision of the diseased, or splintered parts, than have recourse to amputation at the hip, an operation, how- ever, which, as we have seen, has the sanction of authority. [Military- surgery has undergone, with- in a few years, great alterations. Innova- tion has, in some instances, been followed by real and important improvements ; but whether in the full extent supposed by its advocates, admits of a doubt. Ampu- tation at the hip joint, is an operation on which a surgeon can never reflect with- out horror; but 1 am not prepared to say with Mr. Cooper, that " I cannot conceive any circumstances in which a patient would be benefited" by it. The following extracts from a new work on gun-shot wounds, by Mr. Guth- rie, will shew, that, the military surgeons continue, occasionally, to perform it. " I have not much to offer from ac- tual experience of the operation, having performed it but once unsuccessfully. I have however seen many cases in which it ought to have been attempted, and which died. I have seen many in which the operation would have been necessary, if the constitution of the patients could ever have recovered the shock it had re- ceived at the moment of injury. I know that many cases have died after long con- tinued disease of the thigh bone from gun-shot wounds, that would have had a chance of recovery, if the operation had been performed; and I have several times amputated so close to the trochanters, that I could with ease have removed the head of the bone without any increase of the external incisions. This amputation is cf course either pri- mary or secondary ; but the nature ofthe injury or disease differs very much in these two stages; for very few, or none of the cases t!uit render its performance necessary on the field of battle, ever live to the period when secondary amputation is usually recommended. Wounds demanding amputation of tne hip joint on the field of battle, arise from cannon or grape shot, or the explosion of shells. Few surgeons would think ot per- forming it for a wound by a musket ball; although cases may occur that require it, and the principal one that will render it necessary, will be a fracture of the head or neck of the bone, with a wound of the great vessels, or some other arterial trunk causing hemorrhage, and stuffing the thigh with blood. A grape or small cannon shot, may strike the fore part of the thigh, and without wounding the in- guinal artery itself, may, in its passage to the neck of the femur, wound some large arterial branches, causing considerable haemorrhage: the wound shall not be large, and yet the chance of saving the life of the patient will be but very small indeed. I recollect two cases of this kind in particular; one after the battle of Vimiera, by a cannon shot, which proved fatal on the second day after the injury, no one at that time thinking of the amputation at the hip joint. The other occurred at Salamanca, by a large ball, which shattered the neck of the femur and the body, of the bone below. I did not see this person for near forty-eight hours after the injury, but was informed that on his first presentation for assist- ance, an artery, supposed to be a large branch of the femoral, had thrown out its blood per saltum, and was stopped by pressing some lint on the wound. The limb soon swelled to nearly twice its na- tural size, with much external inflamma- tion. The patient himself thought his case desperate, as did every one about him, and declared his willingness to sub- mit to any operation that might be pro- posed ; but the time for operating was past, even if any operation could have been agreed upon. After two months of severe suffering, in which there were even some prospects of life being preserved, this man died. The latter period of the time was passed, however, without any hope of recoven, and surgical aid was given merely with the view of rendering his last moments as easy as possible. The great strength of constitution shewed by this man during the whole course of his illness, and his great endurance of suffering, have always inclined me to think the operation at the hip joint would have succeeded, if it had been performed shortly after the receipt of the injury. A shell bursting near a soldier mav drive a large piece of an inch in thick. AMPUTATION. 71 ness, and a pound or two in weight, into the inner part of the thigh, without wounding the femoral artery, yet frac- turing the head of the bone: here seve- ral large vessels, and perhaps the great sciatic nerve would be divided, and the only chance of life, in my mind, would be in the immediate removal of the whole. I saw a fatal case of this kind during the siege of Ciudad Kodrigo, where the pa- tient livecLlong enough to shew the neces- sity of performing this operation. A piece of a shell may strike between the trochanter and the ilium, go through the neck of the bone, and tear its way out below the tuberosity of the ischium, destroving all the parts in its course, without either killing the soldier by hae- morrhage, or by the shock of the blow to the constitution. This accident hap- pened to a man of the 40th Regiment, at the battle of Salamanca, about four o'clock in the afternoon. He was in a good state to undergo the operation when I saw him next morning, but none of the surgeons present with me would agree to it; all allowed nothing could save the man ; but the opinion entertained of the cruelty of the operation, and of its certain failure prevented its being done. I took this man into Salamanca with me, and his ap- pearance for six successive days before he died, made me reproach myself for my want of courage, in not contemning any remarks that might be made, on my having undertaken it in opposition to tlie opinion of my colleagues; and I declined it, not because the general opinion was against it, but in consequence of the bad success of one, and of the good success of the other, of the two next cases to be related. When a cannon-shot carries away the tlngh above its middle, so as to exclude the more common flap operation close to the trochanter, it is almost always fatal. These accidents generally destroy at once. On the field of battle, I have seen many, having searched particularly- for them, but have found them dead, or beyond the roach of surgical aid. I have seen a case of a cannon-shot striking the outside of the thigh, tearing i.way the trochanter and surrounding parts, without wounding the femoral artery, or any great vessel that would cause any serious haemorrhage, or so great a shock to the constitution as to render the operation impracticable ; yet this man died without any attempt being made for his relief, winch was neither good surgery or humanity.. When die femoral artery has been torn through by a cannon-shot there is, at the moment, a great loss of blood, but the patient does not bleed to death, neither does he appear to die ultimately from the effects of the hxmorrhage; for I have seen several men lose a greater quantity from the same vessel without any such effect, but from the shock to the constitu- tion ; and this observable in many cases of amputation of the thigh, where there has been Uttle loss of blood ; and yet the patient dies, during, or immediately after the operation. A considerable haemor- rhage, on the other hand, renders a pa- tient less able to bear an operation than he otherwise would do, and where there has been much and sudden bleeding, the powers of life are so exhausted as not to be able to bear any further disturbance. Tliis effect is most frequently caused by wounds of the femoral artery, and where it has occurred, the chance of success from the operation, will be very small; and the combination of injury arising from the loss of blood, and the shock of the blow, will have so much diminished the powers of life, that the operation in addi- tion, will destroy the remainder. If (as I have seen in many instances) the bones of the pelvis are injured, in any of the preceding kinds of accident, the result will be fatal, and the operation should not be performed; but some little destruction of the soft parts, should not prevent it, if the patient be otherwise in a favourable state. A very extensive injury of the soft parts of the thigh, if the bone be not , broken, and the femoral artery not divid- ed, does not authorize the operation, al- though the artery be laid bare for three or four inches of its course. An officer of the 88th Regiment, was wounded in the trenches', at the siege of Ciudad Kodrigo, by a twenty-four pound shot, which struck the outside of the an- terior part of the left thigh, and carried away the fore part of it from the groin to within a. hand's breadth of the knee ; the femoral artery lay bare at the bot- tom of tlie upper part of the wound, and was seen pulsating for near three inches ; tlie'sartorious and rectus muscles were carried away, and all the muscles on the outer and inner side of the thigh more or less mangled by the shot, or torn by the laceration ; it was altogether the most frightful looking wound I had seen, not even excepting where the limb has been completely torn oft*. Having the super- intendance of the 3d and 4th divisions of infantry, tlie greater part of the medical officers of both were with me at the time; and on this officer's being brought to our field hospital in the rear of the trenches, they all, without an exception, declared he must shortly die, if the limb was not 72 AMPUTATION. removed. In compliance with this opin- ion, I proposed to tie the artery below Poupart's ligament, and to endeavour to save flaps to cover the great trochan- ter, the bone being sawed off below, as I have since done in several instances; and if this was not practicable, the head of the femur was to be removed. On placing liim on the panniers for the purpose of operating, he was so exceedingly faint, the pulse at the wrist being scarcely per- ceptible, that I conceived the operation would be useless, as he would certainly die under our hands. He was removed to a corner of the hospital, and placed on a hay mat amongst other cases of wounded supposed in a dyintf state, a little lint being laid over this enormous surface. By the next morning he had much recovered, and as his thigh became very painful, he was desired bv the sur- gcon of the division arriving] in succes- sion, to wet it with warm water; this was done, but his countenance was so ghastly that he was considered by every one as dying; indeed his regiment actu- ally returned him dead, and his commis- sion was filled up in England. In this state he remained till the day after the storming of Ciudad Rodrigo, when, from the advance of Marshal Marmont, the wounded were sent across the Agueda. Desirous of knowing whether any strag- glers of the corps I belonged to might still be at the field hospital, I rode to it on leaving the town, and found every one' gone except this poor gentleman, who requested my assistance ; having convey- ance in the town, I offered to take him • to my divisional hospital, five leagues distant, where all the other wounded had been conveyed, wliich offer he gladly ac- cepted, and reached the village of Aldea del Obispo, with less inconvenience than I expected; I daily feared the femoral artery would give way, but nothing of the kind occurred, the slough from the whole surface of the wound soon sepa- rated, and there was much less of it than is usual on such occasions, but this may be attributed in some measure* to the attention paid him, and to the ex- treme coldness of the weather in a room without a fire-place. The discharge of pus was very great, and the artery lay in a channel completely covered by it;—I hourly expected it would ulcerate, but granulations soon began to shoot out, and by the end of three weeks the artery was covered in, although its pulsations were still visible at a dfstance ; the sore gradually contracted in a surprising de- gree, and in two months it was diminish- ed to half its original size, very little new skin having been formed. At this period he left me on his way to the rear, on the army moving down to the siege of Badajos. The attention paid to this officer in regard to diet, attendance, and surgical aid, was very great; more, in- deed, than he could have received under any other circumstances. His recovery was considered so unlikely, that no one looked at his wound after the first day ; all supposed him past relief, as was really the case with an officer of Engi. ncers, lying beside him, whose arm was shattered to pieces by a shell, and the os ilium bared on the outside of the glutaci muscles, and on the inside af the iliacus internus, as if it had been for some time in maceration. The insertions of the ex- ternal and internal oblique, and the trans. versalis muscles were torn out without the peritoneum being opened, which alone prevented the intestines from coming out at the wound. Although this gentleman's life was saved, still, I am of opinion, that very few would have recovered under the same injury. The secondary operation has seldom, I believe, been performed during the high suppurative stage succeeding to injury from gun-shot wounds ; and as I do not believe it can be successful, if done at this period, I would not perform it after the second day, until the third or fourth week. There are not many cases that will demand it at this period, as tha femur, in most compound fractures of the thigh,, can in general be sawed off, at, or immediately below the little tro- chanter." The operation has been twice perform- ed in England: in one case it was com- pletely successful; and in the other, the patient lived thirty days. " Mr. Brownrigg, Surgeon'to the Forces, has performed the operation four or five times : on one occasion the patient lived eight days, and died from fevei**, supposed to arise from causes foreign to the opera- tion. In the last case he was completely sue- cessful. The man received a gun-shot wound in the thjgh, which fractured the bone close to the trochanter, on the 29lh Dec. 1811, near Merida, in Spain. On the 12th of December, 1812, the opera- tion was performed, and the man is now living at Spalding, in Lincolnshire, in per- feet health. ' Mr Brownrigg intends, I believe, to publish the particulars of this case. I have also been informed, that the opera- tion has been performed in the West In- dies. . These cases prove, that the operation is not only necessary, but practicable, AMPUTATION. 73 and that it may be effected with success under certain circumstances. This being granted, it necessarily follows that the operation ought to be recommended and performed in every case in which it can alone bring relief, or offer a prospect of success. No man should, therefore, be allowed to die without its being proposed to him ; and if it be a case for primary operation, the sooner it is done on the field of battle, consistent with propriety, the greater will be the chance of success, for the patient cannot live to the period for secondary amputation. It is in this, and other operations high in the thigh, that the question of time is most import- ant, for haste is as injurious as delay, when improperly applied. If the patient has suffered much loss of blood, or is in a state qf syncope, or nearly approaching to it, unable to arti- culate, with a pulse scarcely perceptible, and the skin clammy and cold, an imme- diate operation would only hasten his death ; but if excited by stimulants and cordials, he will have some chance of re- covering himself in an hour or two, so as to undergo the operation with a bet- ter prospect of success, or he will in that period sink and die. If, on the contrary, he is brought to tiie surgeon, although , much alarmed and reduced by the sud- den shock and loss of blood, with strong sensations of pain, expressed by his cries for assistance, convulsive motions of the limb and body, and tlie powers of the sensorium not destroyed, the operation should be performed immediately; or, in-- stead of becoming more calm and col- lected, he will gradually sink into the state of tlie first described, and be una- ble to bear the operation. . On the other hand, the first mentioned, if he be ex- citable, will in time rather approach to the state of the latter, and from the pain, &.c. he suffers, will call for the fierformance of the operation. This vio- ent nervous commotion, however, is not common; it depends upon particular idi- osyncrasies, and will never in the first be so excessive as in the last. The operations being decided upon, it is, I confess, not like that at the shoul- der-joint, to be done by every one of moderate ability. No surgeon should at- tempt it, unless he is conscious of pos- sessing great coolness, a presence of mind equal to any emergency, and a correct knowledge ofthe parts to be divided. I consider the operation to be best per- formed in the following manner. The patient should be laid on a low table, or two field panniers placed together, co- vered with a folded blanket to prevent the edges giving pain, and properly sup- Vot. I. ported in a horizontal position. An as- sistant leaning over, and standing on the outside,should compress the artery against tlie brim of the pelvis, with a firm, hard compress of linen ; such as is usually used before the tourniquet; he should also be able to do it with his thumb, behind the compress, if it be found in- sufficient. The surgeon standing on the inside, with a strong pointed amputating knife of a middle size, with the back curved, makes his first incision through the skin, cellular membrane, and fascia, so as to mark out the flaps on each side, commencing about four finger's breadth, and in a direct line below the anterior superior spiuous process of tlie ileum in a well-sized man; and continuing it round in a slanting direction at an almost equal distance from the tuberosity of the ischium, nearly opposite to the place where the incision commenced. Bring- ing the knife to tlie outside of the tliigh, he connects the point of the incision where he left off with tlie place of com- mencement, by a gently curved line, by which means the outer incision is not in extent more than one third of the size of the internal one. The integirmients having retracted, the glutaeus maximug , is to be cut from its insertion in the linea aspera, and the tendons of the glu- teus medius and minimus from the top of the trochanter major. The surgeon now placing the flat edge of the knife on the line of the retracted muscles of the first incision, cuts steadily through the whole of the muscles, blood-vessels, &c. on the inside of the thigh. The ar- tery and vein, or two arteries and vein, if the profunda is given off high up, are to be taken between the fingers and thumb of the left hand, until the sur- geon can draw each vessel out with the tenaculum, and place a ligature upon it. Whilst this is doing, the assistants should press with their fingers on any small ves- sels that bleed. The surgeon thfcn cuts through the small muscles running to be inserted between the trochanters, and those on the under part ofthe thigh, not •yet divided; and with a large scalpel opens into the capsular ligament, the bone being strongly moved outwards, by Which its round head puts the liga- ment on the stretch. Having extensively divided it on the fore and inside, the liginientum teres comes into view, and may readily be cut through. The head of the bone is now easily dislocated, and two or three strokes of the knife sepa- rates any attachment the thigh may still have to the pelvis. The vessels are now carefully to be secured. The capsular ligament, and as much ofthe ligamentous I. r-i AMPUTATION. edge of the acetabulum may be removed as can readily be taken away. The nerves, if long, are to be cut short, the wound well sponged with cold water, and tlie integuments brought together in a line from the spinous process of the ilium, to the tuberosity of the ischium. Three sutures will in general be required, in addition to tlie straps of adhesive plas- ter, to keep the parts- together; the liga- tures are to be brought out in a direct line between the sutures, a little lint and compresses are to be placed over the wound, and on the under flap, to keep it in contact with the cotyloid cavity, and assist the union of the parts. A piece of fine linen is to be laid over them, and the whole retained by a calico bandage put round the waist, and brought over the stump. It is recommended to pare the bone, of its cartillage; and if this could be readily done, I would willingly agree to it, but the cartilaginous surface of the acetabu- lum is not to be cut away without much difficulty and some time, which cannot be spared ; for I consider the success of the operation to depend very much upon the quickness with which it is performed,not on account of haemorrhage, but to avoid the shock the constitution receives from J the continued exposure and irritation of so large a surface in the immediate vici- nity of the trunk of tiie body. It is proved by experience to be unnecessary at the shoulder joint; and will, I think, be found equally so at the hip joint. M'hen I wrote these observations, and shewed the method of performing tlie'v operation in the Peninsula, I thought F1 was tlie first to recommend that the artery should not be tied previous to commenc- ing the operation. M. Baffos, however, h.ts the priority in practising it, .which I readily grant to him, and am gratified in having his authority to'adduce in support of the measure. Uni-an by the first intention is to be wished for in a great degree, as lessening the surface of the wound; but as all the parts beneath the skin cannot unite, and especially- about the acetabulum and the inside of the glutxus muscle, it is not advisable to let the skin adhere on the middle and lower part of the stump ; for as the parts deep-seated must suppurate and granulate, a fair opening for the dis- charge should be preserved, and collec- tions of matter in any part should be care- fully guarded against by gentle pressure, compress, and bandage. The after treatment will be the same as in other cases of amputation : the shock, however, ofthe injury and the amputation v ill be so great, that the antiphlogistic regimen to the extent of blood-letting will not be necessary. If the patient be very low, cordials "in small quantities, with opiates, should be given, and a light nourishing diet. If inflammatory symp- toms come on, the appropriate remedies formerly recommended must be employed without delay. If there be heat or un- easiness in the wound, it must be kept wet with cold water. If the surgeon called upon to perform this operation, has not been in the habit of dealing with large arteries, he may feel an unconquerable repugnance to cut- ting through the femoral artery before it has been tied; and although I can most positively assure these gentlemen, there is nothing to fear in doing it, atill they may tie the artery first, if they cannot overcome this feeling ot danjft-r. It is to be done by cutting through the integu- ments in the usual manner, and then dis. secting for the artery and vein, previous to cutting through the muscles. AlUrUTATlOX AT THE SHOULDER JOIST. The first description of this is to be found in Le Dran's Observations. His fa- ther, "it seems, undertook the operation, in a case of caries conjoined with exos- tosis, which affection reached from the middle to the neck of the humerus. He began with rendering himself master of the bleeding, by introducing a straight needle, armed with a strong ligature, doubled several times. This was passed from the front to the back part of the aim, as closely to the axilla and bone as possible. The ligature, including the vessels, the flesh surrounding them, and the skin covering them, was tightened over a compress. Then Le Drun, with a straight narrow knife made a transverse incision through the skin and deltoid muscle down to the joint, and through the ligament surrounding the head of the , humerus. An assistant raised tlie arm, and dislocated the head of the bone from the cavity of the scapula. This allowed the knife to be passed with ease between the bone and the flesh. Le Dran then in- traduced the knife downward,, keeping its edge continually somewhat inclined towards the bone. In this manner, he gradually cut -through all the parts, as far as a little below Ihe ligature. As there *ns a Urge flap, Le Dran made a second , ligature with a curved needle, which li- gature included a great deal of flesh, the redundant portion of which was cut off together with the first ligature, which had become useless. The cure was completed in about ten weeks. Le Dran (the son) does not state, that the operation was a AMPUTATION. fS new one, and it appears, from the Re- divide that muscle and part of the deltoid, cherches Critiques sur Vorigine, &c. de la .all which may be done without danger of Chirurgie en France, and from Lu Faye's wounding the great vessels, wliich will notes on Dion s, that it had been previ- become exposed by these openings. If* ously practised by Morand the fhther. they be not, cut still more of the deltoid Garengeot thought a curved needle, muscle, and carry the arm backward. with sharp edges, would be better for Then with a strong .ligature, having tied making the first* Jigature, and that the the artery and vein, pursue the circular wound need not be so large, if the incision incision through the joint, and carefully were to begin two or three finger-breadths divide the-vessels at a considerable dis- from the acromion, and made so as to tance below the ligature; the other small form two flaps, tlie lower one of which vessels are to be stopped, as in other would correspond to the axilla, and cases. might be brought into contact with the "In doing this operation, regard should other, after the second .ligature was ap- be had to the saving as much skin as plied. possible^ and to tlie situation of the pro- La Faye extended the improvements cessus acmmion, which, projecting con- further. After placing the patient in a siderably beyond the joint, an unwary chair, and bringing»the arm into a hori- operator would be apt to cut upon." zontal position, he made, with a common (Operations of Surgery.) bistoury a transverse incision into the Bromfield's plan consisted in first ex- ♦deltoid muscle-down to the bone, four posing the axillary vessels, by dividing finger-breadths below the acromion. Two the integuments in the axilla. These other incisions, one in front, the other vessels he detached, and tied. Then hav- behind, descended perpendicularly to this ing cut the capsular ligament with scis- first, and made a large flap of the figure sars, he finished the operation on Mr. of a trapezium, which was detached and Sharp's plan. turned up towards the top of the shoulder. At length, P. H Dahl, in 1760, pub- The two heads of the biceps, the tendons lished at Goettingen, a Latin dissertation of the supra-spinatus, infra- spinatus, on amputation at the shoulder, in which teres minor and subscapular'^, and the publication he proposes making one's self capsular ligament, were next divided. The master of the blood, before the operation, head of the humerus could now be easily by a tourniquet, the "pad of which pressed dislocated, when the assistant, who held on the subclavian artery under the clavi- the lower part of the limb, made the bone cle. This enabled the operator to dis- describe the motion of a lever upward, pense with tying the vessels in the first La Faye next carried his incisions down- instance. Gamper had observed, that if ward, along the inner part of the arm, we push the scapula backward, and press until he was able to feel the vessels, which the axillary artery with the finger between he tied as near the axilla as possible., the clavicle, coracoid process, and great Then he completed the separation of the pe\>toral*-muscle, the pulse at the wrbt limb, one finger-breadth lower down. All instantly stops. remaining to be done, was to bring down Dahl's tourniquet was obviously eon- the flap over the glenoid cavity, and dre'ss structed, in conseque/ice of what Camper the wound. (See NouveUe Methode pour had observed, and it consists of a curved, faire I'Operation de I'Amputation dans I'ar- elastic plate of steel, the length of which ticidation du Bras avec I' Omoplate,par M. may be readily imagined. A pad is at- La Faye, in Mem. de PAcad. tie Chirurgie, tached to the shortest end of this plate, Tom. 5, p. 195, Edit, in 12mo. and is made capable of projecting further The advantages of this plan are ob- by means of a screw. The instrument is vious. As only one ligature is applied, applied by making* it embrace the shoulder the patient is saved a great deal of* pain; from behind forward, while the pad presses the flap, which is connected with the on the hollow under the clavicle, between acromion, is more easily applied and kept tlie margins of the deltoid and pectoral on the stump, than the one, which Ga- muscles. The long extremity of tlie steel rengeot recommended to be made, at the plate, wliich descends behind the shoulder, lower part of the axilla. Lastly, any dis- is to be fixed to the body by a sort of charge can readily find vent downward. belt. The pad is then to be depressed, Mr. Samuel Sharp recommended the until the pulsation of the axillary artery following plan. " The patient's arm be- is stopped. ing held horizontally, made an incision Further experiments have proved, how- through the membrana adiposa, from the ever, that this tourniquet may be dis- upper part ofthe shoulder across the pec- pensed with, and the flow of blood in the toral muscle, down to the arm-pit, then axillary artery commanded, by properly turning the knife with its edge upwards, compressing this vessel with a pad, at tlie 76 AMPUTATION. place where it emerges from between the scaleni muscles, above the middle part of the clavicle. Thus> the arteiy becomes pressed between the pad and the first rib, across which it runs. This method, which is as simple as possible, is preferable to that, which requires a tourniquet that is so seldom at hand. Amputation at the shoulder has been in some degree superseded by a preferable operation, even in cases in which it would formerly have been deemed quite indis- pensable, such as considerable gun-shot fractures of the head of the humerus ; a caries of the substance of this part, -Sec. Boucher, in Tom, 2, .Mem. tie I'Acad, de Chir. shews, that considerable wounds, extending into the shoulder joint, were capable of being successfully treated, by extracting the pieces of bone, which had been separated by violence. Instances are also recorded, in which, when the head and neck of the humerus had been totally disunited from the body of that bone, a cure was accomplished by making such incisions as allowed the portions of bone, now become extraneous bodies, to be taken away. Mr. White, of Manchester, proceeded further, and ventured to make a deep incision at the upper part of tlie arm, to dislocate the head ofthe humerus, which he knew was carious, and, pushing it through the wound, took it oft' with a saw. "Edmund Pollit, of Sterling, near Cockey-Moor, in this county, (Lancashire) aged fourteen, of a scrofulous habit' of body, was admitted into tlie Manchester Infirmary, April 6,1768. The account I received with him was, that he had bees suddenly seized, about a fortnight before, with a violent inflammation in his left shoulder, which threatened a mortifica- tion, but at last terminated in a large ab- scess, wliich was opened with a lancet a few days before his admission. The ori- fice was situated near the axilla, upon the lower edge of the pectoralis major, and through it I could distinctly feel the head of the os humeri, totally diverted of its bursal ligament The matter, which was very offensive, and in great quantity, had made its way down to the middle of the humerus, and had likewise burst out at another orifice, just below the processus acromion, through which the head of the os humeri might easily be seen. The whole arm and hand were swelled to twice their natural size, and were intirely useless to him. He suffered much pain, and the absorption of the matter bad brought on hectic symptoms, such as night sweats, diarrhoea, quick pulse, and loss of appetite, which had extremely ema- ciated him. " In these verv dangerous circumstances there seemed to be no resource but from an operation. The common one in these cases, that of taking off the arm at the articulation, with the scapula, appeared dreadful, both in tlie first instance, and m its consequences. I therefore proposed the following operation', from which I expected many advantages, and performed it on the fourteenth of the same month. I began ray incision at that orifice which was situated just below the processus acro- mion, and carried it down to the middle of the humerus, by which all the subja- cent bone was brought into view. I then took hold of the patient's elbow, and easily forced the upper head of the humerus out of its socket, and brought it so entirely out of the wound, that I readily grasped the whole head in my left hand, and held it there till I had sawn it off, with a com- mon amputation saw, having first applied a pasteboard card betwixt the bone and the skin. I had taken the precaution of plac- ing an assistant, on whom I could de- pend, with a compress just above the cla- vicle, to stop the circulation in the artery, if I should have tlie misfortune to cut or lacerate it, but no accident of any kind happened, and the patient did not lose more than two ounces of blood, only a small artery which partly surrounds the joint being wounded, which was easily secured. " He was remarkably easy after the operation, and rested well that night; the discharge diminished every day, the swell- ing gradually abated, his appetite re- turned, and all his hectic symptoms van- ished. h\ about five or six weeks I pav ceived the part from wliich the bone had •. been taken, had acquired a considerable degree of firmness, and he was able to lift a pretty 'arge weight in his hand. At the end of tvo months I found that a large piece of the whole substance of the bor.e that had been denuded by the matter, and afterwards exposed to the air, was now ready to separate from the sound, and with a pair of forceps I easily removed it. After this exfoliation the wound healed very fast, and on August 15, he was dis- charged perfectly cured. On comparing this arm with the other, it is not quite aft inch shorter; he has the perfect use of it, and can not only elevate his arm to any height, but can^,likewise perform the ro- tatory motion as well as ever. The figure of the arm is no ways altered, and from the use he has of it, and its appearance to the eye and to the touch, I think I may safely say the head, neck, and part of the body of the os humeri are actually regenerated. "I did not make use of any splints, machine, or bandage, during the cure, to AMPUTATION. „_ 77 confine the limb strictly in one certain situation, nor was his arm ever dressed in bed, but sitting in a chair, and as soon as he could bear it, standing up with his body leaning forwards, to give room for the application of the bandages, which were no more than what was j ust neces- sary to retain the dressings; and to this method I attribute the preservation of the motion of the joint, which could not have been so well effected any other way, as the joint would in all probability have remained stiff, and formed an anchylosis, if it had not been allowed to play about. " Though from this operation I hoped for many advantages preferable to the am- putation of tUt limb at the scapula, yet my most sanguine expectations fell greatly short of the success attending it. I did not flatter myself with the hopes of a moveable joint, or that the length of the limb would be so nearly preserved, where there was a loss of above four inches of the whole substance of the hone, without any other bone to support-^k as in the leg and forearm, and wher-e^me dreadful condition of the aim, at the time of the operation, prevented me from making use of any machine to keep it extended.* But I suppose the weight of the arm was in this case in some measure sufficient to counterbalance the contractile power of tlie muscles, as his arm was only sus- pended by a common sling, and the pa- tient not at all confined to his bed. I could not help being surprised to find so much strength and firmness, as evidently shewed a regeneration of the. bone, before the lower part had exfoliated, or even be- fore it had begun to loosen. The osseous matter could not proceed from the scapula, the glenoid cavity of that bone not being divested of its cartilage, could it then pos- sibly escape from the end of the sound bone, before the morbid part had begun to separate from it? Or are there any vessels that could convey the bony mat- ter, and deposit it in the place of what had been removed ?f * After the extraction of three inches and ten lines of the os humeri, M. Le Cat made use of a machine to keep the upper and lower pieces of the bone at their pro- per distances. He has given* description of the case, and a figure of the machine in vol. 56 of the Philos. Trans, p. 270. f Mr. Gooch, in his volume of cases and practical remarks, relating the case of a compound fracture of the leg, where a veiy considerable portion of the tibia was sawn off, says, " In about three weeks I was sensible, as were also several sur- geons, whom curiosity led to see so un- " These are points that I will not pretend to decide absolutely, but I am much in- clined to the latter opinion. Is it not pro- bable that there was a regeneration of the cartilage as well as of the bone ? It is well known to every body conversant in ana- tomy, that not only the ends of some bones, wliich are joined to no others, are covered with cartilages, but that they are never wanting on the ends, and in the jointed cavities of such bones as are designed for motion, and I cannot see in this case how the motion could be preserved so complete without a cartilage; and indeed without a bursal ligament, or something analogous to it, to contain the synovia, and keep the bone in its place. " As this is the first operation of the kind-that has been performed, or at least made public, 1 thought the relation of it might possibly conduce to the improve- ment of the art. That ingenious surgeon, Mr. Gooch, has indeed related three in- stances of the heads of bones being sawn off in compound luxations. In one of these cases the lower heads of the tibia and fibula were sawn off!, and in another that of the radius, and in the third that ofthe second bone of the thumb, but these were in many respects different from the present case. I believe it will seldom happen that this operation will not be greatly preferable to the amputation of the arm at the scapula, as this last is ge- nerally performed for a caries of the upper head of the os humeri, and as the preser- vation of a limb is always of the utmost consequence, and what eveiy surgeon of the least humanity would at all times wish for, but particularly where, as in this case, the whole limb, and its actions, are preserved entire, the cure no ways protracted, and the danger of the opera- tion most undoubtedly less. For though amputation is often indispensably neces- common a case, that the substance which grew in the space of five inches entirely void of bone, had acquired in the middle only a greater degree of solidity than flesh, which circumstance not agreeing with the generally received notion of the generation of callus, we proved, beyond dispute, with a sharp pointed instrument; and we ob- served that the ossification was gradually formed from that central point, which was considerably advanced before any exfolia- tion was cast off the ends of the divided bone. In less than four months the whole space was so well supplied with the callus, or rather new bone, that he was able to raise his leg, when the bandage was off', with- out its bending." (Cases and Remarks, new edit. p. 287.) 7B AMPUTATION. sary, and frequently attended with little danger or inconvenience when only part of a limb is removed, yet where the whole is lost, the danger is greatly increased, and the loss irreparable. " I had frequently performed this opera- tion upon dead subjects, and where the parts had not been diseased, and never found any difficulty; and from a dissec- tion of the parts bad no reason to doubt of suceess in a living subject, where the ligaments and muscles are more supple, and the matter, by insinuating itself be- twixt the bone and integuments, has made less dissection necessary. I have likewise, in a dead subject, made an incision on the external side ofthe hip joint, and con- tinued it down below the great trochanter, when, cutting through the bursal liga- ment, and bringing the knee inwards, the upper head of the os femoris hath been forced out of its socket, and easily sawn off; and I have no doubt but this opera- tion might be performed upon a living sub- ject with great prospect of success. " The Royal Academy of Surgery at Paris, proposed for a prize question, whe- ther amputation of the thigh, at its arti- culation with the os innominatum, was ever advisable; but, was I under a necessi- ty of performing this operation, or that which I have been describing, I should not hesitate a moment which to prefer. " I had the honour of shewing to the Royal Society the bones which were taken from the boy's arm, at the time this paper was read, and they are now deposited in their museum." (Cases in Surgery, with Remarks by Charles White, F. R. S. p. 57.) Bent, of Newcastle, has inserted a si- milar case in the 64th Vol. ofthe Philoso- phical Transactions. White made only one incision, from the vicinity of the acro- mion down to the middle of the arm. Bent, not being able to get at the head of the bone, through the wound, which he had made from the clavicle to the attach- ment of the pectoral muscle, detached a portion of the deltoid, where it is connect- ed with the clavicle, and another part, where it is adherent to the humerus. Sa- batier has proposed making two cuts at the upper part of tlie arm, which meet be- low like the letter V, extirpating the flap, dividing the inner head of the biceps, and capsular ligament; dislocating the head of the bone, and sawing it off' (Medecine Operatoire. Tom. 3.) I think the cases, recorded by White and Bent, are truly important, inasmuch as they appear to have been the earliest models of a practice, which promises in a great measure to supersede all occasion for one of the most formidable and muti- lating operations of surgery. To military and naval surgeons, these cases cannot fail to be highly interesting, as they must have frequent opportunities of availing themselves of the instruction, wliich they afford. M. Larrey, who was surgeon go- neral to the French army in Egypt, em- ployed the practice, with the greatest success, in cases of gunshot wounds. He thereby saved limbs, which, according to ordinary precepts and opinions, would have been a just ground for amputating at the shoulder; and, when we consider not only that a most dangerous operation is avoided, but that an upper extremity is saved, for which no substitute can be ap- plied, we must allow, that*he plan, first suggested and practised by Mr. White, cannot be too highly appreciated. When the arm is fractured near its upper ex- tremity by a musket ball, it is considered by most surgeons necessary to amputate the limb, and, in such cases, the opera- tion used .invariably to be performed; but, says ,J^Mtarrey, " I have had the good fortur^7 on ten different occasions, yto supersede the necessity for the opera- tion, by the complete and immediate ex- traction of the head of the humerus, and of the splinters. I perform the operation in the following manner: I make an in- cision in the centre of the deltoid muscle, and parallel to its fibres, carrying the in- cision as low down as possible. I get the edges of the wound drawn asunder, in order to lay bare the articulation, of which the capsule is generally opened by the first incision, and by means of a probe pointed bistoury, I detach with the great- est ease from their insertions the tendons of the^supra and infra spinati, of the teres minor, of the infra scapular, and of the long head of the biceps; then I disengage the head of the humerus, and remove it through the wound in the deltoid by means of my fingers, or of an elevator. I bring the humerus up to the shoulder, and fix it in a proper position by means of a sling and a bandage. Such is the operation which I performed on ten pa- tients, in extirpating the head of the hu- merus ; one of these died of the hospital fever, two of the scurvy, at Alexandria, and the fourth, after he was cured, died of the plague on our return to Syria. The rest returned to France in good health. The arm became anchylosed to the should- er in some, and an artificial joint allowing of motion was formed in others." [On the subject of amputation at the shoulder-joint, Mr. Guthrie has published some valuable remarks:—his diffuse style, however, precludes me from presenting them all to the American reader. The following are selected; AMPUTATION. 79 •"This operation has until lately been con- sidered ofthe utmost danger and import- ance, not only to the life of the person who is unfortunately the sufferer, but to the reputation of the surgeon who has the performance of it: many and various have therefore been the methods recom- mended for conducting it, all impressing on the mind of the operator the great ex- tent of danger, and tending to disturb the steadiness of his judgment. Anato- my, which has thrown so much light on operative surgery in general, has not fail- ed in the last few years to dispel the cloud that obscured this part of military surgery; and experience has proved it to be as simple, easy, and safe an operation, as any other of importance performed on the field of battle. The knowledge ac- quired from this source of its success, has given to military surgeons a confidence in performing it, that-divests it of half its former terrors, and by removing "from the mind of the patient the idea of his having suffered a hopeless operation, diminishes the subsequent danger, and most materi- ally aids his recovery. The dread former- ly entertained of this operation was very great, even by men of the best abilities ; and under certain circumstances in do- mestic surgery, it may still be tedious. It can never however again be considered formidable in military surgery, except un- der bad management, and from extreme ignorance. The distinction between the necessity of the operation, and the possibility of avoiding it, requires in many cases the exercise of the nicest judgment, and a due consideration of attending circum- stances ; for there is no part of military surgery, in which an operation can be per- formed with more advantage at the in- stant ; or, delayed for a few days with a view of gaining information, with more prejudice ; inasmuch as the necessary in- cisions are made in the first instance, in pirts disposed to take on healthy actions, and in the best possible state for undergo- ing sur Jpil operations. The constitution of the pftient being also at that moment generally good, and able to sustain the demands upon it, under untoward circum- stances ; or of supporting, without future injury, tlie restraint and controul requi- site for the successful accomplishment of the cure. The difference- between cutting in sound and diseased parts is justly appreciated by every surgeon, both as to his personal convenience and ease in operating, as well as to the future healing of the wound ; and the advantage here is particularly great, as from thecontiguity of the wound to the chest and the principal organs of life, it is advisable to avoid any excess of actios; and experience has demonstrated that the evil to be apprehended from the equilibrium of the circulation being de- stroyed, is infinitely less than it would be at a subsequent period of three or four weeks, after high suppurative action has been going on. In the latter, the opera- tion is delayed until the parts to be divid- ed have been long carrying on an increas- ed action, and may even be diseased. The health and strength of the patient have been so much reduced, that he may be unable to support the additional pain ahd shock of the operation, which increase with the delay, or of giving that assist- ance requisite for the consolidation ofthe wound. Another and great consideration, is the ease and safety with which a person can be moved after the operation, com- pared with the danger and pain resulting from the disturbance of broken bones, the increase of inflammation, and other atten- dant evils under the same circumstances. It cannot be therefore too strongly im- pressed on the mind, that the necessary examinations should take place; and the operation be performed in those cases de- manding it, as soon after the injury as pos- sible, consistent with the state of the pa- tient ; and the surgeon should not satisfy himself with the idea of being able to accomplish it as safely, or as successfully, when suppuration has been established, and when perhaps he may have better as- sistance at hand ; a kind of self deceit that is occasionally permitted, but which cannot be too much reprobated. The importance of the arm is so great, and even a limited use of it so valuable, that much should be hazarded to save it, when there is a tolerably fair prospect of success: the situation also and structure ofthe upper extremity, together with the command the surgeon lias over it, and the less proportionate inconvenience resulting from a severe wound in that part to any other of equal value, renders its preserva- tion after a serious injury, more practica- ble, and less dangerous than is frequently supposed. The operation should not therefore be performed, unless simple am- putation by the flap operation cannot be successfully accomplished; or, where the limb is evidently destroyed, or, the injury seriously affecting the articulation itself, while the general health ofthe patient, or the unfortunate circumstances of situation, raider the attempt at a farther persever- ance in saving the limb improper. Injuries from musket-balls penetrating the capsular ligament, attended with frac- ture and destruction ofthe head and adja- so AMPUTATION. cent parts of the humerus, and wounding the axillary artery, require immediate operation.* A simple penetrating* or in- cised wound of the joint, of small extent, does not call for any operation, as the pa- tient, with due care, will escape with a certain degree of loss of motion, and of debility in the joint; nor is it proper in a wound from a musket-ball, where there is even some partial injury of the bone, as these cases frequently do well, and the patient preserves the use of the fore-arm. Mr. Guthrie proceeds to state at great length, " accidents in the field," and " subsequent occurrences," which may demand the operation: for these the reader is referred to his work.— It is now time to correct another misap- prehension that the fear of haemorrhage has introduced into this operation; I allude to the idea prevalent amongst many surgeons, that it is to be performed in a different manner from any other of import- ance; that instead of the calm, steady determination that distinguishes a sur- geon of ability, who feels himself master of his subject, he is to forget or lay aside, what on all other occasions is considered most valuable, and endeavour to attain a peculiar precipitation and haste of man- ner, that is excluded from all other parts of surgery. There is still a practical point usually overlooked, that in military surgery there is little or no arm left to use as a lever in facilitating the operation, and that the separation of the head of the bone depends upon the surgeon, and not upon the assistants. The patient should be placed on a seat lower than the surgeon ; (in the field an hospital pannier is the best) and so sup- ported that he may not be able to slide off" during the operation, the assistant in charge of the tourniquet, or instrument described,-j- standing behind, and regulat- ing the support, in such manner that he may always be able to make steady com- pression when required. The shattered arm or stump is then to be raised from the body, sufficiently to enable the hand of the operator to examine the axilla, and as- certain that his assistant can compress the artery when he pleases; for this sim- ple motion of raising the arm to near a right angle with the body, to afford access to the axilla after the pressure is made, will frequently render some alteration of * General Scott of the United States army, happily recovered from such a wound and has a very useful arm. \ The handle of the common tourni- quet covered with a linen bolster, is to be pressed by an assistant on the subclavian artery where it crosses, the first rib. it necessary. The arm should be also raised, so as to point out more clearly the insertion of the pectoralis major, and the posterior fold of the arm-pit; and as being more convenient to tlie operator, who, placing his finger on the lower end of the acromion process in the centre of the shoulder, (the hair in the axilla hav- ing been previously removed) with th% smaller amputating knife commences his incision immediately below it, and with a gentle curve carries it downwards and in- wards throurh the integuments only, » little below the anterior fold of the arm- pit, andwhich the raising of the arm rea- dily points out. The second incision out- wards, is made after the same manner, but something lower down, and is continued underneath, so as to shew the long head of the triceps at the under edge of the deltoid, without dividing any of the mus- cular fibres; by which means the skin has time and freedom to retract, which is a great object, being the part in general most wanted, and when retracted allows of subsequent extension. The third in- cision commencing at the same spot as tlie first, but following the margin of the retracted skin, divides the deltoid on that side to the bone, and exposes the insertion of the pectoralis major, which must be perfectly cut through, to shew the short head of the biceps flexor etibiti, and the coraco brachialis, which are then-readily known by their longitudinal fibres, and the freedom the arm or stump receives from losing its attachment to the fore part of the chest: these two muscles however are not to be touched, although the flap thus formed is to he separated, and raised so as to expose the head of the bone, nearly as far as the coracoid process of the sca- pula. The fourth incision outwards, in the same manner divides the deltoid mus- cle down to the bone, and extending to the long head of the triceps, which it is not necessary to touch, as it would be af- terwards divided : this flap is to be well turned back, so as to shew the insertions of the teres minor and infr*«K>inatus, coming across horizontally fronr the sca- pula, to be inserted into the great tuberos- ity of the humerus; the posterior circum- flex artery will be divided close to the bone, the anterior circumflex, and the continuation of the thoracica humeriana on the integuments of the arm, and some other small vessels may bleed, if the com- pression be not correctly applied; they ought not however to be tied, but merely stopped with the finger, and particularly the posterior circumflex, as this must again be divided, and pressure on the sub- clavian readily commands it; both the outer and inner flap being now raised, the AMPUTATION. 8l head of the bone may be rolled a little outwards, and the teres minor and infra spinatus cut across upon it with a large scalpel, opening at the same time into the cavity of the joint; by which means the error of slitting up the bursa under the acromion, instead of the capsular liga- ment, will be avoided, and continuing the incision upwards, cutting through tlie capsular ligament, the tendon of the supra spinatus, and the long head of the biceps flexor cubiti as close as possible to the edge of the glenoid cavity. The surgeon placing his fingers on the head ofthe bone, cuts through the inner side of the capsu- lar ligament, and wi»h it the subscapulars muscle, going to be inserted into the les- ser tuberosity of the humerus The edge of the knife being constantly towards the bone, he divides the under part ofthe lig- ament, separating the head of the bone from the glenoid cavity: resuming jke small amputating knife, he cuts through the long head of the triceps, to prevent its hanging too much into the wound, and then with one sweep he connects the points of the two first incisions under- neath, separating the arm from the body, dividing again the circumflex arteries above* the first incision, the teres major, latissimus dorsi, coraco brachialis, long head of the triceps, axillary artery, veins, and nerves. This being the only danger- ous step of the operation, the surgeon should inform himself if the artery be sufficiently compressed, which he will know by the posterior circumflex artery not bleeding, and the want of pulsation in the axilla : he should caution the assist- ant to preserve the steady position of the patient, and have another ready to press his closed hand upon the artery, if it should bleed. Laying down the knife, he takes the artery if bleeding between the finger and thumb; or if compressed pulls it out with a tenaculum, and ties it firmly with a small ligature of two good threads. The vessel is found contracted amongst the nerves in the lower third of the wound; all pressure being removed, tlie anterior and posterior circumflex arteries will bleed, and must be secured; or, if the ar- tery subdivides high up, there may be a fourth large branoh. In recent cases of injury I have seldom had occasion to take up more than three arteries, and no cutaneous or other Vessels* besides those divided by the last incision. The nerves, if hinging in the wound must be shortened, which though painful, pre- vents a source of irritation hereafter from their adhering in tiie neighbourhood of the cicatrix. The axillary vein, if it con- tinue to bleed, should be secured with a single thread, as it allows some blood to Vet. I. pass into the wound after it has been brought together, and, what is of more material consequence, permits it to pass into the loose cellular membrane sur- roundingthe vessels down to the clavicfoj which may cause considerable mischief, as the position of the patient is favoura- ble to its gravitation. All compression having been taken off* the artery, the wound should be well cleansed, and here a little delay may be allowed If the tendon of the long head of the biceps flexor cubiti be left long, it ought to be cut off With the scissars, as well as any ragged portions of the capsu- lar ligament. The glenoid cavity need not be deprived of its cartilage. Tfr- pec- toralis major will be observed to have re* traded considerably, and to have doubled or folded in the skin covering it; through this (the p;>rts being brought together,) a suture should be put to the opposite side, and the whole properly supported ^nd compressed by strips of adhesive plasier and bandage, the ligatures being" brought out direct. The incision then forms but one line from the acromion downwards, curving at the bottom to the fore part of the chest, the skin at the axilla being always a little Wrinkled, and much inclined to retract. The flaps of the deltoid meet firmly, sink a little into the hollow under the acromion, lie close upon the glenoid cavity and the cdracoid process; and from the pressure of the adhesive plaster and compress, with the evenness of the wound, the skin of this part nearly unites by the first intention i the hollow round the glenoid cavity is comparatively small to what might be expected, and the Consolidation in healthy subjects, where every thing has done well, goes on steadily, so as not to leave any cause of future inconvenience. The! surgeon, in all his dressings, should take care that no collection forms any where by keeping up a regular and proper com- pression in the course of the artery, the coracotd process, the pectoralis major* and the muscles from the scapula and back. The pain and sensation principally complained of is from the hand and arm j there is seldom any haemorrhage, and the patient does not suffer more than in any other common amputation. I have insisted on the arm being raised from the first, because in all operations) that require the principal artery-to be1 compressed, it should not be done until the limb be placed in the situation in which the operation is intended to be per- formed, as tile mere alteration of postdre removes the pressure from its destined point, as must frequently have been ob- served, when the tourniquet te applied M S2 AMPUTATION. without this caution in the axilla, or thigh. This elevation also allows more freedom to the knife in every direction, and points out more clearly the situation of parts. I beg, however, to be under- stood as rot recommending the arm to be raised in secondary cases, when there is partial anchylosis, or thickening of the ligaments, or other fair obstacles to its being done with ease to the patient. It is not necessaiy to lay bare the acro- mion, on the contrary, the finger should be placed immediately upon it, to insure the first incision, being near half an inch below it, if the eye of the operator be not a sufficient guide; the flaps turn aside sufficiently without it, the head of the humerus is extricated with equal ease, and there is no subsequent danger if the stump should slough, or of the acromion coming through and being a future incon- venience to the patient. In making the last incision of separation, care should be taken to save as much of the integuments as the nature of the ope- ration will permit; and this is done by keeping the head of the bone as far from the glenoid cavity as the att chment of the teres major and latissimus dorsi will allow, and by then cutting ss close to the bone as possible. The long head of the triceps muscle is divided befo e tile last incision, to prevent its hang r.g. too long in the wound, and interfering with the ap- proximation of the integuments. The anterior and posterior circumflex arteries require only a single thread; the latter will be divided about three quarters of an inch from its origin, and the axillary ar- tery in general near an inch, from where it gives off the subscapularis. In giving an account of the success of some of my cotemporaries in the cam- paigns in the Peninsula, I must premise that the operation has become much more common among military surgeons than formerly; whether it be that its own utility has rendered it necessary, or that our surgeons are better operators, or that it has been occasionally performed with- out due discrimination,! cannot determine. Perhaps a combination of the whole of these circumstances may have been the cause of its multiplication; the latter, I I am desirous of believing, to have little increased the number. The following returns of the operation, as*performed in the army under the Duke of Wellington, during a period of six months, from the 21st June to the 24th December 1814, may not perhaps be unins'ructive. It includes the wound- ed at the battle of Vitoria, the destructive siege of St. Sebastian, and the battles of Pampeluna and the Pyrenees, and is ano- ther remarkable dlustration of the neces- sity of operating on the field of battle, in pr-ference to the delay of a secondary operat.on : the operations with the di- visions of" the army having been all p mary, at the general hospitals, se- condary. General Hospitals. Number of operations performed. Died. Cured, or out of danger. Vitoria, Bilboa, Passages, Total 13 5 1 10 5 0 3 0 1 19 15 4 iDivisions ofthe Army. Number of operations performed. Died. Cured. Transferred, but considered out of danger. 1st, 2d, 3d, 5th, 6th, ■Light, Total 3 1 1 12 1 1 0 0 0 0 1 0 2 1 1 12 0 0 1 0 0 0 0 1 19 1 16 2 The 5th division performed the duties of the siege of St. Sebastian, and tlie men were principally wounded in the upper part of the body. The loss with the divisions of the army was as one in nineteen in favour of the primary operation; a success truly asto- nishing. In the General Hospitals, under AMPUTATION. 83 surgeons equally able, the loss was fifteen in nineteen, a want of success as dis- heartening, as in the other encouraging; and arising from all the causes mentioned in the remarks on " Amputation," as con- curring in the ill-success of secondary operations. Bromfield • states, that before his time the operation had been performed in the British armies, but unsuccessfully, which I believe was frequently the case when formerly attempted. It is now, however, the reverse, is in general successful, and performed by military surgeons, without hesitation or fear; and I trust I have proved, that this once formidable opera- tion may now be considered as safe, as sim- ple, and as little hazardous, as any other of importance performed on the human body] AMPUTATION OF T«E HEADS OF BONF.S. In a letter, dated 1782, and addressed to Mr. Pott, Mr. Park, surgeon of the Liverpool Hospital, made the proposal of totally extirpating many diseased joints, by which the limbs might be preserved, with such a share of the motions which nature originally allotted, as to be consi- derably more useful than any invention which art has hitherto been able to sub- stitute. Mr. Park's scheme, in short, was to en- tirely remove the extremities of all the bones, which form the joints, with the whole, or as much as possible, ofthe cap- sular ligament; and to obtain a cure by means of callus, or by uniting the femur and tibia, when the operation was done on the knee; and the humerus, radius, and ulna, when done on the elbow; so as to have no moveable articulation in those situations. To determine whether the popliteal vessels could be avoided without much difficulty in the excision of the knee, Mr. Park made an experiment on the dead subject. An incision was made, begin- ning about two inches above the upper end of the patella, and extending about as far below its lower part. Another one was made across this at right angles, imme- diately above the patella down to the bone, and nearly half round the limb, the leg being in an extended state. The lower angles formed by these incisions were raised, so as to lay bare the capsular lig- ament ; the patella was then taken out; the upper angles were raised, so as fairly to denude the head of the femur, and to * Page 209 of his Chirurgical Observa- tions and Cases. allow a small catling to be passed across the posterior flat part of the bone, imme- diately above the condyles, care being taken to keep one of the' flat sides of the point ofthe instrument quite close to the bone, all the way. The catling being withdrawn, an elastic spatula was intro- duced in its place, to guard the soft parts, while the femur was sawn. The head of the bone thus separated, was carefully dis- sected out; the head of the tibia was then with ease turned out, and sawn off, and as much as possible of the capsular lig:v- ment dissected away, leaving only the posterior part covering the vessel, which on examination had been in very little danger of being wounded. The next attempt was on the elbow, a simple longitudinal incision was made from about two inches above, to the same distance below, the point of the olecra- non. The integuments having been raised, an attempt was made to divide the lateral ligaments, and dislocate the joint; but this being found difficult, the olecranon was sawn off, after wliich the joint could be easily'dislocated, without any trans- verse incision, tlie lower extremity of the os humeri sawn off, and afterwards the heads of the radius and ulna. This ap- peared an easy work; but, Mr. Park con- ceives the case will be difficult in a dis- eased state ofthe parts, and that a crucial incision would be requisite, as well as dividing the humerus, above the condyles, in the way done with respect to the thigh bone. Mr. Park first operated, July 2, 1781, on a strong, robust, sailor, aged 33, who had a diseased knee, of ten years stand- ing. The man's sufferings were daily in- creasing, and his health declining. Mr. I'ark, in the operation, wished to avoid making the transverse incision, thinking that after removing the patella, he could effect his object by the longitudinal one; but, it was found that the difference be- tween a healthy and diseased state of parts, deceived him in this expectation. Hence the idea was relinquished, and the transverse incision made. The operation was finished exactly as the one on the dead subject related above. The quan- tity of bone removed was very little more than two inches of the femur, and rather more than one inch of the tibia. The only artery divided was one on the front of the knee, and it ceased to bleed before the operation was concluded, but the ends of the bones bled very freely. To keep the redundant integuments from falling inwards, and to keep the edges of the wounds in tolerable contact, a few su- tures were used. The dressings were light and superficial, and the limb was 9* AMPUTATION. put in a tin case, sufficiently long to receive the whole of it, from the ankle to the in- sertion of the gluteus muscle. We shall not follow Mr. Park through- out the whole treatment. Suffice it to re- mark, that the case gave him a great deal of trouble, and that it was attended with many embarrassing circumstances, aris- ing chiefly from the difficulty of keeping the limb in a fixed position, the great depth of the wound, and the abscesses and sinuses, which formed in the part. On the other hand, however, the first symptoms were not at all dangerous. But, the patient was obliged to keep his bed nine or ten weeks, and it was many months more before the cure was com- plete. The man afterwards went to sea, and did his duty very well, so useful was his limb to him. Since the publication of the letter ad- dressed to Mr. Pott, another excision of the knee has been done by Mr. Park. This operation was performed on the 22d of June, but the event was unsuccessful, as the patient lingered till the 13th of October, and then died. About the same time that Mr. Park made his proposal, P. F. Moreau, a French surgeon, wrote in favour of a similar me- thod. It only seems necessary to notice here the difference in Moreau's plan of operating from that adopted by our coun- tryman. Moreau, the son, who has pub- lished the account, observes that the mul- tiplicity of flaps is unnecessary, as two an- swer every purpose; and he deems Mr. Park's direction to remove the olecranon, if this be free from caries, at least useless. Moreau, junior, operated on the elbow as follows: he plunged a dissecting scalpel in upon the sharp edge, or spine of the inner condyle of the os humeri, about two inches above its tuberosity; and, directed by the spine, he carried the incision down to the joint. He did the same on the other side, and then laid the two wounds into one, by a transverse incision, which divided the skin and the tendon of the tri- ceps, immediately above the olecranon. The flap was dissected from the bone, and held up out ofthe way, by an assistant. The flesh which adhered to the ti ont of the bone, above the condyles, was now separated, care being taken to guide the point of the instrument with the fore-finger of the left hand, and, when tlie handle of the scalpel could be passed through between the' flesh and the bone, M. Moreau allowed it to remain there, and sawed the bone through upon it. The removal of the piece of bone was next finished, by detaching it from all its adhe- sions. The removal of the heads of the radius and ulna, remaining to "he done, was more difficult, and the first flap beinjjp insufficient, it became necessary to make another. The lateral incision, at the out. er side of the arm, was extended down- wards, along the external border of the upper part ofthe radius. The head of the radius was separated from the surround* ing parts; its connexion with the ulna destroyed, and a strap of linen was intro- duced between the bones, to keep the flesh out of the way of the saw. The ra- dius was sawn through, near the insertion of the biceps, which was fortunately pre. served. Some remaining medullary cells, filled with pus, were removed with a gouge. The ulna was not exposed, by extending the lateral incision on the in. ner side of the arm. Thus another flap was made, and detached from the back part of the fore-arm, and that part ofthe bone which it was wished to remove. The bone, separated from every thing that adhered to it, and a strap of linen being put round it to protect the flesh, about an inch and a half of it was sawn off, measuring from the tip of the "olecra. non, downwards. A few diseased me- dullary cells were taken away with the gouge. Two or three vessels were tied, and the flaps were brought together with sutures. In a fortnight this man became so well, that he was allowed to go wher- ever he pleased, with his arm supported in a case. The arm was at first power. less, but it slowly regained its strength, and the man could ultimately thresh corn and hold the plough with it, &c. Seven months after another operation, performed in the same way as the preced- ing one, by Moreau the father, the patient was completely cured, and two years after this period, the-flexion ofthe fore-arm on the arm, was very distinct. In another case, only one longitudinal incision, and a transverse one, were made, the flap of course was triangular. The patient got well in six weeks, and in three months more joined his regiment. In all Moreau's cases, the flexion and extension of the fore-arm were preserved, which circumstance no doubt depended very much on the insertion of the biceps not being destroyed. After the excision of the knee, however, the bones grew to- gether. Moreau, junior's, method of operating differed from his father's, in having the patient in a recumbent, instead of a sit- ting, posture, and in sawing the os humeri before it was dislocated. In a knee case, Moreau the father ope- rated as follows:—He made a longitudi- nal incision on each side of the thigh be- tween the vasti and the flexors of the' le-ff down to the bone. These incisions began AMPUTATION. §5 about two inches above the condyles of the femur, and were carried down along the sides ofthe joint, till they reached the tibia. They were united by a transverse cut, which passed below the patella, down to the bone. The flap was raised; the patella was attached to it, but being diseased, was dissected out. The limb was then bent to bring the condyles of the femur into view. As it was desired to cut them from the body of tlie bone, before dislocating them, every thing adhering to them be- hind, where they joined the body of the bone, was separated, and, at that place the fore-finger of the left hand was passed through, in order to press back the flesh from the bone, and on that the saw was used. The knee having been bent, Mo- reau drew the cut piece towards him, and easily detached it from the flesh and liga- ments. The head of the tibia was laid bare by an incision, nearly eighteen lines long, made on the spine of that bone. The first lateral incision on the outer side of the knee, was extended nearly as far down on the head of the fibula. Thus were ob- tained one flap, which adhered to the flesh filling up the interosseous space, and an- other triangular flap, formed of the skin, covering the inner surface of the tibia, which bone was of necessity exposed, be- fore the saw could be applied. Upon raising the outer flap, the head of the fibula came into view, and, after being separated from its attachments, was cut off with a small saw. The inner flap was then raised, and the tibia, having been se- parated from the muscles behind, its head was sawn off. It does not appear necessary to insert in this work the account of cutting out the ankle joint; an operation which will never be extensively adopted; nor shall I add any thing more concerning the mode of removing, in a similar way, the shoul- der joint. In treating of amputation in this situation, I have already said enough, and whoever wishes for further informa- tion, respecting this practice, must refer to Dr. Jeffray's Work, entitled " Cases of the Excision of Carious Joints." This pub- lication contains all that is known on the subject. Dr. JefrVay has recommended a particular, and, indeed, a very ingenious, saw, for facilitating the above operation. The saw alluded to is constructed with joints, like the chain of a watch, so as to allow itself to be drawn through behind a bone, by a crooked needle, like a thread, and to cut the bone from behind forward, without inuring the soft parts. An in- strument of this kind was executed in London, by Mr Richards, who was as- sisted in making it by his nephew, the present Mr. Richards, of Brick-lane. In placing the saw under a bone, its cutting edge is to be turned away from the flesh. Handles are afterwards hooked on the in- strument. In my treatise on the diseases of the joints, which was honoured with the pre- mium for 1806, by the College of Surgeons in London, I have made the followintr remarks on the excision of the large joints. " My sentiment has been already stated, with regard to the time, when every hope of curing a diseased joint ought to be abandoned. I have stated, that the approach of dissolution, in other words, the sunk state of the system can be the only solid reason for amputation, and that, as long as the patient's strength is not subdued by the irritation of the lo- cal disease, humanity dictates the propri- ety of persevering in an attempt to save the affected limb, &c. Will a patient, greatly reduced by hectic symptoms, be able to recover from so bold and bloody an operation, as the dissection of the whole of tlie knee-joint out of the limb I If some few should escape, with life and limb preserved, would the bulk of persons, treated in this manner, have the same good fortune ? I cannot admit, that the extirpation of the whole of so large an ar- ticulation as the knee, can be compared with the operation of amputation, in point of simplicity and safety. Hi wever, it is not on the difficulty of practising the former, that I would found my objections; for, I believe, that any man possessing a tolerable knowledge ofthe anatomy ofthe leg, might contrive to achieve the busi- ness." " The grounds on which I shaft at present withhold my approbation from the attempt to cut out large joints, are the following:—1. The great length of time which the healing of the wound requires* Whoever peruses the case of Hector M'Caglian, will find that the operation was performed on the 2d of July, 1781, and that it was February i8th of the fol- lowing year, before all the subsequent abscesses and sores were perfectly healed. This space of time is very neatly eight months ! Mr. Park describes the patient as a strong, robust sailor, and gives no further particulars concerning the state of his constitution, than that his health was declining. I entertain little doubt, that if the excision of the knee had been per- formed in that state of the health, in which amputation becomes truly indis- pensable, this man would not have sur- vived the illness arising from the opera- tion. The only other case, in which Mr. Park extirpated the knee, ended fotally. In the instance related by Moreau, there 86 AMPUTATION. seemed, indeed, to be considerable debi- lity. This patient escaped the first dan- gers consequent to so severe an opera- tion; and, after three months confinement, the patient was in such a state, that Mo- reau expected he would be able to walk upon crutches in another month or six weeks ! The young man in the mean time was attacked by an ep.demic dysentery, and died. 2. Even supposing the excision of the knee to be followed with all possible success, is the advantage of having a mutilated, shortened, stiff limb, in lieu of a wooden leg, sufficiently great to induce any man to submit to an operation, beyond a doubt infinitely more dangerous than amputa- tion ? I think not" (See the author's Treatiseon the Diseasesof the Joints, p. 138 ) AMPUTATION OF THE FINGERS AND TOES, AND PAHT OF THE FOOT. Mr. Samuel Sharp observes, that the amputation of the fingers and toes is bet- tei performed in their articulation, than by any of the other methods. For this purpose a straight knife must be used, anil the incision of the skin be made not exactly upon the joint, but a little to- wards the extremity of the finger, that more of it may be preserved for the easier healing afterwards. It will also facili-, tate the separation in the joint, when you cut the finger from the metacarpal bone, to make two small longitudinal incisions on each side of it first. It may happen that the bones of the toes, and part only of the metatarsal bones, are carious, in wliich case the \eg need not be cut off, but only so much of the f iot as is disordered. A small spring saw is here better than a large one. When this operation is performed, the heel and remainder of the foot, will be of great service, and the wound heal up safely, as Mr. Sharp has once seen. (Operations of Surgery.) In amputating the fingers and toes, the operation is greatly facilitated by cutting into the joint when it is bent. Having made an opening into the back part of the capsule, one ofthe lateral ligaments may easily be cut, after which nothing keeps the head of the bone from being turned out, and the surgeon has only to cut through the rest of tlie exposed ligament- ous and tendinous parts. Some recommend making a small semi- circular flap of skin to cover the bone; but this is quite unnecessary-, if care be taken to draw the skin a li'tie up, and to cut where Mr. Sharp directs. Mr Hey describes a new mode of re- moving the metatarsal hones, which, on repeated trial has fully answered his ex. pectations. Mr. Hey makes a mark across the upper part of the foot, to denote where the metatarsal bones are joined to those of the tarsus. About half an inch from this mark, nearer the toes, he makes a transverse incision, through the intcgu. ments and muscles covering the metatar. sal bones. From each extremity of this cut, he makes an incision along the inner and outer side of the foot to tiie toes • he removes all the toes from the metatar- sal bones, and then separates the integu- ments and muscles, forming the sole of the foot, from the inferior part of the me- tatarsal bones, keeping the edge of the knife as near the bones as possible, in or. der to expedite the operation, and pre- serve as much muscular flesh in the flap as can be saved. He then separates the four smaller metatarsal bones, at their junction with the tarsus, and divides, with a saw, the projecting part ofthe first cuneiform bone, which supports the great toe. The arteries being tied, Mr. Hey ap. plies the flap, which had formed the sole of the foot to the integuments, which re- main at the upper part, and keeps them in contact with sutures. The cicatrix being situated at the top ofthe foot, is in no dan- ger of being hurt, while the place where the toes were situated, is covered with such strong skin, viz. what previously formed the sole of the foot, that it cannot be injured by any moderate violence. (See Practical Observations in Surgery, p. 535, &c) It is certainly veiy often quite unneces. sary to remove the whole foot, when the metatarsal bones are carious, and every other part of the leg is sound. The re- mainder ofthe foot is of immense service in walking, as the use of the ankle is not destroyed. Mr. Hey very judiciously re- commends dissecting out the metatarsal bone ofthe great toe, when diseased, from the cuneiform bone, instead of sawing it The latter plan cannot be easily accom- plished, without removing part of the in- teguments and muscles, and making a transverse, as well as a longitudinal, in- cision. These disagreeable things may be avoided by following Mr. Hev's me- thod. & ' The metatarsal bone of the little toe may be removed in a similar way. It is very awkward to saw the me- tatarsal, and metacarpal bones, and, when the middle ones are to be divided, is indeed hardly practicable, without in- juring the soft parts I am, therefore, of opinion with Mr. C. Bell, that, instead of a iormal amputation, it is better to ex- tract the diseased bones from the foot, er AMPUTATION. 97 hand, as, indeed, Mr. Hey is in the habit of doing. After the perusal of the foregoing ac- count of* the subject of amputation, I tliink a surgeon will derive many useful hints from the valuable observations of M. Louis, although his mode of operat- ing is not now imitated, and several of the things, which he recommends, are not at present attended to, I am of opinion, that the practitioner, who is acquainted with his remarks on this operation, will have a decided superiority over another surgeon that is entirely ignorant of them. Many of the observations are incontro- vertible ; the principles, inculcated, are generally founded on the most correct anatomical considerations; and, in the present indiscriminate fashion of dissect- ing up the skin, often very unnecessarily, and always to the severe suffering of the patient, I am convinced, that M. Louis's sentiments may be studied with advan- tage. It is not to be inferred, however, that I suppose the double incision a bad mode of operating; but, only that I think it the duty of every surgeon to know where the dissection and preservation of skin are necessaiy, and where not. ABSTRACT FROM THE MEMOIRE SUR LA SAILLIE DE l.'0S AFRE8 L*AMFUTATION, &.C. BY M. XOUIS. The contraction of the muscles has hi- therto appeared the most probable reason of the protrusion of the bones, after the amputation of the thigh. There is no complaint of the bones protruding, after the amputation of the arm or fore-arm ; and if we observe things carefully in the amputation of the thigh, we shall con- stantly see muscles protruding from the level of the other flesh, by a real elon- gation, whilst there are some muscles that are drawn back, even on dead bodies, where undoubtedly the contractile power ofthe muscles cannot be supposed to act. The solution of these difficiUties will re- move all the doubts which may arise on the subject here treated of. The protrusion of the bones will never take place, so long as they are immedi- ately encompassed with the fleshy sub- stance of the muscles : this proposition is incontestable. The state ofthe skin, whe- ther longer or shorter, conduces nothing to this protrusion, as we have proved. Thus the precaution of drawing it up- wards, and preserving as much of it as possible, will not prevent this inconve- nience. We do not find this to he the case, either in the leg or fore-arm, because the greater part of the muscles, which are there cut, adhere to the bones, and are contained by aponeuroses, which fix them in their situation. In the amputation of the arm, there is only the biceps-muscle, which can be drawn back towards the upper part. The extremity of the hume- rus always remains encompassed with the brachial and extensor muscles, which are retained and fixed by their adhesions to the bone itself From hence proceeds the facility of curing amputations of the arm, without exfoliation of the bone. But, this is not the case with the th.gh. Only the crural muscle is there fixed to the bone in its whole extent; but this muscle is very slender, its fibres short, and converging to its axis, which is pa- raUel to that of the bone. The vastus in- ternus, the vastus externus, and the tri- ceps muscles, have also adhesions to the femur; but they are not attached to it, except by their interior edge. The plane of these muscular substances is disem- barrassed and pretty large, and conse- quently capable of changing their direc- tion, and folding over each other, after their resection. All the other muscles are separated from each other, as well as the preceding, by the cellular texture, and there is none of them which, in its direc- tion, is parallel to the axis of the femur. Every one of them cut it, by more or less acute angles. From thence it happens, that when these muscles are divided, they change their direction; there is nothing to maintain them, in order to form an equal surface at the extremity of the stump. I have examined minutely into these matters, by the inspection of dead bodies, and recollected, on this occasion, the amputations I myself had made of the thigh, and the much greater number which I had seen performed by others. I do not think there can be any manner of doubt with regard to this fact. I am likewise fully persuaded, that there are no means of preventing this change of situation in the muscles ofthe thigh, after its amputation; but it seems to me, that there is a very simple method of prevent- ing the ill effects of this change, with re- gard to the protrusion ofthe bone. It is laid down as a rule, that, besides the tourniquet, which is fixed to prevent the hemorrhage, during the operation, there should be applied a tight ligature immediately .above the part, where the circular incision is to be made. All au- thors, except Le Dran, recommend the use of this ligature, in order to sustain the flesh in such a manner, that it might be cut with the instrument, smoothly and evenly, and with facility. Guy de Chau- liac would even have the incision made between two ligatures; Verduc and se- veral others have given the same advice. 8*8 AMPUTATION The modern practice is, not to remove the ligature that sustains the flesh, till after the bone is sawn ; and this even our books of surgery prescribe. But in the amputation of the thigh, in case we would prevent the protrusion ofthe bone, (which it has been impossible to avoid, notwith- standing all the precautions hitherto in- dicated) we must take care to remove the ligature that secured tiie flesh, as soon as the section ofthe soft parts shall be made. The muscles, being set at liberty, will be drawn back immediately, and change their situation ; we shall then be able to raise the flesh with tlie retractor, to direct the bistoury on the crural muscle.and to cut the point of adhesion of tlie vasti and tiie triceps at the posterior spine of the femur. By this method the bone may be very easily sawn, three fingers breadth higher, than it could have been, had it been sawn to the level of the flesh sustained by the ligature. This remark will appear very simple to many; but this simplicity does not dimi- nish, either the importance or solidity of it. This consideration induces me to re- fer to another memoir, a series of reflec- tions on the same subject, and to conclude the present with the same words, which Monro, a celebrated professor of Edin- burgh, makes use of, at the beginning of his remarks on amputation of the larger extremities. " There is," says he, "in the operations of surgery, an infinity of mi- nute circumstances, which do not appear, at first sight, very important, and wliich, notwithstanding, the observation or omis- sion of in practice, has considerable con- sequences, by rendering the cure more expeditious or more tedious; by bringing on or preventing dangerous symptoms ; by preserving the patient from violent pains, or increasing them, and putting hi* life in danger; circumstances, the good or ill effects of wliich ought conse- quently to be examined with attention, and concerning which, those who treat of these matters, with a view to the public utility, ought to give the necessary direc- tions." FROM THE SECOND MEMOIRE SUR I,'AMPU- TATION DES GRA3TDES EXTREMITe's, BT M. LOUIS. The frequent opportunities of amputat- ing limbs, and the simplicity of the ob- jects of this operation, one might suppose, ought long ago to have brought it to the highest pitch of perfection ; but, says M. Louis, it frequently happens, that the most familiar things are those, to which we pay the least attention. Modern wri- ters regard amputation, as an operation much more embarrassing, than difficult { and it is, perhaps, on account of its ob- je.ct being simple, and of the proceedings to be followed in its performance, not requiring great dexterity, that surgeon**. adhere to methods, to which they have been accustomed, without examining, whether the practice is as perfect as it is capable of being rendered. The force of custom has not imposed on me; I have made my remarks on this operation; and, I hope, that such readers, as will duly and impartially consider them, will find them not destitute of utility. I do not pretend to insinuate, that most of the rules, which have hitherto served as a guidance, are faulty; but, I am of opinion, that the best are too vague, and ought to be made more determinate. However solid they may appear in general, they will be found respectively erroneous when applied to particular cases, and great blunders may therefore be committed in their applica- tion. The design of amputation i^ to se> parate from the rest of the body, a part, the endeavour to preserve which might cau-e the patient's death. The ancient professors of surgery appear to have al. ways been more occupied about the end, proposed in the practice of this operation, than solicitous to improve the means, by which its pain and inconveniences might be lessened. The nature of the parts, divided in each kind of amputation; their attachments; the change, which naturally or accidentally, takes place in their dis- position after the operation; even tlie uses, which the parts must serve after the cure ; are all considerations, says M. Louis, which appear to me to demand different modes of proceeding, which may be usefully varied according to the diver- sity of circumstances. In this point of view, I imend to examine the received precepts, relative to the surgery of am- putations, and shall offer a series of re- flections, which seem to me to be appli- cable to the operation, in respect to each particular member. SECTION I. REMARKS ON THE AMPUTATION OF THE THIGH, BY M. LOUIS. Of all amputations, that ofthe thigh is the most liable to inconveniences, arising from the method of operating. I have elsewhere explained the reason of this fact (Vid. Mem. de PAcad. de Chir. Tom. 5, p. 273, Edit, in 12mo.) and I have pointed out a very simple mode of avoiding them. So important a subject deserves a more circumstantial detail, which I shall now offer with as much precision as is in my power. AMPUTATION. 85 The patient being put into a suitable situation, and the tourniquet applied,* an assistant is to draw the skin up towards the upper part of the thigh, where it is to be kept by means of a roller, which is to be applied, with sufficient tightness, round the limb, a little above the place, where the incision is to be made. This band makes the skin tense, steadies the flesh, and serves as a guide for the ope- rator, in the direction of his instrument. Guy de Chauliac applied a second liga- ture, below the place, where the ampu- tation was to be done. Experience proves the usefulness of this plan, and several practitioners adopt it,although our modern writers have not thought proper to make any mention of it. The skin and flesh, says M. Louis, cannot be too carefully fixed ; for the incision can then be made more easily, and with greater regularity. There is no occasion to repeat here whjt 1 have observed in my first memoir against what is called the double incision. It is for the thigh, that the preliminary division of the skin and fat is the most strongly recommended. Heister says, that he has often seen the bone project, like a stiok, two, or three finger-breadths, be- yond the flesh, in consequence ofthe dou- ble incision not having been practised. Si muscuH und cum cute und eddemquesec- tione discindantur, musculi hie dissecti for- tissimi tantope sursum retrahuntur, quernad- modum sxpius vidi, ut osfemoris post alteram tertiamve deligatiunem, ad duorum, imd tri- Um, transversorum digitorum longitudinem, super carnem, instar baculi atjusdam emi- nuerit. (Heister, Instit. Chirurg. deAmput. Femoris.) Notwithstanding this authority, con- tinues M. Louis, I am bold enough to assert, that on the thigh, this preli. minary incision of the skin is the least proper. The usefulness of this plan would consist in saving skin enough to cover the muscles; but, their retraction could not be at all lessened by having a greater length of integuments. The pre- caution that is taken to pull the skin up- ward, and keep it so with a band, is the more effectual in amputation of the thigh, inasmuch as the retraction of the musojes is here greater. The inconvenience is, that the end of tlie bone projects beyond the surface of the wound, unsurrounded by the soft parts, which naturally cover it. Besides M. Louis contends, that the preservation of a larger quantity of skin * Among tlie different authors, who may be consulted on the application of the tourniquet, it is essential not to forget Monro, in Edinb. Essays, vol. 4. M Vol. I. will not supply tlie deficiency of muscle, with which it is always desirable to cover the bone. Hence, he maintains, that this first incision, so much extolled, is abso- lutely useless, and that it unnecessarily lengthens ihe operation, and increases the suffering of the patient. He lays it down, as a precept, founded on reason and experience, that i»e should begin the operation by a deep incision, which is to di- vide the muscles and skin at the same stroke. The only thing to be observed, in order to make this first incision as well as possible, is to do ihe whole of the cut with one luru ,of the amputating knife ; an object, which may be accomphshed with ease. The surgeon, placed externally, with one knee on the ground, and his right arm under the thigh, which is about to be amputated, is to take hold of the handle of the knife, which is to be presented to him perpen- dicularly between the patient's thighs. In this position, the point of the instrument is turned towards the operator's chest. Now, if he raises his right hand consi- derably, and turns his wrist very prone, he will be able to commence the incision externally, carrying it from above down- wards. In this first direction of the in- strument, hew dl cut the muscles, covering the outer part of the thigh-bone. Then, carrying the knife in a contrary direction, from below upwards, and round the an- terior part of this bone, he will cut the extensor muscles. The instrument is after- wards to be directed from above down- wards, in order to divide the muscles si- tuated on the inside of the thigh; and the surgeon, now rising1 up, is to complete the circular incision, by cutting the parts on the posterior side of the limb. By fol- lowing this plan, says M. Louis, the flesh will be uniformly cut by one stroke ofthe knife; and the operator, not having oc- casion to reapply the instrument several times, he will run no risk of making an irregular section. As soon as the incision is made,a largish interspace- appears betwixt the divided parts. I have remarked, says M. Louis, that this separation was much more con- siderable in amputations, where only one ligature was applied round the limb. Hence, the gaping of the wound appears to depend principally upon the retraction of the muscles towards their inferior at- tachments. The ligature which fixes the skin, and presses the whole circumference of the member, above the incision, is an obstacle to the shortening of the muscles, and it should therefore be removed, a# soon as the cut has been made. The uti- lity of this method is obvious. The mus- cles, whose action will now be no more re- strained, (especially if M. Petit's tour. N 90 AMPUTATION. niquet be employed,) will contract, and change their situation, according to the difference of their direction. A small scalpel may then be used, for dividing the crurabs muscle, which is intimately at- tached to the femur, and may now be cut even higher than the level ofthe retracted parts. The other portions of muscles attached to the spine of the os femoris, are next to be divided on the same line, and, lastly, the periosteum. The slit bandage, named a retractor, will be an easy means of/enabling the sur- geon to cut such fleshy fibres, as are ad- herent to the bone. There are some wri- ters, who say, that it may be dispensed with; but, it deserves notice, that they have only proscribed its use, when em- ployed with a view of drawing the soft parts upward, in order to protect them from the action of the teeth of the saw; and, it is true, saysM. Louis, that in the received mode of operating, the retractor is not absolutely necessary, because the bone is^ sawn on a level with the flesh, which is steadied and fixed by the ligature. But, as I expressly recommend such ligature to be removed, in order to divide the peri- osteum, and to saw the bone, higher than the level of the soft parts, the retractor becomes extremely useful. We shall mere- ly observe, that the ends of this slit ban- dage ought not to be applied too closely to the bone, since its design is to push upwards the soft parts, which are loose and unfixed, in order to facilitate the di- vision of those fleshy fibres which lie close to the bone, and are firmly attached to it. I shall say nothing about the sawing of the bone, having nothing particular to urge on this point. The operation, says M. Louis, practised "in the way, which 1 have just now been describing, will be attended with all the advantages, which have been constantly- desired, and for the acquisition of which, methods have been practised, which are less simple, and liable to many inconve- niences. I here allude to the amputations with two flaps. It is only' necessary to read the description of such operations (Le Dran, Traitedes Operations,) to be con- vinced, how much this method of ampu- tating increases the patient's suffering; and the idea, thus collected, would not nearly equal that, which would arise from seeing the method tried on the dead sub- ject. We are directed, first tomakeacircu- lar incision, three or four finger breadths, lower down, than the place, where we in- tend to saw the bone. The assistant, who holds the upper part of the limb, is to draw the skin upward, and, on a level with it, the flesh is to be divided down to the bone. Ihe point of the knife is then to be pushed through the thickness of the flesh to the bone, exactly at the place where this is to be sawn; an-d. a longitu. dinal wound is to be made in the integu. ments and muscles, which is to terminate at the'circular incision. The same is to be done on the opposite side. These two incisions must be so managed, that the large vessels will be situated in the middle of one of the flaps. Both these flaps are to be dissected so as to expose the bone; they are then to be drawn up, and kept in this position by a linen re- tractor. The operator now has an opportu- nity of making a circular incision through the fibres attached to the bone, and at the same time through the perios- teum, on a level with the base of the flaps. Lastly, the bone is to be divided with a saw, that has a very narrow blade. This concise account of the manner of executing the flap amputation will enable the reader to judge, how painful such operation must be. Without saying any thing about the first cut through the in- teguments, which is made without any reasonable motive, and may be dispensed with, it is manifest, that the patient has to suffer, in addition to what he suffers in the other operation, two perpendicular wounds, and the dissection of the two flaps thus produced. There can be no doubt, that the swelling and inflammation of the stump, the pain, tever, and all the consequent symptoms, already so formi- dable, independently of any other cause, in the operation done in the most simple manner, must be much more considerable, in proportion to the number of parts di- vided, and the larger surface ofthe wound. And for what is all this train of symptoms and dangers encountered ? The sole ob- ject is to prevent the protrusion of the bone, to make the soft parts extend be- yond its extremity, and to avoid an ex- foliation, the tediousness of wliich some- times seriously protracts the cure. This last consideration, says M. Louis, is fu- tile enough, since the prolongation of the treatment from this cause does not put the patient's life in any danger. How- ever it may be, the operation, which I have described, has all these advantages; the end ofthe bone is covered with flesh, and all the intentions, proposed in the flap amputation, are fulfilled in a manner, that is at once easy, less painful, and as free from inconveniences as possible., The reasons for preferring the method of amputating the thigh, which I have been explaining, admit of intuitive de- monstration. I have performed the ope- ration in the presence of many, who are capable of appreciating its merit. The "^newal of this mode of practising ampu- AMPUTATION. 91 tation will be as advantageous for the af- flicted, as honourable to surgery. I say, the renewal; for the plan is very ancient, and the first description, which we have ofthe manual of amputating limbs, is ,on the principle, which we have been detail- ing more fully, in order that it may be better understood. Upon this subject, Celsus has thus expressed himself: Inter unnam vitiatamque partem incidentla scapello caro usque ad os - - - reducenda ab eo sana caro et circa os subsecanda est, ut ed quoque parte aliquid ossis nutletur ; detn id serrulA prxcidendum est, quam proxime sanx carni etiam tnhxrenti. - - • Cutis sub ejusmodi curatione laxa esse debet, ut quam maxime undique os contegat. (Corn. Celsus, lib. 7. cap. ultimo.) In an historical dissertation on the am- putation of limbs, which is inserted in tlie Memoires de 1'Academie Royal des Sciences, annee 1732, the late M. Petit (the physician) has quoted- this passage in Celsus tn which he finds much-obscurity. Operations, apparently the most easy, are attended with delicacies, of which . only those can be aware, who are in the habit of seeing and reflecting upon them. A surgeon, accustomed to the perform- ance of amputation, and to the consider- ation of tlie inconveniences, to which the operation is liable, must be struck with the flash of light, that issues from the words of Celsus. Mr. S. Sharp, a cele- brated surgeon in London, is in this case; but, prepossessed about the practice of the day, he has only perceived in Celsus a glimmer, that has astonished him; he knew its safety; but, he did not pursue it. A judgment may be formed of what I have been remarking, from the passage, that I am going to cite from Mr. Sharp's work. " The first inconvenience, which I have mentioned, as a consequence ofthe ancient method of amputating, was the protrusion of the bone; for, making the incision di- rectly down to the bone at onCe, the mus- cles and skin afterwards withdrew, leav- ing a large portion of it either naked, or so little covered, that it always perished, and made an exfoliation necessary. This exfoliation was often a tedious and pain- ful work, and frequently, by long pre- venting the cure, reduced the woupd at last to an habitual ulcer. Or, if the wound did heal, the cicatrix proved so large, and the stump so pointed, that it was liable to ulcerate again. " These mischiefs resulte-oVpurely from the want of a lax skin in the neighbour- hood of the wound; for, cicatrization is not effected by the mere generation of a new skin; but, chiefly, by the elongation af the fibre," of the circumjacent skin to- wards the centre; and it is only when tlie skin resists a farther extension, that the cicatrix begins to form; from whence, it must plainly appear, that the more lax the skin is, the more readily will the wound heal, and the smaller will be the cicatrix. " But, though the old surgeons could not apply this maxim to practice, so use- fully as the moderns now do, yet, they made some efforts towards it; 'Jfor, before they amputated, they drew back the skin with all their force, and, after the limb was taken off, they might bring a larger quantity of it over the extremity of the bone, and obviate, in some degree, the inconveniences I have stated. However, this seems to have been all the contrivance they -were provided with to answer so great an end; unless, it may be admitted, that Celsus had a faint idea of the double- incision; and, to speak my own mind, I question, whether it can be doubted. In his chapter on the gangrene, he unluckily happens to be more concise, than usual ;* but, I think, he expressly says, th*t, after we have cut down to the bone, we must draw back the muscles, and cutdeep round the bone, so that a portion of it may be laid bare; after wliich, it is to be sawn off, as close as possible to the flesh. He tells us, that, by this method of treatment, the skin will be so lax as almost to covec the bone. " Perhaps, I may have mistaken Cel- sus's meaning; if I have not, it has been a great misfortune to mankind, that so bene- ficial an instruction should have been either overlooked, or misunderstood. But, it is cer- tain, no writer has copied him, and tlie double incision, as now perfected, is the invent ion of another great man ( Cheseldenf) to whom posterity will be always indebted for the many signal services he has done? to surgery. " It must be confessed, however, that, notwithstanding we derive such benefits * This criticism, passed by Mr. Sharp on Celsus, M. Louis thinks, might be an- swered by citing what a great man in his time has said of the great men of anti- quity ... lis avoient I'esprit eleve, des connoissance varices, approfondies, et des vues generates; et s'il nous paroit au premier coup d'oeil qu'il leur manquat un, peu d'exactitude dans de certains derails, il est aise de reconnoitre en les lisant avec reflexion, qu'ils ne pensoient pas que les petites choses meritassent tine at- tention aussi grande, que celle qu'on leur a donnee dans ces df-rniers terns. (M de Buffon, Histoire Nuturellej Premier Dis- cours, Tov.e 1.) 9J AMPUTATION from the double incision, tlie contractile disposition of the muscles, and, perhaps, of the skin itself, is so great, that, in spite of any bandage, they will retire from the bone, especially in the thigh, and some- times render the cure tedious. ' "To remove this difficulty, I have lately, on some occasions, made use of the cross-stitch, &c. (Sharp's Critical Inquiry into the present state of Surgery, p. 282,284, Edit. 4.) The best way of remedying this inconvenience, says M. Louis, is to follow the method, which Celsus has de- scribed. It seems that Mr. Sharp was the more called upon to adopt it, inas- much as he rightly considered it as a great misfortune to mankind, that so beneficial an instruction should have been either overlooked, or misunderstood. Led away, however, by tlie general prejudice, he commends the pretended advantages of the double inci- sion in saving as much skin as possible; but, he immediately afterwards owns the insufficiency of this method, and con- cludes with proposing, as a very useful assistance, an ancient practice, that is ab- solutely useless and hurtful. This is the opinion, which Vanhorue entertained of it,* and, in my first memoir on amputa- tion, I have adduced facts, which confirm the, sentiment of this writer. Such per- sons, as will take the trouble of reading attentively the reasons, which Mr. Sharp urges in support of this method, will see, that his arguments are by no means strong; and, says M. Louis, there is every reason to hope, that, after he has consulted experience, he will alter his opinion, and be generous enough to condemn it. By such conduct, Mr. Sharp has already gained great honour on points of equal importance. Instances of this kind are never afforded, except by men truly great. General rules, how solid soever they may be, almost always admit of modifica- tions, according to the diversity of the cases, to which they are to be applied. The flap amputation furnishes us with a proof of this observation. I believe, that I have urged strong reasons against this operation: but, it is not to be inferred, that" it should be proscribed in all cases. There are even some instances, in which it appears * Cum Hildano rejicimus Paraci metho- dum descriptam cap. 21, cum qiu.tuor lo- cis cutis fimbriae acu et filo traducto, ad se invicem adducit, et denudatum os ob- tegere satagit, ne ab acre laedatur. Quor- sum euim opus est aegrum non prafuturis carnific'u.is excmciare? (Microtechne, p. 485. See also HUdanus, lib. de Gangrxna et Sphacelo) to me, that it ought to be preferred to tlie other method. In a comminuted fracture, with laceration of the soft parts, where amputation is indispensable, if the cir- cumstances of the accident are such, that there are fewer parts to be divided, and, consequently, the pain will be less, in forming the flaps, than in amputating higher up, according to the other method; in this case, says M. Louis, all other things being equal, I should not hesitate to perform the flap operation. The cases, in which this mode deserves the prefer- ence, cannot be precisely specified. Dis- cernment is necessary to rate the advan- tages and inconveniences of either me- thod, in respect to particular circum- stances, as well as a great deal of saga- city, to be able, with a knowledge of the cause, to select the most proper course in delicate occurrences, where nothing less, than the life of a man, is at stake. SECTION 2. REMARKS ON THE AMPUTATION OF THE ABM, BV M. LOUIS. Authors have made no difference, says M. Louis, between the method of amputating the arm, and that which they have ad- vised for cutting off the thigh. External appearances, indeed, would lead.to a sup- position, that these members are only dissimilar in shape; and that such differ- ence necessarily requires none in the mode of operating. But, when these limbs are viewed less superficially, and the relative disposition, and action.of the component parts of the arm are seriously studied, a source of useful reflections will be discovered, with respect to the oon- duct, which ought to be pursued, in order to perform the amputation of this member with success. The humerus, from its middle to its lower part, is covered by muscles, which are adherent to it, and whose action is direct and parallel to the axis of the bone. This is not the case with the thigh: most of the muscles, which form its bulk, are either not at all adherent to the bone, or are only attached to it by surfaces of small extent. Besides, their direction is not parallel to the axis of the femur. Hence, as soon as they are divided, they draw themselves a great way from it, less on account of their retraction, than their change of situation in regard'to the bone; for, in becoming merely retracted, they retain their parallelism. In the arm, there is only the biceps muscle, along the front of the limb, which retracts itself" under the skin, and how badly soever amputation may be performed, no appre- hensions are ever entertained of the de- AMPUTATION. 98 nudation of the bone.* The stump is only liable to be pointed, which renders the cure more tedious, than it ought to be. I have several times observed the cause of this inconvenience in the amputation ofthe •arm, and I have noticed it even in oper- ations done by men, who had the reputa- tion of operating well; that is to say, of operating quickly, and with all possible dexterity. The soft parts were properly supported ,with two ligatures, between which, an incision was made down to the bone. The periosteum having been cut, and scraped downwards, the humerus was sawn precisely on a level with the muscles, according to the received maxim, that we should endeavour to make the section of the bone, and that of the flesh uniform, so that they may appear like a smooth cut, made at one stroke. What I have always seen happen in such a case, then took place: as soon as the circular liga- ture was taken away, the biceps retracts itself; but, the brachialis internus, the long and short heads of the triceps, and the coracobrachialis, cannot abandon the -hone, because they are adherent to it by one of their surfaces. The rest of the fibres, forming the substance of these muscles, and which are not attached to the bone, however, are retracted, and ren- der the stump conical. The operator, engaged in stopping the hemorrhage, and applying the dressings, does not take no- tice of this retraction; he is entirely taken up with applying the first dressings; and he thinks, that the projection of the bone is caused by the subsequent retrac- tion of the parts, whereas the retraction happens before his face, and is the imme- diate effect of the method of operating. I have not perceived the reason of this effect, in the cases, in which I have oper- ated myself, because 1 carefully followed the precepts given on this subject; and my endeavours to be exact blinded me. I only became conscious of it, as a specta- tor, when 1 was sufficiently well informed to reap instruction from the errors of my masters. The pointed form of the stump, after the amputation of the arm, may easily be prevented. If, after the first incision, made deeply down to the bone, the ligature, wliich supports the soft parts, * The denudation of the bone is uncom- mon even in the thigh, says M. Louis, un- less abscesses have promoted the occur- rence. The change in the situation of tlie muscles causes the femur toform a consi- derable prominence; but, still this bone usually remains covered by the cruralis muscle, and some fibres of other muscles attached to its posterior crista^ is removed, they retract. The muscular fibres, adherent to the bone, and the pe- riosteum, may then be divided, on a level with those fibres, which the retraction has brought nearer to their superior attach- ment. Attention to these circumstances, simple as it may seem, will enable the surgeon to saw the bone an inch higher, than he would be able to do, without such precaution. In this way, says M. Louis, I have accomplished -speedy cures, and never had any exfoliations. The observations, which have just been offered, are only applicable to the ampu- tation of that portion of the arm, where the fibres of tlie muscles are parallel to the axis of the bone. Another mode of pro- ceeding must be followed in operating at the upper part of the member; for, the case is here altogether different. This is an important consideration, which has not hitherto been adverted to. The at- tachments and the direction of the differ- ent muscles, to be cut, and the alteration unavoidably made in their disposition, according to the attitude, in which the limb is placed, merit particular attention. The deltoid muscle, as is well known, covers the Shoulder joint, and reaches ex- ternally nearly as far as the middle of the humerus. Its fibres are convergent to^the axis of this bone, and its action is direct. In order to amputate the arm towards its upper part, the limb should form a right angle with tlie body. In this position, the deltoid is shortened by a strong contrac- tion. This shortening, which precedes the division, incapacitates the fibres of this muscle from becoming any further re- tracted, when they are out. The deltoid, also, not being adherent to the bone,. may be pushed upward with the retract- or, so that thie bone may be sawn above the level of the extremity of the divided fibres. Therefore, inasmuch as this muscle is concerned, no inconvenience will arise. They are to be ascribed to the ill-made section of tlie tendons of the pectoralis major and latissimus dorsi. The action of these is likewise oblique, in regard to the axis of the humerus; their fibres form an angle with this bone; and, it follows from this observation, on the struc- ture and action of the parts, that, after tlie circular incision, tiie fibres of these muscles will retract, and a gaping wound will be produced, because the shortening" of tiie fibres will happen obliquely, on each aide, in a contrary direction. The absorption of the fat, and the shrinking of the soft parts, which, in other amputa- tions, cause the approximation ofthe skin towards the centre of the division, and are the chief means, by wliich nature ac- complishes the re-union of wounds with 9-4 AMPUTATION. loss of substance, cunnot have this salu- tary effect in the wound, that we are con- sidering. It is liable to degenerate into an habitual ulcer. Such instances I have seen, and the reason of them is manifest. The cicatrix never begins to form, till the skin can be extended no further. This is a reflection made by Mr. Sharp. The nearer we approach the upper part of the arm, the more we perceive the cause of this inconvenience, that is to say, of the difficulty, with wliich the skin extends towards the centre of the wound. The long head of the triceps, and the coraco- brachialis, both run obliquely; the last from the coracoid process; the first, from the inferior part of the neck of the sca- pula; to be inserted into the humerus, one anteriorly, the other posteriorly. When they are cut above their attachments to this bone, there is nothing to hinder their retraction, which will take place oblique- ly, in contrary directions. Such disposi- tion must obviously be unfavourable to the approximation of the skin to the mid- dle of the wound. The knowledge of the causes of this inconvenience ought to teach us how to prevent it; and, I believe, the object is not difficult. A preference should here be given to the flap amputation, as would be practised, were' it the intention of the surgeon to perform the operation at the shoulder joint. I reserve, for another memoir, some observations on the manner of executing this amputation. Suffice it to mention the advantage of making a flap, when we have to amputate the arm high up near the shoulder. The least reflection on what has been stated, concerning the direction and action of the muscles, will shew, that they could be retained, so as to facilitate the cure, only by preserving them, with the skin, beyond the level of the bone. The making of a flap will even prevent the symptoms, which are liable to be caused by the imperfect division of the tendons of the latissimus dorsi and pectoralis major. Every thing concurs in favour ofthe adoption of this method. Experience proves the inconveniences of the ordinary operation, as applied to the upper part of the arm. Reason demon- strates the utility ofthe practice proposed, and its success has been proved by seve- ral cases. M. Trecour, surgeon-major of the regiment of Piedmont infantry, and correspondent of the Academy, h .-com- municated to us an interesting fact on this point. During the siege of Maestricht, three days before the suspension of arms, M. de Moyon, a lieutenant in the Piedmont vrginjent. was struck by a cannon ball on the left arm. The humerus was smashed from the elbow to the upper middle por- tion, as high as within a finger breadth of its neck. A piece of the posterior part of- the bone was left, an inch long, and shaped like the mouth of a clarionet. .M. Trecour, on being sent for, went to the hospital ofthe trenches, and begged such of his colleagues, as he found there, to as- sist him with their advice. On viewing the considerable splintering, with wliich the wound was attended, they were of opinion, that the arm should be taken off at the shoulder joint. There were, in- deed, motives in justifica ion of their ad- vice. When we are obliged to amputate a limb, that is broken to pieces by any kind of external violence, it is a rule to perform the operation higher up than the wound. But, if the contusing body has been propelled by the force of gunpow. der, more extent is given to this precept. We are then directed to amputate above the nearest joint. The reasons, assigned for this doctrine, are principally founded on the in .-qualities of the bone, wliich is never smoothly broken, and the splinters of which are apt to extend far above the place, where the violence, has operated. Even, when the bone is neither splin- tered, nor smashed, as far up as the joint above the injury, it is customary to per- form amputation above such articulation, if the wound should be near it, under the apprehension, that the shock, which the member has received, may have injured, contused, or even lacerated the capsular ligament. This would give rise to swell. ing, inflammation, and abscesses of the joint; consequences, of which the patients ordinarily perish. M. Trecour felt all the validity of these reasons : the natural inference was, that the wound, being situated near the supe- rior articulation of the limb, the amputa- tion must be done in that joint. This case, however, gave rise to some doubts. the patient, aged eighteen years, was of the most delicate constitution imaginable; and he seemed little able to bear so tedious an operation, the consequences of which are sometimes grievous. Such are the sinuses, wliich are formed along the ten- dons, and reach even into the substance of the muscles. The advice of M. Tre- cour, was, therefore, followed, which was to make two lateral incisions, to turn up the flap of the deltoid, and, if the head and neck ofthe humerus should be found to be unbroken, not to amputate at the joint. Things proved to be so, and the bone was sawn through at its cervix, just at the base of the fragment shaped like the mouth of a clarionet. The flapsA AMPUTATION. 95 which were saved, extended more than two finger-breadths beyond the end of the bone. Although the operation took up little time, the patient fell into a debilitated state, so that his life appeared to be in danger. It was necessaiy to support him with cordials for two days ; the plan succeeded ; no future bad symptoms oc- curred ; and the patient got perfectly well. M. Trecour assures us, that, the same day, on which this operation was per- formed, his colleagues had occasion to do two amputations in a similar way, for nearly the same sort of injuries, and that the cases did exceedingly well. From these facts, he makes thetollowing infer- ence : *' Among the motives, assigned for the practice of amputating limbs higher than the articulations, above the wound, we should not so generally adopt that, which is deduced from the commotion of the ligaments, holding the heads of the bones in their cavities. It even appears, that the more the bone is broken, the less the shock and concussion must be; as may be observed in injuries of the head, where the commotion is greater, or less, on account of the resistance made by the bones of the cranium." There are few cases, which do not offer some circumstance or another, that has not been the object of particular consider- ation, and that would constantly escape our notice, were we not engaged in eluci- dating some particular doctrine, with which it is connected. M. Trecour men- tions, that he sawed the bone at the base of the end of the fracture. A cursory perusal of this circumstance does not ap- pear to present any prospect of material improvement in practice; yet, says M. Louis, it has been of use, inasmuch as it has led us to investigate the difficulties, which occur in this operation. There is no surgeon, at all versed in practice, that has not experienced the trouble there is in fixing the part during the action of the saw, even in operations, where the limb is entire, and, consequently, where there is the best opportunity of holding it with firmness. The reason of this is self-evi- dent. The assistants only afford move- able points of support ; and whatever pains they may take to fix the extremity operated upon, they cannot prevent the motion, which takes place involuntarily in the articulation of the limb with the trunk. But, wiien we have to saw the end of a bone, which can hardly be laid hold of, the difficulty in fixing it must.be far greater. M. Bertrandi informed me, that he has been a witness of this incon- venience. A Piedmontese officer did not get well after amputation of his thigh, because the bone protruded. It was therefore determined to saw the project- ing part off. Endeavours were made in vain to effect this operation; the limb could not be kept steady enough. M. Bertrandi then proposed a very simple means, which answered the purpose, and wh.ch he has since employed with suc- cess. It is a machine, composed of a per- pendicular piece of wood, firmly fixed on a foot and notched at its upper part, so as to form a kind of fork. This notch affords the end of the bone an invariable fixed point, which renders an assistant unne- cessary for this object, who may now be employed in pressing upon the limb, till the bone is half sawn through. The part must afterwards only be held laterally. With this machine, the bone cannot slip about, and it may be sawn, with as much ease, as a stick on a trestle. Tins means appears to me commendable on account of Us simplicity, and, I believe, there are numerous occasions, on which it may be employed with advantage. In common amputations, a machine, constructed on the principle ofthe Ambi of Hippocrates, in order to support the limb, together with a contrivance, that would answer tlie views of Bertrandi, might be used, in cases, where assistants are not at hand, or instead of careless stupid assistants, by whom the bone is frequently splin- tered. SECTION 3. REMARKS OK THE AMPUTATION OF THE LEG, BT M. LOUIS. Such authors, as have treated the most correctly of the amputation of the leg, have paid some attention to the particular disposition of the parts, which compose the limb. They have recommended the operation to be done below the tuberosity of the tibia, in order to avoid cutting the tendons of the muscles. They have de- termined, that the operator should place himself between the patient's legs, for the sake of sawing the bone with most ease; and they have given directions, how to employ tlie saw most advantageously. Such are nearly tlie particular objects, on which they have dwelt. A considerate reflection on the relative disposition of the. parts, which enter into the formation of the leg, cannot fail to furnish, room for more extensive remarks on this ope- ration. The absorption of tiie fat, the subsi- dence ofthe soft parts, and the diminution of the cellular substance, cause the skin to advance considerably over the stump in amputations of tlie arm and thigh; and 96 AMPUTATION. we have shewn, says M. Louis, that the integuments can never contribute to the inconveniences following those operations. But, thi-. is not the case, with regard to the leg; h-re the skin is the immediate covering of a large surface ofthe principal bo*e. There are no soft parts interposed, the primitive retraction and subsidence of which can occasion the skin to project on the stump. The precept, therefore, to preserve as much of the integuments as possible essentially claims the surgeon's case in the amputation of this part. The precautions directed, on this account, consist in pulling the skin firmly towards the knee, and in adopting the double in- cision. The ancients observed the first of these rules; they were ignorant of the second, but, they obtained all its advan- tages by the position of the patient, and the attitude, in which the limb was put during the operation. We are in the ha- bit of having the thigh and leg held hori- zontally. This posture is attended with obvious objections; for, after the opera- tion, the thigh and stump are placed in a state of flexion, by which means, the skin is drawn up, and tiie end of the tibia is necessarily denuded. Ambroise Pare" wished, that "lajambe fut unpen ploy ee pendant I''operation, et qu'on I'etendit ensuite, afin que les vaisseaux fus- sentplus saillans." This precaution appear- ed to him necessary, because he used to take up the vessels with forceps in order that they might be tied. Guillemeau car- ried his views further; he knew the ad van- tage of bedding the leg, during amputa- tion, in promoting the extension of* the skin over the end ofthe bone after the operation. He directs, .that the surgeon " se mettra entre les jambes du rnalade, et commandera d un serviteur de rehausser gontremont le plus qrlil pourra le cuir et les muscles situes en la partie qu'il eonviendra extirper, ayant auparavantfait plier et Hi- chir letht membre, tant ifin de fau-e prolong- er la pe^u, que les veines et les arteres." The reasons, why this usetul position has been aba idoned, are naturally ob- vious. The limb in amputating must be firmly held, and, when the thigh and leg are bent, it is extremely difficult for the assistants to fix the lower extremity. M. Louis says, it is surprising, that, among the successors of Pare* and Guillemeau, not one should have paid attention to the advantages of the posture, which these celebrated men recommended, with a view of obviating inconveniences, which they had experienced. M. Louis next speaks of an apparatus, by which the leg mi$rht be rendered suffi- ciently steady in the bent position to ad- mit of the saw being used; but, the ob- servations on this subject I have omitted. M Louis, indeed, acknowledges, his con- clusion, that the horizontal position will be always continued by practitioners. In this circumstance, says he, the precau. tion of drawing the skin up towards the knee will not suffice for the preservation of an adequate quantity. Hence, the double incision has been resorted'to; i.e. the skin is first divided by a circular in- cision, an inch below the place, where it is intended to saw the bone, in order to be able to draw the integuments upward, and keep them there with a band, while the muscles are cut on a level with them. I have examined this mode of proceeding attentively, and, I am of opinion, that it admits of being shortened, so as to lessen the pain of the operation. The gastroc- nemius and solxus muscles, which form the major part ofthe bulk ofthe leg, and are the only ones not adherent to the bone, retract as soon as divided. The skin, which is insusceptible of such retraction and is more extensible, will always pro. ject more than those muscles, even were the latter cut on the same line with the wound of the integuments. It follows from this consideration, that the operation by the double mcis.on can only be com- mendable, on the ground of having a suf- ficient quantity of -skin to cover that par. tion of the tibia, vhich is directly under the integuments; and thus, says M. Louis, the benefit, expected from the double in- cision, is limited to a part of the circum- ference of the member. But, this advan- tage may be obtained, by merely making, through the skin of the anterior part of the leg, a semicircular incision, reaching from the internal edge of the tibia to the outside of the fibula. In this method, the patient will be saved from the pain, that would arise from dividing the skin, so as to make the cut completely circu- lar. This first cut may be made more or less advantageously. It has appeared to me, observes M. Louis, that the most proper plan is to draw the skin up, from a point sufficiently low down, and to fix it with a band, in such a way, that the incision, which is to be made above this band, will be an inch lower, than the place where the bone is to be sawn. The band, when applied with due tightness, will keep the skin from descending, and will aid in fixing the soft parts, above the part, where they are to be divided. The semicircular incision of the integuments having been made with a common scalpel, the skin must be drawn-up ward: there.it is to be kept by means of another band; and then the section ofthe soft parts is* to be completed, on a level with tlie skin» "ttttis raised on the front of the limb. AMPUTATION. 97 In performing' this second incision, it will be very useful to incline the edge of the knife obliquely upwards. By this means, the skin will be longer than the muscles, and the cure will be considerably accelerated, &c. After this incision, the flesh, betwixt the two bones, it to be divided, and, then, the periosteum, as usual. It remains to saw the bones. Authors have given different advice on this sub- ject. Some say, we should begin with the fibula, and end with the tibia; be- cause, if we were to saw through the tibia first, the fibula, remaining alone, would hardly be able to bear the action of the saw, without great disturbance ofthe soft parts. Others, whose counsel is most list- ened to, recommend us to apply the saw to both bones, in such a -manner, however, that we are to begin with dividing a part of the tibia, until the instrument has reached the fibula, when the two bones are to be sawn together. Thus, the tibia serves, as a support, while the fibula is divided, and the sawing ends with com- pleting the section of the tibia. This practice seems very rational; but, it does not entirely prevent the moveableness of the fibula, which, unless care be taken, will move about under the saw, and even cause laceration of the muscles. In order to avoid this inconvenience, says M. Louis, I have always taken care to direct the assistants, who hold the limb, to press tlie fibula strongly against the tibia. This precaution, however, cannot be follow- ed, when the bones are much broken, nor in cases of worm-eaten caries, and it is always less safe and commodious, than a plan, which, in these cases, is adopted by Bertrandi. As soon as this surgeon has divided the flesh, which is between the bones, before sawing them, he applies round them a strong narrow ligature. This cotd brings the fibula nearer tlie tibia, and fixes it in a way, that materially facilitates the action ofthe saw. It is on- ly by combining several little practices of decided utility, that we can expect to bring the operative part of surgery to per- fection. On the subject of Verduin's mode of amputating the leg so as to form a flap, M. Louis observes, that the operation is tar more painful, than that which is ordi- narily performed, and Verduin is candid enough to believe this, rather than the modern panegyrists of his method. Ver- duin states positively, that it is cruel and embarrassing; but, carried away, as he was, with the ambition of being praised, as the inventor of a new practice (of which, by the by, not he, but Loudham was,) his seduced imagination made him see unreal Vol. I. advantages in this method, and blinded him, in respect to its defects. In speaking of a young man, on whom this opera- tion was successfully performed, Verduin states, that he walks and bends his knee so freely, that it is hard to say, which leg is of the most use to him. Such an exag- geration, observes M. Louis, is not unusu- al with an author, whose foible is to insist on the merit of his own invention. But, it is very singular, that a modern writer, the only one, who has bestowed, unquali- fied praise on this method, should have alleged, in the most extravagant strain of prejudice, that officers, on whom thi9 operation have been done, have been seen dancing and jumping, just as if they had real legs. Such gratuitous assertions, says M. Louis, are not to be believed; they are the effect of immoderate admiration, and can deceive nobody. I shall pass over what M. Louis urges against Verduin's pretension to effect a cure by apposition ofthe parts, without suppuration. It was alleged, that they, on whom the flap amputation of tlie leg had been performed, suffered no sympathetic pain in the limb. Verduin thought, that this was proved by an example, in which a man had had his leg cut off at sea. He felt severe and grievous pains, seeming as if they were in the amputated foot. As the stump was too long, part was amputated by the new method, and the shootings and pains, formerly experienced, were no longer felt. Celsus, observes M. Louis, would not have approved this second ope. ration; but, would have considered it as superfluous: Stultum est decoris causa rur- sum et dolorem et medicinam sustinere, lib. 5, cap. 26. Had Verduin been offering his opinion on the invention of another, he would have perceived reasons in expla<* nation of the pains being relieved; and, no doubt, he would not, for want of such reasons, have argued, that a solitary fact was sufficient to establish a general con- sequence. Indeed, about five years after Verduin's dissertation was published, the famous Ruysch ^assisted at an operation, performed according to this new method; it succeeded; but, the patient was not exempt from the sympathetic pains. Be- sides, there is no reason authorising the supposition, that such an advantage would result from this manner of operating. Another point, adverted to by M. Louis, is the moveableness of the stump. The panegyrists of this method have regarded the preservation ofthe motion of the knee, as an advantage exclusively belonging to this operation. But, Verduin positively states, that the motion of tlie knee con- tinues free, if care be taken to move it, O 98 AMPUTATION. from time to time, during the treatment. Would not the same thing happen, after the common operation, with the same pre- caution ? Tlie saving of a flap cannot at all promote tlie motion ofthe stump, since the use of the muscles, which compose such flap, is to move the foot. The mo- tion ofthe stump depends upon the action of muscles, wliich are situated in the thigh, and which are inserted into the leg, above the place, where the amputa- tion is performed. The motion of the knee may, therefore, be preserved after the ordinary operation; and it is not an advantage particularly arising from the flap amputation, as has been asserted^ through inattention to the mechanical ar- rangement, and the use of the parts. With regard to the utility, alleged to proceed from the flap serving as a cushion to the bone, so that the patient bear on the end of tiie stump, without any incon- venience, or pain, M. Louis remarks, that he knows not, whether the portion of flesh, that grows in its new situation, is of a nature to sustain, without any ill effects, the weight ofthe body, under narrow sur- faces, and a substance, as hard as the ends of the bones; but, that, to facilitate pro- gression with an artificial leg, which imi- tates the natural one, there is no occasion for the weight of the body to bear on the end ofthe stump. Ttraize of the upper part of the tibia allows a machine to be adapted, that will afford, under the head of this bone, a circular point of sup- port, on which the weight of the body may be sustained. M. Louis argues, that nearly all the partisans of the flap operation, before the time, when he wrote, had only extolled it speculatively. Garengeot was the only one that had practised it. It is a reflec- tion against the real superiority of this method, that it has been relinquished in the very country, where it was first re- ceived as an important discovery, and where it had been originally practised with success, by surgeons of skill and re- putation. Good things, adopted by seve- ral persons at once, in different parts, do not usually fall into disrepute, especially, if pains be taken to cultivate the art, and keep it from declining. Had the flap amputation possessed all the advantages, that were ascribed to it, it would not so soon have been abandoned. Objections to the plan must also have conduced to its declensioM. M. Louis then adverts to the probability, that abscesses frequently formed in the stump, when any part of the flap did not unite; and he concludes with observing, that if the retraction of the muscles, composing the flap, prevented the bone being covered, all the alleged benefit of theplan was lost. This might the more easily happen in the leg, inas- much as the bones were at the circumfer- ence of the wound, and the largest sur- face, which they presented, was exactly at that point of the circumference, which was opposite the base ofthe flap, towards which the retraction must have taken place. In relating the inconveniences and objections, which present themselves to me (says M. Louis,) I do not mean to deny the facts in testimony of the success of the operation; the object of the discus- sion is to ascertain, if this plan is prefer- able to the other. SECTION 4. REMARKS OIT THE AMPUTATION OF THE FOM- ARM, BY M. LOUIS. Of all the amputations which I have seen, that ofthe forearm most frequently proves unsuccessful. From the middle to the lower end of this part ofthe limb, the member is composed of numerous ten- dons ; and amputation, done at any point of this extent, leaves the bone denuded, and the cure is tedious and painfi/i. Towards the upper part ofthe forearm, the radius and ulna are sufficiently co- , vered with muscles, which never leave the bone denuded, because they are adhe- rent to it, and are bound down by strong aponeuroses. These tendinous expan- sions even pass into the interstices ofthe muscles, and furnish these organs with particular sheaths, serving to confine them in their proper direction. The knowledge of this structure of the parts will indicate to us certain rules of conduct, which will contribute to the perfection and success of our operations. The preliminary division of the skin, which we have rejected as useless in some cases of amputation, is essentially proper in that of the forearm. The adhesion of the muscles, and tlie way, in which they are fixed in their direction, make it ne- cessary to save as much skin as possible, in order that this may extend to the edge of the divided muscles. In order to make this first cut advantageously, continues M. Louis, the inferior ligature should first be put round the limb, with the precau- tions, which have been explained in speak- ing of the amputation of the leg. While an assistant draws the skin upward, as much as possible, in embracing the whole circumference of the limb with both his hands, the operator is to apply the liga- ture at least an inch lower than the place, where he designs to saw the bones, He is then to make a circular incision, above this ligature, the assistant observing at AMP ANA 99 the same time to pull the skin towards the elbow joint. The upper ligature is next to be applied with a view of fixing the soft parts, and tlie skin that is drawn up, and the muscles are to be divided on a level with it, in the ordinary way. For making these incisions, says M. Louis, the curved knife does not appear to me so convenient, as a bistouiy with a slightly convex edge; for, the forearm is not round, its figure being that of an oval, flattened on the inside. When the mus- cles and periosteum have been completely divided, the bones are to be sawn. The limb is usually put in a state of pronation, the surgeon standing on the inner side. The saw is to be applied horizontally, in such a manner, that the bones may be cut at once, beginning, however, with the ulna. The radius, every body knows, is exceed- ingly moveable, and is much more diffi- cult to fix, than the fibula. M. Louis, therefore, conceived, that it might be an useful precaution, to tie the two bones of the forearm together with a ligature, as Bertrandi used to do, with respect to those ofthe leg. (See Memoires de I'Acad. de Chirurgie, Tom. 5. Edit, in 12mo.) The following sources of instruction, on the subject of amputation, are parti- cularly entitled to notice : Celsus de Re Medicd. CEuvres tie Pare, livre 12, chap. 30 and 33. Sharp's Operations of Surgery, chap. 37. Sharp's Critical Enquiry into the present State of Surgery, chap. 8. Ravaton's Traite des Plaies d'Armes d Feu. Bertran- dps Traite des Operations de C/ururgie, thap. 23. Le Dran's Traite des Operations de Chirurgie. Heister's Instil. Chirurg. Pars 2. Sect. 1. Young's Currus Trium- phalis e'Terebinthind, Londini 1679. Nou- velle Met/wde pour faire Poperation de PAmputation dans PArticulation du Bras avec I' Omoplatepar M. la Faye. Histoire de PAmputation, suivant la Methode de Verduin et Sabourin, avec la Description d'un nouvel instrument pour cette Operation, par M. la Faye. Moyens de rendre plus simple et plus stire PAmputationd Lambeau,parM. de Ga- rengeot. Observation sur la Resection tie P Os, apres PAmputation de la Cmsse, by M. Vey- ret. Memoire sur la Saillie de P Os apres PAmputation des Membres; ou P on examine les causes de cet inconvenient, les moyens d'y remedier,et ceux tlelaprevenir,parM. Louis. Second Memoire sur PAmputation des Gran- ties Ettre mites, par M. Louis. The forego- ing Essays are in Mem. de PAcad. de Chi- rurgie, 'Tom. 5. Edit. 12mo. Essai sur les Amputations dans les Articles, par M. Bras- dor, in Tom. 15. ofthe same work. Bilguer on the Inutility of Amputation. White's Cases in Surgery. Bromfield's Cldrurgical Obser- vations und Cases, Vol. 1. chap. 2. O'HaHo- run's 'Treatise on Gangrene, &c. with a new method of Amputation. Alanson's Practical Observations on Amputation. Pott's Re- marks on Amputation. Sabatier's Medecine Operatoire, Tom. 3. Hey's Practical Obser- vations in Surgery, Edit. 2. Remarques et Observations sur I'Amputation des Mem- bres, in CEuvres, Chir. de Desault par Bichat, Tom. 2. Encyclopedic Methodique, Partie Chirurgicale, Tom. 1. art. Ampu- tation. Rees' Cyclopxdia, art. Amputa- tion. Vermischte Cliirurgische Schriften, von J. L. Schmucker, Band. 1. John Bell's Principles of Surgery. Cases ofthe Exci- sion of carious Joints, by Park and Moreau, published by Dr. Jeffray. Operative Sur- gery, by C. Bell, Vol. 1. Richter's Anfangs- gr-undeder Wundarzneykunst,Band7 ■ Riche- rand's Nosographie Chirurgicale, Tom. 4, Edit. 2. B. Bell's Surgery, Vol. 5. Me- moire sur PAmputation des Membres, in Pelletan's Clinique Chirurgicale, Tom. 3. Gooch's Chirurgical Works—various parts of the three volumes. Larrey'a Relation Chirurgicale de PArmee iT Orient en Egypte et Sgrie. Petit's Traite des Maladies Chirurgicales, Guthrie on Gunshot wounds, &c. AMYGDALA. The tonsils, so termed from their resemblance to almonds. (See Tonsils.) AMYLUM. Starch. The word is de. rived from «neg. and (t,vX>i, a mill, because starch was formerly made of corn, with- out being ground in a mill. Powdered starch is sometimes used as an external application to erysipelas; but, chiefly, in glysters, when the neck of the bladder is affected with spasm. The following is the formula used at St. Bartholomew's Hospital. $t Mucilaginis Amyli, Aquae distillats, sing. §ij Tinct Opii guttas quadraginta: Misce. ANASARCA, (from xvx, through, and tr»t\, flesh.) A dropsical disease, in which an aqueous fluid is extensively diffused in the general cellular texture of the body. When less extensive, the complaint is termed, xdema, which then becomes a surgical case, unless entirely dependent on constitutional causes. ANASTOMOSIS, (from «y«, through, and oTo/*tt a mouth.) Inoscxuatio. Ana- tomists and surgeons imply, by this term, the communications of the blood vessels with each other, or their running and opening into each other, by which the continuance of a free circulation of the blood is greatly insured. The immense importance of this part of our structure, in all cases in which the main artery, or, vein of a limb, is rendered impervious* is particularly conspicuous in aneurisms. (See Aneurism.) ANATKE3IS,(from«v«, and urftt»,to 100 A N C ANC perforate.) Galen signifies, by this term, the operation of trepanning. ANCHYLOBLE'PHAKON. A concre- tion ofthe eyelids; a closure of them. ANCHYLOGLO'SSUM. . An accretion of the tongue to the adjacent parts 5 also being tongue-tied. (See Frxnum Lingux.) ANOHYLOMtfKl'SMA. A growing together of tlie soft parts. ANCHYLOl'S, (from tvy%i, near, and trjs, the eye.) Same as JEgylops. ANCHYLOSIS, (from ayKvXot, crOok- ed.) This denotes intimate union of two bones, w hich were naturally connected by a moveable kind of joint. All joints ori- ginally designed for motion, may become anchylosed, that is, the heads ofthe bones, forming them, may become so consolidat- ed together, that no degree of motion whatever can take place. Bernard Conner (De stupendo ossium coalitu) describes an instance of a general anchylosis of all the bones of the human body. ' A still more curious fact is mentioned in the Hist, of tlie Acad, of Sciences, 1716, of a child 23. months old, affected with an universal an- chylosis. In the advanced periods of life, anchylosis more readily occurs, than in the earlier parte of it. The author ofthe article anchylosis hi the Encyclopedic Me- thodique, mentions his having preserved a specimen, in which the femur is so anchy- losed with the tibia and patella, that both the compact and spongy substance of these bones appears to be common to them all, without the least perceptible line of separation between them. In old subjects, the same kind of union is com- monly observable between the vertebrs, and between these and the heads of the ribs. The greater, or lesser degree of immo- bility, has caused anchylosis to be distin- guished into the true and false. In the true anchylosis, the bones have grown to- gether so completely, that not the smallest degree of motion can take place, and the case is positively incurable. The position, in which the joint has become thus inalterably anchylosed, makes a material difference in the inconvenience resulting from the occurrence. The false anchy- losis is that, in .iich the bones have not completely growa together, so that their niotiori is only diminished, not destroyed. The true anchylosis is sometimes termed complete; the false, incomplete. Li young subjects in particular, anchy- losis is seldom an original affection, but genially the consequence of some other disease- It very often occurs after frac- tures, 11' the vicinity of joints; after sprlins, and dislocations attended with a great deal of contusion; and after white swell- ing* and abscesses in joints. An?£™™* and swellings and abscesses on the out. tide of a joint, may also induce anchylo- sis. In short, every thing which keepi a joint long motionless, may give rise to the affection, which is generally the more complete the longer such causes have operated. When a bone is fractured near a joint, the limb is kept motionless by the appa- ratus, during the whole time requisite for uniting the bones. The subsequent in- flammation also extends to the articula- tion, and attacks the ligaments and sur. rounding parts. Sometimes, these only become more thickened and rigid; on other occasions the inflammation produces a mutual adhesion of the articular sur- faces. Hence fractures so situated, arc more serious than when they occur at the middle part of a bone. But, it is to be noticed, that all fractures leave, after their cure, a certain degree of stiffness in the adjacent joints; but, this arises from the inactivity, in which the muscles and arti- cular surfaces have been", "and may gene- rally be cured by gradually exercising, and increasing the motion ofthe limb. The position of an anchylosed limb is 1 thing of great importance. When ab- scesses form near the joint of the fingers, and the tendons mortify, the fingers should be bent, that they may anchylose in that position, which renders the hand much more useful, than if the fingers, were per- manently extended. The knee, on the contrary, should always be kept as straight as possible, when there is danger of an- chylosis. The same plan is to be pur- sued, when the head of" tlie thigh bone ii dislocated in consequence of a diseased hip. When the elbow cannot be prevented frambecominganchylosed,thejointshould always be kept bent. No attempt should ever be made to cure, though every pos- sible exertion should often be made to prevent, a true anchylosis. The attempt to prevent, however, is not always propeis for many diseases ofjoints may be said to terminate, when anchylosis occurs. When the false, or incomplete anchylo- sis is apprehended, measures should be taken to avert it. The limb is to be moved as much as the slate of the soft parts will allow. Boyer remarks, that this precaution, is much more neclssary in affections of the ginglhnoid articula- tions, than of the orbicular ones, on ac- count ofthe tendency ofthe former to be- come anchylosed, by' reason of the great extent of their surfaces, the number of their ligaments, and tlie naturally limited degree of then- motion. The exercise of the joint promotes the ANC secretion of the synovia, and the grating first perceived in consequence ofthe defi- ciency of this fluid, soon causes. A cer- tain caution is necessary in moving the limb: too violent motion might create pain, swelling, and inflammation, and even ca- ries of the heads of the bones. It is by proportioning it to the state of the limb, and increasing its extent daily, as the soft parts yield and grow 6upple, that good effects may be derived from it. (See Jioyer Mai. des Os. Tom. 2.) The use of embrocations, and pumping cold water on the joint, every morning, have great power in removing the stiffness of a limb remaining after the cure of fractures, dis- locations, &c. Unreduced dislocations are not always followed by anchylosis. Nature often forms a new joint, especially in persons of the lower order, who are obliged to move their limbr a great deal, in order to obtain a livelihood. The surrounding cellular substance becomes condensed, so as to form, around the head ofthe luxated bone, a membrane serving the purpose of a cap- sular ligament. The muscles, at first im- - peded in their action, become so habitu- ated to their new state, that they resume their functions. This is particularly the case with bones which move in every di- rection, and have round heads; but, in ginglimoid joints, the heads of the bones are only imperfectly dislocated, and the motion is greatly restrained by the ex- tent of surface ; while some of the nu- merous ligaments are only sprained, not ruptured. These causes promote the oc- currence of anchylosis. ' Anchylosis may follow contusions of the joints, and such shocks, as the articular surfaces experience in leaping, or falling * on the feet, from great heights. This is more likely to happen, when the inflam- matory symptoms, resulting from such violence, have not been properly counter- acted by bleeding, and other general re- medies. Sprains, which violently twist the joints, very often, on this account, cause an anchylosis, especially, when the Inflammation has long hindered such joints from being at all moved. When diseases of joints end in a com- plete anchylosis, the occurrence is to- be looked upon, as a very favourable one. In fact, it is as much a means of cure, as the formation of callus is for the union of broken bones. The disease of the verte- brae, described by Pott, is cured, at soon as tlie bones anchylose, nor can the pa- tient be considered well, before this event has taken place. Sec on this subject P Encyclopedic Methodiquc,Partie Chirurgi- cale, Tom. 1. art. Anchylose. Beyer sur les Mai. des Os. Tom. 2. RiokerantPs Noso- graphic C/i-iirgicale, Tom.3,p. 238,edit. 2. A N E 1Q1 ANEURISM, or Aneurism, (from *uv(via, to dilate.) The tumours which are formed by a preternatural dila- tation of a part of an artery, as well as those swellings, which are occasioned by a col- lection of arterial blood, effused in the cellular membrane, in consequence of the rupture, or opening ofthe coats ofthe ar- tery, receive the name of aneurisms. Ac- cording to the common opinion, then, aneurisms are of two kinds; the first be- ing termed true ; the second, spurious, or false. Some writers admit a third species, which is said to happen, when, in conse- quence ofthe external coata ofthe artery having been divided, the internal tunics are protruded, much in the same manner as the peritoneum is by the intestines, or omentum, in cases of hernia. This ima- ginary case has been denominated the mixed aneurism. Aneurisma. herniam arte- rix sistens. It was no less celebrated a man, than Dr. William Hunter, who first supposed, that a disease, like the last, might proceed from the outer coats of an artery being cut, and the inner ones be- coming consequently dilated. But, the experiments of Hunter and Home, as I shall have occasion to mention again, fully prove, that an aneurism will not arise from the kind of weakness, which cutting, or even stripping off, the external coat of an artery must produce; and Scarpa, as I shall presently notice, satisfactorily shews, that, in all common aneurisms, the internal coats of the affected artery are invariably ruptured or wounded. It deserves attention, however, that, by the term mixed aneurism, Dr. Alexander Monro implied the state of a true aneu- rism, when its cyst has burst, and the blood has become diffused in the adjacent cellular substance. This event is cer- tainly a real one ; but, Dr. Hunter's case may be deemed altogether suppositious. Besides these common divisions of aneu- rism, there are two other kinds, one named the aneurismal varix, or venous aneurism ; the other called by Mr. John Bell, the aneurism from anastomosis ; the particulars of both which cases will be offered in due time. Before the time of Galen, the diseases, now known by the name of aneurisms, do not appear to have been noticed. It was the doctrine of this physician, that such swellings were produced either by anas- tomosis, or by rupture, and he has de- scribed their symptoms, without inform- ing us, however, of the characters by which each of these cases was distinguish- able, one from the other. Paulus iEgineta endeavoured to give a more particular ac« count of tlie diagnpsis, and he has de- ' tailed different modes of operating, appli- cable to the various cases of the disc**'' 102 ANEURISM. The sentiments of these writers was adopt- ed by all their successors down to Ferne- lius, who declared, that every aneuris- Hial tumour was occasioned by a dilata- tion of tlie coats of the arteries. This opinion has been almost universally adopt- ed by the moderns, and, until tne late publication of Scarpa, few surgeons en- tertained a suspicion, that a doctrine, so positively taught in the schools, could pos- sibly be erroneous. Even the learned Sabatier say s, there can be no doubt, that many aneurisms depend upon the dilata- tion of the arterial coats; but, continues he, when this happens, the cases present remarkable differences. Sometimes the three arterial tunics are dilated all toge- ther. In other instances, only the two in- ternal coats-are affected with dilatation. While, in more numerous examples, the in- ternal tunics are ruptured, and it is the cel- Udar coat alone, which separates from them, and enlarges, so as to form the aiieurismal sac; de sorte que les arteres, qui sont dans ce cas, sont diloriquees, suivant P expression de Lancisi. Jt is difficult to conceive, observes Sa- batier, how all the coats of an artery can dilate and yield sufficiently to form the investment of such immense tumours as some aneurisms are. Indeed, that very tunic, which composes the greater part of the thickness of the vessel, and wliich is termed the muscular coat, is known to con- sist of fibres, whose texture is firm, and little capable of bearing extension. How- ever, Sabatier states, that there are some observations, which prove, that the mus- cular tunic may become dilated as well as the others. Haller, in describing a very large aneurism, situated in the aorta near the heart, relates, that the innermost coat of this vessel, was ruptured and torn, the loose jagged edges of the laceration being visible in the aiieurismal sac. These were squamous, bony, and of little thick- ness; while the muscular and cellular coats were quite sound. Donald Monro noticed the same tiling in five different aneurisms, which occurred in the course ofthe femoral and popliteal arteries of a man, who had been confined a long while to. his bed, after submitting to the opera- tion for the bubonocele. Monro succeeded in tracing the fibres ofthe muscular coat over these swellings, so that he had no doubt of this tunic being dilated. Saba- tier thinks, that it is not to be inferred, that all such writers, as have related the histories of time aneurisms, proceeding from a dilatation of all the arterial coats, ran have been mistaken, although they have not minutely described .the tex- ture of the sac, in which the blood was contained. Yet, possibly, adds the 5..me judicious writer, most of these aneu- risms may have been of a similar kind to those, which result from the rupture of the internal tunics of the arteries, and the dilatation of the cellular coat; for, in such tumour, the fragments of the lace- rated coats are often blended with osseous, steatornatous, or purulent matter, and confounded with the cellular coat, that forms the exterior investment. (See Me- decine Operatoire, Tom. 3. p. 160—162.) We find then from the foregoing observa- tions, that Sabatier was much disposed to consider the true aneurism, or that sup- posed to be formed by a dilatation of all the arterial tunics, as, by no means a case, that is of usual occurrence, or that has been satisfactorily demonstrated. This eminent surgeon, I think, is the first mo- dern author, who has shewn a propensity to doubt the notion, so generally enter- tained at the present day, concerning the actual dilatation of all the coats of the artery in cases of true aneurism ; and this remark is the more deserving of notice, in consequence ofthe opinions lately pro- fessed by Scarpa, on the point in question. The latter writer, we shall presently see, sides entirely with the ancients on this subject, and, as he is unsurpassed in mi. nute anatomical investigations, and in ac- curacy of observation, his sentiment can- not fail to have great weight in the mat- ter. Previously, however, to offering an account of his opinions, concerning the formation of aneurisms, it seems proper to make the reader acquainted with the various species of the disease, their or- dinary symptoms, and a few other circum- stances, as usually explained by surgical writers. When any part of an artery has the ap- pearance of being dilated, the swelling is commonly named a true, or genuine aneu- rism. In such cases, the artery either seems only enlarged at a small part of its track, and the tumour has a determinate border, or, the vessel seems dilated, for a considerable length, in which circum- stance, the swelling is oblong, and loses itself so gradually in the surrounding parts, that its margin cannot be exactly ascertained. The first case, which is the most common, is termed the circumscribed true aneurism; the last, the diffused true aneurism. When blood escapes from a wound, or rupture, .of an artery, into the adjoining cellular suBstance, the swelling occasioned is denominated the spurious, or false aneurism. In this instance, the blood either collects in one mass, distends the cellular substance, and condenses it into a cyst, so as to form a distinctly cir- cumscribed tumour; or it is injected into all tlie cavities of the surrounding cellu- lar substance, and extends along the ANEURISM. 103 uourse of the great vessels, from one end of the limb to the other, thus producing an irregular, oblong swelling. The first case is named, the circurtucribedfalse an- eurism ; the second, the diffused false an- eurism. (Richter's Atifangsgr. Band. 1.) Mixed aneurism was the name given by Dr. W. Hunter to one which he supposed might proceed from the outer coats of an artery being cut, and the inner ones be- coming consequently dilated. But, the experiments of Hunter and Home, as we shall have occasion to mention again, fully prove, that an aneurism will riot arise from the kind of weakness which cutting, or even stripping off, the exter- nal coat of an artery, must produce ; and Scarpa, as we shall presently notice, sa- tisfactorily shews that the internal coats are always ruptured. By the mixed aneu- rism, Dr. Monro implied, the state of a 'true aneurism, when its cyst has burst, and the blood has become diffused in the adjacent cellular substance. This event is certainly a real one, but, Dr. Hunter's case may be deemed altogether supposi- tious. The symptoms of the circumscribed true aneurism take place as follows : the first thing the patient perceives is an ex- traordinary throbbing in some particular situation, and, on paying a little more at- tention, he discovers there a small pulsat- ing tumour, which entirely disappears, when compressed, but, returns again as soon as the pressure is removed. It is commonly unattended with pain, or change in tlie colour ofthe skin. When once the tumour has originated, it continually grows larger, and, at length, attains a very considerable size. In proportion as it becomes larger, its pulsation becomes weaker, and, indeed, it is almost quite lost, when the disease has acquired much magnitude. The diminution of the pul- sation has been ascribed to the coats of the artery losing their dilatable and elastic quality, in proportion as they are distended and indurated, and, conse- quently, the sneutismal sac being no longer capable of an alternate diastole and systole from the action of the heart. The fact is also imputed to the coagulated blood, deposited on the inner surface of the sac, particularly, in large aneurisms, in which some of the blood is always in- terrupted in its motion. In true aneu- risms, however, the blood does not coa- gulate so soon, nor so often, as in frlse ones. Immediately, such coagulated blood lodges in the sac, pressure can only produce a partial disappearance of the swelling. In proportion as the aneuris- mal sac grows larger, the communication of blood into the artery beyond the tu- mour is lessened. Hence, in this state, the pulse, below the swelling, becomes weak and small, and the limb frequently cold, and ocdomatous. On dissection, the lower continuation of the artery is found preternaturally small and con- tracted. The pressure of the tumour on the adjacent parts also produces a variety of symptoms, ulceration, caries,' ike. Sometimes, an accidental contusion, or concussion, may detach a piece of coagu- lum from the inner surface of the cyst, and the circulation through the sac be obstructed by it. The coagulum may pos- sibly be impelled quite into the artery be- low, so as to induce important changes. The danger of an aneurism arrives when it is on the point.of bursting, by which occurrence the patient usually bleeds to death, and this sometimes in a few se- conds. The fatal event may generally be foreseen, as the part about to give way becomes particularly tense, elevated, thin, soft, and of a dark purple colour. (Rich- ter's Atifangsgr. Bund. 1.) A large axillary aneurism, which burst in St. Bartholomew's Hospital, a few years ago, did not burst by ulceration, but by the detachment of a small slough from a conical, discoloured part of the tumour. Since this case fell under my observation, I have had an opportunity of seeing the process, by which an in- guinal aneurism burst: at a certain point, the tumour became more conical, thin, and inflamed, and here a slough, about an inch in width was formed. On the dead part becoming loose, a profuse bleeding began. We are then to con- chide, that external aneurisms do not burst by ulceration, but, by the forma- tion and detachment of a slough. The false aneurism is alway s owing to an aperture in the artery, from which the blood gushes into the cellular substance. The case may arise from an artery being lacerated in violent exertions ; but, the most common occasional cause is a wound. This is particularly apt to occur at the bend of tiie arm, where the artery is ex- posed to be injured in attempting to bleed. (For this case see Hemorrhage.) In this circumstance, as soon as the punc- ture has been made, the blood gushes out with unusual force, and in a bright scar- let, irregular, interrupted current. It flows out, however, in an even, and less rapid stream, when pressure is applied higher up than the wound. These last are the most decisive marks ofthe artery being opened; for blood often flows from a vein with great rapidity, and in a broken cur- rent, when the vessel is very turgid, and situated immediately over the artery, which imparts its motion to it. Tlie sur- 104 ANEURISM. geon endeavours precipitately to stop the hemorrhage by pressure, and he common- ly occasions a' diffused false aneurism. The external wound in the skin is closed, so that the blood cannot escape from it; but, hence, it insinuates itself into the cellular substance. The swelling, thus produced, is uneven, often knotty, and extends up- ward and downward along the track of the vessel. Tlie skin is also usually of a dark purple colour. Its size increases, as long as the internal hemorrhage con- tinues, and, if this should proceed above a certain pitch, mortification of the limb ensues. The circumscribed false aneurism arises in the following manner. ^ When proper pressure has been made in the first in- -stance, so as to suppress the hemorrhage; but, the bandage has afterwards been re- moved too soon, or before the artery has healed, the blood passes through the tin- cldsed wound, or that which it has burst open again, into the cellular substance. As this has now become agglutinated by the preceding pressure, the blood cannot diffuse itself into its cells, and, conse- quently, a mass of it collects in the vici- nity of tlie aperture of the artery, and distends the cellular substance into a sac. Sometimes, though not often, this cir- cumscribed false aneurism, originates im- mediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceedingly small, and, consequently, the hemorrhage takes place so slowly, that the blood, which is first effused, coagulates, and prevents the entrance of that which fol- lows into the cavities of the cellular sub- stance, and, of course, its diffusion. A membrane, aponeurosis, &c. may also be just over the orifice, so as to prevent the aneurism from being diffused. -The circumscribed false aneurism con- sists of a sac, composed of cellular sub- stance, filled with blood, and situated close to the artery, with which it has a communication. At every pulsation, fresh blood gushes from the opening of the ar- tery into the sac, and distends it; but, its elasticity then makes it contract a little, and urge a portion of the blood back into the vessel. Hence, in false aneurisms, a throbbing is always percep- tible, and is more manifest, the smaller such tumours are. The larger the sac becomes, the less elastic it is, and the greater is the quantity of coagulated blood in it; so that in very large aneu- risms of this kind, the pulsation is some- times wholly lost. The tumour is at first small, and on compression entirely disappears; but, re- turns as soon as this is removed. It also diminishes, when the artery above it is compressed; but^esumes its wonted mag. nitude, immediately such pressure is dis. continued. When there is coagulated blood in the sac, pressure is no longer capable of producing a total disappear- ance of the tumour, which is now hard. The swelling is not painful, and the in- teguments are not changed in colour. It continually increases in size, and, at length, attains a prodigious magnitude. The following are generally enume- rated, as the discriminating differences between circumscribed true and false aneurisms i the true aneurism readily yields to pressure, and as readily recurs on its removal; the false one yields very gradually, and returns in the same way, as the blood in the sac can only pass and repass slowly through the aperture in the artery. Frequently, a hissing sound is very audible, when the blood gushes into the sac. The pulsation of the false aneu. rism is always more feeble, and, as the tumour enlarges, is sooner lost, than that of the true one, which even throbs after it has acquired a very considerable vo- lume. The sac of the true aneurism is the artery itself; that of the false one is cellular substance. (See Richter's An- fangsgr. Band. 1.) Besides these common divisions of aneurism, there are two other kinds, one named the aneurismal vari.r, or venous aneurism, the other called by Mr. J. Bell, the aneurism from anastomosis; the particulars of both of which will be pre- sently explained. If the doctrines, however, of Professor Scarpa, of Pavia, which were published in 1804, are correct, the grand distinc- tion of aneurism into true and false must be rejected, as erroneous: " for," says he, " after a very considerable number of investigations, instituted on the bodies of those, who have died of internal, or ex- ternal aneurisms, I have ascertained, in the most certain and unequivocal man- ner, that there is only one kind, or form of this disease ; viz. that caused by a solu- tion of continuity, or rupture of the pro- per coats of the artery, with effusion of blood into the surrounding cellular sub- stance ; which solution of continuity is occasioned sometimes by a wound, a stea- tomatosis, earthy degeneration, a corrod- ing ulcer, a rupture of the proper coats of the artery, I mean the internal and muscular, without the concurrence of a preternatural dilatation of these coats being essential to the formation of this disease; and, therefore, that every aneu- rism, whether it be internal, or external, circumscribed, or diffused, is always formed by effusion.'' Treatise on Alneu- ritm by A. Scarpa, Trans, by IVisharl ANEURISM. 105 Preface. If this opinion be true, the differ- ence in the symptoms of aneurisms above related, is to be imputed to the difference in the degree of rupture, diffusion, Skc. [In the first volume of the Philadel- phia Medical Museum, a case of vari- cose aneurism is described, different from all those which have been men- tioned. Dr. Physick has illustrated his account of the case, with an engraving from which it appears, that the aneu- rismal sac was formed of cellular mem- brane, ,and situated between the vein and artery, communicating freey with both. A case somewhat similar is described by Mr. Park in the 4th vol. of Medical Facts and Observations, both these cases are also recorded in Wishart's translation of Scarpa on aneurism.] Scarpa observes, that it is an error to suppose, that the aneurism at the curva- ture, or in the trunk,'of the aorta, pro- duced by a violent and sudden exertion of the whole body, or of the heart in par- ticular, and preceded by a congenital re- laxation of a certain portion of this artery, or a morbid weakness of its coats, ought always to be considered, as a tumour formed by the distention, or dilatation of the proper coats of the artery itself, that is, of its internal and fibrous coats. Scarpa considers it quite demonstrable, that such aneurisms are produced by a corrosion and rupture of these tunics, and, conse- quently, by the effusion of arterial blood under the cellular sheath, or other mem- brane, covering the vessel. If ever there be a certain degree of preceding dilata- tion, it is not essential to constitute the disease; for it is not a constant occur- rence, most aneurisms are unpreceded by it, and, in those rare cases, in which the aneurism is preceded and accompanied by a certain degree of dilatation of the whole diameter of the curvature of the aorta, there is an evident difference be- tween an artery simply enlarged in diame- ter, and the capsule, which forms tiie aneurismal Sac. Dissections, carefully conducted, will shew, that the aorta contributes nothing to the formation of the aneurismal sac, anil that this is merely the cellular mem- brane, which, in the sound state, covered the artery, or that soft cellular sheath, which the artery received in common with the neighbouring parts. This is raised by the blood into the form of a tumour, and is covered, in common with the artery, by a smooth membrane. The Italian professor does not deny, that, from congenital relaxation, tiie pro- per coats or the aorta may not occasion- ally yield and become disposed to rup- Voi. I. turo; but he will not admit, that dilata- tion of this artery precedes and -accompa- nies all its aneurisms, or that its proper coats ever yield so much to distention, as to form the aneurismal sac. The root of an aneurism of the aorta never includes the whole circumference of the artery ; but, the aneurismal sac arises from one side in the form of an appendix, or tube- rosity. On the contrary, the dilatation of the artery always occurs «in its whole circumference, and, therefore, differs es- sentially from aneurism. Thus, there is really a remarkable difference between a dilated and an aneurismatic artery, al- though these two affections are some- times found combined together, especial- ly, at the origin of the aorta. If we also consider, that the dilatation of an artery may exist, without any organic affection, the blood being always in the cavity of the vessel; that in an artery so affected, there is never collected any grutnous blood, or polypous layers ; that the dila- tation never" forms a tumour of consider- able bulk, and, that, while the continu- ity of the proper coats remain uninter- rupted, the circulation ofthe blood is not at all, or not so sensibly changed, we "shall be obliged to allow that aneurism differs essentially from the dilatation of an artery. Galen, CEtius, Paulus, Actuarius, Ha- ly, Albucasis, Oribasius, and Avicenna, who only treat of external aneurisms, speak of no other cases, than those by ef- fusion ; and, although some of these writ- ers introduce the distinction, that external aneurisms are produced in three ways, viz. by anastomosis, by diapxdesis, and by dix- resis, they all affirm, that external aneu- risms are invariably formed by the extra- vasation of blood under the skin. By dilatation, the Greek and Arabian physi- cians did not mean the expansion of the proper coats of the diseased artery ; but, that tumour which the effused and coagu- lated arterial blood forms ,in the cellular membrane under the skin. Thus QStius : oritur dilatatio, aut dum sanguis, et sfiiritus ex arteriis firosultarit; aut dum oscula ifi&orum afidriuntur, aut dum rumfiuntur. Sanguis autem et sfiiritus fiaullatim excreti sub cute colliguntur. See also additional quotations in Scarpa from Actuarius, Silvaticus, &c. Fernelius first published the theory of the dilatation of the coats ofthe arteries, as the proximate cause of aneurisms, par- ticularly, internal ones, arising from no evident causes. The theory of Fernelius, however, instead of being c'ed iced from observations on the dead iunject, was only tlie result of his own imagination, and false conjectures, that effused arterial P 106 ANEURISM. blood would immediately putrify, and could never form, out of tlie vessels, a pulsating tumour, sennertus, Hildanus, Barbette, and several others, rejected this theory, and were all convinced, that both internal and external aneurisms were form- ed by the rupture, and not by the dilata- tion ofthe internal coats ofthe artery. Scarpa endeavours to demonstrate, by accurate dissections of arteries both in the sound amd morbid state, what share tlie proper and constituent coats of the artery have in the formation of the aneu- rismal sac, and what belongs to the cellu- lar covering, and other adventitious mem- branes surrounding the artery. The covering of an artery is merely an adventitious sheath, which the vessel re- ceives in common with the parts in the vicinity of which it runs. On cutting an artery across in its natural situation, the segment of the cut vessel retires and con- ceals itself in this sheath. This cellular covering is most evident round the cui-\ature and trunk of the aorta, the carotid, mesenteric, and renal arteries ; it is less dense round the trunk of the brachial, femoral, and popliteal arteries. The pleura lies over the cellular sheath of the arch of the aorta, and over that of the thoracic aorta; and that ofthe abdominal aorta is covered by the perito- neum. Both these smooth membranes adhere to, and surround, two-thirds of the circumference of the vessel. The great arteries of the extremities are not covered, in addition to the cellular substance, by any s.n >oth membrane of this sort, but by a cellular sheath, which is demonstrably distinct from the adipose membrane, and serves to inclose the vessels, and connect them with the contiguous parts. Wli n air, or any other fluid, is injected by a small hole made artificially, between the cellular covering, and the subjacent muscular coat of the artery, the injected matter elevates into a tumour the cellular membrane, which closely embraces the artery, without properly destroying its cells, which it distends in a remarkable manner. When melted wax is injected, and pu-hed with much force, the cellular sheath of the artery is not only raised over the vessel, like a tumour, but, the internal cells of that covering; are also lacerated, and, on examining afterwards the capsule of the artificial tumour, it appears as if it were formed of several layers, rough and i.regular internally, smooth and polished externally. The same tiling happens, when any injection is push- ed with such force into an artery, as to rupture the internal and muscular coats at some point of their circumference. N-cholls performed this experiment seve- ral times before the Royal Society. (Phuot. Trans, an. 1728.) As soon as the internal coat is ruptured, the muscular one also gives way; but, the external cellular sheath, being of an interlaced texture, and tlie thin lamina:, of which it is com- posed, being not simply applied to one another, bui, reciprocaliy intermixed, is capable of supporting great distention, by yielding gradually to the impulse of the blood, without bemg torn, or ruptured This celebrated professor is of opinion, that the same phenomena may be observ- ed, when the internal coat of the aorta becomes so diseased, as' to be ruptured by the repeated jets of blood from the heart. In this circumstance, the blood, impelled by the heart, begins immediate- ly to ooze through the connexions of the fibres, of the muscular coat, and gradu- ally to be effused into the interstices of the cellular covering, forming, for a cer- tain extent, a kind of ecchymosis, or ex- travasation of blood, slightly elevated upon the artery. Afterwards, the points of contact, between the edges of the fibres of the muscular coat being .insensibly separated, the arterial blood, penetrating between them, fills and elevates, in a re- markable manner, the cellular covering of the artery, and raises it after the man- ner of" an incipient tumour. Thus**the fibres and layers of the muscular cW, being wasted, or lacerated, or simply separated from each other, the arterial blood is carried with great force, and in greater quantity, than before, into the cel- lular sheath of* the arluri^ which it forces more outwards ; and, finally, the divisions, between the interstices of the cellular coat being ruptured, converts it into a sac, which is filled with poly potts concre- tions, and fluid blood, and at last forms, strictly speaking, the aneurismal sac. The internal texture, although apparently com- posed of membranes placed one over the other, is, in fact, very different from that of the proper coats of the artery, not- withstanding the injured vessel and aneu- rismal sac are both covered externally, in tne thorax and abdomen, with a smooth membrane. Scarpa has examined a considerable number of aneurisms, of the arch, and of the thoracic, and abdominal trunk, of the aorta, without finding a single one, in which tlie rupture of the proper coats of the artery was not evident, and in which, consequently, the sac was produced by a substance completely different from the internal and muscular coats. The aneurismal sac never comprehends the whole circumference of the ve.-seL At the place where the tumour joins the side of the tube, the aneurismal sac pre- ANEURISM. 107 scnts a kind of constriction, beyond which it becomes more or less expanded. This would never happen, or rather the con- trary circumstance would occur, if the sac were formed by an equable distention ofthe tube and proper coats ofthe affect- ed artery. In incipient aneurisms, at least, the greatest size of the tumour would then be in the artery itself, or root of the swelling, while its fundus would be the least But, whether aneurisms be recent and small, or of long standing and large, the passage from the artery is al- ways nareow, and the fundus ofthe swell- ing greater in proportion to its distance from tlie vessel. The sac is always co- vered by the same soft dilatable cellular substance, w-hich united the artery in a ' sound state to the circumjacent parts. Such cellular substance, in aneurisms of the thoracic aorta, is covered by the pleu- ra, and, in those of the abdominal aorta, by the peritoneum, which membranes in- clude the sac and ruptured artery, pre- sent ing outwardly a continued smooth surface, just as if the artery itself were dilated. But, if the aorta be opened lengthwise on the side opposite the con- striction, or neck ofthe tumour, the place of the ulceration, or rupture, of the pro- per coats of the artery, immediately ap- pears within the vessel, on the side oppo- site to that of the incision. The edge of the fissure, which has taken place, is sometimes fringed, often callous*, and hard, and through it it was, that thfe blood formed itself a passage into the cellular sheath, wliich is converted into the aneu- rismal sac. if, as sometimes happens, in the arch of the aorta near the heart, the artery, before being ruptured, has been somewhat dilated, it seems, at first, as if there were two aneurisms; but, the con- striction, which the sac next to the ar- tery, presents externally, points out ex- actly the limits, beyond which the inter- nal and muscular coats of the aorta had not been able to resist tlie distention, and where of course they have been ruptured. The partition, which n.ay always be seen dividing the tube of the artery from the aneurismal sac, and which is lacerated in its middle, consists of nothing else than the remains of the internal and muscular coats ofthe ruptured artery. By carefully dissecting the proper coats of the ruptured aorta in its situation, and comparing them with the cellular sub- stance forming the sac, the truth ofthe pre- ceding statement may be indisputably de- monstrated. When an incision is made lengthwise in*he side of the'vessel opposite the rup- ture, its proper coats are found either per- fectly sound, or a little weakened and studded with earthy points, but, still ca- pable of being separated into distinct layers. On the contrary, in tlie opposite side of the aorta, where the rupture is, the proper coats are unusually thin, and are •-only separable from each other with dif- ficulty, or even not at all; they are fre- quently brittle, like an egg-shell, and are disorganised and torn at the place where they form the partition between the rup- tured artery and the mouth of the aneu- rismal sac. Continuing to separate these coats, from within outwards, we arrive at the cellular sheath surrounding the aorta.. This sheath being much thickened in large aneurisms, and very adherent to the subjacent muscular coat of the artery at the place of the constriction ofthe sac, is very apt to be mistaken for a dilated por- tion of-the vessel itself. But, even in such cases, we may at last separate it, without laceration, from the tube of the artery, above and below the injury, and, successively, from the muscular coat, as far as the neck of the aneurism. Then it is clear, the muscular coat docs not pass beyond the partition, separating the ca- vity of the artery from that of the aneu- ' rismal sac, over which it is not prolonged, but terminates at the edge of the rupture like a fringe, or in obtuse points. Errors are rendered more apt to occur, in con- sequence of the aorta and sac being both covered by the pleura, or peritoneum. The portion ofthe aorta, within the pe- ricardium, being only covered by a thin reflected layer of this membrane, such layer may also be lacerated, when the proper coats give way, and blood be effused into the cavity of the pericardium. Examples of this kind are related by Walter, Morgagni, &c. and Scarpa him- self. In the latter instance, on making an incision into the concave part of the aorta, opposite the tumour which had formed under the layer of the pericar- dium, which had also burst by a small ' aperture, its internal coat, corresponding to the base of the swelling, was quite rough, interspersed with, yellow hard spots, andactually ulcerated for the space of an inch in circumference. The pre- paration is preserved in the museum at Pavia. But all other parts of the aorta having, between them and the pleura and perito- neum, a cellular sheath of a stronger and more yielding nature, which allows itself to be distended into a sac, and being strengthened internally, by polypous lay- ers, and, externally, by the "pleura or peritoneum, oppose for a long while the fatal effusion of blood. Scarpa believes, that what he calls the slow, morbid, steatomatous-, fungous, 103 ANEURISM. squamous, degeneration of the internal coat of the artery is more frequently the cause of its bursting, than violent exer- tions ofthe whole body, blows, or an in- creased impulse of the heart. This kind of diseased change is very common in the curvature, and thoracic and abdominal trunks, of the aorta. In the incipient state of such disease, the internal coat of the artery loses, for a certain space, its beautiful smoothness, and becomes irre- gular and wrinkl*d. It afterwards ap- pears interspersed with yellow spots, which are converted into grains, or earthy scales, or into steatomatous, and cheese- like concretions, which render the inter- nal coat of the artery brittle and so slight- ly united to ti>e adjoining muscular coat, that, upon being merely scratched with the knife, or point of the nail, pieces are readily detached from it, and, on being cut, it gives a crackling sound, similar to tlie breaking of an egg-shell. This ossi- fication cannot be said to be propftr to old age, since it is sometimes met with in subjects not much advanced in life. The whole of the side of the artery, in that part which is occupied by the morbid af- fection, is, for the most part hard and rigid, sometimes soft and fungous, and, in most cases, the canal of the artery is preternaturally constricted. In the high- est degree of this morbid disorganization, true ulcerations are found on the inside of the artery, with hard and fringed edges, fissures, and lacerations of the in- ternal and fibrous coats of the artery. Whenever an aneurismal sac of an im- moderate size beats violently, and, for a long while against a bone, as the sternum, ribs, clavicle, and vertebrae, the bones are in the end invaris-bly corroded, so that the aneurismal sac elevates the integu- ments of the thorax, or back, and pul- sates immediately under the skin. Scar- pa, with the best modern writers, attri- butes the effect to absorption, in conse- quence of the pressure. Having presented the reader with an abridged account of the most important remarks, made by Scarpa, in support of the doctrine he defends, we now annex his conclusions. 1. That this disease is invariably formed by the rupture of the proper coats of the artery. 2. That the aneurismal sac, is never formed by a dila- tation of the proper coats of the artery, but, undoubtedly, by the cellular sheath, which the artery receives in common with the parts contiguous to it; over which cellular sheath the pleura is placed in the thorax, and the peritoneum in the abdo- men. 3. That if the aorta, immediately above tlie heart, appears sometimes in- creased beyond its natural diameter, this is not common to all the rest of the arte- ry, and when the aorta, in the vicinity ot the heart, yields to a dilatation greater than natural, this dilatation does not con- stitute, properly speaking, the essence of the aneurism. 4. That there are none of those marks regarded by medical men as characteristic of aneurism from dilatation, which may not be met with in aneurism from rupture, including even the circum- scribed figure of the tumour. 5. That the distinction of aneurism into true and spurious, adopted in the schools, is only the production of a false theory; sinc'f observation shews, that there is only one form of this disease, or that caused by a rupture of the proper coats of the artery, and an effusion of arterial blood into the cellular sheath, which surrounds the rup- tured artery. (See Treatise on Aneurism, by A. Scarpa, translated by J. H. Wishart. Edinb. 1808 ) Even the believers in the doctrine of dilatation, will, 1 think, now agree with Sabatier, that, in what they call true aneurisms, the internal coats of* the ar- tery, that is to say, the cuticular and muscular coats, are mostly ruptured, while that which is called cellular, or elastic, is dilated, so as to form the pouch, in wliich tiie blood is contained. This, he says, is particularly apt to be the case, when these swellings are the consequence of some exertion or violent shock. The fenerality of modern surgical authors, y whom the true aneurhm, attended with a real dilatation of all the coats of the artery, is implicitly believed, univer- sally admit, that, when such a tumour has acquired a large size, the inner coats of the vessel, which are imagined to be dilated, may give way and be ruptured. The blood, forcibly impelled into the vessel, or tumour, is described as pro- ducing a laceration of the resisting coatsj becoming effused within the cellular coat, which is very elastic, occasioning a se. paration of this tunic from the others, and collecting within it in a more or less considerable quantity. " I have found this proved," says Sabatier, "in nearly all the aneurisms which I have seen dis- sected, as well as in those, which I have examined myself, but, particularly in a subject, whose carotids I was about to inject. In endeavouring to expose these vessels, I found a large quantity of blood extravasated in the adjoining cellular substance. As they appeared to me to be larger than ordinary, my curiosity was excited, and I traced them to the aorta, which was extremely dilated, as was likewise the pericardium. The dc*p livid colour of this latter membrane shewed, that there was an accumulation ANEURISM. 109 of blood in its cavity. In fact, a large quantity was found there, and the por- tion of the aorta, included within this membrane, was much enlarged. I soon perceived a considerable rent, which led into the cavity of the vessel, and, on this opening being made larger, I found, that the aorta began to be dilated at its ori- gin from the heart, and that the increased size, which it had acquired, extended to the curvature, and the vessels arising there ; that these arteries were contained in a kind of continuous sac, which had borrowed their form, though its width was greater ; that they appeared to be stripped of their cellular covering, just as if they had been dissected for anato- mical purposes ; and, lastly, that it was the aorta itself, which was rent, a little way from the opening, that had taken place in its membranous covering within the pericardium. Similar cases are re- corded by Morgagni, and others." (Sa- batier, op.cit. p. 165, 166.) Iticherand does not altogether reject the doctrine of a dilatation of all the ar- terial coats; but, he asserts that this is only the case when the tumour is small and incipient, while, in aneurisms of a certain size and standing, two out of the three coats, which compose the parietes of the artery, namely, the internal and middle tunics, are constantly lacerated. (Nosografihie Chirurgicale, Tom. 4. p. 81. Edit. 2.) According to Sabatier, true aneurisms most frequently occur in the abdomen and thorax. Here, there are no pathog- nomonic signs, by which the existence of such swellings can be known with cer- tainty, before the disease is sufficiently targe to be felt externally; for, the symp- toms produced differ according to the si- tuation of the tumour, and are very like those of numerous other diseases, so that it is impossible to ascribe the complaints to this or that particular affection. Some- times, the train or circumstances, wliich accompany aneurisms, joined with the patient's complaining of* a strong throb- bing- in the situation of the disease, may lead to a suspicion of the nature of the case, even before tlie turnout can either be felt, or seen. When, however, true aneurisms are situated in the neck, or the extremities, they may easily be known by the ease, with which they yield to pres- sure, and by their pulsations ; but the last symptoms may disappear, when the tumour has become exceedingly large. The greater number of aneurisms in- creases gradually, and sooner or later in- cline to the side, on which the least re- sistance is experienced. De Haen men- tions an aneurism, of the aorta, which first made its appearance between the se- cond and third ribs of the left side, and, which instead of growing larger, as is usual, subsided, and could neither be seen, nor felt, for more than a month be- fore tlie patient's decease, although, on opening the body, a tumour of the arch of thfe aorta was found, three times as large as the first. De Haen imputes the sudden disappearance of the swelling to its weight, the yielding of the parts with which it was connected, and to its gravi- tating into the chest, when the patient lay on his right side; for, the difficulty of breathing, and other complaints, pro- duced by the pressure on the lungs, un- derwent a material increase, as soon as the tumour ceased to protrude. The pulsations, which accompany true aneurisms, continue to be strong, until the inner coats of the vessel give way, or the layers of coagulated blood, lodged in the sac, are numerous. Hence, when soft swellings, situated near any large arteries, lose their pulsatory motion, their course, precise situation, and other circumstances, ought to be most carefully investigated, before the surgeon ventures to make an opening. In many instances, the most fatal accidents have happened, in consequence of" incisions having been made into aneurisms, which were mis- taken for abscesses, because there was no pulsation. Vesalius was consulted about a tumour of the back, which he pro- nounced to be an, aneurism. Soon after- wards, an imprudent practitioner made an opening in the swelling, and the pa- tient bled to death in a very short time*. Ruysch relates, that a friend of his, hav- ing opened a tumour near the heel, which was not supposed to be an aneurism, the greatest difficulty was experience-! in suppressing tiie hemorrhage. De I ken speaks of a patient, who died in con liac and superior mesenteric arteries. Opposite to this aperture, the bodies of the two last dorsal, and of tiie two first lumbar vertebrae, were destroyed; an or- dinary effect of aneurisms on such bones as happen to he near them, but, which effect Pelletan had never previously seen take place in so considerable a degree. The two cavities of the chest contained a large quantity of bloody serum, which had no connexion with the aneurism, and tiie lungs were sound. Pelletan says, he never met with so large an aneurism; he tliinks it probable, that it was brought on by the fall, which the patient met with in 1803, and that it had been increasing for six years. He states, that the man died from nearly the whole mass of the blood having passed I into the aneurismal sac, most of the ves. sels, and the heart itself, being in fact quite empty. However, the most interesting circum- stance in this case, with regard to prac- tice, was the resemblance, which the ap- parent symptoms of this aneurism bore to those of a lumbar abscess, with, or, without a caries of the vertebrae. (See Pelletan's Ctiiuque Chirurgicale, Tom. I, p. 97—100.) Aneurisms often seem to originate spontaneously, it being in many instances exceedingly difficult to assign any cause for the commencement of tlie disease. Among the circumstances, which predis- pose to aneurisms, however, the large size of the vessels may undoubtedly be reckoned. Those trunks, which are near the heart, are said to have much thinner parietes, in relation to the magnitude of the column of blood, with which they are filled, than the arteries of smaller dia- meter ; and since tiie lateral pressure of this fluid against the sides of the arteries, is in a ratio to the magnitude of these vessels, it follows, that aneurisms must be much more frequent in the trunks near the heart, than in such as are re- mote from the source of the circulation. (Richerand,NosographieCkirurgicale,Tom. 4, p. 72, Edit. 2.) The whole arterial system is liable to aneurisms ; but, aays Pelletan, experience proves, that the in- ternal arteries are much more frequently affected, than those which are external. (Clinique Cliirurgicale, Tom. 1, p. 54.) The curvatures of the arteries are an- other predisposing cause of the disease, and, according to Richerand, such cause has manifest effect in determining- the formation of the great sinus of the aorta, the dilatation, which exists between the ANEURISM 113 cposs and the origin of" this large artery, and is the more considerable, the older the person is. Monro rightly observes on this subject, that one half of old persons have an aneurism at the beginning of the aorta. There is one artery of moderate size, without any curvature, which is never- theless more subject to aneurism, than other vessels of much larger diameter: the popliteal artery is that, which is here alluded to. The crural, of which this last is only the continuation, is much less commonly affected. This frequency of anenrisms of the popliteal artery does not depend upon the vessel being situated in the middle of a very extensible cellular substance; for, the crural, at its upper third, is not better supported by the surrounding parts. The cause is imputed by Richerand to the situation of the artery in the ham, at the back of the knee joint, an articulation, of which the extension is only limited by tlie resistance of such tendons, ligaments, and soft parts, as are placed behind it. In the stretching, to which all the parts behind the joint are subjected, when the leg is forcibly extended on the thigh, the artery, whose texture is the slightest, is particularly apt to be lacerated. Riche- rand affirms, that, out of twelve popli- teal aneurisms, which he has seen, either in hospital, or private practice, ten have been caused by a violent extension of the leg. This statement, he says, will derive confirmation from the following experi- ments : Place the knee of a dead subject on the edge of a firm table, and press on the heel, so as forcibly to extend the leg far enough to make the ligaments of the ham snap. Now dissect the part, cut out the artery, and examine its parietes in a good light, when the lacerations of the middle coat will be observable, and ren- dered manifest by the circumstance of those places appearing semitransparent, where the fibres are separated, the parietes at such points merely consisting of the internal and external tunics. (Nosogra- phie Chir. Tom. 4, p. 73, 74, Edit. 2.) The implicit belief, however, which Richerand seems to place in the idea, that the laceration of the middle coat of* an artery will bring on an aneurism, while the inner coat is perfect, will appear to be unfounded, when it is remembered, that Hunter and Home even dissected off the external and middle coats of arteries, with- out being able in this manner to cause an aneurism. Pelletan accounts for the frequency of popliteal aneurisms somewhat differently from It icherand: speaking of the two Vol. I principal motions of the knee, viz. ex- tension! and flexion, he remarks, that the first of these is so limited, that it is actu- ally an incipient flexion, necessarily pro- duced by the curvature backward both of the condyles of the femur, and those of the tibia. This curvature, which would seem to protect the popliteal artery against any dangerous elongation, that might otherwise be caused by a forcible extension of the joint, becomes the very source of such an elongation in persons, who are accustomed to keep their limbs bent, or, who, from this state, proceed hastily and violently to extend the leg. The arterial tubes are really shortened, when the limbs are in the state of flexion, and lengthened, when the extension of the members renders it necessary. Hence, says Pelletan, it is manifest, that an ha- bitual shortened state of these vessels, and their, sudden elongation, must be at- tended with hazard of rupturing their pari- etes. (Clinique Chirurgicale, Tom. Lp. 112.) Aneurisms are exceedingly common in the aorta, and they are particularly often met with in the popliteal artery. Tlie vessels, which are next to these the most usually affected, are the crural, common carotid, subclavian, and brachial arteries. The temporal and occipital arteries, and those of the leg, foot, forearm, and hand, are far less frequently the situations of the present disease. But, although it is true, that the larger arteries are the most subject to the ordinary species of aneu- risms, the smaller arteries seem to be more immediately concerned in the form- ation of one peculiar aneurismal disease, now well known by the name of the aneurism by anastomosis, of which 1 shall hereafter speak. According to surgical writers, the causes of aneurisms operate either by weaken- ing the arterial parietes, or by increasing the lateral impulse of the blood against the sides of* these vessels. It is said to be in both these ways, that the disease is occasioned by violent contusions of the arteries, the abuse of spirituous drinks, mercurial courses too often repeated, fits of anger, rough exercises, exertions in lifting, heavy burdens, &c In certain persons, aneurisms appear to depend upon a particular organic disposition. Of this description was the subject, whose arteries,, on examination after death, were found by Lancisi affected with several aneurisms of various sizes. I have known a person, who had an aneu- rism of one axillary artery, wliich disease got spontaneously well, but, was soon afterwards followed by a similar swell- ing of the opposite axillary artery, which last affliction proved fatal. I have Q 114 ANEURISM •seen another* instance, in which an aneu- rism of the popliteal artery was accom- panied with one of the femoral in the other limb. The most remarkable case, however, proving the existence of a dis- position to aneurisms in the whole arte- rial system, is mentioned by Pelletan. " J'ai pourtant vu plusieurs fois ces nom- breux aneurismes occupant indistincte- ment les grosses ou les petites arteres, mais sur-tout celles des capache> ; fen ai compte soixatite trois sur un seul homme, depuis le volume d'une aveline jusqu' d celui de la moitie d'un xuf tie poule. (Clinique Chirurgicale, 'Tom. 2, p. 1.) In this country it has been noticed, that popliteal aneurisms occur with particular frequency in postilions and coachmen, whose employments oblige them to sit a good deal with the knees bent. It has been observed in France, by Richerand, that the men, who clean out the dissect- ing rooms, and procure dead bodies for anatomists, almost all die of aneurismal diseases. Tins author remarks, that he never knew any of these persons, who were not addicted to drinking, and he comments on the debility, which their in- temperance and disgusting business to- gether must tend to produce. (Nosogra- phie Chirurgicale, Tom. 4, p 74, Edit. 2.) Aneurisms of the axillary artery ap- pear, in some instances, to have arisen from violent extension of the limb. (See the cases recorded by Pelletan in Clinique Chirurgicale, Tom. 2, p. 49, and 83.) In other examples, related by the same interesting practical writer, aneu- risms arose from reiterated contusions and rough pressure on parts. (06. cit. p. 10, p. 14.) •■ The extremity of a fractured bone may injure an artery, and give rise to an aneu- rism, an instance of which is recorded by Pelletan. (Op. cit. Tom. 1.p. 178.) The disease followed a fracture of the lower third of the leg. An aneurism of the an- terior tibial artery, from such a cause, is also described in Mr. Charles White's Cases in Surgery, p 141. The following case of an aneurism of the humeral artery, after amputation, is recorded by Warner: C. D. was afflicted with a caries of the joint of the elbow, which- was attended with such circum- stances, as rendered the amputation of the limb necessary. The operation was performed at a proper distance above the diseased part, and the vessels were taken up by the needle and ligatures. In a few days, after the operation, the humeral artery became so dilated above the ligature as to endanger its bursting. Upon this account, it was judged neces- sary to perform the operation for the aneurism, which was done, and the vessel was secured by ligature, above the upper extremity of its distended coats. After this operation, every thing went on, for some time, exceedingly well, when sud- denly the artery appeared again dilated, and was in danger of bursting above the second ligature. These circumstances made it necessary to repeat the operation for the aneurism. From this time, every thing went on successfully, till the stump was at the point of being healed; when, quite unexpectedly, the artery appeared a third time diseased in the same manner as before ; for which reason, a third ope- ration for aneurism was determined on, and performed. The last operation was near the axilla. The patient continued well, from this time, without any relapse. Query. Could the several aneurisms of the humeral artery, (says Mr. Warner) be attributed to the sudden check alone, which the blood met with from the extre- mity of the vessel being secured by liga- ture ; or is it not more reasonable to sup- pose, that tlie coats of the artery, nearly as high up as the axilla, were originally diseased and weakened? The latter, in the opinion of this judicious writer, seems the most probable way of accounting for the successive returns of the disease of the vessel: since it is found from expe- rience, -that such accidents have been very rarely known to occur after ampu- tations, either of the arm, or thigh, where nearly the same resistance must be. made to the circulation in every subject of an equal age and vigour, who has undergone the like operation. If it should be supposed, that the several dilatations ofthe coats of the vessels, con- tinues Mr. Warner, arose merely from the check in the circulation, it will not be easy to account for the final success of this operation; and, especially, when we reflect, that the force of the blood is in- creased in proportion to its nearness to the heart. (See Cases in Surgery, by J. Warner, F. R. S. p. 139, 140, Edit. 4.) Aneurisms sometimes follow the injury, which a large artery suffers in gunshot wounds. The passage of a bullet through the thigh, in one example, gave rise to a femoral aneurism. (See the Parisian Chi- rurgical Journal, Voi.2,p.l09.) TREATMENT of ANEURISMS IX GENERAL A complete cure of an aneurism cannot be effected, in whatever part of the body the tumour is situated, unless the artery, from which the aneurism is derived, be, by nature or art, obliterated and convert- ed into a perfectly solid, ligamentous sub- ANEURISM. HI stance, for a certain extent above and below the place of the ulceration, lacera- tion, or wound. When aneurisms are cured by compression, the cure is never accomplished, as some have supposed, by tlie pressure strengthening and dilated proper coats of the artery, and restoring, especially to the muscular coat, the power of propelling the blood along the tube of the artery, as it did p^viously to its sup- posed dilatation. M. Petit and Foubert thought, that the natural curative process sometimes consisted in a species of clot, which closed the laceration, ulceration, or wound of the artery, and resisted the impulse ofthe blood, so as still to preserve the continuity of the coats of the artery, and the pervious state ofthe vessel. Hal- ler imbibed a similar sentiment, from ex- periments made on frogs. That a punctured artery may occasion- ally be healed in this manner, Scarpa proves by a case which he examined, in which an aneurism took place from the wound of a lancet in bleeding. In the article Hemorrhage we shall see, that Jones's experiments shew the same thing, and the particular circumstances in which it may happen. But, the occurrence is excessively rare, and can hardly be called a radical cure, as the cicatrix is always found in a state ready to burst and break, if the arm is, by any accident, violently stretched or struck, where the wound was situated. Whenever the ulcerated, lacerated, or wounded artery, is accurately compressed against a hard body, like the bones, it ceases to pour blood into the surround- ing cellular sheath, because its sides, being kept in firm contact, for a certain extent, above and below the breach of continuity, become united by the adhe- sive inflammation, and converted into a solid, ligamentous, cylinder. Molinelli, Guattani, and White, have given exam- ples and plates, illustrative of this fact. When aneurisms get well spontaneously, the same fact is observed after death, as Valsalva, Ford, &c. have demonstrated. lhave myself seen in St. Bartholomew's Hospital, an instance, in which a man had had a spontaneous cure of an aneu- rism in the left axilla, but afterwards .died of hemorrhage from another one under the right clavicle; the artery on the left side was found completely im- pervious. My friend, Mr. Albert, had under bis care, in the' York Hospital, .Chelsea, a dragoon, who recovered spon- .taneously of a -/ery large aneurism of the external iliac artery: the tumour slough- ed, discharged about two quarts of coa- gulated blood, and then granulated and jiealed *»p. Paoli relates a similar ter- . initiation of a popliteal aneurism. Moini- chen and Guattani, relate other exam- ole*. Hunter found the femoral artery quite impervious, and obliterated, at the place where a ligature had been applied fifteen months before. Boyer noticed the same fact in a subject, eight years after the operation. Petit relates a spon- taneous cure of an aneurism at the bifur- cation of the right carotid, and the sub- ject having afterwards died of apoplexy, tlie vessel on dissection, was found closed up and obliterated from the bifurcation, as far as the right subclavian artery. Desault had an opportunity of opening a patient, in whom a spontaneous cure of a popliteal aneurism was just beginning; he found a very hand, bloody thrombus, which extended for three finger-breadths, within the tube of the artery, above the sac, and was so firm, as to resist injec- tion, and make it pass into the collateral branches. Both the spontaneous and surgical curea of aneurisms, have two stages ; in the first, the entrance of the blood into the aneurismal sac is interrupted ; in the se- cond, the parietes of the artery approach each other, and, becoming agglutinated, the vessel is converted into a solid cylin- der. This doctrine is corroborated by the tumour first losing its pulsation, and then gradually diminishing and disappearing. Dr. Thomson, as well as Scarpa, has long expressed his opinion, that the spontane- ous radical cure of aneurisms, may some- times arise from the pressure of the aneu- rismal sac on the trunk of the injured artery, just above the communication between the vessel and the cavity of the aneurism. Morand proved that a vio- lent blow may lead to the obliteration of an artery, and Dr. Jones has demonstrat- ed, that arteries always become imper- vious, after having a tight ligature put round them, even though such ligature be removed the moment after its appli- cation. When an aneurism is affected deeply by gangrene, a dense, compact, bloody, coagulum is formed within the vessel, shutting up its canal, and interrupting completely the course of the blood. Hence the sphacelation which follows, and the bursting of the integuments, and of the aneurismal sac, are never accom- panied by a fatal hemorrhage, and the patient is cured of the gangrene and the aneurism, if he has strength sufficient to resist the destructive action of the sphace- lus on the constitution. When a patient dies of'hemorrhage, after the mortificatioa of an aneurism, it is because only a por- tion of the integuments and sac has sloughed, without the root of the aneu. 116 ANEURISM. rism, and, especially, the arterial trunk, being in this way affected. In order that compression may make the* opposite side of an artery unite, and thus produce a radical cure of an aneu- rism, Scarpa says, the degree of pressure must be such as to place these opposite sides in firm and complete contact, and such as to excite tlie adhesive inflamma- tion in the coats of the artery, which must also possess a state of vitality, presently to be noticed. The point of compression must also fall above the laceration, or wound of the artery; for, when it operates below, it hastens the enlargement of the tumour; and Scarpa adds, that, in prac- tice, bandages, which are expulsive and compressive, are more useful for making pressure, than any tourniquets or instru- ments*, many of which are contrived to operate, without retarding the return of blood through the veins. For pressure to succeed, the coats of the vessel must possess, at the place where it is made, such a degree of vitali- ty, as to be capable of feeling the stimu- lus, and of inflaming. When the arterial coats, round the root of the aneurism, are diseased, as above described, they are insusceptible of the adhesive inflamma- tion, although compressed together in the most scientific manner, and, even when tied with a ligature, which only acts by making circular pressure on the vessel. Some advise trying compression in every case of aneurism, whether small, circumscribed, soft, flexible, indolent, or elevated, diffused, hard, and painful. In the latter case, however, compression is hurtful. Every bandage, which compres- ses the aneurism, and also constricts cir- cularly the affected part, is always in- jtu-ious. The bandage, likewise, which, compressing only the aneurism, directs the point of pressure below the rupture in the vessel; that which, on account of the great size, exquisite sensibility, depth of the root, of the aneurism, and fleshiness of the surrounding parts, can- not effectually compress the artery against the bones, so as to bring the opposite sides ofthe vessel into contact; and, last- ly, the compression applied to a spontane- ous aneurism, attended with a steatoma- tous, ulcerated, earthy, disease of the arterial coats ; ought to be considered as an useless, or rather hurtful plan. In cases of a completely opposite description, ban- dages have produced, and may produce, radical cures of aneurism, and should not be entirely disused. Guattani first employed compression systematically for the cure of aneurisms, and he has related many cases, in which he succeeded. Freer details other ones j- but, in general, pressure has hitherto been applied to the tumour itselt, a me- thod less likely to answer, than that of making pressure on a sound part of the artery. Mr. Freer recommends the em. pfoyment of Sennfio's instrument, or the following method: first place a bandage moderately tight, from one extremity of" the limb to the otfcer ; then place a pad upon the artery, a few inches above the tumour; next, surrounding the limb with a tourniquet, let the screw be fixed upon the pad, having previously secured the whole limb from the action of the instru- ment, by a piece of board wider than the limb itself, by which means the artery only will be compressed, when the screw is tightened. The tourniquet should now be twisted till the pulsation in the tu- mour ceases. In a few hours the limb will become cedematous and swelled, when the tourniquet may be removed, and the pressure of a pad and roller will afterwards be enough. By experiments which this gentleman made on the radial arteries of horses, these vessels were found to become inflamed, and to be rendered impervious by such a process. (Freer, p. 112.) Mr. A. Cooper mentions an excellent machine for compressing the femoral ar- tery, in cases of popliteal aneurism. It was used by Sir W. Blizard. " The points of support for this instru. ment were the outer part of the knee, and the great trochanter, a piece of steel pass- ing from one to the other; and to the middle of this a semicircular piece of iron was fixed, which projected over thefemo- ral artery, having a pad at its end, moved by a screw, by turning which, the artery was readily compressed, and the pulsation in the aneurism stopped, without any in-- terruption to the circulation in the smaller vessels." But, although the patient on whom it was tried possessed unusual forti- tude of mind, and indifference to pain, he was incapable of supporting the pressure of the instrument longer than nine hours. Indeed, the agony arising from long con- tinued pressure is insupportable to almost all men. (Med. and Phys. Journal, Vol. 8.) The grand means most to be depended upon, however, for curing aneurisms, is tying the artery above the tumour. This more certainly prevents the usual ingress of blood into the sac, and, what is more important, more certainly excites the ad. hesive inflammation, by dividing the in- ternal coats of the vessel. The blood in the sac is afterwards gradually absorbed, and the tumour dwindles away in pro- portion. The natural course of the blood ANEURISM. 'H-* bting now peirmanently interrupted in the arterial trunk, it passes more copi- ously into the collateral branches, and these enlarging and anastomosing with others, which originate from the large arteries beyond the obstruction, the ne- cessary circulation is carried on. The ligature of the superficial femoral artery, may be performed with the same confidence of success, as the ligature of the brachial artery, that is, without any fear of destroying the circulation, or de- priving the subjacent limb of its vitality. indeed, the numerous and conspicuous anastomoses, which are met with all" round the knee, correspond exactly with those which are observed round the el- bow, and at the bend of the arm. This is not a peculiarity of the arteries of the extremities, but it is a general rule which nature has followed in the distribution of all the arteries, that the superior trunks communicate with the inferior, by means of the lateral vessels. After the prin- cipal trunk of an artery is tied, its lateral branches not only carry on the circula- tion in the parts below the ligature, but do so with greater quickness and activity than they did before, when the course of the blood was unimpeded through the principal trunk. This evidently arises from the increase of pressure which the blood, that takes the rout of the lateral vessels, receives, as well as from the en- largement in the diameter of these ves- sels. After the amputation ofthe thigh, wliile the blood fjows in a full stream from the superficial femoral artery, very little or no blood is poured out of the lateral vessels ; but as soon as that ar- tery is tied, the blood issues with impe- tuosity from the small arteries which run along, within the vasti and crurseus mus- cles ; and, on these smaller arteries being also tied, the blood immediately oozes out, from the minute arterial vessels of the muscles and cellular membrane. When tlie principal trunk of an artery is tied, its lateral branches gradually ac- quire a much larger diameter. After am- putation of the thigh, on account of a popliteal aneurism, the size and situa- tion of which could not fail materially to impede the course of the blood through the trunk of the femoral artery, it has been often remarked, that, although both the trunk and the greater and smaller branches, had been tied with the greatest accuracy, the patients have been in danger of losing their lives, on account of the repeated copious hemorrhages from the innumerable small lateral vessels, that had become unusually enlarged. In se- veral cases, during the treatment, and especially ajter the radical cure of pop. liteal aneurism, by tying the superficial femoral artery, in the upper third of the thigh, all the ramifications of the recur- rent popliteal arteries have been felt beating strongly round the knee. Boyer found, in a man, who some years before had been operated on for a popliteal aneu- rism, but had afterwards died from a caries of the tibia, that the arterial branch, which runs through the substance ofthe sciatic nerve, was dilated so much, as to be equal in diameter to the radial artery. White, in dissecting the arm of a lady, who, fifteen years before had been operated on for an aneurism in the bend of the arm, found the brachial ar- tery obliterated, and converted into a solid cylinder, for three inches below the place of the ligature, and as far as the division into the radial and ulna arte- ries ; but, the recurrent radial and ulnar branches had become so much enlarged that, taken together, they exceeded the size of the brachial artery, above the situ- ation of the ligature. In the dead body it is found, that an anatomical injection will pass more freely from one extremity to the other of an ani^reumatic, than of a sound limb, and this, even when no vessels are visibly enlarged. Although it be self-evident, that the circulation. through the collateral vessels ought to be much more easy and quick the lower down the ligature is applied to the prin- cipal trunk; yet, experience shews, that this difference is not to be estimated very high; for in cases of popliteal aneurism, cxteris paribus, the success is the same, whether the femoral artery be tied very low down, or very high up in the thigh. (Scarpa.) This facility of the passage of the bloofl through the lateral vessels, is not the same in subjects of all ages ; and, in the same subject; it is not the same in the inferior, as in the superior extremity. An age under forty-five, and the operation being done on the arm, which is nearer the source of the circulation, than the lower extremity, increases the chance of success. The circumstances chiefly preventive of success, especially in the popliteal and femoral aneurisms, are the following: Rigidity, atony, or disorganization of the principal anastomoses, between the supe- rior and inferior arteries of the ham and leg; sometimes depending on advanced age, or'on it, together with the large size ofthe aneurism, which, by long continued pressure, has caused a great change in the neighbouring parts: or sometimes on steatomatous, ulcerated, earthy, cartila- ' ginous, disorganization of the proper coats of the artery, not c-pnfinei to the n8 ANEURISM. seat of the rupture, but extending a great way above and below the aneurism, and also to the principal popliteal recurrent arteries, tibial arteries, artd occasionally, to portions of the whole track of the su- perficial femoral artery. Sometimes, the pressure of large aneurisms, renders the thigh bone carious. In such circum- stances the ligature is apt to fail in clos- ing the trunk of the artery; and, if it should succeed, the state of the anasto- mosing vessels will not admit of a suffi- cient quantity of blood being conveyed into the lower part of the limb. Hence, when the patient is much advanced in hfe, languid and sickly, when the in- ternal coat of the artery is rigid, and in- capable of being united by a ligature; when the aneurism is of long standing, and considerable size, with caries of the os femoris, or tibia; when the leg is weak and cold, much swelled, heavy, and cede- matous; Scarpa considers the operation contra-indicated. I must, however, de- clare in this place, that I have seen very large aneurisms, as well as aneurisms in persons of advanced age, cured by the Hunterian plan, in St. Bartholomew's Hospital. It appears, then, that the obliteration of the artery, for a certain extent, above and below the place of rupture, forms the primary indication in the radical cure of aneurism, whether compression or the ligature, be employed. All other means are only auxiliary. Internal remedies may be useful in so far as they tend to moderate the determination of the blood towards the place, where the artery has been tied or compressed. Bleeding in young, very robust, plethoric patients, low diet, diluent drinks, gentle laxatives and glysters, mental and bodily rest, and cool air, have such effect. When there is weakness, not from age, but from pain, long want of rest, or loss of blood, tonics, cordials, and a moderate diet, may be given. Scarpa also advises the outward use of corroborants and stimulants; but, I think, few English surgeons will ap- prove the practice. Notwithstanding, however, aneurisms cannot in general be cured, as Scarpa has explained, unless the artery be rendered impervious for some extent above and below the tumour, I believe, we must make an exception to this observation, with respect to the few aneurisms of the aorta, (especially those of its arch,) which, according to the records of surgery, have been diminished and cured by Valsalva's treatment. In such examples, we are not to suppose, that the aorta becomes obliterated at its very beginning; but, that th* diminution of the quantity of circulating blood, the reduced impetus of this fluid, the lessened distention of the aneurismal sac, the general weakness in- duced in the constitution, and the in- creased activity of the lymphatic system, all necessary effects of Valsalva's method, have combined to bring about a partial subsidence of the tumour. In internal aneurisms, and other cases, out of the reach of operative surgery, practitioners have usually been content with prescribing occasional bleedings, debilitating remedies, abstinence, a milk diet, and quietude, &c. As bleeding-, however, cannot always be frequently re- peated, instead of it, Scarpa says, the hands and feet may be immersed in tepid water, the limb rubbed, and water given internally, with a small quantity of Hoft'- man's liquor anodynus mineralis. (Spir. AEtheris. Comp.) The great difficulty of breathing, adds the same writer, may receive a temporary relief, by applying sinapisms. All pressure on the tumour, when it protrudes externally, should be avoided, as it might increase the com. pression on the viscera, and would cer« tainly accelerate the fatal bursting of the aneurism. Digitalis has been given with advan- tage ; but, occasional bleedings, and opi- um, have been found to produce most re- lief. In the latter stage, opium can alone be relied on. (Freer!) It must be acknowledged, that practi- tioners have too commonly abandoned, such aneurisms as do not admit of an operation, as inevitably fetal, and, what- ever measures have been taken, in cases, of this kind, have rather been pursued with a view of palliating the patient's sufferings, than with any hope of effecting a cure. Yet, we shall find, in the ensuing section of this article, that some exceed- ingly large aneurisms of the aorta itself, have been cured by copious and repeated, venesections, and the rigorous adoptiou of Valsalva's practice. Were the same treatment more generally followed, no doubt, internal aneurisms might seem much more curable than they have usu- ally been regarded. The celebrated Desault conceived, that, when an aneurism was so situated, that a ligature could not be applied to tlie ar- tery leading to the swelling, a cure might possibly arise from tying the ves- sel, on that side of the tumour, which was most remote from the heart. De- sault conjectured, that, by this means, the circulation through the sac would be stopped, the blood in it would coagulate, that the circulation would go on by the collateral arteries, and that the tumour would be finally aJaorbed. These spe< ANEURISM. W fulations, however, were not found to answer in practice. Dechamps tied the femoral artery below an inguinal aneu- rism ; but the progress of the disease, instead of being checked, seemed to be accelerated by this novel experiment. The operator was obliged, as a last re- source to open the tumour, and try to take up the vessel. In this attempt, the patient lost a large quantity of blood, and died eight hours afterwards. (See QZuvres Chir. de Desault par Bichat, Tom. 2, p. 568.) OP ANEURISMS OF THE AOnTA, AND VAL- saxva's TREATMENT. This afflicting and fatal disease is by no means unfrequent, and the arch of the aorta is the most common situation of the tumour. Dr. Hunter was of opinion, that the latter circumstance depended on the forcible manner, in which the blood, K repelled from the left ventricle of the eart, must be driven against the angle ofthe curvature ofthe vessel. The same distinguished physician also thought, that the aneurismal sac was composed of the dilated coats of the artery, which parts nature thickened and studded with ossi- fications, after the origin of the disease, for the purpose of resisting its increase. The writings of Scarpa, however, make it appear highly probable, that, the gene- rality of aneurisms of the aorta are the consequence of a rupture of the proper coats of this large vessel; and that the cellular sheath of the artery is what be- comes distended into the thickened and ossified aneurismal sac. It seems also a fact, that, when tlie coats of the aorta jrive way in a certain situation (viz. with- in the pericardium) where they only re- ceive a very slight external membranous "covering, this last part is also apt to be ruptured at the same time, so as to bring on a copious effusion of blood in the chest, and sudden death. If these things be true, (and, they ap- pear to be confirmed by^nost careful and accurate dissections) the common distinc- tion of aneurisms into true and false, or into aneurisms by dilatation and rupture, can no longer be regarded as accurate, as we have already explained. Therefore, the idea of Dr. Hunter, that aneurisms of the aorta were swellings of this vessel itself was a mere supposition, and the aneurismal sac, in these, as in all other cases, is composed of the sheath of cel- lular substance, which surrounds the ar- tery. We have stated, that Dr. Hunter con- sidered the ossifications of the sac as con- sequences of the disease; but the cele- brated Haller looked upon such scales of bone in the aorta as the very cause of the affection, by rendering the artery inelas- tic, and incapable of yielding to each pul- sation of the heart. It is very certain, that aneurisms of the aorta are most commonly met with in per- sons, who are advanced in life, and, it is equally well known, that the aorta of every old subject, whether affected with aneu- rism, or not, is almost always marked in some place, or another, with ossifications, or, rather, with calcareous concretions. Such productions appear to occasion a decay, or absorption, of the muscular and inner coats of the vessel, so that, at length, the force of the blood makes the artery give way, and this fluid, collecting on tiie outside of the laceration, or rup- ture, gradually distends the external sheath of the artery into the aneurismal sac, which itself becomes at least of consi- derable thickness and studded with ossi- fied specks. " If any person, who is not prejudiced in favour of the common doctrine, with regard to the nature and proximate cause of this disease (says Scarpa), will examine, not hastily and superficially, but, with care and by dissection, the intimate struc- ture and texture of the aneurism of the aorta, unfolding with particular attention the proper and common coats of this ar- tery, and, in succession, those, which constitute the aneurismal sac, in order to ascertain distinctly the texture and limits of both, he will clearly see, that the aorta, properly speaking, contributes nothing to tiie formation of the aneurismal sac, and, that, consequently, the sac is merely the cellular membrane, which, in the sound state, covered the artery, or that soft cel- lular sheath, which the artery received in common with the neighbouring parts. This cellular substance, being raised and compressed by the blood, effused from the corroded or lacerated artery, assumes the form of a circumscribed tumour, covered externally, in common with the artery, by a smooth membrane, such as the pleura in the thorax, and the peritoneum in the abdomen. " I do not pretend to deny, (continues this accurate anatomist,) that, sometimes, in consequence of congenital relaxation of the proper coats ofthe aorta, at its exit from the heart, a certain degree of yield- ing of these coats may contribute to the rupture of the aorta at this place, and, by that means, to the formation of an aneu- rism, which, in this case, is likewise con- joined with a certain degree of preterna- tural dilatation of the whole tube ot the artery. I only deny, that dilatation of this arteryprecedesand accompanies every aneurism of the aorta, and am unwilling C21 ANEUUlsM. to admit, that, in the formation of this formidable disease, the proper coats of the aorta ever yield so much to disten- tion, as to form the aneurismal sac. With regard to this point, it is a fact worthy of the attention of medical men, and of all those, who wish to investigate this sub- ject, that the root of an aneurism of the aorta, in whatever point of this artery it appears, never includes the whole circum- ference of the tube of the artery; but, that the root constantly occupies and in- volves only the one, or the other side of the artery, from which side, the aneuris- mal sac rises and enlarges, in the form of an appendix, or tuberosity, more or less large and extended, according to the cir- cumstances of the place, or of the period of the disease; while, on the contrary, the dilatation of tlie artery occurs con- stantly in the whole circumference ofthe tube, and therefore differs essentially from aneurism." (Scarpa on the Anatomy, Pa- thology, and Surgical Treatment of Aneurism, Transl. by Wisliart,p. 55, 56.) In whatever manner aneurisms of the aorta are formed, there are no diseases, which are more justly dreaded, or which more completely fill the surgeon, as well as the patient,' with despair. No afflic- tion, indeed, can be more truly deplor- able ; for, tbe sufferings, which are occa- sioned, hardly ever admit even of pallia- tion, and the instances of recovery are" so very few, that no consolitary expectation can be indulged of avoiding the fatal end, to which the disease naturally brings the miserable sufferer. The existence of aneurisms of the aor- ta, is scarcely ever known with certainty, before they have advanced so far, as to be attended with an external pulsation, and a tumor, that admits of being felt, or even seen. In very thin subjects, the throbbing of the abdominal aorta is some- times unusually plain through the integu- ments and viscera, and this has occasion- ally given rise to the suspicion of an aneu- rism; a circumstance, which deserves to be remembered by eveiy surgeon, desirous of not pronouncing a wrong opinion. While thoracic aneurisms of the aorta are accompanied with no degree of external swelling, the symptoms are all equivocal, and might depend on a disease of the heart, angina pectoris, and several other affections. Violent and irregular throb- bings frequently occur between the fourth and fifth true ribs of the left side; the same irregularity of the pulse prevails as often proceeds from organic affections of the heart; the respiration is exceedingly obstructed; the voice altered; and, in a more advanced period of the malady, the patient is at times almost •Buffocated. The pressure of the internal swelling on tf* trachea, bronchia, and lungs is sufficient to account for this difficulty of breathing. In many instances, the irritation and com. pression, produced by tiie tumor, occa- sion an absorption of the greater part of the lungs, and abscesses and tubercles throughout the portion, which remains. Even the function of deglutition suffers interruption, in consequence of* the pres- sure made on the oesophagus, which may even be in a state of ulceration. Tha% in an example recently published, we read, that "the cavity of the windpipe was nearly obliterated from the pressure of the aneurism; and the extremities of four of its cartilages lay in the oesopha- gus, having entered that canal, through an ulcer in its coats." (Transactions of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol, 3, p. 83.) The way, in which aneurisms of the thoracic aorta prove fatal, is subject to consider- able variety. These swellings do not al- ways destroy the patient by hemorrhage; in numerous instances, the magnitude of the disease so impedes respiration, that death seems induced by suffocation, and not a drop of blood is found internally effused. Frequently, (to use the descrip- tion of Mr. John Bell) before the awful and fatal hemorrhage has had time to oc- cur, the patient perishes of sufferings too great for nature to bear. The aneurismal tumour so fills the chest, so oppresses the lungs, compresses the trachea, and curbs the course of the descending blood, that the system, with a poor circulation of ill- oxydated blood, is quite exhausted. And, thus, though the patient is saved from the most terrible scene of all, he suffers great miseries; he experiences in hit chest severe pains, which he compares with the stabbing of knives ; terrible pal- pitations ; an awful sense of sinking within him; a sound within his breast, as if of the rushing of waters; a continual sense of his condition; sudden startings during the nighj; fearful dreams and dangers of suffocation, until, with sleep- less nights, miserable thoughts by day, and the gradual decline of an ill-supported system, he grows weak, dropsical, and expires. (See Anatomy ofthe Human Body, by John Bell, Vol. 2, Edit. 3, p. 234, 235.) The situations, in which aneurisms of the curvature of the aorta buret, are dif- ferent in different cases. Sometimes the swelling bursts into the cavity of the chest, or that of the pericardium, and the patient drops suddenly down. In other examples, the blood is effused into the trachea, or bronchia, and the patient, af- ter violent coughings and ejections of blood from the mouth, expires. In cer- ANEURISM. 121 t.tin cases, the swelling beats it* way through the .ribs, destroys the vertebra, and injures the spinal marrow, so that the patient suffers a species of death, some- what less violent and sudden. But, al- though aneurisms in the chest do some- times present at the back, a circumstance, that depends on the particular situation ofthe disease, (see Pelletan's Clinique Chi- rurgicale, Tom. 1, Obs. 7, p. 84.), they more commonly rise towards the upper part of the breast, where a throbbing tu- mour occurs, which has caused an absorp- tion of the opposing parts of the ribs and sternum; and sometimes dislocated the clavicles. The swelling now pulsates in an alarming way. The blood is only re- tained by a thin covering of livid skin, which is becoming thinner and thinner. At length, a point of the tumour puts on a more conical, thin, and inflamed appear- ance than the rest; a slough is formed, and, on this becoming loose, the patient is instantaneously carried off by a sudden gush of blood. A singular case of aneurism of the aorta is related by Dr. C. W. Wells. The dis- ease, being unattended with any exter- nal swelling, it seems, was not known with certainty during tiie patient's life- time. The following is an abstract of the symptoms, and particulars of the case. Mr. A. B. a gentleman, thirty-five years of age, and temperate in his habits, be- came affected in 1789 with symptoms, which were thought to denote the ap- proach of pulmonary consumption. These, however, after some time, entirely disap- peared. In 1798, he was attacked with a slight hemiplegia, from which he also recovered, with the exception of an in- considerable sense of coldness in the foot, which had been paralytic. In March 1804, he complained of being frequently troubled with a noise in his ears, flatu- lence in his bowels, and pains in his hands and feet, sometimes attended with slight swellings in the same parts. From one, or more of these symptoms, he was never afterwards quite free; but, he did not complain of any unusual feelings in his chest. August 11, 1807, he fatigued himself considerably with walking; ate rather a hearty dinner; and, liaving re- freshed himself with some sleep after- wards, he played about with his children. While thus amusing himself, he was sud- denly seized, between eight and nine o'clock, with great oppression in his chest. He soon afterwards became sick, and, in the matter thrown up, some streaks of blood were observed. He now went to bed; but, though the weather was v arm, and he was covered with bed- Voi. I clothes, his skin felt cold to the attend- ants. At midnight he laboured under a constant cough, and expectorated mucus tinged with bloou. His body was moist- ened with a cold sweat, and his pulse was extremely feeble; sometimes, it was scarcely perceptible. About five in the morning, his pulse was feeble and irregu- lar ; his breathing difficult, his skin pale, cold, and covered with a clammy sweat. He frequently tossed, and writhed liis body, as if he was suffering great pain or uneasiness. The mental faculties, how- ever, seemed unimpaired. Shortly, after- wards, he expired, having complained, just before his death, of much heat in his chest, and thrown off* the bed-clothes. The most remarkable circumstance found on opening the body, is thus re- corded : " The ascending aorta was dis- tended to about the size of a large orange. The tumour adhered to the pulmonary artery, just before its division into the right and left branches. Within the-cir- cumference of this adhesion, there was a ' narrow hole, by means of which a com- munication was formed between the two arteries." j£ Dr. Wells concludes with observing, that, though such a disease might easily have been imagined, he has found no in- stance of it in books, and that it has not been observed by any of the surgeons, or anatomists in London. He supposes, that the communication, between tlie aorta and pulmonary artery, took place on the even- ing before the patient's death, when the oppression in the chest was first felt; and that, in consequence of M^ superior strength of the left side «|Pne heart, a part of the blood, which was thrown into the aorta, must have been forced into the pulmonary artery, from which circum- stance, he conjectures most of the symp- toms originated. (Trans, of a Society for the Improvement of Med. and Clururgical Knowledge, Vol. 3, p. 85.) The bursting of an aneurism of the. aorta into the pulmonary artery is then another possible mode, in which the dis- ease may prove fatal. It is well worthy of notice, that aneu- risms of the arch of the aorta may occa- sion a tumour, so much like that of a sub- clavian aneurism, as to be in danger of being mistaken for the latter disease. An example of this kind is related by Mr. Allan Burns, " a case," says he, " on which several of the most distinguished practitioners in Edinburgh, and almost every surgeon in Glasgow were consulted. The nature of the disease appeared to be so decided, and its situation in the sub- clavian artery so clear, that, on that sub- ject, there was no difference of opinion It 122 ANEURISM. Some were, however, of opinion, that an operation might be performed, while others were fully convinced, that the case was hopeless. For myself, I must confess, that I was firmly persuaded, that, in the early stage of the disease, an operation might have been beneficial," &c. (Sur- gical Anatomy of the Head and Neck, p. 30.) After death, the vessel, which was supposed to have been most materially affected, Was found perfectly healthy.— (P. 39.) After detailing all the particulars of this interesting case, Mr. A. Burns observes, that, " it corroborates Mr. Astley Cooper's remark, that aneurism of the aorta may assume the appearance of being seated in one of the arteries of the neck; an infer- ence, drawn from the examination of a case, wliich came under his own observa- tion, and of which he had the goodness to transmit a short history to me, along with a sketch, illustrative ofthe position ofthe tumour.. In one case, the aneurism was attached to the right side of the aortic arch, and involved a part of the arteria Snominata; in Mr. Cooper's, the tumour ose from the left side of the arch, from between the roots of the left subclavian, and carotid arteries. It formed a florence- flask-like cyst, the bulbous end of which projected at the root of the neck, fi-om behind the sternum, and so nearly resem- bled aneurism of the root of the carotid artery, that the practitioner, who consult- ed Mr. Cooper, actually mistook the dis- ease for carotid aneurism." (Allan Burns, Op. cit. p. 41^ As we ha^fllready noticed, aneurisms of the aortalre-most frequent at its cur- vature r but,*Jlhey are also met with on the other portion of this vessel in the thorax, and likewise on that part of it, which is below the diaphragm. In subjects, pre- disposed to aneurisms, such swellings are frequently seen affecting various parts of the aorta at the same time. When the disease occurs in the abdo- minal aorta, a preternatural pulsation generally becomes perceptible at some point of the parietes of this part of the body. The pressure of the tumour inter- feres with the functions of the viscera; tlie breathing is rendered difficult by the swelling resisting ihe descent of the dia- phragm ; the patient suffers at times ex- cruciating internal pains; sometimes he is affected with costiveness; sometimesj with diarrhoea; and, not unfrequently, with incontinence of the urine and feces. At length, an immense external swelling is formed, which pulsates alarmingly, and, if the patient survives long enough, destroys him by a sudden external, or internal effusion of blood. Aneurisms, within the thorax and ab- domen, being entirely out of the reach of operative surgery, have been too com- monly abandoned as unavoidably fata), and when any thing has been done in such cases, it has generally been only with a. view of palliation. Moderating the force of the circulation by bleedings and-low diet, avoiding every thing that has the least tendency to heat the body, or quieken the motion ofthe blood, keeping the bow- els well open with laxa'.ve medicines, and lessening pain with opiates, have been the means usually employed. Of late years, also, the digitalis, which has a peculiar power of diminishing the action of sanguiferous system and impetus ofthe blood, has been prescribed, with every appearance of benefit. It was tlie opinion of the celebrated Valsalva, that the utility of a lowering plan of treatment might do more, than merely retard the death of aneurismal patients. It was his belief, that the me- thod might entirely cure such aneurisms as had not already made too much pro- gress, and he put it into practice with such rigour and perseverance, that the treat- ment became considered as particularly his own. The plan, alluded to, is not de. scribed in his writings; but, was published in the first volume of the Commentaries of the Academy of Bologna, by Albertini, one of his fellow students; and several persons, who had learnt this method of Valsalva, afterwards imparted it to others. Thus, as Morgagni was passing through Bologna, in 1728, Stancazi, a physician of that place, is said to have informed him of Valsalva's practice. After taking away a good deal of blood by venesection, Valsalva used next to di- minish the quantity of food gradually, till the patient at length was allowed only half a pint of soup in the morning, a quar- ter of a pint in the evening, and a very small quantity of water, medicated with mucilage of quinces, or with the lapis osteocolla. Whef*, the patient had been so reduced, as to be incapable of getting out of his bed, Valsalva used to give him more nourishment till this extreme debility was removed. Valsalva was sure, that some aneurisms, thus treated, had got well, be- cause every symptom disappeared, and liis conviction was verified by an oppor- tunity, which he had of dissecting the body of a person that had been cured of this disease, and afterwards died of an- other affection -, for, the artery, which had been dilated, was found contracted and in some degree callous. Morgagni relates, that this method of treating aneurisms, is somewhat Hke the plan, which Bernard Gengha tried with ANEURISM. 123 success, as well as Lancisi, and he refers us to the 24th chapter of the 2nd. vol. of the Anatomy of the one, and to lib. 2, cap. 4, of the Treatise on the Heart and Aneurisms, of the other. But, Sabatier tells us, that, in consequence of this in- struction, he examined both these works, without finding any thing on the subject. However this may be, we are informed by the latter, that he has seen the good ef- fects ofthe practice in an officer, who had an alarming aneurysm in front of the hu- meral extremity of the clavicle, in conse- quence of a sword wound in the axilla. The patient, after having been bled se- veral times, was confined to his bed, and kept to an extremely low diet. He was allowed, as drink, only a very acid kind of lemonade. He took pills containing alum, and the swelling was covered with a bag, full of tan mill dust, which was every now and then well wet with port wine. By a perseverance in this treat- ment, the swelling was reduced to a small- ish hard tubercle, having no pulsation, and a perfect cure ensued. (See Sabatier's Medecine Operatoire, Tom.3,p. 170—172.) A French surgeon, named Guerin, has written in favour ofthe efficacy of apply- ing ice water, or pounded ice to aneuris- mal swellings; a plan, which he repre- sents, as being often of itself sufficient to effect a cure. This topical employment of cold applications may be rationally and conveniently adopted in conjunction with Valsalva's practice. The most interesting and convincing facts, hi proof of the efficacy of this mode of treatment, have been lately published at Paris by M. Pelletan. Indeed, upon the whole, I have no hesitation in saying, that I have never read any modern collec- tion of surgical cases, which have appeared tome more valuable, than those which com- pose the Clinique Chirurgicale of this ex- perienced writer. The following extract from a well written critique on this work will serve to convey to tlie reader some idea of the important information con- tained in the memoir on internal aneu- risms. " The intent in the treatment is to reduce the patient gradually to as ex- treme a degree of weakness, as is possi- ble, without imminently endangering life. It is done by absolute rest, a rigorous diet, and bleeding; to these means, M. Pelletan adds the external application of ice, or cold and astringent washes, &c. He has here detailed many cases from his own practice, of partial, or complete success, which cannot be too generally known, as they may be the means of cre- ating in some, and of confirming in others, a good opinion of the only method of treatment, which has been found at all efficacious in a dreadful and not unfix* quent organic disease. " Of the cases here recorded, some ap- pear to have been cured; in others, the treatment had marked good effects. In extreme cases, at best, it afforded but par- tial and temporary relief. We can notice but a few of these cases, which are, in every respect, highly interesting. In one, a robust man, an aneurism at the root of the aorta, with a pulsating tumour of the size of an egg, projecting between the ribs, (the edges of which were already partly absorbed) was reduced, so as to recede within the ribs in the course of eight days. At the end of this time, the patient re- fused to submit any longer. The tumour did not appear again for nearly a year, although he returned to very drunken and irregular habits. He died in about two years and a half, with the tumour again appearing, and much increased in volume. The aneurismal sac communicated with the aorta by a smooth and round opening, opposite to one of the sigmoid valves. There can be no doubt of the efficacy of the treatment in this case ; and it is high- ly probable, that,his health and his life might have been long preserved, but for his own indiscretion. In a case somewhat similar, but not so far advanced, the pa- tient appears to have been cured. There was a swelling on the right side of the breast, about six inches in circumference, with a very strong beating. The pulsa- tion was accompanied by a pain, which stretched towards the scapula and the oc- ciput. It was evident, that the disease was, an aneurism of the great arch of the aorta. The patient was a trier, of a strong frame, who was accustomed to drink free- ly. In the four first days, he was bled eight times, drawing three dishes, " pa- lettes" in the morning, and two in the evening. On the fifth, the pains and the beating were much lessened, but the pulse was still full. He was agjiin bled once. The pulse was in a favourable state, as to strength till the seventh day, when it. again rose, and the man was twice bled. During this time, the man was kept to a most rigorous diet. A cold poultice of Unseed and vinegar was placed on the tumour, and renewed when it became warm. At. the end of eight days, the good effects of this plan were very evident, the pain and the pulsation were gone. The patient, though weak, was in health and tranquil. He was now allowed more food by degrees. At the end of four weeks from the commencement ofthe treatment, he left the Hotel Dieu well. He after- wards led a sober life, became fatter than before, without any vestige of disease^ except a slight and deep pulsation at the 124 ANEURISM. part, in which the aorta may always be felt beating in its natural state. He died, two or three years after, of another com- plaint. His death was not known, and the body was not examined." (See Lon- don Med. Review, Vol. 5, p. 123.) M. Pelletan also cured by similar treat- ment a large axillary aneurism, which was regarded as beyond the reach* of operative surgery. On the thirteenth day, the pa- tient Was reduced to a degree of weakness, which alarmed many of the observers. From that time, all pulsation in the tu- mour ceased. The contents were gradu- ally absorbed ; and the patient returned to his former laborious life with his arm as strong as ever. The pulse at the wrist was lost, in consequence ofthe obliteration of the axillary artery, and the limb only receiving blood through the branches of the subclavian artery. By a beaucoup cTex- emples cPaneurismes gueris spontenemant et sans le secours de Part; (says Pelletan) mais on ne peut leur comparer le cas que nous venons de dec.rire; Vetat extreme de la maladie, Tenergie des moyens employes, et Teffet immediat et successif qrd en est r£- sulte, prouvent assez que le succes a ete dft tout entier d I'art." (Clinique Chirurgicale, Tom. 1, p. 80.) In this work, we find not less than three cases, in which aneurism of "the aorta is stated to have been effectually cured. One instance was greatly relieved; but, the disease returned, the next year, in consequence of the patient's intemperate mode of life. In another example, an aneurism at tiie origin of the aorta was cured; but, the disease recurred in an- other part of that vessel further from tlie hei-rt. Even such cases, as proved incura- ble, to the number of fourteen, all receiv- ed various degrees of palliation from the treatment adopted. I shall now proceed more particularly to the consideration of aneurisms, Which may be cured by a surgical operation, and, here, we shall be fully satisfied, that " Part de gicerir ne triomplie jamais plus lieureuse- ment que lorsqu'il peut employer la mede- cine efficace, e'est d dire, les moyens chirur- gicaux ou operatoires." (Clinique Chirur- • gicale, Tom. 1, j&.'HO.) OF THE POPLITEAL AXEURiaM, AITD OPERATION FOB ITS CURE. The practice of tying arteries, wounded either by accident or in the performance of surgical operations, and even the plan ■st" tying the humeral artery for the cure of the aneurism at the bend of the arm, were known long before the operation for ""fihe relief of the popliteal aneurism was attempted. The considerable size of the femoral artery; its deep situation, the urgent symptoms ofthe disease, and igno- rance of the resources of nature for trans- mitting blood into the limb, after the li- gature of the vessel, are the circum- stances, which appear to Pelletan to have deterred former surgeons from this opera- tion. Valsalva, indeed, had treated pop- liteal aneurisms on the debilitating me- thod, and has adduced one or two equi- vocal proofs of its success. In Pelletan's first memoir on aneurism, and in the third vol. of Sabatier's Mede- cine Operatoire, as I have already stated, are two cases of axillary aneurisms, which were cured by Valsalva's treatment. But, encouraging as such examples may be, experience is not yet sufficiently favoura- ble to this practice to allow it to bear a comparison, in point of efficacy, with the surgical operation, or to justify the gene- ral rejection of this last more certain means of cure. As Pelletan admits, Valsalva's treatment is extremely severe -, the event of it is doubtful; and, should it not be found to answer, it is questionable, whe- ther the patient would be left in a condi- tion to bear the operation, for the success of which, it seems necessary, that, a cer- tain strength of vascular action should ex- ist in order that the blood may be freely transmitted through such arterial branch- es, as are to supply the place of the main trunk, after this last has been tied. The time, therefore, has not yet arriv- ed, when surgical operations for the relief of aneurism should be relinquished. (Pel- letan, Climque Chirurgicale, Tom. 1, p. 114, 115.) The cure of popliteal aneurisms by means of compression is occasionally ef- fected; but, it happens too seldom to claim a great deal of confidence, or to less- en in any material degree the utility and importance of operative surgeiy in this part of practice. Pelletan records the cure of one popliteal aneurism by compression and absolute repose, during eleven months (Tom. 1, p. 115,) *nd other examples might be cited, were it necessary. Aneurisms in general, and, among them, the popliteal case, are all attended with some little chance of a spontaneous cure; yet, this desirable event is too uncommon to be a judicious reason for postponing the operation, especially, as it is the usual course of the disease to continue to in- crease, the cure in the early stage may be more speedily accomplished, and the expe- rience of modern operators leaves no room for apprehending that the anastomoses will not suffice for the due nourishment of the leg, and, consequently, proves, that waiting for the enlargement of the collateral vessels to take place, js alto- ANEURISM. 125 oether an unnecessary and ineligible me- thod. Popliteal aneurisms, as well as •other external tumours of the same na- ture, stand the best chance of a spontane- ous cure, when any cause induces a gene- ral, violent, and deep inflammation all over the swelling; for, then, the commu- nication, between the sac and arteiy, may possibly become closed with coagulating lymph, and the pulsation of the tumour be suddenly and permanently stopped. If, in this state, the disease sloughs, and the patient's constitution holds out, the coa- gulated blood in the sac and the sloughs, are gradually detached, leaving a deep ulcer, wliich ultimately heals. An exam- ple, in which a popliteal aneurism seems to have been cured by such a process, is related in the Trans, of a Society for the Improvement of. Med. and Chirurgical Knowledge, Vol. 2, p. 268. After what has been stated, it is almost unnecessary to say, that, in former times, when all hopes of curing a popliteal aneu- rism by Valsalva's method,, by compres- sion, or a natural process, were at an end, amputation ofthe limb was considered as the sole and necessary means of saving the patienf s life. In modern times, a great and beneficial change of opinion has taken place upon this subject, and not only may the patient's life be in general saved, but his limb also, and this without any opera- tion, that can be compared with amputa- tion, in regard to severity. It is alleged, that Teislere, Molinelli, Guattani, Mazotti, and some other cele- brated Italian surgeons, were the first, who ventured to tie the popliteal artery for the cure of aneurism. The path, as Pelletan remarks, had been pointed out to them by Winslow and Haller, whose va- luable descriptions and plates of the ar- terial anastomoses about the knee joint, shewed by what means the lower part of the limb would be nourished, after a liga- ture was made on the principal arterial * trunk. For almost thirty years, however, the practice of tying tb/ popliteal artery was confined to the Italian surgeons. Pel- letan believes, that he was the first, who attempted such an operation at Paris nearly thirty years ago, (alluding to about the year 1780, the Clinique Chirurgicale being dated 1810.) However, this operation of opening the tumour and tying the popliteal artery it- self, was a severe and often a fatal pro- ceeding, and does not admit of being com- pared with the Hunterian operation, in point either of simplicity, safety, or suc- cess, as I shall explain, after a few parti- culars relating to the popliteal aneurism have been detailed. On whatever side of the artery the tu- mour is produced, -it can be plainly felt in the hollow between the hamstrings, and its nature is as easily ascertained by the pulsation in every part of the tumour. Though the disease may, perhaps, not occur in the popliteal artery so often as in the aorta itself, yet, it certainly is seen more frequently in the former vessel, than any other branch, which the aorta sends oft". As Mr. Home has observed, this cir- cumstance has never been satisfactorily explained, and, what is rather curious, in many recent instances of this disease, the patients have been coachmen and posti- lions. Morgagni found aneurisms of the aorta most frequent in guides, post-boys, and other persons, who sit almost conti- nually on horseback. This he imputes to the concussion and agitation, to which they arc exposed. When we contemplate the effects of va- rious postures of the leg and thigh on the popliteal artery, and the obstruction, which the circulation in it must expe- rience, when the knee is in a state of flexion, we perceive an assignable cause, why this artery should be so often diseas- ed. This account is, in some degree, strengthened by aneurisms of the aorta itself, occurring more frequently at its cur- vature, than any other part. (Home in Trans, of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 1.) The popliteal aneurism is generally supposed to arise from a weakness -in the coats of the artery, independently of dis- ease. If this were true, we might reasona- bly conclude, that, except at tlie.dilated part, the vessel would be sound. Then the old practice of opening the sac, tying tlie arteiy above and below it, and leaving the bag to suppurate sand heal up, would naturally present itself. Mr. Hunter finding, that the arterial coats were al- tered in structure higher up, than the tumour, and that the artery, immediately above the sac, seldom united when tied; but, Jhati when the ligature came away, the bleeding destroyed the patient; con- cluded, that some disease affected the coats ofthe vessel, before the actual oc- currence of the aneurism. Dissatisfied with Haller's experiments on frogs, shew- ing that weakness alone could give rise to aneurism, he tried what would happen in a quadruped, whose vessels were very similar in structure to the human. Hav- ing denuded above an inch of the carotid arteiy of a dog, and removed its external coat, he dissected off the other coats, layer after layer, till what remained was so thin, that the blood could be seen through it. In about three weeks, the dog was killed, when the wound was found closed over the artery, which w as 126 ANEURISM. neither increased, nor diminished in size. It being conjectured, that aneurism was perhaps, prevented, by the parts being immediately laid down on the weakened portion of the arteiy, Mr. Home stripped off the outer layers of the femoral arteiy of a dog, placed lint over the exposed part of the vessel to keep it from uniting to the sides of the wound, and, in six weeks, killed the animal, and injected the artery, which was neither en- larged, nor diminished, and its coats had regained their natural thickness and ap- pearance. These experiments strengthened Mr. Hunter's belief, that aneurismal arteries are diseased; that the morbid affection frequently extends a good way from the sac along the vessels ; and that the cause of failure in the old operation, arose from tying a diseased arteiy, wliich was inca- pable of uniting, before the separation of the ligature. Mr. Hunter's reflections led him to propose taking up the artery in the ante- rior part of the thigh, at some distance from the diseased portion, so as to dimi- nish tlie risk of hemorrhage, and be en- abled to get at the vessel again, in case it should bleed. The flux of blood into the sac being stopped, he concluded, the sac and its contents would be absorbed, and the tu- mour gradually disappear, so as to render any opening of the sac unnecessary. The first operation of this kind, ever done, was performed on a coachman, by Mr. Hunter, in St. George's Hospital, December, 1785. An incision was made on the anterior and inner part of the thigh, rather below its middle, which wound was continued obliquely across the inner edge of the sartorine muscle, and made large, in order to facilitate doing whatever might be necessary. The fascia, covering the artery, was then laid bare, for about three inches, after which the vessel itself could be plainly felt. A cut, about an inch long, was then made through this fascia, along the side of the arteiy, and the fascia dissected off. Thus the vessel was exposed. Having disengaged it from its connexions with the knife and a thin spatula, a double ligature was put under it, by means of an eye probe. The doubled ligature was then cut, so as to% make two separate ones. The artery was now tied with both these ligatures, but, so slightly as only to compress the sides together. Two additional ligatures were similarly applied a little lower, with a view of compressing some length of ar- teiy, so as to make amends for the want of tightness, as it was wished to avoid great pressure on any one part of the vesseL The ligatures were left hanging out of the wound, which was closed with sticking plaster. On the second day, the aneurism had lost one-third of its size, and, on the fourth, the wound was every where healed, except where the ligatures were situated. On the ninth, there was a considerable discharge of blood from the apertures ofthe ligatures, but it ceas- sed on applying a tourniquet and did not recur. On the fifteenth day, after the operation, some of the ligatures came away, followed by a small quantity of matter, and about the latter end of Janu- ary, 1786, tiie man went out of the hos- pital, the tumour having become still less. In the course ofthe spring, some abscesses in tiie vicinity of the cicatrix followed, and some pieces of ligature were dis- charged, from time to time. In the be- ginning of July, a piece of ligature, about one inch long came away, after which the swelling went off' entirely, and the man left the hospital again on the 8th, per- fectly well, tiiere being no appearance of swelling in the ham. This subject,died of a fever in March, 1787, and, on dissection, the femoral ar- tery was found impervious from the giv- ing off of the arteria profunda down to the place of the ligature, and an ossifica- tion had taken place for an inch and a half along the course of this part of the vessel. Below this portion, the vessel was pervious, till just before it came to the aneurismal sac, where it was again closed What remained of the sac was somewhat larger than a hen's egg, and it had no remains of the lower opening into the popliteal artery. The rest of the particulars of this dissection are very in- teresting. (See Med. and Chir. Trans. Vol. 1. p. 153.) This celebrated case led to the know- ledge, that simply taking off the force of the circulation is sufficient to cure an aneurism, the tumour being then taken away by absorption. To confirm the fact, Mr. Home relates a case of femoral aneurism, which got well without an operation, but, on the same principle. A trial of pressure had been made, without avail. The tumour became very large, and such inflamma- tion took place in the sac and integu- ments, that mortification seemed im- pending. In this state, no pulsation could be felt in the tumour, or the arteiy above it. A coagulum, which we know always occurs in an artery previously to mortification, seemingly to prevent bleed- ing, probably formed in this instance, and kept the blood from entering the sac. (Home.) Mr. Hunter's second operation was on ANEURISM. 127 a trooper. Instead of using several liga- tures, which were found hurtful, he tied the artery and vein with a single strong one ; but, unluckily, made the experiment . of dressing the wound from the bottom, instead of uniting it at oftce: the event was, tlie man lost a good deal of blood, and died. After this, Mr. Hunter's practice was to tie the artery alone with one strong ligature, and unite the wound as speedily as possible. ■Since the time of Hunter, several in- novations, and some considerable im- provements in the mode of operating have been proposed. The peculiarity in Mr. Abernethy's first operation consisted in applying two ligatures round the artery, close to where it was surrounded with its natural con- nexions. For this purpose, he passed two common sized ligatures beneath the fe- moral vessels, and having sliifted one upwards, the other downwards, as far as these vessels were detached, he tied both the ligatures firmly. The event of this case was successful. An uneasy sensation of tightness, how- ever, extending from the wound down to the knee, and continuing for many days after the operation, made Mr. Abernethy determine, in any future case, to divide the artery between the two ligatures, so as to leave it quite lax. Mr. Abernethy next relates a case of popliteal aneurism, for which Sir Charles Blicke operated, with the innovation of dividing the artery between the ligatures. The man did not experience the above kind- of uneasiness; and no hemorrhage ensued when the ligatures came away, although there was reason to think, that the whole arterial system had a tendency to aneurism, as there was also another tumour of this kind in .the opposite thigh. Mr. Abernethy has referred bleeding, after operations for aneurisms, to two causes; viz. 1st', the inflammation and ulceration of the arteiy; 2dly. the want of union between the sides of the vessel. "When an artery is laid bare, and detached from its natural connexions, and the middle of such detached portion tied with a single ligature, as was Mr. Hunter's practice, it is observed by Mr. Abernethy, that the vessel, so circumstanced, must necessarily inflame, and be very likely to ulcerate. The occurrence of bleeding led to a practice, which this gentleman justly censures, viz. applying a second ligature above the first, and leaving it loosefi but ready to be tightened, in case of hemorr- hage. As the second ligature, however, must keep a certain portion of the artery separated from the surrounding parts, and must, as an extraneous substance, "jrritate the inflamed vessels, it must make \ts ulceration more apt to follow. For the same reason, Mr. Abernethy thinks pieces of wood, cork, &c. hurtful, and when employed with a view of hindering the ligature from cutting completely through the arteiy, their interposition is not necessary, as such an accident scarce- ly ever occurs, and, as they would prevent the ligature from dividing the inner and muscular coat, (See Hemorrhage) they would tend to prevent the adhesion of the opposite sides of the vessel to each other. When the artery is tied in Mr. Aberne- thy's manner, and is divided in the space between the ligatures, it becomes quite lax, possesses its natural attachments, and is, as nearly as possible, in tlie same circumstances as the femoral artery is, when tied on the surface of a stump. (See Surg, and Physiol. Essays by J. Aber- nethy.) Notwithstanding Scarpa has excelled other writers so muph, in his description of the anatomy and formation of aneu- risms, his practice in regard to the opera- tion, is certainly far inferior to Mr. Aber- nethy's, and that of practitioners in gene- ral in this country. His interposing a cylindrical roll of linen, between the arte- ry and knot of the ligature, and his not bringing the sides of the wound toge- ther immediately after the operation, are particularly objectionable parts of his method. There is one excellence, however, in Scarpa's mode of operating, which I think will soon obtain the universal approba- tion of the surgical profession; he pre- fers making the incision in the upper third of the thigh, or* a little higher than the place where Mr. Hunter used to make the wound. His reason for this, is to avoid the necessity of removing the sartorus muscle too much from its posi- tion, or of turning it back, to bring the artery into view, so as to be tied. 1 have seen the best operators embarrassed, by having the sartorius muscle immediately in their way after the first incision, anil as the vessel is more superficial a little higher up, the place is further from the diseased part of the artery, and there is no hazard of the anastomoses failing to keep up the circulation; this part of Scarpa's practice is highly deserving of imitation. It will in no manner diminish the merit of those men, who have success. fully laboured to improve the present part of the practice of surgery, to state, that the most ancient surgeons seem to 128 AXEUttIS"M have known and practised some of the chief things, upon which the superiority of the plan now adopted appears princi- pally to depend. Such methods having quite sunk into oblivion, and John Hunter not being one who pried into old works, his innovations claim all the ho- nour due to the strictest originality. It is a fact, worthy of notice, that the Greeks were acquainted with the prac- tice, lately recommended, of tying and dividing the trunk of the artery high above the tumour, as will appear from the following extract: (.Etii. 4 Serm. Tetr. 4. cap. 10.) At vero quod in cubiti co- mitate fit aneurisma, hoc modo per chirurgiam aggredimur : primurn arteria superne ab ula ad cubitum per internum brachii parte sim- plicem sectionem, tribus, aut quatuor digitis infra alam, per longitudinem facimus, ubi maxime ad factum arteria occunit.- atque ea paulatim denudatu, deinceps incumuentia cor- puscula sensim excoriamus ac separamus, et ipsamarteriam cxcouncino attractum duobus fili vinculis probe adstringimus, mediamque inter duo vinculo dissecamus; et sectionem pol- linethurisexplemus, ac linamentis inditis con- gruas deligationes adlubemus. Afterwards we are directed to open the aneurismal tumour at the bend of the elbow, and when the blood has been evacuated, to tie the artery twice, and divide it again. If the ancients had only omitted the latter part of their operation, they would ab- solutely have left nothing to be disco- vered by the moderns. What a striking example of the bold manner in which our forefathers have acted, without being guided by the lights of anatomy and phy- siology ! But there are two or three pas- sages in Galen, Celsus, and Hippocrates, from which we may suspect, that even ./Etius himself was not the inventor of this operation, &c. See also Paul. AEgin. lib.6. cap. 37. (Rees'Cyclopedia, Art. Aneu- rism.) The French surgeons of the present day are exceedingly jealous about the improvements, which British practi- tioners have been the means of introduc- ing into this branch of surgery. Pelletan declares, that, with regard to dividing the artery between the ligatures, his countryman M. Tenon, used to advise this practice forty years ago. (Clinique Chirurgicale, Tom. 1, p. 192.) Yet we find that M. Tenon himself must give up the claim of priority to -"Etuis, and other an- cients. The merit of the thing appears to me to consist in the revival of the practice, and in insisting on its advan- tages, with sufficient stress to make it extensively approved. M. Richerand seems also offended, that Hunter's name should be affixed to an operation, wliich he conceives wax in reality the invention of Guillemeau. Here we observe, A-:tius again puts in a prior claim, and, with much more effect, be- cause his operation truly resembled Mr. Hunter's, inasiiiuch as it was done at some distance above the swelling, while Guillemeau only tied the artery close above the disease, and opened the swell- ing, a serious deviation from the Hunterian practice. Guillemeau (says Richerand) a con- temporary, and disciple of Ambrose Pare, having to treat a tumour of blood, at the bend ofthe arm, in consequence of bleed- ing, exposed the artery above the tu- mour, tied this vessel, then opened the sac, took out the coagulated blood con- tained in it, and dressed the wound, which healed by suppuration. After more than a century, Anel, on being con- sulted about a similar case, tied the ar- tery above the swelling, but left this to itself. The pulsations ceased, the tu- mour became smaller, and hard, and after some months, no traces of the dis- ease were perceptible. In 1785, Desault operated in the same manner for a popliteal aneurism: the swelling diminished by one half, and the throbbings ceased; on the 20th day, it burst, coagulated blood and pus were discharged in large quantities, and the wound, after continuing a long time fis- tulous, at length healed. Towards the ' end of the same year, says Richerand, Hunter applied the ligature somewhat differently; instead of placing it close to the swelling, or directly above it, he put it on the inferior part of the femoral ar- tery. (See Riclierand's Nosographie Chi- rurgicale, Tom. 4, p. 98, 99, edit. 2.) Unquestionably, M. Anel did in one solitary instance, tie the humeral artery immediately above an aneurism at the bend ofthe arm, and effected a cure with- out opening the swelling; but he did not think of applying the plan to the femoral artery, or draw the attention of the French surgeons sufficiently to the mat- ter, to make the latter imitate his opera- tion: on the contrary, the method fell into oblivion, and was never practised. With regard to Desault's operation, said to have been done in an earlier part of 1785, than-Mr. Hunter's first operation, it is only necessary to say, that Desault tied the popliteal arteiy itself, while the grand object in Mr. Hunter's method was to take up the femoral artery, at a dis- tance from the disease, and that it is this last mode alone, which has gained such approbation, and been attended wjth un- paralleled success. Mr. Astley Cooper lias published a cast ANEURISM. 129 ui popliteal aneurism, in which a parti- cular occurrence happened, that led this gentlemrn to make a little innovation in the method of tying arteries for the cure of aneurisms. The femoral artery had been tied with two ligatures, as firmly as could be done without risk of cutting it through. " But, (says Mr. A. Cooper) as I was proceed- ing to dress tlie wound, I saw a stream of blood issuing from the artery, and when the blood was sponged away, one of the ligatures was found detached from the vessel. Soon after the other was also forced off, and thus the divided femoral artery was left without a ligature, and unless immediate assistance had been afforded him, the patient must have pe- rished under hemorrhage." The same kind of accident has occurred in Mr. Cline's practice. These events naturally induced Mr. A. Cooper to reflect on the means, wliich were to be employed to obviate them, and the first which suggested itself was to in- clude a larger portion of the artery be- tween the two ligatures. But this plan was given up, when it was recollected, that many branches of arteries must be divided, and that it was a mode of secu- rity (if it was so) which could only apply to particular cases of aneurism, since in some situations of that disease, there is scarcely any length of vessel between the tumour and a principal anastomosing branch of the artery. Mr. A. Cooper thinks, that a plan of greater security, and more general appli- cation, consists in conveying the ligatures, by means of two blunt needles under the artery, an inch asunder, and close to the coats ofthe vessel, excluding the vein and nerve, but passing the threads through the cellular membrane surrounding the artery. When these are tied, and the artery is divided between them, the liga- tures will be prevented from slipping from the artery by the cellular membrane through which they are passed. Mr. A. Cooper next relates a case of aneurism after bleeding, which he cured by this way of operating. "But although this plan, as to the event, answered my expectations, yet a different mode of securing the ligature, suggested to me by my young friend Mr. H. Cline, struck me so forcibly for its simplicity and security, that I felt imme- diately disposed to adopt it." Mr. A. Cooper put the new plan to the test of experiment in operating for a popliteal aneurism on Henry Figg, aged 29. " An incision being made on the middle of the inner part of the tliigh, and the femoral arterv exposed, the arterv Vol. I. was separated from 'he vein and nerve, and all the surrounding parts, to tiie ex- tent of an inch, and an eye-probe, arm;. J with a double ligature, having a curved needle at each end, was conveyed under the artery, and the probe cut away. The ligature nearest the groin was first tied ; the other was separated an inch from the first, and tied also. Then the needles were passed through the coats of the ar- tery, close to each ligature and between them. The thread they carried, was tied into the knot of the ligature, which had been already secured around the vessel; and thus a barrier was formed in the ar- tery, beyond which the ligature could not pass." The event of this operation was successful. (Med. and Pliys. Journ. Vol.8.) Upon the foregoing proposal a few ob- servations are necessary, and these I shall offer with due deference to the eminent character, whose fame alone has attached undue importance to the innovation. In the first place I shall prove that Mr. H. Cline's proposal is not an original one. It appears to have been mentioned by Dionis, and to have been noticed by some subsequent writers. In the 13th chapter, on hemorrhage, in Richter's An- fangsgrundetier Wundarzneykunst,we read the following passage. Die hervorgezog- ne Schlagader umwickelt man mit dem gewo"hnlichen Faden zweymal, befestigt den- selben miteiiwm Knoten, ziehet daruufwenn die Schlagatler gross ist, vermittelsteinerNa- del ein ende des Fadens vor tier Unterbm- dilng durch dieselbe, knuft beyde Enden zu- sammen,und la'sstsie wie gewo" hnlich her ab- ha'ngen. Dritte Aufiage. 1799. " The ar. tery, when drawn out, is to be twice sur- rounded with the common ligature. This is to be tied in a knot, and when the ar- tery is large, one end of the ligature is to be passed, by means of a needle, through the vessel before the knot, then both ends are to be tied together, and left hanging out of the wound, as in the ordinary way." Edition 3. 1799. In making this quotation, my object is to remove the supposition, that the world is indebted to Mr. H. Cline for the suggestion, if we may use the term indebted, when the plan has certainly very little merits and would undoubtedly never have acquired much celebr*tv, had not Mr. A. Cooper's name een coupled with it. What power can possibly force the liga- ture, when tied with due tightness, off the extremity of the vessel ? If Mr. A. Cooper had reflected a little, he would have seen, that no action of the heart, or artery itself, no turgid state of this vessel, could do so. If a piece of string were tied round any tube for the purpose of 130 ANEURISM preventing a fluid from escaping from its mouth, provided the string is applied with due tightness, no fluid can possibly escape, however great the propelling pow- er may be, supposing that the string, and structure of the tube, do not break. If the ligature be applied so slackly as to slip, who can doubt, that a hemorrhage will stdl follow, even though the ligature is carried through the end of the vessel, and tied in the way mentioned above. In the case, in which tlie ligature slip- ped off, as mentioned by Mr. A. Cooper, we must, therefore, conclude that the ar- teries were not tied with a sufficient tight- ness, perhaps through an unfounded fear that a ligature, might cut its way com- pletely through all the coats of an arteiy. The inner coats of the artery we know, from the experiments of Dr. Jones, are invariably cut through when the vessel is properly tied, and the circumstance is al- ways useful in promoting its closure. OF ANEURISMS HIGH UP Til's FEMORAL ARTERY. Mr. Aberoetliy has been called upon in at least four cases to take up the exter- nal iliac artery. The events of all these have shewn, that the anastomosing vessels were fully capable of conveying blood enough into the limb below, and that a vessel even of this size could become per- manently closed after being tied. Messrs. Freer and Tomlinson, of Birmingham, have both also done tlie same operation with success. Our limits, however, will only allow us to describe the operation, and the particulars must be consulted in Abernethy's Surg, and Physiol. Essays; his Surgical Observations, 1804; Edinb Sled. and Surg. Journal for January, 1807; and Freer's Observations on Aneurism, 1807. J.n Mr Abernethy's first operation of tins kind, an incision, about tlu-ee inches in length, was made through the integu- ments of the abdomen, in the direction of the artery, ,and thus the aponeurosis of the external oblique muscle was laid bare. This w:is next divided, from its connexion with Poupart's ligament, in the direction of the external wound, for the extent of about two inches. The margins of the internal oblique and transverse muscles being thus exposed, Mr. Abernethy ia- troduced his fingers beneath them to protect the peritoneum, and then divided them. Next he pushed this membrane with its contents upwards and inwards, and took hold of the external iliac artery with his finger and thumb. It now only remained to pass a ligature round the artery,and tie it;Tmt, this required cau- tion, on account of the contiguity of tlie vein to tlie artery. These Mr. A, sepa- rated with his fingers, and introducing a ligature under the artery with a common surgical needle, tied it about an inch and a half above Poupart's ligament. {Sur. Essays) The following was the method Mr. Abernethy adopted the second time of tying the external iliac artery. An incision of three inches in length was made through the integuments ofthe abdomen, beginning a little above Pou- part's ligament, and being continued up- wards ; it was more than half an inch on the outside of the upper part of the abdo- minal ring, to avoid the epigastric artery. The aponeurosis of the external oblique muscle being thus exposed, was next di- vided, in the direction of the external wound. The lower part of the internal oblique muscle was thus uncovered, and the finger being introduced below the in- ferior margin of it and ofthe transversalis muscle, they were divided with the crook- ed bistoury for about one inch and a half. Mr. Abernethy now introduced his finger beneath the bag of the peritoneum, and carried it upwards by the side of the psoas muscle, so as to touch the artery about two inches above Poupart's liga- ment. He took care to disturb the peri- toneum as little as possible, detaching it to no greater extent than would serve to admit his two fingers to touch the vessel. The pulsations ofthe artery made it clear- ly distinguishable, but Mr. Abernethy could not get his finger round it with fa- cility. He was obliged to make a slight incision on either side of it, in the same manner as is necessary when it is taken up in the thigh, where the fascia which binds it down in its situation is strong. After this the forefinger could be put be- neath the arterv, which Mr. A. drew gently down, so as to see it behind the perito- neum. By means of an eye-probe, two ligatures were conveyed round the vessel; one of these was carried upwards as far as the artery had been detached, and'the other downwards: they were firmly tied, and the vessel was divided in the inter- space between them. (Sur. Observ. 1804 ) Mr. Abernethy, in his third instance of tying this vessel, operated exactly as in the foregoing case, and with complete success. (See Edinb. Sur?. Jour. January 1807.) Mr. Freer, in his operation, made an incision about one inch and a half from the spine ofthe ilium, beginning about an inch above it, and extending it down- wards about three inches and a half no ANEURISM. 131 as to form altogether an incision four inches uid a half long, extending to the base of the tumour Tiie tendon of the external oblique being exposed, was care- fully opened, and also the internal ob- lique, when the finger was introduced be- tween the peritoneum and transversalis, and served as a director for the crooked bistoury, which divided the muscle. Avoiding all unnecessary disturbance, Mr. Freer separated tlie peritoneum with his finger, till he could feel the artery beating, which was so firmly bound down, that he could not get his finger under it without dividing its fascia. The vessel being separated from the surrounding parts, a curved blunt needle, armed with a strong ligature was put under it, and tied very tight, with the intention of di- viding the internal coats of the vessel. The operation led to a perfect cure. (Freer on Aneurism, p. 83.) Mr. Tomlinson applied only one liga- ture, and, of course, left the artery undi- vided ; the event was attended with per- fect success. Since the first edition of this publica- tion, tiie operation of tying the external iliac artery has been performed in nume- rous examples, and, I am happy to say, that most of the events of these cases have been highly favourable to a conti- nuance ofthe practice. Mr. Astley Cooper has taken up this vessel in several in- stances, and saved his patients from im- minent death. Even on the other side of the Atlantic, the operation has now been practised with the most successful con- sequences. Such facts must be highly gratifying to Mr. Abernethy, through whose'•judgment and boldness, the me- thod was first suggested and practised. In my opinion, had this gentleman made no other improvement in his profession, this alone ought to crown him with un- fading honours. The practice seems to astonish our neighbours, who appear al- most to withhold their belief: " Lorsqu un aneurisme a commence vers la partie la plus ehee de la crurale, au moment meme ou elle vient tic sortir de V abdomen, peut-on se permettre iTinciser la partie iiiferieure de eette cavite", de couper I arcade crurale, et tie chercher Partere iliaqne cxterne, pour Pern- brasserpur la ligature? S'il enfullait croire des observations inserees dans la B/b/i- otheque britanmque, cette operation hardie aurttit ete fuite avec succes a Londres, pur le docteur Abernethy, dans un cas iPiineii- risme du commencement tie la crurale; ce. partickn n'hesita pas, tlit on, de penetrer dans le bassin, en incisant le ligament tie Fallope; mais, en mettant de cote la difftculte d' Poperation dans laquelle on estoblige de travailler en sous-auvre, et suns que la vue puisse guiderP aiguille,que Pon passe aut our du vaisseau, la ligature simultanee, de la veine iliaque, et desnerfs places sur les cotes du detroit superieur du bassin, occasionnera la grangrene. Quels vaisseaux continueront d nourrir le membre dans le defaut presque absolu tPanastomoses ? Enfin, dans la sup- position peu probable, qu'il ne tombdt pas en gangrene, ties hernies enormes seraient Pin- "evitable resultat de Paffaiblissement des parois abdominales." (Richerand, Nosogra- phie Chirurgicale, Tom. 4, p. 106—107, edit. 2.) In this passage, M. Richerand is full of error; he supposes an easy operation difficult; he forgets all the amastomosing arteries, which are branches of the in- ternal iliac, and emerge from apertures ofthe pelvis; and he is impressed with a thorough expectation of gangrene, her- ni-x, &c. which, in fact, have never arisen, in consequence of this operation. But, it is enough to say in reply to this gentleman, that he is arguing against cases, many of which were in public hospitals, and seen by hundreds of spec- tators. Some of the cases, on which Mr. Aber- nethy operated, I was an eyewitness of, and can therefore bear testimony to the ease and simplicity of the necessary ope- ration. The external iliac artery was most readily tied the beginning of the present vear, 1812, by Mr. llumsden, when the aneurismal swelling rose much higher than Poupart's ligament. The patient, it is true, died; but, his age was not less than 70; and, yet, notwithstanding this circumstance, the limb had a full supply of blood, and not the least tendency to gangrene shewed itself [The operation was first performed in America, in August 1811, by the editor of the present work. The result was com- pletely successful.—The use of a curved forceps, for the purpose of conveying the needle round the artery, was found to facilitate the operation very greatly.—For a particular account of the case, the reader is referred to Dorsey's Elements of Surgery.] The many operations, which have now been done'on the external iliac artery, have impressed me with a conviction, that, in subjects under a certain age, 1 here is no reason to fear, that the anastomoses, will not suffice for the supply of the lower extremity. 1 h.ve heard of no instance to the contn.ry, and, should such an event ever happen, it cannot be common, nor ought it, as, being only an unusual occurrence, to be admitted as a just rea- son for deluy, until the collateral vessels hive hud time to enlarge. 1 believe, that, in all aneurismal diseases, early 132 ANEURISM. operating is tlie best, and most judicious practice. I say this, not without recol- lecting, that all aneurisms "are attended with a chance of getting spontaneously well in time. 1 saw the inguinal aneu- rism, which did so, under Mr. Albert, in the York Hospital, but as this also is a rare incident, I da not .believe that it ought to influence us against having speedy recourse to an operation. Besides, the cure by inflammation and sloughing, ap- pears to me to be attended in reality with more peril, than a well executed opera- tion, and, consequently, has less recom- mendations, than many may imagine. Had not Mr. Albert's patient been a very strong man, he would certainly have fallen a victim to the extensive disease, which the burs-ting and sloughing of tlie tumour created. ANEURISMS OF THE BRAC»iHr. AIITKKT, AND THE OPEHATJON FOR THEM. Surgical wTitings contain many histo- ries of aneurisms in the bend of the arm, produced by the puncture of the brachial artery in venesection, or caused by a deep wound inflicted ut the bend of the arm, along the inner side of the humerus, or in the axilla. Such cases must indisputably be formed by effusion. Although Morand, &c. have found, lhat along with aneu- risms, caused by a wound of the brachial artery, the diameter of the vessel is some- times unusually enlarged through its whole length, above (he seat of tl:*£ tu- mour, this e<*lurgemeiit, which is very rare, might have existed naturally, before the puncture occurred. Even were it frequent, such an equable longitudinal expansion of the tube of the artery could not explain the formation of the aneu- rismal sac in the bend of the arm, along the inner side of the humerus, or in the axilla, after wounds. (Scarpa,p. 160.) The proximate cause of these cases may invariably be traced to the solution of continuity in the two proper coats of the artery, and the consequent effusion of blood into the cellular substance. The effect is the same, whether from an inter- nal morbid affection, capable of ulcerat- ing the internal and fibrous coats of the artery, the bhxd be effused into the neighbouring cellular sheath surrounding the artery, which it raises after the man- ner of an aneurismal sac ; or, tlte wound of the integuments having closed, the blood issue from the artery, and be dif- fused in the surrounding p-irts. The cellular substance, on the outside of the wounded vessel is first injected, as in ecchymosis; the blood then distends it, and elevates it in the form of a tumour, and, the cellular divisions being destroyed, converts it at last into a firm capsule, or aneurismal sac. (Scarpa p. 167.) The circumscribed or the diffused na- tufe of tlie aneurism, and the rapidity or slowness of its formation, depend on the greater or less resistance to the impetus of the blood, during the time of its effu- sion, by the interstices of the cellular sub- stance surrounding the artery, and by the ligamentous fasciae and aponeuroses, ly- ing over the sac The aponeurosis of the biceps muscle, being only half an inch broad, and situated lower than the com- mon place for bleeding, cannot, at least, in most cases, materially strengthen the cellular substance surrounding the artery, as is commonly supposed. (Scarpa, p. 168—170.) This author refers the greatest resistance to the intermuscular ligament, wliich after having covered the body of the biceps muscle extends over the whole course of the humeral artery, and is im- planted into the internal condyle. This ligamentous expansion has a triangular shape, the base of which extends from the tendon of the biceps, to the internal con- dyle, while the apex reaches upward along the inner side of the humerus to- wards the os bracliii. The humeral ar- tery and median nerve, kept in their situ- ation by the cellular sheath, and this ligamentous expansion run in the furrow, formed between it and the internal mar- gin of the biceps. (Scarpa, 171.) This author anatomically explains many cir- cumstances relative to the diffusion, cir- cumscription, shape, &c. of brachial aneu- risms, from this intermuscular ligament. While aneurisms, from an internal cause, are not unfrequent in the aorta, thigh, and ham, they are very rare in the brachial artery; but, such instances, however, arc recorded. (Scarpa, 174.) The mode of distinguishing a wound of the brachial artery, in attempting to bleed, and the method of trying to effect a cure by pressure, are described in the article Hemorrhage. Anel is said to have been the first who tied tlie brachi:-! artery, for the cure of aneurisms in the s-rm, in the same way that Hunter did the femoral, for the cure of those in the ham, viz. within one ligature above the tumour, without mak- ing any incision upon, or into, the sic itself. The operation is performed as fol- lows :—the surgeon having traced the course of the brachial artery, and felt its pulsations above the aneurism, he may either cut down to the vessel immediately above the tumour, or much higher in the long space between the origins ofthe supe- rior and inferior collateral arteries. The ANEURISM. 133 integuments are to be divided in the course ofthe artery, and also the cellular sheath, for the space of about two inches and a half. The surgeon now introducing his left fore-finger to the bottom of the wound, will feel the denuded vessel, and, if it is not sufficiently bare, he must di- vide the parts which still cover it, op- serving to introduce the edge ofthe knife, on the side next to the internal margin of the biceps, to avoid dividing any of the numerous muscular branches, which go off from the opposite side of the arteiy. He is then to insulate, with the point of his finger, the trunk of the vessel, alone if he can, or together with the median nerve and vein, and raise it a little from the bottom of the wound. He is to se- parate the median nerve and vein, for a small space from the artery, and with an eyed needle is to pass a ligature under the latter, and then tie it with a simple knot. Whoever, after these directions, says Scarpa, shall have the treatment of a cir- cumscribed aneurism in tlie bend of the arm, -will no longer, it is to be hoped, fol- low the method of those, who, supposing the tumour to be formed by the dilatation of the artery, used first to divide the in- teguments over the tumour, insulated the sac, and sought for the vessel above and below the aneurism, in order to tie it in two places; and then endeavoured to make the sac slough away. The opera- tion is now reduced to the greatest sim- plicity, viz. tying the artery merely above the tumour. (See Scarpa, p. 358, 359.) When the aneurism is diffused, and ac- companied with violent inflammation and swelling of the whole arm, from the ex- cessive distention of the clots of effused blood, Scarpa recommends the old ope- ration of opening the tumour, and tying the artery at the bottom of the sac, above and below the wound made by the lancet. In this method it will be proper to apply a tourniquet to the upper part of the arm, near the axilla; or, if the limb should be very painful and swelled, it is better to let an assistant compress tlie artery from above the clavicle, against tlie first rib. The incision having been made into the tumour, and the biood discharged, a probe is to be introduced into the puncture in the vessel, from below upwards, so as to raise the arteiy. This, being separated from the parts beneath, and the median nerve, for a small extent, is to have two ligatures put under it, one of which is to be tied above, the other below, the wound in the vessel. Then tlie tourniquet," or pressure is to be taken off', and if there be no bleeding, the wound is to be brought together. (See Scarpa, p. 359.) MH. £A-UB1RT's FltOPOSAt. Having observed, after an operation performed in the common way, by a liga- ture above and below the aperture in the artery, such violent pain, swelling and inflammation, as threatened gangrene bf the limb, and which symptoms, when mi- tigated, left the arm weak, and with a much more feeble pulse, than in the other arm, this gentleman Wished to see the operation done, so as to make less disturb- ance of the chculation. " I recollected," he remarks, ••* all that I had seen or read ofthe effects of styptics, of pressure, and of ligatures, in the cure of hemorrhages. I considered the coats and motions of ar- teries, and compared their wounds with the wounds of veins and other parts. I reflected upon the process of nature in the cure of vVounds in general, and con- sidered, in particular, how the union of divided parts was brought about in the operation of the harelip, and in horses necks, that are bled by farriers. Upon the whole, I was in hopes, that a suture of the wound in the artery might be suc- cessful ; and, if so, it would certainly be preferable to tying up the trunk of the vessel. 1 communicated my thoughts to Mr. Hallowell, Mr. Keenlyside, and some other friends of the profession. A case of art aneurism from bleeding occurred, and fell to Mr. Hallowell's lot. I re- commended the method ? have hinted. He put it in execution June 15, 1759. Every thing w is done in the usual me- thod, till'the artery was laid bare, and its wound discovered; and the tourniquet being now slackened, the gush of blood per saltum shewed there was no deception. Next, two ligatures, one above the ori- fice, and one below, were passed under the artery, that they m'ght be ready to be tied at any>time, in c:*s< the method pro- posed should fail. Then a small steel pin, rather more than a quarter of an inch long, was passed through the two lips of the wound in the artery, and secured by twisting a thread round it, as in the hare- lip. This whs found to stop the bleed- ing, upon "Which the arm was bound up, the patient put to bed, and ordered to be kept quiet, &c. The pin came away with the dres.*-i-..gs, June 29, and July 19th, tlie patient was discharged from tiie hos- pital perfectly well, and with a pulse in that arm nearly as strong as in the other.. Indeed, the pulse was very little altered immediately after the operation ; it was weakened in a small degree, as might be expected from the diameter of the vessel being straitened , but it was so strong and equal, that we had not the least doubt of the blood's continuing to circu- 134 ANEURISM. late freely through it." (Medical Obser-- vations and Inquiries, Vol. 2.) We need hardly inform the reader, that the idea of healing the wound in the ves- sel, so as to preserve the pervious state of it, is a mere hypothesis, certainly never realized by adopting Mr. Lambert's me- thod. If ever a small puncture of an ar- tery heals, so as to leave the tube pervi- ous, it is under the circumstances pointed out by Dr. Jones. (See Hemorrhage.) Had Lambert had an opportunity of examin- ing the state of the vessel, sometime after the above operation, he would have found its canal obliterated; and the preserva- tion of the perviousness of the artery be- ing the only foundation for Lambert's method, the practice must of course fall to the ground. AXILLABT ANEURISMS. Aneurisms occasionally take place in the axilla, and rather than that the pa- tient should perish of hemorrhage, it is the duty of the surgeon to tie the subcla- vian artery, if it be necessary, even as far inward, as where it proceeds over the first rib. A question, which here natu- rally presents itself is, whether the sur- geon should attempt the operation in an early period of the disease, or wait till circumstances are urgent; the aneurism large and far advanced; tlie arm cede- tnatous and insupportably painful; and the tumour in danger of bursting? It cannot be denied, that, in all cases of aneurism, there is a certain chance of the disease getting spontaneously well; and one axillary aneurism in a man in St. Bartholomew's Hospital a few years ago, had certainly disappeared of itself, as was proved by the account which the man gave of the case while living, and by the obliteration of the artery, found on in- spection after death. I believe, however, we ought not to suffer our conduct to be too much influ- enced by the hope of so unfrequent an event, and, from the observations, which I have made on this subject, I am now decidedly- of opinion, that the operation should never be delayed, so as to allow the tumour to acquire an immoderate size. The operation is always difficult; but, the difficulty is seriously increased, when the swelling has extended far to- wards the breast, and has become so large as to push considerably upwards the ciavicle. The memorable and inter- esting examples, in which Mr. Keate and Mr. R.imsden tied the subclavian artery, have shewn, that the anastomoses are fidly competent for the supply ofthe limb with blood, and, I think, that delaying the operation, with a view of allowing the inosculating arteries to enlarge, is not necessary, and, as giving time for the swelling to increase, ought to be con- demned. At all events, the tumour should never be suffered to acquire an enormous size. A wound of the axillary artery, might render it necessary to do this operation. This vessel was tied by a Mr. Hall, in Cheshire, when it had been wounded with a scythe, so as to bring the ends of the artery into view; and the arm was pre- served, though it remained afterwards i little weak, which, indeed, might be ow- ing to some large nerve being divided. (See Scarpa,p. 372.) Mr. White, of Man- Chester, relates another instance of this vessel being tied, in the case of a wound; but, mortification of the limb, and death followed. Three of the nerves were found included in the ligature- London Medical Journal, Vol. 4.) There are two modes of operating for axillary aneurisms; one by cutting below the clavicle; the other by making the wound above this bone. The first of these methods has been at- tempted in France by Desault and Pelle- tan. The former undertook the opera- tion in a case, where the axillary artery had been wounded. An incision, six inches long, was made below the external third of the clavicle; two thoracic ar- teries cut were immediately tied; the two lower thirds of the great pectoral muscle were next divided with a bistoury guided on a director; a large quantity of co»- gulated blood was now discharged; and the artery was directly taken hold of, and tied, together with tiie brachial plexus of the nerves. The arm mortified, and the patient died. This case, we must agree with Scarpa, was not a fair trial of the operation, inasmuch as the inclusion of the plexus of nerves in the ligature was an improper measure, and must have promoted the occurrence of sphacelus. It seems also probable from the account, that the vein was likewise tied; another serious and objectionable proceeding. Besides, it is worthy of notice, that the case was a wound of the axillary artery, attended with a copious effusion of blood in the cellular membrane, hi all exam- ples of this kind, gangrene is more readily induced, than when the case is a mere circumscribed aneurismal tumour. (See GCuvres Chir. tie Desault par Bichat, Tom. 2, p. 553.) As for Pelletan's example, it hardly deserves recital, because the ope- ration in fact was not achieved. His col- leagues objected to dividing the pectoral muscle ; a random thrust was made with a needle and ligature; but, the artery ANEURISM. 1-35 was not included, and the experiment was not repeated. (See Clinique Chirurgicale, Tom. 2, Obs. 7, p. 49.) In a case of axillary aneurism, which had actually burst, and the hemorrhage from whicli could only be stopped by pressing the artery against the first rib, Mr Keate, the surgeon-general, practised the following operation, which was- at- tended with completely successful conse- quences. This gentleman determined on taking up the artery, above the diseased and ruptured part, in its passage over the first rib. Accordingly, he made an inci- sion obliquely downwards, divided the fibres of the pectoral muscle, that were in his way, and, when he came to the artery, passed a curved, blunt-pointed, silver needle, armed double, as he conceived, under the artery, and tied two of the ends. After a careful examination, finding that the artery pulsated below the ligature, he determined on passing another liga- ture higher up, and nearer to the clavicle: lie, therefore, passed the needle more deeply, so as evidently to include the ar- tery. In a few days the swelling of the arm began to subside, the wbund suppu- rated, and the ligatures came away with the dressings. The arm afterwards re- covered its feeling, and the patient re- gained, in a great measure, .the.entire motion of the .shoulder, &c. (See Med. Review and Magazine for 1801.) Mr. Keate's operation is objectionable, inasmuch as it was a dive made with a needle, and attended with great danger of wounding and. tying parts, which should be left undisturbed. The subclavian artery might be got at below the clavicle, as follows : the sur- geon is to make an incision, through the integuments, about an inch from the sternal end of this bone. The cut is to run in the direction towards the acro- mion, deviating a little downward from a line parallel to that of the clavicle. This wound will bring into view some fibres of the great pectoral muscle originating from the last mentioned bone. These are next to be divided. Some cellular substance will be found underneath, which is to be carefully raised with a pair of dissecting forceps, and cut. The operator will thus arrive at the great subclavian vein, and cephalic vein uniting with it. Under the subclavian vein, and a little further backward, more under the clavicle, the subclavian artery may be felt and tied. (See Charles Bell's Operative Sur- gery, Vol. 2. p. 370.) The axillary artery may be got at by making an incision above the clavicle, and it is undoubtedly not a very difficult plan to accomplish in the dead subject, without any tumour under the clavicle*. But it is more difficult in a living subject, having a large axillary aneurism ; for, then the clavicle becomes so much ele- vated, and the artery lies so deeply be- low it, that the vessel can hardly have a ligature carried under it, without a par- ticular needle for the purpose. This was the case in an attempt which I once saw made to tie the artery, and in which one of the cervical nerves, affected by the pulsation of the artery, was mistaken for it, and tied, so that the aneurism soon afterwards burst, and a fatal hemorrhage arose. Were a surgeon to operate above the clavicle, he should adopt the follow- ing plan:—-An incision should be made just over the sternal end of the clavicle, and the clavicular portion of the sterno- cleido-mastoideus muscle be detached with a blunt pointed curved bistoury. No further use should be made of a cat- ting instrument. The chief difficulty would now be, to get a ligature under the arteiy; but, it may be done with the aid of an ingenious needle, which Mr. Ramsden has described, and which is ex- actly similar in principle to one employed by Desault, called by the French, aiguille d ressort. As the artery communicates its pulsations to the cervical nerves in the vicinity, the operator should be particu- larly careful not to mistake one of them for the vessel itself. In order to avoid the inconveniences of the needles ordinarily used for conveying ligatures under deep arteries, Desault (says Bichat) inventea " une aiguille 4 ressort," composed of a silver tube, or sheath, which was straight at one end, and bent at the other in a semicircular form. This sheath enclosed an elastic wire, the projecting extremity of which ; was accurately fitted to the end of the sheath, and perforated with a transverse eye. The instrument was passed under the arteiy, and, as soon as it had reached the other side of the vessel, the sheath was kept fixed, while an assistant pushed the elastic wire, which, rising from the bottom ofthe wound, presented the aper- ture or eye to the surgeon, who now pass- ed the ligature through this opening. The wire was next drawn back into its sheath again, and the whole instrument brought from beneath the artery, by which means, the ligature was conveyed under the vessel. (See OZuvres Chirur- gicale de Desault, par Bichat, Tom. 2, p. 560.) The invention of this needle makes a material diminution in tlie difficulty of taking up the subclavian artery from above the clavicle; nor, can it be won- dered, that, without such an instrument; Io* ANEURISM. the operation should have baffled even so skilful a surgeon as Mr. A. Cooper. The following example is the first in which the attempt to *e tiie subclavian artery, by cutting above the clavicle, was ever accomplished. I conceive, that it reflects great honor on Mr. Ramsden, vrtio undertook it, and who preferred ex- posing himself to a failure, rather than omit the only possible means of saving his patient from an imminent death. John Townly, a tailor, aged thirty-two years, addicted to excessive intoxication, of an unhealthy and peculiarly anxious countenance, was admitted into St. Bar- tholomew's Hospital, on Tuesday, the 2d of November, 1809, on account of an aneurism in the axilla of his right arm, which had been coming on about four months. The prominent part of the tu- mour in the axilla was about half as big as a large orange, and there was also much enlargement and distention under- neath the pectoral muscle, so that the elbow could not be brought near tiie side ofthe body. " The temperature of both arms," says Mr. Ramsiten, "was alike, and the pulse in the radial artery of each of them was correspondent. After the patient had been put to bed, some blood taken from the left arm, and his bowels emptied, his pulse, which, on his admission had been at ISO, became less frequent; his coun- tenance appeared more tranquil; and he experienced some remission of the dis- tressing sensations in the affected arm: this rehef, however, was of short dura- tion ; the weight and incumbrance of his arm soon became more and more oppres- sive, and, in resistance to eveiy medical assistance, his nights were again passed without sleep, and his countenance re- assumed the anxiety, which had charac- terized it,-when he first presented him- self for advice. " On the sixth day, after his admission, his decline of health became so very evi- dent, and the progressive elevation ofthe clavicle, from the increasing bulk of the tumour, was so decidedly creating addi- tional difficulties to any future operation, that I considered it necessary to convene my colleagues, and avail myself of their opinions, as to the propriety of perform- ing the operation; when it was agreed in consultation, that as the tumour, (al- though increasing) did not appear im- mediately to endanger the life of* the pa- tient, from any probability of its burst- ing suddenly, it would be adviseable yet to postpone the operation, for the purpose of allowing the greatest possible time for the anastomosing vessels to become en- larged ; and, in the meanwhile, that the case should be most vigilantly watchei!. "About this period of the case, tlie pulsation of the radial artery of the af. fected arm gradually became more ob- scure, and soon after either ceased entire- ly, or, what is more probable, was lost in the succeeding oedema ofthe forearm and hand, both of which became loaded to a great extent. "Notwithstanding the aneurismal tu. mour had continued to increase, and the patient's health had proportionately de. clined, yet no particular alteration was observed on the integuments, until I vi. sited him in the evening of the twelfth day after his admission, when I found him complaining of more than usual we«. riness and weight in the affected limb, and painfully impatient for the impos- sibility, as he described it, of finding a posture for the arm. " On examining the tumour, a dark spot appeared on its centre, surrounded by in. flammation, which threatened a more ex. tensive destruction of the skin. Under these symptoms and appearances, no far- ther postponement of the operation being admissible, I performed it the next day in the following manner. " The patient being placed upon an operating table, with his head obliquely towards the light, and the affected arm supported by an assistant at an easy (lis- tance from the side, I made a transverse incision through the skin and platysma myoides along and upon the upper edge of the clavicle, of about two inches and a half in length, beginning it nearest to the shoulder, and terminating its inner extremity at about half an inch within the outward edge of the sterno-cleido- mastoideus muscle. This incision di- vided a small superficial artery, which was directly secured. The skin, above the clavicle, being then pinched up, be- tween my own thumb and finger, and those of an assistant, I divided it, from within, outwards and upwards, in the line of the outward edge of the sterno- cleido-mastoideus muscle, to the extent of two inches. " My object, in pinching up the skin for the second incision, was to expose at once the superficial veins, and by dissect ing them carefully from the cellular mem- brane, to place them out of my way, with- out wounding them. This provision proved to be very useful, for it rendered the flow of blood during the operation very trifling comparatively with what might otherwise have been expected; and, thereby, enabled me with the greatest facility to bring into view those parts, which were to direct me to the arterv. ANEURISM. I.i7 *♦ My assistant liaving now lowered the shoulder, for the purpose of placing the first incision above the clavicle, (wliich I had designedly made along and upon that bone) I continued the dissection with my scalpel, until I had distinctly brought into sight the edge of the anterior sca- lenus muscle, immediately below the angle, which is formed by the traversing belly of the omo-hyoideus aid the edge of the stcrno-cleido-mastoideus, and hav- ing placed my finger on the artery, at the point where it presents itself between the scaleni, I found no difficulty in tracing it without touching any of the nerves to the lower edge of the upper rib, at which part, I detached it with my finger nail for the purpose of applying the ligature. " Here, however, arose an embarrass- ment, which (although I was not unpre- pared for it) greatly exceeded my expect- ation. I had learned from repeatedly performing this operation, many years since, on the dead subject, that to pass the ligature under the subclavian artery, with the needle commonly used in aneu- risms, would be impracticable; 1 had therefore, provided myself with instru- ments of various forms and curvatures to meet the difficulty, each of which most readily conveyed the ligature underneath the arteiy ; but, would serve me no far- ther ; for, being made of solid materials, and fixed into handles, they would not allow of their points being brought up again at the very short curvature, which the narrowness of the space, between the rib and the clavicle afforded, and which, in this particular case, was rendered of unusual depth, by the previous elevation of the shoulder by the tumour. " After trying various means to over- come this difficulty, a probe of ductile metal was at length handed me, which I passed under the artery, and bringing up its point with a pair of small forceps, I succeeded in passing on the ligature, and then tied the subclavian artery at the part, where I had previously detached it for that purpose. The drawing of the knot was unattended with pain, the wound was closed by tlie dry suture, and the patient was then returned to his bed." (See Practical Observations on the Sclerocele &c. to which are adiladfour cases of opera- tionsfor Aneurism, by Thomas Ramsdnn, sur- geon to Christ's Hospital, &c.p. 276, &c.) It only seems necessary for me to add, that immediately, the artery was tied, the pulsation of the swelling ceased; that the arm of the same side continued to be freely supplied with blood, and was even rather warmer than the opposite arm; that the operation, which was severe from Vol. I. the length of time it took up, was after a time followed by considerable indispo- sition; that the patient died about five days after its performance; that, after the artery had been tied, the oedema of the arm, and the aneurismal tumour part- ly subsided; and, that, on examinat.on after death, nothing, but the vessel, was found included in the ligature. The case, in my opinion, does Mr. Ramsden great honor; for, the difficulty he had to encounter in conveying the li- gature under-the artery was such as would have haffled all men of ordinary manual dexterity. In this-gentleman's publica- tion are descriptions of instruments, which will be of great service to any fu- ture performer of this operation. The chief one is a needle, resembling that, which was invented and used by Desault, and of which I have already endeavoured to give an idea. By means of this in- strument, I conceive, that the main dif- ficulty of the operation will for die future be no longer experienced, llud Mr. Ramsden had its assistance, his patient would have been detained a very little time in the operating theatre, and the event of the case might have been com- pletely successful. Having witnessed all the circumstances of the case, the infer- ence, that 1 drew from tliem was, that, if the operation could have been done in a moderate time, which now seems prac- ticable with the aid of the aiguille a res- sort, the case in all probability would have ended well. The preceding case is particularly memorable, as being the first instance, in which tiie subcla- vian artery has been scientifically tied, without any random thrust of a needl*, and without the inclusion of any part be- sides the arteiy in tlie ligature. It is a fact, that furnishes an encouragement to repeat the experiment, holds out the hope, that axillary aneurisms may hereafter be cured as well as inguinal ones; and con- firms the competency of the anastomosing arteries to nourish the whole upper ex- tremity, when the subclavian is tied where it emerges from behind the ante- rior scalenus muscle CAn-OTID ANEURISMS. Tlie possibility of tying the carotid ar- tery, in cases of wounds and aneurisms, without any injurious effect on the func- tions of the brain, now seems completely proved. Petit mentions, that the advo- cate Viellard, had an aneurism at the bifurcation of the right carotid, for the cure of which he was ordered a very spare diet, and directed to avoid all violent exer- T US ANEURISM. else. Three months after this prescription, the tumour had evidently diminished; and, at last, it was converted into a small, hard, oblong, knot, without any pulsa- tion. The patient having died of apo- plexy, the right carotid was found closed up and obliterated, from its bifurcation, as low down as the right subclavian ar- teiy.—(Acad, des Sciences de Paris, an. 1765.) Hebenstreit, vol. 5, of his Trans- latiou of B. Bell's Surgery, mentions a case, in which the carotid artery was wounded, in extirpating a scirrhous tu- mour. The hemorrhage would have been fatal, had not the surgeon immediately tied the trunk of* the vessel. The patient lived many years afterwards. Dr. Baillie knew an instance, in which one carotid was entirely obstructed, and the dimeter of the other considerably lessened, without any apparent ill effects on the brain. (See Trans of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 1. p, 121.) Mr. Astley Cooper has also recorded an example, in which the left carotid was obstructed by the pressure of an aneurism of the aorta. (See Metlico-Chirurgical Transactions, Vol. l.p.223.) Mr. Abernethy was under the necessity of tying the trunk of the carotid, in the case of a large, lacerated wound of the neck, in which accident the internal ca- rotid, and all the branches in front of the external one, were wounded. The pa- tient seemed to be going on very well at first, but in the night he became deli- rious and convulsed, and died about thirty hours after the ligature was ap- plied. Mr. A. considers tlie delirium and the inflammatory appearance found on the brain, on opening the body, as effects of stopping the supply of blood to the brain. I was fortunate enough to be a spectator of this interesting case, and, with due deference to Mr. Abernethy, cannot help thinking, especially when the above facts press on mv mind, that the delirium might more properly be regard- ed as the consequence of so terrible a la- cerated wound as this poor man received. Stopping the flow of blood to a part, has always been considered a chief means of averting inflammation of it, not bringing it on. That the carotid may be tied without injuring the functions'of the brain, and that aneurisms of this artery admit of being cured by the operation, is now fully proved. On Friday, Nov. 1, 1805, Mr. Astley Cooper operated on Mary Edwards, aged 44, who had an aneurism of the right carotid artery. At this time, the tumour reached from near the chin to beyond the angle of the jaw, and downward to with- in two inches and a half from tiie cla- vicle. The swelling had a strong pulsatory motion. The woman also complained of a particular tenderness of the scalp on the same side of tiie head, and of such a throbbing in the brain as prevented her from sleeping. An incision, two inches long, was made on the Inner edge of the stemo-cleido- mastoideus muscle, from the lower part ofthe tumour to tiie clavicle. This wound exposed the omo-hyoideus, and sterno- hyoidetis muscles, which being drawn aside towards the trachea, the jugular vein presented itself to view. The mo- tion of this vein produced the only dif- ficulty in the operation, as, under the dif- ferent states of breathing, the vessel sometimes became tense and distended before the knife, and then suddenly col- lapsed. Mr. Astley Cooper introduced his finger into the wound to keep the vein out of the way of the knife, and, having exposed the carotid artery by another cut, he passed two ligatures under this vessel by means 6f a curved aneurism- needle. ' Care was taken to exclude the recurrent nerve on the one hand, and the par vagum on the other. The ligatures were then tied about half an inch asun- der; but, the intervening portion of the artery was left undivided. The pulsation of the swelling ceased immediately, the vessel was tied, and, on the day after the operation, the throbbing in the brain had subsided, while no di- minution of nervous energy in any part of the body could be observed. The patient was occasionally afflicted with bad fits of coughing; but, upon the whole went on at first pretty well. On the eighth day, however, a paralysis ofthe left leg and arm was noticed, attended with a great deal of constitutional irrita- tion. Nov. 8th, the putient could move her arm rather better; but, became un- able to swallow solids. Nov. 12th, the palsy of her arm had now almost disap- peared. The ligatures came away. Nov. 14th, the woman was in every respect better; she swallowed with less difficul- ty; the tumour was smaller, and quite free from pain. On the 17th, she became very ill; the tumour increased in size, and was sore when pressed. The wound was as large as immediately after the ope- ration, and discharged a sanious serum. Great difficulty of swallowing, and a most distressing cough, were also expe- rienced. The pulse was ninety -six, and the left arm again very weak. On the 21st, the patient died, the difficulty of swallowing having previously become still ANEURISM. 139 greater, attended with a further increase of the tumour, the skin over which had acquired a brownish red colour. On opening the swelling after death, the aneurismal sac was found inflamed, and the clot of blood in it was surfbund- ed with a considerable quantity of pus. The inflammation extended on the out- side of the sac, along the par vagum, nearly to the basis of the skull. The glottis was almost closed, and tlie lining of the trachea was inflamed and covered with coagulating lymph. The pharynx was so compressed by the" tumour, which had suddenly become much enlarged by the inflammation, that a bougie, of the size of a goose-quill, could hardly be in- troduced into the oesophagus. Mr. Ast- ley Cooper concludes with expressing his opinion, that these causes of the fatal event might in future be avoided by ope- rating before the tumour is of such size as to make pressure on important parts ; or, if the swelling should be large, by opening it, and letting out its contents, as soon as inrlammation comes on. (See Medico- C/drurgical Transactions, Vol. 1.) Mr. Cline operated for a carotid aneu- rism, Dec. 16,1808, in St. Thomas's Hos- pital. Tlie tumour was veiy large, and had increased with great rapidity. The pres- sure of the swelling was such as to inter- rupt both respiration and deglutition; and to put the larynx out of its natural position. The patient had besides a fre- quent and troubleso-ne cough. The pain was confined to the tumour and same side ofthe face. These symptoms seemed relieved dur- ing the first twelve hours after the ope- ration. They tin n became worse, parti- cularly the cough and difficulty of* breath- ing, and a violent irritative fever took place. The man died on the 19th ofthe same month. (See London Medical Re- view, No. 3.) In the month of June 1308, Mr. Astley Cooper operated, in Guy's Hospital, on a man, aged 50, who had a carotid aneu- rism, attended with pain on one side of tiie head, throbbing in the brain, hoarse- ness, cough, slight difficulty of breathing, nausea, giddiness, &c. The patient got quite well, and resumed his occupation as a porter. The facial and temporal arteries ofthe aneurismal side of the face afterwards had no perceptible pulsation. On the opposite side the temp-oral arteiy became unusually large The tu- mour was at last quite absorbed, though a pulsation existed in it till the beginning of September. The man's intellects re- mained perfect; his nervous system was un-ift'-cted ; and *t.he severe pain, which, :,*»*fore the operation used to affect the aneurismal side of the head, never're- turned. The swelling, at the time of the opera- tion, was about as large as a pullet's egg, and situated on the left side about the acute angle, made by the bifurcation of the common carotid, just under the angle of the jaw. Mr. Astley Cooper began the incision opposite the middle of the thyroid carti- lage, at the base of the tumour, and ex- tended the wound to within an inch of the clavicle, on the inner side of the sterno- cleido-mastoideus muscle. On raising the margin of this muscle, the omo-hyoideus could.be distinctly seen crossing the sheath of the vessels, and the nervus descendens noni was also brought into view. The sterno-cleido-mastoideus was now sepa- rated from the omo-hyoideus, wh.en the jugular vein was seen. This vessel be- came so distended at every expiration as to cover the artery. When the vein was drawn to one side, the par vagum was manifest, lying between this latter vessel and the carotid artery, but a little to the outer side of the arteiy. The nerve was easily avoided. A double ligature was then conveyed under the arteiy with a blunt iron-probe. The lower ligature was immediately tied, and tlie upper one was also drawn tight, as soon as about an inch of" the artery had been separated from the surroundingparts above the first ligature, so as to allow the second to be tied at this height. A needle and thread were passed through the ves- sel below one ligature, and above the other. The artery was then divided. (See Medico. Chirnrg. Transact. Vol. 1.) Mr. Travers, anatomical demonstrator at Guy's Hospital, tied the carotid artery in a woman, who had an aneurism by anastomosis in the left orbit. The dis- ease had pushed the eye out of its socket. Two small ligatures were applied, which came away on the twenty-first and twenty- second day. No hemorrhage, nor im- pairment of the functions of the brain took place, and the disease in the orbit was effectually cured. (See Medico-Chi- rurgical 'Transactions, Vol. 2, part 1. and tlie Ijondon Medical Review, No. 7.) In order to get at the carotid artery in the safest manner, Mr. Abernethy has re- commended making an incision on diat side of it next the trachea, where no im- portant parts are exposed to injury, and then to pass a finger -underneath the ves- sel. The par vagum must be carefully excluded from the ligature ; for, to tie it would be fatal.—(Surgical Observations, 1804.) [Dr. Port, of New York,-successfully performed the operation of tying up 140 ANEURISM. the carotid artery, in January 1813. An account of this interesting case of carotid aneurism, has been published in s.mie of the periodical works, and also in the " Elements of Surgery."] ANXURISJIAL VAIUX, OR VENOUS ANEURISM. The scat of this tumour is, in general, in the basilic vein, which is enlarged, so as to form an oblong swelling, in the mid- dle of which is the scar, made by the lan- cet in bleeding. The tumour seldom ex- tends more than two inches above ami be- low the injury; beyond this distance the vein regains its natural size. Dr. W. Hunter is undoubtedly the first who gave an accurate description of this disease, although Professor Scarpa is dis- posed to claim a share, ofthe merit for his own country man Guattani, who, about the tame time when Dr. Hunter wrote in the Medical Observations and Inquiries, pub- lished the history of two cases of aneuris- mal varix. " Dies it ever happen in surgery," says Dr. Hunter, " that when an arteiy is opened- through a vein, a communication, or anastomosis, is afterwards kept up be- tween these two vessels ?■ It is easy to conceive this case, and it is not long, since I was consulted about one, that had all the symptoms that might be expected, supposing such a thing to have actually happened, and such symptoms, as other- wise must be allowed to be very unac- countable. It arose from bleeding; and was of some years standing, when I saw it about two years ago, and I understand very little alteration has happened to it s.ncc-that time. The veins, at the bend- ing of the arm, and especially the basilic, which was the vein that had been opened, were there prodigiously enlarged, and came gradually to their natural size, at about two inches above, and as much below the elbow. When emptied by pressure, they filled again almost instan- taneously, and this happened, even when a ligature was applied tight round the forearm, immediately below the affect- ed part. Both when the ligature was made tight, and when it was removed, they shrunk, and remained of a small size, while the finger was kept tight upon the artery, at .the part where the vein had been opened in bleeding. There was a general swelling in the place, and in tlie direction of the artery, which seemed larger, and beat stronger, than what is natural, and there was a tremu- lous jarring motion in the vein, which was strongest at the part, which had been punctured, and became insensible at some distance both upwards and down- wards," (Medical Observations and Inqui- ries, Vol. \.) In the second volume of this work, Dr. Hunter adds some further remarks on the aneurismal varix. " In the operation of bleeding, the lan- cet is plunged into the arteiy through both sides ofthe vein, and there will be thrce:wounds made in these, vessels, viz. two hi the vein, and one in the arteiy, and these will be nearly opposite to one another, and to the wound in the skin. This is what all surgeons know has often happened in bleeding, and the injury done the arteiy is commonly known by the jerk- ing impetuosity of the stream, whilst it flows from the vein, and by the difficulty of stopping it, when a sufficient quantity is drawn." " In the next place, we must suppose that the wound,of the skin, and ofthe ad- jacent, or upper side ofthe vein, heal up as usual; but, that the wound of the ar- tery, and ofthe adjacent, or under side of the vein, remain open, (as the wound of the artery does in the spurious aneurism) and, hf that means, the blood is thrown from the trunk ofthe arteiy, directly into the trunk of the vein. Extraordinary as this supposition may appear, in reality it differs from the common spurious aneu- rism in one circumstance only, viz. the wound remaining open in the side of the vein, as well as in the side of the arterv But this one circumstance will occasion a great deal of difference in the symptoms,. in the tendency of the complaint, and ;n tie proper method of treating it: uporP" which account the knowledge of such a case will be of importance in surgery." "It will differ in its symptoms from the common spurious aneurism principally thus. The vein will be dilated, or become varicose, and it will have a pulsating jar- ring motion on account ofthe stream from the artery. It will make a hissing noise, which will be found to correspond with the pulse for the same reason. The blo»d ofthe tumour will be altogether, or almost entirely fluid, because kept in constant motion. The arteiy, 1 apprehend, will become larger in the arm, and smaller at tlie wrist, than it was in the natural state; which will be found out by comparing the size, and the pulse, ofthe artery in both arms, at these different places. "The rea- son of which, I shall speak of hereafter. And the effects of ligatures, and of pres- sure upon the vessels above tiie elbow and below it, will be what every person may readily conceive, who understands any thing of the nature of arteries and veins in the living body." " The natural tendency of such a com- plaint will be very different from that of ANEURISM. 1«' the spurious aneurism. The one is grow- ing worse every hour, because of the re- sistance to the arterial blood, and if not remedied by surgery must at last burst. The other, in a short time, comes to a nearly permanent state; and, if not dis- turbed, produces no mischief, because there is no considerable resistance to the blood, that is forced out ofthe artery." " The proper treatment must, therefore, be very different in these two cases, the spurious aneurism requiring chirurgical assistance, as much, perhaps, as any dis- ease whatever; whereas, in the other case, I presume it will be best to do nothing." " If such cases do happen, they will no doubt be found todiffer among themselves, in many little circumstances, and parti- cularly in the shape, &c: of the tumefied parts. Thus the dilatatiofl of the veins may be in one only, or in several, and may extend lower, or higher, in one case, than in another, &c. according to the manner of branching, and to the state ofthe valves in different arms. And the dilatation of the veins may, also, vary, on account of the size of the artery, that is wounded, and ofthe size ofthe orifice in the artery and in tlie vein." " Another difference in such cases will arise from the different manner, in which the orifice ofthe arteiy may be united or continued with the orifice of the vein. In one case, the trunk of the vein may keep close to the trunk of" the artery, and the very thin stratum of cellular membrane be ween them, may, by means of a little inflammation and coagulation ofthe blood among its filaments, as it were solder the two orifices of these vessels together, so that there shall be nothing like a canal going from one to the other; and then the whole tumefaction will he more regular, and more evidently a dilatation of the veins only. In other instances the blood, that rushes from the wounded artery, meeting with some difficulty of"admission and passage through the vein, may dilate the cellular membrane, between the arteiy and vein, into a bag, as in a common spu- rious aneurism, and so make a sort of canal between these two vessels. The trunk of the vein will then be removed to some distance from the trunk of the arteiy, and the bag will be situated chiefly upon the under side of the vein. The bag may take on an irregular form, from the cellu- lar membrane being more loose, and y ield- ing, at one place, than at another, and from being unequally bound down by the fascia of the biceps muscle. And if the bag be very large, especially, if it be of an lingular figure, no doubt, coagulations of blood may be formed, as in the common spurious aneurism." After relating two cases, very illustrative of the nature ofthe aneurismal varix, Dr. W. Hunter proceeds to enquire: " Wby is the pulse at the wrist, so much weaker in the diseased arm, than in the other; surely, the reason is obvious and clear. If the blood can easily escape from the trunk of the arteiy directly into the trunk of the vein, it is natural to think, that it will be driven along the extreme branches with less force, and in less quantity." 2. " Whence is it, that the artery is en- larged all the way down the arm ? I am of opinion, that it is the consequence of the blood passing so readily from the artery into the vein, and is such an extension, as happens to all arteries, in growing bodies, and to the arteries of particular parts, when the parts themselves increase in their bulk, and, at the same time, retain a vascular structure. It is well known, that the arte- ries of the uterus gro^f much larger in the time of utero-gcstation. I once saw a fleshy tumour uponT the top of a man's head, as large nearly"as his-head; and his temporal and occipital arteries, which fed the tumour, were enlarged in proportion. I have observed the same change in the ar- teries of enlarged spleens, testes, &c. so that I should suppose it will be found to be universally true in fact, and the reason of it in theory seems evident." (See Me- dical Observations and Inquiries, vol. 2.) Professor Scarpa, Dr. Hunter, Mr. B. Bell, Pott, and Garneri, mention cases of the aneurismal varix, which remained stationary for fourteen, twenty, and thirty. five years. Several cases are related by Brambilla, Guattani, and Monteggia, of a cure having been obtained by means of compression. But, as this method of cure, if it does not succeed, exposes the. patient to the danger of a complication ofthe dis- ease with an aneurism, it ought not to be employed, except in recent cases, where the tumour is small, and in slender pa- tients, at an early period of life, and where both of the vessels can be compressed ac- curately against the bone. If the dis- ease is complicated with an aneurism, which threatens to become diffused, we are under the necessity of having recourse to an operation. (Scarpa on Anatomy, &<:. of Aneurism.) ANKOniSM VTtOM AX4.ST03IOSIS. This is*the term which Mr. John Bell, of Edinburgh, has* given to a species of aneurism, which resembles such bloody tumours, (nxvi materni) as appear in new- born children, grow to a large'size, and, « 143 ANEURISM. ultimately bursting, emit A considerable quantity of blood. We find clear descriptions of this dis- ease in writers, though before the publi- cation of Mr. John Bell's Principles of Surgery, it was not classed with aneu- risms. Thus, Desault has recorded a cas2 of this affection, for the express purpose of proving, that pulsation is an uncertain sign of tiie existence of an aneu- rism. (See Parisian Chirurgical Journal, Vol. II. p. 73.) The aneurism from anastomosis often affects adults, increasing from an appear- ance like that of a mere speck, or pimple, to a formidable disease, and being com- posed of a mutual enlargement of the smaller arteries and veins. The disease originates from some accidental cause; is marked by a perpetual throbbing; grows slowly, but incontrollably ; and is rather irritated, than checked, by compression. The throbbing is at first indistinct, but when the tumoihiis perfectly formed, the pulsation is veiy manifest. Every exer- tion makes the thjobbing more evident. The occasional tui'gid states ofthe tumor produce sacs of blood in the cellular sub- stance, or dilated veins, and these sacs form little, tender, livid, very thin, points, which burst, from time to time, and then, like other aneurisms, this one bleeds so profusely, as to induce extreme weakness. The tumour is a congeries of active ves- sels, and the cellular substance, through which these vessels are expanded, resem- bles, as Mr. John Bell describes, the gills of a turkey cock, or the substance of the placenta, spleen, or womb. The irritated and incessant action of the arteries fills the cells with blood, and from these cells, it is reabsorbed bytheteins. The size of the swelling is increased by exercise, drinking, emotions of the mind, and by all causes w hich accelerate the circulation. The hemorrhage from the aneurism by anastomosis sometimes usurps, in the fe- male subject, the place of menstruation, as the following example illustrates. Ann Vachot, of St. Maury, in Bresse, was born with .a tumour on her chin, of the size and shape.of a small strawberry, without pain, heat, or discolouration of tlie skin. As it produced no uneasiness, nor inconvenience whatever, it excited little attention, particularly as it did not seem to increase with the growth of the child. For the first fifteen years, there was but little alteration; but, about the menstrual period, it increased • suddenly to double the size, and became more elongated in its form. A quantity of" red blood was observed to oose from its ex- tremity. This flux became, in some mea- sure, periodical, and sometimes was suf- ficiently abundant to produce an alarming degree of weakness. Each period of iljt return was preceded by a violent pain in tiie head and numbness. Before and after the appearance of these symptoms, there was no alteration in"the size of the tumour; the only difference was a small enlargement of the cutaneous veins, with an increase of heat in the part, occasioning some degree of tenderness. The menses at length took place, but, in small quantity, and, at irregular pe- riods, without influencing the blood dis- charged fi-om the tumour, or the frequency of the evacuation. The breasts- were not enlarged till a late period, nor did the approach of pu- berty seem to have its accustomed influ- ence on those glands, &c. (See Parisian Chirurgical Jourmal, Vol. II. p. 73, 74.) " This aneurism, (observes Mr. John Bell,) is a mere congeries of active vessels, which will not be cured by opening it; all attempts to obliterate the disease with caustics, after a simple incision, have proved unsuccessful, nor does the Inter- rupting- of particular vessels, which lead to it, affect the tumour; the whole group of vessels must be extirpated. In varicose veins, or in aneurisms of individual arte- ries, or in extravasations of blood, such as that produced under the scalp from blows upon the temporal artery, or in those aneurisms, produced in schoolboys by pulling the hair, and, also, in those bloody effusions from blows on the head, which have a distinct pulsation, the pro- cess of cutting up the varix, aneurism, or extravasation, enables you to obliterate the vessel and perform an easy cure. But, in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is ' not to cut into, but to cut it out.' These purple and ill-looking tu- mours, because they are large, beating, painful, covered with scabs, and bleeding, like a cancer in the last stage of ulcera- tion, have been but too often pronounced cancers! incurable breeding cancers! and the remarks, which 1 have made, while they tend, in some measure, to explain the nature and consequences ofthe disease, will remind you of various unhappy cast s, where either partial incisions oulv had been practised, or the patient left entirely to his fote." (See John Bell's Principles of Surgery, Vol. I.) In the section on carotid aneurisms, I have mentioned the case, in which Mr. Travers cured an aneur.sm by anastomo- sis in the orbit, by tying the common ca- rotid artery. For information on aneurism, consult Louth's Scriptores Latini de AneurismaH- bus, which-work contains .Inman's Disser- tatio Medico limit rp traits tie Annmsmtite; Guattani,de Extemis An<'.i/Hsmatibu*:LaL ANT cisf de Aneurysmatibus. Opus Posthumum; Mtitani de Aneurysmaticis Prxcordiorum Morbis Animadversiones; Verbrugge, Dis- sertatio Anatomico Chirurgica de Aneuris- mate; Wetinus Dissertatio Inauguralis Me- dico tie Aneurysmate Vero Pectoris Externa Hemiplegix Sobole; Murray, Observations in Aneurismata Femoris; Trew, Aneurys- matis Spurii Post Venx Basilicx Sectionem Orti, Historia et Curatio. See also an ac- count of Mr. Hunter's Method of perform- ing the Operation for the Cure ofthe Popli- teal Aneurism, by E. Home, in the Trans, of a Society for the Improvement of Med. and Chirurgical Kiwwledge, Vol. I. p. 138, and Vol. II. p. 235. Sabatier's Medecine Ope- ratoire, Tom. 3. Medico-Chirurgical Tran- sactions, Vol. I. and II. Cases in Surgery by J. Warner, p. 141, &c. Edit. 4. Richer- and's Nosographie Chirurgicale, Tom. 4. Pelletan's Clinique Chirurgicale, Tom. 1 and 2. A Burn's Surgical A/uitomy ofthe Head and Neck. Ramsden's Practical Observa- tions on the Sclerocele, with four cases of operations for aneurism. CEuvres Cliirur- gicales de Desault par Bichat, Tom. 2, p. 553. Wells in Transact, of a Society for the Improvement of Med. and Chiricrg. Knowledge, Vol. 3, p. 81—85, SJc. Corvi- sart, Essai sur les Maladies et les Lesions Organiques du Ceeur et des Gros Vaisseaux. Edit. 2. _ C. Bell's Operative Surgery, Vol. I. Jolm BelPs Principles of Surgery, Vol. I. Richter's Anfangsgrunde der Wundarz- neykunst, Band 1. Abernethy's Surgical Works. Monro's Observ. in the Edinb. Med. Essays. Various productions in the Med. Observ. and Inquiries. TAe article Aneu- rism in Rees's Cyclopedia. Freer'.i Observa- tions on Aneurism, 1807; and a Treatise on the Anatomy, Pathology, and Surgical Treatment of Aneurism by A. Scarpa, trans- lated by J. H. Wishart, 1808. The original Italian was published 1804. ANODYNES, (from «neg. and o^vvsj, pain.) Medicines are so termed, wliich diminish, or remove, pain, and they are in- dicated in. surgery in all cases, in which it is desirable to relieve any intense pain. Opium is the principal one deserving con- fidence. ANTHRACOSIS,(from «v0*»«f, a burn- ing coal.) A red, livid, burning, sloughy, very painful tumour, occurring on the eye- lids. At fir*t, antiphlogistic means, are proper; but the grand thing is to make a free and early opening for the discharge of the matter contained in the swelling. The eye-lids and eye should be bathed with a collyrium, and kept cool with the satur- nine lotion. ANTHRAX, («t,'?«^, a burning coal.) See Carbuncle. ANTIMONIUM CALCINATUM,—or puivis axtixohialis. (Supposed to be ANT 143 very similar to James's Powder.) Is now called the antimonial powder. In all cases of surgery, in which it is desi- rable to promote the secretions in ge- neral, and those of urine, perspiration, and of the alimentary canal, in particular, it is proper to have recourse to this im- portant preparation. In all inflamma- tions ofthe brain and its membrane, and, in every instance, in which there exists an inflammation of aviscusof high importance in the system, antim ;ny should be exhi- bited, and, in general, the antimonial powder is as eligible a prescription as any. For an adult, four or five grains may be ordered, and tlie dose, if requisite, may be repeated, two or three times a day. ANTIMONHJM MURIATUM. This has often been named, butter of antimony, and is employed in surgery as a caustic. ANTIMONIUM TARTARIZATUM, (Emetic Tartar.) This medicine is well known as the most common emetic. For this purpose, it may be given in either of the following ways, as the indications of the case may demand. 5*. Antimonii Tart. gr. ij. Aq. distil. !|iv. Misce et cola. Dosis %"$ij.pro emetico; vel ^ss quadrante quoque hora:, donee supervenerit vomitus. If tartarised antimony be exhibited merely to excite a diaphoroesis, half an ounce, or one table spoonful, of the above mixture is to be given once every six hours. This preparation is very much employed by the best continental surgeons, for in- creasing the gastric secretions, and main- taining, for a length of time, a lax state of the bowels. We shall have occasion to notice its efficacy in the cure of numerous surgical diseases, particularly Amaurosis, Erysipelas, Injuries ofthe Head, &c. ANTIPHLOGISTICS, (from «Vr/, against, and tpxeya, to burn.) All means are so termed, which have a tendency to subdue inflammation. (See Inflammation.^ The first of these, to which the surgeon should direct his attention, when he wishes to cure an inflammatory affection, is to re- move as far as it is in his power, the oc- casional cause. Extraneous bodies, lodged in parts, susceptible of this kind of ir- ritation, and which substances produce inflammation by their mechanical opera- tion, should be extracted as soon as pos- sible, if their particular situation, shape, &c. will admit of it. The removal of substances, which irritate by their che- mical properties, is difficult, and some- times impracticable. On account of their great activity, how- ever, it is necessary to oppose their effects, without loss of time. This is accomplished, in a certain degree, by diluting such sub- stances with aqueous fluids, defending the parts from their action by oily and sedative* HI v ANT applications; and, by correcting the spe- cific irritation of the substances applied, by means of other substances, which have a particular affinity with them. Antiphlogistic remedies, properly so called, are divided into general ones, by which are meant such as affect the whole system ; and into topical ones, the opera- tion of which is, at least, for a certain time, entirely local and circumscribed. Generalanliphlogistics are: 1. Bleeding. (See this word.) 2. Glysters, and gentle laxative medi- cines. The most active cathartics may sometimes be considered in the same light; but, there are many inflammations, in which the effect of strong purgatives is hurtful and dangerous. Such are, in par- ticular, all instances, in which there is inflammation ofthe thoracic, and abdomi- nal viscera. 3. Aqueous diluting beverages, taken in large quantities. 4. The warm bath. 5. Cooling medicines, such as acid drinks, saline draughts, and some of the neutral salts, such as nitre, the ammonia muriate, aq. amnion, acet. &c. 6. Anodynes, especially opium, only to be given, however, under the circumstan- ces, and in the way, to be noticed in the article, Inflammation. W ith these direct means of diminishing the action of the sanguiferous system, we must combine a more or less complete ab- stinence from all solid animal food. Too warm an atmosphere should also be avoid- ed, as well as aiL stimulants whatever, every kind of noise, every thing likely to alarm, or disturb the mind, &c. Topical antiphlogistics are: 1. Local bleeding practised by means of leeches, scarifications, or cupping. 2. Emollient poultices, which are pro- per, when the inflammation is accompanied with an extraordinary degree of pain and hardness, and, especially, when it is dis- posed to suppurate. The best emollient poultice is that of linseed, described in the article Inflammation. Some use the one made of bread and milk; some dis- liking milk, in consequence of its inutility, and its tendency to turn sour, only use water: while others make the bread into a poultice by softening it, and beating it up, with Goulard's lotion. 3. Discutients are particularly used in all cases, in which the inflammation is less acute, and seems to have no tendency to suppurate. Cold water, various prepara- tions containing lead, a solution of sal ammoniac in vinegar and water, spirit of wine, vinegar, aether, the various infu- sions of bitter aromatic plants, and the decoction of bark, are very good discutient remedies. ANT 4. The maintenance of a continual eva- poration from the surface of the inflamed part, by applying folded linen, wet with the lotio aq. litharg. acet. cold water, % solution of zincum vitriolatum, &c. Spi- rits, atlier, snow, or powdered ice, pro- duce more cold, and, are sometimes, though not very commonly, made use of. This is the ordinary principle, on which surgeons conduct the local treatment of phlegmonous inflammation, when there is the prospect of avoiding the formation of an abscess. 5. Fomentations. These are prepared by dipping flannels in some warm liquor, squeezing a certain quantity of fluid out of them, and then placing them quite warm on the inflamed part. They are mostly used in cases, in which emollient poultices are the permanent local applica- tions, and when the patient suffers extra- ordinary pain. A decoction of while pop. py heads, or camomile flowers, is the liquor commonly employed. Fomentations are very temporary means, being only ap- plied in general, about half an hour, two, or three times a day. The best opportu- nity of doing this, is when the poultice is to be changed. 6. Among the means, essential to an antiphlogistic regimen, perfect quietude, both of body and mind*, is not the least important. (See Inflammation.) Encydt- pedie Methodique ; Partie Chirurgicale. ANTISEPTICS, (from . *m, against, and e-ijiru, to purify.) This name is given to such remedies, as are supposed to have the virtue of resisting the tendency to putrefaction in the human body, or to arrest its progress, after it has commen- ced. According to these ideas, they are, indicated in cases of mortification, and sloughing ulcers. " The greatest part of antiphlogistic re- medies are also antiseptic, as we shall see the reason of in the article Mortification. The most renowned antiseptic remedies of tiie internal kind, are vegetable, and mineral acids, fluids impregnated with carj i bonic acid gas, wine, aromatics, camphor, bitters in general, and, particularly, bark. The chief external antiseptic applications are prepartions of lead, cold water, snow, ice, spirits, turpentine, or aromatics, suck as camomile flowers, rue, &c.Mt has als6 been recommended to apply the carbonic acid gas itself. This may be done, either by directing the air against the parts affected through a funnel, as soon as the gas is extricated from the substances, which contain it; or by applying to the parts affected poultices, composed of such ingredients, as will ferment, and form a large quantity of the gas. (See I'Encyclo- pedie Methodiqtuf; Partie Cltirttrgicale.) ANTRUM. 145 ANTRUM MAX1LLARE. This is a considerable cavity, situated in the upper jaw bone. It is also named the Sinus Max- illaris, or Antrum Highmorianum, from the name of an anatomist, who gave the first accurate description of it. The antra are liable to several morbid affections. Sometimes, their membranous lining inflames, and secretes pus. At other times, in consequence of inflammation, or Other causes, various excrescences and fungi are produced in them. Their bony parietes are occasionally affected with ex- ostosis, or caries. Extraneous bodies may be lodged in them, and, it is even asserted, that insects may be generated in them, and cause, for many years, very afflicting pains. ABSCESSES IN THE ANTRUM. Of all the above cases, this is far the most common. Violent blows on the cheeks, inflammatory affections ofthe ad- jacent parts, and, especially, of the pitui- tary membrane lining the nostrils, expo- sure to cold and damp, and, above all things, bad teeth, may induce inflamma- tion and suppuration in the antrum. The first symptom is a pain, at first imagined to be a tooth-ach, particularly if there should be a carious tooth, at this part of the jaw. This pain, however, extends more into the nose, than that usually does, which arises from a decayed tooth; it also affects, more or less, the eye, the orbit, and the situation of the frontal sinuses. But, even such symptoms are insufficient to charac- terize the disease, the nature of which is not unequivocally evinced, till a much later period. The complaint is, in general, of much longer duration, than one entirely dependent on a caries of a tooth, and its violence increases more and more, until, at last, a hard tumour becomes percepti- ble below the cheek bone. The swelling, by degrees, extends over the whole cheek: but, it afterwards rises to a point, and forms a very circumscribed hardness, which may be felt aboye the back grin- ders. This symptom is accompanied by redness, and sometimes by1 inflammation and suppuration of the external parts. It is not uncommon, also, for the outward abscess to communicate with that within the antrum. The circumscribed elevation of the tu- mour, however, does not occur in all cases. There are instances in which the matter makes its way towards the palate, causing the bones of this part to swell, and, at length, rendering them carious, unless. timely assistance be given. There are other cases, in which the matter escapes between the fangs and sockets ofthe teeth. Lastly, there are other examples, in which Vox. T matter, formed in tiie antrum, makes its exit at the nostril of the same side, when the patient is lying with his head on the opposite one, in a low position. If this mode of evacuation should be frequently repeated, it prevents the tumour, both from pointing externally, and bursting, as it would do if the purulent matter could find no other vent. But this evacua- tion of pus from the nostril is not very common ; for, according to Mr. Hunter, the opening between the antrum and cav- ity of the nose, is generally stopped up. This celebrated anatomist even seems in- clined to think, that the disease may sometimes be occasioned by the impervious state of this opening, in consequence of which obstruction, the natural mucus of the antrum may collect therein such quan- tity, as to irritate and inflame the mem- brane, with which it is in contact. This may happen in the same way as an obstruc- tion in the ductus nasalis hinders the pas- sage ofthe tears into the nose, and causes an abscess in the lachrymal sac. (See Natural Hist, of tlie Human Teeth, &c. by John Hunter, p. 174.) However, in the ma- jority of cases, we may conclude, that the impervious state of the opening is rather an effect, than the cause, of the disease, since inflammation in the antrum is often manifestly produced by causes of a dif- ferent kind, and since the opening in question is not invariably closed. Abscesses in the antrum require a free exit for their contents, and, if the surgeon neglects to procure such opening, the bones become more and more distended and pushed out, and, finally,carious. When this happens, the pus nukes its appear- ance, either towards the orbit, the alveoli) the palate, or, as is mostly the case, to- wards the cheek. The matter having thus made a way for Its escape, the disease now becomes fistulous. In all cases the principal indication is to discharge the matter, whether the pus is simply confined in the antrum, or whe- ther the case, be conjoined with a carious affection of the bones. The ancients seem to have known very little of the treatment of diseases of the antrum. Drake, an English anatomist, is reputed to be the first proposer of a plan for curing abscesses of this cavity. Meibo- mius, however, had, a long while before him, proposed, with the same intention, to extract one or more of the teeth, in order that the matter might find an open- ing for its escape, through the sockets. This plan may be employed with success. The pus frequently has a tendency to make its way outward towards the teeth ; it often affects their frogs; and, after their extraction, the whole of the abscess is seen U U6 ANTRUM. to escape through the sockets. But this very simple plan will not suffice for all cases, as there are numerous instances, in which there is no communication between the alveoli and the antrum. Drake, and, perhaps, before him, Cow- per, rtook notice of the insufficiency of Meibomius's method, and, hence, they proposed making a perforation through the socket into the antrum with an awl, for the purpose of letting out the matter, and injecting into the cavity such fluids as were judged proper. The extraction of one or more teeth, and the perforation of the alveoli, being essential steps in treating diseases of the antrum, we must consider what tooth ought to be taken out in preference to others. A caries, or even a mere continual ach- ing, of any particular tooth, in general ought to decide the choice. But, if all the teeth should be sound, which is not often the case, writers direct us to tap each of them gently, and to extract the one, which gives most pain on this being done. When no information can be thus obtained, other circumstances ought to guide us. All the grinding teeth, except the first, correspond with the antrum. They even sometimes extend into this cavity, and the fangs are only covered by tiie pituitary membrane. The bony lamella, which se- parates the antrum from the alveoii, is at- tenuated, towards the back part of the upper jaw. Hence, it is best, when the choice is in our power, to extract tlie third or fourth grinder, as, in this situation, the alveoli can be more easily perforated. Though, in general, the first grinder and canine tooth dohot communicate with the antrum, yet, their fangs occasionally ap- proach the side of this cavity. When one or more teeth are carious, they should be removed, because they are both useless and hurtful. The matter fre- quently makes its escape, as soon as a tooth is extracted, in consequence of the fang liaving extended into the antrum, or rather in consequence of its bringing away with it a piece ofthe thin partition between it and the sinus. Perhaps a discharge may follow from the partition itself being ca- rious. If the opening thus produced, be sufficiently large to allow the matter to escape, the operation is already completed. But, as it can easily be enlarged, it ought always to be so when there is the least sus- picion of its being too small. However, when no pus makes its .appearance, after a tooth is extracted, the antrum must be opened by introducing a pointed instru- ment in the direction ofthe alveoli. Some use a small trocar, or awl; others a gim- blet for this purpose. The patient should sit on the ground, in a strong light, resting his head on the surgeon's knee, who is to sit behind him. Immediately the instrument has reached the cavity, it is to be withdrawn. Its en- trance into the antrum is easily known by the cessation of resistance. After the matter is discharged, surgeons advise the opening to be stopped up with a wooden stopper, to keep victuals from getting into the antrum. The stopper is to be taken out, several times a day, to allow the pus to escape. This plan soon disposes the parts affected to discontinue the suppuration, and resume their natural state. Sometimes, however, the pus continues to be discharged, for a long time after the operation, without any change occurring, in regard to its quality or quantity. In such instances the cure may often be accelerated by employing injections of brandy and water, lime-wa- ter, or a solution of zincum vitriolatum. Some surgeons prefer a silver cannula instead of the stopper, as it can always be left pervious except at meals. If no opening were made in the antrum, the matter would make its way, some- times towards the front of this cavity, which is very thin; sometimes, towards the mouth, and fistulous openings, and caries would inevitably follow. When the bones are carious, the above plan will not accomplish a cure, until the affected pieces of bone exfoliate. A probe will generally enable us to detect any ca> ries in the antrum. The fetid smell, and ichorous appearance of the discharge, also, leave little doubt that the bones are diseased; and, in proportion as the bones free themselves of any dead portions, the discharge has less smell, and its consist- ence becomes thicker. There are cases, in which there are loose pieces of dead bone to be extracted, and, in which it is requisite to make a larger opening into the antrum, than can be ob- tained, at its lower part. Instances also occur, in which patients have lost all the grinding teeth, and the sockets are quite obliterated, so that a perforation from below could hardly be effected. Some practitioners have also objected to ever sacrificing a sound tooth. In these cir- cumstances, it lias been advised to make a perforation in the antrum, above the al- veolary processes, M. Lamorier is the first who proposed this method. It con- sists in making a transverse incision, be- low the malar process, and above the root ofthe third grinder. Thus the gum and peri isteurn are divided, and the bone ex- ANTRUM. H7 posed. A perforating instrument is to be conveyed into tlie middle of this incision, and the opening in the antrum made as large as requisite. There are cases of very extensive exfoliations of the antrum, in which it is absolutely necessary to ex- pose a great part of the surface of the bone, and to cut away the dead pieces which are wedged, as it were, in the liv- ing ones. A small trephine may some- times be advantageously applied to the malar process of the superior maxillary bone. Surgeons formerly treated carious af- fections of the antrum in the most absurd and unscientific way, introducing setons through its cavity, and even having re- course to the actual cautery. The mo- derns, however, are not much inclined to adopt this sort of practice. It is now known, that the detachment of a dead portion of bone, in other terms, the pro- cess of exfoliation, is nearly, if not en- tirely, the work of nature, in which the surgeon can at most only act a very infe- rior part. Indeed, he should limit his in- terference to preventing the lodgment of matter, maintaining strict cleanliness, and removing the dead pieces of bone, as soon as they become loose. But, it is to be understood, that there are occasional ex- amples, in which the dead portions of bone are so tedious of separation, and so wedged in the substance of* the surrounding living bone, that an attempt may be properly made to cut them away. TUMOURS OF THE ANTRUM. Ruysch, Bordenave, Desault, Aber- nethy, and many others, have recorded cases of polypous, fungous, and cancer- ous diseases of the antrum, and of the parietes of tliis cavity being affected with exostosis. The indolence of a*ny ordinary fleshy tumour in the antrum, while in an inci- pient state, certainly tends to conceal its existence; but, such a disease rarely oc- curs without being accompanied by some affection of the neighbouring parts, and, hence its presence may generally be as- certained before it has attained such a size as to have altered the conformation of the antrum. This information may be ac- quired by examining, whether any of the teeth have become loose, or have sponta- neously fallen out; whether the aveolary processes are sound, and whether there are any fungous excrescencess making their appearance at the sockets; whether there is any habitual bleeding from one side of the nose; any sarcomatous tumour at the side of the nostril, or towards the great angle of the eye. When the swelling kae attained a certain size, the bony pariete* ( of the antrum are always protruded out- wards, unless the body of the tumour should be situated in the nostril, and only its root in the antrum. This case, how- ever, is very uncommon. As soon as a tumour is certainly known to exist in the antrum, the front part of this cavity should be opened, without waiting till the disease makes further pro- gress, In a few instances, indeed, we may avail ourselves of the opening, which is sometimes found in the alveolary pro- cess, and enlarge it sufficiently to allow the tumour to be extirpated. If the front of the antrum were freely opened, it would in general be better to cut away the disease in its interior. A swelling of the parietes of the an- trum, in consequence of an abscess, or a sarcomatous tumour in its cavity, may lead us to suppose the case an enlarge- ment of the bones, or an exostosis. The symptoms of the two first affections have been already detailed. A sign of an exos- tosis is, when besides the absence of the symptoms characterizing an abscess or a sarcoma, the thickened parietes of the an- trum form a solid resistance; whereas, in cases of mere expansion, the dimensions of the surface of the bone being increas- ed, while its substance is proportionally attenuated, the resistance is not so consi- derable. When such an exostosis depends upon a particular constitutional cause, and, es- pecially, upon one of a venereal nature, it must be attacked by remedies suited to tliis affection. But, when the disease re- sists internal remedies, and its magnitude is likely to produce an aggravation of the case, a portion of the bone may be re- moved with a trephine, or a cutting in- strument; Such operations, however, require a*great deal of delicacy and pru- dence. Mr. B. Bell, vol. 4, describes a kind of exostosis of the upper jaw, very different from what we have mentioned, since in- steadofitsbeingdistinguishable from other diseases ofthe antrum by the greater firm- ness of the tumour, the substance of the bone gradually acquires such suppleness and elasticity, that it yields to the pres- sure of the fingers, and immediately re- sumes its former plumpness, when the pressure is discontinued. If the bone be cut, it is found to be as soft as cartilage, and, in an advanced stage of the disease, its consistence is almost gelatinous. The swelling increases gradually, and extends equally over the whole cheek, without be- coming prominent at any particular point, or only so in the latter periods of the ma- lady, when the soft parts inflame and le- 148 ANTRUM. come affected. The complaint is describ- ed as totally incurable. Cutting and tre- phining the tumour, as recommended in other cases of exostosis, only exasperate the patient's unhappy condition. Mr. Abernethy has related an account of a very singular disease of the antrum. The patient, who was 34 years of age when the account was written, perceived, when about ten years old, a small tumour on his left cheek, which gradually attained the size of a walnut, and then remained, for some time, stationary. About a yea* afterwards, the tumour having again en- larged, a caustic was applied to the inte- guments, so as to expose the bone. The actual cautery was next applied, and an opening thus made into the antrum. After the exfoliation the antrum became filled with a fungus, which rose out upon the cheek, and could not be restrained by any applications. Part of the fungus also made its way into the mouth, through the •socket of the second tricuspid tooth, the other teeth remaining natural. The dis- ease continued in this state nine years, occasionally bleeding in an alarming way. When the patient was in his 20th year, the whole fungus sloughed away during a fever, and has not returned. Aft er this the sides of the aperture in the bone be- gan to grow outwards-, forming an exos- tosis, winch has grown to a great magni- tude. A small exostosis took place in the mouth, but became no larger than a horse bean. The exostosis of the maxillary bone is of an irregular figure, and pro- jects from the whole circumference ofthe aperture a great way directly forward. Mr. Abernethy compares its appearance, when) he was writing, with that of a large tea-cup fastened upon the face, the bot- torn of which may be supposed to commu- nicate with the antrum. The diameter of the cup, formed by the circular edge of the bone was three inches and a half; the depth two inches and seven-eighths. The general height ofthe sides ofthe exostosis, from the basis of the face was two inches ; its walls were not thick, and terminated in a thin circular edge. The integuments, as they approach this edge, become at- tenuated, and they extend over the edge into the cavity. The exostosis now reaches' to the nose in front, and to the masseter muscle behind; above It includes the very ridge of the orbit, and below it grows from the edge of the,alveolary process. A line that would have separated the diseas- ed from the sound bone, would have in- cluded the orbit and nose, and indeed, one half of the face. Mr. Abernethy saw no means of affording the man relief. (Trans* of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 2.) In a case of fungus growing in the an- trum, and which had distended the an- trum, hindered the tears from passing down into the nose, raised the lower part of the orbit, caused a protrusion of the eye, made two of the grinding teeth fall out, and occasioned a carious opening in the front of the antrum, through which opening a piece of the fungus projected, Desault operated as follows : the cheek was first detached from the os maxillare, by dividing the internal membrane ofthe mouth, at the place where it is reflected over this bone. Thus, the outer surface of the bone was denuded of all the soft parts. A sharp, perforating instrument was applied to the middle of this surface, and an opening made more forward than the one already existing. The plate of bone, situated between the two apertures, was removed with a little falciform knife, which, being directed from behind for- ward, made the division without difficulty. The opening, thus obtained, being insuf- ficient, Desault endeavoured to enlarge it below, by sacrificing the alveolary process. This he endeavoured to accomplish with the same instrument, but, finding the resistance too great, he had recourse to a gouge and mallet. A considerable piece of the alveolary arch was thus detached, without any previous extraction of the corresponding teeth, three of wliich were removed by the same stroke. In this man- ner an opening was procured in the exter- nal and inferior part of the antrum, large enough to admit a walnut. Through this aperture a considerable part ofthe tumour was cut away with a knife, curved side- ways, and fixed in its handle. A most pro- fuse hemorrhage took place; but, Desault, unalarmed, held a compress in the antrum for a short time; this being removed, the actual cautery was applied repeatedly to the rest of the fungus. The cavity was dressed with lint, dipped in powdered colophony. On the eighteenth day the swelling was evidently diminished, the eye less promi- nent, and the epiphora less visible. But, at this period a portion of fungus made its appearance again. This was almost entirely destroyed by applying the actual cautery twice. It appeared again, how- ever, on the 25th day, and required a third and last recourse to the cautery. From this time the progress ofthe cure went on rapidly. Instead of fungous excrescences, healthy-granulations were now formed in the bottom of the sinus. The parietes of the antrum, gradually approaching each other, the large opening made in the ope- ration was obliterated, and reduced to a small aperture, hardly large enough to admit a probe. Even this little opening ANTRUM. 149 was closed in the fourth month, at which time no vestiges of the disease remained, except the loss of teeth, and a very ob- vious depression just where they were situated.! In all fungous diseases of the antrum, making a free exposure of them is an es- sential part of the treatment: if you ne- glect this method, how can you inform yourself of the size, form, and extent, of the tumour .*" How could you remove the whole of the fungus, through a small open- ing, which would only allow you to see a very little portion of the excrescence ? How could you be certain that the disease were extirpated, to its very root ? Even when the antrum is freely opened, this circumstance can only be learnt with dif- ficulty ; and how could it be ascertained, when only a point of the cavity is opened -? A portion, left behind, very soon gives origin to a fresh fungus, the progress of which is more rapid, and the character more fatal, in consequence of being irri- tated by the surgical measures adopted. (CEuvres Cldrurgicales de Desault par Bichat, Tom. 2.) I imagine that English surgeons* unac- customed to use tiie actual cautery, will peruse with a degree of aversion, tliis means so commonly employed in France by Desault, and other celebrated sur- geons. Nor can I expect that they will altogether approve the use of the mallet and gouge, for making a free opening into the antrum. Perhaps, it might be better to trephine this cavity with a small instrument for the purpose, and then cut the fungus away. After removing as much of it as possible in tliis manner, some instrument of suitable shape might be used to scrape the part, where the tu- mour has its root. However, if there be any case in which potent and violent mea- sures, like those of Desault, are allow- able, it is the one, of which we have just been treating. Inveterate diseases de- mand powerful means, and tampering with them is generally more hurtful than useful. [To this preference of the trephine over any other method of exposing the cavity, the American editor begs leave to give his decided approbation: having perform- ed that operation, he can testify its facility and safety.] There is an interesting case of a fungus in the maxillary sinus, related in the first volume of the Parisian Chirurgical Jour- nal. It was at last cured by opening the antrum, applying the cautery, and tying the portion of the tumour, which had made its way into the nose. In the se- cond volume of the same work, is an ex- cellent case, exhibiting the dreadful ra- vages,, which the disease may produce when left to itself. IWSECTS IN THE AKTRUM. It is said, that insects in this cavity may sometimes make it necessary to open the part. This case, however, must be ex- ceedingly rare, and even what we find in authors (Pallas de insectis viventibus intra vivcntia), appears so little authentic, that we should hardly have thought it neces- sary to make mention ofthe circumstance, if there were not, in a modern work (Med. Comrn. Vol. 1.) a fact which appears enti- tled to implicit belief. Mr. Hey sham, a medical practitioner at Carlisle, relates, that a strong woman, aged sixty, in the habit of taking a great deal of snuff, was subject, for several years, to acute pains in the antrum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than summer, and were always subject to frequent periodical exasperations. The patient had taken several anodyne medi- cines, and others, without benefit, and had twice undergone a course of mercury, by which her complaints had been in- creased. All her teeth on the affected side had been drawn. At length it was deter- mined to open the antrum with a large trocar, though there were no symptoms of an abscess, nor of any other disease in this cavity. For four days no benefit resulted from tHis operation. During this space, bark injections, and the elixir of aloes, were introduced into the sinus. On the fifth day a dead insect was extracted, by means of a pair of forceps, from the mouth of the cavity. It was more than an inch long, and thicker than a common quill. The patient now experienced relief for several hours: but, the pains afterwards recurred with as much severity as before; oil was next injected into the antrum, and two other insects, similar to the former, were extracted. No others appeared, and the wound closed. The pains were not completely removed, but they were con- siderably diminished for several months, at the end of which time they became worse than ever, particularly affecting the situation ofthe frontal sinus. M. Bordenave has published, in the twelfth and thirteenth volumes of the Mem. de I'Acad. de Chir. Edit. 12mo. two excellent papers on the diseases of tite antrum. In the thirteenth volume, he re- lates the history of a casv, in whch sefe- ral small whitish worms, together with a piece of fetid fungus, were discharged from the antrum, after an opening had been made on account of an abscess ofthe antrum, attended with caries. (P. 381.) 150 A N U ANU But, in this instance, the worms had pro- bably been generated after the opening had been made in the cavity; for, when they made their appearance, tiie opening had existed nine months.—(See on this subject Precis d' Observations sur les Mala- dies du Sinus Maxillaire ParM. Bordenave, in Mem. de PAcad. Royale de Chirurgie, Tom. 12, Edit, in 12mo. Also Suite cP Ob- servations on tlie same Subject, byM. Borde- nave, Tom. 13, ofthe said Work. L'Ency- clopedic Methodique, Partie Chirurgicale, art. Autre Maxillaire. Remarques et Obser- vations sur les Maladies du Sinus Maxil- laire, in GZuvres ChirurgicAles de Desault par Bichat, Tom. 2, p. 156.' Desault's Pa- risian Chirurgical Journal, Vol. 1 and 2. Medical Communications, Vol. 1. Trans. of a Society for the Improvement of Med. and Chirurgical Knowledge, Vol. 2. Natural History ofthe Human Teeth, by John Hunter, p. 174,175, Edit. 3. Gooch's Chirurgical Works, Vol. 2,p.61,and Vol. 3,p. 161,Edit. 1792.) ANUS. The lower termination of the great intestine, named the rectum, is so called, and its office is to form an outlet for the feces. The anus is furnished with muscles, which are peculiar to it, viz. the sphinc- ter, which keeps it habitually closed, and the levatores ani, which serve to draw it up into its natural situation, after the ex- pulsion of the feces. It is also surround- ed, as well as the whole of the neighbour- ing intestine, with muscular fibres, and a very loose sort of cellular substance. The anus is subject to various diseases, in which the aid of surgery is requisite : of these we shall next treat. IMPERFORATE ANUS. This complaint is sometimes met with, though not very often. As it is of the ut- most consequence that such mal-forma- tions should not remain long unknown, one of *he earliest duties of an accoucheur, after delivery, should be the examination of all the natural outlets of the new-born infant. 1 Such an inspection sometimes evinces, that the place in which the extremity of tiie rectum, or the anus, ought to be, is entirely, or partly shut up by a mem- brane, or fleshy adhesion. In other in- stances, no vestige of the intestine can be found, as the skin retains its natural co- lour over the whole space, between the parts of generation and the os coccygis, without being more elevated in one place than another. In such cases the intestine sometimes terminates in one or two culs- de-sac, about an inch upward from the ordinary situation of the anus. Some- times it does not descend lower than the upper part of the sacrum; sometimes it opens into the bladder, or vagina. When a surgeon is consulted for such cases, he must not lose much time in de- liberation; for, if a speedy opening be not made for the feces, the infant will certainly very soon perish, with symptoms similar to those of a strangulated hernia. After ascertaining the complaint, which is an easy matter, we should endeavour to learn, whether the anus is merely shut by a membrane, or fleshy adhesion: or whether tiie anus is altogether wanting, i« consequence of the lower portion of tlie cavity ofthe gut being obliterated, or the rectum not extending sufficiently far down. When a membrane, or a production of the skin closes the opening of the rectum, the part producing the obstruction, is somewhat different in colour from the neighbouring integuments. It is usually of a purple or livid hue, in consequence of the accumulations of the meconium on its inner surface. The meconium, pro- pelled downward by the viscera above, forms a small, roundish prominence, which yields like dough to the pressure of the fingers; but, immediately projects as be. fore, when the pressure is removed. When a fleshy adhesion closes the intestine, the circumstance is obvious to the eye, if the part protrude, which is generally the case. The finger feels greater hardness and resistance, than when there is a mere membrane, and the livid colour of the meconium cannot be seen through the ob- structing substance. These last signs alone are enough to convince the surgeon of the necessity of the operation; but, they do not clearly shew, whether the intestine descends, as far as it ought, in order to form a proper kind of anus. Complete information on this point can only be acquired, after the membrane, or adhesion, has been divid- ed ; or else after the child's death, when the operation has proved ineffectual. Though there be no mark to denote, where the anus ought to be situated, and no degree of prominence, yielding, like soft dough, to the pressure ofthe fingers, and rising again, when such pressure is removed; yet, it may happen, especially on our being consulted immediately alter the child is born, that, notwithstanding the absence of such symptoms, denoting the presence of the meconium, and the natural extent of the intestine, as far as where tlie anus ought to be, the gut may exist, and have a cavity, as far as the mem- brane, or adhesion, closing it. When the anus is only covered with skin, and its place pointed out by a pro- minence, arising from the contents of the ANUS. 151 rectum, we have only to make an opening with a knife, sufficient to let out the me- conium. Levret recommends making a circular incision in the membrane; but, a transverse cut is sufficient. A small tent of lint is afterwards to be introduced, in order to keep the opening from closing. If the anus should only be partly closed by a membrane, the opening may be di- lated with a tent; but, if the aperture should be very small, it is preferable to use the bistoury for its enlargement. When no external appearance denotes where the situation of the anus ought to be, the case is much more serious and em- barrassing; and this, whether the intes- tine is stopped up by a fleshy adhesion, or the coalescence of its sides, or whether a part of the gut is wanting. However, it is the surgeon's duty to do every thing in his power to afford relief. For this purpose, an incision, an inch long, is to be made in the situation where the anus ought to be, and tlie wound is to be carried more and more deeply in the natural direction ofthe rectum. The cuts are not to be made directly upwards, nor in the axis of the pelvis, for the vagina, or bladder, might thus be wounded. On the contrary, the operator should cut back- ward, along the concavity of the os coccy- gis, where there is no danger of wounding any part of importance. In all cases of this kind, the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recommended, until he reaches the feces, or has cut as far as he can reach with his finger. If he should fail in finding the meconium, as death must unavoidably follow, one more at- tempt ought to be made, by introducing, upon the finger, a long trocar, in such a direction as seems best calculated for find- ing the rectum. By the prudent adoption of such pro- ceedings, many infants have been pre- served, wliich otherwise would have been devoted to certain death. Hildanus, La Motte, Roonhuysen, and many others, have successfully adopted the above prac- tice. Mr. B. Bell informs us, he has seen two of these cases, in which the intestine was very distant from the integuments, and in which he was so successful, as to form an anus, which fulfilled its office tolerably well for several years; but, he found it exceeding difficult to keep the passage sufficiently large and pervious. A* soon as he removed the dossils of lint, and other kinds of tents, used for main- taming the necessary dilatation, such a degree of contraction speedily followed, that the evacuation of the intestinal mat- ter became very difficult, for a long while afterwards. He employed, at different times, tents made of sponge, gentian root, and other substances, which swell on be- ing moistened. But these always pro- duced so much pain and irritation, that it was impossible to persevere in their use. After remarking such inconveniences, he recommends, in opposition to the advice of other authors, not to make use of such tents in these cases. He is of opinion, that whoever makes trial of them upon parts, as sensible as the reClum, will soon find, that the advice ofthe writers alluded to is ill-founded. Tents, made of very soft lint, dipped in oil, or rolls of bougie plaster, cause less irritation, than those composed of any other materials. Though keeping the opening dilated may seem simple and easy, to sUch men as have had no opportunities of seeing cases of this description,%it is far otherwise in ' practice. Mr. Bell assures us, that he * never met with any disease, which gave him so much "trouble and embarrassment, as he experienced in the two cases of this sort, which occurred in his practice. Al- though in both instances he at first made the openings sufficiently large, it was only by very assiduous attention, for eight or ten months, that the necessity for another operation, and even repeated ones, was prevented. When only the skin has been divided, the rest of the treatment is doubt- less more simple; for, then, nothing more is requisite, than keeping a piece of lint, for a few days, in the opening made with the knife. But, when the extremity of the rectum is at a certain distance, though we may generally hope to effect a cure, after having succeeded in giving vent to the intestinal matter; yet, the treatment, after the operation, will always demand a great deal of attention and care on the part ofthe surgeon, for a long while. The difficulty of success may be considered as, in some measure, proportioned to the depth of the necessary incision. Sometimes, while the anus appears per- vious and well-formed, infants suffer the same symptoms, as if there were no-, anus at all. Tlie reason of this depends upon the intestine being occasionally closed by a membranous partition, situated more or less upward, above the aperture of the anus, and, sometimes the symptoms are/ owing to the termination of the gut in a cul-de-sac. This erroneous formation may always be suspected, whenever an infant, whose anus is externally open, does not void any excrement, Tor two or three days after its birth, and, especially, when ur- gent symptoms arise, such as swelling of tlie belly, vomiting, &c We are now 152 ANUS. to endeavour to ascertain, whether the rectum is impervious above the anus, by attempting to inject glysters, or to intro- duce a probe. If the gut be shut up, there is nothing to be done, but having recourse to the method described above, and form- ing a communication by means of a bis- toury guided on the finger, or else with a pharyngotomus. If the obstacle should only consist of a transverse membrane, the operation will be easy, and its success almost certain. But, if there should be a strangulation, or obstruction of the intes- tine, the case is infinitely more serious. However, as the operation is the only re- source for saving the child's life, we ought not to hesitate about performing it. When the anus is imperforate, the in- testine sometimes opens into the vagina, or bladder. The first of these cases is the least dangerous of all the malformations of this sort. The intestine may also open, and terminate at two places, at the same time, viz. at the usual place, so as to form a proper anus, more or less perfect; and also in the vagina. If these two openings should be ample enough for the easy evacuation of the ex- crement, nothing can be done at so tender an age; for, though voiding the feces through the vagina, is a most unpleasant inconvenience, yet, there is no effectual means of closing the opening of the intes- tine in this situation, nor could one be de- vised, which would not seriously incom- mode the infant. But, when the two openings are ex- ceedingly small, and the alvine evacua- tions cannot readily pass out, even with the aid of glysters, the opening of the anus ought to be dilated by cannula of different sizes. If this method should not avail, the knife must be employed, and the wound dressed, as already ex- plained. For the most part, the intestine has only one opening in the vagina. In tliis circum- stance, as in the instance in which the feces have no vent at all, we must make an incision in that place, which the anus ought to occupy. The natural course of the feces being opened by this operation, which in such a case is not at all perilous, much less excrement will pass out of the vagina, and, of course, the infirmity will be diminished. By the introduction of a tube into the new anus, the communica- tion between the rectum and vagina, might possibly be obliterated, and a per- fect cure accomplished. The opening between the intestine and vagina, may, also, be too small Tor the easy evacua- tion ofthe feces, and this might even ex- nose the infant to the same sort of dan- gerous symptoms, as it would be subject to, if the* rectum had positively no opening at all. In male infants, the rectum sometimes opens into ihe bladder, and, in this cir. cumstance, there is generally no anus. The case is easily known by the meconium being blended with the urine, wliich -ac- quires a thick greenish appearance, and is voided almost continually, though in small quantities. The most fluid part of the meconium, is the only one voided in this manner. The thicker part not get- ting from the rectum into the bladder, nor from the bladder into the urethra, greatly distends the intestines and bladder, and produces the same symptoms, as take place, in cases of total imperforation. Hence, without the speedy interference of art to form an anus, capable of giving vent to the feces, with which the urinary organs cannot remain obstructed, the in- fant will inevitably die. This case must, therefore, be treated like the foregoing ones. Though we can hardly hope to completely prevent the inconveniences, re- suiting from the rectum opening into the bladder, since even a new passage will not completely hinder the feces from fol- lowing the other course; yet, we shall thus afford the child a very good chance of preservation, and tiie only one which its situation will allow. In cases, in which we cannot procure an outlet for the feces, by any of the me- thods pointed out above, it has been pro- posed to make an opening into the abdo- men above the pubes, or on the right side, in order to get at the colon, and form an artificial anus, in one of these situations. But the prospect of" success would be so small, that the plan is not likely to be much adopted. (See De la Medecine Ope- ratoire par Sabatier, Tom. 1. Also Re- marques sur Differ ens Vices de Conforms tion, que les Enfians apportent en naissant Par M. Petit, in Mem. de PAcad. Royak de Chirurgie, Tom. 2,p. 236, Edit.inl2mo, Richerand's Nosographie Chirurgicale, Tom. 3, p. 415, &c. Edit. 2.) ABSCESSES OF THE A^US.—FISTULA IN AS0. The custom of giving the appellation of fistula to every collection of matter formed near to the anus, has, by conveying a false notion of them, been productive of such methods of treating them, as are di- ametrically opposite to those which ought to be pursued. A small orifice or outlet from a large or deep cavity, discharging a tliin gleet, or sanies, made a considerable part of the idea, which our ancestors had of a fistu- lous sore, wherever seated. With th< ANUS. 153 term fistulous, they always connected a notion of callosity: and, therefore, when- ever they found such a kind of opening yielding such sort of discharge, and at- tended with any degree of induration, they called the complaint nfistula. Imagining this callosity to be a diseased alteration made in the very structure of the parts, they had no conception that it could be cured by any means, but by removal with a cutting instrument, or by destruction with escharotics: and, therefore, they immediately attacked it with knife or caustic, in order to accomplish one of these ends: and very terrible work they often made. That abscesses, formed neap the funda- ment, do sometimes, from bad habits, from extreme neglect, or from gross mistreat- ment, become fistulous, is certain; but the majority of them have not, at first, any one character or mark of a true fis- Jule; nor cah, without the most supine neglect on the side of the patient, or the most ignorant mismanagement on the part of the surgeon, degenerate, or be con- verted into one. Collections of matter from inflamma- tion (wherever**' formed) if they be not opened in time, and in a proper manner, do often burst. The hole, through which tlie matter finds vent, is generally small, and not often situated in the most conve- nient, or most dependent part of the tu- mour: it therefore is unfit for the dis- charge of all the contents of the abscess ; and, instead of closing, contracts itself to a smaller size, and becoming hard at its edges, continues te drain off what is furnished by the undigested sides of the cavity. When an abscess about the anus bursts, the smallness of the accidental orifice; the hardness of its edges ; its being found to be the outlet from a deep cavity ; the daily discharge of a thin, gleety, disco- loured kind of matter; and the indura- lion of the parts round about, have all contributed to raise, and confirm the idea of a true fistula. Upon this idea was built the old per- nicious doctrine of free excision, or as free destruction. Abscesses about the anus present them- selves in different forms. Sometimes the attack is made with symptoms of high inflammation; with pain, fever, rigor, &c. and the fever ends as soon as the abscess is formed. In this case, a part of the buttock near to the anus is considerably swollen, and has a large circumscribed hardness. In a •short time, the middle of this hardness Vol. I. becomes red, and inflamed; and in the center of it matter is formed. This (in the language of our ances- tors) is called in general a phlegmon,- but when ie appears in this particular part, a phvma. The pain is sometimes great, the fever high, the tumour large, and exquisitely tender; but however disagreeable the ap- pearances may have been, or however high the symptoms may have risen, be- fore suppuration, yet, when that end is fairly and fully accomplished, the patient generally becomes easy and cool; and the mutter formed under such circum- stances, though it may be plentiful, yet is good. On the other hand, the external parts, after much pain, attended witil fever, sickness, 8tc. are sometimes attacked with considerable inflammation, but without any of that circumscribed hardness, which characterised the preceding tumour; in- stead of which, the inflammation is ex- tended largely and the skin wears an ery- sipelatous kind of an appearance. In this, the disease is more superficial; the quantity of matter small, and the cellu- lar membrane sloughy to a considerable extent, Sometimes, instead of either of the pre- ceding appearances, there is formed in this part, what the French call une sup- puration gangreneuse; in which the cellu- lar and adipose membrane is affected in the same manner, as it is in the disease called a carbuncle. In this case the skin is of a dusky red, or purple kind of colour; and although harder than when in a natural state, yet it has, by no means, that degree of tension or resistance, which it has either in the phlegmon, or in the erysi- pelas. The patient has generally, at first, a hard, full, jarring pulse, with great thirst, and very fatiguing restlessness. If the progress of the disease be not stopped, or the patient relieved by medicine, the pulse soon changes into an unequal, low, faul- tering one ; and the strength and the spi- rits sink in such manner, as to imply great and immediately-Stipending mis- chief. The matter formed under the skin, so altered, is small in quantity, and bad in quality; and the adipose membrane is gangrenous and sloughy throughout the extent of the discolouration. This gene- rally happens to persons whose habit is either naturally bad, or rendered so by intemperance. In each of these different affections, the whole maladv is often confined to the skin X 154 ANUS. and cellular membrane underneath it; and no other symptoms attend, than the usual general ones, or such as arise from lh* formation of matter or sloughs in the part immediately affected. But it also often happens, that, added to these, the patient is made unhappy by complaints arising from an influence, which such mischief has on parts in the neighbourhood of the disease ; such as the urinary bladder, the vagina, the urethra, the haemorrhoidal vessels, and the rectum; producing re- tention of urine, stranguiy, dysury, bear- ing dov/n, tenesmus, piles, diarrhoea, or obstinate costiveness : which complaints are sometimes so pressing, as to claim all our attention. On the other hand, large quantities of matter, and deep sloughs are sometimes formed, and great devastation committed on the parts about the rectum, with little or no previous pain, tumour, or inflammation. Sometimes the disease makes its first appearance in an induration of the skin, near the verge of the anus, but without pain or alteration of colour; which hard- ness gradually softens and suppurates. The matter, when let out, in this case, is small in quantity, good in quality; and the sore is superficial, clean, and well- conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation appar- ently slight, yet the matter is large in quantity, bad in quality, extremely of- fensive, and proceeds from a deep crude hollow, wliich bears an ill-natured as- pect. The place also where the abscess points, and where the matter, if let alone, would burst its way out, is various and uncer- tain. Sometimes it is in the buttock, at a distance from the anus -, at other times near its verge, or in the perineum: and this discharge is made sometimes from one orifice only, sometimes from several. In some cases, there is not only an open- ing through the skin externally, but an- other through the intestine into its cavity : in others, there is only one orifice, and that either external, or internal. Sometimes the matter is formed at a considerable distance from the rectum, which is not even laid bare by it; at others, it is laid bare also, and not per- forated ; it is also sometimes not only de- nuded, but pierced; and that in more places than one. All consideration of preventing sup- puration, is generally out of the ques- tion : and our business, if called at the beginning, must be to moderate the symp- toms ; to forward the suppuration; when the matter is formed, to let it out; and to treat the sore in such manner, as shall be most likely to produce a speedy and lasting cure. When there are no symptoms which re. quire particular attention, and all that w AQU ARN a day in cases of cancer. Mr. Barnes once shewed me a case of herpes of the nose, or noli me tangere, which was greatly benefited by this remedy externally ap- plied. The patient was under Mr. Har- vev, in St. Bartholomew's Hospital, and, at "the time when I saw her, Mr. Barnes was using the lotion with double the pro- portion of arsenic. There are many ulcer- ations round the roots of the nails of the fingers and toes, to which many apply Plun- ket's caustic; hut, the aquae kali arseni- cati would, in all probability, be quire as efficacious an application, and, certainly, it is a nearer one. AQUA KALI PURI. (lio.cor totassae, L. P.) This has been given with a view of dissolving urinary calculi, in consider- able doses, for a length of time. The trials, however, have not proved so suc- cessful as could have been wished, nor is the exhibition of so active a remedy un- attended with disadvantageous conse- quences to the system; for which reason, under the name "of mephitic alkaline water, vegetable alkali supersaturated with fixed air, has of late been much substituted. The proper dose, at first, is from ten to twenty drops, twice a day, in some lin- seed tea. At Saint Thomas's Hospital, the following is the w.y, in which the aqua kali puri is prescribed: . £ Aquae Kali puri Ji. Aquae Distillatae gij. Misce. Dosis Drachma una bis die ex unciis quatuor infusi lini. AQUA LITHARGYRI ACETATI. (liq.uor plumbi acetatis, L. P.) Is ex- tensively used largely diluted with water, as an application to inflamed parts. One dram to a quart of water is quite •strong enough for common purposes. .Mr. .Tustamond and Dr. Cheston used to ap- ply it mixed with an equal proportion of a spirit resembling the tinctura ferri muri- ati, to the edges of cancerous sores. The fear of the absorption of lead, has induced many practitioners to give up the use of this remedy, and have recourse to solutions of vitriolated zinc, which, it is said, answer equally well; but it is now rendered probable, from the experiments of Mr. Baynton, of Bristol, that cold water alone is of as much service as either in removing inflammation. (See Pharmaco- pxio ChirurgUta,) AQUA PICIS. May be applied to tinea capitis. There are ulcers on the legs, surrounded with a scorbutic redness, and pimples, covering a large extent of the skin. In such instances, the aqua picis, used as an application round the limb, over the dressings, is of great service. AQUEOUS HUMOUR OF THE EYE. The proposal of letting out this fluid, and the circumstances, in winch such an operation may be proper, will be considered in the article Opthalmy. ARDOR UlilNiE. Difficulty and pain in making water, attended with a sense of heat in the urethra, a symptom of go- norrhea, and some other affections. ARGEMA.or ARC EM ON. (from cc?y0( white.) A small white ulcer ofthe globe of the eve. (See Cornea, ulcers of) ARGENTI "NITR AS. (Nitrate of silver, lunar caustic.) Is the best of the mildest caustics. Its utility for stimula- ting indolent ulcers, and keeping granu- lations from rising too high, is known to every one. Mr. Hunter recommends the use of the argentum nitratum, on the first appear- ance of a chancre, before absorption can be supposed to have taken place. He di- rects the caustic to be scraped to a point, like a blacklead pencil; so that, when it is applied, every part of the surface ofthe chancre may come into contact with it; and he advises the repetition of", this pro- cess, till the last slough, which is thrown off, leaves the sore florid and healthy, (Hunter on the Venereal.) From this treatment, there is a chance, that the constitution will not be infected; but it is generally prudent, notwithstand- ing, to give the pil. hydrargyri. The important use of the argentum ni- . tratum, in the cure of numerous diseases, we shall have occasion to remark in vari- ous places of this work; particularly when we come to the article Urethra, strictures of, in the removal of which disease it is pe- culiarly useful. The argentum nitratum is often used in the form of a solution, in the proportion of a dram of the caustic to an ounce of dis- tilled water. In general this application ought to be at first more or less weakened, by the addition of a quantity of distilled water. Cancerous ulcers, and sores about the nose and neighbouring parts of the face, commonly going under the denomi- nation' of noli me tangere are often consi- derably benefited by the argentum nitra- tum, both in the solid and fluid state. The solution agrees very well with cer- tain sores, which occur round the roots of the nails of the fingers and toes. The lotion is sometimes applied with a camel- hair-pencil ; in general, however, by dip- ping little soft bits of lint in the fluid, laying them on the part, and covering them with a pledget. ' ARNICA. (xfiiKti, from ctgs, a lamb.) Leopardsbane. Amaurosis is the principal case in which surgeons now ever employ this medicine. From a dram to half an ounce ofthe flowers may be infused in a pint of water, and ARSENIC. 171 this may be taken in the course of four and twenty hours. Arnica, thus exhibited, sometimes produces vomiting, profuse per- spiration, and an increased secretion from the kidneys. At other times, no evident effects of tliis sort arise. The virtues of this medicine have undoubtedly been ex- aggerated, though no one can question that, as it is a powerful one, the trial of" it should still be continued. ARSENIC, (from the Arabic Arsenek, orapo'w, masculus, from the strength of its qualities.) Every one is acquainted with the deleterious effects of this mineral, wliich, in the dose of a few grains, acts as the most violent poison. Notwithstand- ing such effects which are generally dread- ed, practitioners have ventured to employ arsenic as a remedy for diseases, and this has sometimes been done with success, not only as an external topical applica- tion, but, even as an internal medicine. Arsenic is the principal ingredient of a secret remedy, which, in Ireland, has long possessed very great celebrity for the cure of. cancer, and which is known by the name of Plunket's caustic. This ap- plication is said to consist of the ranuncu- lus acris, the greater crow-foot, the flatn- mula vulgaris, and the lesser crow-foot: an ounce of each is to be bruised, and added to a dram of arsenic, and five scru- ples of sulphur. The whole is to be beaten into a paste, formed into balls, and dried in the sun. When used, they are to be beaten up with the yolk of an egg, and applied on a piece of pig's bladder. The use of the ranunculus is to destroy the cu- ticle, on which the arsenic does not act. The application is to remain on twenty- four hours, and the slough is to be after^ wards dressed with any simple, unirritat- ing ointment. Arsenic seems to have been first recommended as an external appli- cation to cancers, and it was generally combined with opium. It certainly some- times produces a salutary change in the appearance of the sore. We have reason to regret, that this change is usually not of permanent continuance. Besides Plun- ket's remedy, various other preparations of arsenic have been externally employed. Mr. Justamond's applications to cancer, originally suggested by a receipt, said to be preserved in the Earl of Arundel's fa- mily, were somewhat varied. They were generally combinations of arsenic and sul- phur. The above receipt directs an ounce of yellow arsenic, with half that quantity of armenian bole, and sometimes as much red precipitate. Mr. Justamond also em- ployed a sulphuret of arsenic, and a com- bination of this siilj.'iurel with crude an- timony. The at-iciiicul prestation, pre- frrred, was scraped-and laid on the mid- dle ofthe sore, while its edges were mois- tened with a combination of niuriated iron, and sal ammoniac. The effects were, the correction of the fetid smell, melioration of the appearance of the sore, and sepa- ration of the cancerous part. In the Pharmacopoeia Chirurgica, Mr. Justamond's arsenical caustic is directed to be made in the following manner: * an- timonii pulverizati ^ij. arsenici pulveri- .zati J j. These are to be melted together in a crucible. The application may be reduced to any degree of mildness by the addition of powdered opium. The latter ingredient may also act specifically in di- minishing the pain. M. Febure's remedy consisted of ten grains of arsenic, dis- solved in a pint of water, with an ounce of the extract of cicuta, three ounces of Goulard's extract, and a dram of lauda- num. With this fluid the cancer was washed every morning. He gave also arsenic internally, and directs two grains to be dissolved in a pint of water, to which must be added syrrup of chicory, with half an ounce of rhubarb. A table- spoonful is to be given night and morn- ing, with half a dram of the syrup of poppies. It may be remarked, that the dose of the arsenic, in this preparation, is one twelfth of a grain. The kali arsenicatum is an excellent preparation for internal exhibition, and is thus made: 5t Arsenici Albi, Nitri Punficati, singu- lorum unciam: Crucibulo amplo igne candenti injice nitrum, et liquefacto adde gradatim arse- nicum in frustulis, donee vapores nitrosi oriri cessaverint. Solve niateriam, in aquae distillatae libris quatuor et post idoneam evaporationem sepone, ut fiant crystalli. Dosis, Grani pars decima ter quotidie. It may be given in the following way. 5< Kali arsenicati gr. ij. . Aq. Mentha; Sativae ^;iv. Spirit. Vinosi tenuionsjjij. M. et. cola. Dosis drachmae duae ter quotidie. The following-is Dr. Fowler's method of preparing arsenic for internal use. Take of powdered arsenic, and prepared kali, each sixty-four grains; boil them gently in a Florentine flask, or other glass vessel, with half a pound of distilled water, un- til the arsenic is dissolved. To this so- lution, when cold, add half an ounce of the compound spirit of lavender, and as much water as will make the whole equal to a pint, or fifteen ounces and a half in weigh. The dose of this solution is as follows: From two years old to four, gutt ij or iij tQ v; from five to seven, guttv -J72 ARSE to vij ; from eight to twelve, gutt. vij to x; from thirteen to eighteen, gutt. x to xii; from eighteen upwards, gutt. xij. . These doses may be repeated once in eight or twelve hours, diluted with thick ^gruel or barley-water. It will only be in my power to specify here"" a few of the numerous surgical cases, hi which the internal employment of arsenic has been proposed. The follow- ing are particularly worthy of attention : tetanic affections ; cancer: noli me tan- gere ; elephantiasis; numerous unnamed malignant ulcers ; several obstinate cuta- neous diseases; pseudo-syphilis, and those sequelae of the venereal disease, which cannot be subdued by mercury, &c. Arsenic has also been recommended for the prevention of hydrophobia by Dr. J. Hunter. (See Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, Vol. J) Subsequent trials of this medicine, however, in such cases, do not seem to en tide it to much confidence. After the sympu-ms have begun, arsenic decidedly has no power in arresting the disease. It was lately tried by Dr. Mar- cet. Three drops of Fowler's solution were ordered to be taken, every other hour, in two drams of peppermint or water, w ith half a dram of syrup. How- ever, no relief whatever seemed to be de- rived from the medicine. (See Medico- Chirurgical Transactions, Vol. I. p. 141— 156.) But, although arsenic has hitherto fail- ed in producing benefit in cases of hydro- phobia, some facts have been recently pub- lished by Mr. Ireland, surgeon to the 4th Battulion of the 60th Regiment, which make it appear a truly valuable and effi- cacious remedy for counteracting the poi- son of serpents. (See Medico-Chirurgical Transactions, Vol.11, p. 393, and tlie article, Wounds—Bite of the Viper, in this Dic- tionary.) > Surgeons are frequently desired to ex- amine the bodies of persons, suspected of having been poisoned with arsenic, and every practitioner should qualify himself to judge whether the suspicion is rightly formed, or not. Often,* indeed, the life of the person, supposed to have adminis- tered the poison, will entirely depend upon the nature of the medical evidence. Be- sides, in certain cases, the symptoms, which precede a natural death, are of- such a description, as to create strong sus- picions that the patient has died of poi- son, when the fact is otherwise. Hence, it must be plain, that, both with respect to tlie question of murder, and of suicide, the evidence ofthe surgeon will frequently be of the utmost importance. * » The symptoms and effects of arsenic, when taken into the stomach, ought to be well remembered. A pricking and burn- ing sensation will soon be experienced in this organ. Sudden and excruciating pains will be felt in the bowelsr A severe vomit- ing will arise. The tongue, mouth, and throat, will become rough, and parched, and an unquenchable thirst will prevail, with much anxiety and restlessness. When the dose of arsenic has been considerable, and proper antidotes have not been em- ployed in time, an inflammation of the stomach and intestines will be the conse- quence, and it sometimes terminates in gangrene. Distention of the abdomen, coldness of the extremities, slow feeble pulse, fetid vomiting and stools, hiccough, and, lastly, death, ensue. In one instance of death from arsenic, related by Dr. Yel- loly, not the least mark of pain, or ten- derness, in the abdomen, was perceptible while the patient lived. (See Edinb. Med. and Surgical Journal, Vol 5. p. 391.) When the body of a person, who has . been poisoned with arsenic, is opened, the small intestines will generally be found to be inflamed and thickened, their external surface being in some places of a florid red colour, and in others, of a purple hue; while here and there effusions of coagulating lymph may be observed. The large intestines in general seem to suffer less, though, in some cases, they are found more or less inflamed as far as tlie extremity ofthe rectum. Sometimes, the bowels are even quite mortified in various places. The villous coat ofthe stomach is con. siderably inflamed, and points of extra- vasated blood may commonly be noticed upon it. In one case, examined by Dr. Yelloly, there were observed two, or three circular spots, of tiie size of a shilling, which were abrasions of the membrane. In some places, the villous coat seemed to be thickened by an effusion of lymph. The convolutions of the intestines will often be found connected together by ad- hesions. The lining of the oesophagus will also sometimes partake of the in- flammation. Very violent and even fatal effects may also arise from the absorption of arsenic from the skin into the circulation. (See Med. and Physical Journal, Vol 5. p 543.) There are five methods of detecting the • presence of arsenic. First, by precipi- tating this mineral from ajiy fluid, in which it is dissolved, by an alkaline hy- dro-sulphuret. Secondly, by precipitating any solution of arsenic by the sulphate of copper. Thirdly, by reducing the oxide into the metallic state, by heating it with extraneous substances in a glass-tube. Fourthly, by observing the effect, which ARSENIC. 173 arsenic has, in whitening copper, when heated in contact with it. Fifthly, by perceiving the peculiar odour, which is exhaled, when arsenic is evaporated from a heated surface. When some of the solution of sulphuret of potash (kali sulphuratum) is added to A solution of the white oxide of arsenic, a precipitate is instantly formed of a bright orange colour. ' All surgeons, however, should be aware, that a very similar effect is produced by adding the solution of kali sulphuratum to a solution of tartarised antimony; but, the puecipitate is not formed so readily as when arsenic is concerned. The .second means of ascertaining the presence of arsenic is by precipitating a mixed solution of the white oxide of this metal and potash, by adding some of the solution of the sulphate of copper, (Cu- prum vitriolatum.) The precipitate, formed by this process, is of a beautiful green colour, and is well known by the name of Scheele's green paint. In order to produce such precipitate in the best way, Dr. Bostock recommends, that the proportions of the* oxide of arsenic, pot- ash, and sulphate of copper, be to each other, as one, three, and five. (Edinb. Med. and Surgical Journal, Vol 5, p. 169.) The third method of detecting arsenic consists in reducing the oxide into the metallic state, by mixing the suspected powder with a little charcoal, putting these substances into a glass tube, and exposing them for a full quarter of an hour to a. red heat. One end of the tube should be hermetically closed, the other stopped with a plug of clay. The glass must also be every where well coated with clay and sand, be about a quarter of an inch in diameter, and "eight incbes in length. On the application of caloric, the oxygen of tlie arsenic unites with the car- bon, and forms carbonic acid gas, leaving the arsenic on the inside ofthe glass tube reduced to the metallic state. This is reckoned the most decisive test of. the presence of arsenic; but, it will not an- Bwer when the quantity of the latter mi- neral is less than a grain. The quality, wliich arsenic has, of uniting with copper and forming a white compound, is the fourth means of detect- ing the presence of the first of these me- tals. For tliis purpose, put one gram of suspected powder, with half a grain of powdered charcoal, and two drops of oil, between two plates of polished copper, wliich are to be bound together with some wire, and exposed, for some time, to a red heat. Dr. BQstockhas explained, that, when a paste of charcoal and oil alone is put between plates of copper, and exposed to heat, a somewhat similar white appear- ance is produced on them, so that the communication of a white colour to cop- per by arsenic is not' the most eligible cri- terion, particularly, when the quantity of the suspected substance is small. The fifth'mode of judging of the pre- sence of arsenic is by the. low, bluish, white, flame, alliaceous smell, and white smoke, which arise when that mineral is thrown on a red hot body. This experi- ment will only afford information, to be depended upon, when the quantity of arse- nic is considerable, and it is unmixed with other substances. Of all the foregoing modes, Dr. Bos- tock deems that, in which the green pre- cipitate is produced with the sulphate of copper, the most convenient, delicate, and decisive. Of late, a new test of arsenic has been suggested. The following is the account given of it by Dr. P. M. Roget: " Let the fluid, suspected to contain arsenic, be fil- tered : let the end of a glass rod, wetted with a solution of pure ammonia, be brought into contact with this fluid; and let a clean rod, similarly wetted with a solution of nitrate of silver, be brought into contact with the mixture. If the minutest quantity of arsenic be present, a precipitate of a bright yellow colour, inclining to orange, will appear at" the point of contact, and will readily subside to the bottom of the vessel.— (Note. As this precipitate is soluble in ammonia, particular care should be taken to avoid adding it in excess; indeed, the quantity of eiiher ammonia or nitrate of silver employed, can scarcely be too small for the purpose of detecting the presence of arsenic.) •' In examining the circumstance.0, at- tending the agency of this test, the fol- lowing particulars were observed. On adding successively ammonia and nitrate ol" silver to distilled water, no precipitation takes place. Fowler's arsenical solution affords a precipitate of a yellow colour, si- milar in appearance to that produced by a solution of the white oxyd; but, a solution of arsenic acid gives a precipitate of a red brick colour. The fixed alkalies, when substituted for ammonia, likewise produce a yellow precipitate; but, the results are less distinct, since, in the circum- stances, in which the experiment is made, they decompose the nitrate of silver, an effect, which ammonia does not produce. We found, by comparative experiments, that the precipitates, thrown down by the same reagents, (namely, ammonia andlii- trate of silver,) when either zinc, iron, copper, mercury, or lead was contained 174 ARb ART in the fluid, had an appearance totally different from that produced by arsenic ; and that the latter could readily be de- tected by the same means, notwithstand- ing the presence of these metals. The salts of copper, or lead, when previously mixed with a solution containing arsenic, occasioned no difference in the results. With a solution of oxymuriate of mer- cury, ammonia alone will occasion a white precipitate ; but, if arsenic be also pre- sent, on addition of nitrate of silver the precipitate immediately acquires a yel- low colour. The efficacy of this com- pound test is not weakened, but, on the contrary, seems to be rather increased by the presence of sulphate of iron. Sul- phate of zinc was not found to interfere with its operation, any otherwise than re- quiring a larger quantity of ammonia, in order to saturate tlie sulphuric acid; but, when this has been effected, and the whole of tlie zinc precipitated, the addition of nitrate of silver produces the same yellow tint as in tlie other experiments. There is, therefore, reason to presume, that no admixture of metallic, or other salts, will occasion ambiguity, or enable the arsenic to escape detection, when the above test is properly applied. (Dr. Roget observes, in a note, that in the Philosophical Ma- gazine, for 1809, Mr. Hume has proposed boiling the suspected matter with a solu- tion of carbonate of potash, and bringing into contact with it a stick of dry nitrate of silver: a method, somewhat analogous to that above described, but, much less convenient in its practical application.) " Being curious to determine the limit of minuteness in the quantity of arsenic, discoverable by this test, we dissolved a grain of white arsenic in a known quan- tity of distilled water, and, by successive additions of water to determinate portions of this solution, prepared other solutions, containing respectively one 2C00tli, one 20,000th, and one 200,000th of their weight of arsenic. By applying the test to a small quantity in a watch-glass, we found, that, when it contained only jpne 25,000th of a grain of arsenic, the preci- pitate was of a bright yellow colour. It was still distinctly yellow, when the quan- tity of arsenic was reduced by dilution to one 50,000th of a gram. When further diluted, the yellowness was gradually less and less discernible, and the precipitate appeared of a light blue. It retained this colour, until its quantity became too minute for observation. A bluish cloud, however, was very distinctly visible, when the fluid examined contained only the 250,000th part of a grain of arsenic. " If, (says Dr. Roget) along with the extraordinary -degree, of delicacy of this test, we take into consideration the ex- treme facility of applying it, and the reater convenience of operating upon uids, than upon solid bodies, as we are obliged to do, when we have recourse to the usual methods, it appears decidedly entitled to preference. (See Medico Chirurgical Transactions, Vol. 2, p. 156— 160.1 The following plan should be pursued, when arsenic has been swallowed in such a quantity as to endanger life. An eme- tic of white m* blue vitriol should be ex- hibited immediately, and large quantities of water swallowed, in which the liver of sulphur (k di sulphuratum) is dissolved. The stomach having been thus emptied, a mixture containing the kali sulphura- tum, about a scruple to a dose, should be frequently exhibited, milk, butter, or caster oil, being freely given in the in- tervals. The employment of .copious blood-let- ting, in cases of poison from arsenic, was suggested by Dr. Yi Holy, on the prin- ciple of removing inflammation. " Ana- logy (says he) seems to indicate its em- ployment; but, its particular fitness can only be determined by experience." (Edin- burgh Medical and Surgical Journal, Vol 5, p. 393.) Dr. Roget has put this proposal to the test of experhnent, and the reco- very, which was effected by that gentle- man, after a large quantity of arsenic had been swallowed, and most alarming symp- toms had come on, seems to be much in confirmation of the utility of the practice. (See Medico-Chirurgical Transactions, Vol. 2, p. 136.) This article would admit of being con- siderably lengthened; but, as some ofthe subject is as much medical as surgical, I think it will be sufficient in this work to re- fer the reader to sources, from which more extensive information may he obtained. (See Observations on the different Methods recommended for detecting minute Portions of Arsenic, by John Bostock, M. D. Edinb. Med and Surgical Journal, Vol. 5, p 166, also p. 14. Dissertatio Inauguralis de Effec- tibus Arsenici in varios organismos necnon de indiciis quibusdam veneficii ab Arsenica Ulati ; quamprxside C. F. Kiclmayerpublice defendet, Jan. 1808. Auctor Georg. Fried. Jaeger, Stuttgardianus, 8vo. Tubrisgx. in Nouvelles Experiences sur les Contre-poisons de PArsenic, par Casimir Renault, Paris an 1Xc Murray,s System of Chemistry, Vol. 3, p. 356, Edit. 2. Observations on tlie Use of Arsenic, by G. N Hill, in Edinburgh Med. and Surgical Journal, Vol. 5, p. 19—312. Pharmacopceia Chirurgica. Medico-Chirur- gical Transactions, Vol. 1, p. 141 y0l 2, p. 136, 156, and 393, &c. ARTERIOTOMY. (from «£rvpi*t an BAN BAN 175 artery, and "rtfuu, to cut.) The operation of opening an arteiy, for the purpose of taking away blood for the relief of dis- eases. (See Bleeding.) ARTERIES, Wounded. (See Hemor- rhage.) ARTICULATIONS, Diseases of. (See Joints.) ASTRINGENTS, (from astringo, to bind.) In medicine, are those substances which possess a power of making the liv- ing fibres become contracted, condensed, and corrugated. They are employed in the practice of surgery chiefly as exter- nal applications, either for restoring di- minished tonic power, or checking various discharges. They are also deemed very eligible local remedies for phlegmonous inflammation. ATHEROMA, (from «6npct, pap.) An encysted tumour, so named from its pap- like contents. (See Tumours Encysted.) AXILLARY ARTERY, Wounded.— When, in a case of this description, it is necessary to tie the injured vessel, Scarpa believes, that nothing tends more to em- barrass the surgeon, than an injudicious smallness ofthe first incision through the skin and such other parts as conceal the wound in the artery. An assistant must compress the vessel, from above the cla- vicle, as it passes over the first rib.' When the weapon has penetrated, fi-om below upward, directly into the axilla, the sur- geon is to make a free dilatation ofthe wound upon a director, or his finger. This must be done to a sufficient height to expose a considerable portion of the arterv, and the precise situation of the wound in it. When the weapon has pierced oblique- ly, or from above downwards, through a portion ofthe great pectoral muscle, into the axilla, Scarpa advises the surgeon to cut through the lower edge of this muscle, and enlarge the wound, on a director, or his finger, so as to bring f-.irly into view the injured part of the artery. The tho- racic arteries, divided in this operation, must be immediately tied. The clots of blood are then to be removed, and the bottom of the wound cleaned with a sponge, by which means the opening in the axillary artery will be more clearly seen. As this vessel lies imbedded in the brachial plexus of nerves, the surgeon must take care to raise it from these lat- ter parts with a pair of forceps, before he ties it. Two ligatures will be required ; one, above, the other below the wound of the arteiy. *>e$o< B. BALSAMUM COPAIViE. Exhibited by surgeons principally in cases of gonorrhea, gleet, and piles. A dram may be Riven thrice a day. „,,«» BALSAMUM PERUVIANUM CUM FELLE BOVINO. * Fellis Bovim guj B:dsami Peruv. 3 j M. Dr. H. Smith has advised this application to be occasionally dropped into the ear, when there is a fetid discharge from it. The meatus audito- rius externus is also to be washed out every dav, by syringing the passage with water, to which some recommend soap to be added. . BANDAGE. (Deligatio. Fascia.) An apparatus, consisting of one or several pieces of linen, or flannel, and intended for covering, or surrounding parts of the body for surgical purposes. The use of bandages is to keep such compresses, remedies, &c. in their proper situation, as are applied to any particular part; to compress blood-v-esse.s, so as to restrain hemorrhage; to rectify certain deformities by holding the deranged parts in a natural position; and to unite parts, in which there is a solution of continuity. As the application of bandages is a very important branch ol surgery, authors have not neglected it. Much has been written on the subject, and almost every writer has devised new bandages, perhaps with- out much benefit to surgery. Unfortu- nately, it is next to impossible to give very, clear ideas of the numerous sorts of bandages by description. The surgeon can only acquire all the necessary instruc- tion and information from the experience and habit resulting from practice. Hence, we shall confine ourselves to a general account of the subject. Bandages should be made of such ma- terials as possess sufficient strength to fulfil the end proposed in applying them, and they should, at the same time, be supple enough to become accommodated to the parts to which they are applied. Bandages are made of linen, cotton, or flannel. If possible, they should be with- out a scam, and Unen is woven for this *76 BANDAGE. purpose ; but the selvage is always harsh, and, as 'he edges are necessarily covered by the i ext round, they are sometimes inconvenient. Most surgeons prefer, there- fore, old linen, and more readily submit to the inconvenience ofthe edges unravel- ling, than to the irregularity which any stitching would produce. There are cases, in which the bandage should have a degree of firmness, that does not belong to the materials usually made use of. This circumstance is ob- vious in cases of hernia, and in all those in which there is occasion for elastic band- ages. As we have already observed, linen, , "flannel, and cotton (calico), are the com- mon materials. The first employment of flannel bandages is imputed to the Scotch surgeons, who preferred them to linen ones, in consequence of their being better calculated for absorbing moisture, while, being more elastic, they yield in a greater degree in cases requiring this property ; as in the swelling subsequent to disloca- tions, fractures, &c. It has been asserted, that Unen is better than flannel, because*' more cleanly; but neither one nor the other will continue clean, unless care be taken to change it very often. The employment of cotton or calico bandages is a more recent method, and many advantages are attributed to the softness and elasticity of this material. In applying a bandage, care must be taken, that it be put on tight enough to fulfil the object in view, without running any risk of stopping the circulation, or doing harm in any other way. If it be not sufficiently tight to support the parts in a proper manner, it is useless; if it be too tense, it will produce swelling, in- flammation, and even mortification. To apply a roller skilfully, the part which it is to cover, must be put in its proper situation; the head of the roller held in the surgeon's hand, and only so much unrolled as is requisite for covering the part. In general the bandage should, if possi- ble, be applied in such a manner as will admit of its beir>g removed with the most ease, and allow the state of the parts be- neath to be examined, as often as occa- sion requires. For this reason, in fractures of the leg and thigh, the eighteen-tailed bandage is generally preferred to a simple roller. The former may be loosened and tight- ened, at pleasiue, without occasioning the smallest disturbance ofthe affected limb; a thing which could not be done, were a • common roller to be employed. As soon as a bandage has fulfilled the object for which it is applied, and it has become useless, its employment should be discontinued; for, by remaining too long on parts, it may obstruct the circulation, diminish "the tone of the compressed fibres, and vessels, and thus do harm. Bandages are either simple or compound. They are also sometimes divided into general and • particular. The latter often derive their names from the parts, to which they are usually applied. A simple bandage is a long piece of linen or cotton, of an indefinite length, and from three to six inches in breadth. When about to be applied, it is commonly rolled up, and the rolled part is termed its head. When rolled up from each end, it is called a double-headed roller or bandage. The chief of the simple bandages are the circular, the spiral, the uniting, tlie retaining, the expellent, and the creeping. The circular bandage is the simplest; the rolls cover each. other, and it is sel- dom long, as two or three turns are ge- nerally enough. The spiral bandage is the most fre- quently used of all; for, it is this which we see in such common employment on the limbs, in cases of ulcers, &c. In apply- ing a common roller to the whole of a limb, the bandage must be carried round the part spirally, or else it is obvious that the whole member could never be covered. When the leg is the part, the surgeon is to begin by surrounding the foot with a few turns. Then carrying the head ofthe bandage over the instep, he is to convey it backward, so as to make the bandage unroll, and apply itself just above the heel. The roller may next be brought over the inner ankle ; thence again over the' instep, and under the sole; and the surgeon then brings the bandage spirally upward once more to the outer part of the leg. After this, every circle of the roller is to be applied, so as to ascend up the limb in a gradual, spiral form, and so as to cover about one third of the turn of the roller immediately below. The increasing and diminishing diameter of the Umb, is one great cause, which brings into view the unskilfulness of a surgeon in this common operation; for, it prevents the- roller from lying smoothly, although spirally applied, un- less a particular artifice be dexterously adopted. The plan alluded to, is to dou- ble back the part ofthe roller that would not be even, were the application to be continued in the common spiral way, without this manoeuvre. When the bulk of the Umb increases very suddenly, it is sometimes necessary to fold, or, as it is termed, reverse, every circle of the ban- dage in the above manner, in order to make it lie evenly on the limb. It is mani- BANDAGE. 177 fest, that the pressure ofthe roller will be greatest where the duplicatures are situat- ed, and hence, when it is an object to' compress any particular part, the surgeon should contrive to reverse the turns of the bandage just over the situation where most pressure is desirable. When a roller is to be applied to the forearm, it is best to make the few first turns ofthe bandage round the hand. Care must be taken not to make the bandage very tight, if it be intended to wet it afterwards with any lotion; for, it is always rendered still more tense by moisture. Mr. John Bell describes the principal purposes for which a roller is employed, as follows.- " Although in recent wounds, it is with plasters and sutures that we unite the parts point to point, yet it is with the bandage that we support the limb, preserve the parts in continual and perfect contact with each other, and pre- vent any strain upon the sutures, with which the parts are immediately joined, and we often unite parts by the bandage alone. (This is called the Uniting Band- age, and will be presently described) But it is particularly to be observed, that in gun-shot wounds, and other bruised wounds, though it would be imprudent to sew the parts, since it is impossible that they should altogether unite, yet the gen- tle and general support which we give by a compress and bandage, prevents them from separating far from each other, unites the deep parts early-, and lessens the extent of that surface, which must na- turally fall into suppuration. "In the hemorrhagy of wounds, we cannot always find the artery; we dare not always cut parts for fear of greater dangers; we are often alarmed with bleedings from uncertain vessels, &c. or from veins as well as arteries : these he- morrhages are to be suppressed by the compress; which compress, or even the sponge itself, is but an instrument of compression, serving to give the bandage its perfect effect. Frequently, in bleed- ings near the groin, or the arm-pit, or the angle ofthe jaw, wherever the bleeding is rapid, the vessels uncertain, the cavity deep, and the blood not to be commanded by a tourniquet, and where the circum- stances forbid a deliberate and sure ope- ration, we trust to compress and bandage alone. "Bandage is very powerful in sup- pressing bleeding. At one period of sur- gery, it took place of every other method, &c. If a compress be neatly put upon the bleeding arteries, if there be a bone" to resist the compress, or even if the soft parts be firm below, and the bandage be Voi. I. well rolled, the patient is almost secure. But such a roller must be rolled smoothly from the very extremity of the fingers or toes; the member must be thoroughly supported in all its lower parts, that it may bear the pressure above. It is par- tial stricture alone that does harm, creates intolerable pain and anxiety, or brings on gangrene. Hemorrhagy requires a very powerful compression, which must there- fore be very general, Sic. It must not be made only over the bleeding arteries, which is all that the surgeon thinks of in general, Sec. "In abscesses, where matter is work- ing downwards along the Umb, seeking out, as it were, the weak parts, under- mining the skin, and wasting it, insulat- ing and surrounding the muscles, and penetrating to tiie bones, the bandage does every thing. The expelling bandage, the propelling bandage, the defensive bandage, were among the names, which the older surgeons gave to the roiler, when it was applied for these particular purposes; and these are properties of the roUer, which should not be forgotten." (Principles of Surgery, Vol. 1.) Soon after this description of some of the chief surgical uses of the roller, Mr. John Bell proceeds to explain, in what manner this most simple of all bandages may be put on a limb. " Practice will convince you, that the firnfftpss.and neatness of a bandage de- pend altogether upon these two points; first, upon tlie turns succeeding each other in a regular proportion; and, secondly, upon making reverses, wherever you find any slackness likely to arise from the va- rying form of the limb. Thus, in rolling from the foot to the ankle, leg, and knee, you must take care, first, that the turns, or, as the French call them, doloircs, of the roller lie over one another by just one third ofthe breadth of the bandage ; and, secondly, that at every difficult part, as over a joint, you turn the roller in your hand, make an angle, and lay the roller upon the limb, with the opposite flat side towards it; you must turn the bandage *so as to reverse it, making, what the French call, a renversee of the roller at the ankle, at the calf of the leg, and at the knee. You must be careful to roll your bandage from below upwards, and sup- port the whole limb by a general pressure. That you may be able to support the dis- eased part with a particular pressure, you must lay compresses upon the hol- lows and upon the bed of each particular abscess, and change the place of these com- presses from time to time, so as now to prevent matter sinking into a particular hoUow, now. to press it out from a place A a 173 BANDAGE. where it is already lodged, and again to reunite the surface of an abscess already completely funned, iromwl.irh thcmaiier has been discharged." (Principles of Sur- gery, Vol. 1.) Id the article Joints, we have taken notice of the good effects of the pressure of a roller m tlie cure of white-swellings. Here we shall just introduce Mr. John Bell's sentiments upon the subject: "In a diseased bursa, as in a relaxation of tlie knee-joint, that disease, which, with but a little indulgence, a very little encourage- ment of fomentations, poultices, bleeding, and low diet, would end in white-swelling of the knee; may be stopper! even by so simple a matter as a well-rolled bandage. (Vol. I,p.l27.) The uniting bandage, or spica descendens, used in rectilinear wounds, consists of a double-headed roller, with a longitudinal slit in the middle, of three Or four inches long. The roller having one head passed through the slit-, enables the surgeon to draw the lips of the wound together. The whole must be managed, so that the band- age may act equally. When the wounds are stitched, this bandage supports the stitches, and prevents their tearing through the skin. When the wound is deep, wri- ters advise a compress to be applied on each side, in order to press the deeper part of its sides together. When the wound is very long, two or three bandages should be employed, and great care must be taken, that the pressure is perfectly equable. Henkel and Richter recommend a unit- ing bandage, which allows the surgeon to see the wound, over which only narrow tapes cross. The reader, if he should ever wish to employ this contrivance, may read a description of it in Rees' Cyclo- pa:dia, or Motherby's Medical Dictionary, though I confess I could not understand it from the description in those works, until I looked at the plate in'Richter's Anfangsgr. der Wundarzn. Band 1. When we make use of a single-headed roller, as a retentive bandage only, we should always remember to begin the ap- plication of it on the side opposite the wound. The obvious reason fin- so doing is to prevent a farther separation of the lips of the wound, as the contrary man- ner of applying the roller would tend ciirectlv to divide them. (Gooch, Vol 1, p. 143.) The intention of the expel lent bandage is to keep the discharge sufficiently near the orifice of the wound to prevent the formation of sinuses In general, a com- press of unequal thickness is necessary; the thinner part of t*,e compress being placed next, and immediately contiguous to, tiie orifice of the wound the thicket part below. Before the bandage is ap- plied, the pus must be completely pressed out, and the rolling begin with two, or three, circular turns on the lower part of the compress. The bandage must then be earned spirally upw arils, but not quite so tightly, as below, li is afterwards to be rolled downward to the place, where it began. The creeping is a simple bandage, every succeeding turn of which only just covers the edge of the preceding one. It is em- ployed in cases, in which the object it merely to secure the dressings, and not to make any considerable, or equable pressure. A bandage is termed compound, when several pieces of linen, cotton, or flannel, are sewed together in different directions, or when the bandage is torn or cut, so as to have several tails. Such are the T bandage, the suspensory one, the capi- strum, 8ic. The eightecn-tailed bandage is one of the "^ost compound. It is now in general use for all fractures of the leg and thigh, some- times for those of the forearm, and, fre- quently, for particular wounds. Its great recommendations are the facility with which it can be undone, so as to aUow the parts to be examined, and its not creating, on such an occasion, the small- est disturbance of tlie disease, or acci- dent. The eighteen-tailed bandage is made by a longitudinal portion of a common roller, and by a sufficient number of trans verse pieces, or tails, to cover as much of tiie part as is requisite. Each of the cross pieces is to be pro- portioned in length to the circumference of the part of the limb, to wliich it is to be applied; so that in making this sort of bandage for the leg, or thigh, the up- per tails will be twice as long as the lower ones. After laying the long part ofthe bandage on a table, fix the upper end of it in some way, or another. Then begin laying the upper tails across it, and pro- ceed with placing the rest. Each tail must be long enough to extend about two inches beyond the opposite one, when they are both applied. The tails, being all arranged across the longitudinal band, they are to be stitched in this position with a needle and thread. When the bandage is intended tor the leg, a piece of the longitudinal part of the roller be- ' low, is to extend beyond the tails. Tliis is usually brought under the sole of the foot, and then applied over the inner an- kle in the first instance, aftf-r the bandage has been put under the limb. Then the surgeon lays down tiie first of tlie lowef BANDA8E. X7Q tails, and covers it with the next one above. In this way, he proceeds upwards, till all the cross pieces are applied, the uppermost one of which he fastens with a pin. This bandage has a very neat ap- pearance. The tails are said to lie bet- ter, when placed across the longitudinal piece a little obliquely. (Pott.) The T bandage is, for the most part, used for covering parts of the abdomen and back, and, especially, the scrotum, perinseum, and parts about the anus. Its name is derived from its resemblance to the letter T, and it is, as Mr. John Bell remarks, the peculiar bandage ofthe body. If the breast, or belly, be wounded, we make the transverse piece, which encir- cles the body, very broad, and having split the tail-part into two portions, one of these is to be conveyed over each side of the neck, and pinned to the opposite part of the circular bandage, so as to form a suspensory for the latter, and prevent its slipping down. But, says Mr. JohniBell, if we have a wound, or disease, or opera- tion, near the groin, or private parts, the tail-part then becomes the most important part of the bandage; then the transverse piece, which is to encircle the pelvis, is smaller, while the tail-part is made very broad- When the disease is in the pri- vate parts, perinxum, or anus, we often split the tail according to circumstances • but, when the disease is in one groin, we generally leave the tail-part of the band- age entire and broad. The linteum scissum, or split-cloth, is a bandage applied occasionally to the head, and consists of a central part, and six, or eight tails, or heads, which are applied, as follows : When the cloth has six heads, the mid- dle, or unsplit part of the cloth is applied to the top of the head. The two front tails go round the temples, and are pinned at the occiput; the two back tails go also round the temples, and are pinned over the forehead, the two middle tails are usually directed to be tied under the chin ; but, as Mr. John Bell observes, this suf- focates and heats the patient, and it is better to tie them over the top of the head, or obliquely, so as to make pressure upon any particular point. (Principles of Sur- gery, Vol. I, p. 131.) The old surgeons usually split this middle tail into two parts, a broad, and narrow one. In the broad one, they made a hole to let the ear pass through. This broad portion was tied under the chin, while the narrow ends were tied obliquely over the head. As Mr. John Bell has observed, though this gave the split-cloth the effect of eight tails, yet, the ancient surgeons did not name il the split-cloth with eight tails. When they split the cloth into eight tails, and, especially, when they tied the eight tails in the fol- lowing particular manner, they called the bandage cancer, as resembling a crab in the number of its legs. The cancer; or Split-cloth of eight tails, was laid over the head, in such a manner, that four tails hung over the forehead and eyes, while the other four hung over the back of the head. They were tied, as follows; first, the two outermost tails, on each side in front, were tied over the forehead, while the two middle tails in front were left hanging over the knot. Then the two outermost, or lateral tails behind were tied round the occiput. Next the middle tails were tied, the two anterior ones be- ing made to cross oyer each other, and pass round the temples to be pinned at the occiput; while the two middle tails be- hind, were made to cross each other, and pass round the temples, so as to be pin- ned over the ears, or near the forehead* (See John Bell's Principles, Vol. 1, p. 132.) The triangular bandage is generally a handkerchief doubled in that form. It is commonly used on the head, and, now and then, as a support to the testicles, when swelled. The French term it couvre-chef en triangle The nodose bandage called also seapha, is a double-headed roller, made of a fillet four yards long, and about an inch and a half broad. It must be reversed two, or three times, so as to form a knot upon the part, which is to be compressed. It is employed, when a hemorrhage from a wound is to be stopped, or, for securing the compress, after bleeding in the tem- poral arteiy. The most convenient bandage in gene- ral for the forehead, face, and jaws is the four-tailed one, or single split-cloth. It is composed of a strip of cloth, about four inches wide, which is to be torn at each end, so as to leave only a convenient portion of the middle part entire. This unsplit middle portion is to be applied to the forehead, if the wound be there, and the two upper tails are carried backward, and tied over the back part of the head, while the two lower ones are to be tied either over the top of the head, or under the chin? as may seem most convenient. When the wound is on the top of the head, the middle of the undivided part is to be applied to the dressings. The two posterior tails are to be tied forward, and the two anterior ones are to be carried backward, so as to be tied behind the head. This is sometimes called Galen's bandage. < It is curious, that writers on bandages should use the terms head, and 180 BAN BEL tail, synonymously, and hence this four- tailed bandage is often caUed the sling with four heads. Such confusion of language is highly reprehensible, as it contributes, in a very great degree, to obstruct the comprehension of any, the most simple subject. If the upper lip be cut, and a bandage needed, which is seldom the case, it is almost superfluous to say, that this band- age will serve tiie purpose. It serves also in cuts of the lower lip, though there, also, we trust rather to the twisted su- ture, than a bandage. The single spUt-cloth is particularly useful in supporting a fractured lower jaw, and, in such cases, is the only one employed in modern surgery. This band- age, when used for this particular pur- pose, namely, supporting the lower jaw, is named capistrum, or bridle, because it goes round the part somewhat like a horse's halter. " In some cases, (says Mr. John Bell) the circumstances require us to support the chin particularly, and then the unslit part of the bandage is applied upon the chin with a small hole to receive the point; but, where the jaw is broken, we pad up the jaw-bone into its right shape, with compresses pressed in under the jaw, and secured by this baiidage. When we are in fear of hemorrhagy after any woiiHd, or operation, near the angle of the jaw, we can give the sling a very remarkable degree of firmness. For this purpose, we tear the band into three tails on each side, and we stitch the bandage at the bottom of each split, lest it should give way, when drawn firm, Sic." (Principles of Sur- gery, Vol. 1.) We have already described one way of applying a handkerchief, as a bandage to the head, when we noticed the triangular one, or couvre-chef en triangle. The other manner of applying the handkerchief, called the grand couvre-chef, is as fol- lows : You take a large handkerchief, and fold it, not in a triangular, but a square form. ,You let one edge project about three finger-breadths beyond the other, in order to form a general border for the bandage. YoU lay trie handkerchief upon the head, so as to make tlie lower fold, to which the projecting border belongs, lie next the head; while the projecting bor- der itself is left hanging over the eyes, tiU the bandage is adjusted. Tiie two coiners of the outermost fold are first to be tied under the chin; the projecting border is then to be turned back, and pinned in a circular form round the face, while tlie corners of the fold next the head are to be carried backward, au-d tied. After the outer corners of this bandage have been tied under the chin ; after the inner corners have been drawn out and carried round the occiput; and after the border has been turned back and pinned; the doubling of the handkerchief over each side of the neck hangs in a loose awkward manner. It remains, therefore, to pin this part of the handkerchief up above the eaF, as neatly as can be con- trived. (See J. Bell's Principles.) The grand couvre-chef has certainly no- thing to recommend it, either in point of utility, or elegance. A common night-cap must always be infinitely preferable to it. In the event, however, of a cap not being at hand, it is proper that the sur- geon should know, what contrivances may be substituted to fulfil the objects in view. Having, in the numerous articles of this Dictionary, noticed the mode of applying bandages in particular cases, and allotted a few separate descriptions for such band- ages, as are not here mentioned, but, which are often spoken of in books, we shall conclude for the present, with re- ferring the reader for further information' to Motherby's Medical Dictionary; Rees' Cyclopxdiu; and John Bell's Principles of Surgery, Vol. 1. Galen and Vidus Vidius are reckoned tlie best of the old writers on the subject; M. Sue, Thillaye, Heister, Lombard, and Bernstein ; of the modern ones. The latter are said, however, to be all loo prolix. (See Rees' Cyclopxdia, art. Bandage.) BARK, Peruvian. (See Cinchona.) BA'THRON. A Greek word, denot- ing, in a surgical sense, a machine for ex- tending broken limbs, sometimes called the Scamnum Hippocratis. It is described by Oribasius and Scultetus. BA'TRACHOS, or Ba'tracirts. The tumour, which occasionally takes place under tlie tongue, and is more commonly called Ranula. BDE'LLA. In a surgical sense, a va- rix, or dilated vein. BELLADONNA. Deadly Nightshade. Is violently narcotic. The leaves were first used externally for discussing scir- rhous swellings, and they have been sub- sequently given internally, in scirrhous and cancerous diseases, amaurosis, &c. Five -grains are reckoned a powerful dose: one is accounted enough to begin with. At present, the extract, as directed by the London College, is more commonly prescribed. From the power, which belladonna is known to possess, of lowering the action of the whole arterial system, it seems to BLA B L A 181 be a fit medicine in many surgical cases, where that object is desirable, particu- larly in examples of aneurism. A very peculiar virtue, which bella- donna has, is that of causing a dilatation of the pupil, when used as an external application to the eye-brow and eye-lids. The late Mr. Saunders was in the habit of employing belladonna a good deal for tliis express purpose. A little while be- fore undertaking the operation for the congenital cataract, he was accustomed to introduce some dissolved extract of belladonna between the eye-lids, or rub the eye-brow and skin about the eye freely with the same application. The conse- quence was, that, if there were no adhe- sions of the iris to other parts, a full di- latation of the pupil was produced in less than an hour, and the whole of the cata- ract was distinctly brought into view. This was unquestionably a considerable hnprovement in practice, as the iris was kept out of danger, and the operation materially facilitated. I allude here more particularly to Mr. Saunders's own method, in which he introduced the nee- dle through the cornea, in front of the iris, and then conveyed it to the cataract through the enlarged pupil. Belladonna was also externally applied by Mr. Saun- ders, after the operation, with a view of preventing the edge of the iris from be- coming adherent to the edges of the torn capsule. BINOCULUS. (from binus, double, and oculus, the eye.) A bandage for keep- ing dressings on both eyes. Its applica- tion will easily be understood by referring to Monoculus. BISTOURY. (Bistoire, French.) any small knife for surgical purposes. BLADDER, Puncture of. This is an operation, to wliich we are obliged to have recourse, after having in vam em- ployed all the other means indicated for preventing the bad, and even fatal conse- quences of a stoppage of the evacuation of the urine, and distention of the bladder. Various accidents, and diseases, both acute and chronic, may occasion tliis dangerous state, as we shall more parti- cularly notice in the article, Urine, Reten- tion of. The bladder, which can conveniently hold about a pint and a half of urine, is no sooner dilated, so as to contain two pints, than uneasy sensations are experi- enced. The desire of discharging the water now becomes very urgent, and if the inclination be not gratified, and the bidder be suffered to be cUlated beyond its natural state, it loses all power of contraction, and becomes paralytic. The desire, indeed, continues, and the efforts are renewed in painful paroxysms; but, the power is lost, and tiie bladder becomes more and more distended. When this viscus is dilated in the utmost degree, and neither its own structure, nor the space in the abdomen can allow a further distention; either the bladder must be lacerated, which it never is, so equally is it supported by the pressure of the sur- rounding parts; or its orifice must ex- pand and the urine begin to flow. After the third day of the retention, the urine often really begins to flow, and, whatever descends from the kidnies is evacuated in small quantities from time to time, and at this period, the bladder is distend- ed in as great a degree, as it ever can be, however long .the patient may survive. This dribbling of the urine, which be- gins, when the bladder is dilated to the utmost, and continues till the eighth, or tenth day, or till the bladder sloughs, has long been understood, and is named by the French, " urine par regorgement" To practitioners, who do not understand it, the occurrence is a most deceitful one. The friends felicitate themselves, that the urine begins to flow ; the surgeon believes it, basins and cloths, wet with urine, are easily produced; but, the patient lies un- relieved. The continued distention of the bladder is followed by universal in- flammation of the abdomen. The insen- sibility, and low delirium of incipient gangrene, are mistaken for that reUef, which was expected from the flow of urine, till either hiccough comes on, and the patient dies of fever, and inflamma- tion, or the urine gets through an aper- ture, formed by mortification, into the abdomen. Let no surgeon, therefore, trust to the reports of nurses and friends, but, lay his hand upon the hypogastric region, and tap with his finger, that he may distinguish the distended bladder, and the fluctuation of urine. As the bladder suffers no further distention, af- ter the third day, why should it burst .*" Not from laceration ; for, it is supported by the uniform pressure of the surround- ing viscera; not by yielding suddenly, for it is distended to its utmost on the third day of the retention, and y-et seldom gives way before the tenth; not by at- tenuation, for it becomes thickened. The term laceration was never more wrongly applied, than in this instance,- for, when there is a breach in the bladder, it is found, on dissection, to be a small round hole, such as might be covered with the point of the finger. The rest of the vis- cus, and the adjacent bowels, are red and inflamed, while this single point is black, and mortified. Delay is more dangerous, BLADDER. than even the worst mode? of making an opening into the bladder, and, while life exists, the patient should have his chance. —(See John Bell's Principles of Surgery, , Vol 2, Part 1, p. 262, &c.) That many patients die after the para- centesis of the bladder is an undoubted truth, and this circumstance has rather intimidated practitioners against the ope- ration. It appears to me, however, that death may in general be more fairly as- cribed io the effects of the disease, than to the puncture of the bladder, and that, if this last measure were not deferred so long, as it often is, the recoveries would be more numerous. Hence, when relief cannot be obtained by the treatment described in the article, Urine, Retention of; when no urine has come away, before the end of the third day ; when it only does so in a dribbling manner after this period, while the blad- der continues distended, and no catheter can be introduced; the operation should not be delayed. In urgent cases, one should rather operate, as soon as forty- eight hours have elapsed. j No doubt, a man, who is exceedingly skilful in the use of the catheter, and knows how to practise with science and judgment all the other means for reliev- ing the retention of urine, will not fre- quently find it necessary to have recourse to the operation of puncturing the blad- der. This is said to have been so much the case wjth the eminent Desault, that, in the course of ten years, he had occasion pnly once to perform such an operation in the Hotel Dieu, where diseases of the urethra are always extremely numerous. (See CEuvres Chir. de Desault par Bichat, 'Tom. 2, p. 316.) When, however, this superior manual dexterity with the cathe- ter is not the acquirement of the practi- tioner, the timely performance ofthe para- centesis ofthe bladder should ever be ob- served. I shall next treat of the three modes of doing the operation. 1. Puncture through the Perinxum. The first surgeon that ever performed thi-. operation is said to have been M. Tolet, a French surgeon, well known for a valuable treatise, entitled, " Traite de Iithutomie, ou de l'extraction de la pierre hors de la vessie, Troisieme edition, Paris 1681." According to Sabai r, it was cus- tomary, at the tune of Dioi.is, to make the opening with a nam \v pointed scal- pel, about tour or five inc'ies long, which w.is> plunged into the bl idder, at the place where the incision in the apparatus major terminated. (See Lithotomy.) The escape of the urine indicated when the surgeon iad reached the bladder. A straight probe was then conducted along the knl\ and, then a cannula was passed along thr probe into the bladder, where it was allowed to remain as long as necessary, care being taken to fix it by means of* tapes, passed through the rings at the broad part of the instrument; and to stop up the opening with a linen tent. Some practitioners, hrwever, began with cut- ting the perineum, afier introducing a staff as far into the urethra as possible. Having made an opening into this canal, they conveyed a gorget along the staff into the bladder, and a cannula was next passed into the same viscus along the gor- get, and allowed to continue there. This mode of proceeding, which Sabatier terms more methodical, than that which has been first mentioned, could only answer in cases, where the obstruction about the neck of the bladder was inconsiderable, and where in fact the introduction of tin catheter was not yet impracticable. At least, therefore, the method was unne- cessary. The other plan of piercing the urethra in several places, and making a passage for the urine through the prostate, says Sabatier, increased the inflammation, with which this gland was affected, and rendered the disease, if not mortal, at least much more difficult of cure Sabatier represents Dionis, as the first who suggested the method of opening the bladder on one side of the perineum, at the part, where Frere Jacques used to perform lithotomy. Dionis conceived, that, by operating in this way, the patient would suffer less pain, because neither the urethra, nor the neck of the bladder, would be injured ; but at the same time, he has recommended a process to be fol- lowed, which was similar to that pursued in making the puncture in tlie middle of the perineum, viz. that a narrow scal- pel should first he introduced, so as to make a passage for the probe, along which the cannula is to pass into the bladder. The idea of substituting for these unsuitable instruments a "trocar of convenient length was exceedingly sim- ple, and, for this improvement, which took place in 1721, surgery is indebted to Juncker, (See Conspectus Chirurgix, Tab. 97, p. 674,) unless the follow ing passage be correct: " In the year 1717, or 1718, M. Peyronie shewed in the Kind's garden a long trocar, which he had successfully employed i» ;i similar puncture." (De- sault's Parisian Chirurgical Journal, Vol 2, p. 267.) The patient having been placed in the same position as for li'hoomy, an ..ssist- ant is to press with his left hand on the region ofthe bladder, above the pubes, in order to propel that viscus as far down- BLADDER. 1-S3 "ward into the lesser pelvis as possible, while, with his right hand, he supports the scrotum. The surgeon is then to in- troduce the trocar at the middle of a line, drawn from the tuberosity of the ischium to the raphe of the perineum, two lines more forward than tlie verge of tlie anus. The instrument is first to be pushed in a direction parallel to the axis ofthe body ; and its point is afterwards to be turned a little inwards. Here, according to Bichat, there is no occasion to convey the cannula so for into the bladder, as is done, when the operation is performed above the pubes. The portion of this Viscus, that is pierced, being incapable of changing its position, with regard to other parts in the perineum, if the cannula only project a tew lines into its cavity, it will not be liable to slip out. It would be wrong, indeed, to carry it in furtner; for, the pressure of its end against tlie posterior parietes of the bladder would do harm. Lastly, the cannula is to be fixed in its place, by means of the T bandage. (See (Euvres Chirurgicales de Desuidt, Tom. 3, p. 320.) Sonr£ writers recommend the introduc- tion of the left index finger into the rec- tum, in order to draw this intestine out of the way ; but Sabatier thinks it better to use this finger for pressing on the part of the perineum, where tiie puncture is about to be made, so as to make the skin tense, and assist in the guidance of the trocar. (Medecine Operatoire, Tom. 2, p. 126.) The parts, divided in this puncture, are the skin, a good deal of fat, and cellu- lar substance, the levator ani muscle, and that portion ofthe lower part ofthe blad- der, which is situated on one side of its neck. The following is the judgment which Bichat has passed upon this method: There is in the track, which the trocar describes, no part, of which the puncture must of necessity give rise to bad symp- toms. A surgeon, moderately exercised in the practice of tliis operation, is almost always sure of piercing the bladder. This viscus is opened in the most de- pending sr nation, at a part, which con- stantly bears the same delation to the perinxum. But, tiie position, in which the patient is placed for the operation, is a great deal more disagreeable, than that for the puncture above tlie pubes. Seve- ral assistant s are required to fix him, and one is necessary for compressing the blad- der in the hypogastric region. There is a possibility of wounding the 'vessels of the perineum, and of prickiti, the nerves, wlur.h accompany them. It the point of ihe trocar is carried too much outwards, it may gUde on the external side of the bladder. If it is inclined forwards, it may slip between this viscus and the pubes. If it is turned too miich inwards, it may pierce the prostate gland. If directed too much backwards, it may wound the vasa deferentia, the rectum, the extremity of the ureter, and the vesiculae seminales. While the cannula is kept introduced, also, the patient can neither walk about, nor sit down ; but, must continually keep himself in bed. Listiy, this mode of operating is frequently counter-indicated, by tumours, or other common diseases, at this part of the body, in consequence of retentions of urine. (OSuvres Clarur- gicales de Desault par Bichat, Tom. 3, p. 321.) The puncture of the bladder from the perineum is now almost universally aban- doned by British surgeons. " We may esteem it fortunate," says Desault, " if the trocar penetrates directly into the bladder, after piercing tlie tat and the muscles, situated between the tuberosity of the ischium and the anus; and, as this viscus is subject to much variation in its form, the surgeon will be often defeated, unless he is perfectly clear in his ideas, respecting its situation and figure. This disappointment is not without example, and there is sufficient to deter a practi- tioner from performing this operation, in- dependently Of the danger of wounding with the trocar the vasa deferentia, vesi- culx seminales ureter," &c. (Parisian Chirurgical Journal, Vol. 2, p. 267.) If there are now any practitioners, who may be averse to the total relinquishment of this method, I think tlie following caution, given by Sabatier, may be of service to them: perhaps, the operation would be more safe, if the surgeon were to begin with making a deep incision in the perineum, as is practised in the la. teral Way of cutting for the stone, and if he were to desist from plunging the tro- car into the bladder, until he had assured himself of the situation of this viscus, and felt the fluctuation of the urine. Garengeot has given this advice to Fou- bert, in regard to the mode of cutting for the stone practised by the latter, and it seems equally applicable in the present place. (Medecine Operatoire, Tom. 2. p. 127.) \2. Puncture above the Pubes. The invention of the method of tap. ping the bladder from above the pubes was suggested by the practicableness of extracting calculi from that viscus, by what is usuaUy denominated the high operation. The first periormers of the puncture above tiie pubes are said to have 184 BLADDER. employed a straight trocar, the very same instrument as was used for tapping the abdomen in cases of dropsy. The con- sequence was, that when such a trocar was too long, its cannula was apt to hurt the opposite parietes ofthe bladdej^, so as to occasion inflammation and a slough, on the separation of which the urine was liable to insinuate itself either into the abdomen, or rectum, as happened in a case mentioned by Mr. Sharp, where no more urine was discharged through the cannula, and the patient died of a sort of diarrhaea. When the trocar is short, the bladder, on subsiding and contracting it- self, gradually quits the cannula, which becomes useless, and a necessity for mak- ing another puncture is produced. What- ever pains may be taken to direct the trocar obliquely downwards and back- wards, so that the cannula may be, in some degree, parallel to the axis of the bladder, one, or the other of these acci- dents, cannot always be prevented. Their prevention, however, may be effected by merely employing, instead of a straight trocar, a curved one, which Vill naturally take a suitable direction. This improvement was embraced by Frere Come, the inventor of the litho- tome cache, who also devised a curved trocar, for the paracentesis of the blad- der, veiy superior to the instrument of the same shape previously in use. To this way of operating, Mr. Sharp was partial, and Mr. Abernethy has more recently recommended it, under certain circumstances. The former celebrated surgeon remarks, that it is an operation of no difficulty to the surgeon, and of little pain to the patient, the violence done to the bladder being at a distance from the parts affected. It is equally appUcable, whether the disorder be in the urethra, or prostate gland, and when there are strictures, the use of bougies may be continued, while the cannula re- mains in the bladder. (Critical Enquiry, p. 125, edit. 4.) Some writers recommend making an incision, about two inches long, through the linea alba, a little way above the pubes, and then introducing a trocar into the bladder. Others deem this pre- liminary incision quite useless, asserting, that the operation may be performed with equal safety, and less pain to the patient, by puncturing at once the skin, the Unea alba, and the bladder. When the trocar has been introduced, the stilette must be withdrawn, and the cannula kep in its position by a ribbon, passed through two little rings, with which ft should be con- structed, and fastened round the body. The orifice of the cannula should be stopped up with a Uttle plug, so as to keep the urine from dribbling away In- voluntarily, and taken out as often as oc- casion requires. (EncyclopedicMethodique; Part. Chirurg.Art.Paracentesedela Vessie.} The trocar should be introduced in a direction obliquely downward and back- Ward; for as this corresponds with the axis of the bladder, the instrument is less likely to injure the oj-Tiosite side of that organ. Nearly all writers advise the puncture to be made an inch, or an inch and a half, above the pubes. The reasons for so doing are the following: " If the punc- ture be made close to-the os pubis, the bladder in that part, often rising with an almost perpendicular slope, leaves a chasm between it and the abdominal muscles, or, to speak more strictly, a certain depth of membrana cellularis only, so that, if the trocar penetrate but a little way, it possibly may not enter into the bladder. If it penetrates considerably, it may pass through the bladder into the rectum, or, if not in the operation itself, some days afterwards, when by the course of the ill- ness and confinement the patient is more wasted. For, the abdominal muscles, shrinking and falling in, occasion the extremity ofthe cannula to press against the lower part of the bladder, and, in a small time, to make a passage into the rectum." (Sharp in Critical Enquiry, p. 127.) Though the reasons here adduced seem at first as formidable, as they are numerous, does not the danger of injuring tiie peritoneum, form an objection to plunging in a trocar at the above distance from the pubis ? Certain it is, peritonitis would be more apt to be induced by such practice, than by introducing the instru- ment immediately above the pubes. Rich- erand decidedly condemns the plan, prin- cipally because the higher the puncture is made, the more apt will the bladder be to quit the cannula, on the urine being discharged. (SeeNosographie Chirurgicale, Tom. 3, p. 472, edit. 2.) In Desault's works, by Bichat, the puncture is also advised to be made immediately abov« the pubes. Tom. 3, /». 318. Some of Mr. Sharp's objections are done away, by taking care to pass the trocar into the bladder in the axis of this viscus, and employing one which is somewhat curv- ed, as Hunter, Frere Come, Sabatier, &c. have advised. Mr. Sharp confirms the danger of using too long a cannula, by mentioning an accident, which occur- red in his owti practice. Though he in- troduced the instrument-'" more than an inch and a half above the 03 pubis, yet having pushed it full two inches and a half, below the surface of the skin, its BLADDER. 1& extremity in six, or seven days insinuated itself into ihe rectum. (Critical Enqttiry, p. 127) The instrument, says an excellent writer, should be more or less long, ac- cording to the embonpoint of the pa- tient; but, the ordinary length should be about four inches and a half. The curvature should be ftjiform, and form the segment of a circle about eight inches in diameter. (Qluvres Chir. de Desault par Bichat, Tom. 3. p. 317.) A catheter left in the bladder, longer, than ten days, may possibly gather such an incrustation from the urine, as not only to render the extraction of it pain- ful, but even impracticable. This should caution us, therefore, never to leave the cannula in the bladder quite a fortnight. If necessary to leave one so long, Mr. Sharp advises a second one to be intro- duced, made with an end, like that of a catheter. (Critical Enquiery, p. 129.) Mr. Abernethy first made an incision, between the pyramidales muscles, passed his fingers along the upper part of" tiie symphysis pubis, so as to touch the dis- tended bladder, and introduced a com- mon trocar, of the middle size, in a di- rection obliquely downwards. On with- drawing the stiiette, he passed a middle- sized hollow elastic catheter, through the cannula, into the bladder. The can- nula was withdrawn, and the catheter left in, till the urine passed through the urethra. After a week, as the instrument was stopped up with mucus, it was taken out, and a new one introduced. (Surgical Observations, 1804.) It might be objected to this plan of employing a hollow bougie, that, as it is smaller, than the wound, the urine is not kept from passing between the instrument, and parts, into which it is introduced, as well as through the tube it- self. This happened in Mr. Abernethy's case, and, though no urine in this in- stance, got into the cellular membrane; yet, it would probably do so sometimes, because, it is not till after inflammation has tiken place, that the cavities of the cellular substance are closed by coagulat- ing lymph. After a time, however, the cannula of the trocar might be with- drawn, and the hollow bougie employed, if preferred, though it seems difficult to discover a reason for chusing it. The following is one of Mr. Home's conclusions: (Med.andChir.Trans. Vol.2.) " When the puncture is made above the pubis, tlie cannula, which incloses the trocar is not to be removed, till the sur- rounding parts have been consolidated by inflammation, so as to prevent the urine in its passage out from insinuating itself into the neighbouring parte; for where- tvcr the urine lodges, mortification takes Vol. I. place. Any advantage, therefore, which may arise from a more flexible instrument remaining hi the bladder, is more than counterbalanced by its not filling com- pletely the aperture through the coats of the bladder, and allowing the urine to escape into the cellular membrane." There is much truth in the following passage: The abdomen is inflamed; the preliminary incisions, which prepare for the introduction of the trocar, sometimes pass through several inches, of fat, and cellular substance ; the incisions must be wide in proportion to their depth; the cannula is no sooner lodged here, than it is displaced, in some degree, by the con- traction ofthe bladder, which, when emp- tied, subsides under the pubis. The can- nula stands so obliquely, that the urine never flows with ease, but, by running out upon the wound,and by being injected among the cellular substance, it causes the wound to inflame; the wound by its proximity to the inflamed peritonaeum soon mortifies, and thus, notwithstanding the temporary relief, produced by the emptying of the bladder, the patient dies on the third or fourth day. (John Bell's Principles ofSurgeiy, Vol. 2, p. 271.) That this operation is infinitely better, than that of making the puncture in the perineum is indisputable. There are even now some good surgeons, who seem to prefer it to the method of tapping the bladder from the rectum. In the CEuvres Chirurgicales de Desault, Tom. 3, p. 324, it has received the preference, and at p. 319 ofthe same book, a high encomium is bestowed on it, in the following terms. " This operation is easy. The little thickness of the parts, which are to be wounded, renders it quick and triflingly painful. The surgeon has occasion for no assistance. The patient is neither in- timidated, nor fatigued with the posture in wliich he is put. It is almost impos- sible to miss the bladder, except it were exceedingly contracted. There is no risk of piercing the cavity of the abdomen. Anatomy proves, that here the bladder is in immediate contact with the recti mus- cles, and that when tliis viscus is distend- ed with urine, it pushes the peritoneum upwards and backwards, under which membrane it enlarges, and thus makes the point of the trocar become more and more distant from the cavity of th * abdo- men. The patient may easily lie on lis side, or abdomen, so as to discharge all the urine contained in the bladder. There are here no nerves, nor vessels, of which the injury can be dangerous. No difficulty is experienced in fixing the cannula, and the presence of this instrument does not hinder the patient from sitting, standing B B 186 BLADDER. up, or even walking about in his chamber. When the cannula, also, is introduced to the lower part of the bladder, this viscus cannot possibly quit it. Lastly, the wound heals with more facility, than that made in any o'her method.'' Respecting this advice to push the can- nula so far into the bladder, it is highly ob- jectionable, for the reason already explain- ed. The writer of the preceding commen- dation seems to me rather too partial. He has toid us of the little thickness of the wounded parts, and, yet a little before bestowing these praises, he has acknow- ledged, " ilest rare, que dans cetteponction, on traverse directement la ligne blanche : on passe presque toujours sur ses elites, et I'on divise lapeau,Paponeurose des muscles larges du bas-ventre, les muscles droits, quclquefois Pun ties pyramidales, et la parol anterieure de la vessie." ('Tom. 3, p. 318.) According to my own judgment, the plan, v Inch is about to be described, is the safest and best, when the circum- stances of the case afford a choice, and that it would be for the benefit of the afflicted, if the puncture above the pubes were only performed in cases in which the enormous enlargement of the prostate gland prevents a puncture from being b&fLly made from the rectum. 3. Puncture from the Rectum. This method is nitre generally appli- cable, than either ofthe two plans above related. It is not, like the puncture in the perinacum, liable to the objection, that the wound is made on diseased or inflamed parts, which afterwards become gangrenous. Nor is it, like the puncture above the pubes, attended with a chance of the urine diffusing itself in the cellular membrane It has also the advantage of emptying the bladder completely. The puncture is made sufficiently far from the neck of the bladder not to increase any inflammation existing in that situation; and the operation is really attended with Utile pain, since there is no skin, nor muscles to be wounded, merely the coats of the bladder and rectum, at a point where these viscera lie in contact with each other. The enlargement of the prostate gland, is, perhaps, the only solid reason against its being uniformly preferred. When the bladder is to be tapped from the rectum, two fingers should be intro- duced into the intestine, instead of one, as has been directed. In this manner, the cannula can be more conveniently guided, and held in a proper position, while the trocar is introduced with the other hand. The stilette, however, must never be introduced into the cannula. except when this is properly placed, with its extremity against the part, where it ii intended to "make the puncture. We read in the Philosophical Transac- tions for 1776, of a case of" total retention of urine, from strictures, where the blad- der was successfully punctured from the rectum. Mr. Ihrtnilton, who did the operation, thought of the plan, in con.se. quence of feeling the bladder exceedingly prominent in the rectum, on introducing his finger into the anus. The patient was placed in the same position as that in lithotomy; a trocar was passed along the finger into the anutj and pushed into the lowest, and most projecting part of the swelling, in the direction of the axis of the bladder. A straight catheter was immediately in'ro- duced through the cannula, lest the blad- der by contracting -tiiould quit the latter, which was taken away, and, as soon as the water was discharged, the catheter wa's also removed. Notwithstanding the puncture, the bladder retained > he urine as usual, until a desire to make water occurred. Then the opening made by the instrument seemed to expand, and the water flowed in a full stream from the anus; The urine came away, in this manner, two days, after wh ch it passed the natural way, with the aid of a bougie, winch had been passed through the urethra, into the bladder, and which was used, till all the disease in tliis canal was cured. , The method is said to have been ori- ginally proposed in 1750, by M. Fleurant, surgeon of the hospital La Charite, at Lyons, and Pouteau, in 1760, published an account of it, and three cases in which Fleurant had operated. It was also the feel of the bladder, on the intro- duction of a finger intra anum, which kd the latter surgeon to choose making a puncture in this situation. The unre was immediately discharged, and the cannula supported in its place with the T bandage, until the natural passage was reduced previous again. But the cannula, being allowed to remain in the rectum, became incommodious to the pa- tient, when he went to stool, and, the in- convenience was vastly increased by the continual dribbling ofthe urine from the mouth of the instrument. Hamilton avoided both these inconveniences, by withdrawing the cannula at first. In another instance, however, Fleurant left the cannula in the anus and bladder, thirty-nine days, without the least incon- venience. In order to lessen the inconvenience, at- tending the presence ofthe cannula, Fleu- rant suggested that it would be better to BLADDER. 187 have the tube made of a flexible sub- stance; a proposal, that seems to merit attention, though, I believe, the inconve- niences of wearing the cannula are not in general very serious, and, were a case of this kind to present itself, I should have no hesitation in withdrawing the tube al- together. In the first volume of tlie Mem. of the Medical Society of London, two cases are , related, in wliich, after tapping the blad- der from tiie rectum, the cannula was im- mediately withdrawn, without any bad effect. Another similar -fact is recorded in the Medical Communications, Vol. 1. A long, curved, cylindrical trocar, is the best for performing the operation, and was the one recommended by Pouteau. It should be introduced a little beyond the prostate gland, exactly in the centre ofthe front ofthe rectum, and sufficient- ly far up this intestine. In this way the vesiculae seminales, which diverge from each other above, cannot be injured; and, even were they so, perhaps no serious Consequences would follow. It is not necessary to retain the can- nula in the puncture, after the inflamma- tion has consolidated the sides of the wound, and there is no danger of the aperture closing up, till there is another passage made for the urine. Mr. Home thinks, that after about thirty-seven hours, the cannula may be properly taken out. (Med. and Chir. Trans. Vol. 2.) Indeed, I am not acquainted with any fact, shew- ing tiie ill effect of removing the cannula at once; for, here the urine has only to pass through a mere opening, without any longitudinal extent, as after puncturing above the pubes. The safety and sim- plicity of tapping the bladder from the rectum, will always recommend this me- thod with impartial practitioners. The wound is made at a distance from the peritoneum, paSses through no thickness of parts, and is quite unattended with any chance of the urine becoming ex- travasated in the cellular substance. Whe- • ther the bladder be morbidly contracted and thickened; whether the neck of the ■bladder be inflamed; it is equally appli- cable : the diseased enlargement of the prostate gland, can alone warrant the puncture above the pubes being ever pre- ferred. I am happy trtjoin the experienced and judicious Mr. Hey with the advocates for this mode of performing the operation, and as his opinion on this subject must have considerable influence, I shall quote the foUowing passage from his valuable work, particularly as the observations confirm some other points adverted to in the present article. " It is sometimes impossible, fi-om various causes, to make a catheter pass through the urethra. The puncture of the bladder then becomes , necessary, if the retention of urine con- tinues. This operation may be perform- ed, either above the pubes, or through the rectum. I have seen it performed in both these methods ; but, give the preference to the latter. It is more ea-v to the sur- geon; and less painful to the patient. Pouteau's carved trocar is a very conve- nient instrument; and may be used with safety for puncturing the bladder through tlie rectum; but, the operator should cautiously avoid -wounding an artery, which may be felt running towards the anus, where the bladder is most protu- berant. The finger, which is introduced into the rectum to guide the trocar, may be conveniently placed a little on either, side of this vessel. It is not always ne- cessary to leave the cannula in the blad- der, as the urine sometimes begins to flow through the penis, within a few hours after the bladder is emptied. Perhaps, this event may be the most frequent, when the introduction of the catheter has been prevented by a stricture in the ure- thra. If the wound becomes closed, be- fore the power of expelling the urine is regained, recourse must be had to a repe- tition of the operation, which gives very little trouble to the patient; neither is he much incommoded by suffering the can- nula to reman two or three days in the bladder. This is sometimes necessary, and seldom improper." (Hey's Practical Observations in Surgery,p.430—43 l,edit.2.) Women seldom stand in need of the paracentesis of the bladder; but, when tlie operation is necessary in them, it is more safely and easily performed from » the vagina, than in any other way. If it should be proper to leave in the cannula, this must be long enough to allow its ori- fice to be situated on the outside of the labia, where it must be fixed with a T bandage. Consult particularly Sharp on the Ope- rations, Chap. 15, and his Critical Enquiry, L'Encyclopedic Methodique, Partie Chirur- gicale; art. Puracentese de la Vessie. Saba- tier's Medecine Operatoire, Tom. 2. Med. and Chir. 'Transactions, Vol. 2. Abemethy's Surgical Observations, 1804. John Bell's Principles of Surgery, Vol. 2. QHuvres Cld- rurgicales de Desault par Bichat, Tom. 3, p. 315, &c. Richeruna*s Nosographie Chirur- gicale, Tom. 3, p. 471, &c. edit. 2. Hey's Practical Observations in Surgery, p. 430, edit. 2. Metunges de Chirurgie,par Pouteau, Lyon, 1760, p. 500. Parisian Chirutgifal Journnl, Vol. 2,/>. 156, and p. 265. 188 BLA BLE Bladdeii, Tumour extirpated from. Mr. Joseph Warner, surgeon of Guy's Hos- pital, has recorded a case, in which an excrescence, growing from the inside of a young woman's bladder, was success-^ fully removed. The patient, on the 24th' of June, 1747, strained herself in endea- vouring to lift a great weight, and she was immediately seized with a pain in the small of her back, and a total reten- tion of urine. In April, 1750, she applied to Mr. Warner, who found, upon enquiry, that she had never been able, from the moment of the accident, to void a drop of urine, without the assistance of the ca- theter; that she was in continual pain, and had lately been much weakened, by having several times lost considerable quantities of blood, occasioned by the force made use of in introducing the in- strument into the bladder. Mr. Warner, upon examining the parts, with his forefinger, which he had great difficulty in introducing into the meatus urinarius, discovered a considerable tu- mour, which seemed to be a fl-eshy sub- stance, and took its rise from the lower part of the bladder near its neck. When the patient strained to make water, and the bladder was full, the excrescence pro- truded a little way out of the meatus urinarius ; but upon ceasing to strain, it presently returned. A purgative having been given the day before the operation, and tiie rectum emptied by means of an emollient clyster, Mr. Warner directed the patient to strain, so as to make the swelUng project. He then hindered it from returning into the bladder by passing a ligature through it, and endeavoured to draw it forther out.— The latter object was found impracti- cable, on account of the size of the tu- mour. Seeing this, Mr. Warner dilated the meatus urinarius on the right side, by cutting it upwards, about half way to- wards the neck of the bladder, when, by pulling the swelling forwards, he was enabled to tie its base, which was very large, with a ligature. For three days after the operation, a good deal of pain was felt in the abdo- men. On the sixth day, the tumour dropped off". From the first day, the urine came away without assistance, and tlie patient got quite well. The tumour resembled a turkey's egg in shape and size. (See Warner's Cases in Surgery, edit. 4, p. 303.) Perhaps, in this example, tying the tumour was preferable to cutting it away, even though its base was large ; for, had .the knife been used, there would have been some danger of the bladder becom- ing fi led with blood. Blaudf.*, Herrtia of. See Hernia. Blauurk, Insects discharged from. Tjfce instances in which worms are stated to have been discharged from the bladder, are very numerous. Many cases of this kind are referred to in Voigtel's Hand- buch der pathologischen Anatomie, b. 3, p. 337—342. A most interesting* example has also been lately recorded by Mr. Wil. liam Lawrence. (See Medico-Chirurgical Transactions, Vol. 2, p. 382, &c.) Bladder, Deficiency of. Numerous ex- amples, in which this deviation from the natural structure has occurred, are re- corded by medical writers. The publica- tions, however, which, as far as I know, contain the most ample information, on the subject, are, a Gottingen inaugural dissertation, entitled, " De Vesicx Uri- narix Prolapsu Nativo," by Dr. Roose, late professor in Brunswick, and a paper, called, " An attempt towards a systematic account of the appearances, connected with tlie malconformation of the Urinary Organs, in which the ureters, instead of terminating in a perfect bladder, open externally on the sur- face of the Abdomen," by A. Duncan, jun. in Edinb. Med. and Surgical Journal, Vol. 1. In this last production may be seen references to all the most noted cases on record, both male and female. Bladdkh, Wounds of. See Gunshot Wounds. BLEEDING. By this operation is understood the taking away of blood for the relief of diseases. Bleeding is called general, when practised with a view ofiles- sening the whole mass of circulating" blood ; topical, when performed in the vi- cinity of the disease, for the express pur- p se of lessening the quantity of blood in a particular part. General Blood-letting is performed with a lancet, and is subdivided into two kinds ; viz. the opening of a vein, termed phlebotomy, or venesecliuti ; and the open- ing of the temporal artery, or one of its branches, termed arteriotomy. Topical Blocd-lettingisperformed, either by means of a cupping-glass and sca- rificator, by leeches, or by dividing the visibly distended vessels with a lancet. The latter is frequently done in cases of opthalmy. PnLEBOTOMT, OR VBKESECTIOW. The mode of bleeding most frequently practised is that of opening a vein ; and it has been done in the arm, ankle, ju- gular vein, frontal vein, veins under the tongue, on the back of the hand, &c. In whatever part, however, venesection is performed, it is always necessary to com- press tlie vein, between the place where BLEEDING. 189 tlie puncture is made, and the heart. Thus the return of blood through the vein is stopped, the vessel swells, becomes con- spicuous, and when opened, bleeds much more freely than.it would otherwise do. Hence, according to the situation of* the part of the body where the vein is to be opened, with regard to the heart, the fil- let for making the necessary pressure must be applied, either above, or below the puncture. All the apparatus essential for blood- letting, on the part of the patient, is a bandage, or fillet, two or more small pieces of folded linen for compresses, a basin to receive the blood, and a little clean water and a towel. The bandage ought to be about a yard in length, and near two inches broad, a common ribbon or garter, being frequently employed. The com- presses are made by doubling a bit of linen rag, about two inches square. On the part of the surgeon, it is necessary to have a good lancet, of proper shape. He should never bleed with lancets with which he has been in the habit of opening any kind of abscesses, as very troublesome complaints have been the consequence of doing so. The shape of the instrument is also a matter of some importance. If its shoulders are too broad, it will not readily enter the vein, and when it does enter, it invariably makes a large open- ing, which is not always desirable. If the lancet be too spear-pointed, an in- cautious operator would often run a risk of transfixing the vein, and wounding the artery beneath it. More, however, cer- tainly depends on the mode of introduc- ing the lancet, than on its shape. In blood-letting, tiie patient may lie down, sit down, or stand up, each of wliich positions may be chosen according to cir- cumstances. If the patient be apt to faint from the loss of a small quantity of blood, and such fainting can answer no surgical purpose, it is best to bleed him in a re- cumbent posture. But, when the person is stro-ig and vigorous, there is little oc- casion tor this precaution, and a sitting posture is to be preferred, as the most convenient, both for the surgeon and pa- tient. This, indeed, is the common posi- tion. In some cases, however, particu- larly those of strangulated hernia, it is frequently an object to produce fainting, in order that the bowels may be more easily reduced. In this circumstance the patient may be bled in an erect pos- tnre, and the wound made large, as a sudden evacuation of blood is particularly apt to bring on the wished for swoon. For the same reason, if we wish to avoid making the patient faint, we should then make only a small puncture. Every operator should be able to use the lancet with either hand, which will enable him to bleed the patient in the right or left arm, as circumstances may render most eligible. At the bend of the arm, there are se- veral veins in which a puncture may be made; viz. the basilic, cephalic, median basilic, and median cephalic." The me- dian basilic vein, being usually the largest and most conspicuous, is that, in which the operation is mostly performed: but, surgeons should never forget, that it is under this vessel that the brachial artery runs, with the mere intervention of the aponeurosis sent off from the tendon of tiie biceps muscle. In very thin persons, indeed, the median basilic vein lies almost close to the artery, and nothing is then more easy than to transfix the first of these vessels and wound the last. Hence^ Richerand advises all beginners to prefer opening the median cephalic, or even the trunk of the cephalic itself, to puncturing either the basilic, or the median basilic, which last are internally situated, and nearer the brachial artery. Nosographie Chirurgicale, Tom. 3, p. 383, Edit. 2.) In exceedingly fat subjects, the large veins at the bend of the arm are sometimes totally imperceptible, notwithstanding the fillet is tightly applied, the limb is put in warm water, and every thing done to make those vessels as turgid as possible. In this circumstance, if the surgeon has not had much experience in the practice of venesection, he will do well to be content with opening one of the veins ofthe back of the hand, after putting the member for some time in warm water, and applying a ligature round the wrist. In children, a sufficient quantity of blood cannot always be obtained by venesection, and, in this event, the free application of leeches, and occasionally, the puncture ofthe temporal artery, are the only effectual methods. With respect to the choice of a vein in the arm, the most experienced operators give a preference to one, which rolls least under tlie skin. Such a vessel, though sometimes less superficial, than another, may commonly be opened with greater facility. The surgeon, however, is always to fix the vein, as much as he can, by pi .cing the thumb of his left hand a little below the place, where he intends to introduce the lancet. In bleeding in the arm, the fillet is to be tied round the limb, a little above the elbow, with sufficient tightness to inter- cept the passage of the blood through all the superficial veins ; but, never so as to stop the flow of blood through the arteries, which would tend to prevent the veins fi-om rising at all. The veins being thus render- 190 BLEEDING. ed turgid, the surgeon must choose the one which seems most conveniently situ- ated for being opened, and large enough to furnish as much blood as it may be proper to take away. Before applying the fillet round the arm, however, the operator should always feel where the pulsation of the artery is situated, and, if equally convenient, he should not open the vein immediately over this part. It is also prudent to ex- amine where a pulsation is situated, on account of the occasional varieties in the distribution of the arteries of the arm. The ulnar artery is sometimes given off from the brachial very high up, and, in this case, it frequently proceeds superfi- cially over the muscles, arising from the internal condyle, instead of dividing un- der them, in the ordinary manner. When the external jugular vein is to be opened, the surgeon generally makes the necessary pressure with his thumb. The orifice should be made in the direction of the fibres of the platysma myoi'des mus- cle ; and the vein is not so apt to glide out •f the way, when the surgeon makes the puncture just where it lies over a part of the sterno-cleido-mastoideus muscle. When blood is to be taken from the foot, the Ugature is commonly applied a little above the ankle. The fillet liaving been put on the arm, the operator is to take the blade of the lancet, bent to a somewhat acute angle, between the thumb and fore-finger, and, steadying his hand upon the other three fingers, he is to introduce the lancet, in an oblique direction, into the vessel, till the blood rises up at the point of the instru- ment. Then bringing up the front edge in as straight a line as possible, the wound in the skin will be made of just the same size as .that in the vein. The operator next takes away the thumb of his left hand, with which he steadied the vessel, and allows the blood to escape freely, till the desired quantity is obtained. The arm ought to be kept in the same position while the blood is escaping, lest the skin should slip over the orifice of the vein, keep tiie blood from getting out, and make it insinuate itself into the cellular sub- stance. When the blood does not issue freely, however, most surgeons direct the patient to move his fingers or turn something round and round in his hand. This puts tlie muscles of the arm into action, and the pressure, they then make on the veins, makes the blood circulate more briskly through these vessels. The proper quantity of blood being dis- v charged, the fillet is to be untied. The flow of blood now generally ceases; though sometimes, when the orifice is large, and the circulation very vigorous, it still con- tinues. In this circumstance, the opera- tor may immediately stop the bleeding, by placing the thumb of his left hand firmly on the vessel, a little below the puncture. The blood is next to be all washed off the arm, tlve sides of the wound placed in contact, and the compressrv applied, and secured with the fillet, put round the elbow in the form of a figure of 8, and regularly crossing just over the com- presses. The patient should be advised not to move his arm much, till the fillet is remov. ed, which may be done after twenty-four hours. In order to open the external jugular vein, the patient's head is to be laid on one side, and properly supported. Then the operator is to press upon the lower part of the vein with his thumb, so as to make the part above swell, and then the lancet is to be pushed at once into the vessel, with tiie cautions already stated. There is commonly no difficulty in stop- ping the bleeding, after the pressure is removed. Some practitioners have di- rected a scalpel to be used for dividing the integuments, before opening the vein it- self; but, tins is quite unnecessary. Blood-let,ing in the feet is executed on the same principle as in other parts; but, the blood from the veins in this situation, in general not flowing with much cele- rity, it is customary to immerse the feet in warm water, in order to promote the bleeding. [The use of the German fleame, or, as it is oftener called, the spring lancet, has in some parts of the United States, almost entirely superseded that of the lancet; it certainly possesses some ad- vantages over the latter, although I am not disposed to deny that it is in some respects inferior. In a country situated like the United States, where every sur- geon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instru- ment, and no one can calculate with cer- tainty the depth to which it will enter: to sharpen a lancet, is regarded by the cut- ler, as one of his nicest and most difficult jobs; it is one to wliich few surgeons are competent. The 'safety of using the fleame is de- monstrated by daily experience ; there ia BLEEDING. 191 no country in which venesection is more frequently performed tlinn in the United States, and perhaps no one .where fewer uccitlent*from the operation have occurred, of these few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used. The manner of using the spring lancet differs in nothing from the operation de- scribed by Mr. Cooper, excepting that the surgeon must place the instrument in such a situation over the vein, that when the spring is touched, the orifice into the vein will have a proper size and direction. Dexterity in this is very readily and speed- ily acquired. In point of facility in its use it has a great advantage over the lancet. Among the advantages of the spring lancet economy is not the least. A country practitioner, who is constantly employing the English lancets, and who is particular in using none but the best, must neces- sarily consume half the emolument deriv- ed from the operation, in the purchase of his instruments. One spring lancet, with an occasional new blade, will serve him all bis life.] AKTEniOTOMY. The only arteries from which blood is ever taken in practice, are the trunk and branches ofthe temporal artery, which lie in such a situation, that they may easily be compressed against the subjacent bones, and the bleeding stopped. When the vessel which the surgeon chooses to open, lies very near the surface, or may be as- certained by feeling, or even seeing, its pulsation, it may be opened at once with a lancet. But, in many instances, it is so deeply situated, that it becomes necessary, in the first place, to make a cut in the skin, and then puncture the vessel. Tlie bleeding generally stops without any trouble; and may always be suppress- ed by'a compress and bandage. In a very few cases, the blood bursts forth from time to time, and more is lost than is necessary. When this happens, notwithstanding pres- sure,it is recommended to divide the vessel completely across, which facilitates the process of nature in closing the end of the vessel. TOPICAL BLEEDING.—CCPPINB. This is done by means of a scarificator, and a glass, shaped somewhat like a beU. The sacrificator is an instrument contain- ing a number of lancets, sometimes as many as twenty, which are so contrived, that when the instrument is. applied to M*y part of the surrace of tiie body, and a spring is pressed, they suddenly start out, and make the necessary punctures. The instrument is also so constructed, that the depth to which the lancets penetrate, may be made greater, or less, at the option of the practitioner. As only small vessels can be thus opened, a very inconsiderable quantity of* blood would be discharged, were not some method taken to promote the evacuation. This is commonly done with a cupping-glass, the air within the cavity of which is rarified by the flame of a little lamp, containing spirit of wine, or as some choose, by setting on fire a piece of tow, dipped in this fluid, and put in the cavily ofthe glass. When the mouth of the glass is placed over the scarifica- tions, and the rarified air in it becomes condensed, as it cools, the glass is forced down on the skin, and a considerable suc- tion takes place. Trials have been made of syringes, cal- culated for exhausting the air from cup- ping-glasses ; but the plan is not found so convenient as the one we have de- scribed. When the glass becomes moderately full, and it is desirable to take away more blood, it is best to remove it and put on another one. A common pledget is usually applied as a dressing for the punctures made with the scarificator. LEECHES. Leeches are often preferable to cup- ping, which is attended with more irri- tation than many surfaces, in particular circumstances, can bear, especially when the topical bleeding is to be frequently repeated. Leeches occasionally cannot easily be made to fix on the particular part we wish; but, they will do so, if the place be first cooled with a cloth dipped in cold water, or if it be moistened with cream or milk, and they are confined in the situation with a small glass. When they fall oft, the bleeding may be pro- moted, if necessary, by fomenting the part. SCARIFICATION WITH A LAXCET. is mostly done in cases of inflamed eyes. An assistant is to raise the upper eye-lid, while the surgeon himself depresses the lower one, and makes a number of slight scarifications, where the vessels seem most turgid, trying particularly