.V NATIONAL LIBRARY OF MEDICINE Washington f «•* • r f ■ »i«. I«t<^ >«» I ^ wjjfa^-tf* I ♦ .^ SYSTEM OF SURGERY: BENJAMIN BELL, MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF EDINBURGH AND IRELAND, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. ILLUSTRATED WITH COPPERPLATES. VOLUME I. SECOND AMERICAN, FROM THE SEVENTH EDINBURGH EDITION, CORRECTED AND ENLARGED. e ■ . '> .* ' .' >»" rj XW& <,'•- '.■i..j;:«ij TROY, NEW-YORK: PRINTED BY O. PENNIMAN AND CO. FOR THEMSELVES; THOMAS AND ANDREWS, BOSTON ; T. S. ARDENj NEW-YORK; AND J. CONRAD AND CO. PHILADELPHIA, I804. PREFACE TO THE SEVENTH EDINBURGH EDITION. I HAVE reafon to hope, that this, the feventh edi- tion of my Syflem of Surgery, will be found con- fiderably improved : I have been at pains to infert in. it all fuch real improvements as have been made in Surgery fince the firft editions of it were publifhed ; and to give reprefentations of fuch ufeful inftruments as have been invented during that period. It is alfo my intention, ftill to keep thefe objects in view, and to incorporate in fuch future editions as may be called for, every improvement in Surgery with which I may become acquainted. I mufl, however, obferve, that I do not engage to notice all that may be mentioned to me as improve- ments, or that authors may judge proper to publifh: for not having done fo, I have already indeed been pointedly blamed : but authors fhould recollect, that with whatever partiality they may view their own pro- ductions, and thofe improvements which they them- felves or their friends may bring forth, that others may not value them fo highly. Anxious to avoid controverfial writing, In which, a full occupation of my time, in what I judge to be more ufeful puriuits, does not permit me to engage, A 2 iv PREFACE. and to which my inclination is altogether adverfe, nothing fhall tempt me to give way to it. This re- mark I am induced to fuggefl, from being informed, that fome have written in fuch a petulant manner on different parts of my publications, as if they wifhed and expected I fhould reply to them : books of this kind, however I fhall never read : no advantage could accrue to this or any other publication, nor credit to myfelf, from replying to authors who feem chiefly to write for the purpofe of declaiming againfl others, and for afferting their own fuperiority over all who have gone before them: leaving others to act in this mat- ter as they may judge proper, I fhall continue, as I have hitherto done, without regard to the opinions of individuals, to detail, what from experience and ob- fervation I know to be the befl practice, and to ftate my opinions clearly and decidedly ; but without at- tempting to force thofe opinions upon others, I fhall allow the Public to determine, whether thefe, or thofe of other men, fubmitted to their consideration ought to be followed. In fpeaking of the late improvements in Surgery, I have elfewhere obferved, what may here with propri- ety be repeated, that were I to endeavour to trace all that have been propofed within thefe lafl fifty or fixty years, I fhould often find it difficult, and in fome in- ftances impoffible, to determine, by whom the prac- tice, as it is now eftablifhed, was introduced ; and in order to give a fair account of the progrefs of the dif- ferent operations of fur^.ery, from their rude to their PREFACE. " V improved' flate, I fhould be obliged to enter on a full chronological hiftory of each : while this kind of in- quiry could ferve no ufeful purpofe, it would tend to render more prolix, a work which, from the variety of its objects, muff neceffarily extend to a great length: I fhall, therefore, in general, decline it: when the author, however, of any remarkable improvement is with certainty known, I fhall never fail to give him all the credit which his difcovery feems to merit: but to notice every inconfiderable alteration that may be pro- pofed upon inftruments and operations, and to enu- merate the opinions contained in many publications, often the productions of men of no practice or obfer- vation, as it could tend to no utility, it will not there- fore be attempted. I have alfo formerly remarked, that I wifh every where to avoid theoretical difquifitions : when the fub- ject under confideration can be rendered more clear and intelligible, I have occafionally employed fuch reafoning as experience and common fenfe feem evi- dently to fupport; but I have fludioufly guarded againfl the difcuflion of doubtful fpeculative opinions : in addition to this, I may obferve, in the words of a celebrated German practitioner, that I have carefully avoided general maxims: in no fcience, he very pro- perly obferves, does felf-fufficiency, or bold and gen- eral affertions, and decided axioms, more certainly mark ignorance and want of experience than in the fcience of medicine.* Infomuch, that in whatever * Aug. Gottlieb Richter, M. D. vi PREFACE. publication they abound, there is much caufe to fu£ pect that the author has not enjoyed thofe full oppor- tunities of obferving the progrefs of difeafes, and the numberlefs varieties that they affume, which every man ought to have done before he attempts to give information to others. To this publication it has been objected by fome, that it is too minute, and of courfe too extenfive. But it mufl be recollected, that it is chiefly written for thofe who are learning, or who are yet young in the profeffion of furgery, and not fo much for men of ex- perience, who alone have flated this objection, and*. who in this inflance feem to have forgot the fleps by which they themfelves gained the knowledge which they poffefs, or that they ever required affiflance in the more early part of their chirurgical purfuits. It was the want of this kind of affiflance, when I enter- ed on the ftudy and practice of furgery, and which at that time was generally felt and complained of, that firfl fuggefled to me the propriety of publifhing this work ; and if it fhall continue to afford to the young- er part of the profeffion, what I have reafon to hope it has hitherto done, an eafier method than they form- erly poffeffed, of acquiring knowledge in the practical part of furgery, and of the pilnciples on which it is founded, I fhall not be difpofed, from the remarks of a few, to alter the manner in which it is written. At fome future period, I, or my fon, now engaged in the fame profeffion, may give an abridgement of the whole, which may ferve as a manual or directory, for thofe. PREFACE. vu who are occupied in the line of chirurgical operations; but the concife defcription of an abridged work, would be ill calculated for thofe who have feen nothing, and who have therefore all to learn. In this and the fixth edition, a confiderable change will be perceived in the arrangement of the fubjects ; and the volume on Inflammation and Ulcers, former- ly publifhed feparately, makes part of the prefent work. A general index is alfo fubjoined to the laft volume. With a view to illuflrate this work, and to give me an opportunity of adverting more particularly than can be done in a general fyftem, to many of the more important parts of furgery, I have, for many years paft, been occafionally employed in arranging for the prefs, narrations of fuch accidents and difeafes, in the management of which I have been perfonally concern- ed, as I conceive will anfwer this purpofe ; and they will be judged to be the more valuable, as a great pro- portion of all that I fhall felect will relate to circum- ftances, in which I have had occafion to act on con- fultation with other practitioners. Two volumes of this kind are nearly ready, and will be publifhed as foon as they are finifhed, under the title of, " Con- " sultations and Observations on many4 of the " more important parts of furgery." Edinburgh, 1 Sept. 1, 1801. J CONTENTS. CHAPTER I. Page On Inflammation, - - i Sect. I. Of the Symptoms and Caufes of Inflam- mation, - - - lb. § i, General Remarks on Inflammation, ib. § 2. Of the Symptoms and Terminations of Phlegmon, - 2 §3. Of the Exciting and Predifpofing Caufes of Inflammation, 3 §4. Of the Proximate Caufe of Inflammation, 4 Sect. II. Of the Treatment of Inflammation by Refolution, 8 § 1. Refolution of Inflamed Tumors, not al- ways proper, - - ib. § 2. Of the Remedies to be employed for the Refolution of an Inflamed Part, - 9 § 3. Remarks on the Preparations of Lead, and other Sedatives, - - 10 Sect. III. Of Suppuration, - - 18 § 1. General Remarks on Suppuration, ib. § 2. Of the Formation of Pus, - 19 §3. Of Remedies for producing Suppuration, 11 § 4. Of Abfceffes, and the proper Period for opening them, - - 28 § 5. Of the different Methods of opening Ab- fceffes, ... 30 Sect. IV. Of Mortification, - - 36 § 1. General Remarks on Gangrene, ib. § 2. Obfervations on Carbuncles, - 38 § 3. Of the Caufes of Gangrene, - 39 § 4. Of the Prognofis in Gangrene, 41 § 5' Of the Remedies for Gangrene, 42 x CONTENTS. CHAPTER II. Page Of Tumors, - - - 51 Sect. I. Of Tumors in General, and their Claf- fification, : - - ib. Sect. II. Of Acute or Inflammatory Tumors, 55 § i. Of Eryflpelas, - - ib. §2. Of Inflammation of the Ear, - 58 § 3. Of Angina, - - 59 § 4. Of Inflammation and Abfcefs of the Liver, - - - 61 § ^. Of Inflammation and Abfceffes in the Mamma, - - - 66 § 6. Of Inflammation of the Tejies, 68 §7. Of Venereal Buboes, - 70 §8. Of Lumbar Abfceffes, - - 77 § 9. Of Paronychia or Whitlow, - 84 § 10. Of Chilblains, - - 88 §11. O/- Sprains and Contufions, - 91 Sect. III. Of Chronic or Indolent Tumors, 96 § 1. General Remarks on Indolent Tumors, ib. §2. Of Encyfled Tumors, - ib. § 3. Of Ganglions, - - 106 § 4. Of Swellings of the Burfa Mucofiz, 108 § 5. Of Collections within the Capfular Liga- ments of Joints, - - no § 6. Of Concretions and Excrefcences within the Capfular Ligaments of 'Joints, 113 §7. Of Anafarea or Oedema, - 117 §8. Of the Spina Bifida, - 119 § 9. Of Scrofulous Tumors, - - 121 o. Of White Swellings of the Joints, 125 1. Of Bronchocele, - - 138 2. Of Navi Materni, - 145 3. (jfV/arts, - - 147 4. Of Tlcfhy Excrefcences, - 149 5. Of Cans, - - 150 6. 0/ Simple Fxcflofis, Venereal Nodes, 'nd Spina Ven.'rfa, - - 151 CONTENTS. xi CHAPTER III. Page Of Wounds, - - - 163 Sect. I. Of Wounds in General, - ib. Sect. II. Of the Cure of Simple Incifed Wounds, 175 Sect. III. Of Punclured Wounds, - 207 Sect. IV. Of Lacerated and Contufed Wounds, 215 Sect. V. Of Wounds in the Veins, - 223 Sect. VI. Of Wounds in the Lymphatics, 224 Sect. VII. Of Wounds of the Nerves and Ten- dons, - 225 Sect. VIII. Of Wounds in the Ligaments, 232 Sect. IX. Of Wounds in the Face, - 239 Sect. X. Of Wounds in the Trachea and Oefo- phagus, - - - 241 Sect. XI. Of Wounds in the Thorax, 246 § 1. General Remarks on Wounds of the Tho- rax, ib. §2. Of External Wounds of the Thorax, 253 §3. Of Wounds penetrating the Thorax, 156 § 4. Of Wounds of the Lungs, - 260 S 5' Of Wounds of the Fleart and large vef- fels connected, with it, and of Wounds of the Thoracic duel, - - 166 § 6. Of Wounds of the Diaphragm, Mediaf- tinum, and Pericardium, - i6y Sect. XII. Of Wounds in the Abdomen, 270 § 1. Anatomical Defeription of the Abdomen, and of its Contents, - - ib. § 2. Of Wounds of ihe Teguments and Muf- clcs of the Abdomen, - - 275 § 3- Of Wounds that penetrate the Cavity of the Abdomen, but whieh do not injure any of the contained Parts, • 279 §4. Of Wounds of the Alimentary Canal, 290 § 5- Of Wounds of the Sto?nach, - 298 § 6. Of I founds of the Omentum and Mefen- tery, - - - 299 xii * CONTENTS. Page § 7' Of Wounds of the Liver and Gall blad- ,der, 300 § 8. Of Wounds of the Spleen, Pancreas, and Receptaculum Chyli, - - 302 § 9. Of Wounds of the Kidneys and Ureters, 303 § 10. Of Wounds of the Bladder, 304 \ \\. Of Wounds of the Uterus, and its ap- pendages, - - - 306 Sect. XIII. Of Poifoned Wounds, - 309 Sect. XIV. Of Gun/hot Wounds, - 315 CHAPTER IV. Of Burns, ... 331 CHAPTER V. On the theory and treatment of ul- cers, - - - - 336 Sect. I. General Obfervations on Ulcers, ib. Sect. II. Obfervations on the Simple Purulent Ulcer, - - - 350 § 1. Of the Symptoms, Caufes, and Prognojis of the Simple Purulent Ulcer, - ib. § 2. Remarks vn the Growth of new Parts in Sores, - - - 351 § 3. Of the Decay of the contiguous found Parts in the Cure of Ulcers, - 353 § 4. Of the Effecl of Comprejfion in the Cure of Ulcers, ... 357 § 5. Of the Advantages to be obtained from Art in the Production of Granulations in Sores, - - 359 § 6. Remarks on the Indications of Cure, and on the Remedies to be employed for the Cure of the Simple Purulent Ulcer, - 362 Sect. III. Obfervations on the Simple vitiated Ul- cer, - _ . - 373 § 1. Of the Symptoms, Caufes, and Prognojis in the Simple vitiated Ulcer, - ib. CONTENTS. • xiii ' Pagc §2. Of the Cure of the Simple vitiated Ulcer, 374 Sect. IV. Obfervations on the Fungous Ulcer, % 380 §i.O/" the Symptoms and Caufes of the Fun- gous Ulcer, - - - ib. § 2. Of the Cure of' tJye Fungous Ulcer, 381 Sect. V. Obfervations on the Sinuous Ulcer, 385 § 1. Of the Symptoms and Caufes of the Sin- uous Ulcer, ib. § 2. Of the Cure of the Sinuous Ulcer, 386 Sect. VI. Obfervations on the Callous Ulcer, 389 § 1. Of the Symptoms and Caufes of the Cal- lous Ulcer. ib. § 2. Of the Cure of the Callous Ulcer, Z9° Sect. VII. Obfervations on the Carious Ulcer, 392 § 1. Of the Symptoms and diagnofis of the Ca- rious Ulcer, - - - ib. § 2. Of the Caufes and Prognojis of the Ca- rious Ulcer, - - - 396 § 3. Of the Cure of the Carious Ulcer, 399 Sect. VIII. Obfervations on the Cancerous Ulcer, 408 § 1. Of the Sy?npto?ns and Diagnofis of the Cancerous Ulcer, - - ib. § 2. Of the Caufes of Cancer, - 409 § 3. Of the Treatment of Cancer, 419 Sect. IX. Obfervations on the Cutaneous Ulcer, 430 § 1. General Remarks on Cutaneous Affec- tions, - - - - ib. § 2. Of the different Species of Herpes, 431 § 3. Of the Cure of the Cutaneous Ulcer, 433 Sect. X. Obfervations on the Venereal Ulcer, 444 § 1. Varieties of the Venereal Ulcer, ib. § 2. Of the Cure of the Venereal Ulcer, 449 Sect. XI. Obfervations on the Scorbutic Ulcer, 452 §1.0/" the Symptoms and Caufes of the Scor- butic Ulcer, ib. § 2. Of the Cure of the Scorbutic Ulcer, 455 Sect. XII. Obfervations on the Scrofulous Ulcer, 458 § 1. Of the Sytnptoms and Caufes cf the Scro- fulous Ulcer, - - - ib. xiv CONTENTS. Page § 2. Of the Cure of the Scrofulous Ulcer, 459 Sect. XIII. General Corollaries relative to the Management of Ulcers, - - 462 CHAPTER VI. Of Sutures, - 464 Sect. I. General Obfervations on Sutures, ib. Sect. II. Of the Interrupted Suture, - 465 Sect. III. Of the Quilled Suiure, - 468 Sed. IV. Of the Glover's Suture, - 469 Sed. V. Of the Twifted Suture, - ib. CHAPTER VII. Of the ligature of arteries and other means employed by art for putting a stop to hemorrhages, - 475 CHAPTER VIII. Of Bloodletting, - - 403 Sed. I. Of Bloodletting in general, - ib. Sed. II. Of a Thrombus, or Fcchymofis, 507 Sed. III. Of Wounds of the Arteries, - 508 Sed. IV. Of wounds or Pricks in the Nerves and Tendons, - - _ r 12 Sed. V. Of Bloodletting in the Arm, 524 Sed. VI. Of Bloodletting in the Jt/gular Vein, 527 ERRATA. VOL. II. Page 39, 3d line from top, for fig. 2. read fig. $. volT 11 r. Page 202, 15th line from top, for fig. r. read fig. 3. Page 235, 4th line from bottom, for fig. 5. read fig. 4. VOL. IV. In Explanation of Plates, (error in copy.) Plate II. fig. 2, for Chap. XIII. Seft. I. read Chap. VIII. Sed. I. SYSTEM OF SURGERY, CHAPTER I. bN INFLAMMATION. SECTION I. Of the Symptoms and Caufes of Inflammation: § i. General Remarks on Inflammation. INFLAMMATION is the moft frequent, as it isj perhaps, the moft important, objed of the fur- geon's attention. We daily meet with it as the confequence of operations, and in the treatment of wounds, contufions, and ulcers. It is therefore confidered as a fit fubjed for the firft article of a Syftem of Surgery. Every organized part of the body is liable to in- flame, but as the inflammation of internal parts is generally produdive of fymptoms which more pro- perly fall within the province of Medicine, it would here be foreign to our purpofe to give any account of them. I fhall therefore treat of this fymptom, and its various confequences, as they commonly occur in the external parts of the body ; and as all the phenomena of inflammation will be underftood Vol. I. B y * 2 Of the Symptoms and Chap. I. from the confideration of phlegmon, or local in- flammation, any obfervations that I fliall offer will be more particularly confined to that variety of the difeafe. % 2. Of the Symptoms and Terminations of Phlegmon. Phlegmon is a term which we apply to a cir- cumfcribed tumor, attended with heat, rednefs, tenfion, and a throbbing pain. Thefe are the firfl appearances of phlegmon ; and when they are flight, and the part affeded of no great extent, they have frequently no apparent influence either on the pulfe or health of the patient; but, when- ever they are confiderable, and the inflammation extenfive, the pulfe becomes quick, full, and gen- erally hard ; and at the fame time, the patient complains of univerfal heat, thirft, and other fymp- toms of fever. If, either by an effort of nature, or by the appli- cation of remedies, the pain, heat, and tenfion are removed, the other fymptoms that I have men- tioned likewife abate, and the patient foon gets well. This is juftly reckoned the moft defirable manner in which inflammation can in general ter- minate, and is termed Refolution. When, inftead of diminifhing, however, the fymptoms of heat, pain, and rednefs rather increafe; when the febrile fymptoms likewife augment, and the tumor acquires a larger fize, turns foft, fome- what prominent in the middle, and acquires a clear fliining appearance, the different fymptoms of fe- ver then abate, and on the tumor being compreffed on each fide, a fluid is found to fluctuate under- neath. In this manner inflammation is faid to ter- minate in Suppuration. But when the pain and rednefs of the part in- creafe, together with the fulnefs of pulfe and other fymptoms of fever, at the fame time that the tu- Sed. L Causes of Inflammation. 3 mor does not become more prominent, we have then reafon to fear, that Gangrene or Mortifica- tion will enfue. Mortification firft appears by a change of colour in the part affeded, which, from being of a bright red, becomes livid, while fmall veficles, containing a thin acrid ferum, are frequently difperfed over its furface ; the pain abates; the pulfe finks, but con- tinues frequent; the tufnor at laft lbfes its tenfe- nefs, turns black and flaccid, and thus terminates in a real mortified or dead fpot. Thefe are the feveral ordinary confequences of inflammation. We fliall now proceed to treat of the various caufes by which it is induced, and laft- ly of the method of cure. § 3« Of the exciting and predifpoflng Caufes of Inflam- mation. The exciting caufes of inflammation, are, in general, whatever tend to ftimulate, or produce pain : fuch as, all variety of wounds, whether Am- ple, lacerated, or pundured, and with whatever Inftrument they may be produced ; alfo bruifes and burns, whether by the adual or potential cautery; likewife all corrofive and irritating applications, as, the different ftrong acids, cantharides, and all the clafs of rubefacientia. Ligatures may likewife be mentioned, and in fome inftances tumors that ad as ligatures, by producing an undue cdmpreflion on any of the blood veffels and nerves ; as alfo, vio- lent exercife of any particular member, and cold applied to a particular part. Thefe are the moft common external caufes of phlegmon : but there are others which tend to produce the fame effed, which we are to confider entirely as internal; fuch are the different vitiated ftates of the fluids, excited by the prefence of mor*' b 2 4 Of the Symptoms and Chap. t. bid matters of different kinds, as the matter of lues venerea, fmall pox, and meafles. Fevers, too, that end in critical inflammation, and confequent ab- fceffes, feem likewife to ad in the fame manner. Under one or other of thefe heads may be com- prehended almoft all the exciting caufes of inflam- mation. I may here, however, obferve, that there are other caufes, which, with fufficient propriety, may be faid to be of the predifpofing kind, in fo far as they tend to produce fuch a ftate of the fyf- tem, as renders it more fufceptible of inflammatory complaints than it otherwife would be. The moft remarkable of thefe, is a plethoric habit of body, moft frequently induced by full living; in fome cafes by want of due bodily exercife, and not un- commonly by a combination of both. We alfo ob- ferve, that inflammatory difeafes are more frequent in young than in old people, and in men more than in women. § 4. Of the proximate Caufe of Inflammation. Various opinions have prevailed on the proxi- mate caufe of inflammation : fome of which have never been generally admitted, and others, after having prevailed for a time, have at laft, too, been rejeded. The dodrine on this fubjed, which for fome years has prevailed in this Univerfity, as it readily accounts for the adion of the feveral exciting caufes of inflammation, for the effeds of the difeafe, and for the operation of the medicines ufually em- ployed in the cure, appears moft clearly ta explain* the proximate caufe afro. From obferving the various phenomena of in- flammation, an increafed adion of the veffels of the part affeded will, in every inftance, be found to take place ; and as, from an increafed adion in the arteries of a part, all the circumftances of inflam- Sed. I. Causes of Inflammation. 5 mation may be explained, we are hence induced to confider this ftate of the veffels as the caufe by which it is immediately produced. This opinion, as I have already obferved, is par- ticularly fupported by a review of the feveral ex- citing caufes of inflammation ; all of which being of a ftimulating nature, their application to living or fenfible parts muft of courfe tend to excite a pre- ternatural exertion of the veffels in fuch parts. Thus, to reafon from analogy, we obferve, that fter- nutatories applied to the internal membrane of the nofe, the aliments to the ftomach and inteftines, and the blood to the internal furface of the veffels in which it is contained, all ferve, as fo many ftim- ulants, to an adion of a different kind ; and in the fame manner, corrofive or irritating fubftances, when applied to the coats of the arteries, naturally in them produce the fame effeds as in other muf- cular organs. We thus, in a very probable manner, account for the adion of all dired ftimulants, in the pro- dudion of inflammation. It frequently happens, however, that inflammation takes place when the application of ftimulants, or irritating fubftances, cannot in any degree be fufpeded. In fuch cafes, the increafed adion of the arteries and of the heart, when it occurs, feems to be fupported by a fpafm or conftridion of the extreme veffels, either of a particular part, or of the whole body : and hence, from the known tonic or aftringent power of cold, we account for the frequent occurrence of inflam- matory difeafes in the cold feafons of winter and fpring; and hence, too, the throat and lungs are more efpecially apt to inflame, from thefe parts be- ing more particularly liable to the immediate adion of cold. Dr. Cullen, who confidered fpafm as the fole proximate caufe.of inflammation, when treating of this fubjed, fays, " That a fpafm of the extreme 6 Of the Symptoms and Chap. I, veffels takes place in inflammation, is prefumed from what is at the fame time the ftate of the whole arterial fyftem. In all confiderable inflam- mations, though arifing in one part only, an affec- tion is communicated to the whole fyftem ; in con- fequence of which, an inflammation is readily pro- duced in other parts befides that firft affeded. This general affedion is well known to phyficians, un- der the name of Diathejis Phlogijlica. It moft com- monly appears in perfons of the moft rigid fibres ; is often manifeftly induced by the tonic or aftrin- gent power of cold; is increafed by all tonic and ftimulant powers applied to the body; is always attended by a hardnefs of the pulfe ; and is moft effedually taken off by the relaxing power of blood- letting. From thefe circumftances, it is probable, that the diathefis phlogiftica confifts in an increaf- ed tone, or contractility, and perhaps contradion, of the mufcular fibres of the whole arterial fyf- tem,"* An increafed adion in the veffels of a part, being admitted as the proximate caufe of inflammation, we can pretty clearly account for the operation of the feveral predifpofing caufes, as well as for the fymptoms which occur in the courfe of it. Thus the increafed adion of an artery, by forc- ing or propelling into the fmaller fets of veffels, red globules, and other denfe parts of the blood which they cannot eafily tranfmit, very readily ac- counts for the rednefs, tumor, tenfion, and throb- bing pain, which occur in every cafe of phlegmon : as likewife, in fome meafure, for the augmentation of heat, which increafed attrition muft in fuch caf- es always produce. It is probable, however, that the accumulation of animal heat alone, which muft neceffarily arife from a larger proportion of bloocl being fent to a part than it naturally receives, will have a confiderable influence in the produdion of an increafed degree of heat. • See Firft Lines of the Pra£ice of Phyfic, p. 88. Sed. I. Causes of Inflammation. 7 The method of cure, as I have already obferved, tends alfo to confirm the opinion that I have ven- tured to fuggeft as the caufe of inflammation. Thus the moft effedual remedies, in almoft every cafe of inflammation, are exactly fuch as would be advifed for the removal of an increafed tone in any particular part, were we convinced that this alone was the difeafe, viz. a low diet, bloodletting, and other weakening evacuations, together with emollient fedative applications: but this, when we come to fpeak more particularly of the different remedies, wall more fully appear. In almoft every cafe of phlegmon that does not run to an unufual depth, and not attended with fymptoms uncommonly violent, we may venture upon a favourable prognofis. For, if refolution, which is the eafieft and moft defirable termination, is not effeded, fuppuration will moft probably en- fue: and the danger arifing from this, when the conftitution is otherwife healthy, is not common- ly very material. When, however, an inflamed part is of large ex- tent, with the tumor paffing to a confiderable depth, and the general fymptoms of fever violent, a good deal of danger is to be dreaded. For befides the rifk arifing from the fever itfelf, if the fymptoms continue fevere, without fhowing a tendency ei- ther to refolution or fuppuration, gangrene will, in fuch circumftances, probably follow: and in what manner this may terminate, is always uncertain. 8 Of the Treatment of Chap. I, SECTION II. Of the Treatment of Inflamtnation by Refolution. § i. Refolution of Inflamed Tumors, in fome infiances, not to be attempted. FROM what has been faid, it will appear, that in the treatment of phlegmon we ought in general to have it in view to accomplifli a cure by refolution. Some exceptions, however, occur to this, in which the removal of inflammatory tumors by refolution ought not to be attempted. Thus tumors fucceeding to fevers, and other inr ternal difeafes, ought very commonly to be brought to fuppuration; for nature in that way pointing out an exit for fome fuperabundance of fhijds ex- ifting in the fyftem, it might be produdive of hazard to give her any interruption. It is indeed, in all fuch cafes our fafeft and beft pradice to aflift her as much as poflible, by the ufe of fuch applir cations as will moft readily tend to promote fuppu- ration. Some tumors, however, even arifing from in- ternal caufes, are of a nature that praditioners fhould not meddle with, either in view of curing them by refolution, or in bringing them to fuppu- ration : thus, in fwellings proceeding from fcro- fula, it might be dangerous to make ufe of repel- lent applications, at the fame time that it is not often advifable to promote their fuppuration, from the cure of the fore^s which fucceed to this proving always tedious and uncertain ; and fuch fwellings, it is well knov/n, may remain for a great length of time, without any fort of rifk to the patient ; fo that, in general, we think it moft prudent never to meddle with them. Sed. D. Inflammation by Resolution. 9 In lues venerea, too, as we are poffeffed of al- moft a certain antidote for the virus ; and as bu- boes, and other inflammatory fwellings which oc- cur in that difeafe, are commonly, when opened, exceedingly troublefome, and very difficult of cure, it is our fafeft pradice to remove them by difcuf- fion ; and this more efpecially, as their being brought to fuppuration can by no means free the patient from the difeafe; but leaves him, on the contrary, under the fame neceffity of undergoing a mercurial courfe, as if no evacuation from the tu- mor had taken place. In cafes of eryfipelas, likewife, which is a variety of inflammation, but which is eafily diftinguifhed from real phlegmon, by the colour of the inflamed part not being of fuch a bright red, but having a more dark copper-like appearance ; and by the fwelling that occurs in it, not rifing evidently intq a tumor, but being more diffufed, and ending as it were imperceptibly upon the furrounding parts, we Jhould always endeavour to remove the difeafe by difcuffion; for when fwellings of an eryfipelatous, nature terminate in the produdion of matter, they feldom either afford good pus, or heal kindly when opened. It is, however, with thefe fewr exceptions, our beft pradice to endeavour to remove every inflam- matory tumor by refolution. § 2. Of the Remedies to be employed for the Refolution of an inflamed Part. In the incipient ftate of phlegmon, when the fymptoms are not fo violent as. to produce fever, topical remedies alone, with a due attention to reg- imen, often anfwer the purpofe. But when the in- flammation runs high, and excites heat, and a fe- brile affedion of the pulfe, other remedies muft be employe.!. io Of the Treatment of Chap. I. In almoft every cafe of phlegmon, it has been the prevailing pradice to employ warm fomentations and cataplafms ; but, as warm emollient applica- tions have the moft powerful influence in promot- ing fuppuration, as will be fhewn more particular- ly hereafter, the ufe of fuch remedies, while the cure is to be attempted by refolution, muft necefia- rily be improper. In the treatment of inflammation by refolution, the firft objed of our attention fhould be the re- moval of the exciting caufes of the difeafe ; fuch as, extraneous bodies in wounds ; pieces of fradur- ed bones; luxations ; and, in fhort, whatever may appear to have influence in exciting irritation. Of the various applications ufually employed for the difcuflion of inflammation, we truft chiefly to thofe of a fedative nature; and, next to thefe, emollients prove moft ufeful. Of the former kind, may be confidered all the preparations of lead diffolved in vinegar ; and the vegetable acid by itfelf appears likewife to ad as a fedative. Our beft emollient applications, are all the vari- ety of bland expreffed oils, fuch as thofe of al- monds, olives, and linfeed; alfo ointments of a foft confiftence, made with any of thefe and pure wax. § 3. Remarks on the Preparations of Lead, ana] other fedative Applications. In fpeaking of fedatives for the cure of external inflammation, it will not be underftood that I mean to recommend indifcriminately the whole clafs of medicines which in different circumftances are found to be of this nature. Thus, opium, though one of the moft powerful of all fedatives, yet, as its external application to the human body is fre- quently found to excite irritation, however ufeful it may at times have been found in fome varieties Sed. II. Inflammation by Resolution. 11 of inflammation, it will never probably, as an ex- ternal application, be generally admitted. Warm emollient fomentations, too, although they undoubtedly ad as fedatives, by tending more effectually to remove tenfion and pain, than per- haps any other remedy, yet, from much experience of their effeds in local inflammation, I have long been convinced, when the refolution of inflamed tumors is wifhed for, that fuch applications very commonly do harm: for, in general, they either tend to promote fuppuration, or, when long con- tinued, are apt to induce fuch a relaxed ftate of the parts, as renders the entire removal of the tu- mor always tedious. No fuch reafons, however, have occurred againft the preparations of lead. On the contrary, it may be affirmed, that while they may be ufed with per- fed fafety, they prove alfo much more powerful as difcutients than any other remedy that hitherto has been employed. We are induced to fuppofe, that the prepara- tions of lead ad chiefly as fedatives, not only from their effeds upon the ftomach, which appear all to be of a fedative tendency ; but from their immedi- ate and obvious operation when applied externally to an inflamed part: which, when the preparation is of a proper ftrength, is almoft conftantly an abatement of the different fymptoms of pain and tenfion, at the fame time that an agreeable footh- ing fenfation is communicated to all the parts to which they are applied. Mr. Goulard, in his Differtation upon the exter- nal ufe of the preparations of lead, recommends them as almoft equally proper in every ftage of in- flammation. Even when tumors have come to full fuppuration, a proper ufe, he fays, of his Extraclum Saturni, not by its repelling quality, for he will not allow it to be poffeffed of fuch, but by its occafion- ing an exfudation of the contained matter, renders 12 Of the Treatment of Chap. I. it almoft always unneceffary, he fays, to open them. He likewife mentions the fame remedy as a pro- per application in gangrene. From my own expe- rience, however, of the preparations of lead, I can- not take upon me to recommend them in either of thefe cafes. I have, indeed, made trial of them all in gangrene, but with no obvious benefit: and, however flrongly they may be recommended by Mr. Goulard, in the cure of abfceffes, or colledions of completely formed pus, I muft own, that in this ftate of the difeafe I never thought of employing them. So that it is in the real inflammatory ftate of phlegmon only, and while a cure by difcuflion may ftill be expected, that fuch applications are here meant to be advifed. From the deleterious effeds commonly fuppofed to arife from lead, when taken into the fyftem, an objedion has, by fome authors, been raifed againft the external application of all the preparations of lead. That lead, in different forms, has, on being tak- en into the ftomach, frequently proved poifonous, there is no reafon to doubt; and that, in fome par- ticular inftances, difagreeable fymptoms have occur- red, where fome of the preparations of lead have been externally ufed/is alfo perhaps certain. That fuch bad fymptoms, however, if they were not merely accidental, or produced by other caufes, are, at leaft in general, very rare effects of the remedy in queftion, I can venture certainly to affirm. For in all the experience which I have had of the ex- ternal application of the preparations of lead ; and in many cafes, particularly of burns, I have known the greateft part of the whole furface of the body covered with them for days, nay, even for weeks together ; I do not recoiled an inftance of any dif- igreeabie fymptom being produced by them. jed. II# Inflammation by Resolution. 13 Of all the preparations of lead for external ufe, saccharum saturni, or ceruffa acetata, as it is now termed, is perhaps the beft, as it has all the advan- tages of the others ; while, in it the exad ftrength of the preparation is more certainly afcertained. For although in the extrait de saturn of Goulard, as likewife in the acetum lithargyrites of our Dif- penfatories, which are both, it may be obferved, very nearly the fame, we may be certain of the quantity of lead employed to the vinegar ; yet we can never, but by cryftallization, know exactly, or even nearly, how much of the lead the menftruum may have diffolved, as this muft depend upon dif- ferent circumftances and particularly on the ftrength of the acid, and exad degree of heat that may be employed ; which are points, we may obferve, not always in our power exadly to regulate. For thefe reafons, therefore, the fait, or fugar of lead, as it is called, fhould be always preferred, when it can be procured in an unadulterated ftate ; but, as of late it has often been found mixed with chalk, and oth- er fubftances not foluble in water, I have elfewhere had occafion to remark, that till this abufe is obvi- ated, the acetum lithargyri will neceflarily be pre- ferred. The beft mode of applying the remedy, feems to be in the form of a watery folution ; for the pre- paration of which, the following proportions are, for general ufe, found to anfwer: §>. Sacchar. faturn. unc. fs. Solve in acet. pur. unc. iv. Et adde aq. fontan. deftillat. lb. ii. The addition of vinegar renders the folution much more complete than it otherwife would be; and without it, indeed, when fuch a large propor- tion of the lead is ufed, a confiderable part of it commonly feparates and falls to the bottom. This is the form which I commonly employ for the ufe of this remedy; but as Goulard's extrad 14 Of the Treatment of Chap. I. and water are preferred by many, I think it right to mention his method of preparing them. The extrad is prepared as follows : To each quart, containing thirty-two ounces of French wine vinegar, add one pound of litharge of gold. Put them into a glazed earthen veffel, and let them fimmer for an hour, or an hour and a quarter, upon a gentle fire, taking care to ftir them during the ebullition with a wooden fpatula: the veflel is now to be removed from the fire, and the feces being allowed to fubfide, the liquor Upon the top muft be poured into bottles for ufe. The water ufed by Mr. Goulard, which he terms the vegeto-mineral water, is prepared by adding two tea-fpoonfuls, which he fpecifies to be one hundred drops, of this extrad, to a quart of water, and four tea-fpoonfuls of brandy. The quantity of the ex- trad and brandy to be diminifhed or increafed ac- cording to the nature of the cafe, or degree of fen- fibility in the inflamed part. In making ufe of thefe folution?, as it is a mat- ter of importance to have the parts kept conftantly moift, cataplafms prepared with crumb of bread completely foaked in them, in general anfwer the intention beft. But, when the inflamed part is fb tender and painful as not eafily to' bear the weight of a poultice, a circumftance by no means uncom- mon, pieces of foft linen, moiftened with the folu- tion, anfwer the purpofe tolerably well: although when this objection to the ufe of cataplafms does not occur, as they retain the moifture longer, they fhould always be preferred. Thefe remedies fhould be always ufed cold, or with no greater warmth than is pleafant to the feelings of the patient; they1 fhould be kept unremittingly applied to the part affeded, and renewed always before turning hard. When, in cafes of phlegmon, the tenfion and irritation of the fkin are confiderable, emollients firove often ufeful: the pained parts being, in this Sed. II. Inflammation by Resolution. 15 ftate of the difeafe, gently rubbed over with any mild expreffed oil two or three times a day, the tenfion, irritation, and pain, are thereby much re- lieved, and the difcuffion of the tumor greatly pro- moted. In every cafe of inflammation, indeed, emollient applications afford relief. But as the preparations of lead prove ftill more effedual, and as unguents of every kind tend confiderably to blunt the adion of lead, thefe two fets of remedies fhould never be combined: nor fhould emollients be ever prefcrib- ed, while we hope to accomplifh a cure by refolu- tion ; but only when irritation, tenfion, or pain, are fo confiderable as to render their application indifpenfable. When parts affeded with inflammation are not very tender, and efpecially when they lie deep, the application of the vegetable acid is often employed with advantage ; and the beft form of ufing it is in cataplafms, made with the ftrongeft vinegar and crumb of bread. In fuch cafes, too, I have fome^ times found, that an alternate ufe of this remedy, with the faturnine folution already pointed out, has produced more beneficial effeds, than we common- ly derive from the continued ufe of any one of them. ^ At the fame time that thefe applications are con- tinued, bleeding with leeches, or cupping and fcar- ifying, as near as poffible to the part affeded, proves generally ufeful, and in no cafe of local inflamma- tion of any importance fhould ever be omitted. In all fuch cafes, the difeafed part fhould be kept as much as poffible at reft : the patient fhould be kept upon a cooling regimen, and fhould abftain entire- ly from the ufe of wine and fpirits. In all the flighter degrees of inflammation, a due perfeverance in the remedies I have mentioned, will, in general, prove fufficient. But, when the pulfe is quick, full, or hard, and accompanied with 16 Of the Treatment of Chap. L other fymptoms of fever, general bloodletting ought never to be omitted ; the quantity to be determin- ed by the violence of the difeafe, the age and ftrength of the patient. Gentle laxatives, too, to- gether with cooling diaphoretics, prove in fuch circumftances very commonly ufeful. Thefe evacuations being premifed, we endeavour to procure eafe and reft to the patient; an objed I may remark, which in the treatment of every in- flammatory tumor, fhould be confidered as of the firft importance. Where the patient is deprived of natural reft, and in all cafes accompanied with pain and irritation, opium is the remedy upon which alone we can place dependence. In large wounds* efpecially after amputations and other capital ope- rations ; and in pundures of all kinds ; large dofes of opium very commonly prove ufeful. In all fuch cafes, however, opium, in order to have full effed* muft be given in large dofes: otherwife it is very apt to do harm ; a circumftance to be confidered as the chief reafon of opiates having by many been unjuftly condemned in every cafe of inflammation. With proper attention to the circumftances I have mentioned, the refolution of phlegmon, in general begins to take place in the courfe of three or four days ; at leaft before the end of this period, it may for the moft part be known how the tumor will terminate. If the heat, pain, and other at-* tending fymptoms, abate ; and efpecially if the tu-< mor begins to decreafe, without the appearance of gangrene; we may then, with fome certainty, con- clude, that perfeverance in the fame mode of treat- ment, will at laft accomplifh a cure by refolution. But, on the contrary, if all the fymptoms rather increafe ; and efpecially, if the tumor runs larger, and fomewhat foft, with an increafe of throbbing pain ; we may then conclude with certainty that fuppuration will take place: in fuch circumftances, thofe applications fhould be laid afide that were Sed. II. Inflammation by Resolution. If advifed while a cure by refolution was judged to be pradicable, at the fame time that nature fhould be as much as poffible affifted in the formation of pus, or what is called the maturation of the tumor. For this reafon, bloodletting, and other evacua- tions which may have been advifable, in attempt- ing to remove the fwelling by difcuflion, fhould never be carried a greater length than may be merely neceffary for rendering the febrile fymptoms moderate j for where the fyftem is much reduced, and fuppuration afterwards takes place, the matu- ration of the tumor not only proceeds flowly, but the patient becomes unable to bear the difcharge that enfues from it. But although I have already remarked, that if fome appearances of refolution do not take place in the courfe of a few days, fuppuration will moft probably enfue, and that confequently a change of treatment will become neceffary, yet this, it muft be obferved, is to be taken in a limited fenfe. For the beft time of defifting from one mode of treat- ment, and commencing the other, can only be af- certained by clofe attention to the various circum- ftances of every particular cure. In a confiderable degree we find that it depends on the feat of the inflammation ; phlegmon being in fome parts much more apt to terminate in fpeedy fuppuration than in others. Thus, in the cellular membrane, as well as in every foft part of the body, inflammatory tumors fuppurate much more quickly than when tough membranous parts are affeded. Hence, in the coats of the eye and of the tefticles, very fevere degrees of inflammation often continue for many days, nay, even for weeks, without either abating in the fymptoms, or ending in fuppuration. In fuch caf- es, therefore, that go on even to confiderable length, we need not be afraid of continuing our difcutient Vol. I. C id Of Suppuration Chap. L remedies for a much longer time than otherwife would be proper ; nor fhould we ever be deterred from ufing them, ulilefs either an evident fuppura- tion has taken place, or there appears from the vio- lence of the fymptoms a confiderable rifk, either of gangrene, or of fome incurable obftrudion: irr which event, we fhould no doubt endeavour to promote the fuppuration of the tumor. Among other applications for the removal of in- flammation by refolution, blifte'rs ought not to be omitted, and I have in fome inftances known them prove ufeful, even where fuppuration had com- menced. In the early ftages of inflammation, blis- ters fhould be applied directly upon the pained part; but when the fkin is much inflamed, they excite fo much pain, that we rather apply them to the contiguous found parts : in this manner they have appeared to promote the difcuflion of venereal bu- boes, even where matter has been evidently form- ed. SECTION III. Of Suppuration. § i. General Remarks on Suppuration. BY the term Suppuration, is underftood, thai procefs, by which the contents of tumors and ulcers are converted into a whitifh, thick, opaque, fomewhat fetid matter, termed Pus. This, for the moft part, is the effed of a natural exertion of the fyftem ; but we know from obfervation, that the formation of pus can be promoted by artificial means. Before proceeding, however, to confider the treatment neceffary for this purpofe, it will not Bed. Ill Of Suppuration. 19 be improper to premife an examination of the dif- ferent opinions that have prevailed on the nature of pus, and this efpecially, as it will tend to eluci- date the adion of thofe remedies on which we chiefly depend in this ftage of the difeafe. § 2. Of the Formation of Pus. By many praditioners pus has been fuppofed to confift in a diffolution of the blood veffels, nerves, mufcles, and Other folids^ of the pahs in which in- flammation occurs; This was the opinion of Boerhaave,* Platner,f and many others. Others, again, have fuppofed purulent matter to be formed in the blood; and that it is fecreted, in its complete ftate into abfceffes, wounds, and ul- cers. That the firft of thefe opinions is ill founded, is obvious from this, that very extenfive wounds and ulcers continue often for a great length of timej without being attended with any lofs of fubftance ; which would not be the cafe, if the difcharge which they afford was produced by a diffolutiori of the folids of the parts in which they are feated. Iffues, likewife, afford Inftarices of this; by their yielding, for a number of years, even a daily dif- charge of pus, without producing any evident al- teration or diminution in the ftate of the folids. The other opinion has probably arifen from ab- fceffes being fometimes obferved to form fuddenly, and without being preceded by any obvious inflam- mation ; fo that the matter contained in them has been fuppofed to be at once depofited from the blood, in a ftate completely purulent. Previous, however, to the formation of pus in any part, where due attention is given, fome de- gree of inflammation is always obferved. But as * Aphorifm 387. \ InlUrutionci Chirurgise, § 54. &c. C 2 Vo Of Suppuration. Chap, t, inflammation often occurs in a flight degree, and without being attended with much pain, it fome- times proceeds to fuppuration, without being par- ticularly noticed by the patient; efpecially in cafes of internal colledions ofmatter. We are told, in- deed, of very quick tranflations of matter from- one part of the body to another : but if fuch in- ftances ever occur without the intervention of in- flammation *, a circumftance, however, much to be doubted ; yet, ftill, it is no material objedion to our argument, as fuch cafes can only be confider- ed as particular and very unufual exertions of the fyftem. It may be remarked-alfo, that if purulent mat- ter frequently exifted in the blood, as it undoubt- edly would do if this opinion was well founded ;; in fome cafes, at leaft, it would furely be liable to- detedion : but no matter of this kind has ever yet been difcovered in blood. < Such pus, too, as is found in wounds and ulcers, would not at firft ap- pear thin and ferous, as it always does, if depofited. in a completely formed ftate. The moft probable opinion hitherto advanced* concerning the formation of pus, is, that it is a change produced by a certain degree of fermenta- tion, upon the ferous part of the blood, after being, fecreted into the cavities of ulcers and abfceffes -y and that this fermentation is produced either by the natural heat of the part, or by heat artificially applied. . That it is the ferum only of blood, which is pro-* per for the formation of pus, and that it is pro-- ducedby the application of a certain degree of heat, was firft made probable by an experiment related. by Sir John Pringle, in the appendix to his Trea- tife on the Difeafes of the Army ;*' and the opinion was afterwards confirmed by other experiments of She fame nature made by Mr. Gaber, and related: * Experiment %W, Sed. IH. Of Suppuration. 2T by him at full length in the fecond volume of the Ada Taurinenfia. Sir John Pringle found, that pure ferum, kept for fome days in a furnace regulated to the human heat, after becoming turbid, dropped a white pu- rulent fediment. The craffamentum of blood, in the fame fpace of time, and degree of heat, chang- ed from a deep crimfon to a dark livid colour ; fo that, when any part of it was mixed with water, it appeared of a tawny hue. Serum, digefted with A few red globules, and in the fame circumftancess was of the fame colour. Mr. Gaber's experiments tend all to corroborate the fame opinion, namely, that pure unmixed pus is formed only of ferum. The addition of red glo- bules to ferum, and craffamentum digefted by it- felf, exhibited nearly the fame appearances as thofe quoted above from Sir John Pringle.* Fat, which is thought by many to be a principal ingredient in the formation of pus, was found by Mr. Gaber, when expofed to the trial that I have mentioned, to exhibit no appearances of that matter ; nor were any portions of flefh, when digefted either with fe- rum or water, convertible into it From all which, it may be concluded, that the addition of any of thefe articles to ferum, inftead of rendering it capable of producing good pus, has; always the contrary effed; and that it is pure fe-*f' rum alone from which pus can be obtained, *'[*% It may here be remarked, once for all, that what * is meant by pure ferum, is not that finer halitus, which, in a healthy ftate of the body, is conftantly fecreting into the different cavities, merely for the purpofe of lubricating and keeping them moift, and which is again generally abforbed; but it is that ferous fluid which feparates fpontaneoufly from blood, upon that fluid being allowed to remain at reft when difcharged either from an artery or a * A&. Taurin. vol. ii. page 87, JL 22 Of Suppuration. Chap, h vein ; and in which, though there is never fuppof- ed to be any mixture of red globules, yet there is certainly always more or lefs of the coagulable lymph; fome proportion of which feems abfolutely neceffary for ferum to poffefs, to render it capable of producing pus. The feveral effeds that I have mentioned as arif- ing from digeftion upon ferum out of the body, there is reafon to think, will occur from it, when colleded in the cavities of ulcers ; and, from the refult of the experiments that I have quoted, it is probable, that, according as ferum is there depofiteo* more or lefs free from mixtures of fat, red globules, and other fubftances, it will yield pus of a more pure or vitiated nature. This account of the formation of pus, is the moft fatisfadory, I conceive, of any that has as yet been given ; and this efpecially, as it renders evi- dent, as J have already obferved, the operation o£ the remedies which ufually prove moft effedual in the cure. § 3. Of the necejjary Remedies for promoting Suppura* tion. When, for the reafons that I have given, it is judged proper to advife means for promoting the fuppuration of an inflamed part, then fuch reme- dies as were previoufly ufed for coring the difeafe by refolution, ought immediately to be laid afide. No further evacuations can then in general be admitted ; and if the patient has been much weak- ened, a full allowance of diet, and even a propor- tion of wine, become neceffary. For although a high degree of inflammation proves always unfavourable to fuppuration, by pro- moting the progrefs of gangrene^, as will be after- wards mentioned; or by tending to propel into> the cellular membjane, which in general is the feat Sed. IIL Of Suppuration. 23 of abfceffes, a quantity of1 red globules^ together with the ferum of the blood, which alone ought to be extravafated for the formation of good pus; yet, in order to have a due quantity of ferum fe- creted for the purpofe of fuppuration, and, at the fame time, to have its fermentation properly car- ried on, the different inflammatory fymptoms muft never be allowed to fubfide fuddenly; otherwife an abfcefs, containing ill digefted matter, as it is termed, will moft probably enfue. Thus we find in fmallpox, which may be con- fidered as fmall phlegmafiae, that although blood- letting and other evacuations to a certain extent prove frequently ufeful, yet a proper fuppuration never takes place if the patient has been much de- bilitated by any confiderable difcharge ; and the fame thing very certainly happens, in fimilar cir- cumftances, in abfceffes of a larger fize. The pa- tient, therefore, fhould neither be allowed to live fo fully as might raife the inflammation too high, nor reduced in fuch a manner, by evacuations and low diet, as to induce the contrary extreme. Having in this manner endeavoured to procure a depofition in the cellular membrane, of ferum .proper for the formation of pus, the next circum- ftance requiring attention is, that a due degree of fermentation be excited, and preferved in it, fo that its progrefs towards fuppuration may not be retarded. This we accomplifh with moft certainty by the ufe of fuch applications as tend to preferve a pro- per and conftant degree of heat in the fwelled part; and were this kept fufficiently in view, there is rea- fon to believe that almoft all the foft tumors that we meet with in pradice, might be made to fuppu- rate; and that according to the degree of heat in which they are kept, they form into tumors of melicerous, fteatomatous, or other confiftences. For unlefs a due degree of heat be applied and continu. 24 Of Suppuration. Chap. I. ed, ferum being merely extravafated, will never produce pus : hence in afcites, and other dropfical tumors, large quantities of ferum remain in this ftate for a great length of time, without any fup- puration taking place ; merely from their beingj produced without any inflammation at firft, fo that ho affiflance is obtained from any degree of preter- natural heat; and the natural heat of thofe parts in which ferous colledions ufually occur, is feldom fufficient of itfelf. The degree of heat beft fuited for promoting fuppuration, is not, perhaps, eafily afcertained ; but the more confiderable it is, at leaft to a certain ex- tent, the more quickly, it is probable, pus will be formed. This we find, indeed, from Mr. Caber's experi- ments, is fo far the cafe :* and the obfervation is likewife confirmed by daily experience, in every cafe of phlegmon ; in which the tumor, cateris par- ibus, always proceeds more quickly or flowly to fuppuration, as it is feated nearer to, or at a great- er diftance from, the heart. Hence, in the extrem- ities, particularly in the legs, inflammatory tumors proceed flowly to fuppuration ', while they com- monly fuppurate quickly on the trunk and head. Thus, inflammation of the ears and throat frequent- ly arrives at complete maturation, and even burfts of itfelf, in the courfe of forty-eight hours from the firft attack. We ought, therefore, never to fail in preferving a due degree of heat in every inflamed part that we wifh to bring to fuppuration ; more efpecially in fituations very diftant from the heart, where ar- tificial heat is moft wanted, and where, if duly ap- plied, almoft every tumor, though feated on the extremities, might probably be made to fuppurate * When fpealung of pus being formed in, and fubfiding from ferum di- gefted in a degree of heat equal to that of the human body, Mr. Gaber fays, " E6 autem cuius fubfidebat quo calor erat major." Loco citato. Sed. III. Of Suppuration. 35 in the fame fpace of time with thofe in the ears and other parts that I have mentioned. I am not only convinced by obfervation, of what is here afierted of the advantages to be obtained from this ; but alfo from a courfe of experiments in which I was engaged fome years ago upon the fame fubjed. But as the refults of thefe were ex- actly fimilar to thofe of Mr. Gaber, I did not pre- ferve an account of them. I recoiled, however, that in a heat equal to 1 oo° of Fahrenheit's ther- mometer, the depofition of matter from ferum took place in little more than half the time that was re- quifite for the fame effed at even eighty degrees. It was the profecution of thefe experiments that firft fuggefted to me the probability of the advan- tage to be derived from the prefervation of a due degree of heat in inflamed parts; and I have ac- cordingly, on many occafions fince that period, found the treatment of fuch cafes go on more ea- fily than otherwife I fhould either have expeded or have been able to explain. Warm fomentations and cataplafms are the means commonly employed for the application of heat to an inflamed part; and when regularly and frequently renewed, nothing can more effectually anfwer the purpofe. But, in the ordinary manner in which they are applied, being renewed only once, or at moft twice, in the day, they muft <,fjjfe- quently do more harm than good. For as foon as the degree of heat which they at firft poffefs, is dif- fipated, the moifture which they keep up, with the confequent evaporation that enfues, muft always render the part colder than if it had been merely wrapped in flannel, without the ufe of any fuch application. In order to receive all the advantages of fuch remedies, the part affeded fhould be well fomented with flannels preffed out of a warm emollient de- codion, applied as warm as the patient can eafily 26 Of Suppuration. Chap. I. bear them, continued at leaft half an hour at once, and renewed four or five times a day. Immediately after the fomentation is over, a large emollient poultice fhould likewife be applied warm, and renewed every fecond or third hour at furtheft. Of all the forms recommended for emol- lient cataplafms, a common milk and bread poul- tice, with a proportion of butter or oil, is perhaps the moft eligible; as it not only poffeffes all the advantages of the others, but for the moft part can be more eafily obtained. Roafted onions, garlic, and other acrid vegeta- bles, are frequently made ufe of as additions to ma, turating cataplafms: when there is not a due de- gree of inflammation in the tumor, and when there is reafon to think that the fuppuration would be quickened by the inflammatory fymptoms being fomcwhat increafed, the addition of thefe fubftan* ces may prove ufeful; but when ftimulants are neceflary in fuch cafes, a fmall proportion of ftrain- ed galbanum, or of any of the warm gums, dif- folved in the yolk of an egg, and added to the poultice, is not only a more elegant, but a more certain form of applying them- In fome cafes, too, the fame intention may, with more certainty, be obtained, by combining a fmall quantity of can- tharides with any application that we mean to em- Whenever'inflammation, however, takes place in any confiderable degree, ftimulating fubftances can never be neceffary, and ought nqt to be em- ployed. Tumors attended with little inflammation, are commonly faid to be of a cold nature; and as they are generally indolent, and proceed very flowly to fuppuration, plafters compofed of warm gums are often applied to them with advantage ; in fuch caf- es, they prove ufeful, not only by the ftimulus and irritatipn which they excite, but by the heat whicl} Sed. in. Of Suppuration. ty they tend to preferve in the part. They become particularly neceffary, when the patient, by being obliged to go abroad, cannot have cataplafms fre- ijuently renewed, or conveniently applied : but, if it be not when fome fuch objedion as this occurs, the latter, for very pbvious reafons, fhould always be preferred. Dry cupping, as it is termed, that is, cupping without the ufe of the fcarificator, is frequently employed with advantage for promoting the fup- puration of tumors: it is only, however, in tumors of flow progrefs, where there feems to be a defi- ciency of inflammation, that it can ever be neceffa- ry ; but in all tumors of an indolent nature, and where there is ftill fome probability of fuppuration taking place, I have feldom obferved fuch good effeds from any other remedy. Matter being fully formed in a tumor, is known by fome degree of remiffion of all the fymptoms taking place ; the dolor pulfatilis, that before was frequent, now goes off; and the patient complains of a more dull, conftant, heavy pain : the tumor points at fome particular part, generally near to its middle; where, if the matter is not encyfted, or deep feated, a whitifh yellow appearance is obferv- ed, inftead of a deep red that formerly took place; and the fluctuation of a fluid underneath, is, upon preffure, very evidently difcovered. Sometimes, indeed, when an abfcefs is thickly covered with mufcular and other parts ; and when, from con- curring circumftances, there can be little doubt of the colledion of matter being confiderable, yet the fluctuation cannot be readily diftinguifhed : but it does not often happen, that matter is fo very deep- ly lodged as not to be perceived on proper exam- ination. This, however, is a circumftance of much im- portance in pradice, and deferves, it may be re- marked, more attention, than it commonly meets 28 Of Suppuration. Chap. L with. In no part of the furgeon's employment, is experience in fimilar cafes of more ufe to him than in this ; and however fimple it may appear, yet nothing more readily diftinguifhes a man of obfer- vation, than his being able eafily to deted collec- tions of deep feated matter: whilft nothing fo ma- terially affeds the charader of a furgeon, as his having, in fuch cafes, given an inaccurate or uniuft prognofis; for the event comes generally at laft to be clearly demonftrated to all concerned. Together with the feveral local fymptoms of th« exiftence of pus which I have enumerated, the fre* quent fhiverings that patients are liable to on it? firft formation, may likewife be mentioned: thefe, however, feldom occur, fo as to be diftindly ob- ferved, unlefs the colledion is confiderable, or feat- ed internally'in fome of the yifcera. But, in every large abfcefs, they are almoft conftantly met with ; and, when they appear along with other fymptoms of fuppuration, they tend, in a very material de* gree, to afcertain the real nature of the difeafe. § 4. Of Abfceffes, and of the proper Period for opening them. In the treatment of abfceffes, it is a general rule, not to difcharge their contents till complete fuppu- ration has taken place: for, when laid open more early, and while any confiderable hardnefs remains, they commonly prove troublefome, and feldom heal kindly. In fome cafes, however, it is neceffary to deviate from this general rule, and to open them much fooner ; particularly in all fuch critical abfceffes as occur in malignant fevers. In the plague, too, we are commonly advifed to open the tumors that ap- pear in it, as foon as they are tolerably advanced, and not to wait till they are fully maturated; for, in fuch inftances, it is found' that the patient re- Sed. III. Of Suppuration. $9 xeives more benefit from an early difcharge of mat- ter, than he can fuffer harm from the tumors be- ing fomewhat prematurely laid open. Abfceffes fituated upon any of the joints, or upon either of the large cavities of the breaft and abdo- men, more efpecially when they feem to run deep, fhould be opened as foon as matter is perceived in them. For, when the refiftance is on every fide equal, they will juft as readily point internally as outwardly; and the confequence of a large abfcefs burning into either of thefe cavities, is well known to prove moft frequently fatal : an inftance of which, in the following cafe, I had fome time ago an opportunity of obferving, which, with very lit- tle attention, might have been prevented. A furgeon of eminence, and of extenfive prac- tice, was applied to by a young healthy looking man, with a large abfcefs upon the left fide of his cheft. A fluid, upon preffure, was evidently found to fluctuate; and an opening was determined upon* to give vent to the matter. But the operator be- ing much engaged in bufinefs, two or three days were allowed to pafs, when unluckily the patient died fuddenly in his bed, the night before the ab- fcefs was to have been opened. On examining the body, the tumor was found to have difappeared entirely, without any external opening being perceived; and, on laying the tho- rax open, the matter was obferved to have burft inwardly upon the lungs, and hence had produced immediate fuffocation. In all other cafes, however, the rule in opening abfceffes fhould be, to allow a free fuppuration to take place, before giving vent to the matter: we have next to determine on the mode in which this ftiould be done. 3d Of SuppuratM Chap, t § 5. Of the different Methods of opening Abfceffes. Two methods of opening abfceffes have been re- commended by authors, namely, by cauftic and incifion. To the former,' however, there are many objedions. It does not anfwer the purpofe better than a fimple incifion; upon a tender inflamed part, it gives much more pain; it is more flow in its effeds; and the furgeon never has the command of it fo entirely as to deftroy thofe parts he would incline, and no more; for all the different kinds of cauftic, notwithftanding the greateft attention, will fometimes fpread farther, and penetrate deep- er, than the operator intends. Of this, I fome years ago, met With a remarkable inftance in a cafe of hydrocele,^ in which ferum is contained in the tunica vaginalis teftis, in circumftances quite fimi- lar to matter colleded in an abfcefs. Cauftic was applied to the anterior part of the fcrotum, with a view to produce a radical cure: but whether there had been little water colleded, or whether a preternatural adhefion of the teftis to' the tunica vaginalis had, at this part, been produced,' is uncertain -, but the cauftic penetrated to the body* of the tefticle, and gave the patient, as may readily be imagined, a great deal of diftrefs. It did, to be fure, accomplifh a cure: but the danger attending! fuch an accident, although it probably might not frequently occur, is, I fhould imagine, a very ftrong' objedion to the ufe of cauftic in all fuch cafes ; and it is now indeed very generally, I believe, laid afidey the preference being juftly given to the fcalpel. When tumors are not large, they are commonly opened by a longitudinal incifion, with a lancet or fcalpel. This fhould be fo direded as to terminate at the moft depending part of the fwelling, and of fuch a fize as may give a free difcharge to the mat- ter : about two thirds of the length of the tumor is for this purpofe perfectly fufficieritr Sed. m, Of Suppuration. V When abfceffes, however, are of great extent,- they are commonly laid open through their whole length ; and when the teguments have been much ftretched, we are advifed by many to take part of them away altogether. But this is a pradice which feldom, or perhaps never, fhould be followed ; for fcarcely any abfceffes are fo large as to deftroy en- tirely the contradile power of the integuments > and while this remains in any degree, there is ftill caufe to hope that the parts may again recover their former tone and dimenfions. It is furprifing indeed to obferve the extent to which this obfer- vation applies. In many inftances, the fkin has been known to recover its tone entirely, after hav- ing been for a time completely deprived of it. Thefe are the feveral modes of opening abfceffes with the fcalpel. Some inconveniences, however, are found to proceed from all of them : as foon as an opening is made in a tumor, the whole contain^ ed matter is difcharged fuddenly and at once: whereby, when the colledion is large, faintings and other difagreeable fymptoms are apt to enfue ; and a free adm'iffion of air is given to a great extent of ulcerated furface. The bad effeds of air on all varieties of fores, is well known to every praditioner; but its perni- cious influence, on a newly opened abfcefs, is often really aftonifhing. It firft occafions a total change in the nature of the matter, and turns it from per- haps a very laudable pus to an ill digefted fanies ; and afterwards brings on a quicknefs of pulfe, de- bilitating fweats, and other fuch fymptoms, which, for the moft part, when the colledion has been con- fiderable, either carries the patient off in a fhort time, or terminates in a confirmed phthifis, which fooner or later proves fatal. This I have, in many inftances, had occafion to obferve ; and that in fuch cafes it is the admiffion of air alone which produces the bad fymptoms, there £i Of Suppuration. Chap. U is little reafon to doubt, from patients in this fitu- ation being often found to remain for a great length of time without any hedic fymptom. In all large colledions of matter, I have feldom known an in- ftance of their being opened by a large incifion, without almoft every hectic fymptom taking place ; commonly in lefs than forty-eight hours from the time of their being laid open. In what manner the admiflion of air to an abfcefs operates in producing fuch a powerful and fudden effed, is perhaps difficult to determine. The irri- tation which it excites on a large extent of ulcera- ted furface, is perhaps the chief reafon : by ading as a ftimulus on the extremities of the abforbents opening into the fore, it may occafion a larger ab- forption of matter than would otherwife take place ; and it may likewife, by rendering the matter more putrid than before, give even to the fame quantity when abforbed, greater adivity in producing fever; That this conjedure is well founded, with refped to an increafe of putrefcency being one of the cauf- es of the bad effeds arifing from the admiflion o£ air to fores, there is much reafon to believe. For,- in the firft place, although the difcharge from abfceff- es is commonly mild, and free from any difagree- able fetor on their being newly laid open ; it almoft conftantly becomes thin, acrid, and more fetid in the courfe of a few dreffings, which is a certain proof of a greater degree of putrefcency having then taken place. On this principle, too, we may account for the operation of many of the remedies commonly employed in the treatment of fores; and more efpecially of thofe powerful antifeptics, fixed air, and Peruvian bark. We know from experiment likewife that other fubftances, as well as that part of the blood from Which pus is formed, is rendered putrid, and more quickly fo, by the admiflion of air, than otherwife, Sed. IH. Of Suppuration. 33 while in the fame degree of heat, they probably ever would be.* From thefe considerations, therefore, the great- eft caution fhould be obferved in preventing the ad- miflion of air to the internal furface of every large colledion of matter; and this, we may remark, is moft effedually done, by opening colledions of this kind by means of a feton or cord, and not with cauftic or the fcalpel. This method of difcharging the contents of tu- mors, by the introdudion of a cord, is attended with every advantage of that by incifion : it, moreover, empties the fwellings, of whatever fize they may be, not fuddenly, but very gradually ; it effedually prevents a free admiflion of air; it is not commonly attended with fo much pain and in- flammation ; nor is the cicatrix occafioned by it ever fo inconvenient, or unfeemly, as it often is af- ter a large incifion. At one time it was the pradice in the royal in- firmary of this place, to open large abfceffes, as well as thofe of a fmaller fize, by extenfive incifions: the confequences were fuch as I have related; ma- ny of the patients were thrown into fuch obftinate hedic fevers as they never recovered from ; and others, though they did get better at the time, were commonly fo much reduced, that they were apt to be feized with other diforders, from which they feldom recovered. This was the moft frequent refult of our treat- ment of large abfceffes by incifions; and fimilar confequences will flill be found to prevail where this pradice is continued: but fince the feton came to be generally ufed, few or no fuch difagreeable circumftances have occured. Many of the largeft * Vide Sir John Pringle's and Mr. Gabtr'. experiments on tldi fub- je. Aq. alexiter. fimp. cinnamon, fort, aa unc. iv. tindtlr. aromat. unc. i. Pulv. cort. Peruv. fubtil. unc. fs; mifce. Coch. ii. omni. femihora fumendis, agitata phiala. In this manner a drachm of the bark is taken every hour, which frequently, in lefs than twenty- four hours, has fome influence on the appearance of the difeafe. Much depends upon the medicine being in fine powder, as patients often bear confid- erable quantities in that ftate, when they rejed even very fmidl dofes of a coarfe powder. 46 Of Mortification. Chap, h Two varieties of bark have of late years been em- ployed in this country, which we never had an op- portunity of ufing before : I mean the yellow and red barks, but I have not found that either of them are equal to the beft ordinary bark of a brown or cinnamon colour. One remarkable inftance of this, I fhall mention with regard to red bark, and I could alfo mention others of 4 fimilar nature of the yellow bark: a gentleman, for feveral years, had laboured under a finuous ulcer, the difcharge of which, once in two or three months, always became thin, putrid, and very acrid. The influence of com- mon bark, in correding this, was fo remarkable, that a few dofes commonly had a confiderable ef- fed in rendering the matter thick, and lefs offen- five. From the tafte, and other fenfible qualities of the red bark, being ftronger than thofe of the ordinary kind, I was at firft inclined to think fa- vourably of it; and among others I prefcribed it to this patient. But although he continued for feveral days to take it in the fame dofes he had al- ways ufed of the other, it did not prove in any de- gree ufeful, while on the common bark being again employed, the matter, from being thin and fetid, was quickly converted into pus of a proper confift- ence. One trial, however, is by no means fuflicient for enabling us to form a juft opinion of any medicine: and accordingly I was refolved to put it to the fame teft in future occurrences of a fimilar nature. It has now been three times tried in the fame man- ner, and the refult has been always the fame. The red bark has never produced any change on the nature of the difcharge, while the influence of the other has been uniformly the fame. Our patient indeed is now fo much convinced of the inefficacy of red bark, that it is with reludance he is induced to take it; although, at firft, his expedations from it were raifed very high, not only from the opinion Sed. IV. Of Mortification. 47 that I ventured to give of it, but from the high panegyrics beftowed on it by others. This is the moft remarkable cafe I have met with, for comparing the effeds of the different kinds of bark: but I have likewife feen the red bark fail in other cafes, where the common kind of it proved evidently ufeful; fo that, although I cannot with certainty fay that* the red bark will never prove ufeful in cafes of mortification, and in fuch ulcers as 1 have defcribed* yet from the refult of all the experience I have yet had of it, I am inclined to confider it as of an inferior nature to the other. Further obfervation, however, is neceffary to de- termine a matter of fuch importance. Together with bark, the vitriolic acid is frequent- ly employed in gangrene with advantage; and the beft form of ufing it is, by acidulating the patient's drink with elixir of vitriol. Thefe are almoft the only internal remedies to be depended on in cafe of gangrene. Many others, indeed, have been recommended; but all the ad- vantages to be obtained from any of them, may be procured with more certainty from a proper appli- cation of the few that I have enumerated. A variety of external applications are pointed out by authors, particularly thofe of the antifeptic kind; fuch as, the warm gums and balfams, ardent fpirits, and even alcohol: and to admit of their nearer application to the found parts, with a view to the prefervation of thefe from putrefadion, deep fcarifications through the difeafed, and into the found parts, have been generally advifed. But although articles of this kind may prove ufeful in preferving dead animal fubftances from Corruption ; that they will prove equally fervicea- ble when applied to living bodies, is much to be doubted: there is even caufe to imagine, by the ftrong irritation which they excite when applied to a living fibre, that, in almoft every cafe of gangrene, 48 Of Mortification. Chap. L they may father* do harm; it being only, as I hav« obferved already, a very flight degree of inflam- mation that ought to be excited. The incifions, too, when carried into the found parts, with a vieMfr to facilitate the operation of remedies, may like- wife do harm, not only from the rifk of wounding the blood veffels, nerves, and tendons, that lie in the way ; but alfo, by allowing# free and farther entrance of the putrefcent matter into the parts not yet affeded : and unlefs they are carried fo deep as freely to reach the found parts, applications of the antifeptic kind can never have any effed in anfwering the purpofe for which they are meant. For thefe reafons, and from never having obferved any advantages to accrue from fcarifications, I have long advifed them to be laid afide.* Theriac was, in former times, and ftill is with fome praditioners, a very common application in gangrene ; but from any opportunities I have had of feeing it ufed, I cannot fay that it ever feemed to produce any obvious benefit. All the advantages we derive from the great va- riety of applications ufually pointed out for gan- grene, are obtained with more eafe, and generally with more certainty, from the ufe of ftimulating embrocations; which, by exciting a flight irrita- tion upon the furface, and efpecially when aflifted by a free ufe of bark, at laft commonly excites the wifhed for degree of inflammation. With this view I have frequently employed a weak folution * Although I was convinced, from experience, of what I have advanced a^uliiil the ufe of fcarifications, as well as of the impropriety and inefiica- «.y ot very warm ftimulating applications in mortification ; it was not without diffidence that I firft ventured to a flirt it, the opinion at that time being in a great meafure new. I am now happy to find, howeveri in a late publication, the fame practice recommended from the beft autho- rity. Vide Chirurgical Obfervations, by Percival Pot, F. R. S. &c. In the fame publication is given a particular defcription of a fpecies of mortification incident to the toes and feet, in which Peruvian bark ha» little cr no influence, and in which opium, given in large dofes, frequently repeated, proves an eiTedual rtmedy. Beft. IV. Of Mortification. 49 of fal ammoniac in vinegar and water, and often with advantage : a drachm of the fait to two ounces of vinegar, and fix of water, form a folu- tion of a proper ftrength for every purpofe of this kind; but the degree of ftimulus can be eafily ei- ther increafed or diminifhed, by ufing a larger or fmaller proportion of the fait. Although, for^the reafons I have given, incifions may not, in general, be proper, yet, whenever the mortification runs deep, fcarifications fhould be made in the difeafed parts, with a view of remov- ing them, which, by taking off a confiderable load of putrid dead matter, not only leffens the fetor, which, in fuch cafes, is always confiderable, but of* ten renders it more eafy for the found parts to throw off the remainder: when incifionsj howev- er, are employed for this purpofe, care fliould be taken that they be not carried fo deep as to injure the found parts. When, by the means of cure that I have thus ventured to propofe, or by the effeds of a natural exertion of the fyftem, a flight degree of inflam- mation begins to appear between the difeafed and found parts, we may, in general, with fome cer- tainty, exped, that in due time, an entire fepara* tion will take place: and when a full fuppuration has fairly commenced, there is ftill lefs caufe to doubt, of a cure being to be obtained. On the mortified parts being removed, the re- maining fore being in the ftate of a fimple purulent ulcer, muft be treated as fores of this defcription ought always to be, with mild eafy dreffings; at the fame time, that the ftrength of the patient fhould be fupported by the continuance of nourifhing diet, the bark, and fuch quantities of wine as he can eafily bear. In this manner, all ulcers produced by gangrene, may be healed, where the difeafe has not been verv Vol. I. E 5° Of Mortification. Chap. 1. extenfive; but where mortification, feated on any of the extremeties, has penetrated deep, fo as to reach the bones, and where the furrounding foft parts are in any confiderable degree deflroyed, amputation of the member becomes our only re- fource : this meafure, however, fhould never be advifed, till a full and complete feparation of the mortified parts has taken place; 'and it ought, in every cafe of gangrene, to be held as an eftablifhed maxim, never to amputate a limb till a full flop has been put to the difeafe, or till the mortified parts have been completely feparated from the found: for, although the parts immediately conti- guous to thofe evidently difeafed, may outwardly ap- pear to be found, yet there can never be any certain- ty of the parts, even diredly beneath, remaining fo till a feparation occurs; fo that, till this takes place, the difeafe will ftill be apt to return upon the re- maining flump. It muft be obferved, however, that as foon as an entire feparation of the gangrene is perceived, no time fhould be loft in putting the operation in prac- tice ; for, as long as any of the corrupted parts re- main in contad with the found, the fyftem muft ftill continue to fuffer, by the conftant abforption of putrefcent particles, that fo long will be going on. Sed. I. Of Tumors in general. Sl CHAPTER II. OF TUMORS. SECTION I. Of Tumors in general. EVERY preternatural enlargement, in whatev- er part of the body it is feated, may be term- ed a tumor/ Tumors daily occur in one form or another: they are often followed with important confequen- ces, and frequently give much embarraffment both to patients and furgeons: for thefe reafons they merit particular attention. We meet with much variety in the general ap- pearances of tumors, as well as in the method of treatment beft fuited for their removal: but thofe varieties only fhould be mentioned in a work of this kind, which require fome peculiarity in the method of cure. Tumors may with propriety be divided into two general claffes i into thofe that are acute or inflam- matory, and fuch as are chronic or indolent. Au- thors have for the moft part diftinguifhed them in- to fuch as are faid to be of a warm nature, and thofe which they fuppofe to be cold, from their be- ing deftitute of pain and rednefs, fymptoms which we commonly obferve to accompany heat. But I prefer the terms of acute or inflammatory, and chronic or indolent, as being more fcientific; at the fame time that they are more expreffive of the real nature of the different affedions : for it will be E 2 52 Of Tumors in general. Chap. II. found to hold perhaps univerfally, that tumors are acute or indolent, that is, that they are rapid or flow in their progrefs, nearly in proportion to the degree of inflammation with which they are at- tended. I mean* therefore, to rank in the firft clafs of tumors, all thofe which, from their com- mencement, are accompanied with inflammation ; and, in the fecond, all thofe which«are not evident- ly accompanied with this fymptom. It will unavoidably however happen, that fome tumors will be mentioned under one clafs, which, during fome part of their progrefs, may appear to belong to the other: thus, a tumor beginning from inflammation, may terminate in a ftate of perfed indolence; while others, which at firft were evi- dently chronic or indolent, may at laft become in- flamed. My views on this point are to charader- ize them by thofe fymptoms which appear mofl obvioufly at their commencement; a mode of dif- tindion which appears to be the moft accurate; for it is not what a tumor may eventually become, but what it adually is on its being completely formed, that can admit of any defcription r and although all the variety of tumors which fall within our ob- fervation, or of which I mean to treat, are enume- rated in the following claflification, fome of them will fall, with more propriety, to be confidered in other parts of the work. Thus, the confideration of aneurifm and thrombus fucceeds to bloodletting, as being moft frequently induced by that opera- tion. Colledions of matter in the antrum maxil- lare, gum boils, and other affedions of the mouth, fall to be noticed immediately after toothache ; while we have already finifhed the confideration of abfcefs and mortification, as the confequence of phlegmon. Sed. I. Of Tumors in general. Si CLASS I. Acute or Inflammatory Tumors. Phlegmon, with its confequences, abfcefs and mor- tification. Eryfipelas. Ophthalmia. Inflammation of the ear. Angina, or inflammation of the throat. Inflammation and abfcefs of the liver. of the breafts of women. of the teftes. of the anus and perinaeum. Venereal buboes. Lumbar abfceffes. Paronychia or whitlow. Chilblains. Sprains and contufions. CLASS II. Chronic or Indolent Tumors. Encyfted tumors, ufually fo termed. Ganglions. Swellings of the burfae mucofae. Concretions and preternatural excrefcences within the capfular ligaments of joints. Aneurifms. The true, the falfe, and varicofe aneurifms. Varicofe veins. Hemorrhoidal fwellings. Hydropic fwellings. anafarca or oedema. hydrocephalus. hydrops pedoris, and hydrops pericardii. 54 Of Tumors in general. Chap. IL afcites. dropfy of the ovaria. hydrocele. fpina bifida. Swellings in the fublingual glands. Tumors containing air. General emphyfema produced by air efcaping from the lungs into the cellular fubftance, as fome- times happens from the fpiculae of fradured ribs penetrating the fubftance of the lungs. Local emphyfematous tumors produced by putre- fadion in a particular part. This is a rare oc- currence ; but cafes of it are recorded by differ- ent authors. Tympanites. Tumors formed by the difplacement of particular parts. Herniae: of the brain. inguinal and fcrotal. congenital. crural. umbilical. ventral. at the foramen ovale. in the perinaeum. of the alimentary canal and mefentery. of the omentum. of the liver, fpleen, and other abdominal vifcera. of the bladder. of the inteftines into the vagina. Protrufion of the eyeball. Prolapfus uteri. Prolapfus ani. Tumors formed by the difplacement of bones in cafes of diflocation. Scrofulous tumors. White fwellings of the joints. Sed. II. Of Acute Tumors. 55 Bronchocele. Sarcomatous tumors. Sarcocele. Schirrus. Cancer. Polypous excrefcences in the nofe and throat, Polypi in the ear. in the uterus. Condyloma'tous tumors in the anus. Excrefcences in the urethra. Nasvi materni. Warts. Corns. Tumors of the bones. Simple exoftofes. Venereal nodes. Spina ventofa. SECTION II. Of Acute or Inflammatory Tumors. THE general theory and management of inflam- mation having been fully confidered in the laft chapter, in proceeding to fpeak particularly of inflammatory tumors, thofe circumftances only will be noticed which require fome peculiar mode of treatment. § i. Of Eryfipelas. Erysipelas, as being a variety of inflammation, has in fome inftances been miftaken for phlegmon: it may, for the moft part, however, be eafily dif- tinguifhed from phlegmon. In phlegmon, the in- flammation is circumfcribed and elevated. In a great proportion of cafes, it is feated in the cellular ' 56 Of Acute or Chap. II, fubftance ; and any effufion which takes place is for the moft part converted into purulent matter : but in eryfipelas, the tumor is diffufed, and not much elevated; it feldom proceeds deeper than the fkin ; any effufion with which it is attended is common- ly thin and acrid, and not convertible into pus, and the fkin acquires a kind of copper colour, inftead of that of crimfon red, which occurs in the firft ftage of phlegmon. By experience we know, that fores proceeding from eryfipelas are difficult to cure: it fhould therefore be our firft objed to endeavour to prevent that effufion by which thefe fores are produced. Some indeed allege, that this pradice muft be ar> tended with rifk, as eryfipelas, for the moft part, appears to proceed from fome difeafe of the confti- tution ; and hence we are advifed rather to encour- age the difcharge of that matter which nature in fuch cafes feems inclined to depofit. This obferva- tion, however, is not confirmed by experience, for we find that the difcuflion of eryfipelas may be at- tempted with the fame freedom and fafety as in- flammation of any other kind. A common prejudice prevails againft the ufe of . unduous and other moift applications in eryfipelas ; and fine flour, flarch, or hair powder, are almoft the only remedies that are applied to it. Thefe are ufed with a view to abforb the acrid matter, which eryfrpelatous inflammation often throws out in the form of puftules, and which unduous and moift applications are rather fuppofed to encourage. But to me it appears that they prove more ufeful in preventing the effufion or formation of that matter, than in abforbirig it afterwards. By foothing or allaying that uneafy fenfation which ufually accom- panies eryfipelas, and which they often do very ef- fedually, they neceffarily tend to leffen that preter- . natural adion of the difeafed veffels, which in eve- ry cafe of inflammation we confider as the caufe of Sed. II. Inflammatory Tumors. $f the fubfequent eflufion; and as they ufually prove more pleafant in every refped than hioift applica- tions, they fhould therefore in the firft ftages of the difeafe be preferred. It happens, indeed, in fome cafes, that they have little or perhaps no effed in procuring relief. In fuch inftances, I have fome- times found, that by keeping the inflamed part ex:- pofed to the air, and wetting it every now and then with a feather, foaked in a weak folution of faccha- rum faturni, immediate eafe has been procure^ and no difadvantage has afterwards occurred from it. In general, however, the dry farinaceous pow«f ders anfwer better. Almoft an universal prejudice has prevailed againft bloodletting and other evacuations" in eryfipelas: and as eryfipelas is commonly fuppofed to be at- tended with fome degree of putrefcency, inftead of evacuations, bark, wine, and ftimulating cordials, are commonly advifed. It appears, however, that the ideas of praditioners upon this point have not been founded on obfervation : for it is now known, that blood may be difcharged with the fame fafety in eryfipelas as in other cafes of inflammation ; and by doing fo, and adhering in every refped to an antiphlogiflic regimen, we have it often in our pow- er to prevent the difeafe from terminating in thofe effufions that I have mentioned, and which, at all times, we fhould endeavour to do. It is proper, however, to remark, that local blood- letting, which in other varieties of inflammation proves often ufeful, is not admiflible here : for the orifices by which the blood is drawn off are apt to degenerate into thofe troublefome ulcers, which eryfipelas when it terminates in effufion, is very apt to produce. By one or more general bloodlettings, according to the' ftrength of the patient; by the ufe of gentle laxatives, mild fudorifics, and a cooling diet; and by frequently dufting the part affeded with one or 58 Of Acute or Chap. II, other of the powders I have mentioned, almoft ev- ery eryfipelatous tumor may be difcuffed. But when effufion is found to have occurred in any con- fiderable quantity, it fhould be difcharged immedi- ately by a fmall opening in the moft depending part of it. In this ftate of the difeafe, emollient cata- plafms are commonly applied, with a view to bring the contents of the fwelling to fuppuration. This, however, proves always pernicious: for the effur fion being of a nature which cannot be converted into pus, poultices can never be of the fame ufe as in cafes of phlegmon; and as it is commonly fharp and acrid, if it be not fpeedily difcharged, it is apt to do harm, by corroding the fkin and contiguous parts. The beft applications in this ftate of the dif- eafe, are thofe of the faturnine kind, fuch as Gou- lard's cerate, or wax orntment with a fmall propor? tion of faccharum faturni. § 2. Of Inflammation of the Ear* The paffage, as well as the bottom of the ear, is entirely membranous; confequently the inflamma- tion which attacks it proves always in a high de- gree painful: for we know that inflammation of membranous parts gives more pain than that of parts of a loofer texture, from the blood veffels not yielding fo readily as thofe of the latter, to the difr tention which inflammation never fails to excite. The remedies to be employed in inflammation of the ear, fhould be regulated by the ftage of the difeafe. When it has fubfifted fo long as to give reafon to think that it will fuppurate, which it is apt to do quickly, emollient applications prove moft ufeful: with this view, the ear fhould be frequent- ly fomented with warm emollient fleams, and there- after covered with a warm emollient poultice. But on the firft approach of inflammation, we ought, if poffible, to prevent the formation of matter; for Sed. II. Inflammatory Tumors. 59 when matter has once formed in the ear, it is often difficult to remove it, and by hurting the bones of the ear, it is very apt to produce deafnefs: with this view a fmall blifter fhould be applied behind the ear, and blood fhould be taken from the con- tiguous parts, with a fufficient number of leeches. We alfo have it frequently in our power to leffen or remove the pain, by pouring a few drops of warm laudanum into the ear, either by itfelf, or mixed with fine oil; and the pain being removed, we find, from experience, that the rifk of fuppuration is thereby leffened. Our endeavours, however, for this purpofe, do not always fucceed: in which event, and when matter has evidently formed, we fhould endeavour to bring it off as freely as poffible, by bathing the ear in warm water, and even by injeding a little warm milk or water into it. By thefe means we often put a flop to the difcharge: but when it ftill continues to flow, aftringent injedions, of lime wa- ter or mild faturnine folutions, fhould be employ- ed ; which feldom fail when the difeafe is folely confined to the foft parts of the ear. When the bones of the ear become difeafed, which we eafily know by the matter acquiring a very offenfive fmell, and being of a black or dark brown colour, all that art can do is to keep the paffage clear by the ufe of injections. The cure of deafnefs arifing from this caufe is not to be looked for, and we truft to na- ture alone for throwing out the difeafed bones. S 3* QT Angina. Inflammation of the throat is commonly term- ed Angina, or Quinfy. As abfceffes in the throat prove always trouble- fome, and often dangerous, we fhould in every in- ftance endeavour to prevent their formation, by attempting to remove by refolution every degree 60 Of Acute or Chap. II. of inflammation with which the parts in which they are commonly feated may happen to be at- tacked. With this view, a full bloodletting fliould be pre, fcribed; the quantity to depend on the ftrength of the patient, and urgency of fymptoms. Smart purgatives prove here particularly ufeful; and fome advantage is often derived from diaphoretics. None of thefe remedies, however, can be trufted with fuch certainty as the local difcharge of blood from the part affeded, and the application of a blifter to the contiguous parts. In Plate IX. figs, i. and 3. inftruments are delineated for the purr pofe of drawing blood from the throat by means of fcarifications; and when employed with free. dom on the firft appearance of inflammation, fup. puration may very commonly be prevented, Fo* menting the throat with fleams of warm vinegar proves fometimes ufeful; and confiderable advan- tage has in different inftances been derived from aftringent gargles, of infufions of oak bark, of red rofe leaves, with a proportion of alum or vitriolic acid, and of faccharum faturni diffolved in water, A general prejudice prevails againft the ufe of fat- urnine applications in the form of gargles, from their being fuppofed to be of a poifonous nature, But although I have often ufed them, I never knew an inftance of their doing harm; and they have frequently proved highly ferviceable. In fmall quantities they might even be fwallowed with fafe- ty; but we all know that gargles may be employ* ed without any part of the liquor being allowed to pafs into the ftomach. It will often, however, happen, that thefe and all other remedies will fail, either from their being applied too late, or from the inflammation being fevere. When fuppuration is probably to take place, it fhould be promoted by the application of warm poultices to the throat, and by the patient being Sed. II. Inflammatory Tumors. 6.1 made to infpire the warm fleams of milk, or of any emollient decodion, by means of the machine de- lineated in Plate IX. fig. 2. When matter is fully formed, it fhould be difcharged by an opening of a fufficient bore being made into the abfcefs with one of the inftruments mentioned above for fcari- fying the throat. § 4. Of Inflammation and Abfcefs of the Liver. The fubftance of the liver being foft and of a yielding nature, we would not a priori imagine that it fhould be liable to inflame. We find, however, in warm climates, particularly in the Eaft and Weft Indies, that the liver becomes more frequently in- flamed than any other part of the body; probably from the bile in thefe climates being apt to become acrid and thus to excite irritation in the parts to which it is applied. In fome cafes too, the liver inflames from external violence. Inflammation of the liver is attended with a dull uneafy fenfation over all the contiguous parts ; with pains refembling thofe of cholic, and fevere ficknels at ftomach ; the patient is liable to fre- quent cold and hot fits; and for the moft part, the colour of his fkin, as well as his urine, is tinged yellow. When fuppuration takes place, and efpecially when the abfcefs is large, the patient complains of pain extending up the right fide to the top of the fhoulder. In fome cafes this fymptom occurs even in the inflammatory ftate of the difeafe; but it hap- pens more frequently after the formation of mat- ter, probably from the weight of the abfcefs ading upon the diaphragm and pleura, with which the liver is conneded. The region of the liver be- comes daily more tenfe ; and if the convex part of it is chiefly affeded, a foftnefs, and even a fluctua- tion of matter is often difcovered through the 62 Of Acute or Chap. II, teguments, particularly when the parts are not much covered with fat. In the commencement of this affedion, thofe re- medies anfwer beft, which prove moft ufeful in other cafes of local inflammation. Hence blood- letting fhould never be omitted; the quantity to be determined by the feverity of the fymptoms and ftrength of the patient: but inftead of taking blood from a vein, it fhould be drawn off by cup- ping and fcarifying the pained part. When the fcarifications are made of a fufficient depth, almoft any quantity of blood may be got in this manner; and no remedy with which we are acquainted, proves fo effedual in removing the inflammation. Bliftering the pained part proves alfo ufeful; the bowels mould be kept open, with mild laxatives; and a gentle perfpiration fhould be encouraged' over the whole body. In general, this treatment will prove fuccefsfuf, when employed early in the difeafe; but when the fymptoms do not foon yield, mercurials fhould be advifed without further delay; for in the removal of inflammation of the liver, nothing has hitherto proved fo ufeful as mercury in one form or anoth- er. Calomel, calcined mercury, and the blue mer- curial pill of the Edinburgh Difpenfatory, are the beft preparations of mercury that I have tried, and they ad with more certainty when conjoined with fmall dofes of opium. Fridions with mercurial ointment on the region of the liver are alfo occa- fionally employed with advantage: but whatever form of the medicine is ufed, it fhould be quickly carried fo far as to affed the gums, which fhould be kept moderately fore for feveral weeks, unlefs the difeafe fubfides immediately; in which cafe a fhorter courfe will be fufficient. As it is of importance in all cafes of this kind to give a free difcharge to the bile, if the patient does not otherwife get regular and eafy ftools, he fhould, Sed. II. Inflammatory Tumors. 6$ during the mercurial courfe, have a gentle faline purgative every third or fourth day, by which the difcuffion of the inflammation is often much pro- moted. Suppuration, however, will often take place, not- withftanding all that can be done to prevent it; and when this is found to have happened, an inci- fion fhould without delay be made into the abfcefs to difcharge the matter. When the matter is feat- ed on the convex or prominent part of the liver, and the quantity confiderable, we readily difcover it by the touch; and in this cafe there is no room to hefitate. But even, where we have not this for our diredion, we may very commonly judge with certainty whether fuppuration has occurred or not. If along with pain in the right fhoulder and neck, it is obferved that the region of the liver is more bulky than it was before, and that the correfpond- ihg teguments are become foft and cedematous, and efpecially if the patient complains of frequent fhiv- ering fits, a fymptom which very conftantly accom- panies internal fuppuration ; we may conclude with much certainty that matter is formed. Wherever an abfcefs is feated, the matter fhould be difcharged, perhaps as foon as it is known that complete maturation has taken place. But abfcef- fes in any of the larger cavities, fhould be opened even before there is reafon to fuppofe that all the effufed fluids are fo completely converted into pus as we might otherwife wifh them to be. Indeed this fhould be confidered as an eftablifhed maxim in pradice ; for the chance of thefe colledions burfting inwardly is much greater than of their opening outwardly, where the teguments which cover them are thick and ftrong when compared with the cyft in which the matter is contained, the only covering between them and the inteftines. Abfceffes of the liver have been known to burft through the diaphragm, fo as to be emptied into 64 Of Acute or Chap. II. the thorax: in a few cafes the matter has been car- ried into the duodenum by the common paffage of the bile ; and fometimes, by the great arch of the colon adhering to the liver, a communication has been formed between them ; by which the matter of abfceffes in this fituation has been very complete- ly difcharged into that part of the gut: but for the moft part, when not difcharged by an external opening, the abfcefs burfts into the cavity of the abdomen. With a view to prevent this occurrence, which commonly terminates fatally, the affiflance of fur- gery fhould be defired as foon as the appearances and fymptoms give caufe to fufped that matter is collected : an incifion of a fufficient length fhould be made with a fcalpel through the external tegu* ments in the moft depending part of the tumor; and on reaching the abfcefs, it may either be open- ed with the point of the fcalpel, or with a lancet; but piercing it with a trocar is preferable, as in this manner we have it in our power to evacuate the matter flowly, which in large colledions is a point of importance, and therefore merits atten- tion. Even this opening into the abfcefs, howev- er, fhould be afterwards enlarged, otherwife there would be fome rifk of its clofing before the cyft containing the matter collapfes fufliciently for the prevention of further colledions. This being done, a pledget of foft lint, covered with any emollient ointment, or merely dipped in oil, fhould be gent- ly infinuated to a fufficient depth between the lips of the wound, to prevent them from uniting till the abfcefs collapfes and fills up from the bottom ; a procefs that will be much haftened by a proper application of preffure on the tumefied parts, by means of a flannel or cotton roller paffed two or three times round the body. When the vacuity produced by the difcharge of maf.ter does not foon fill up, it will be proper to Sed. II. Inflammatory Tumors. *5 introduce a canula to preferve a free paffage for any matter that may afterwards form. But this pre- caution is feldom neceffary ; for abfceffes in the liv- er heal fooner, and with fewer inconveniencies, than fimilar affedions in perhaps any other part of the body. Indeed this is fo well afcertained, that I would advife an opening to be made into the ab- fcefs in every inftance where there is the leaft caufe to fufped that matter has formed in the liver. Many praditioners indeed affert, that no attempt of this kind is admiffible unlefs the abfcefs is feated in the convex part of the liver. It muft be allowed, that abfceffes in this fituation are more acceffible than fuch as are feated in the concave part of it. But wherever they are fituated, a proper vent fhould be procured for the matter ; for if not eva- cuated by an external opening, we may conclude almoft with certainty, that it will be emptied into the abdomen, by which, in a great proportion of cafes, the patient will certainly die. In warm climates, Peruvian bark is very com- monly given on the firft appearance of a difeafed liver: the putrefcent tendency of the bile is the of- tenfible reafon of this. But I believe it will be found, that no dependence fhould be placed upon the bark during the firft or inflammatory ftage of this difeafe. During this period the bark may even " do mifchief; but when fuppuration has taken place, and when the matter is difcharged from the ab- fcefs, bark proves equally ufeful as in fimilar affec- tions of other parts of the body. When, by too long delay, it unfortunately hap- pens that an abfcefs either burfts into the cavity of the cheft or into the abdomen, the matter fhould be drawn off immediately; in the one cafe, by the operation of the empyema, deferibed in Chapter XXVI.; and in the other, by the common opera- tion of the paracentefis, for which fee Chapter XXV. Vol. I. F 65 Of Acute cr Chap. II. § 5. Of Inflamtnation and Abfceffes in the Breafts- of Women. The breafts of women are liable to fuffer from the fame caufes which excite inflammation in other parts of the body; but abfceffes in thefe parts oc- cur moft frequently in nurfes by the gorging or ftoppage of the milk, which almoft conftantly takes place from fudden or imprudent expofure to cold: the part becomes ftiff, fwelled and painful; the milk runs off in fmall quantities, but not fo as to afford effedual relief; the patient grows hot and reftlefs, much thurft prevails, together with a full quick pulfe. Practitioners are not agreed on the treatment beft fuited to cafes of this kind : by fome it is faid-, that milk tumors of the breaft fhould always be difcuffed ; while others affert, that when this prac- tice does not fucceed, it often does harm, by in- ducing fwellings of a fchirrous nature, which can- not afterwards be diffolved, and which are apt to terminate in cancer. In judging of this point, from my own obferva- tion, it does not appear to me that there is room for doubt: our practice in inflamed breafts fhould be the fame as in every cafe of inflammation, wher- ever it is feated. In the firft flages of the difeafe, difcuffion of the tumor fhould be always attempt- ed; while it would be in vain, and highly im- proper, for this to be advifed when any tendency to fuppurate has taken place. The rifk of our in- ducing fchirrus by this pradice, feems to me to be in a great meafure imaginary : it rather appears, indeed, that cancer is more apt to occur from the improper management of thofe fores which enfue from colledions of matter in the mamma, than from any means that can be ufed to prevent the matter from forming; but we are further induced Sed. II. Inflammatory Tumors. 6j to follow the pradice, from the great diftrefs which always accrues from fuppuration in the mamma : indeed, the pain and mifery of the patient is in fuch cafes often fo great, that no doubt can remain with unprejudiced praditioners of the propriety of endeavouring in every cafe to prevent it. It is fcarcely neceffary to remark, that the fame remedies prove ufeful here, that fucceed in the dif- cuflion of inflammation in other parts: but it is truly furprifing, that there fhould be almoft an univerfal prejudice in every inflamed breaft againft the moft powerful of all difcutients, bloodletting. Afraid of this evacuation tending to diminifh the quantity of milk, we avoid it entirely. In this, however, I am convinced we are wrong. In every cafe of this kind, I have been in the pradice of bleeding freely. It has not appeared to diminifh the flow of milk ; while its effeds in preventing fuppuration, are, for the moft part, evident. The quantity of blood to be taken away, muft always be determined by the violence of the inflammation, and ftrength of the patient: but, in general, the pradice will be more effectual, when as much as the patient can bear to lofe, is taken at once, than when the fame^ or even a greater quantity, is tak- en at different times. Purgatives prove particular- ly ufeful; and a cooling diet is equally neceffary here, as in other cafes of inflammation. As nothing tends more to prevent the difcuffion of inflamed tumors than pain, nothing fhould be omitted that can tend to- remove it: and as no re- medy proves fo effedual as" opium, it fhould al- ways be given, and in fuch dofes as are fufficient for the purpofe. With a view to remove the ten- fion of the breaft, the parts fhould be gently rub- bed with althea ointment, or with oil: but the ap- plications on which we chiefly depend, are thofe of a cooling aftingent kind ; fuch as a folution of fill F 2 68 Of Acute or Chap. II. ammoniac in vinegar and water; fpiritus Minde- reri; and all the faturnine applications. Cloths dipped i.i one or other of thefe, fhould be kept conftantly applied to the breaft ; by which, and by attention to the other parts of the treatment that I have already advifed, almoft every tumor of this kind may be removed, unlefs the inflammation has been of long duration; in which cafe, when the pain and tenfion are confiderable, it is more advif- able to endeavour to bring the tumor to fuppurate, than to attempt any other method of cure. For this purpofe, we rely with moft certainty on a fre- quent renewal of warm fomentations and poultices; and when matter appears to be fully formed, it fhould be difcharged by an opening made in the moft depending part of the colledion : at leaft, an opening fhould always be advifed, when it is found that the matter is pointing at an improper part, wrhere it would not find a free vent. In the treatment of inflamed breafts, which oc- cur in nurfing, it is a doubt with many pradition- ers, whether the milk fhould be drawn off or not. Indeed many affert, that drawing it off, either by continuing the child, or with glaffes, does harm ; and therefore they advife it not to be done. I have never obferved, however, that any inconvenience enfued from it; and as it always gives relief, I ad- vife it in every inftance. When the breaft is much fwelled, the nipple cannot be laid hold of by the child: in fuch cafes, the glaffes reprefented in Plate LIII. may be ufed with advantage. § 6. Of Inflammation of the Teftes. Inflammation of the teftes may be induced in various ways: by the application of cold ; by ex- ternal violence ; and by every other caufe that tends to excite inflammation in other parts of the body. But the moft frequent caufe of it is gonorrhoea vir- Sed. II. Inflammatory Tnmors. 69 ulenta. The common opinion refpeding thi&was, that it occurred from the matter in gonorrhoea falling down, as it was termed, upon the teftes: and this appeared the more probable, from its be- ing obferved that the teftes were apt to fwell upon the difcharge being ftopped, at the fame time that the infedion of the teftes was commonly relieved by a return of the running. It is now however known, that no communica- tion fubfifts between the urethra and teftes, by which matter can be conveyed from the one to the other: and the moft probable opinion is, that in the fwelled teftes from gonorrhoea, the inflamma- tion is communicated from the urethra, and fpreads along the vafa deferentia to the teftes. A fudden flop being put to the difcharge, wheth- er by the ufe of irritating injedions, or by any oth- er caufe, very commonly excites an increafed de- gree of inflammation : to abate which, nothing proves more effedual than a return of the running. In this way, we account more clearly than in any other, for the effed produced upon the teftes by the ftate of the difcharge. Inflammation of the teftes very rarely terminates in fuppuration : but this fhould not prevent the moft timous application of thofe remedies that we know to be the moft powerful difcutients. Blood- letting is perhaps the moft effedual remedy; but it always proves moft ufeful when the blood is taken directly from the pained part by means of leeches. After difcharging a fufficient quantity, the fwelling fhould be kept conftantly moift with a folution of faccharum faturni; the fcrotum and teftes fhould be properly fufpended ; the bowels fhould be kept moderately open ; a low diet fhould be prefcribed; and the patient fhould be ftridly confined to a horizontal pofturc. When there is faufe to.fufped that the conftitution is tainted with lies venerea, nothing will prove f.rviceable if a 70 Of Acute or Chap. II. mercurial courfe is negleded. And when it appears that the difeafe has been induced by the difcharge having been too fuddenly checked, we fhould en- deavour to promote a return of it, by bathing the penis in warm water; by injeding warm oil into the urethra; or by the ufe of bougies. In this manner, we fcarcely can fail of removing inflammation of the teftes by difcuffion : but when this does not happen, either from the ufe of the remedies not being duly perfifted in, or from the inflammation being particularly fevere, and when fuppuration is found to have taken place, the mat- ter muft be difcharged by an opening made in the moft depending part of the abfcefs; which in eve- ry refped fhould be treated like colledions of pus in other parts of the body. § 7. Of Venereal Buboes, Swellings of the lymphatic glands from the ab- forption of the venereal virus are termed Venereal Buboes. They may appear in any gland feated be- tween a venereal fore and the heart; but they are moft frequent in the groin, in confequence of the abforption'of venereal matter from fores in the pe- nis. For the moft part they are produced by mat- ter abforbed from chancres, and in fome cafes the glands fwell from fympathy in gonorrhoea: but in- ftances likewife occur of buboes arifing without any previous ulceration or difcharge from the penis where the matter appears to be abforbed without any perceptible erofion of the fkin. . A fad highly important in pradice, and of which therefore I have given a more particular account in my Trea- tife on the Venereal Difeafe. The moft material point to be determined in the treatment of bubo is, whether we fhould endeav- our to difcufs the tumor, or bring it to fuppura- tion ? While the opinion prevailed that buboes were Sed. II. Inflammatory Tumors. 71 produced by the depofition of venereal matter from the fyftem, it was not furprifing to find pradition- ers advifing us in every inftance to promote their fuppuration: for on this fuppofition it was proba- ble, that nature meant by thefe fwellings to throw off the infedion. But now when we know that buboes arife, not from matter difcharged from the fyftem, but from its paffing into it; that the quan- tity of venereal matter is increafed inftead of being diminifhed by buboes being brought to fuppurate ; and that the fores which enfue from them are oft- en very difficult to cure; fcarcely any will doubt of the propriety of removing them by difcuffion. With this view the patient fhould be put upon an antiphlogiftic regimen. His bowels mould be kept open by the ufe of purgatives ; leeches fhould be applied to the hardened gland; and it fhould be kept conftantly wet with a ftrong folution of fac- charum faturni. Along with thefe, however, mer- cury fhould be given in quantities fufficient for eradicating the difeafe : and as we know from ex- perience, that mercury proves moft effedual when made to pafs through the difeafed glands, it fhould always be applied in the form of undion to thofe parts in which the lymphatics of the difeafed glands are known to originate ; which never fails to prove more effedual than the dired application of mer- cury to the glands themfelves. Thus, in the dif- cuffion of a bubo in the groin, fridion with mer- curial ointment upon the thigh and leg proves more fuccefsful than rubbing it upon the gland it- felf. To many this has been long familiar ; and it would appear that the pradice could fcarcely fail of occurring to any who have paid attention to the difcoveries made by the moderns in the anatomy of the lymphatic fyftem. When buboes are early noticed, the courfe that I have propofed very commonly anfwers the purpofe, when the mercurial frictions are properly applied 72 Of Acute or Chap. 1L and continued for a fufficient length of time. It often happens, however, that all our efforts fail, either from the difeafe being too far advanced be- fore the mercury is applied, or from the tumor not being altogether venereal, but of a mixed nature ; a circumftance not unfrequent. Thus, it frequent- ly happens that buboes are combined with fcrofula and icurvy, and in fome cafes with eryfipelas or with common phlegmon. In fuch cafes we are not furprifed at the failure of mercury : and according- ly we fometimes find, that inftead of forwarding the difcufiion of the fwelling, it tends rather to bring it to fuppuration. Cafes of this kind prove often very perplexing both to the patient and prac- titioner ; fo that no point in pradice requires more accurate difcrimination : for by proceeding to throw in great quantities of mercury, as is ufually done while buboes remain obftinate, if they are not alto- gether venereal, we feldom fail to do harm, not merely to the local affedion, but to the fyftem at large. In all fuch cafes, the beft pradice, I believe, is to defiil from the ufe of mercury as foon as it appears that no advantage is derived irorn it. In the mean time, by a change of diet, a/id otjier means adapted to the ftate of the patient for the time, fuch an alteration may take place in the conftitu- tion, that a fecond trial of mercury mayJ^rove fuc- cefsful: at leafl, in different inftances, tRis has fuc- ceeded with me, where I had reafon to think that perfifting longer with mercury at firft would have done harm. When it is found that a bubo cannot be difcuff- ed, and that it will probably fuppurate, a frequent renewal of warm emollient poultices and fomenta- tions are the remedies on which we chiefly depend. The opening of buboes, when fuppuration has taken place, next demands our attention. Some difiuade us from opening them at all, alleging that they Ii?al fooner when allowed to bur ft of them- Sed. II. Inflammatory Tumors. 7$ felves: while a fmall pundure with a lancet, a lon- gitudinal cut through the whole extent of the fwelling, or the application of cauftic, have all had their abettors. When a bubo is altogether venereal, and not combined with any other affedion, any of thefe methods will fucceed, provided a fufficient quanti- ty of mercury be given : but when a bubo termi- nates in a fore difficult of cure, we are too apt to blame the particular method in which it was open- ed ; for in whatever manner it is done, we know that the cure will often prove tedious and perplex- ing. The objed of praditioners fhould be nearly the fame here^as in colledions of matter in any other part. Such an opening fhould be made as will af- ford a free vent to the matter : but there is feldom any neceffity for making it larger. In large bu- boes, indeed, the teguments are apt to be fo loofe and flabby, and the texture of the fkin fo much de- ftroyed, that the cure would be rendered tedious, were it allowed to remain. In fuch cafes, it is ad- vifable to difcharge the matter with cauftic, appli- ed in fuch a manner as to deftroy any part of the teguments that appear to be fuperabundant. This, however, is feldom neceffary; and for the moft part it will^be found, that an opening made from the centre of the tumor, where the matter com- monly points, down to the moft depending part of it, will prove fufficient. Even a fmaller opening than this would often anfwer; but it is better to make it of a fufficient fize at once, than to be oblig- ed to repeat a very painful operation perhaps once and again, as is often neceffary when buboes of a large fize are opened by fmall pundures. In fmall buboes, a mere pundure will fometimes prove fuf- ficient ; nay, in thefe, the matter being allowed to burft, often anfwers extremely well: but when the collection is large, this fhould never be trufted. 74 Of Acute or Chap. II, When buboes come forward to full maturation, without.much injury being done to the fkin, I have in various inftances difcharged the matter by the introdudion of a fmall cord ; and the pradice has fucceeded. This requires, however, the teguments to be firmer than they commonly are when a bubo is ready to be opened. We all know that it is of much importance to prevent the acceflion of air to fores ; and as we fometimes obferve buboes ooze out the matter which they contain by a number of fmall openings over their furface, and as thefe commonly heal ea- fily, I conclude that they do fo from the openings being fo fmall as to exclude the air entirely. In different cafes, I have with this view attempted to imitate nature, by making a number of fmall punc- tures with the point of a lancet over the whole exr tent of the bubo ; and for the moft part with fuc- cefs. The matter comes flowly off; the fides of the abfcefs contrad gradually; and when complete- ly emptied, we commonly find the whole parts that have been affeded, fufficiently firm, without any fores or finufes remaining. While means are employed to promote the fup- puration of a bubo, the patient fhould ftill contir nue the mercurial courfe, by which no time will be loft; and the forfe produced by the opening, will afterwards heal more quickly than if the mercury had been interrupted. The fore, however, often proves tedious, even where we are convinced that a fufficient quantity of mercury has been given, and where there is reafon to fuppofe that the fy- philitic virus is eradicated. The edges become hard and livid ; the matter, thin, fharp, and fetid; and inftead of healing, the ulceration gradually be- comes more extenfive ; or if it heals in fome parts, it breaks.out in others, giving a honeycomb ap- pearance to all the under part of the abdomen and upper part of the thigh. Sed. II. Inflammatory Tumors. 75 Patients labouring under fores of this kind, are frequently reduced to the greateft diftrefs and dan- ger. The pain with which the fores are attended, is often intenfe ; the abforption of acrid matter in- duces hectic fever; the patients become hot and refllefs through the night; and almoft a total want of appetite foon deprives them entirely of ftrength. As I have happened to be concerned in a large number of fuch cafes, I can fpeak with fome confi- dence of the method of treatment. In the firft place, we are here to fuppofe, that the patient has taken a fufficient quantity of mercury, and that no finufes are left, in which matter in any quantity will be allowed to lodge. Cicuta, in fuch circum- ftances, has fometimes proved ufeful; and I have had different inftances of fores of this kind being healed by the external ufe of it, when no benefit was derived from the ufual dreffings. In fuch cafes, it was applied in the form of poultices, by mixing the juice of the frefh herb with the common emol- lient cataplafm. I have fometimes obferved too, that in the internal exhibition of cicuta, the recent expreffed juice has proved more effedual than any other form of it. I have given the hyofcyamus and belladona very complete trials in various in- ftances ; but commonly with no material advan- tage. Sarfaparilla, guaiacum, and mezereon, all prove ufeful here ; and they feem to ad with moft advantage, when ufed all at the fame time: guaia- cum and mezereon prove even ferviceable when ufed feparately ; but I have, in different inftances, found that they ad with more advantage, when pombined in the following form with farfaparilla : R. Rafur. ligni guaiac. §fs. Radicis farfaparillx, §ifs. Corticis radicis mezerei, 3i. Radicis glycyrrhizae, 5iii. Aq. fontanae, Ifciii. ; coque ad Icii. Colatune, adde Syrup, altheaz, Bi. 76 Of Acute or Chap. II, This quantity to be ufed daily, by drinking a cup- ful from time to time. But the moft effedual courfe I have hitherto tri- ed, is the deftrudion of the hard edges of the fores either with lunar cauftic or the fcalpel. When, cauftic is ufed, it muft be applied repeatedly ; whereas in ufing the fcalpel, we remove all the du* eafed parts at once. Opium proves in this ftate of thefe fores a very ufeful remedy; it not only gives temporary relief, but by leffening or removing pain, excites a tendency in the fores to heal, and ought therefore in all fuch cafes to be ufed with freedom. In the local treatment of fores in this ftate, I trufted for a confiderable time entirely to emolli- ents, fuch as wax ointment, faturnine cerate, and cerate prepared with calamine. I now, however, find, that efcharotics anfwer better, and that in general they may be ufed with freedom, particu- larly thofe of the mercurial kind. After deftroy- ing the edges of the fores with the fcalpel, which I now always prefer to cauftic, red precipitate mer- cury, in fine powder, is the remedy on which I chiefly depend. In fome cafes it is fprinkled over the fores daily ; but for the moft fart it ads with fufficient effect when mixed with any of the com- mon ointments; in the proportion of one-fourth of the powder to three-fourths of the ointment. Inftead of creating pain, it commonly removes it; and it feldom fails to alter the difcharge from a thin fharp fanics to a thick well digefted pus. Mu- cilage of gum arabic, impregnated with calomel, fometimes anfwers in the healing of thefe fores, when the ufuai dreffings fail. A drachm, or even more, of calomel may be mixed with one ounce of thick n.ucilare. • %~J Opruivi proves fometimes ufeful here as an ex- ternal application; for although I have never had proof of its curing r.i'y fymptom truly venereal, I Sed. II. Inflammatory Tumors. 77 have had many inftances of fores, remaining after the venereal difeafe being completely removed by it, where large quantities of mercury had previ- ously been given in vain. It often appears that thefe fores, as well as others proceeding from dif- ferent caufes are kept up by that pain and irrita- tion with which they are commonly accompanied when the matter is thin and acrid. Opium, by removing this ftate of irritability, feems to deftroy the difpofition in the veffels of the fore to form that kind of matter which, by its own acrimony, ferves to perpetuate itfelf; and this being accom- plifhed, if no other interruption takes place, nature alone will feldom fail to complete the cure. If this idea is well founded, there can be no neceffity for giving opium in fuch large quantities as of late have been advifed. On the fuppofition of opium being poffeffed of fome fpecific powers in the cure of the venereal difeafe, it has been given in as large dofes as the patient could poffibly bear ; and by begin- ning with fmall dofes, and increafing them gradu- ally, there have been inftances of its being taken to the extent of half a drachm or more, two or three times a day. I have not heard, however, that any advantage has been derived from it in thofe large quantities, that did not accrue from a more mod- erate ufe of it: and in the courfe of my own expe- rience, it has in every inftance proved equally ufe- ful, when it merely leffened or removed pain, as *%hen given in the largeft dofes.* § 8. Of Lumbar Abfceffes. Every colledion of matter feated on any part of the loins, may be denominated a Lumbar-Abfcefs. But it is that variety of the difeafe we are how' to * A more particular account of buboes, and of the fores which cnfue from them, may be feen in a Treatife which I have publifhed on the Ve- nereal Difeafe, than could with propriety be inferted here. 78 Of Acute or Chap. II. confider, which originates about the fuperior part of the os facrum ; and in which we find, by diffec- tion, that the matter contained in a cyft, is com- monly lodged on the anterior furface of the inter- nal iliac and pfoas mufcles. Thefe abfceffes are preceded by pain and tenfion over the loins ; which often fhoots up along the courfe of the fpine, and down towards the thighs; and for the moft part they are accompanied with difficulty of Handing in an ered pofture. In fome cafes thefe fymptoms are at firft fufpeded to be nephritic; but for the moft part the difeafe affumes the appearance of lumbago. When fuppuration enfues, fhivering fits are apt to occur; but the pain, which at firft is always acute, becoming dull and lefs perceptible, the patient is led to conclude that he is getting better, till the matter, after fall- ing down in a gradual manner behind the perito* 3 naeum, is obferved to point outwardly, either ajbd the anus by the fide of the redum, but more fre- quently on the upper and forepart of the thigh, Jfl where the large blood veffels pafs out beneath Pau- jl part's ligament, from the abdomen. When the matter takes the courfe of the gut, j and appears near to the anus, it either foon burfts, or is laid open, on the fuppofitibn of its being an abfcefs originating in the contiguous parts. But when it paffes down with the femoral artery, which we find to be moft frequently the cafe, as it lies deep, and is covered with the ftrong tendinous fafcia of the thigh, inftead of pointing at any par- ^ ticular part, it falls gradually lower, till in fome cafes it reaches near to the joint of the knee. In fome I have known thefe abfceffes firft appear im- mediately within the fpine of the ilium, and the matter burft out above the os pubis, but in gener- j al, before burfting, it falls farther down upon the thigh. Sed. II. Inflammatory Tumors. 7c) The tumor is feldom attended with more pain than might be fuppofed to enfue from the diften- fion of the fafcia and contiguous parts by the mat- ter colleded beneath. There is no difcolouring of the fkin ; the teguments, for the moft part, retain- ing their natural appearance to the laft. A fludu- ation of a fluid is evidently difcovered through the whole extent of the tumor, particularly wrhen the patient is ered ; for at this time the fwelling is al- ways more tenfe than when the body is lying in a horizontal pofture, when a confiderable part of the matter runs along the fac towards its origin in the loins. I have already obferved, that this variety of ab- fcefs, when the matter falls down towards the anus, may be miftaken for a colledion of matter origin- ating in the neighbourhood of the redum. But no further inconvenience can occur from this mif- take, than that the fore, which enfues from laying it open, or from the matter burfting out, will not fo readily heal as when the difeafe is local: and it is probable that this is one caufe of abfceffes in thefe parts being in fome inftances fo difficult of cure. But in the more ordinary form of the difeafe, where the matter falls down beneath Paupart's lig- ament, the tumor exhibits appearances fo fimilar to thofe of a crural hernia, that the one has often been miftaken for the other. Of this I have feen different inftances, even where praditioners of ex- perience were deceived. This proceeds, however, from inattention ; for the two difeafes may be clearly diftinguifhed from each other. The hiftory of the rife and progrefs of the tumor fhould be firft afcertained : a crural hernia ufually appears fuddenly, after fome fevere exertion, and without any previous fymptom ; for the moft part it is attended with obftrudion to the paffage of the feces, with vomiting, and other fymptoms of her- nia ; and from the firft, the tumor is accompanied 80 Of Acute or Chap. II. with pain on preffure. But in the lumbar abfcefs, before the matter appears at the top of the thigh, the patient is previously diltrcffed with fymptoms of inflammation over all the under part of his back and loins. No obftrudion of the bowels takes place, nor any fymptom of hernia ; and the patient admits of the tumor being freely handled. In the crural hernia, the fwelling feldom arrives at any confiderable bulk; and when it does become large, it is by flow degrees : no fluduation is perceived in it: on the contrary, it feels either foft like < dough, or knotty and unequal, according as the omentum or faeces contained in it have been long lodged in it or not. But in lumbar abfceffes of this kind, the tumor commonly falls quickly down j the thigh for the fpace of feveral inches ; a fludu- | ation is always perceived; and no inequalities are obferved in it. In hernia, even when not ftrangu- lated, fome degree of preffure is ufually neceffary to make the contents of the tumor recede. But' in the lumbar abfcefs, the tumor becomes flaccid immediately on the patient lying down, whether i any preffure is applied to it or not: and it often 1 happens, when the matter has fallen any confider- able way down the thigh, and when the patient is in an ered pofture, that a certain fpace can be dif- covered between the upper part of the matter and the inferior border of the abdominal mufeles, which can never be done in hernia; and which, therefore, in this ftate of the difeafe, is always a certain means of diftindion. It is fcarcely neceffa- fy to obferve, that in this kind of examination the patient fhould be put into different poltures. By due attention to thefe circumftances, we may always diftinguifh one of thefe tumors from the other. Both indeed may occur at the fame time in the fame thigh, by which a mixture of appear- ances will be produced. This, however, muft be extremely rare ; and when it does take place, as Sed. II. Inflammatory Tumors. 81 the matter of the abfcefs and the parts protruded from the abdomen will always be contained in feparate facs, the combination will for the moft part be eafily difcovered. In the treatment of thefe tumors, the period of the difeafe firft requires attention. While the in- flammatory ftate continues, the ftrideft antiphlogif- tic courfe fhould be purfued, in order if poffible to prevent the formation Of matter. For the moft part, we difcover, that it has been induced by fome injury done to the fmall of the back or loins, not unfrequently by a twift in wreftling, by carrying a heavy load, or by a fevere bruife; and if acci- dents of this kind were immediately treated with that attention which their importance merits, thofe difagreeable confequences which are apt to enfue from them might frequently be prevented. When- ever a patient, who has fuffered in this manner, Complains of fevere pain in the injured part, blood- letting fhould be immediately advifed; and as lo- cal bloodletting proves always in fuch cafes moft effectual, it fhould be done by cupping and fcarify- ing the pained part. The affected parts being deeply feated, the lancet of the fcarificator fhould be made to go to a confiderable depth; for which purpofe the fpring of the inftrument fhould be ftronger than ufual, by which means any quantity of blood that we may wifh for may be taken with eafe ; and I am convinced, that by carrying this pradice a fufficient length, we might very common- ly in the early ftages of the difeafe, remove it en- tirely. It is difficult to fay when injuries of thefe parts would terminate in fuppuration or other- wife ; but I have met with different inftances, where, from the feverity of the pain, and other fymptoms, there was much caufe to fufped that matter would have formed, if it had not been prevented by a timous and plentiful difcharge of blood from the Vol. I. G Si Of Acute or Chapv II. injured parts; a remedy which cortimonly gives relief to the pain, however violent it may be. But at the fame time that we depend chiefly on local bloodletting, other remedies which experience fhows to prove ufeful in inflammation fhould not be neg- leded: of thefe, blifters, opiates, and gentle purga- tives, are moft to be relied on. Thefe, however, as well as every other remedy, will in fome inftances fail; and in others, pradi- tioners are not called till fuppuration has taken place, and till the matter has adually begun to point, either in the neighbourhood of the anus, or on the forepart of the thigh. In this fituation, what are we to do ? Are we to allow the matter to remain, or to difcharge it by making an opening into it ? In my opinion there is no room for hesi- tation : the matter fhould be evacuated as foon as a fluduation is diftindly perceived in the tumor. I know, however, that praditioners have formed different opinions upon this point: for it is alleged, that as lumbar abfceffes are fo deeply feated, it would be vain to attempt to cure them ; and there- fore that no advantage can be derived from laying them open ; while much harm, they obferve, may accrue from the air being freely admitted to them. But it does not appear that this reafoning is found- ed on obfervation. I have always held it as-a lead- ing chirurgical maxim, that the matter of every ab- fcefs, feated upon, or near to, any of the large cav- ities of the body, fhould be difcharged as foon as its existence is clearly afcertained : fo that in the treatment of the lumbar abfcefs, I have uniformly given vent to the matter, and without any bad confequences enfuing; while much mifchief may occur from this being omitted. We find by diffec- tion after death, that thefe abfceffes, when of long duration, affed not only the fofter parts that cover the vertebrae of the loins, but the fubftance of the vertebras themfelves, which in fome cafes have been Sed. II. Inflammatory Tumors. 83 found carious, and even partially diffolved iri the matter of the abfcefs. Now thefe accidents are furely more likely to happen when the matter is al- lowed to continue in the abfcefs, than wThen dif- charged early : at the fame time, by emptying the fac, the matter is prevented from burfting into the cavity of the abdomen, which in different inftan- ces has happened, to the great hazard of the pa- tient. The matter, however, ought certainly to be difcharged in fuch a way as to prevent the air as effedually as poffible from getting accefs to the cav- ity Of the abfcefs. With this view a trocar may be ufed with advantage. By preffing the matter down to the moft depending part of the abfcefs, the fkin is made fo tenfe, that a trocar is eafily intro- duced. This I have done in different cafes with complete fuccefs ; and the patients wore a fmall canula in the opening for feveral months, for the , purpofe of giving a free vent to the matter. But when the cafe is not perfedly obvious, and where any doubt remains of the contents of the tumor:, inftead of pufhing a trocar into it, the opening fhould be made in a flow gradual manner with a fcalpel, in the fame manner as is done in hernia; fo that in the event of any of the contents of the abdomen being down, no injury may be done to them. After the matter has continued to flow for fome time, and if at the end of two or three weeks the quantity does not become lefs, it may prove ufeful to throw up with a fyringe a weak folution of fac- eharum* faturni, lime water, or any other gentle aflringent; by which the difcharge will be gradual- ly diminifhed, and at laft may ceafe entirely. But although this fhould never happen, and although the patient, during life, fhould fubmit to the in- convcnicncy of a conilant flow of matter from the fore ; yet even this would be preferable to the rifk « 2 34 Of Acute or Chap. If- of allowing every abfcefs of this kind to remain unopened. . As I have happened to meet with many instan- ces of this difeafe ; as practitioners are divided in opinion refpecting it; and as few authors have giv- en a diftind account of it, I have judged it proper to fpeak of it more fully than otherwife I might have done. § 9. Of the Paronychia or Whitlow. The paronychia is a painful inflammatory fwelk ing, occupying the extremity of one of the fingers, moft frequently under the nail. Many varieties of this difeafe are described by authors; but three only require to be distinguish- ed, and even thefe are all of the fame nature, the one being only more deeply feated than the oth- ers. > In the firft, the patient complains of an uneafy burning fenfation for feveral days over the point of the finger ; the part becomes tender and painful to the touch ; a flight degree of fwelling takes plaoe>. but with little or no difcoloration ; and if the in- flammation be not removed by refolution, an info- fion is at laft produced between the fkin and parts beneath. On difcharging this by an incifion, it ap* pears to be a thin, clear, acrid ferum ; and the pa- tient, in general, gets complete relief by the oper- ation. In the fecond variety of the difeafe, the fame fet of fymptoms take place; only the pain is more fe- vere, and attended with fome uncafinefs over the whole finger and hand. The efrufion of matter is not fo perceptible as in the other; and on laying it open, it is found to lie beneath the mufcles of the iir.ger, between thefe parts and the periofteum. And in the third, the pain is ftill more intenfe In the point of the finger, at the lame time that the Se&. IL Inflammatory Tumors. 85 whole hand and arm becomes ftiff, fwelled, and painful. The lymphatics leading from the finger, and even the glands in the armpit, fwell and in- flame ; and on making an incifion into the effufion, it is found to lie between the periofteum and bone, the whole correfponding phalanx being very com- monly carious. Swellings of this kind may be produced by vari- ous caufes. They frequently occur from external violence, particularly from pundures and contu- fion: but they happen more frequently without any obvious caufe, and without our being able to account for them. Two fets of remedies are employed in parony- chia : the one confifts of fomentations, poultices, and other emollients; the other of ardent fpirits, vinegar, and other altringents. As we find from experience that no benefit en- fues from the effufion which occurs in this difeafe; on the contrary, that it is always produdive of much additional pain ; all thofe applications fliould be avoided which might tend to promote it. Some praditioners have been induced to employ warm emollient poultices on the firft appearance of the fwelling. This they do with a view to promote fuppuration; but I have never obferved that any v advantage accrues from them. The matter of a whitlow is never of the purulent kind, nor is it ev- er converted into pus, or rendered mild by poulti- ces, or any other remedy. We fliould endeavour therefore in every inftance to prevent it from be- ing effufed ; and this is done with moft certainty by local bloodletting, and the ufe of aftringent ap- plications. Indeed the fame remedies prove moft effedual here, that we find to be fo in the removal of inflammation in other parts. In various inftan- ces, I have found even fevere degrees of pain almoft immediately removed by the application of leeches over the difeafed phalanx of the flnjer. But in 86 . Of Acute or Chap. II. the more violent degrees of pain, where the arm fwells, and efpecially when fever takes place, gen- eral bloodletting becomes likewife neceffary, at the fame time that large dofes of opiates are indicated. After as much blood is difcharged by leeches as is judged proper, the immerfion of the pained parts in ftrong brandy, or even in fpirit of wine or alco- hol, is one of the beft remedies: and when the bites are fomewhat healed, or when leeches have not been employed, fpirit of turpentine or ftrong vinegar may be ufed in the fame manner. It is proper, however, to remark, that it is in the firft ftages only of this affedion that remedies of this kind can prove ufeful: for when efliifion has adually taken place, that ftate of the difeafe is produced which they were meant to prevent; and it does not appear that they have any effed in re- moving it. As foon as we are convinced that ef- fufion has occurred, an opening fhould be made without delay: for we have already obferved, that it is in vain to attempt to convert the effufed fluid into pus ; and being in itfelf acrid, it is apt to in- jure the contiguous parts, while at the fame time the patient is kept in an extreme degree of pain as long as it remains confined. When the colledion is fuperficial, and merely covered with fkin, this is ^.very fimple operation. A pundure with a lancet commorly proves fufficient: but when the matter is more deeply feated, it requires fome attention to avoid the flexor and extenfor tendons of the finger. When the matter lies above the periofteum, all that we have to do is to make the opening fuffi- ciently large for difcharging it, and to drefs the fore as if it was produced by any other caufe. But, when the matter lies between the periofteum and bone, the latter is always rendered carious : hence it is the common pradice to endeavour to keep the incifion open till an exfoliation of the difeafed parts, Sed. II. Inflammatory Tumors. 87 of the bone takes place; but no advantage ever ac- crues from this. The procefs is not only extreme- ly painful, but tedious. The matter is apt to lodge beneath the nail ; painful fungous excrefcences fprout out over the fore, which it is difficult even with the ftrpngeft cauftic to keep down; and at laft it very commonly happens, after the patient has fuffered feveral months of diftrefs, that inftead of a partial exfoliation, the whole difeafed phalanx comes away. I have long, therefore, been in the pradice of removing the whole of the difeafed bone immediately on its being found, by the intro- dudion of a probe, to be carious ; by which much time and trouble are faved both to the patient and furgeon. By making a free incifion along the whole length of the difeafed phalanx, the bone is eafily removed with common forceps. The pain attending the operation is indeed fevere, but it is only momentary: and as it does not deprive the patient of the ufe of the joint, fo much as might be imagined, it is feldom keenly oppofed when the furgeon advifes it. I have had feveral inftances of people who in this manner loft the laft phalanx of bone in one finger, having fuch a degree of firm- nefs in the parts which remained, as to fuller very little inconvenience from the want of it. When the difeafed bone is removed, the remain- ing fore commonly heals eafily. It requires fome attention, however, to preferve the lips of the fore from uniting till it fills up from the bottom. This is moft eafily done by infinuating between them, at each drefling, a fmall pledget of foft lint, fpread with any mild emollient ointment. In almoft every variety of paronychia, the nail is apt to fall off; but this proves only a temporary inconvenience; for when the parts are properly proteded, nature never fails to fupply the defi- ciency. 88 Of Acute or Chap. II. In the commencement of paronychia, the laft phalanx of the finger only is affected ; and to what- ever extent the pain and fwelling of the fofter parts may fpread, we feldom find that the bone of the contiguous phalanx fuffers, unlefs from improper management in allowing the difeafed bone to re- main, or the acrid matter to lodge too long. In fuch cafes, the furrounding teguments are apt to fwell and inflame, and fmall ulcerations to occur over the whole extent of the carious bone. In this fituation we are often under the neceffity of advifing the finger to be amputated, in order to prevent the difeafe from fpreading to the hand. § 10. Of Chilblains. These are painful inflammatory fwellings, tq which the fingers, toes, heels, ears, and other ex- treme parts of the body, are liable, on being much expofed to fevere degrees of cold. The tumor is for the, moft part of a deep purple, or fomewhat of a leaden colour : the pain with which it is attend- ed is not conflant, but fhooting and pungent; and, in general, it is accompanied with a very diftrefs- ful degree of itching. In fome cafes the fkin re- mains entire, even although the tumefadion is con- fiderable ; but in others it burfts or cracks, and difcharges a thin fetid matter. And where the de- gree of cold by which the difeafe was produced has either been great, or the application of it long con- tinued, all the parts that have been affeded are apt to mortify and Hough off, by which a very foul ill conditioned ulcer is always left. I have obferved above, that it is the extreme parts of the body chiefly that are liable to be at- tacked with chilblains: and we likewife find, that they are more frequent in delicate children and old people than in thofe who are robuft. It is alfo re- Sed. IL Inflammatory Tumor:. 89 marked, that they are particularly fevere in people of fcrofulous constitutions. The beft preventative of chilblains is to avoid ex- pofure to cold and dampnefs ; for when once a per- fon has fuffered from chilblains, if the injured parts be not proteded by fufficient coverings, they are apt to return every winter. Much diftrcfs, there- fore, and inconvenience, may be prevented by keep- ing this precaution in view. Chilblains may be confidered as a leffer degree of what is ufually termed froftbiting: hence parts attacked with them fliould never be quickly warm- ed. The patient fhould not be allowed to approach a fire: inftead of which, he fhould be put into a cold apartment; and the froftbitten parts fhould be firft well rubbed with fnow when it can be pro- cured, and afterwards immerfed in cold wrater. Nothing proves fo certainly hurtful to parts in this ftate as heat fuddenly applied. Even fnow and cold water afford a warm fenfation to parts attack- ed with chilblains; but it is found by experience, that no detriment enfues from this. After the parts have been treated in this manner, the patient may in a gradual way be brought into a greater degree of heat; but he fliould for a confiderable time be kept at a diftance from fire. Rubbing the parts with fait will in this fituation prove ufeful; and immerfion in warm wine is likewife employed with advantage. A patient much benumbed with cold fhould not even have cordials given to him fuddenly. A glafs of cold wine may at firft be allowed. Afterwards warm wine may be given, either by itfelf or mix- ed with any of the warmer fpices : and when ftronger cordials are required, ardent fpirits may be employed. Remedies of this kind, how*ever, are only necef- fary in the more fevere degrees of thefe affedions. In common caiei of chilblains occurring in this 90 Of Acute or Chap. II. country, as foon as the part is perceived to be af- feded, it fhould be well rubbed either with fpirit of turpentine, or camphorared fpirit of wine ; and pieces of foft linen, moiftened in one or other of thefe, fhould be kept conftantly applied to it. In this manner we have it often in our power to re- move chilblains, which otherwife would be produc- tive of much diftrefs : but I muft again obferve, that the beft advice that can be given to patients liable to chilblains, is to proted the parts much ex- pofed to fuffer from cold as much as poffible dur- ing the winter ; and when by accident they get wet with fnow, which proves more particularly hurtful than moifture of any other kind, that they fliould be dried as quickly as poffible. As fome patients fuffer feverely with chilblains every winter, our being able to prevent them with- out that inconvenience to the patient which always attends confinement and much caution, would of- ten be an objed of importance ; and it is a point upon which praditioners are frequently confulted. In various inftances I have derived the moft obvi- ous benefit from fea bathing during fummer ; and in one patient who had fuffered feverely from the effeds of cold for feveral winters, I advifed a cham- ber bath to be ufed even during winter ; by which the parts which ufed to fuffer were fo much strengthened, that feveral years have elapfed with- out any return of the difeafe. - When chilblains ulcerate, by the teguments be- ing altogether thrown off, or merely cracking and oozing out matter, warm poultices and emollient ointments are commonly employed. For the pur- pofe of cleanfing the fores, and inducing a difcharge of right matter, poultices may with propriety be advifed for a few days ; but they fhould never be Jong continued : nor fhould emollient ointments be much perfifted in ; for they very univerfally induce • fungous excrefcences over the fores, which are of- Sed. II. Inflammatory Tumors. 91 ten difficult to remove. The daily application of cauftic to the edges of the fore, and dreffing the fore itfelf with common digeftive ointment, mixed with a due proportion of red precipitate, are the beft preventatives of this. Common diachylon plafter, fpread upon thin leather, makes an ufeful application for fores of this kind. % 11. Of Sprains and Contufions. Contusions of the fofter parts of the body, and fprains of the tendons and ligaments of joints, are ufually produdive of immediate pain and inflam- matory fwellings. Slight injuries of this kind feldom meet with much attention ; but whenever they are fevere, the moft diftrefsful effeds are apt to refult from them, and can only be prevented by the greateft fkill and attention of the praditioner, accompanied with much caution on the part of the patient. An increafed adion in the arteries of an injured part, by which red globules are forced into veffels which naturally do not admit them, will account for all the phenomena which ufually attend inflam- mation : but in the feverer degrees of fprains and contufions, along with an increafed adion of the arteries in the part, which muft neceffarily refult from the pain with which they are accompanied, it is evident that inftantaneous effufion likewife takes place, from the rupture of a great number of fmall veffels. In no other way can we account for thofe tumors of confiderable bulk, which often fuc- ceed almoft inftantly to fprains. For the moft part the effufion muft be of the ferous kind, as the fkin ufually retains its natural colour for fome time af- ter the accident: but the tumefied parts are fome- times of a deep red, and on other occafions of a leaden colour, from the firft; owing to a rupture pf fome of the veffels containing red blood. 9 a Of Acute or Chap. II. In the treatment of fprains and contufions, two circumftances chiefly require attention. In the firft place, we fhould endeavour to prevent the fwelling, as far as this can be done, and afterwards thofe remedies fhould be employed which we know to prove moft powerful in preventing or removing inflammation. It is alleged, indeed, by fome, that the fwelling which occurs from contufions never does harm, and therefore requires no particular attention. In contufions of the cellular fubftance, or even of the mufcles, I allow that this is often the cafe; for to whatever extent the tumefadion may proceed, the effufed fluid is in thefe parts very commonly abforb- ed. But even here the fwelling in fome cafes proves *. very obftinate; and in fprains of the tendons and ligaments, a very troublefome, painful thicknefs of the parts that have been injured, is apt to continue for a great length of time ; in fome cafes, even for life: and I have commonly obferved, that this has been nearly in proportion to the fize of the tumor which occurred at firft ; for it would appear that effufions thrown out by ligamentous parts are not fo readily abforbed as thofe which take place in oth- er parts of the body. Hence, in accidents of this kind, it is always an objed of importance to pre- vent the fwelling from arriving at any confiderable fize. With this view, we depend chiefly on aftringent applications ; fuch as the lees of red wine, ardent fpirits of every kind, and vinegar. By immerfing a fprained or contufed part in any of thefe imme- diately on an injury being received, if the effufion and fwelling be not altogether prevented, they will at leaft be rendered much lefs than otherwife they probably might have been. We alfo find that the immediate application of cold peeves frequently ufeful. Plunging a fprained limb into cold water, or even into water rendered artificially cold by a Sed. II. Inflammatory Tumors. 93 mixture of nitre, very commonly anfwers a good purpofe, and fhould always be advifed in the firft place, till one or other of the articles that I have mentioned can be procured ; for as the effufion takes place quickly, no time fhould be loft in the application of the remedies. It fortunately happens, that the remedies which anfwer beft in preventing the effufion that enfues from fprains, prove Ukewife ufeful in preventing inflammation. But as this fymptom is in fevere fprains apt to proceed to a great height, other re- medies are required; and none that I have ever employed anfwer fo well as local bloodletting. By the time that cold water and other difcutients may be fuppofed to have produced any effed, which cannot be in lefs than an hour, a number of leech- es fhould be applied over all the tumefied part; or, in contufions of flefhy mufcular parts, cupping and fcarifying may be employed. But in whatever way it is done, a quantity of blood fhould be drawn off fomewhat proportioned to the ftrength of the pa- tient and feverity of the fprain. For a confiderable time paft, 1 have been in the pradice of employing local bloodletting in fprains and contufions of every kind; and whether the injury has been flight or fevere, it has very com- monly proved an ufeful, pleafant, remedy. In flight fprains, one plentiful evacuation of blood by means of leeches, in general proves fufficient. But when the injury has been fevere, we are obliged to apply them once and again: they require indeed to be repeated from time to time as long as any fevere degree of pain continues. Even when the inflammation and fwelling of the teguments that arife in fprains are gone, a fulnefs or thickening is often difcovered in the tendons and ligaments ;. and we conclude, that they continue inflamed, as long as they are much pained either by preffure or motion. In this situation nothing ever proves fo 94 Of Acute or Chap. II; effedual as the application of leeches: this remedy indeed feems to prove equally beneficial, whether the inflammation be feated entirely in the fkin, or in the more deep feated parts; fo that it fliould not in any cafe be omitted. In violent fprains the pain is often fo fevere, as to induce quicknefs of pulfe and other fymptoms of fever. In fuch cafes, along with local blood- letting, it proves fometimes neceffary to take blood in larger quantities With the lancet: opiates alfo become neceffary, together with all the remedies that prove ufeful in fevers arifing from inflamma- tion. After blood has been freely taken from a fprain- ed part, the beft remedy that we can ufe at firft, is" a folution of ceruffa acetata ; and afterwards, for the removal of that thickened ftate of the liga- ments, which often fucceeds to fprains, the pour- ing of warm water upon the part two or three times a day, for the fpace of a quarter of an hour or fo each time, proves often ufeful. Even com- mon fpring water frequently anfwers the purpofe ; but it feems to prove more ufeful when impregna- ted with fea fait, or crude fal ammoniac. There is likewife reafon to think, that the warm waters of Bath and Buxton are rendered more effectual in cafes of this kind, by the impregnations which they contain, than they otherwife would be. Along with warm bathing, fridions with emol- lients prove fometimes ufeful in removing this thickening of the parts induced by fprains. But they require to be perfifted in for a great length of time. During the cure of a contufion or fprain, the in- jured part fhould be kept as much as poffible in an eafy pofture. In every inftance this fhould be kept in view, but more efpecially when the pain is very fevere, which it "always is when the fibres of any of the fprained tendons have been ruptured, and Sed. II. Inflammatory Tumors. 95 which nothing will cure fo readily as the limb in which it has happened being kept for a confidera- ble time in a relaxed pofture. I have already mentioned the warm bath as a remedy in fprains. In various cafes cold bathing alfo proves ferviceable. After fprains have been of fome duration, the injured part is apt to continue weak and relaxed, even when the paia and fwell- ing are gone. In this situation, cold water being poured upon the part from a height, or being fud- denly dallied on it, and repeated once or twice dai- ly, proves more effedual in strengthening the weak- ened limb than perhaps any other remedy. It is for the removal of debility only, however, that cold bathing fliould be employed; and there is much reafon to think that it has done mifchief when ufed in the more early ftages of fprains. While much thickening of the tendons and liga- ments remains, and which often proves the moft formidable, as well as the moft obftinate fymptom which accompanies fprains, a long continued ufe of cold bathing feems to do harm, by rendering the thickening more firm than it was before, while the contrary effed often refults from a proper ap- plication of warm water. A bandage or roller applied over the injured parts, as tight as the patient can eafily bear it, proves often ufeful in fprains. By fupporting the relaxed parts, it not only prevents pain, but the cedematous fwellings alfo, to which fprained limbs are often liable. The roller fhould be of flannel, which yields more readily than linen to any varie- ty in the fize of the limb, while it ferves as the moft effedual preventative of thofe rheumatic af- fedions with which limbs that have fuffered from fprains are liable to be attacked. The roller fliould be carried fpirally upwards from the inferior part of the limb, with an equal preffure on every part of it, in order to prevent oedema which might oth- erwife take place. 96 Of Chronic or N Chap. II. SECTION III. Of Chronic or Indolent Tumors. § i. General Remarks. THE general charader of this clafs of tumors is, that they are flow in their progrefs, and not neceffarily attended with inflammation. Tu- mors of every kind may eventually, indeed, in- duce inflammation : thus, fwellings which have long remained indolent, by an increafe of bulk will often diftend the fkin fo much as to become in- flamed ; and all the varieties of hernia, although not neceffarily accompanied with inflammation, for they frequently take place without it, tend often to induce it, for reafons too obvious to require be- ing mentioned. But in thefe, we confider inflam- mation as an accidental occurrence only, and in no way conneded with the rife or formation of the difeafe. Of the chronic tumors we fhall firft con- fider thofe that are encyfted. § 2. Of Encyfted Tumors. Every tumor might be confidered as encyfted, the contents of which are furrounded with a bag or cyft, as is the cafe with every variety of hernia and hydrocele, as well as with fome other tumors; but in common pradice thofe tumors only are termed encyfted that are contained in cyfts of a preternatural formation. In common language, thefe, as well as various tumors of the farcomatous kind, are termed wens.- Sed. III. Indolent Tumors. 97 The different parts of which an animal body is compofed, are conneded together by a common medium, termed the cellular fubftance; which is fo univerfally diffufed, that it feems to form a very confiderable part of every fibre. In a ftate of health the cells of this fubftance communicate with each other ; and, in like manner with the large cavities of the body; thefe cells are kept foft and moift by a fecretion conftantly palling into them by the ex- halents, and returning from them by the abforb- ents. In fome parts of the body this fecretion is entirely ferous ; while in others it confifts evident- ly of oil or fat. While the abforption of this fluid is in propor- tion to the quantity exhaled, no accumulation takes place: but various caufes may concur to deftroy the equilibrium; and in whatever way this may happen, if more is fecreted than is carried off by the abforbents, a fullnefs or fwelling muft neceffari- ly enfue. Where this fuperabundance is of the fe- rous kind, a dropfical fwelling will be produced ; when of an oily nature, obefity or fatnefs will take place. A general difpofition in the fyftem to this kind of accumulation is a frequent occurrence ; but caufes fometimes occur by which colledions are produced in particular parts. In a found ftate of the cellular fubftance, that natural communication that I have mentioned as fubfifting between the1 dif- erent cells of which it is compofed, muft neceffari- ly prevent any partial or circumfcribed colledion. And accordingly we know, that all ferous effufions very readily pafs from one part of this membrane to another. But this communication may be in- terrupted by inflammation as well as other caufes, and accumulation of this natural fluid may there- fore take place in a particular part. Vol. I. H £8 Of Chronic or Chap, it We thus account for the formation of encyfted tumors; to which different names have been apj plied, according to the confiftence and appearance of their contents. When of the confiftence of honey, the tumor is termed meliceris : when of a foft cheefy confiftence, or refembling dough, it is termed an atheroma ; and fteatoma, when formed Of fat. But it is proper to remark, that various degrees of confiftence are obferved in each of thefe. Thus, the fteatoma is fometimes foft like butter, and at other times firm like fuet: and the fame kind of variety occurs in the contents of the atheroma and meliceris, which in fome cafes are equal in firmnefs to new cheefe, and in others not firmer than the thinneft honey. The matter forming fteatomatoUs tumors, we conclude to be from the firft of an oily or fatty na- ture ; and that their different degrees of confiftence will depend upon the remora of their contents, and quantity of thinner parts of them that happen to be abforbed. And I think it probable, that athe- romatous and melicerous tumors are originally formed by a depofition of ferum, with perhaps a confiderable proportion of coagulable lymph ; and that the degrees of confiftence of which we find them, will depend upon various caufes: upon the the particular quantity of coagulable lymph which they contain ; upon their being of longer or short- er continuance ; and particularly, upon their hav- ing been inflamed or not; and upon the extent to which this inflammation may have proceeded. For the moft part, praditioners accuftomed to this branch of bufinefs, may be able to distinguish with fufficient exadnefs the nature of thefe tumors before laying them open. Thus, in general, the fteatoma is of a firm confiftence: it is commonly loofe, and rolls more readily than the others under the fkin ; and its furface is apt to be unequal: the Sed. III. Indolent Tumors. 99 atheroma is foft and compreffible, but no fludua- tion is obferved in it: while, in the meliceris, the fluctuation of a fluid or thin matter is in general very diftindly perceived. It is proper, however, to remark, that neither thefe, nor any other means of diftindion, will at all times prove fufficient: for in fome cafes, the fteatoma, inftead of bing firmer than the others, is much fofter ; infomuch that I have met with different inftances of the fat of which they are formed, fluduating or moving be- tween the fingers like thin purulent matter; and where, acccordingly, the opinion that was previ- ously formed of it was altogether erroneous. The atheroma and meliceris are fometimes combined in the fame tumor: one part of it will be of a foft pultaceous nature, and contained in a feparate cyft or cell, while the reft is perhaps of the fame con- fiftence with purulent matter. In a few cafes, too, the fteatoma is conjoined with thefe, but this is not a frequent occurrence. In judging of the nature of thefe tumors, fome advantage may be derived from attending to their fituation. Thus we obferve that in fome parts of the body fat is more apt to be depofited in the cel- lular fubftance than in others. In fome parts, in- deed, fat is fcarcely ever perceived in it; as is the cafe over a great part of the head; while in others, particularly over the prominent part of the abdo- men, we commonly meet with it even in the lean- eft fubjeds. Now I believe it will be obferved, that fteatomatous tumors are feldom, if ever, met with in thofe parts of the body which are not ufually in a ftate of health fupplied with fat: at leaft this has been fo much the cafe in the courfe of my pradice, that I have never met with an inftance of it; and it tends much to confirm the idea, which I have endeavoured to eftablifh, of the formation of thefe tumors. The head, as I have obferved, is h 2 V7 too • Of Chronic or Chap. II. very fparingly fupplied with fat, at the fame time that we find it more liable than any part of the body to encyfted tumors; but thefe tumors are ve- ry univerfally of the atheromatous or melicerous kinds.* Nor have I ever met with the fteatonia- tous tumor but where fat is ufually depolited in the contiguous cellular fubftance. They are rarely indeed, obferved on that part of the body which is moft plentifully fupplied with fat. We feldom meet with thefe or any other variety of encyfted tumor on the abdomen ; and at firft view this may be confidered as an objedion to our theory : on further attention, however, it will rather appear to fupport it. The parietes of the abdomen being formed of foft yielding parts, with no bone or hard body beneath, we may readily fuppofe that they will fcarcely, if at all, be affeded with preffure : fo that this caufe of obftrudion will not here have the fame effed as on the head and other parts where the cellular fubftance lies immediately above the bone. All the tumors of the encyfted kind are fmall at firft, and increafe by flow degrees. They are of very different fhapes and fizes : in fome they re- femble a walnut; on the head they are commonly round and fmooth, and do not often arrive at any great bulk; but in other parts of the body they are often of an irregular form, at the fame time that they are more apt to acquire a greater fize. I have met with fleatomatous tumors weighing up- wards of twenty pounds ; and fometimes they are double this weight. They are never at firft attend- ed with pain; and the fkin for a confiderable time * By atheromatous and melicerous, I mean to exprefs different degreet of confiftence of a curdy pultaceous matter. By fome, the firmer kinds of this have been miftaken for, and defcribed as, the contents of the fteato- matous tumor; but they will be found to be in every refpect different from the fatty fubftance contained in the real fteatoma; nor does the one Taiitty of thefe tumors ever chauge ieto the other. Sed. III. Indolent Tumors. 101 retains its natural colour. But when, by long du- ration, they become large, the veins of the fkin, as well as thofe of the fac, become large and varicofe; and the prominent part of the tumor acquires a clear red colour, fimilar to that which accompanies inflammation : but it feems to be different from this, as it is feldom attended with pain, unlefs when injured by external violence. A blow or bruife will readily, indeed, excite inflammation, by which the fkin will become tender and painful, and will crack or burft, if not prevented by the con- tents of the tumor being difcharged by an opera- tion. This is the ordinary progrefs of thefe tumors: but it is proper to remark that although they nev- er advance quickly, yet in fome situations they ter- minate much fooner, and arrive at a greater bulk, than in others. Thus, in the head they do not ufually become larger than a pullet's egg. In a few cafes, indeed, they are larger; but for the moft part they terminate before they acquire this fize, by the teguments becoming tenfe and thin, and even burfting if not prevented in the manner I have mentioned. But on other parts of the body, par- ticularly on the back, on the fhoulders, and thighs, the fkin fometimes retains its natural colour long after a tumor has become very large. This feems to proceed from different degrees of laxity in the fkin. In the head, the teguments are firm, and do not yield fo readily to distention as in other parts of the body; by which any tumors lying beneath them muft neceffarily be more quickly brought to a period. The fituation of thefe tumors has likewife a con- fiderable effed on the firmnefs with which they are attached to the contiguous parts. In fome parts they are fo loofe and moveable, efpecially while they continue fmall, that they readily yield even to flight degrees of prellure : but in others, parti- 102 Of Chronic or Chap. II. cularly where covered with any fibres of mufcles, they are apt to be firmly fixed from their com-. mencement. The attachment of tumors is alfo in- fluenced by their remaining more or lefs free of inflammation ; for they never become inflamed, even in the flighteft manner, without fome degree S of adhefion taking place between the cyfts and cor- refponding teguments. In the treatment of encyfted tumors, we are di- reded by authors to attempt to cure them in the firft place by refolution ; and if this fails by extir- pation. With a view to accomplifh a cure by re- folution, fridions with mercurial ointments are re- commended, together with gum plafters, and a va- riety of other applications. No praditioner, how- :■$ ever, of the prefent age, will depend upon this management; nor will he exped to be able to re- move thefe tumors in any other manner than by the aid of furgery. We fhall therefore, fuppofe, that the removal of one of them by an operation is agreed on: the next point to be determined is the mode of effed- ing it; and this in a great meafure fhould depend on the contents of the fac. If they appear to be of the thin melicerous kind, which for the molt part will be the cafe if a diftind fluduation is per- ceived through the whole body of the tumor, it ought to be treated like a common abfcefs. In fmall colledions the matter may be difcharged by laying the moft depending part of the tumor open with a common lancet, and treating it in the ordi- nary way till it fills up or adheres from the bot- tom : but as in large fwellings of this kind, the free admiflion of air proves always hurtful, the opening fhould be made in a manner the leaft like- ly to be attended with this inconvenience. In a preceding part of this work, I have recommended the palling of a feton or cord through large ab- fceffes as the beft method of laying them open ; Sed. III. Indolent Tumors. I03 and as the fame method may with equal propriety be employed in encyfted tumors formed by collec- tions of any thin matter, we fhall now refer to what was then faid upon the fubjed.* I fhall at prefent only obferve, that the cord fhould pafs through the whole extent of the tumor, from the fuperior to the moft depending part of it; and that the inferior opening at which it paffes out, fhould be fufficiently large for admitting the matter to be freely difcharged, In this manner I have had ma- ny inftances of large encyfted tumors being healed with more eafe than almoft ever happens under the ordinary method of treatment. Several years ago, I gave my opinion upon this point at confiderable length; and further experience of the advantages which refult from it has tended much to confirm it,t This method of cure, however, is only applicable where the contents of tumors are fo thin as to be eafily difcharged by a fmall opening. When too firm to admit of this, they muft either be emptied by an extenfive opening into the cyft, or the c\ ft with its contents muft be diffeded out. Where a cyft containing matter adheres fo firm- ly to the contiguous parts as to require much time to remove it by diffedion, it fhould never be at- tempted. It will be fufficient to lay it freely open through its whole extent, and to remove any por- tions of it that may be loofe. The contents of the tumor will in this manner be completely removed; and the cure may either be effeded in the ufual way, by preferving the wound open till it fills up with granulations from the bottom ; or it may be attempted by drawing the divided edges of the fkin together, and trufting to moderate preffure and the ordinary effeds of inflammation for producing a * Vide Chap. I. t Vide Treatife on Ulcers, &c. Part I. 104 Of Chronic of Chap. II. complete reunion. I have fucceeded in both ways; and I think it neceffary to obferve, that both are equally certain. To thofe who have been accuftom- ed to think that it is neceffary to remove the cyfts of thefe tumors entirely, it will at firft appear to be unfafe to allow any part of them to remain: many I know are of this opinion, but experience would foon convince them that it may be done with fafe-? ty: when we refolve, however, on removing the cyft, it is better to open it by a longitudinal cut through the whole length of the tumor than to re- move it entire. When the cyft is empty, it is more readily laid hold of with the fingers or forceps, and more eafily diffeded out, than when the bag re- mains full and diflended. When the bag is thus removed, the teguments fliould be laid together, and retained with adhefive plafters, or with two or three futures, as the ope- rator may incline: and if a due degree of preffure is made over the whole, a cure may thus be ob- tained by the firft intention. In every part of the body this is an objed of importance, as it tends to fliorten the cure; but it is particularly proper in the face and other external parts of the body, where the cicatrix produced by a tedious fore proves for the moft part very unfeemly. The arteries which fupply the cyfts of thefe tu. mors are fometimes fo large as to pour out much blood when they are cut. In this cafe, they fliould be immediately fecured with ligatures : and if the threads are left of fuch a length as to hang out at the lips of the wound, they prove no obftacle to the cure being completed in the manner I have dired- ed; for when applied with the tenaculum, as they ought always to be, they may be drawn away with eafe and fafety at the end of the fecond or third dreffing. By an ill timed caution, fome pradition- ers, from an apprehenfion that ligatures in fuch cir. cumflances may do harm, have advifed that none Sed. III. Indolent Tumors. io5 of the arteries which appear in the removal of thefe tumors fhould be tied. Nay, fome have gone fo far as to fay, that it is feldom or never neceffary to apply ligatures to fuch arteries as are cut in the removal of tumors of any kind, not even of cancer- ous mammas: but as I have known different in- ftances of patients dying fuddenly from lofs of blood where this precaution was negleded, and as I never met with a fingle cafe of any harm being done by it, I would advife every artery to be fe- cured that does not flop foon after being divided. Befides the real danger to be dreaded from this being negleded, it is apt to fruftrate our intention of healing the fore without the formation of mat- ter. In the removal of cancerous breafts, where the edges of the divided fkin have been drawn to- gether fo as to cover the fore, by the burfting of an artery which had not been fecured, fuch a quan- tity of blood is occafionally effufed between the teguments and parts beneath, as tends either to pre- vent them from uniting, or to render it neceffary to remove the bandages, and to lay the parts again open, in order to difcover the bleeding veffel. Of this I have met with fuch a number of inftances, that I am convinced every praditioner of experi- ence muft have done the fame; and as they never fail to produce much disturbance both to the pa- tient and furgeon, the caufe from which they ori- ginate ought undoubtedly to be avoided. In tumors of an ordinary fize, there is no necef- fity for removing any part of the fkin. By a fin- gle incifion along the courfe of the tumor, in the manner I have direded, the fac will either be laid fufficiently open, or it may be removed with equal eafe as if it were opened by a crucial incifion ; and although the fkin may at firft appear to be too ex- tenfive, yet in the courfe of a fhort time it will con- trad fo as merely to cover the parts beneath. But in tumors that are large, where the fkin is fo much 106 Of Chronic or Chap. II. diftended that it will be much puckered if part of it be not removed, it ought without hefitation to be done. This is beft effeded by including in two femilunar cuts as much of the fkin as we mean to remove ; and this being done, the portion of fkin thus feparated muft be taken away along with the cyft. In the fame manner, when we are operating upon a tumor where the prominent part of the fkin ^ is either ulcerated, or rendered fo thin by diften-' tion that we cannot with propriety attempt to fave ( it, fuch parts of it as are thus affected fhould be in- cluded between two femilunar cuts, and removed 1 in the manner I have mentioned. In other re- fpeds, the cure muft be conduded as if none of the Jj fkin were taken away, by drawing the divided S edges of the teguments together, and endeavouring « to make them unite by the firft intention, in the manner I have advifed. ■ Where wens are fo large as to render it necefla- I ry to remove any part of the fkin, we are defired I by fome praditioners to do it with cauftic; and J by others cauftic is ufed for opening every tumor. Cauftic, however, fhould never be employed where ' 1 patients have refolution to. fubmit to the ufe of the fcalpel. § 3. Of Ganglions. By the term Ganglion, we here mean an indo- j lent moveable tumor which forms upon the ten- ] dons in different parts of the body, but moft fre- quently on the back part of the hand and joint of the wrift. Thefe tumors poffefs a confiderable degree of elasticity ; by which they may in general be diftin- guifhed from the encyfted tumors defcribed in the laft fedion. They feldom arrive at any great bulk; they are not often attended with pain ; and for the moft part the fkin retains its natural appearance, Sed. III. Indolent Tumors. 107 On being laid open, they are found to contain a tough, vifcid, tranfparent fluid, refembling the white of an egg. It feldom happens that ganglinous tumors be- come fo large as to render them the objeds of fur- gery. On their firft appearance, they may often be removed entirely, either by moderate fridion frequently repeated, or by gentle preffure with thin plates of lead properly fecured with a bandage. In this manner, they are more readily difcuffed than any other kind of fwelling: but neither the fric- tion nor the preffure fhould be carried too far, oth- erwife the fkin may be fo much fretted as to give rife to inflammation ; by which fuppuration, and abfceffes of difficult cure may be induced. When this method of removing a ganglion does not fucceed, nothing further fhould be attempted while the tumor remains of a moderate fize : but when it becomes fo large as to prove troublefome, either by impeding the motion of a joint, or in any other manner, it ought to be removed by excifion, in the fame manner as I have advifed in the treat- ment of encyfted tumors, when the cyft is to be taken away ; that is, by making a longitudinal cut through the teguments over the whole extent of the tumor ; and after feparating the fkin on each fide, to diffed it off from the tendon : or, when it is found to adhere fo firmly to the contiguous parts as to render this impradicable, an incifion may be made into it of fuch a depth as to difcharge the contents of it, after which a cure may be obtained by preferving the wound open till it fills with gra- nulations from the bottom. In general, practitioners are averfe to operate on thefe tumors, on the fuppofition of the wound be- ing difficult to heal; but I have feldom known this to be the cafe. *o$ Of Chronic or Chap. H § 4. Of Swellings of the Burfa Mucofa. The burfae mucofae are fmall membranous bags, feated upon, or very contiguous to, the different large joints. They naturally contain a thin, tranf. parent, gelatinous fluid, which feems to be intend. cd for lubricating the parts upon which the ten- . ;L dons move that pafs over the joints. They are met with in other parts of the body, but chiefly about the hip joint, the knee, ankle, moulder, elbow, and wrift.* j In a ftate of health, the fluid contained in thefe 1 burfie or facs is in fuch fmall quantity, that it can. \ not be difcovered till they are laid open by diffec. tion ; but in fome cafes it accumulates to fuch an ' extent as to produce tumors of a large fize. This is not an unfrequent effed of contufions and fprains; and I have often met with it as a confequence of rheumatifm. The fwelling is feldom attended with much pain : it yields to preffure, but is more elaf. tic than where ordinary matter is contained: at firft it is always confined to one part of the joint; but in fome cafes the quantity of accumulating flu- id becomes fb confiderable as nearly to furround the joint. The fkin always retains its natural ap- pearance, unlefs attacked with inflammation. The contents of thefe tumors are found to be of different kinds, and this feems to depend on the caufe by which the fwelling is produced ; a circum- ftance meriting particular attention. Thus when the tumor is induced by rheumatifm, the contents of the fac are commonly thin and altogether fluid, refembling the fynovia of the different joints ; at leaft this has been the cafe in any of thofe which I have opened, while in fuch as proceed from fprains, * The bed account that has yet appeared of the fituation 3nd number of the burfx mucofae, may be feen in a publication upon this fubjedt by Dr. Alexander Monro fenior, of this University. Sed. IB. Indolent Tumors. 109 we ufually find, mixed with this tranfparent fluid, a confiderable quantity of fmall elaftic concretions. In a few cafes I have met with thofe concretions of a foft texture, fo as to be eafily compreffed between the fingers; but in general they are firm and elaf. tic. We may commonly, however, judge of this, even before the tumor is opened, by the kind of fluctuation that takes place. When the concretions are foft, the fluduation is ufually diftind; but when they are firm, it is not fo clearly perceived, while at the fame time they are eafily felt beneath the fingers on being preffed from one part of the fac to another. In pradice it will be found to be an objed of importance, our being able to diftinguifh between thofe collections whkh proceed from rheumatifm, and fuch as are the confequences of old fprains: for in the firft, I believe, it is feldom or never ne- ceffary to propofe an operation ; as in moft inftan- ces, perhaps in all, the fwelling will at laft disap- pear, merely by keeping the parts warm with flan- nel ; by frequent frictions; by warm water being frequently pumped upon them ; or by the applica- tion of blifters. At leaft this has happened in ev- ery rheumatic cafe of this kind in which I have been concerned. But in thofe fwellings of the bur- fae mucofae, which originate from fprains, although the quantity of effufed fluid may remain stationa- ry, or may even leffen in quantity, it will feldom, if ever, disappear entirely. In fuch cafes, therefore, when the tumor becomes troublefome from its fize, we are obliged to leffen or remove it by an opera- tion. The only operation that is admiffible, is that of opening the fac, fo as to difcharge the matter con- tained in it, and to preferve the wound open till it fills with granulations from the bottom. In moft fituations this may be done with fafety; but in fome parts, particularly about the joint of the wrift, no Of Chronic of Chap. & thefe colledions are fo covered with tendons, that the greateft caution is required in every operation of this kind. When the contiguity of tendons , prevents the fac from being opened to fuch an ex- tent as may enfure a cure, it will be better to lay it open at each end; and after prefling out the con- tents, to pafs a fmall cord of filk from one opening • to the other. In this manner a flight degree of \ inflammation will be excited on the infide of the fac, when the cord may be withdrawn, fo as to-ad- mit of a cure being attempted by gentle preffure, applied with a roller over the courfe of the tumor. I have fometimes fucceeded in this way, when a cure could not be obtained by any other means; and wrhen the cord is cautioufly introduced with a blunt probe, no harm occurs from it, even when it paffes beneath fome of the tendons. The cord, j-J however, fhould not be continued lo long as to in- duce much pain or inflammation ; for in the neigh- bourhood of large joints this might prove alarm- ing : and we know from experience, that even a flight degree of inflammation anfwers the purpofe fufficiently well. A confiderable degree of ftiffnefs is very apt to re- main upon that part of the joint where the tumor was feated. The moft effectual remedy for this, is frequent fridions with emollients, and a proper application of warm fleams to the part affeded. § 5. Of Colledions within the Capfular Ligaments of Joints. Collections of various kinds are met with in the capfular ligaments of joints. Blood may be effufed within them. Inflammation is here, as in other parts, frequently fucceeded by the formation of matter ; and they are liable to ferous effufions, forming what are commonly termed dropncal .fwellings of the joints. Sed. III. Indolent Tumors. Ul Thefe fwellings fhould be diftinguifhed with pre- cision from others which they refemble. They are moft apt to be confounded with colledions in the burfas mucofae, or with matter effufed in the cellu- lar fubftance covering the joints. From the firft of thefe they may be diftinguifhed, by the contained fluid paffing with freedom from one fide of the joint to the other ; and from its being diffufed over the whole of it: whereas, when a fluid is con- tained in any of the burfas, the tumor is more cir- cumfcribed ; being for the moft part fixed above or upon one fide of the joint. Colledions of mat- ter in the burfas mucofae are feldom painful, while every tumor feated within the capfular ligaments' of joints is apt to excite violent degrees of pain. Tumors of this kind are more eafily diftinguifh- ed from matter colleded in the cellular fubftance covering the joints. In the laft, the colledion is evidently superficial; and it is not fo much con^ fined to the joint itfelf, being in general found to extend in every diredion further than the boun- daries of the capfular ligaments. We judge of the nature of the fluid colleded in thefe fwellings, by the circumftances with which they have been preceded as well as by the fymp- toms with which they are accompanied. When a violent bruife of a joint is immediately fucceeded by a large effufion within the capfular ligament, it will commonly be found to confift of blood. This is not a frequent occurrence; but as I have now met with it in feveral inftances, I conclude that it may happen in others. When inflammation of a joint terminates in ef- fufion within the capfular ligament, there is reafon to fufped that the matter forming the tumor is of a thin ferous kind, with fome tendency to purulen- cy; for well conditioned pus is feldom met with in ligamentous or membranous parts. And, laftly, when colledions within the capfular ligaments fue- 112 Of Chronic or Chap, ft. ceed to rheumatic affedions, there is much reafon to fuppofe that they are entirely ferous ; for we know from obfervatian, that effufions which take place in rheumatifm are very commonly of this kind. The importance of our being able to afcertain the kind of matter contained in thefe fwellings, becomes obvious from the difference of pradice which they require : as the making an opening in- to a large joint is always hazardous, from the pain and inflammation being confiderable which it is apt to excite, it fhould never be advifed but from real neceffity. One of the caufes that has in gen- eral been fuppofed to require it, is matter collected within the capfular ligaments: but when by expe- rience we difcover that a particular kind of mat- ter may be allowed to colled in this situation, with- out doing harm, we rather allow it to remain, than incur the rifk which might enfue from letting it out. Now this is uniformly the cafe, as I have al- ready obferved, with thofe effufions which fucceed to rheumatifm. Whether colleded in the burfas mucofae, as mentioned in the preceding article, or within the capfular ligament of a joint, they fhould never be laid open. Of whatever fize they may be, they will very commonly be difcuffed by the remedies I have mentioned, namely, by fridions; pouring warm water upon the parts affeded ; pro- per covering with flannel; and the ufe of blifters; or, when thefe fail, fupporting the tumefied parts with a laced flocking, or a roller, will commonly prove fuccefsful. But whether this fhall diffipate the fwelling or not, when we are convinced that it is of the rheumatic kind, it ought not to be open- ed. The patient may continue to complain of fome uneafinefs and ftiffnefs in the joint, but this will be trifling when compared with the pain and inflammation which may occur from laying it open. But when matter is colleded in the cavi- Sed. III. Indolent Tumors. 113 ties of joints, which may do harm if allowed to re- main, an opening fhould be made for difcharging it. The matter which forms in confequence of high degrees of inflammation, and effufed blood, are of this kind. Blood is frequently extravafated among foft parts without much detriment; but when in contad with cartilage or bone, it foon hurts them materially; and the fame effed is fure to enfue from the lodgement of matter produced by inflammation. The danger that accrues from this operation feems to depend in a great meafure upon air find- ing admiflion to the cavity of the joint, which ought therefore to be as much as poffible guarded againft. For this purpofe the opening fhould be made with a trocar ; and if the fkin is previously drawn tight to the upper part of the tumor, by pulling it down immediately on withdrawing the canula after all the fluid is difcharged, the rifk of air being admit- ted is in this manner greatly leffened. A piece of adhesive plafter fhould be diredly laid over the opening in the fkin; and the whole joint fhould be firmly fupported, either with a laced flocking, or a flannel roller properly applied round it. As a further preventative of bad confequences from this operation, if the patient is plethoric, he fhould lofe blood to fuch an extent as his ftrength will bear : he fhould be put upon a ftrid antiphlo- gistic regimen ; and in every refped fhould be man- aged wiih much caution: for inflammation being very apt to enfue from it, we cannot be too much on our guard againft it. § 6. Of Concretions and preternatural Excrefcences within the Capfular Ligaments of Joints. Joints fometimes become painful, and their mo- tion impeded, by the preternatural formation of Vol. I. I rr4 Of Chronic or Chap. II. fubftances within their capfular ligaments. In fome inftances thefe bodies are fmall and loofe, and of a firmnefs equal to that of cartilage ; while in others they are of a foft membranous nature, fprouting from an eroded furface of one of the bones form- ing the joint, or from the inner furface of the cap- fular ligament. In fome cafes, they remain fixed, or nearly fo, without being much affeded either by preffure or the motion of the joint. This is particularly the cafe in thofe that are foft and membranous, which are in fome degree fixed by their attachments. But the others, which have nearly the firmnefs of cartilage, are commonly fo moveable, that their fituation is altered by every motion of the limb; and they flip fo eafily on being touched, that it is difficult to fix them even with the fingers. In the former, which remain fixed nearly to the fame fituation, the pain is conftant, but feldom fe- vere ; whereas, in the latter, it is only felt in par- ticular situations, chiefly, I fuppofe, when the con- neding membrane paffes between the ends of the bones: but in thefe cafes it proves often fo fevere, as to be altogether infupportable. I have known different inftances of thisj where in certain poftures of the leg, for it is in the knee in which thefe con- cretions feem chiefly to occur, the pain became fud- denly fo exquifite as to induce fainting. And where this returns frequently, the patient is fo much afraid of it, that he inclines rather to avoid walk- ing almoft entirely than incur the rifk of inducing it. Nay, in fome cafes, I have known the patient roufed from the moft profound fleep, by the limb being merely moved when in bed. As thefe fubftances are of a nature that will pro- bably for ever refill the power of medicine, and as they can only be removed by the joint being laid open, the queftion to be determined is, whether this ought to be attempted or not ? Many have Sed. III. Indolent Tumors. 115 fpoken of this as an operation of fo little hazard, that praditioners are apt to advife it in all cafes where the pain induced by the difeafe is fevere. In two cafes, indeed, which fell under my own man- agement, the joints of the knee were laid open ; the foreign bodies were removed ; and the wounds healed almoft with the fame eafe, as probably would have happened with injuries of the fame extent in any other part; but other inftances, I muft own, have occurred, in which the moft alarming fymp- toms fucceeded to this operation, and ultimately even required the amputation of the limb. I nev- er obferved, indeed, fuch high degrees of inflam- mation from any other caufe; neither is the in- flammation confined to the joint itfelf. The whole limb, both above and below the wound, becomes fliff and fwelled in a remarkable degree, with pain- ful inflammatory tenfion, extending from one end of it to the other. The uncertain fuccefs of this operation renders it doubtful, how far, in any inftance, it ought to be advifed. The following is the opinion I have form- ed of it, drawn from a good deal of experience in cafes of this kind. Where concretions formed within the capfular ligaments of joints, appear, up- on examination with the fingers, to be loofe and detached, if the pain which they excite is fevere, rather than fubmit to this, we fliould venture, in a cautious manner, to take them out, by making an incifion into the joint: but wherever there is reafon to fufped that the concretions are conneded with any part of the joint, the patient fhould rath- er be advifed to fubmit to the pain which they in- duce, and which in general will be rendered mod- erate by avoiding exercife, than to run the rifk that attends this operation. The pain, indeed, even in a retired life, may be- come infupportable. In this cafe, I would advife 1 2 ti6 Of Chronic or Chap. II. the amputation of the limb. The remedy is, ntf doubt fevere; but it is lefs painful, as well as lefs hazardous, than the excifion of any of thofe con-» cretions when attached to the capfular ligaments. The opening into the capfular ligament for the removal of thefe loofe bodies, fhould be made in the following manner ; if in the joint of the knee or ankle, the patient fliould be laid upon a table or on a bed; but if any of the joints of the arm are to be opened, he may be allowed to fit ; only, in whatever pofture he may be, the limb fhould be fecured in the firmeft manner by afiiftants, in that pofture which admits of the body to be taken out, being felt in the moft diftind manner. On this being done, the furgeon fhould endeavour to fix it with one hand towards the upper part of the joint, after an afliftant has been defired to draw the fkin as much as poffible upwards from the part where the incifion is intended to be made; when, with a fcalpel in the other, he is now to make an incifion through the teguments and capfular ligament, di- redly upon the fubftance itfelf, of fuch a fize as, will admit of its being eafily taken out; which will; be moft eafily done by the end of a blunt probe be- ing paffed beneath it. If it is found to be conned- ed by fmall filaments, either to the capfular liga- ment or cartilages of the joint, they fhould be cau- tiously divided, either with a probe pointed biftou- ry or fciffars, after drawing the fubftance itfelf as far out as can be done, with fmall forceps, or with a fharp hook when of a texture that admits of a hook being pufhed into it. When more concre- tions than one are difcovered, they fhould all be taken out at the fame opening, when this can be done: but when they lie on oppofite fides of the joint, two openings are required; only in this cafe it is better to allow the firft incifion to heal before attempting the fecond, fo as to avoid as much a& poffible the rifk of exciting inflammation. Sed. III. Indolent Tumors. 117 After the concretions are removed, the fkin fliould be immediately drawn over the wound in the capfular ligament; and the lips of the opening in the fkin being laid together, they fhould be fe- cured in this fituation with pieces of adhefive plaf- ter, fo as to prevent the air from finding accefs to the cavity of the joint, Till the wound is com- pletely healed, the patient fhould not pnly be con- fined to bed, but the limb fhould be kept as much as poffible in one pofture ; and a ftrid antiphlogif- tic regimen fhould be obferved. But for the fur- ther management of fuch cafes, and of the fymp- toms with which they are apt to be attended, we muft refer to Chap. III. Sed. VIII. when treating of wounds in the ligaments. I have mentioned, that the incifion into the cap- fular ligament, fhould be made at the upper part of the joint. The intention of this is to prevent the fynovia, after the fkin is drawn over the opening in the ligament, from finding fuch ready accefs as it otherwife would do to lodge in the cellular mem- brane immediately beneath the fkin ; a precaution that is eafily obferved, and from which fome ad- vantage may be derived. § 7. Of Anafarca or Oedema. The terms Anafarca and CEdema are appiied to that variety of dropfical fwelling where the water is colleded, not in any diftind cavity, but in the cellular fubftance. The part is generally cold, and of a pale colour ; and being poffeffed of little or no 'elasticity, it retains the mark of the finger when compreffecL Anafarcous fwellings are for the moft part con- nected with fome difeafe of the fyftem ; but in fome cafes they occur in particular parts, from caufes which affed thefe parts only. Thus, legs or .arms which have been much weakened by contu- n8 Of Chronic or Chap. II. fions or fprains, are apt to become cedcmatous. Tumors preffmg upon any of the larger lymphatics are apt to induce them; and they fometimes occur from the lymphatics of a limb being cut, either by accident or in chirurgical operations. In the treatment of thefe fwellings, the circum- ftance of their being general or local requires par- ticular attention. When induced by tumors prefix- ing upon the lymphatics, the removal of thefe tu- mors alone will accomplish a cure : and when they occur as the effed of weaknefs from fprains or con- tufions, the beft method of cure is to fupport the weakened parts either with a laced flocking or a flannel roller, to prevent their yielding to diften- fion, till in courfe of time, and by the effeds of cold bathing and moderate fridions, they recover their natural tone. But in thofe anafarcous fwellings of the feet and legs which take place as a fymptom of general dropfy, we muft not venture upon removing or preventing them by comprefiion ; for if the ferum is prevented from falling down to the legs, it will be apt to remove to parts of more importance. In thefe cafes, we truft to the difeafe in the fyftem be- ing removed by medicines, for a complete cure: but when the fwelling is confiderable, we have it in our power to procure temporary relief by mak- ing fmall pundures through the fkin into the cel- lular membrane, in the moft prominent part of it. The relief which this procures is often very con- fiderable, and it ought to be advifed more early in the difeafe than is commonly done; for befides the prefent eafe which it affords, it prevents that lofs of tone which the cellular fubftance fuffers when anafarcous fwellings are permitted to go to fuch a height as they often do. Inftead of pundures, incifions are ufually em- ployed ; but fmall punctures made with the point of a lancet anfwer better: they give a fufficient Sed. HI. Indolent Tumors. 119 vent to the water, at the fame time that they are not fo apt to inflame and mortify. But as we fhall have occafion to fpeak of this when treating of the Anafarcous Hydrocele in Chap. X. Sed. II. I fhall now refer to that part of our fubjed. Where the fwelling is induced by any of the lymphatic veffels of a limb being cut, as fometimes happens in extirpating indurated glands from the armpit, fmall pundures made in the under part of the limb afford immediate relief; while little ad- vantage is derived from blisters or any other re- medy. § 8. Of the Spina Bifida. The term Spina Bifida is applied to thofe foft fwellings which fometimes appear in the courfe of the fpine in new born children, moft frequently at the inferior part of it, between the two laft verte- bras of the loins. A fluduation is diftindly per- ceived in them ; and the fluid which they contain can in fome meafure be preffed in at an opening which takes place between the fpinous proceffes of the two vertebrae on which they are feated. In fome cafes this opening is found on diffedion to proceed from a natural deficiency of bone ; in others it is the effed of the fpinous proceffes of the vertebrae being merely feparated from each other: in all of them, the tumor is produced by ferum colleded within the natural coverings of the fpinal marrow. In a few cafes this difeafe is conneded with hydro- cephalus ; but this is not common. For the molt part it is entirely a local affedion. This is perhaps one of the moft fatal difeafes to which infancy is liable ; for as yet no remedy has been difcovered for it. In fome cafes, however, children labouring under it have lived for two or three years ; but in general they linger and die in the fpace of a few months. All the affiftance that 120 Of Chronic or Chap. II, art has hitherto been able to afford, is to fupport the tumor by gentle preffure with a proper band-. age. In this manner it has for fome time been prevented from increafing, by which life has been protraded; but this is all that we have yet been able to do. It has fometimes happened, where the nature of thefe tumors has not been underftood, that they have been laid open with a view to difcharge the fluid which they contained. Experience, however, fhows, that no attempt of this kind fhould be made; for hitherto it has in every inftance proved unfuccefsful. The patient has either died fudden* ly, or in the courfe of a few hours after the ope- ration. If conjedure may at any time be indulged, and propofals for innovation mentioned, it muft be allowable in cafes hopelefs as the one we are now considering. If the fwelling in the fpina bifida is produced by real difeafe fubfifting in the veffels of the fpinal marrow, or in thofe of its membranes, it is not probable that any remedy will remove it: but if the opening between the fpinous proceffes of the vertebras with which it is always accompanied, be not the effed of the difeafe, as is commonly im- agined, and if the want of fupport, which this de- ficiency of bone muft create to the membranes of the fpinal marrow, be the caufe of ferous effufions within thefe membranes, might not fome advan- tage be derived from applying a ligature round the bafe of the tumor, not merely with a view to re- move it, but alfo to draw the bottom of the cyft fo clofely together, that it may ad as a proper fup- port to the parts beneath ? Whether any benefit may be derived from it or not, is no doubt very uncertain : but in a difeafe which we know will otherwife terminate fatally, we are warranted in propofing whatever can afford even the fmalleft chance of fafety; fo that I mean to attempt it in Sed. III. Indolent Tumors. 121 the firft cafe of this kind that falls under my care. After applying a ligature as clofely as poffible to the bafe of the tumor, and as foon as the tumor itfelf has fallen off, I would propofe to apply a firm fluffed pad, fimilar to that of a rupture trufs, to the opening between the vertebrae ; and by means of a proper bandage, to fecure it with fuch a degree of tightnefs as may ferve to fupport the parts on which it is placed. Whether or not this method may in any in- ftance accomplish a cure, is very uncertain ; but it appears to be the moft probable way of prolonging life : for wherever the tumor has been opened, death feems to have enfued more from the removal of fupport from the contained parts than from any other caufe. Now, no method of treatment we could advife would fo readily comprefs the parts within, and at the fame time remove the tumor. The tumor termed fpina bifida occurs, as I have already obferved, in different parts of the fpine, al- though moft frequently at the under extremity of that bone ; but a fwelling of perhaps the fame na- ture is fometimes met with on different parts of the head. A tumor is obferved at birth ; and on examination it is found to be formed by a fluid lodged beneath the membranes of the brain, which have been forced out at fome unoffified part of the fkull. In fome cafes the fwelling remains station- ary for a great length of time ; but for the moft part it becomes quickly larger, and at laft termi- nates in death. Hitherto the fame effed has re- fulted from laying this kind of tumor open, as I have mentioned in fpina bifida: the patient has commonly died in a few hours after the operation. § 9. Of Scrofulous Tumors, The firft and moft important point to be deter- mined in the chirurgical treatment of fcrofulous 122 Of Chronic or Chap. II. tumors, is, whether or not we fhould endeavour to forward their maturation, by means of poultices and other external applications ? For a confiderable time, I adopted this pradice in the freeft manner, and applied warm poultices and fomentations to every tumor of this kind, till at laft I was convinc- ed by experience of its inefficacy. Nay, I now think, that it does harm : for fcrofulous tumors being formed of matter not convertible into pus, poultices and other warm applications have little effed in bringing them forward; and when long ufed, they weaken and relax the parts fo much, that the fores which enfue are more difficult of cure than when poultices are not employed. In all fcrofulous fores, the parts are apt to remain long foft and fpongy, by which they are prevented from healing. The effed of thefe emollient applications, is to in-, creafe this tendency to foftnefs in a degree which often proves hurtful. As I know of no application which in the real fcrofulous tumor ever proves ufeful, either in re- tarding its progrefs or in bringing it forward, I now advife even every covering to be laid afide, unlefs the patient wifhes to prevent the fwelling from being feen ; in which cafe he is defired to cov- er it in the manner that is moft agreeable to him- felf. But as I do not obferve that expofure to the air does harm, and as in fome cafes I have thought that this expofure of the tumor renders the fubfe- quent fores more eafily cured,! would prefer this mode of treatment, whenever it can be adopted. Even the external application of hemlock, which in the form of poultices is often advifed in fcrofu- lous tumors as a difcutient, fhould be laid afide. In fcrofulous fores, I have obferved fome advantage derived both from the internal exhibition and out- ward application of hemlock: but although I have often known it ufed in tumors of this kind, I can- not fay that any advantage ever accrued from it, Sed. III. Indolent Tumors. 123 The only remedy I have ever known to ad with any apparent efficacy in the difcuffion of fcrofulous tumors, is a long continued ufe of the cold bath, and mineral waters, efpecially thofe of Moffat: but in order to produce any effed, they fhould be en- tered upon early in the difeafe, while the tumors are fmall, and in every inftance they ought to be long continued. As foon indeed as a patient is at- tacked with fcrofula, I would advife him to enter on the ufe of thefe remedies, and to perfevere for feveral years in applying them. In what manner the drinking of mineral waters, and of fea water, operates in preventing the formation of tumors in fcrofulous patients, will be difficult to determine : but it feems to be probable, that cold bathing, par- ticularly in fait water, proves chiefly ufeful by in- • vigorating the fyftem at large, and particularly the lymphatic fyftem, which in fcrofula appears to be remarkably weak and relaxed. Of late, a new tonic remedy has come into no- tice, muriated barytes, and it feems to ad with ad- vantage in the difcuffion of fcrofulous tumors. I have now made ufe of it in a great number of cafes, and in many of thefe with obvious advan- tage. It excites appetite ; strengthens the constitu- tion ; and in fome inftances both fcrofulous tu- mors and fores, which previously refilled all other remedies, have difappeared while patients were ufing it. The medicine is prepared by diffolving aerated barytes in the muriatic acid ; evaporating the folution, and diffolving the cryftals in water. Of the faturated folution fix or seven drops are given at firft to an adult, repeated three times a day, and the dofe gradually increafed to thirty or forty drops, till it excites ficknefs or naufea, by adding two drops or fo every fecond or third day to each. The next point of importance in the treatment pf fcrofulous tumors, is, whether they fhould be 124 Of Chronic or Chap. II. opened, or allowed to burft of themfelves ? This in a great meafure fhould be made to depend on their fituation. When feated upon any of the large joints, or on the cavities of the thorax or abdo- men, the matter fhould be difcharged as foon as it is difcovered, by a free opening with a lancet or fcalpel ; or in large collections, where it would prove hurtful to expofe the cavity of an extenfive j abfcefs to the air, it may be done with more fafety with a trocar or with a feton. But where fcrofu- lous tumors are fo fituated that no harm can arife from the matter being allowed to remain, it is bet- ter that thqy fhould break of themfelves : for even when managed in the moft judicious manner, the fores which enfue prove often tedious and difficult of cure, while an unfeemly fear takes place, whe. I ther the tumor has been opened or not; and the, patient and his friends, from ignorance of the na- ture of the difeafe, as- well as from other motives, are apt to blame any opening that is made, as the caufe either of a tedious cure, or of difagreeabU marks. As an additional reafon for this pradice, I 1 believe it will be found, that fores enfuing from I fcrofulous tumors will for the moft part heal more kindly when allowed to burft than when opened 1) I in any way whatever. <■< 1 I have only to obferve further, that tumors of a fcrofulous nature are occafionally met with, which i from inadvertency are fometimes miftaken for thofe of the fchirrous kind. I alfo believe that miftakes of this kind have tended to raife the reputation of ' medicines, particularly of cicuta, and that they have been the caufe of tumors being extirpated, which ought not to have been touched. When fcrofu- lous tumors are deeply feated, they have common- ly a degree of firmnefs which they do not poffefs in the more external parts; and when in a fufpi- cious fituation, as in the glandular part of a wo* man's breaft, they are very apt to be miftaken on Sed. III. Indolent Tumors. 125 a flight examination for fwellings of a fchirrous na- ture. Thefe mistakes, however, may always with due attention be avoided. Even the firmeft kind of fcrofulous tumors are foft and compreffible when compared with fchirrus. They are of an equal fmooth furface ; they are feldom, in their early ftages, attended with pain ; and for the moft part fimilar affedions appear in other parts of the body: whereas the real fchirrous tumor is always unequal or knotty on its furface ; and although it does not for a confiderable time become uniformly painful, a flinging difagreeable pain is commonly felt in it from time to time, even from its firft ap- pearance ; and it is not neceffarily conneded with fymptoms of fcrofula. ft § 10. On White Swellings of the Joints. Few difeafes prove either more hazardous to patients, or are lefs understood by praditioners, than white fwellings of the joints : infomuch, that when completely formed, the difeafe may in almoft every inftance be confidered as incurable. White fwelling may be defined, a painful en- largement of a joint, not attended with external inflammation ; but there are evidently two varie- ties of the difeafe, which it is of much importance to diftinguifh: the one arifing from rheumatifm, the other from fcrofula. 1 fhall firft defcribe the fymptoms and appearances of each, and afterwards the method of cure, which in the courfe of my experience has hitherto proved moft fuccefsful. The rheumatic white fwelling begins with acute pain over the whole difeafed joint and contiguous parts ; and the pain is always increafed by motion. As a relaxed pofture gives relief, the limb is kept conftantly bent, by which the flexor tendons be- tome fo fliff and immoveable, that from this caufe 126 Of Chronic or Chap; IL alone the motion of the limb is often irretrievably loft. If the difeafe is not foon carried off, the fwelling, which at firft is inconfiderable, begins to augment, and goes on till in fome cafes it arrives at twice the natural fize of the part. The cuticular veins become turgid and varicofe; the limb below the fwelling decays confiderably in its mufcular fubftance, while it frequently acquires an equal or greater bulk by becoming cedematous: the pain turns more intolerable, efpecially when the patient is warm in bed, or is otherwife heated; and abfceffes form in different parts of the fwell- ing, and run in various diredions and at different depths. In all thefe abfceffes, the fluduation of matter is always obvious; but befides this they are fpringy or elaflic; yielding to preffure, at the fame time that they do not, like cedematous fwellings, retain the mark, but inftantly rife again as foon as the preflure is removed. Thefe different colledions, either upon breaking of themfelves, or on being laid open, difcharge large quantities of purulent like matter. This, however, foon degenerates into a thin, ill digefted fanies; and has never, at leaft in proportion to the quantity difcharged, any effed in reducing the fize -of the fwelling, which ftill remains nearly as large as before. j If the openings from whence this matter flows are not artificially kept open, they foon heal up; and new colledions forming in different parts, again break out and heal as before: fo that, in courfe of time, the whole furrounding teguments are marked with cicatrices of old fores. Long before the difeafe has arrived at this ftate, the health of the patient begins to fuffer; firft, from the violence of the pain, and then, from the abforption of matter which takes place in fome de^ Sed. Ilh Indolent Tumors. 127 gree from the time of its firft formation; but which does not indeed appear fo evidently, till the abfceffes in which it is contained are either laid open by incifion, or burft of themfelves. When this takes place, the pulfe becomes quick, accompa- nied with nodurnal fweats and a colliquative di- arrhoea, by which the patient is at laft carried off if the member is not foon amputated. When the limb is taken off early, the only pre- ternatural appearance with which we meet on lay- ing the parts open, is a morbid thicknefs of the fur- rounding ligaments, accompanied with a contrad- ed ftate of the flexor mufcles of the limb, but with- out any difeafe of the joint itfelf. The bones and cartilages remain found, and the fynovia in a nat- ural condition, both in quantity and confiftence. . This thickening of the ligaments is in general in proportion to the duration of the difeafe. This, however, is not always the cafe; for I have met with fome recent inftances, in which the ligaments were more thickened, than in others where the difeafe had continued longer. In this cafe indeed the previous fymptoms had been always violent. In the more advanced flages of white fwelling, when abfceffes have formed in different parts of the joint; when the pain has been long violent, and the tumor large, on laying the parts open, an effu- fion into the furrounding cellular fubftance is dif- covered of a thick glairy matter, which appears to be the caufe of that elasticity peculiar to thefe . fwellings, of which particular notice was taken in the defcription that I have given of the fymptoms. The different abfceffes which take place here are found to run in various diredions through this glairy albuminous congeftion, without, however, teeming to mix with it. In fome few inftances, again, together with collections of pus, we meet with a number of fmall hydatides ; and in the fur- ther progrefs of the difeafe, all thefe together form ta8 Of Chronic or Chap. tf. fuch a confufed mafs that its^lmoft impoffible, by diffedion, to procure a diftimd view of them. Even all thefe appearances are fometimes found to take place without any of the bones that form the joint, or the cartilages by which tbey are cov- ered, being in any degree difeafed. When, however, the ligaments are eroded by the matter, both the cartilages and bones'are foon brought to fuffer ; the bones becoming carious, as foon "as the cartilages, by the acrimony of the mat- ter, have been deftroyed. The tendons of the flexor mufcles do not, upon diffedion, exhibit any morbid appearances, either with refped to hardnefs or enlargement, but the mufcles from whence they proceed are always hard and contraded. In white fwelling arifing from fcrofula, the pajp is generally very acute, and, inftead of being dif- fufed, it is more confined to a particular fpot, moft frequently to the middle of the joint. In fome in- ftances I have known the patients fay, even in ad- vanced flages of the difeafe, that they could cover the whole pained part with a crown piece, or lefs. The fwelling is never at firft large; infomuch that it requires attention to difcover the difference between the difeafed joint and the oppofite found one : the leaft degree of motion excites pain ; the joint is therefore always kept in a bent pofition, by which the flexor mufcles and tendons become stiff and contraded. On the fwelling continuing to advance, the pain becomes more violent, and the fwelling more con- fiderable, accompanied with an evident enlarge- ment of the ends of the bones that form the joint. In courfe of time, tfie^whole circumference of the tumor becomes xlaftic; varicofe veins appear over its furface ; and colledions of matter occur in different parts of it: thefe, upon burfting, or on being laid open, difcharge large quantities of thin Sed. HI. Indolent Tumors, 129 ill digefted matter; and if a probe is introduced, and paffed to the bottom of the fores, the bones are found carious, and pieces of them are afterwards difcharged at the openings. - - *.. ■■ On the farther continuance of the difeafe, the con- stitution becomes injured; and the patient is at laft carried off by diarrhoea and profufe night fweats, fymptoms which commonly indicate extreme degrees of weaknefs. ^ When joints affeded in this manner are diffeded, either after death, or after amputation of the member in the firft ftages of the difeafe, the foft parts feem not to be much injured, but in all, even the flighteft that I have feen, the whole ends of the bones, or their epi- phyfes, are enlarged. In fome this enlargement of the bones is confined to one fide of the joint, but in others it appears equally in both: in fome, this occurs without any other mark of difeafe, but in general the foft fpongy parts of thefe bones are diffolved into a thin fetid matter, in fome cafes even without the car- tilages which furround them being affeded: this I have in different inftances feen, although the cartila- ges for the moft part are alfo found diffolved at laft. The fame thickening of the ligaments, and effufion of vifcid glairy matter, is met with here that occurs in the other variety of white fwelling. ^ The moft frequent caufe of white fwelling is a pre- vious difpofition to rheumatifm or fcrofula; for al- though it is often induced by external violence, par- ticularly by fprains and bruifes, the difeafe feldom proves obftinate or fevere where the rheumatic or fcrofulous diathefis does not evidently prevail. Hence white fwellings of the rheumatic kind are moft frequent at that period of life, and in thofe con- ftitutions, in which rheumatifm occurs in the moft obvious form of the difeafe : we daily meet with it in the young and plethoric, and not often in patients of oppofite temperaments, or in people advanced in Vol. I. K 130 Of Chronic or Chap. IL years : we alfo find, that it is frequently induced by cold, which may be confidered as the moft common caufe of rheumatifm, and it attacks chiefly thofe parts on which rheumatifm is particularly apt to fix. Rheu- matifm for the moft part attacks the large joints on- ly, and chiefly the ligamentous parts of them: now we meet with ten inftances of this variety of white fwelling in the knee for one in any other joint, and we find on diffedion, that in the firft ftages of the difeafe, the ligaments only are affeded, as in moft in- ftances is alfo the cafe in rheumatifm. The effufion into the cellular fubftance of that glairy matter that I mentioned in the defcription is probably occafioned by an exfudation from the veffels of thofe ligaments that have been at firft inflamed ; for we know that ligamentous parts never furnifh a fluid proper for the formation of pus. In the courfe of the difeafe, in- deed, abfceffes containing purulent matter frequently form, but never till the inflammation has fpread to the furrounding parts, which more readily afford a fluid fit for this purpofe. In like manner, although the other variety of white fwelling commonly begins in the bones, fcarcely a doubt can arife of its being fcrofulous : it appears, in- deed, to be the real fpina ventofa of authors,* which there is much reafon to think is a difeafe of the fame nature an the bones, that fcrofula, in its ufual form, is in the foft parts. The appearances of the two dif- eafes are exceedingly fimilar: they both begin with confiderable enlargement or fwelling of the parts which they attack, and this in both generally ends in ulceration, and they both often occur in the fame per- fon at the fame time : this variety of white fwelling is moft frequent in early life, a period in which other fymptoms of fcrofula are alfo mofl frequent; and if other fymptoms of fcrofula do not fubfift at the time, we commonly find that they have prevailed at fome * Vide § 16, of this Seclioa Sed. III. Indolent Tumors, 13I former period, or that the patient is defcended from 1 fcrofulous parents, and therefore that the feeds of the difeafe are probably lurking in his constitution. In the management of white fwelling, it is a point of importance, as I have already obferved, to diftiii- guiih with accuracy between the two varieties of the difeafe ; for in the one, namely, the rheumatic, we may frequently accomplish a cure; while, in the oth- er, no material advantage is to be looked for from any remedy with which we are acquainted. By not difcriminating between the two varieties of white fwelling, remedies are often employed, which, how- ever beneficial they might prove in the one difeafe, in the other can be of no avail, and may even do harm ; and the fame want of difcrimination is apt to make us defpair in every inftance, from finding that, in a great proportion of cafes, no advantage is obtained from any meafures that we employ. In the rheumatic white fwelling, we derive confid- erable advantage from due attention to an antiphlo- gistic courfe. The firft remedy which, with this view, fhould be employed, is bloodletting ; but inftead of taking blood with the lancet, it anfwers better to take it from the {>art affected. Cupping and fcarifying proves particu- arly ufeful. The instrument fhould be applied to each fide of the difeafed joint; on each fide of the rotula, for inftance, when the knee is the part affeded: eight or ten ounces of blood fhould be difcharged, and this fhould be repeated at proper intervals, once, twice, or oftener, according to the violence of the fymptoms, and ftrength of the patient at the time. In the ordinary way of difcharging only an ounce or two of blood by this operation, it has, in general, little or no influence ; but in the quantities which I have mentioned, and which, by thofe accuftomed to the pradice, are commonly eafily obtained, it feldom fails of giving relief. K 2 ?3* Of Chronic or Chap. ft. It muft be obferved, that cupping proves here more beneficial than the application of leeches; which & not only a more tedious method of procuring the fame quantity of blood, but the fwelling which leeches occafion, proves often troublefome ; and, what is of ftill more importance, it gives an interruption, for a time, to the ufe of other remedies. In fome inftan- ces, however, when the fwelling of the joint is confid- erable, it proves difficult, or even impradicable, to procure a fufficient quantity of blood by cupping : in fuch cafes, we are under the neceffity of having re- courfe to feeches. Upon the-anterior part of the joint, where the cup- ping glaffes or leeches have not been placed, a fmall blifter fhould be applied ; and the part fhould be kept open with iffue ointment, till the wounds from whence the blood was difcharged are fo far healed, that a blifter may likewife be applied on one fide of the joint; and on this being nearly healed, the other fide fhould be alfo bliftered. By thus applying blifters alternately, firft to one fide, and then to the other, almoft a conftant stimu- lus is excited on the furface ; which, in deep feated inflammation, feems in many inftances to have even a more powerful effed than all the difcharge which blifters produce. Gentle laxatives, given at proper intervals, prove alfo ferviceable ; and the patient fhould, in every re- fped, be kept upon a ftrid antiphlogistic regimen: no animal food fhould be allowed, nor fhould he be permitted to take drink ftronger than gruel or whey. In the firft flages of the difeafe, this mode of treat- ment feldom fails to prove ufeful: local bloodlet- ting, when carried to a fufficient length, very com- monly relieves the fymptoms induced by inflamma- tion, and the blifters often remove them entirely: thefe remedies, however, are not to be trufted in the more advanced flages of white fwelling, nor ought they ever to be long perfifteo>in, when they do not > Sect. m. Indolent Tumors. J33 foon procure relief. In this -flate of the difeafe, we depend upon other remedies. Mercury proves here particularly ufeful, not given fo as to falivate, but merely to affed the gums gently, and to keep them in that ftate for a few weeks. In fuch circumftances, the beft method of ufing mercury is by external fridion; and the undion fhould be of fuch a ftrength, as to admit of being ufed in the quantity of two drams three times a day ; for fridion, in order to prove ufeful, fhould be frequently repeated and continued for the fpace of an hour at each application. Gentle mercurials may alfo be given internally, but, as all the advantages to be derived from them, are obtained from undion, together with any benefit that may enfue from the fridion ufed in applying it, the latter fhould in general be preferred. By Le Dran, and other French writers, the pour- ing of warm water on fwellings in this fituation is much recommended; and I have found in the courfe of much experience in this branch of bufinefs, that more advantage is derived from it than from any other remedy; particularly from the application of warm fleam : this remedy, however, in order to prove ufeful, requires to be applied to the parts particularly affeded, and to be frequently renewed. When warm water proves ufeful here, it may not only act from the degree of heat which it contains, but in proportion to the height from which it falls: hence, in fome cafes, I have defired it to be poured from the height of fifteen or fixteen feet, and in dif- ferent inftances with advantage. It is eafily done by pouring the water through a leather or tin tube. The application of fleam, and the fall of warm wa- ter, proves particularly ufeful in the removal of that contraded .ftate of the flexor mufcles, which very uni- verfally takes place in white fwellings of the joints. The ftiffnefs of joints affeded in this manner, is often in fuch a degree as to give caufe to think that it can 134 Of Chronic or Chap. II. only be produced by the ends of the bones forming the joint having run into one another, or by the fyn- ovial fluid of the joint becoming thick, and totally un- fit for lubricating the parts to which it is applied: I believe, however, that thefe occurrences are both ex- ceedingly rare: of all the difeafed joints I have diffed- ed, and the number has been considerable,! have on- ly met with two inftances of the different bones of a joint adhering to each other, and not one inftance of the fynovia being infpiffated : neither have I met with any anatomift who ever obferved it: I therefore con- clude, that the ftiffnefs of joints which fucceeds to white fwelling, proceeds in almoft every inftance from the caufe I have mentioned, a morbid contradion of the flexor mufcles of the difeafed limb. I have already obferved, that in the removal of this contraded ftate of the mufcles, the application of warm fleam, and the fall of warm water from a height, prove particularly ufeful: we alfo derive much advan- tage from the ufe of emollients : by long perfeverance in rubbing contractions of this kind with greafy emol- lients, I have in many inftances fucceeded, where the patient, after being lame for years, had defpaired of ever getting better. Emollients, however, in order to prove ufeful, muft be applied for a great length of time. They muft be rubbed for the fpace of an hour three times a day, over all the difeafed parts. The fridion fhould not be confined, as is commonly done, to the rigid tendons, but fhould be extended over the whole correfponding mufcles, from one extremity to the other, and more efpecially over the flefhy parts of the mufcles, where the principal caufe of fuch com- plaints is probably feated; thefe parts being chiefly, if not altogether, poffeffed of the contractile, and con- fequently of the refifting powers. The affedion we are now considering, is fo obvi- oufly one of thofe requiring the ufe of emollients, that almoft every old woman has fome particular form or pther of recommending them; one of which I cannot Sed. HI. Indolent Tumors. *i$ avoid mentioning, as I have frequently known it ufed, and in fome inftances, with very evident advantages, namely, the web or omentum of a new killed fheep, or of any other animal, applied over all the difeafed parts diredly on being cut out of the animal. In two of the cafes to which I allude, one was in the knee, and the other in the hand; and the motion of the joints, after having been totally loft, was almoft perfedly reftored. The application fhould be fre- quently renewed, once a day at leaft, or oftner when it can be done: for on being more than four or five hours applied, it becomes difagreeable; after this in- deed it commonly turns ftiff, and cannot therefore be of much utility. The fame kind of remedy, ufed in fomewhat a different manner, I find recommended by Lieutaud, a celebrated French praditioner.* I have entered more particularly into the confipler- ation of this fubjed, from having often found, that, -with due attention, the ufe of many joints might be recovered, which, from a miftaken opinion of their caufes, have generally from the firft been confidered as incurable : and I muft here alfo refer to fome fur- ther obfervations which I fhall find neceffary to make upon the fame fubjed, in Chap. XLIII. when fpeak- ing of distorted limbs. Hitherto I have fuppofed the difeafe not to be fo far advanced as to have occafioned the formation of matter ; for, when come this length, no material ben- efit can be derived from any of the remedies I have mentioned ; but, even in this ftate of white fwelling, if the health of the patient is not greatly impaired, amputation of the limb fhould by no means be advif- ed, as is ufually done. For, by opening the different abfceffes foon after they form, no effential injury will be done to the capfular ligaments of the joints; the * M. Lieutaud fays, when fpeaking of fuch affections, " Obvolvitur etiam pars afFec^a pelle calida vervecis., yituli, alteriufve pecudis, recens maclati, vel immittitur in imum ventrem bovis, vitali calore haud defraw- data:." Synopfis Univerfx Praxcos Mediae, Vol. I. p. 400, 136 Of Chtonic or Chap. II. deftrudionfdf*which would no doubt render it necef- fary immediately to removes the limb. •■ All colledions of• this kind fhould be difcharged, by paffing a feton through them. This never proves hurtful, and by preventing the accefs of air, as I have elfewhere endeavoured to fhew, abfceffes opened in this manner heal more readily, than they ufually do when laid open with large incifions.* By opening the different abfceffes as quickly as matter is found to form in them, and fupporting the patient with light nourifhing food,- we often fucceed in faving limbs which otherwife it would be neceffary to remove. At the fame time, it muft be acknowl- edged, that inftances often occur, in which none of our remedies prove fuccefsful, and in which we have no other method of faving life. In fuch circumftan- ces, we have no room to deliberate, and amputation of the difeafed limb ought no doubt to take place. In Chap. XLV. I fhall find it neceffary to confider this fubjed more particularly, but at prefent I may obferve, with refped to the moft proper period of am- putating limbs in white fwelling, that, even in point of fuccefs from the operation, it ought never to be ad- vifed till the difeafe is far advanced. For though it might a priori, be imagined, that the more early, in the difeafe the operation is performed, the more fuc-r cefsful it fhould prove ; and although this, indeed, has been made ufe of as an argument for amputating early in every cafe of white fwelling; ye% however plaufible the observation may appear, it will not, from experience, be found to hold good. For, in this, as well as in other difeafes, I have conftantly found, that amputation has more frequently fucceeded, that is, a greater proportion of patients have recovered, who • have previously been confiderably reduced, than of fuch as have ftill remained in a full habit of body. * Vide Chap. I Sect. III. §. 5. Sed. ffl. Indolent Tumors, 137 In the former, when the constitution has not been too much broken, and we have it commonly in our power to guard againft its being fo, the feveral fymp- toms of hedic fever, which previously took place, are ufually removed in a few days after the limb is taken off: no high degree of inflammation is ever produc- ed ; the patient daily improves in health; and a com- plete cure, if he has not been too much reduced, is generally foon obtained. In the latter, again, the very reverfe of this takes place: the patient, from be- ing in high health at the time of the operation, is gen- erally thrown into a fmart inflammatory fever; which is, no doubt, often removed, but which frequently ei- ther carries him off immediately, or produces fuch ef- feds as he never recovers from. So that in no cafe whatever is it proper to advife amputation till every probable mean for faving the limb has been tried in vain. All the means that I have hitherto mentioned, re- late particularly to the rheumatic fpecies of white fwelling; and when employed in time, and duly con- tinued, they feldom fail of fuccefs: but when the dif- eafe is fo far advanced as to have destroyed the cap- fular ligaments of the joint, and perhaps even the car- tilages and bones themfelves, amputation of the limb is then our only refource. In the more fatal variety of white fwelling, namely, the fcrofulous, as I know no certain remedy for fcro- fula, even in its milder form in the foft parts of the body, I cannot here pretend to offer any thing fatif- fadory upon the fubjed. In the fmall joints, when the difeafed parts of the bone begin to caft off, a cure may be fometimes pro- moted by affifting the efforts of nature; but in all the large joints, particularly in the knee, ankle, elbow, and wrift, it is not probable that any other refource than amputation will ever afford relief. In this varie- ty of the difeafe, indeed, many are of opinion, that amputation fhould never be advifed ; for the fwelling 13* Of Chronic or Chap. II. being conneded with fcrofula in the conftitution, the difeafe they conclude will appear in fome other part: this in fome inftances will no doubt happen, but I know from experience, that in a great proportion of cafes it will not; and, were the rifk of this even much greater than it is, ftill I would advife the operation, in preference to the conftant torment with which pa- tients in this fituation are univerfally diftreffed. ^ When, however, amputation of the member is not to take place, we endeavour by other means to alle- viate as much as poffible the painful feelings of the patient: with this view, cicuta and hyofcyamus are fometimes given, both feparately and combined ; but in great degrees of pain we depend upon opiates alone. §11. (y Bronchocele. Every indolent tumor, feated on the forepart of the neck, is commonly termed a Bronchocele. In the Englifh language we have no precife denomina- tion for it. In French this difeafe is termed Goitre. Swellings in this fituation would with more propri- ety be termed Tracheacele: but with a view to pre- vent confuiion, I think it better to retain that appel- lation under which they have commonly been de- fcribed. Authors mention different difeafes under this ckr nomination : fome contend, that the term broncho- cele fhould be confined to one variety of tumor; and others, that it may be applied to fwellings of very dif- ferent kinds: difputes of this nature, however, anfwer no good purpofe: and as pradical obfervations are the chief objeds of this work, I think it better to men- tion the varieties of the difeafe, which I have either feen, or which have been accurately defcribed by au- thors, with the treatment fuited to each, than to en- ter the lifts of controverfy upon this part of the fub- jed. Sed. III. Indolent Tumors. *39 i. The forepart of the neck, like every part of the body fupplied with large arteries, is liable to fwellings of the aneurifmal kind. Aneurifms do not frequent- ly occur in this fituation, but in fome inftances they are met with. This variety of the difeafe may be diftinguifhed by all the ordinary fymptoms of aneurifm: by appearing fuddenly after fome violent exertion ; particularly in coughing or laughing; being foft and compreflible from the firft; by the tumor being at firft feated di- redly on the courfe of one of the carotid arteries; and a ftrong pulfation being difcovered through the whole extent of it. 2. Encyfted tumors, particularly thofe of the meli- cerous kind, are fometimes met with on the courfe of the trachea. They are charaderized by the fame fymptoms in this fituation by which they are marked in other parts of the body: they are foft and com- preflible ; the flu&ugtion of a fluid is perceived upon preffure; although always fmall at firft, they frequent- ly become fo extenfive, as to reach from one ear to another; and the fkin ufually retains its natural ap- pearance to the laft. The feat of this variety of the difeafe is evidently in the cellular membrane. 3. Inftances have occurred of tumors forming in this fituation, by the lining membrane of the trachea being forced out between two of the cartilages in vi- olent fits of fneezing, coughing, and laughing. In this cafe the fwelling is at firft fmall ; and although foft and compreflible, no fluduation is perceived in it. 4. The lymphatic glands of the neck have in fome cafes of fcrofula become fo fwelled, as to produce tu- mors of confiderable magnitude over the whole courfe of the trachea. They are diftinguifhed by the fymp- toms which ufually accompany fcrofulous fwellings. 5. The thyroid gland has been known to fwell to a great bulk, fo as to induce tumors of an enormous fize, extending from the trachea to the angle of each jaw. In this variety of the difeafe, the fwelling is at 14° Of Chronic or Chap. IL firft foft; but no fluduation is for fome time per- ceived in it; the fkin retains its natural appearance; and no pain takes place in it: but as the tumor advan- ces in fize, it becomes unequally hard ; being firm or elaftic in fome parts, and perfectly foft in others: the fkin acquires a copper colour, and the veins of the neck become varicofe; and in this ftate of the difeafe the face becomes flufhed, and the patient complains of frequent headache, as well as of flinging pains through the body of the tumor. This is mentioned by authors as that variety of the difeafe which occurs fo frequently among the inhabi- tants of the Alps and other mountainous countries, and which in general is fuppofed to originate from the ufe of fnow water. 6. Whatever may be the nature of thofe varieties of bronchocele which occur in other kingdoms, I can* not pretend to fay; but I have reafon to think, that in this country the thyroid gland is not fo frequently the feat of the difeafe as is commonly imagined. In fome, this gland inftead of being increafed, is evident Iy diminifhed by the compreffion produced by the tumor; and the fwelling itfelf is found to be formed of a condenfed cellular fubftance, with effufions in different parts of it of a vifcid brown matter. In one of the cafes that I have had occafion to examine after death, the tumor was chiefly fixed on one fide of the neck; but in others it occupied both fides, and reachr ed from one ear to the other, and from the flernum to the chin. In fome, the fwelling had fubfifted for a great number of years; and in one inftance the par tient died at laft of another difeafe. At firft they had no other appearance than might have been fuppofed to arife from a natural increafe in the parts lying con* tiguous to the trachea; they were foft and compreflL ble; but no fluduation was perceived in them, and the fkin retained its natural colour: but as they in? creafed in fize, they likewife became firmer; for al- though at laft a foftnefs, and even a fluduation, was Sed. III. Indolent Tumors. 14* difcovered in fome parts of them, yet the principal part of the tumor continued hard, while others had a peculiar fpringinefs or elasticity, fimilar to that of a tin canifter: the veins on the furface of the tumors became turgid; and the face of a livid colour, evi- dently from the blood being impeded in its courfe from the head. All of thefe patients complained of much giddinefs: the breathing in all of them was much obftruded; and one patient who died of the difeafe, feemed to fuffer chiefly from this circum- ftance. To fuch varieties of bronchocele, no one mode of treatment it is obvious can be applicable. Hence the abfurdity of fpecifics for this difeafe, fuch as calcined fponge and egg shells, propofed and ftrongly recom- mended by many : for although this and other reme- dies might prove ufeful in one variety of tumor, it would be abfurd to fuppofe that they can do fo, as by many has been afferted is the cafe, in all of them. 1. In the aneurifmal bronchocele, the treatment fuited to aneurifm in general muft be obferved. To fecure either of the carotid arteries with a ligature, muft in all circumftances be a hazardous operation : but here there is no alternative; of whatever kind the aneurifm may be, death will certainly enfue, if not prevented by this operation. This chance, therefore, ought always to be given; and, as is done in other cafes of aneurifm, the artery fhould be tied both above and below the tumor. I know from experiment, that one of the carotids may be tied in other animals, and that death will not enfue: this gives caufe to fuppofe that it may like- wife be done in the human body. 2. Where the difeafe is found to be an encyfted tumor upon the trachea, the general management of encyfted tumors may be kept in view, for which fee § 2. of this fedion. While yet fmall, the cyfts with their contents may be removed in the manner I have mentioned : and even in the moft enlarged ftate of 142 Of Chronic or Ckrn.IR them, we need not defpair of being able to afford ef- fedual relief. The fleatomatous kind, confifting en- tirely of fat, however large they are, may with fafety be removed; for the connedion of tumors of this de- scription with the contiguous parts is fo flight, that they are eafily taken out: the veffels on the furface of the tumor are often indeed enlarged; but thefe are chiefly veins, and may be eafily avoided. In tu- mors formed altogether of fat, I have never feen any of the arteries of fuch a fize as when cut to give much disturbance ; they are always fmall, and eafily fecur- ed by preffure when they lie beyond the reach of lig- atures^ 3. When, again, the contents of a bronchocele are fluid, they may be difcharged either by an incifion with a fcalpel, or by paffing a feton or cord through the cyft ; and when the contained matter is of a puj. taceous confiftence, forming what is termed an athe- roma, it fliould be difcharged by a large opening in the moft depending part of the tumor. 4. Where the tumor is formed by a hernia or pro- trufion of the lining membrane of the trachea, gentle preffure with a roller is the only remedy on which we can depend, and all fuch exertions fhould be avoided as might have any influence in producing it; particu- larly violent laughter, fneezing, coughing, and crying. Where the difeafe is fcrofulous, we muft depend chief- ly on thofe remedies which prove moft ufeful in other cafes of fcrofula; and with a view to remove the com- preffion produced upon the trachea, as well as upon the veins returning from the head, the contents of the tumors fhould be difcharged as foon as they appear to be fufficiently fluid. 5. Where the difeafe originates from tumefaction of the thyroid gland, frequent fridions prove ufeful, particularly when employed early, before the fwelling has become large; and faponaceous and mercurial plafters have in fome cafes appeared to prove fervice- able. Praditioners, however, are feldom confulted ii Sed. Ill* Indolent Tumors. »43 that ftage of the difeafe in which remedies of this kind may be ufefully appplied: for as the fwelling does not give uneafinefs at firft, it is feldom mention- ed by the patient till it has fubfifted for fome time- In an enlarged ftate of this gland, I do not fuppofe that any remedy will ever be found fufficiently pow- erful to difcufs it; fo that the only points to be con- fidered are, whether we fhould attempt to remove thefe tumors by an operation ? and whether it fhould be done with cauftic or the fcalpel ? We know that the thyroid gland is very plentiful- ly fupplied with blood, and that the arteries which be- long to it are ufually much enlarged in this difeafe. This, together with the contiguity of the thyroid gland to the carotid arteries, which in this enlarged ftate of that gland are even apt to be compreffed by it, ren- ders the extirpation of it in an advanced period of the difeafe extremely hazardous. The arteries here are of fuch magnitude as to pour out a great deal of blood in a fhort fpace of time; while they lie at fuch a depth in this enlarged ftate of the parts, that they cannot be eafily laid hold of with ligatures, nor can much compreflion be applied to them from their fitu- ation with refped to the trachea. I therefore con- clude, when tumors of this defcription have acquired any confiderable bulk, that it would be improper to run the hazard of removing them with a knife, and that the patient fhould rather truft to the treatment ufually emplyed in fuch cafes for palliating the fymp- toms as they occur.* ^ And although we are inform- ed, that in this fituation the potential, and even the " Mr. Gooch relates a cafe, where, in an attempt to remove a bron- chocele by exeifion, fuch profufe haemorrhagy took place, that the opera- tor, although very intrepid, was obliged to defift before the operation was half finifhed. No means that were employed could put a total flop to the blood; and the patient died in lefs than a week. Another cafe had very nearly terminated fatally; and the patient's life was only preferved by having a fucceffion of perfons to keep a conftant preffure upon the bleeding veffels, day and night, for near a week, with their fingers on proper compreffes, after the operator had been repc-atedlv difappoinud in the ufe of the needle and ligature. Vide Gooch's Medical 144 Of Chronic of Chap. IL adual cauteries have been employed with advantage, yet the pradice has not become fo general as to give us reafon to believe that it has ever proved fuccefsful; nor do I think that it fhould ever be advifed in any ftage of this difeafe. But although the reafons that I have given may be fufficient .for preventing the removal of thefe tumors when they are much enlarged; yet while they con- tinue fmall; when fridions and other remedies fail; and when the difeafe continues to advance; I think any praditioner would be warranted in advifing it to be removed by excifion: for in this early period of the difeafe, the difficulty of fecuring the arteries with ligatures is much lefs than it afterwards becomes ; at lealt the rifk occurring from this muft be fmall, when compared with that which muft probably enfue from the tumor being allowed to remain. In the fixth and laft variety of the difeafe which I have mentioned, fridions with mercurial ointment have in its early flages appeared to prove ufeful. In one cafe the progrefs of the tumor was evidently re- tarded by repeated blifters ; but the patient going to a diftance, they were negleded, and at laft it arrived at a very enormous fize. In this ftate I faw him at 9 the diftance of feveral years, but I did not learn in what manner the cafe terminated. I have reafon to think, however, from the appearance of the fwelling, both at its commencement and in its more advanced flages, that it proceeded from an effufion into the cel- lular fubftance of the neck, attended with that con- denfed ftate of this fubftance which was difcovered by diffedion in fome of the cafes that I have mention- ed above. But however ferviceable blifters, as well as other remedies, might prove in the early flages of the dif- and Chirurgical Obfervations, p. 136. And in the courfe of my own ex- perience, I have met with various cafes, all tending to evince the great danger of extirpating this gland. It would add, however, too much to the length of this article to give them in detail here, but they will appear in the volumes of Cafes and Confutations that I have in view to publifli. Sed. III. Indolent Tumors. 145 eafe, no advantage can be expeded from them when the tumor has acquired any great bulk. In this fitu- ation, palliatives only fhould be employed; for the bafis of the fwelling ufually runs fo deep, that it could not be removed but with the utmoft hazard; and it is not probable that any advantage would be derived from laying it open; for, a confiderable part of it being firm and folid, the fize of the tumor would not be much diminished by the difcharge which might be procured, while the fore that would enfue might de- generate into cancer. § 12. Of Navi Materni. By Naevi Materni are meant thofe marks which we frequently find in different parts of the body at birth; and which are fuppofed to originate from impreffions made on the mind of the mother during pregnancy. They are of various forms, being frequently found to refemble strawberries and cherries, and in other in- ftances grapes, figs, pears, and other varieties of fruit. Their colour is various; but for the moft part they are of a deep red, refembling the colour of claret or red port. Many of thefe marks are perfedly flat,, and never rife above the level of the fkin; and not being pain- ful, they never in this ftate become the objeds of fur- gery. But occafionally we meet with them from the firft in the form of fmall protuberances, which in fome increafe fo quickly as to arrive at a confiderable fize in the courfe of a few months. I once faw a tumor of this kind in a child, of a year old, of the fize of a goofe's egg, which at birth was not larger than a pea. No fluctuation is difcovered in thefe tumors; on the contrary, they feel to be firm and flefhy. In fome cafes they are pendulous, and hang by flender attach- ments to the contiguous parts \ but for the moft part they are fixed by broad extenfive bafes. Vol. I. L 146 Of Chronic or Chap. II, Various remedies have been recommended for the removal of thefe excrefcences; and in ancient times different charms were propofed for them. The myf- tery proceeding from this, is perhaps one reafon of the general averfion which ftill prevails againft any attempt being made to remove them by chirurgical operations: but it has not appeared in the courfe of my obfervation, that more danger attends the remov- al of this kind of fwelling than the extirpation of any other tumor of the farcomatous kind. They are fup- plied, indeed, more plentifully than other tumors with blood ; for in many inftances they appear to be entirely formed by a congeries of fmall blood veffels; but the arteries which go to them are in general ea- fily fecured with ligatures. It is proper, however, to remark, that the operation fhould never be long de- layed ; for as the fize of the veffels depends upon that of the tumor, they fometimes become fo large as to throw out a good deal of blood before they can be fecured ; fo that the operation fhould always be pro- pofed as foon as it is obferved that the tumor, inftead of remaining stationary, proceeds to increafe. ^ The operation is of a very fimple nature. The tu- mor, with all the difcoloured fkin, is to be diffecled off with a fcalpel; and the arteries being fecured, the edges of the remaining fkin fhould be drawn together, and kept in this fituation either with adhefive plafters or futures : or, when they cannot be drawn complete- ly together, they may at leaft be made to cover a con- fiderable part of the fore ; by which the cure will be much shortened, and the cicatrix leffened. In this cafe, that part of the fore which is left uncovered, muft be treated like a wound from any other caufe. It is fcarcely neceffary to mention, that where the tumor is pendulous, and conneded to the parts be- neath by a narrow neck only, it may be removed by tying a ligature round it, of a degree of tightnefs fuf- ficient for putting a flop to the circulation through j the whole of it. Sed. III. Indolent Tumors. 147 § 13. Of Warts, Warts are indolent, hard, colourlefs excrefcences * which appear on different parts of the body, but chief* ly on the fingers and hands. They take their rife from the cutis and cuticle. They occur at every pe* riod of life, but more frequently in infancy than old age. When from their fize or fituation warts do not prove troublefome, they fhould not be touched ; for generally in courfe of time they either fall off or wafte gradually away. But fometimes they are fo large and fo fituated, that we are under the neceffity of employing means for removing them* When warts are pendulous, and have narrow necks, the eafieft method of taking them away is with liga- tures : for this purpofe a hair is fometimes ufed, but a fine filk thread is preferable. But when their bafes are broad, we remove them either with the fcalpel or efcharotic applications. Few patients, however,- will fubmit to the fcalpel; and as we feldom fail with ef- charotics, they are generally employed. The lunar cauftic, or lapis infernalis, are the moft powerful remedies for this purpofe; but warts com- monly become very painful after being two or three times rubbed with them. The fame objedion occurs to a folution of quickfilver in aquafortis, otherwife it proves a very powerful efcharotic. Mercury diffolved in an equal quantity, or even in double its weight, of ftrong fpirit of nitre, Would remove warts of every kind ; but as the folution is apt to fpread, it requires to be ufed with great caution. Pulvis fabinae being daily applied to warts, will f6r the moft part remove them in the courfe of two or three weeks; but the belt application I have tried is crude fal ammoniac: it ads flowly, but the pain it excites is inconfiderable, and, excepting in the very hardeft kind of wart, it fel- l 2 t48 Of Chronic or Chap. U. dom fails of fuccefs. They fhould be well rubbed two or three times daily with a piece of the fait pre- viously moiftened in water. Liquefied fait of tartar fometimes anfwers the purpofe; and I have known fpirit of hartfhorn prove fuccefsful. Warts frequently appear upon the penis in the ve- nerial difeafe; and as they are nearly of the fame na- ture with thofe we have been confidering, the fame method of treatment will apply to them. In general, the tendency in the fyftem to produce them does not continue long; and if the parts are kept clean, they at laft often begin to decay, and go entirely oil, whether any application is made to them or not. But as patients are always anxious to get free of them, praditioners are fometimes induced,, to make trial of remedies too early, for till this tendency to'their for- mation is removed, warts rife almoft as quickly as they are rubbed off. Nor has mercury any influence in preventing this: I have known mercury advifed for the removal of warts; but never with any advan- tage. When we have reafon to fuppofe, therefore, that every other fymptom of the difeafe is eradicated, the continuance of warts fhould be no inducement to the exhibition of more mercury. ^vhen venereal warts are tender on the furface, and produce matter, as is fometimes the cafe, warning them morning and evening in lime water, or in a weak folution of faccharum faturni, will commonly remove this; and at laft they will disappear in the manner I have mentioned. But when this delay will not be agreed to, one or other of the efcharotics mentioned above muft be employed; or if the patient confents to their being removed with the fcalpel, the parts from whence they are cyt may be touched with lunar cauf- tic, in order to prevent them, with as much certainty as poffible, from returning. It is proper to remark, that in the treatment of warts of every kind, we fhould with much caution avoid every application that tends to excite much in- Se€t. HI. Indolent Tumors. 149 flammation; for although under a flight degree of in- flammation, warts very commonly decay and drop off, they are apt to fpread and excite troublefome fores when feverely inflamed. For the fame reafon, when a wart is to be removed with the fcalpel, we fhould rather encroach a little upon the found fkin, than run any rifk of injuring the wart itfelf, or of leaving any part of it. By want of attention to this, I have known the moft formidable fymptoms induced, by what at firft appeared to be fuch a trifling excref- cence, as not to deferve notice. In one cafe, indeed, fuch a painful obstinate fore enfued on the leg, from the removal of a fmall wart, that amputation of the limb became neceffary, in order to fave the life of the patient. (jjES^ § 14. Of Flefhy Excrefcences, Almost every part of the body is liable to the for- mation of flefhy excrefcences. Thefe tumors differ from warts in being fofter, and in being apt to ac- quire a confiderable bulk. They are feldom painful, They are of a more deep red colour than the fkin in health, and for the moft part they have a firmnefs of confiftence refembling that of the lips. When firft laid open, they exhibit nearly the fame appearances with a piece of mufcular fubftance newly divided; but on further examination, they do not appear to be fibrous. They feem to confift chiefly of cellular fub- ftance, very plentifully fupplied with blood veffels in- finitely ramified. In the treatment of thefe tumors, no external ap- plication is found to anfwer any good purpofe. Ef- charotic s have fometimes been employed for remov- ing them ; but they feldom prove effedual, and they are apt to irritate and excite inflammation. When- ever it is determined, therefore, to remove a tumor of this kind, it fhould either be done with a ligature, or with the fcalpel. When the neck is narrow, the 150 Of Chronic or Chap. II. method by ligature fhould be preferred ; but when the bafe.is broad, this is inadmiffible. In whatever. way it is done, care fhould be taken that no part of the tumor is left; and when the fcalpel is employed, the edges of the divided fkin fhould be drawn fo to- gether, as to cover as much of the remaining fore as can with propriety be done. When any part of it does not heal by the firft intention, it muft be treated like wounds produced in any other manner, § 15. Of Corns. Corns are fmall hard tubercles, which form on different parts of the body, particularly on the toes and foles of the feet. In fome cafes they appear to ,; be of a horny inorganic nature ; but in others they are evidently fupplied both with blood veffels and \ nerves, as appears from their being painful, and dif- ■! charging blood on being cut. For the moft part they are feated in the fkin ; but in fome inftances they pafs to fuch a depth as to reach the periofteum; and in this cafe they prove always very diftrefsful, particular- ly when feated on any of the joints, or on parts thinly 1 covered with flefh. The beft preventative of corns, is the wearing of wide fhoes, fo as to obviate preffure on the joints of the toes, and other parts of the feet where they are moft apt to occur ; and unlefs this meets with atten-> tion, it is impoffible in any cafe to accomplish a cure. Various remedies are recommended for the cure or removal of corns. One of the moft fimple and in-. offenfive of thefe is to pare off all the inorganic part of them, after bathing in warm water, and immedi7q\ Chap. II. fore-arm are affeded, it muft pafs W^fcn the radius and ulna. Different forms of faws haveMfcmemployed for dividing bones in this fituation ; buT^ll common faw ufed in amputations anfwers better perhaps than any other. When the portion of bone is removed, the fore ffiould be dreffed with the mildeft applications; a piece of foft lint fpread with common wax liniment, Or merely dipped in oil, fhould be inferted between the lips of the wound; and if any thing is employed for retaining them, it fhould be the many tailed band- age which can be undone without moving the limb. It is a point of importance to place the limb in a fitu- ation the moft favourable for the difcharge of matter; and as the operator has it commonly in his power to make the wound more or lefs inclined to any fide of the limb, this ought to be kept in view in the firft part of the operation. When the operation has been performed upon eith- er of the bones of the leg or fore-arm, the remaining found bone will keep the limb at its full length, fo that there will be no rifk of its becoming fhorter. But when a portion of a fingle bone is taken out, fome attention is required to prevent the limb from becoming fhorter during the cure. For this purpofe different machines have been invented; but I have never found any affiflance of this kind neceffary: for if the patient is informed of the great importance of keeping the limb in a proper pofture, he will give it all the attention that is requifite: and befides, much inconvenience, pain, and inflammation, are apt to en- fue from any instrument ufed for this purpofe, when applied with that degree of tightnefs that is neceffary for keeping the limb in a ftate of extenfion. During the cure of the fore, the chief objed is to prevent matter from lodging and palling between the contiguous found parts. If this is prevented, and the lips of the wound kept open by the eafy drollings I have mentioned, till it fills up with granulations from V Sed. IH. .-^J& Indolent Tumors. 157 the botlbfr?, ^l^c will accomplish the reft. Thofe foft granui|Mfcs which at firft occupied all the va- cancy he^3w the ends of the divided bones* will foon acquire the confiftence and ftrength of bone; and in the courfe of a fhort time, if the health of the patient continues good, the limb will become equally ufeful as it was before. Hitherto we have fuppofed the difeafe to be feated in the extremities. But tumors of this kind are alfo found in other parts of the body; on different parts of the fkull; on the under jaw ; on the ribs and cla- vicles ; and I once faw a large exoftofis on the upper part of the fcapula. But wherever they are fituated, the treatment is the fame. While they give no un- eafinefs, nothing fhould be done ; for they will fome- times continue fmall and stationary for life: but when they increafe and prove troublefome, the fooner they are removed the better; for the earlier the operation is performed, the more eafily will it be done. In that variety of exoftofis termed a Node, proceed- ing from lues venerea, the firft circumftance to be af- certained is the ftate of the fyftem. The patient ffiould be immediately put upon fuch a courfe of mer- cury, as can be depended upon for the cure of any infedion he may labour under; and if the tumor in the bone is recent, and not far advanced, any pain which it has induced may be removed by mercury alone. With a view, however, as much as poffible, to enfure the efficacy of the medicine, it ought to be thrown in as quickly, and in as great quantities as the patient can bear: for as the fyftem is completely in- reded with the virus before nodes appear, it requires, for the moft part, a very large fupply of mercury to check their progrefs. At the fame time that mercury is given inwardly, we are commonly advifed to rub the part itfelf with mercurial ointment, or to keep it covered with mer- curial plafter. I have not obferved, however, that any advantage is derived from this; and I think it 158 Of Chronic or . !# Chap. If, is apt to do harm. In tumors 4vhtf kind there is reafon to fuppofe that the perioiteuA|pEcomes in- flamed from the firft. In different inflrnop, the in- flammation has appeared to be aggravated, both by the application of plafters, and by the fridion ufed with mercurial ointment. Till we know whether the internal exhibition of mercury is to prove effedual or not, fome mild fedative application, fuch as faturnine folutions, or the unguentum nutritum, which is a pre- paration of lead, fhould only be employed. Thefe keep the parts eafy; and by tending to remove in- flammation, they may even have fome influence in re- moving the tumor. But if we find, after there is full evidence of the mercury having entered the fyftem, that the local af- fedion of the bone ftill continues to advance, that the tumor becomes larger, and the pain more fevere, oth- er remedies fhould be advifed. In this fituation, I have fometimes found the pain relieved immediately by the application of leeches over the tumor ; and the pain being moderate, we have it thereby in our power to delay every other remedy till a more complete trial is given to mercury. In fome cafes, where leeches have failed, blifters applied diredly upon the parts af- feded have proved fuccefsful. Neither blifters, how- ever, nor leeches, can have any influence on the ori- ginal difeafe : they will not leffen the tumor of the bone ; but by leffening the tenfion of the periofteum, they fometimes prove more ufeful than perhaps any other remedy we could employ. When thefe means, however, are too long delayed; when the tumor advances with more rapidity than ufual; or when acrid matter is perhaps confined be- neath the periofteum ; neither leeches nor blifters af- ford relief. In fuch cafes, an incifion made along the courfe of the tumor to the depth of the bone, will of- ten give immediate eafe. The matter evacuated from thefe tumors is frequently a thin brown fanies, at other times a vifcid tranfparent mucus. Sed. III. Indolent Tumors. 159 In fome cafes $e incifion heals kindly by common treatment, eveft when the tumor of the bone is by no means inconliderable. Healthy granulations will form, and a cure of the fore will be accomplifhed, even be- fore the patient has taken as much mercury as may be judged neceffary for the cure of the difeafe. In fuch cafes, the tumefadion of the bone is not to be regarded : it may probably, indeed, continue during the life of the patient; but no inconvenience will en- fue from it. So that unlefs it is fo fituated as to pro- duce much deformity, it ffiould never be touched. But, in other inftances, the fore, inftead of healing eafily, remains obftinate, notwithftanding all the re- medies we employ. In fuch circumftances, this ob- ftinacy of the fore is for the moft part fuppofed to arife from the venereal virus not being destroyed, and a further continuance of mercury is therefore advifed. The mercurial courfe ffiould no doubt be carried as far as there is any chance of its proving ufeful. But beyond this, it will commonly prove hurtful, and rather tend to protrad the cure of the fore. This, however, is a point upon which no precife diredions can be given, and muft be determined by the judg- ment of the praditioner in attendance. When the obftinacy of fores in this fituation de- pends upon other difeafes of the fyftem, the removal of thefe will forward the cure. But when there is a tendency in the difeafed bone to exfoliate, the com- pletion of this procefs will alone prove effedual. In fuch circumftances, the treatment beft fitted to pro- mote exfoliation ought to be purfued : but as we fhall elfewhere have occafion to confider this fubjed more fully, it is unneceffary to enter upon it at prefent.* After all the difeafed parts of the bone are remov- ed, the fore will for the moft part heal eafily. But in fome cafes, fuch a thickening of the periofteum and contiguous parts has been produced by the long con- • Vide Chap. IV. Sed. VIL i6q Of Chronic or Chap. II. tinuance of the difeafe, that the cure ftill proceeds flowly. In fuch circumftances, mild emollient appli- cations do harm, and nothing in general proves fo ufeful, as ointments ftrongly impregnated with red precipitate or verdigrife. In fome cafes, even thefe do not ad fpeedily ; when touching the furface of the fore, once in two or three days, with lunar cauftic, or lapis infernalis, will make the floughs throw off; and for the moft part their place will be fupplied with healthy granulations; after which, the cure common- ly proceeds without interruption. In describing this variety of exoftofis, I have re- peatedly mentioned the pain which attends it; a fymptom which always takes place; at leaft I never met with an inftance of its being wanting. Venereal nodes, particularly thofe on the head, are not indee4 always accompanied with much pain, but merely with a flight uneafinefs. This variety, however, of node does not originate from the bone, but proceeds mere- ly from an affedion of the periofteum. In this cafe the tumor commonly fubfides entirely, either by the effeds of mercury alone, or the application of a blif- ter : but in the other, if the bone is affeded in any confiderable degree, the tumor never fubfides if a large portion of the bone does not exfoliate. Even after every other fymptom of the difeafe is removed, thefe tumors in the bones continue equally fixed and large as they were at firft. We judge that a node proceeds from the bone itfelf; by the pain, as I have juft obferved, being acute ; by the tumor being con- fiderably harder than when the periofteum only is af- feded ; by its advancing flowly, and continuing fixed and permanent, notwithftanding all the applications that we make to remove it. We come now to fpeak of the treatment of fpina ventofa, or that variety of exoftofis which we fuppofe to originate from fcrofula ; and I am forry to obferve, that I have nothing fatisfadory to offer upon it. Fo- mentations, ointments, plafters, and a variety of other Sed. III. Indolent Tumors. i6| remedies, have been advifed for k; but I know ,pf none that any advantage has ever been derived from. Tumors of this kind which appear formidable at firft, will fometimes indeed continue stationary, either from the fcrofulous difpofition in the fyftem being checked by cold bathing, or fome other fimilar remedy; or from fome change taking place in the conftitution, with the nature of which we are perhaps altogether unacquainted. But this is a rare occurrence : for, in general, notwithftanding all the remedies we employ, a fpina ventofa, from its firft appearance, proceeds in a gradual manner to become worfe. When the difeafe appears at the fame time in dif- ferent parts of the body, all we can with propriety do is to fupport the conftitution with a proper diet; to advife bark and cold bathing as the beft strengthen- ing remedies; and when the pain is fevere, to en- deavour to render it moderate by adequate dofes of opium. But when one part only is difeafed, as often happens with the knee and other large joints in cafes of white fwelling, it becomes frequently advifable to remove the difeafed part by an operation. In affec- tions of the joints, it has been the common pradice in this fituation, to amputate the difeafed limbs entire- ly. But an attempt has lately been made by Mr. Park, an ingenious furgeon of Liverpool, to fave limbs that are thus difeafed, by removing the heads of the affected bones only, and afterwards healing the fore at which they were taken out. In treating of the operation of amputation, I fhall enter more fully on the confideration of this ; for it is highly deferr- ing of notice: at prefent I fhall only remark, that there is caufe to fear that it will not prove fo general- ly ufeful, as at firft view might be expeded. But where thefe fwellings occur on the middle of bones, the pradice may be purfued which I have already ad- vifed in thofe cafes of exoftofis proceeding from ex- Vol. I. M 16* Of Chronic tumors. Chap. II. ternal violence: the fwelled portion of bone may be cut out when feated on any of the long bones of the extremities; and the whole bone may be removed when any of the fhort bones of the hands or feet are affeded. Sed* L Of Wounds in general. 163 CHAPTER III. OF WOUNDS* SECTION I. Of Wounds in general: VARIOUS definitions have been given of a wound; but few, if any of them, appear to be accurate. Boerhaave defines a wound to be, a re- cent, bloody folution of continuity, in any foft part, by the motion, preffure, or refiftance^ of fome hard or fharp body* By Sauvages, it is faid to be a me- chanical divifion of any flefhy part, attended with a feparation of the parts newly divided, together with a difcharge of blood, and a tendency to inflame and fup- purate.^ And Ludwig defines a wound to be a mor- bid divifion of parts which in a ftate of health ought to be united* Thefe are the definitiohs of this term which have been moft generally adopted; but it is evident that none of them are corred. A part may be deeply cuts even large blood veffels may be divided, without any difcharge of blood taking place, as fometimes happens in lacerated wounds, and in thofe attended with much contufion : and where the fmaller veffels only are di- vided, the difcharge of blood very commonly ceafes in the courfe of a few hours from the time that the wound was inflided. The definition recited above from Mr. Sauvages is too extenfive: it comprehends a period or ftage of wound which does not always exift, viz. a tendency to fuppurate. We know that wounds frequently ter- M 2 164 Of Wounds in general. Chap. III. minate in gangrene, and even in death, without any previous fuppuration ; while, in other inftances, they heal by the firft intention, and their edges adhere to each other without any appearances of pus. Neither is Dr. Ludwig's definition of a wound cor- red : parts which ought to be united, may be divided without being wounded. Thus a blood veffel, nerve, tendon, or mufcle, may be completely^ruptured either by a violent fprain or a contufion ; but unlefs the cor- refponding fkin and other teguments are divided, we do not fay that fuch parts are wounded. Nor are thefe affections confined to the fmaller mufcles and tendons ; for inftances often occur of the different parts, even of the largeft mufcles, being thus violent- ly feparated from each other. Every recent folution of continuity, in whatever part of the body it may be, when attended with a cor- refponding divifion of the teguments, may be denom- inated a wound. From this definition of wounds, it is evident, that they will exhibit much variety in their appearances. This will arife from different caufes, but more parti- cularly from the nature of the injured parts ; from the manner in which they have been produced; and from their extent. Thus wounds in mufcular parts are different, both in their nature and appearances, from fuch as affed membranous or tendinous parts only. Wounds made with a ffiarp cutting instrument, are materially differ- ent from fuch as are attended with contufion or lacer- ation : and pundured wounds exhibit very different appearances, and for the moft part are produdive of very different effeds, from thofe which are more free and extenfive. In the fubfequent parts of this fedion, thefe varieties in wounds will be confidered. In the mean time, I fhall defcribe the phenomena which ufu- ally take place in the moft frequent form of wound, what may be termed a fimple incifed wound; by which Sed. I. Of Wounds in general. •65 both the theory and pradice which I wifh to inculcate will be rendered more intelligible. On the instrument being withdrawn with which an incifed wound has been made, the firft appearance that we take notice of is a feparation to a certain ex- tent of the divided parts ; which is always in a great- er or leffer degree, according to the depth and length of the wound, and according as the fibres cf the in- jured part are divided more or lefs tranfverfely. Thus a wound even of confiderable length, if it runs in the fame diredion with the fibres of a mufcle, will be at- tended with little retradion of the fkin, while a large vacuity will take place in a wound perhaps of lefs ex- tent, where a ftrong mufcular part is cut diredly acrofs. Nay, in this laft cafe, the feparation of the di- vided parts is in fome cafes fo confiderable, as to give caufe to fufped that a portion of them has been re- moved ; while in the other it is often fo trifling, that even an extenfive wound will have the appearance of a straight line only ; a circumftance by which pradi- tioners are apt to be fo much deceived as to confider as of little importance, wounds which in their confe- quences prove to be formidable ; by which the pro- priety of examining every wound with attention is ftrongly pointed out. The next appearance which ufually takes place in wounds, is a difcharge of blood to a greater or leffer extent, in proportion to the fize of the cut, and to the number and fize of the veffels that are divided; at leaf! this is the cafe in wounds made with a ffiarp cut- ting edge. Where the parts have been much bruifed or lacerated, I have already remarked, that even large blood veffels may be divided without any hsemorrhagy taking place. For the moft part, the difcharge of blood proves fo alarming, that means are immediately employed to flop it; but when this is either negleded or not con- fidered as neceffary, if the arteries that have been cut are not large, the irritation produced by the wound 166 Of Wounds in general. Chap. Ill, itfelf, as well as by the free accefs of the external air, excites in the divided extremities of thefe veffels fuch a degree of contradion, that in this way alone the haemorrhagy is commonly foon checked. The dif- charge of red blood becomes gradually lefs: it then ceafes entirely, and is fucceeded by an oozing of a fe- rous fluid, which in the courfe of a few hours likewife flops, when the whole furface of the fore is found either fomewhat dry or even parched ; or it is covered over with a cake of coagulated blood. In this way nature feems to operate in putting a flop to haemorrhagies produced by wounds. Anoth- er idea is commonly entertained indeed of this faluta- ry procefs : it is fuppofed that fmall coagula of blood plug up the orifices of the veffels, and that in this manner they are preferved of the fame fize as before they were cut. This, however, is by no means the cafe, as is clear- ly proved on diffeding the flumps of patients dying after amputations. Inftead of the mouths of the di- vided arteries being plugged up with blood, they are found perfedly empty and contraded for a confider- able fpace from their extremities ; nay, in moft inftan- ces, they become firm folid cords, fo as never after- wards to be capable of receiving a fupply of blood. Nor is this procefs of nature difficult to explain. It is arterial haemorrhagies we are now confidering ; for wounded veins, if they be not compreffed between the injured part and the heart, feldom difcharge fo much blood as to prove alarming. Now, as arteries are poffeffed of a ftrong contractile power, they will read- ily exert this power on the irritating caufes which ac- company wounds, being applied to them. In this manner the blood is prevented from flowing in its ufual channel; but nature does not fail to provide a different route for it: it is foon forced through the contiguous anaftomofing arteries, which at laft be- come fo much enlarged, as to allow it to pafs with freedom ; wliile, in the mean time, that contiadioia, Sed. I. Of Wounds in general. 167 of the divided arteries, produced at firft as I have juft obferved, by irritation, terminates at laft in a firm ad- hefion of their fides, in confequence of that degree of adhefive inflammation with which every wound is in fome degree accompanied. The pain attending a wound made with a clean cut- ting instrument, is in general inconfiderable at firft, unlefs a nerve or a tendon has been partially divided; in which cafe it proves commonly fevere. But in ev- ery wound the parts become painful in the courfe of a few hours from the time of the injury being inflid- ed. They become red, tenfe, and even confiderably fwelled: and where the wound is extenfive, an in- creafed degree of heat takes place, together with thirft, quicknefs of pulfe, and other fymptoms of fever. In fome inftances thefe fymptoms continue to in- creafe, and to prove more and more fevere, till at laft they terminate in mortification; but for the moft part they are carried off in a more favourable manner. The furface of the wound, which for fome time re- mained dry, is gradually rendered moift and foft by a thin ferum oozing into it; which being allowed to colled, is at laft, by the heat of the affeded parts, and in fome cafes by the application of artificial heat, con- verted into purulent matter : while in general, the preceding fymptoms of pain, tenfion, and fever, abate more or lefs quickly, according as this formation of matter is more or lefs plentiful. From the time that ferum begins firft to ooze into the cavity of a wound, the tenfion and pain begin to abate, and for the moft part thefe fpmptoms difappear on a free fuppuration taking place, by which the moft natural balfam is pro- duced that can be applied to wounds. From this hiftory of the progrefs of wounds, it is evident that all the fymptoms which they induce ori- ginate from inflammation. They are exadly fuch, indeed, as accompany a common prlegmon, The pain, rednefs, and tenfion, which always to a certain degree takes place in wounds, are the" leading fymp- 163 Of JVounds in general* Chap. III. toms of phlegmon; and the ferous effufion into the cavities of wounds, with the fuppuration which en- fues, are circumftances exadly fimilar to thofe which occur in all cafes of abfcefs. A wound may there- fore be confidered as an exciting caufe of inflamma- tion ; and fome advantage, I think, may be derived in pradice, from viewing it chiefly in this light. This, however, will more clearly appear, when we come to fpeak of the method of cure: when it will become obvious, that in the treatment of wounds, thofe means prove uniformly moft ufeful which are moft powerful in preventing violent inflammation. The defcription that I have given of wounds relates to the moft fimple and leaft hazardous kinds of them ; in which the injury has been done, as was already re- marked, with a ffiarp cutting inftrument, and where the parts have been laid freely open. In fuch circum- ftances, when no organ of much importance to life has been divided, and when the cut is feated in a flefhy mufcular part, if nature be not impeded in her opera- tion, the whole furface of the fore becomes covered with granulations almoft immediately on a free fup- puration taking place; and thefe continuing to ad- vance, a cure is at laft accomplished, in the manner to be defcribed in an enfuing chapter,* This happy termination of a wound, however, may be prevented by various caufes. It requires, indeed, the concurrence of many circumftances. Thefe we fhall afterwards have occafion to confider in a parti- cular manner. At prefent I fhall enumerate thofe only which arife from the nature of the wound. In a free incifed wound, the inflammation that takes place is not in general more .than is neceffary for the produdion of that degree of fuppuration which I have fhown to be requisite; and in wounds of this defcription, the matter gets freely off, being commonly difcharged almoft as foon as it is formed; * Vide Chap. IV. Section II. $ 3. Sed. I. Of Wounds in general. 169 points of the utmoft moment in the management of wounds. It is known indeed to every praditioner, that the cure of wounds cannot be accomplifhed when the inflammation is either fevere, or when a free out- let is not given to the difcharge : every circumftance therefore in the nature of a wound, which tends either to excite an undue degree of inflammation, or to pro- duce a lodgment of matter, muft be confidered as unfavourable: and hence pundured wounds, and thofe that are attended with contufion or laceration, are particularly hazardous. Pundured wounds prove often more dangerous than wounds of greater outward extent, from large blood veffels and other deep feated parts being apt to be hurt; and they are commonly more painful, being frequently attended with a partial divifion of conti- guous nerves or tendons; a circumftance produdive of more violent pain than ufually enfues from their being freely divided. But the- greateft rifk in a punc- tured wound arifes from the lodgment of matter; a circumftance which takes place more readily in this than in any other variety of wound ; and to obviate which the niceft attention on the part of praditioners is often requifite. In contufed and lacerated wounds, if the violence with which they have been inflided has not been con- fiderable, the parts will frequently recover their tone ; the attending inflammation will not run high ; and a free fuppuration being induced, a cure will at laft be accomplifhed in a manner fimilar to what I have de- scribed in cafes of fimple incifed wounds. But it of- ten happens that the contiguous parts are fo much injured as to give no caufe to exped fuch a favoura- ble event. When violently contufed, the texture of the injured parts is fometimes fo completely destroy- ed, that the circulation is ftopped, and mortification enfues ; and where this proceeds to any confiderable extent, the danger attending it is always great. Again, in wounds attended with much laceration, mortifica- 170 Of Wounds in general. Chap. III. tion is apt to occur from a different caufe. The pain and irritation proceeds fometimes to fuch a height, as to induce a great degree of inflammation ; which, notwithftanding the means ufually employed to pre- vent it, very frequently terminates in the manner I have mentioned. Indeed, fo far as my obfervation goes, inflammation induced by this caufe is more apt to ter- minate in gangrene than any other inflammatory af- fedion proceeding from external violence. In forming a prognofis of wounds, the circum- ftances we have juft been considering merit particular attention ; but there are others which fhould likewife be kept in view; and thefe more efpecially are, the age and habit of body of the patient; the texture of the wounded part; the part of the body in which the injury is inflicted; and the rifk of parts of much im- portance to life being ultimately brought to fuffer, ak though not immediately injured. Thus, it is obvious, that in healthy constitutions, wounds will, ceteris paribus, be lefs hazardous than in people of difeafed habits of body ; for we com-; monly obferve, where the fyftem is tainted with any difeafe, that even the flighteft wounds are apt to be- come troublefome, and to degenerate into fores which do not heal till the difeafe of the fyftem is removed. We alfo obferve, that the healing of fores depends in fome meafure upon the age of the patient; and that the cure is for the moft part more quickly accom- plifhed in youth and in middle age, than in very adi vanced periods of life. There are many exceptions, however, to this ; for whenever the natural firmnefs and elaflicity of the mufcular fibres are not much impaired, we do not find that old age proves unfavorable to wounds. When the conftitution is fuch, that any wounds which take place, are found to excite a due degree of in- flammation, old age ought by no means to be con- fidered as a difadvantage. On the contrary, in fuch circumftances, it proves always falutarv, bv tending Sed. I. Of Wounds in general. 171 to render the fymptoms more moderate than they are apt to be in more early periods of life. This is par- ticularly the cafe in extenfive wounds of every kind : and we obferve it in a remarkable manner in chirur- gical operations ; efpecially in lithotomy, and in the amputation of any of the extremities; which have commonly, in the. courfe of my experience, proved more fuccefsful in healthy old people than at any other period of life, and evidently from the caufe that I have endeavoured to point out. With refped to the texture of a wounded part, it is well known that wounds heal not only more quick- ly but more kindly in fome parts than in others. Thus, wounds of the cellular fubftance heal more eafi- ly than thofe of mufcles; while thofe that are con- fined to the flefhy parts of mufcles prove much lefs formidable than wounds of tendons or ligaments; for, befides occafioning lefs inflammation and pain, they do not fo readily produce any permanent incon- venience. The deepeft cuts may be inflided on the belly of a large mufcle, with little or no rifk of any future inconvenience being produced ; but the conti- guous joints are apt to remain ftiff and unmanageable when the tendons which pafs over them are much in- jured. When wounds penetrate to a ftill greater depth, fo a$ to do any material injury to bones, they prove al- ways more tedious and uncertain than when foft parts only are divided; for in fuch cafes wounds feldom heal till fome portion of the bone exfoliates; a pro- cefs which very commonly requires a confiderable length of time to accomplish.* Wounds in glandular parts are more to be dread- ed than the mildnefs of the fymptoms which appear at firft would lead us to imagine. When fmall glands only are divided, they often heal readily ; but when the larger glands are injured, the fyftem is not only » Vide Chap. III. Sed. VII. 172 Of Wounds in general. Chap. III. apt to fuffer from the fecretion for which they are in- tended being impeded, but the fores which enfue very commonly become fungous, and are cicatrifed with difficulty. When any of the larger lymphatic veffels are wounded, the cure often proves tedious, from a con- stant difcharge of a thin limpid fluid, by which the formation of a cicatrix is prevented : and when at laft a cure is obtained, very troublefome fwellings are apt to occur in the under part of the limb, from the ob- ftrudion given to the lymph in its paffage to the heart by the newly formed cicatrix. Of this every pradi- tioner of experience muft have feen fome inftances. I have met with many ; particularly after the extirpa- tion of fchirrous glands when deeply feated in the arm- pit. In fuch cafes, the large lymphatics of the arm are very frequently cut, and very obftinate cedematous fwellings of the whole member are apt to enfue. When a large nerve is completely divided, the pain attending it is feldom great; but the parts beneath will be deprived both of their fenfibility and power of motion, unlefs they are fupplied with fome other branches. But when a nerve is only pundured, the pain which takes place is commonly fevere : and this is apt to be followed with a high degree of inflamma- tion ; fmart fever; fubfultus tendinum ; convulfions ; and even death. Thefe violent appearances, howev- er, do not often occur in northern climates ; but they are frequent in warm countries, where they are apt to terminate in a fymptom which often proves fatal, the locked jaw. In wounds of the larger blood veffels, our firft ob- jed is to difcover, whether the hsemorrhagy which en- fues proceeds from arteries or veins ; for in general no material inconvenience is experienced from wounds even of the largeft veins, while much danger is to be dreaded from wounds of the large arteries. If a wounded artery is large, and fo fituated that a liga- ture cannot be put round it, the lofs of blood will Sed. I. Of Wounds in general. 173 probably foon prove fatal: and even where the dif- charge of blood can be ftopped with eafe, if the limb has no other artery to fupply it, a mortification is to be dreaded. It often happens, indeed, that even large arteries are fecured with ligatures without any detri- ment to the parts beneath : but in this cafe there are other arteries or anaftomofing branches of fuch a fize as to give paffage to a fufficient quantity of blood. The fite of a wound is alfo an objed of importance. Thus wounds in the extremities, when confined to parts lying above any of the hard bones, are not to be confidered as fo hazardous as thofe which pafs into any of the joints; and wounds which penetrate any of the larger cavities, prove always more dangerous than thofe which do not run to fuch a depth. This may proceed from different caufes. The dan- ger will be increafed by the chance of fome organ of importance being diredly injured ; by air, and in fome cafes by extraneous bodies, finding accefs to cavities which nature never meant to be expofed; and, laftly, by the lodgment of matter; a circumftance always with much difficulty avoided, in wounds which pene- trate to a great depth. We have likewife to confider, that although no or- gan of importance may be directly wounded in fuch a manner as to produce immediate death, yet that much danger may eventually arife from a variety of circum- ftances ; and that wounds may at laft prove mortal, which at firft were not attended with any obvious rifk. Thus wounds in the lungs and other vifcera prove fometimes fatal, from continuing to difcharge fuch quantities of blood for a confiderable time, as at laft deftroy the patient; although at firft the difcharge might not perhaps appear to be of much importance. The ftomach, and different parts of the alimentary ca- nal, may be injured in fuch a manner as to terminate in death, without exhibiting any immediate appearance of danger. The external coaf of the aorta has been 174 Of Wounds in general* Chap. IIL removed by the point of a fmall fword; and the wound has been nearly healed, when the patient died fuddenly from a rupture of the artery: and wounds of the gall bladder, or of its excretory dud ; of the receptaculum chyli; of the thoracic dud, and fome other vifcera; may for feveral days afford no fufpicion of danger, and yet terminate fatally at laft* Wounds fometimes prove fatal from inflammation fpreading to contiguous vifcera, which were not at firft injured; and wounds, which have at firft appear- ed to be of little of no importance, have at laft ter- minated in the worft manner, merely by mifmanage- ment, either in the application of dreffings or band- ages, or in the conduct of the patient with refped to food, drink, and exercife ; for it is well known, that much mifchief has been done by improper dreffings, and efpecially by too tight bandages; and We like- wife know, that riiifcondud with refped to food is daily the caufe of wdUnds going wrong, which others wife would probably have done welh It thus appears, that various circumftances fall to be confidered in judging of the probable termination of wounds. In doing this with accuracy, pradition* ers of experience have frequent opportunities of shew- ing their fuperiority. This fubjed ought therefore to be confidered as highly important by all who wifh to distinguish themfelves. A minute knowledge of anat- omy, a cool temper, and a fteady hand, will enable any praditioner, even with no great experience, to perform many of our moft important operations fuf- ficiently well: and accordingly, in different hofpitals, we daily meet with good operators; but we do not often find furgeons poffeffed of that knowledge in the prognofis of chirurgical difeafes which might be ex- peded ; that attention being feldom bellowed which is neceffary to attain it. Sed. II. Of Simple Incifed Wounds, 175 SECTION H. Of the Cure of Simple Incifed Wounds. IN the management of wounds, the firft objed re- quiring our attention is the haemorrhage; more efpecially when it is profufe. The fafety of the pa- tient requires it: the alarm which it gives, not only to byftanders, but to the praditioner himfelf, renders it neceffary. Nor can the real ftate of a wound be difcovered with accuracy, till the difcharge of blood is checked. Hsemorrhagies are moft immediately ftopped by preffure applied to that part of the divided artery which is next to the heart: this preffure is beft made by the tourniquet, when the wound is in any of the extremities ;* and by the hands of affiftants, in wounds of the trunk of the body or of the head. In this manner, if the preffure is properly applied, almoft any heemorrhagy may be ftopped till the wounded veffels can be fecured with ligatures ; which I fhall hereafter fhew to be the fafeft, as it is the eafi- eft, method of preventing injuries of this kind to pa- tients.f Much indeed has been faid, even of late years, of the inconveniencies which ligatures are fup- pofed to induce: but this has arifen either from the interested views of fome individuals who may have wifhed to eftablifh the reputation of different flyptics; or from the groundlefs fears of young praditioners. Where the contiguous nerves, or even where much of the furrounding mufcular parts, are included in li- gatures, fevere pain, and other troublefome fymptoms, will no doubt be induced j but this is not the fault of the remedy, but of the method of ufing it. Indeed this is fo obvioufly the cafe, that reafoning in the fur- ' Vide Chap. VI. f Vide Chap. VI. 176 Of Simple. Chap. III. ther fupport of it does not feem to be neceffary; for every praditioner of experience will admit, that a proper application of ligatures is feldom it ever pro- ductive of any material inconvenience, and that we can depend on it with more certainty than on any other remedy, for putting a flop to haemorrhagies from wounded arteries. In the preceding editions of this work, when treat- ing of the method of applying ligatures to arteries, I gave it clearly as my opinion, that it may be beft done by the tenaculum, an instrument reprefented in Plate II. fig. 1. And after much additional experi- ence of its utility, I now think it right to fay, that I am more and more convinced of its being much fupe- rior to the needle; which cannot be ufed without a portion of the contiguous foft parts being included in the ligature ; a circumftance which in every inftance we fhould endeavour to avoid. Many imagine that the tenaculum may be ufed with fafety in fecuring ar- teries of a middling fize, while they are afraid of cut- ting thofe of a fmall fize afunder, if fome of the con- tiguous cellular fubftance be not included along with them ; and, in tying the large trunks of arteries, they fufped, that the ligatures would be apt to be forced off by the ftrong pulfations of thefe veffels, if they were not fupported by being firmly fixed in the con- tiguous parts. I have not, however, had a Angle in- ftance of obferving, that either of thefe objedions to this pradice is well founded. For a great number of years paft, I have laid afide the needle, for the pur- pofe of applying ligatures to arteries, almoft entirely; and in the courfe of that time, I have employed the tenaculum indifcriminately in hemorrhagies from ar- teries of all fizes. Wounded arteries are feldom fo fituated as to pre- vent the haemorrhage from being ftopped in the man- ner I have mentioned: for when they lie at the bot- tom of "deep wounds, with narrow contraded mouths, die wound may commonly be enlarged, fo as to ad- Sed. II. " Incised Wounds. iff mit of their being tied with ligatures; arid for the moft part it may be done with fafety. Where the en- largement of a wound is not clearly neceffary, no perfon of experience would advife it ; but the pradice is always fafe and proper in haemorrhagies proceeding from arteries lying fo deep that ligatures cannot oth- erwife be applied to them. As this pradice, howev- er, has been very inadvertently condemned by fome praditioners in every inftance, from their fuppofing it to be rarely if ever neceffary, a timidity has been thereby introduced, which, in various inftances, has done much harm. Patients have been tormented with the application of tight bandages, and with the trial of different flyptics, which feldom if ever fuc- ceed, when the haemorrhagy might have been ftopped in the moft effedual manner by a fmall enlargement of the wound: nay, many limbs have been ampu- tated from the fame caufe, which might eafily have been faved; particularly in cafes of compound frac- ture, where haemorrhagies proceeding from deep feat- ed arteries which cannot be eafily tied, are too fre- quently confidered as a fufficient reafon for removing the limbs. From particular circumftances, in a few cafes of compound fradure,- it may happen that haemorrhagies cannot be ftopped without laying the injured parts fo extenfively open, as might induce more hazard than amputation itfelf. This, however, is a very rare occurrence; and it will feldom take place where the cafe has been properly treated from the beginning. When a divided artery runs in the fubftance of a bone, no ligature, it is evident, can be applied to it; and therefore, in fuch a cafe, enlarging the wound could not be attended with much advantage. But arteries in this fituation are feldom lb large as to lead us to be much afraid of any haemorrhagies that may proceed from them; nor does it often happen that they continue to bleed long after they have been com* Vol. I. N 1*1% Of Simple Chap. Ill, pletely divided. An artery thus fituated, being mere- ly wounded, may difcharge a great deal of blood ; but 1 have met with different inftances of the haemorrhagy flopping almoft immediately on the veffel being cut acrofs. Authors indeed have faid, that the utmoft danger has been induced by arteries furrounded with bone being wounded; nay, that death itfelf has hap- pened from this caufe, owing to the impoffibility of including them in ligatures. I am convinced, how- ever, that it is a partial divifion only of fuch arteries that will ever produce haemorrhagies of any import- ance ; for they are always fmall, and they never ad- here fo firmly to the furrounding bone, as to be pre- vented from contracting on being freely divided. Where the difcharge of blood proceeds from large veffels, the means that I have mentioned are the mofl effedual with which I am acquainted, for putting a flop to it. But when it occurs from an infinite num- ber of fmall arteries over the whole furface of a wound, other remedies muft be employed. I muft here refer, however, to a fubfequent chapter of this work, where this fubjed will fall more properly to be fully confidered.* The haemorrhagy being ftopped, the next objed requiring our attention in the treatment of wounds, is the removal of any extraneous bodies from every part of them, and where the fubftances to be removed are not deeply feated, this is done both with moft eafe and fafety with the fingers alone; for when forceps and other instruments are employed, we can fcarcely fail to injure the contiguous parts. The examination of wounds, with a view to difcov- er extraneous bodies, ought to be made with much delicacy; for handling the parts roughly gives unne- ceffary pain, and is befides apt to induce a degree of inflammation, which often proves hazardous. * Vide Chap. VI. Sed. II. Incised Wounds. 179 But although it is always proper to accomplish the removal of extraneous bodies with as little pain to the patient as poffible ; yet wherever we have any certain* ty of bodies of this kind being lodged, we ought by all means to proceed with firmnefs, in the firft place, in difcovering their fituation, and afterwards in re- moving them, excepting in thofe cafes where it can- not be done without much rifk of injuring parts of real importance to life. In fuch circumftances, the judgment of the praditioner muft decide between the danger that may probably enfue from the extraneous body being allowed to remain, and that which might arife from his proceeding to remove it immediately. Modern praditioners ftridly forbid the removal of extraneous bodies from wounds that are not eafily dif- covered, for they very properly obferve, that in for- mer times much mifchief was done by exploring wounds to a greater extent than was neceffary; by which much pain was induced, and cures rendered more tedious than they otherwife would have been. But in this matter the moderns feem to have gone from one extreme to another: for although much handling of fores, and a free ufe of probes, forceps, and other instruments, is feldom neceffary, it is equal- ly true, that by allowing extraneous bodies, which might have been removed at firft, to remain in wounds, much future pain and inflammation have arifen. In fupport of the pradice, we are told, that various cafes are on record, of extraneous bodies continuing to lodge in different parts of the body without any harm or inconvenience ; that this will commonly hap- pen when the fubftance is not of a ftimulating nature ; and when it is of fuch a form or texture as to induce pain, that it will foon excite fuch a plentiful fuppura- tion as will quickly throw it out in a much more eafy manner than if it had been removed at firft. In an- fwer to this, I fhall obferve, that where extraneous N 2 180 Of Simple Chap. III. bodies in wounds cannot be removed without giving the patient a great deal of pain ; and efpecially where there is any rifk in doing fo of large contiguous blood veffels being wounded; we ought by no means to make the attempt. In fuch cafes, it is better to truft to the fubfequent fuppuration for throwing them out; but they ought always to be taken out immediately, • when it can be done with tolerable eafe, or without injuring any parts of importance. In this way a more expeditious cure is obtained, and with more eafe, than could be done in any future ftage of the fore. For in a recent wound, while no inflammation or tenfion takes place, the contiguous parts eafily ftretch and yield to the extradion of any fubftance that may be ^ lodged in them, if it be not of an angular form, and if the operation, inftead of being performed quickly, be done with flownefs and caution: whereas, when the contiguous parts become ftiff and painful, which they always do in the courfe of a fhort time, any fub- ftance lodged in them is removed with much pain and difficulty: for even after a free fuppuration has taken place, although the parts are commonly much relaxed, yet ftill they are more ftiff and tenfe than they were at firft; and the opening through which the fubftance is to be extraded is likewife diminifhed. Another very material advantage is gained by the immediate removal of extraneous bodies from wounds. While a fore is recent, patients, for the moft part, will allow every thing to be done which the pradi- tioner in attendance may propofe, while they frequent- ly refufe, in future ftages of the fore, to fubmit to any thing more than the ufual dreffings. It may be remarked, in this place, that of the ex- traneous bodies that are apt to be lodged in wounds, fome are more harmlefs than others. A prudent practitioner will therefore be more or lefs anxious in attempting to remove them. Thus we all know, that a lead ball may be lodged very deeply for a great length of time, without being productive either of Sed. II. Incised Wounds. 181 pain or trouble; while a fplinter of wood, glafs, or iron, or even a bit of cloth, will often excite much diftrefs. When, therefore, it is known that a lead ball is the only fubftance that is lodged in a wound, if it cannot be eafily removed, we have at leaft the fatisfadion of being affured, that it will not probably do much harm. We will therefore allow it to re- main, either till it is loofened by a plentiful fuppura- tion, or till fome future period, when it may perhaps be difcovered in a different fituation, fo as to be tak- en out with fafety at a counter opening: while, on the other hand, when fuch fubftances are lodged in wounds as will probably excite much irritation and pain, it will be much for the intereft of the patient, and will be the means of preventing much perplexity and trouble to the furgeon, to have them removed as foon as poffible after the injury is inflided. I have obferved above, that in removing extraneous bodies from wounds, it fhould be done with the fin- gers alone, rather than with forceps. Some few ex- ceptions may occur to this, which I fhall afterwards have occafion to mention. But fubftances are fome- times lodged in wounds that cannot be eafily taken out either with the fingers or forceps. This is parti- cularly the cafe with fand, duft, and fmall pieces of glafs. Thefe are beft removed by bathing the parts in warm water, or by pouring warm water upon them ; fqueezing the water gently from a fponge, or injeding it flowly with a fyringe. In performing even this very fimple operation of wafhing a wound, as well as in extrading foreign fub- ftances with the forceps, or in any other way, it is proper to obferve, that much advantage may be de- rived from placing the patient in fuch a pofture as tends moft effedually to relax the injured parts, fo as to obtain as wide a feparation as poffible of the lips of the wound. I have feen different inftances, where, from want of attention to this circumftance, patients have fuffered much unneceffary pain; where, after 182 Of Simple Chap. III. various trials, the praditioner has been obliged to de- fift without accomplishing his objed ; and where another praditioner has proved at once fuccefsful, merely by putting the wounded parts in a relaxed po- rtion. ' We proceed now to confider the cure of wounds. In incifed wounds, a feparation takes place of the parts that have been divided ; and as every wound proves a caufe of irritation, the feparation which oc- curs at firft continues for fome time to increafe, mere- ly by the contradile power of the injured mufcles. In the ufual way of covering wounds with lint, or with pledgets of ointments, and where the parts have not •been previoufly drawn together and retained in their fituation, an effufion of a ferous fluid foon takes place over their whole furface, from the fmall veffels that have been cut. This is afterwards converted into pu- rulent matter: foon thereafter the parts are found to be covered with an infinite number of fmall fprouts or granulations ; and thefe having advanced to a cer- tain extent, a dry pellicle of fcarf fkin, termed a cica- trix, forms over the whole extent of the wound, and thus the cure is completed, In this manner the healing of wounds is effeded when nature is not affifted by art, or when her oper- ations are only promoted by proper coverings, and protedion merely given to fuch parts as are injured. But, although, in fome cafes, this is our only refource; and although even in this way praditioners have it al- ways in their power to forward the cure of fores ; yet it is liable to many very important objedions, which may be obviated by a different treatment. When a wound is healed in this manner, if the di- vided parts have feparated to a great extent, the fup- puration which enfues will be abundant; by which, if the conftitution is weak, the patient is apt to be much injured. In extenfive fores, this method of cure is always tedious ; when deep mufcular parts are injured, the motion of the contiguous joints is apt to Sed. II. Incised Wounds. 183 be affeded; and the cicatrix of a large wound, when cured in this manner, is always ftiff, unfeemly and difagreeable; nor is it poffeffed of that ftrength and firmnefs which the parts beneath require for their pro- tedion. Patients, however, are feldom under the neceffity of fubmitting to thefe inconveniences : for, in gener- al, wounds may be cured in a more eafy as well as in a more agreeable manner : we know from experience, that two inflamed furfaces of an animal body, when kept in contad, will foon adhere together. This was probably at firft pointed out by accident; but practi- tioners now derive much advantage from the knowl- edge of it, not merely in the management of wounds, but in a variety of important operations : by drawing fuch parts as have been divided into contad with each other ; and taking care to have them all as complete- ly covered as poffible with the cutis vera, very exten- five wounds are in this manner often quickly cured ; the power of moving and of ufing limbs with freedom is often preferved which otherwife would be loft ; the fear or mark which remains is feldom of any impor- tance ; and the wounded pai ts have the advantage of being fufficiently proteded. It has long been known that parts recently divided will unite together, if kept in contad for a fufficient length of time. The caufe, however, of this phenom- enon has not hitherto been clearly explained : the pre- vailing idea is, that it proceeds from a dired inofcula- tion or j undion of the different parts that have been divided ; and that thofe parts only will adhere togeth- er which were formerly united. Thus it is imagined in the healing of wounds in this manner, that a divid- ed artery on one fide of a cut muft be made to ad- here diredly with its fellow on the oppofite fide ; that veins muft unite with veins, and mufcular fibres with fibres of a fimilar nature. But although it is neceffa- ry in pradice to keep this idea fo far in view, as to place parts that are to be healed as exadly oppofite 184 Of Simple Chap. III. to each other as poffible ; yet this proceeds more from a requifite attention to fymmetry and neatnefs after the cure is performed, than from any other caufe: for it is certain, that no fuch exadnefs is required for the mere adhefion of the divided parts; and whoever doubts of the fad, may with little difficulty prove it experimentally. A membrane may be made to ad- here to a bone; and the divided end of an artery or a vein will unite with almoft any animal fubftance with which it is kept in contad. It is indeed true, that blood circulates through the cicatrix of a wound; a fad which few will doubt, and which probably gave rife to the opinion we are now confidering. But we have reafon to believe that this circulation does not take place immediately on the formation of a cicatrix. It feems rather to be an after procefs of nature, and is evidently accomplifhed by an infinite number of fmall vafcular fprouts or newly created blood veffels, which proceed from the larger arteries and veins on each fide of the wound, and inofculate with each other, fo as to form a fuffi- cient circulation in the parts through which they pafs. At leaft I have found, in different inftances, on ex- amining the cicatrix of a large wound, that it was al- ways very vafcular; and I conclude that it happens from a new formation of fmall blood veffels, as the divided extremity of every blood veffel, whether ar- tery or vein, when of fuch a fize as to be eafily dif- tinguifhed, is always lhut, and even obliterated, for a certain fpace from the point where the injury happen- ed, in the fame manner as in arteries that are tied with ligatures in cafes of amputation and other capi- tal operations. And if this happens in veffels of a large fize, there is reafon to fuppofe that it does fo in thofe that are fmaller. In confirmation of this opinion, we may obferve, that a circulation of blood betwixt adhering furfaces, takes place where inofculation of the kind in queftion can never occur, from no previous divifion of blood Sed. II. Incised Wounds. 185 veffels having been made. Thus, when the fkin of two contiguous fingers or toes becomes raw or tender, without any blood veffels being injured, it is difficult to prevent them from adhering; and when they do adhere, a free circulation is afterwards found to take place between them. Other inftances might be ad- duced ; but I notice this one, as it is not unfrequent, and as it is perfectly applicable to the prefent quef- tion. I therefore conclude, that wounds cured in this way, are healed in the fame manner as adhefion is produced between inflamed furfaces, namely, by ex- fudation of the glutinous part of the blood from the extremities of the divided veffels ; which in the firft place retains the parts together, and afterwards ferves to fupport the new formation of fmall blood veffels, which nature puts forth as a farther and more certain means of retention. 1 have entered into this phyfiological difcuffion, imagining that it tends to eftabliffi a material point in practice. It has commonly been fuppofed, that the fpace of twelve, fourteen, or fifteen days, is neceffary, for the complete adhefion of divided parts : a fuppo- fition which proceeds upon the idea that this adhefion is formed folely by the inofculation of blood veffels. But if agglutination alone is neceffary, in the firft in- ftance, to accomplish this adhefion, it is evident that it may be effeded fooner. Accordingly, I have uni- formly found divided parts adhering firmly about the fifth day : nay, I have known the bandages acciden- tally removed from wounds on the fecond and third days, without any feparation being produced of the parts newly united : from this it appears, that a short- er application of the ufual means of retention will an- fwer than is commonly pradifed. Surgeons term this treatment of fores, healing by the firft intention ; and as it is in every refped the moft defirable method of cure, it ffiould always be followed when it appears to be eafily pradicable. 186 Of Simple Chap. III. In fome varieties of wounds, different reafons oc- cur to prevent them from being cured in this manner. Thefe we fhall afterwards have occafion to confider, but in the fimple incifed wound, where the injury has been inflided with a clean cutting inftrument, without producing pundure, laceration, or contufion, the on- ly objedion that appears to it, is our not being able to draw the divided parts into contad, and to retain them in that fituation till they adhere together. This, however, will feldom happen, unlefs a lofs of fubftance takes place to a confiderable degree. Where a large portion of fkin, with the mufcles beneath, has been entirely cut out, it may in fome cafes be impoffible to bring the retracted edges of the wound together ; but we may always make them approach fo as greatly to diminifh the fize of the fore, and may thus have it in our power in every inftance to forward the cure. In deep tranfverfe wounds, even where no fubftance is loft, the retradion is often fo great, as to render this pradice fomewhat difficult: but by placing the injur- ed part in that fituation which tends moft effedually to relax the divided mufcles, we may effed our pur- pofe almoft in every inftance. It is indeed furprifing to fee how completely divided parts will be made to approach, which, while the mufcles were upon the ftretch, were feparated to a great diftance. We fhould never therefore defpair too foon ; for even in the worft cafes we feldom fail, by due perfeveranee in this mode of treatment, to obtain fome very effential advantage. When it is found that the divided parts may be drawn together, we have next to fix upon the belt and eafieft method of retaining them in this fituation dur- ing the cure. Various means are propofed for this ; namely bandages of different kinds, adhesive plafters, and futures. The fides of longitudinal wounds, in any of the ex- tremities, and of fome wounds of the head, may be retained by the uniting bandage. But this feldom an- fwers hi the trunk of the body; nor can it ever prove Sed. II. Incised Wounds. 187 ufeful in wounds, either in the legs or arms, that run tranfverfely : and even where there is reafon to think that it will anfwer fufficiently well for retaining the fides of a wound in contad, we ought never to truft to it entirely; for we cannot depend upon a bandage alone for preferving the ikin fmooth and equal; a cir- cumftance of much importance in the cure. The eafieft method of retaining the fkin exadly in its fituation, is by means of adhefive plafters applied in the manner reprefented in Plate LI. In fome cafes plafters alone prove fufficient; but when much re- tradion takes place, the uniting bandage fhould be applied over them whenever the diredion of the wound renders it admiffible. Many praditioners, in all cafes of wounds, prefer adhefive plafter to the ufe of futures ; but it is in par- ticular inftances only that this preference is proper. Adhefive plafters may be ufed with advantage in fu- perficial wounds that do not penetrate much deeper than the cellular membrane; and where there is a lofs of fubftance to fuch an extent as to prevent the fides of a wound from being drawn clofe together, they may be employed for the purpofe of retaining the retraded parts as near as poffible to each other. But in all wounds that penetrate to any confiderable depth, and when their edges can be drawn into con- tact, the twilled future is by much the beft for retain- ing them. For a defcription of this and other futures, I muft refer to Chap. V. The common interrupted future is indeed more frequently employed than the other ; but it does not fupport the parts with fuch certainty ; the ligatures are more apt to tear or cut out the parts which they furround; and they fre- quently leave difagreeable. marks. It is a common opinion, I may remark, that adhe- five plafters and futures are admiffible only in the re- cent ftate of wounds. But however defirable it may be, for various reafons, to have the application of ei- ther of them made as early as poffible ; yet when ne- 188 Of Simple Chap. III. gleded at firft, they may commonly be employed with advantage during any ftage of the fore ; for we are wrong in fuppofing, as is commonly done, that wound- ed parts will not adhere when in a ftate of purulency. I have repeatedly treated, in this manner, fores of two, three, and four weeks duration, and very commonly with advantage : infomuch, that I believe the pradice will generally fucceed in every ftage of a fore, when the retraded edges can be brought together. Whether adhefive plafters or futures are preferred, we fhould be very attentive in fupporting the parts, as far as it can be done, by the pofture of the pa- tient ; for if this be not done, futures of every kind will yield fo as not to anfwer the purpofe : and along with this, when plafters are ufed, a further advantage, as I have already obferved, may be derived from a proper application of the uniting bandage; but for the reafons that will be given in the chapter on Su- tures, a point that will alio be further taken notice of, when treating of the hare lip in Chap. XXXIII. nei- ther this nor any other bandage can with propriety be employed along with the twilled future. When a wound is treated in this manner, as foon as the retraded edges are drawn together and proper- ly fupported with plafters or futures, no other dref- fings are neceffary, excepting a thin covering of foft lint to proted the parts beneath from cold; and with a view to prevent as much as poffible any accefs to air, the lint fhould be fpread either with fome undu- ous fubftance, or with mucilage of gum arabic, or any other inoffenfive gum. This being done, the patient ffiould be made to preferve the injured parts in the moft favourable pof- ture ; and care ffiould be taken to enjoin a well re- gulated diet. If the patient is low and emaciated, he may with propriety have a fmall allowance of animal food ; but when plethoric, or liable to inflammatory affedions, and the wound extenfive, a ftrid antiphlo- gistic courfe is requifite: for although inflammation Sed. H. Incised Wounds. 189 to a certain extent may be neceffary for the cure of wounds ; yet a prudent praditioner will always guard againft excefs of inflammation, as produdive of much harm. In open wounds, the moft effedual remedy for the removal of extreme degrees of inflammation, is warm emollient cataplafms; but as they tend to induce the formation of matter, and as this is diredly oppofite to our views in the mode of cure that we are now confidering, it is evident in fuch circumftances that they are inapplicable. But although warm emollients cannot with propriety be employed; yet much ad- vantage may be derived from a proper ufe of any cold emollient oil or unguent. When the attending fymp- toms of pain and inflammation are moderate, the dreffings ffiould never be removed till the cure is completed; but whenever the pain becomes fevere, as it would be apt to terminate in feme high degree of inflammation, by which our views might be com- pletely frustrated, the dreffings fhould be immediately taken away, fo as to admit of the pained parts being gently rubbed or even bathed with an emollient. By this being repeated from time to time, I have feen different inftances of very diftrefsful degrees of pain being alleviated, and of the contiguous parts being fo much relaxed, as to' admit of the cure by adhefion going on without interruption. In fome cafes, how- ever, we are under the neceffity of employing other means; and of thefe the moft effedual are opiates and bloodletting, particularly local bloodletting with leeches; which often proves effedual in removing pain and inflammation, when every other application has been tried in vain, In general, a continuation of thefe means will an- fwer the purpofe : but it fometimes happens, notwith- ftanding all our endeavours, that the pain and inflam- mation increafe, and the tenfion of the wounded parts becoming more confiderable, the plafters and liga- tures with which they have been kept together muft 190 Of Simple Chap. IIL be taken away, otherwife they will do halm. In fuch circumftances, the ligatures ffiould be removed at once; and for the mofl part this will give the patient immediate relief: the pain and tenfion will foon dis- appear ; and a cure muft be accomplifhed in the or- dinary way, as it might prove hazardous to attempt the fame method of treatment again. I think it right, however, to remark, that, in gene- ral, the cure goes on without any interruption of this kind; and where this is the cafe, our views are com- pleted as foon as a firm degree of adhefion has taken place between the edges of the wound. I have alrea- dy remarked, that this procefs is commonly accom- plifhed in a fhorter time than is ufually imagined. In fuperficial wounds, the ligatures, or other means of retention, may be removed fooner; but even in deep extenfive wounds, if the habit of body is found, they may with fafety be taken away on the fifth or fixth day. By this time every advantage that can be derived from them will be gained; while much in- convenience, and fome mifchief, might arife from their being allowed to remain longer. I have already mentioned many of the advantages which refult from this method of curing wounds. They are indeed fo important, that we ffiould feldom hefitate to advife it; for even when it fails, we know that any troublefome fymptom which it may induce, will be removed by due attention to the means that I have mentioned ; while much time will be gained when it fucceeds. Two objedions are commonly made to it, which I fhall now fhortly con- fider. It is faid, that the ligatures with which it is often neceffary in wounds to fecure the arteries, will ad as extraneous bodies, and prevent the fides of the wound from uniting. And it is likewife obferved, that in the courfe of the cure matter is apt to form, from the lodging of which, troublefome finufes are produced. Neither of thefe objedions, however, are well founded; at leaft, I have never met with a fin- Sed. II. Incised Wounds. 101 gle inftance of their being fo. It feldom happens that more than one or two arteries in any wound require to be tied: but I know from experience, that wounds may be cured by drawing their edges together, even where a large number of arteries has been fecured with ligatures: for the threads occupy very little fpace, and when applied with the tenaculum, which ought always to be done, they are eafily removed without any difturbance being given to the reft of the wound. And again, with refped to finufes being apt to form from this method of treatment, if the edges of a wound are only drawn together above, a cavity will thus be formed beneath, where matter will no doubt be apt to lodge; but this fliould not be attri- buted to the method of cure, but to the mode of put- ting it in pradice: for in every wound treated in this manner, the whole of the fides or edges fhould be drawn together from the furface to the bottom, by which the formation of finufes is effedually guarded againft. ^We have now to fpeak of thofe wounds which do not admit of this mode of treatment. When the edges of a^ cut cannot be drawn together, after the haemorrhagy is ftopped, and extraneous bodies remov- ed, we find by experience, that the moft effedual af- fiflance we can afford, is to promote as much as pof- fible the formation of matter: for the fad is undoubt- ed, that in every wound of this kind, a free fuppura- tion proves the moft effedual relief to every fymptom; at the fame time that it appears to be fo materially conneded with the cure, that the healing procefs nev- er begins till the fore is covered with good pus; a circumftance not difficult to explain. The cure of fores healed in this manner, is fo far an effort of na- ture alone, that although fome advantage may be de- rived from art, yet the chief objed of praditioners in this branch of bufinefs, ffiould be merely to remove fuch impediments as might tend to obftrud the oper- ations of nature, and to proted the injured parts till 192 Of Simple Chap. III. the cicatrix becomes fufficiently firm. Now, as we know that granulations do not readily form in fores as long as they remain painful ; and as nothing with which we are acquainted proves fo mild an application to wounds as pus, we may conclude, that it proves chiefly ufeful by preferving the injured parts, in that eafy, pleafant ftate, which feems to be indifpenfably neceffary for the cure. It ffiould therefore be our firft objed, in the treatment of fores of this defcrip- tion, to forward the formation of pus, as quickly a3 poffible; and the moft effedual method of doing it is, by treating every wound in the fame manner as we do a common phlegmon; that is, by a free ufe of warm emollient poultices and fomentations. In the firft place, the parts fhould be immediately covered with a pledget of lint, fpread with an emol- lient mild ointment, with the view of preventing the admiflion of air. When the pain is exceffive, poulti- ces may be diredly applied above the dreffings, as be- ing the fureft means of relieving it: but, when the pain is moderate, it is better to delay the ufe of poul- tices for a day or two ; for as pus cannot be produc- ed till a ferous effufion has taken place, and as we know that fome degree of inflammation is required for effeding this, when the pain and tenfion in wounds are moderate, an immediate application of poultices is apt to do harm, either by preventing altogether, or by retarding and rendering too languid, that ftate of in- flammation which appears to be neceffary for the cure. But in every inftance of wounds of confidera- ble extent, remedies of this kind prove always ufeful after the firft two or three days have elapfed : for by this time a fufficient degree of inflammation has com- monly taken place, for effeding the wiffied for effu- fion ; and I have already taken various opportunities of ffiewing, that in no other way can this be fo readi- ly converted into purulent matter, as by a free appli- cation of heat; * ib that whenever we wiffi to advife •■ See Chap. I. Sed. HI. Sed. H. Incised Wounds. m it, we ffiould carry it to the fame extent as in cafes of phlegmon. It is proper, however, to remark, that in the treat- ment of wounds, this remedy ffiould be ufed With cau- tion. For although heat, whether conveyed by means of poultices or fomentations, is perhaps the moft ufe* ful application in the ftage of wound we are now eon» fidering ; yet when long continued, it is very apt to do harm, as we have daily opportunities of obferving, Where it is employed by thofe who do not confider upon what principles it ads in the cure. When the purpofe that I have mentioned is gained, namely, a free and kindly fuppuration, as it is for this only that poultices are ufed, they ffiould then be laid afide: fof when continued longer, they almoft conftantly do harm, by relaxing the parts to which they are applied too much; by which they are apt to become pale, foft, and fpongy, inftead of being of a healthy red col- our, and of a firm texture. Nay, they are at laft of- ten produdive of the very contrary effed for which they are employed: for although much inflammation proves hurtful in the cure of wounds, yet in fome de- gree it is always neceffary. Now, by continuing the ufe of warm emollients too long, this falutary degree of inflammation is fo entirely carried off, that the mat- ter becomes thin and in too great quantity. And thug troublefome vitiated fores are produced, which under different management would not probably have hap* pened. The period at which the ufe of poultices atid othef warm applications ffiould be laid afide, muft be deter- mined in every cafe by the judgment of the pradition- er. This general rule, however, may be fafely adopt- ed that they may at all times be perfifted in as long as much pain and inflammation continue; but thefe fymptoms becoming moderate, the difcharge being good, and the furface of the wound covered with granulations of a healthy appearance, they fhould be Vol. I. O 194 Of Simple Chap. III. left off. In this ftate of a fore, all the advantages are gained which poultices can produce; and when long continued, fome of the inconveniencies I have men- tioned are very apt to enfue. In the enfuing chapter, I fhall have occafion to en- ter upon a more particular detail of the beft dreffings for wounds. It will not, therefore, be neceffary at prefent, to fpeak minutely upon this part of our fub- jed. I have already had occafion to remark, that a cer- tain degree of inflammation is requifite for the cure of every fore; but as this very rarely proves deficient, and as we have more to dread from this fymptom proceeding too far, efpecially in the firft ftages of large wounds, the mildeft dreffings only ffiould be employ- ed. During the progrefs of the cure, much advan- tage indeed is occafionally obtained from deffings of an irritating, or even of an efcharotic nature. This, however, is only the cafe, when a wound has advanc- ed to the ftate of an ulcer. While yet recent, the mildeft application is always the beft. In this coun- try, foft dry lint is commonly employed, while fome praditioners advife pieces of foft fponge ; and it muft be admitted, that they anfwer much better than any of the irritating balfams, which till of late were very univerfally ufed, and which in moft parts of Europe are ftill continued; for it was in Britain that mild dreffings to wounds were firft introduced ; and it is in this country only where even yet they have been generally received. But although dry lint is a mild application when compared with many others, it al- ways creates pain and irritation on being firft applied, befides being apt to adhere to the edges of wounds, fo as to be with difficulty removed. With a view to prevent thefe inconveniencies, the lint ffiould be thinly fpread with any mild ointment; fuch as Goulard's cerate, or common wax ointment. By this means it gives no pain in the application, while it is removed with eafe, at the fame time that it ferves more effedu- Sed. II. Incised Wounds. 195 ally than dry materials to prevent the air from finding accefs to the fores. As dry lint, however, has long been generally employed in this country, any innova- tion will not be readily admitted ; but what I have ad- vifed, being the refult of much experience, I can with confidence recommend it. A piece of foft lint, fpread with any ointment of this kind, being laid over the wound, a bolfter of fine tow ffiould be applied above ft for the purpofe of keep- ing the parts warm, as well as for absorbing any mat- ter that may-be difcharged ; and this being covered with a comprefs of old foft linen, the whole ffiould be retained by a bandage of fine flannel or cotton, which is preferable to linen, in fo far as it is commonly more agreeable to the feelings of the patient, and as it yields more eafily to any accidental fwelling of the neigh- bouring parts: whereas linen, poffeffing little. or no elafticity, is very apt to do harm, by remaining ftiff and immoveable, notwithftanding any fwelling that may enfue. Praditioners are not agreed upon the time at which the firft dreffings of fores fhould be removed; and nothing decifive can be faid upon it, as in fome mea- fure it muft be direded by the circumftances of every cafe. This general rule, however, may be kept in view, that fores fhould always be dreffed when plenti- fully covered with matter. This will generally be the cafe about the fourth or fifth day ; but as the forma- tion of pus depends upon different circumftances, par- ticularly upon the health of the patient, and on the degree of heat in which the parts are kept, fome lati- tude muft be allowed in it. A free ufe of poultices after the fecond day, puts it in our power to remove the dreffings much fooner than we otherwife could do : for they not only promote the formation of mat- ter, but foften all the coverings that have been ufed, fo as to admit of their being eafily taken away. o 2 ig.6 Of Simple Chap. III. When the cure of a wound goes on without inter- ruption, the fecond, as well as the fubfequent dref- fings, ffiould be precifely the fame as the firft : for our objed being ftill the fame, no variation, it is evi- dent, can he neceffary. As nothing proves more hurt- ful to fores than expofure to the air, one great objed in the application of dreffings, is to prevent any in- convenience which might arife from this. And the fame reafon renders it neceffary to change the dreffings as feldom as is confiftent with cleanlinefs; and to be as expeditious as poffible in renewing them. In gen- eral, however, no harm will occur from the daily • dreffing of wounds. They fhould not but in very particular circumftances, be dreffed more frequently ; nor can it often be proper to drefs them feldomer than this: for when matter is allowed to lodge long, the heat in which patients with large wounds are ufually kept, is apt to render it putrid and offenfive. But as I fhall elfewhere have occafion to fpeak fully upon this fubjed,* it is not at prefent neceffary to confider it more particularly: I fhall juft obferve further, with refped to the continuance of mild dreffings to wounds^ that it ought to be regulated by the progrefs of the cure. As long as the cure continues to advance, mild dreffings ffiould be continued ; but when the fore affumes any vitiated or morbid appearance, fome variety in the dreffings becomes necelTary; and the nature of any change to be thus adopted muft be reg- ulated by the ftate of the fore at the time. For the further confideration, however, of this part of our fub- jed, I fhall refer to the different fections of the enfu- ing chapter. I have hitherto been fuppofing that none of the fymptoms are violent; in which cafe the cure will, for the moft part, go eafily on, under the mode of man- agement I have mentioned. But in fome cafes the healing of the fore is not only much interrupted, but ' Vide Chap. IV. Sed. II. Incised Wounds. 197 much hazard is induced by the unufual height to which fome of the fymptoms proceed ; and thefe par- ticularly are, pain, inflammation, and convulfive af- fedions of the mufcles. I fhall therefore offer a few obfervations upon the means of obviating thefe fymp- toms, when they proceed to fuch a height as to prove hazardous. A wound cannot be inflided without inducing pain : for even the flighteft cut muft neceffarily injure fome of the fmaller branches Of nerves; by which pain, to a certain degree, muft be induced. It commonly happens, however, that the pain in wounds is not at firft fo fevere as to require any par- ticular management: and, in general, it fubfides en- tirelv, on all extraneous bodies being removed, and a plentiful formation of matter being induced. But oc- cafionally the pain continues fevere even on this hav- ing happened : in fuch circumftances we truft chiefly to opiates, and they feldom fail to give relief. But it frequently happens that their effed is only temporary, the pain being apt to recur after the ftrength of the opiate is exhaufted. In this event we are to fearch with much care for the caufe of the pain. It may proceed from fome particles of extraneous matter which have not been difcovered ; from inflammation of the wounded parts ; or from fome portion of a nerve or tendon being par- tially wounded without being divided ; or merely from irritation over the whole furface of the fore. We fhould, therefore, in the firft place, examine the wound with attention, fo as to be as certain as pof- fible that no extraneous matter has found accefs; for when pain proceeds from any foreign body lodged in a wound, the removal of this will, for the moft part, procure relief; while no other remedy will have any effed as long as it is allowed to remain. When not readily difcovered, or when the particles of any extra- neous matter that may be lodged in a wound are fo fmall that they cannot be removed with the fingers, I 198 Of Simple Chap. III. have already advifed the injeding of warm water, by which they will often be waffied out when every oth- er trial has failed, But when this does not fucceed, the wound fhould be immerfed for a confiderable time, perhaps for an hour, morning and evening, in warm water, or in warm milk; by which particles of matter are fometimes diffolved and carried out, which would otherwife have continued to give much unea- finefs. When all the trials, however, that we make for re- moving pain happen to fail, we muft fearch for fome other caufe of its proving fo uncommonly obftinate; and it will often be found to originate from inflam- mation. When the external parts of a wound are inflamed, this caufe of pain is at once rendered obvi- ous ; for even the flighteft degree of external inflam- mation is readily perceived; but it fometimes hap- pens, that the periofteum, and other deep feated parts, are inflamed, without any external marks of it taking place. This, however, is only the cafe for fome fhort period after the inflammation has commenced: for even when it firft attacks parts that are deeply feated, it commonly fpreads in the courfe of a day or two, fo as to be difcovered outwardly; and when this does not happen, we may in general be direded to the Caufe, by the heat of the patient's body : by the ftate of his pulfe; and by the degree of third, which in cafes of this kjnd is always increafed. When thefe fymptoms of fever run high, it is fometimes neceffary to advife bloodletting to a con- fiderable extent; but inftead of taking blood with a lancet, our views are with much more certainty an- fwered by the application of leeches along the edges of the wound. In fuch circumftances, indeed, no re^ medy proves, fo ufeful as the difcharge of blood in this manner. I have long been in the pradice of ufing it in wounds accompanied with much inflammation, and very commonly with much advantage. In cafes of pain proceeding from this caufe, I have known the Sed. II. Incised Wounds. 199 application of a few leeches to the edges of a wound procure immediate relief, even where large dofes of opiates, as well as other remedies, had previoufly been tried in vain. And that it is not the quantity of blood, but the manner of difcharging it, which proves fuccefsful, is evident from this, that the pain is often relieved immediately on a few drops being taken with leeches, which did not yield in any degree to the lofs of large quantities by venefedion. In ufing leeches for this purpofe, they ffiould be applied as near as poffible to the edges of the wound; nay, when they will fix within the wound itfelf, the pradice proves ftill more fuccefsful: but unlefs the inflammation is deeply feated, this meafure is feldom neceffary. It fometimes happens, however, as I have obferved above, that in deep wounds no inflammation of any importance appears externally, while the periofteum and other deep feated parts are much inflamed and painful. In this fituation, nothing affords fo much relief as fcarifications made in the inflamed parts, eith- er with the fhoulder of a lancet, or the point of a fcal- pel. Nor need we hefitate to advife them, under the dread of their being apt to produce exfoliations of the bone beneath. Inftead of this, they tend more cer- tainly than any other remedy to prevent them; for exfoliations feldom happen from the periofteum being merely divided ; of which we have daily inftances in wounds penetrating to this depth, which are rarely attended with this effed, unlefs the bone itfelf is at the fame time injured. In different cafes I have fca- rified the periofteum and other parts deeply feated in wounds, and always with advantage. It removes pain and tenfion in the moft effedual manner, and thus tends with more certainty than any other remedy to relieve the moft diftrefsful fymptoms which wounds ever excite. After as much blood is difcharged as may be judg- ed proper, whether by leeches or fcarifications, no ap- plication will prove fo ufeful as warm emollient poul- 200 Of Simple Chap. III. tices and fomentations frequently renewed; for in fuch circumftances nothing affords fuch complete re- lief as a plentiful formation of matter. We conftant- ly obferve, that as long as a wound remains dry on the furface, the parts are tenfe,. much inflamed, and painful; and that they become lax and eafy as foon as they are properly covered with purulent matter. ^ For- the moft part, the means that I have advifed will be attended with the defired effed: and efpecial- ly if the operator is not too timid in making the fca- rifications,- when they are judged to be neceffary ; for I inufl: again obferve,. that this may be done with mose; fafet-y and freedom than is commonly imagined; and. when membranes in any fituation are much in- flamed, nothing with which, we are acquainted fo cer- tainly tends to prevent the acceffion. of gangrene as cfeep and free fcarifications. Even, this remedy, how- ever, will not always fucceed : for in fome cafes the inflammation, inftead of abating, becomes more and more violent,, till at laft it terminates in mortification. When wounds are attended with violent, pain pro- ceeding from inflammation, the caufe., as I have ob- ferved above, is for the moft part readily perceived. But fevere pain is fometimes induced by other caufes; for although much pain feldom fails to induce an in- flamed ftate of a wound at laft, it often fubfifts for a confiderable time before this takes place. In fuch cafes, and efpecially where we have no caufe to fufc pect that the pain arifes from the lodgment of matter, it m\\ often be. found to proceed from the partial di- vifion of a nerve or tendon: for we know, that in various inftances the moft excruciating pain is induc- ed in this manner. In fome cafes, the pain produced by this, is reliev- ed by putting the injured parts into a.ftate of relaxa- tion ; but, for the moft part, the only remedy upon which we can depend is a complete divifion of the wounded nerve or tendon: and as this is a mean of cure which may at all times be pradifed without rifk, Sed. IL Incised Wounds. 201 it ffiould never be delayed when the pain is found to proceed from this caufe; and efpecially when, from its violence, there is reafon to fufped that it may in- duce convulfions and other alarming fymptoms. As a free ufe of the fcalpel, however, is neceffary, pa- tients in general do not eafily fubmit to this remedy ; nor do we commonly find that praditioners advife it. But I can fay from many inftances of its beneficial effeds, that we ought more frequently to pradife it; for it feldom fails to give relief, even in fevere de- grees of pain ; and 1 never heard of its proving hurt- ful. It ought always, however, to be advifed as foon as the other means that may be employed have fail- ed : for when violent pain has fubfifted fo long as to induce any material affedion of the convulsive kind, even this remedy will not always remove it. On the parts being freely divided, they ffiould be placed in a relaxed pofture ; and an emollient poultice being laid over them, if the pradice proves fuccefsful, the pa- tient will foon find himfelf relieved, and the wound may afterwards be treated in the ufual way. But when the operation does not prove fuccefsful, as will be the cafe, when from timidity, or any other caufe, it has been long delayed, there will be much caufe to fufped that the patient will at laft die convulfed, not- withstanding the ufe of opiates, and every other re- medy we can employ, In fome wounds again, the pain, inftead of being deeply feated, which it always is when it proceeds from an injury done to a particular nerve or tendon, is found to originate from a peculiar degree of irrita- bility of the nerves on the furface of the fore. The pain, in fuch inftances, is not fevere ; but it often proceeds to fuch a height as to excite much uneafu nefs, by which the patient is apt to be deprived of reft, and the matter difcharged from the fore render- ed fharp and acrid. For the removal of this, emollient poultices, and other warm applications, are commonly employed ; loz Of Simple. Chap. III. but feldom with any advantage. They often appear, indeed, to increafe the irritabifity. Large dofes of opium afford the moft certain relief; and a folution of opium in water, or a weak faturnine folution, are the belt external remedies. When of a proper ftrength, they commonly prove fuccefsful. While fpeaking of the caufe and removal of pain, it was ne- ceffary to mention inflammation, with the means belt adapted for the cure. We have now to attend to the nature and treatment of fome convulfive affedions which injuries of this kind fometimes induce. Subfultus tendinum, and other fpafmodic fymp- toms, are frequent confequences of wounds : they are more particularly apt ro enfue from the amputation of limbs, when they often prove the caufe of much dif- trefs ; for the starting which they are apt to produce in the affeded limb, excites a violence of action which mufcular parts newly divided are not well fitted to fupport. And when thefe are fevere, and return fre- quently, they prevent the dreffings from being kept properly applied, at the fame time that they are often the caufe of haemorrhagies from arteries which have even been tied with ligatures. We ought, therefore, in every inftance, to treat this fet of fymptoms with attention. Indeed the rifk of their producing hae- morrhages is fo confiderable, and the fenfations which they excite are fo diftrefsful, that a prudent pradi- tioner will at all times judge them to be of import- ance. As thefe convulfive twitchings are evidently the effed of irritation produced by the wound, thofe means are moft likely to prove effedual in the cure, which are moft powerful in procuring eafe. Hence much advantage is derived from placing the patient's body, and efpecially the affeded limb, in the eafieft pofture : indeed more benefit is derived from this than we are often aware of. I have known the fe> vereft fpafms almoft inftantly removed, by changing Sed. II. Incised Wounds. 203 the pofture of a flump. But when this does not an- fwer, opiates will feldom fail. It is worthy of obfervation, in ufing opium for this purpofe, that it anfwers better to give it in fmall do- les frequently repeated, than in large dofes at once. The latter often excite ficknefs, and even vomiting; and after their effeds are over, the fpafms are apt to become more fevere than they were at firft; which feldom happens with opiates in fmall dofes, although frequently repeated. Thefe, however, are not the moft alarming fymp- toms of the convulfive kind which arife from wounds. Tetanus and locked jaw fometimes proceed from them, particularly in warm climates. Occafionally, indeed, thefe fymptoms originate from other caufes, the nature of which we cannot always difcover ; but when not obvioufly induced by deep or extenfive wounds, they may often be traced, by a more minute investigation, to fome flight injury done to the furface of the body. Even the flighteft fcratch, not pene- trating to a greater depth than the fkin, has been known to induce them. As we know that fevere degrees of pain often ex- cite involuntary contradions of injured mufcles, we would naturally exped that deep and extenfive wounds would be frequently attended with this effed. But we do not fo readily fee how the moft violent af- fedions of this kind ffiould be moft apt to occur from fuch wounds as are fo flight as fcarcely to be noticed, and which never of themfelves produced much unea- finefs : this, however, certainly happens. Nor do injuries of greater importance induce thefe fymptoms fo readily while they are recent and pain- ful : for thev feldom occur in large wounds till the cure is far advanced ; and in fome inftances, particu- larly after the amputation of limbs, they are never more apt to appear than when the cicatrix is nearly completed. At leaft this has been the cafe in every inftance of locked jaw that I have met with in this 204 Of Simple Chap. III. country ; and we are told, from very certain authori- ty, that the fame obfervation has been made in warm climates.* The caufe of this, it may be difficult to explain; but our knowledge of the fad leads to fome advan- tage m pradice. We have hitherto been made to fuppofe, that the locked jaw, and other convulfive fymptoms which fometimes fucceed to wounds, are mofl apt to occur from the violence of pain induced at, or foon after, the time of wounds being inflided; and therefore praditioners have guarded with molt affiduity againft them, while the pain has continued fevere- But when it is known that thefe fymptoms feldom or never occur at this period, and that they frequently appear in more advanced ftages of wounds, thofe means of prevention which are found to prove moft effedual, will more readily ad with advantage if applied at this time. Practitioners, therefore, in warm climates, ffiould have this particularly in view in the advanced ftages of wounds ; and the moft effedual remedy we can employ, on the firft appearance of a locked jaw, is immerfing the patient, fo as to cover the whole body, in a warm bath. The heat of the bath ffiould be reg- ulated by the feelings of the patient; and he ought to remain in it as long as he is able to bear it. Water is commonly ufed for this purpofe ; but where milk can be procured, it ffiould be preferred: for as the warm bath proves here chiefly ufeful by its relaxing powers, we have reafon to fuppofe, that the oily parti- cles contained in milk render it particularly proper ; and the idea appears to be well founded by the bene-. ficial effeds which in different inftances have refulted from the ufe of it. It may often happen, however, that milk cannot be procured in quantities fufficient for this purpofe. In fuch situations, fat broths, or water combined with * Vide Obfervations on the Difeafes incident to Seamen, by Gilbert Blane, M. D. &c. Sed. II. Incised Wounds. 2oc oil in any other form, may be ufed inftead of it. When one application of a bath proves fuccefsful the ufe of it need not be continued ; but for the moft part feveral repetitions of it are neceffary. Nor are we to imagine that warm bathing is a certain remedy. It has frequently, indeed, proved highly ufeful, and many cafes of locked jaw have been cured by it; but we muft likewife confefs that it has often failed, and that patients are daily carried off in warm climates by this and other convulfive fymptoms, notwithftanding the moft ample application of the warm bath, and of every other remedy that has hitherto been employed. The failure of warm bathing has induced fome praditioners to make trial of the cold bath ; and in fome convulfive affedions it has certainly proved ufe- ful ; particularly in cafes of univerfal tetanus : but as et it has not been fo frequently employed as to ena- le us to judge with precifion, whether it will often prove ufeful or not in the locked jaw, which we are to confider as the moft obftinate, as it is the moft dan- gerous, fymptom of this kind. At the fame time that we perfift in the ufe of warm bathing, other remedies ffiould not be negleded ; and of thefe opium is the moft certain. Opium proves ufeful here, whether it is ufed outwardly or given in- ternally. By rubbing the contraded mufcles with laudanum, or keeping them covered with extrad of opium, or with opium merely foftened with fpirits of water, the fpafm has in fome inftances been leffened: but the moft effedual relief obtained from this reme- dy is by giving it inwardly; not in large quantities as I have remarked above, but in fmall dofes, frequently repeated. The dofes fhould be fuch, however, as may effedually allay the pain and uneafinefs produced by the difeafe ; but more than this is unneceffary. When given in large dofes, it feems to do mifchief, by induc- ing that very ftate of the fyftem which it was meant to prevent, namely, a great degree of irritability : for as foon as the operation of a large dofe of opium is ao6 Of Simple Incised Wounds, Chap. IIL over, we commonly find in all fpafmodic affedions, that the difeafe returns with double violence. But this may be eafily prevented, by giving fuch dofes as the patient can eafily bear, and repeating them at fhort intervals, in fuch a manner that the effeds of one may not be over before another is given. iEther and mufk have fometimes been conjoined with opium in convul- five fymptoms of this kind ; but fo far as my experi- ence goes, no obvious benefit has ever enfued from them. I have mentioned opium as an external application ; but no outward application proves ever fo ufeful here, as emollients freely laid over the contraded parts. The nature of the difeafe feems ftrongly to point them out; and experience has, in fome inftances, fhewn, that they ad with advantage. Emollients of every kind may be employed for this purpofe ; but animal fats of the fofter kinds feem to be the beft ; for in all cafes of contraded mufcles, they relax the parts more powerfully than any of the vegetable oils ; at leaft, in the courfe of my experience, this has uniformly been the cafe. I have elfewhere obferved, that a very pure oil of this kind is obtained by boiling recent bones in water; and the fat of all kinds of fowls anfwers equal- ly well. ' Mercurials have been frequently given in locked jaw; but where they have ever proved ufeful, has been in fuch cafes only where mercury was rubbed upon the contraded parts in the form of an ointment, and where it would probably ad with advantage as an emollient. When a locked jaw is produced by a wound in any of the extremities, if the difeafe does not yield to the remedies that I have mentioned, it has been propofed to amputate the limb ; and in various cafes this has been done. I am forry, however, to obferve, that we have fcarcely an inftance of the operation proving ufe- ful : for in this difeafe, as in almoft every fpafmodic affedion, the efled is apt to remain after the caufe is Sed. HI. Of Pundured Wounds. 207 removed. We have therefore no encouragement, from paft experience, to put this remedy in practice. Inftead of tending to fave life, it appears rather to ag- gravate every fymptom, and even to accelerate the ap- proach of .death. The remedies, therefore, which we have to depend on, are thofe that I have mentioned, namely, the warm bath, opiates, and a free ufe of emollients. While we are fruiting to thefe for effeding a cure, the patient's ftrength ffiould be fupported by mild nourishment given by the mouth, when this can be done ; and by glyflers of ftrong broths, when the jaws are fo firmly fixed together as to prevent food from being received by the mouth: and we may, by re- moving a tooth or two, even in cafes of this kind, con- vey food to the ftomach ; fo that wherever the fymp- toms of locked jaw are obferved to be approaching, one or two of the teeth fhould be taken out, as they cannot be removed but with much difficulty after the jaws are firmly clinched. Having thus confidered the various circumftances relating to wounds in their moft ufual form, with the means of cure on which we ought to depend, I fhall now proceed to mention more particularly fome vari- eties in wounds which require a different mode of treatment; and thefe are, pundures, laceration, and contufion. SECTION III. Of Pundured Wounds. A WOUND is faid to be pundured, when it is made with a fmall pointed inftrument; and when the external aperture, inftead of being wide and extenfive in proportion to the depth, is fmall and con- 2o8 Of Pundured Wounds, Chap. III. traded. A wound made by a thrufl with a bayonet or fmall fword, is of this kind. Pundured wounds prove, in general, more hazard- ous than incifed wounds of much greater extent; from deep feated nerves and other parts of importance being more apt to be partially hurt; from extraneous bodies being often carried to a depth from whence they cannot be eafily removed ; from the difcharge which they afford being more apt to lodge ; and from the fides of the pundured parts being with difficulty made to adhere. Thefe are points of the utmoft mo- ment, not only from their being often produdive of much diftrefs to patients, but from the embarraffment which they give to praditioners, who are more apt to fail in their treatment of this variety of wound than of any other which falls within their management. Much of the rifk arifing from pundured wounds proceeds, it is evident, from their being fo contraded, that free accefs cannot be got to their full depth : and it is equally evident that this can be obviated only by laying them open. Indeed, this is the idea which, in the treatment of pundured wounds, we fhould always keep in view, that of converting them, as far as with fafety can be done, into incifed wounds with exten- five openings. This, however, is a queftion about which practitioners are not agreed: fome advife the openings of pundured wounds to be enlarged either with tents or with the fcalpel; while others allege that this is feldom requifite: and they have alfo dif- fered with refped to the time at which the dilatation ffiould be made ; for while fome advife it to be de- layed for a few days only, others do not make the at- tempt till every other means have failed. In the treatment of pundured wounds our views" ought to be the fame as In cafes of finus. Indeed, this kind of wound is exadly a finus in a recent ftate ; and by confidering it as fuch, the means of cure that will moft likely prove fuccefsful, are at once pointed out. In every finus, our intention is to procure a re* Sed. III. Of Pundured Wounds. 209 union of the parts which have been divided ; but we know from experience that this cannot be accomplifh- ed till a certain degree of inflammation is induced on every part of them. For this purpofe, the introdudion of a cord or feton along the courfe of a finus has fre- quently proved fuccefsful; and feme have, with the fame views, employed irritating injedions. When by thefe means the internal furface of the finus is fuffi- ciently inflamed, the cure is to be completed by com* preffion, applied in fuch a manner as to keep the parts intended to be united in clofe contad, till a fuf- ficient degree of adhefion is produced. Now, in the application of this treatment to pundured wounds, it is obvious, that the previous fteps which I have advif- ed for exciting inflammation, would at firft be feldom neceffary; for one certain effed of every wound is to induce inflammation over all the parts which have been injured: fo that d priori we ffiould be led to con- clude, that compreffion alone would in all fuch cafes be fufficient; for we know that it feldom fails in oth- er cafes of finus where a due degree of inflammation is induced. But we are deterred, in pundured wounds, from the immediate ufe of this remedy; chief- ly where they penetrate to any confiderable depth, from our uncertainty with refped to extraneous bod- ies being lodged in them or not, and from the inflam- mation in this variety of wound being apt to run too high. In fuperficial wounds, indeed, where we are certain of being able to extrad any extraneous mat- ter, and where the inflammation is inconfiderable, compreffion may be employed immediately ; and when properly applied, it will not often fail. But for the reafons which I have given, it can feldom be employ- ed with fafety in wounds of much importance. The pradice that I have long adopted in pundured wounds is this: when they do not run deep, and their diredion is fuch as to prevent a cord from being car- ried along their whole courfe, I lay them open imme- VOL. I. P ijo Of Pundured Wounds. Chap. III. diately from one extremity to the other, or as far as it can be done with fafety, either with a probe pointed biftoury, or with a fcalpel and diredor: and this be- ing done, the parts are dreffed in the manner I have advifed above, in cafes of fimple incifed wounds. But when it appears that a feton can with propriety be ufed, emollient poultices are firft applied and continu- ed till a free fuppuration is induced, and till there is no caufe to fear that the fymptoms of inflammation are to proceed too far. A cord is then introduced nearly equal to the fize of the opening ; and being al- lowed to remain till there is reafon to imagine that any extraneous matter lodged in the wound is difcharged, it is then gradually leffened, by taking away a thread or two every three or four days ; and when reduced to a third of its original thicknefs, it is taken out en- tirely ; when the remainder of the cure is for the moft part eafily effeded, by the application of moderate preffure along the courfe of the wound. When a pundured wound is laid open at both ends, a cord may be eafily introduced by means of a blunt probe, with an eye in one end of it. But when the wounding inftrument has not paffed through the in- teguments on the oppofite fide to which it entered, a counter opening muft be made, either by cutting with a fcalpel on the round end of a blunt probe, or by paffing a lancet pointed needle, covered with a canu- la, along the finus, and puffiing it out at the oppofite fide with the feton attached to it. In either of thefe ways the cure of pundured wounds may frequently be accomplifhed. But wherever the pradice is admiffible, I am clearly of opinion, that laying them open immediately after the accident is preferable to the other : for in this manner all extra- neous bodies are at once brought into view; haemor- rhagies are eafily restrained ; and the pain which fome- times occurs from a partial divifion of nerves and ten- dons is diredly obviated. Nor is the inflammation, which often fucceeds to pundured wounds, apt to run Sed. III. Of Pundured Wounds. 2ii fo high, when they are treated in this manner, as it ufually does when any other method of cure is adopt- ed : fo that much diftrefs would be prevented, and a good deal of time faved, if this method of cure were more generally pradifed. To thofe not much acuf- tomed to this kind of bufinefs, the enlarging of a fmall pundure, fo as to form an extenfive wound, appears to be unneceffary and cruel: but whoever has feen much of this branch of pradice, will know, that the greateft diftrefs often arifes from the fmalleft punc- tures ; that furgeons are often baffled, and much dif- appointed, in their attempts to cure them ; and that nothing fo effedually obviates this as the pradice that I have advifed, of laying the pundures freely open as foon as poffible after they are inflided. Indeed the fooner it is done the better. No advantage can accrue from delay ; and a patient always fubmits to the oper- ation moft readily at firft, while at the fame time it excites lefs pain than when the parts are fwelled and inflamed, which they commonly are in the courfe of a few days from the time of their being wounded. In every wound therefore of the pundured kind, partic- ularly in wounds received in duels with fmall fwords, and in battles with the points of bayonets, the enlarge- ment ffiould take place even before the parties are car- ried from the field ; by which much of that inconve- nience and diftrefs which ufually arife from pundured wounds would be guarded againft. Some cafes, however, occur, in which this pradice cannot be advifed ; particularly where pundures run deep among the large mufcles, or contiguous to large blood veffels and nerves. As more danger would ac- crue from thefe parts being wounded, than could prob- ably be compenfated by any advantage to be gained by dilating the wounds, it is better in fuch circum- ftances to reft fatisfied with laying the parts open as far as with fafety it can be done ; to truft to the fup- puration which will enfue, for bringing off any extra- neous matter that may be lodged in the wound ; and p 2 211 Of Pundured Wounds. ♦ Chap. III. to a proper application of preffure, for completing the cure. Or the pradice that I have mentioned above, of introducing a feton, may be attempted ; for a cord may be paffed with fafety where it might be very im- proper and unfafe to make a deep incifion. But it is proper to obferve, that there are fome caf- es in which even a feton cannot be introduced: for a pundure fometimes runs in fuch a diredion, as not to admit of a counter opening. We muft here truft to a proper application of preffure, not merely for pre- venting any lodgement of matter, but for producing adhefion of the divided parts ; and when this fails, in- jedions of a moderate degree of aftringency may be ufed with advantage: but as remedies of this kind tend to counterad the very intention for which fetons are employed, they ffiould never be advifed till it ap- pears that the latter will not fucceed. Setons, as I have already obferved, prove ufeful, by exciting in- flammation along the courfe of a finus. Now, one ufual effed of aftringent applications is, to diminish or even to remove inflammation. They fhould never therefore be employed, till all the ordinary means of cure have failed, when they may be ufed with a view to check the flow of matter when it appears to be too abundant, and to induce fome degree of callofity over the fides of the fore. It is here proper to remark, that praditioners have differed much in opinion with refped to the ufe of af- tringent injedions in wounds ; for while fome are in the daily habit of employing them, others have faid that they are always pernicious, and ought never to be ufed. In the early ftages of wounds they can nev- er be neceffary ; and as they may do harm by waffling away the matter too freely, they ffiould never be ufed as long as a cure is expected, either by the formation of new granulations, or by adhefion: but whenever there is reafon to think that this cannot probably hap- pen, injedions may with propriety be advifed. Vari- ous forms of injedion are mentioned by authors; but Sed. III. Of Pundured Wounds. 213 none of them are fo harmlefs, and at the fame time anfwer with fuch certainty, as weak folutions of fac- charum faturni, in the proportion of a grain to every ounce of water. Lime water is ufed with the fame views ; and water ftrongly impregnated with alum, or mixed with an equal quantity of claret or port wine, is often employed with fuccefs. It is highly neceffary, however, to obferve, that much caution is neceffary in the ufe of injedions for the cure of wounds, for if much force is employed, the liquid is very apt to pafs between the fibres of the contiguous parts, and in this manner to do much harm ; but with due care on the part of the furgeon, this inconvenience may always be guarded againft and prevented. In the treatment of pundured wounds, where fe- tons cannot be employed, it is fometimes difficult to prevent the external aperture from clofing long before any tendency to heal appears in the bottom of the fore; and, if not prevented, much mifchief is apt to enfue by matter colleding beneath, and burfting out from time to time. With a view to prevent this dif- trefsful occurrence, tents are employed of prepared fponge, gentian root, and other articles that fwell by the moifture of the fores, and thus ferve very effedu- ally to keep them open. But while they anfwer this purpofe, they are very apt to do mifchief. When the opening of a fore is plugged up with a tent, the mat- ter can never be difcharged but at the renewal of the dreffings ; whereby it muft neceffarily colled in fuch quantities, as to give rife to abforption, as well as to the formation of finufes, by fpreading between the layers of the contiguous mufcles. Tents, therefore, which are of folid materials, ought never to be of fuch magnitude as to fill the openings of fores. They will not readily do harm when of fuch a diameter as to admit of the matter being difcharged while they are inferted. But when employed of fuch a fize as to fill the openings entirely, they ought always to be 214 Of Pundured Wounds. Chap. III. hollow; by which the apertures into the fores will be prevented from contrading, while the matter will be difcharged as quickly as it is formed. For this purpofe praditioners fhould be provided with tubes of different forms and fizes, fo as to be able to fuit any aperture they meet with. Silver tubes are com- monly employed; but thofe of lead anfwer better. Being fofter than the others, they do not create fo much uneafinefs, and they are more readily made to take any particular ffiape, fo as to anfwer for finufes of a straight or crooked diredion. I muft obferve, however, that tents and tubes of every kind fhould be ufed with caution; and it is more particularly neceffary that this ffiould be held forth to beginners, for there is no point in pradice in which they are more apt to err. As they are early made fenfible of the danger to be expeded from mat- ter colleding in fores, they very univerfally fly to the affiflance of tents wherever a pundure or finus is dif- covered. But it is right they ffiould know that tents are feldom neceffary: for when once a vent is given to matter, the opening will in general be preferved merely by the continuance of the difcharge. In a few inftances, indeed, it is otherwife; and in all fuch caf- es, leaden, filver, or gold tubes fhould be preferred. We come now to confider thofe wounds which are attended with laceration and contufion; and as both of thefe circumftances require nearly the fame method of treatment, it will not be neceffary to fpeak of them in feparate fedions. Sed. IV. Of Lacerated Wounds. 3*5 SECTION IV. Of Lacerated and Contufed Wounds. A WOUND is faid to be lacerated, when the parts, inftead of being divided with a ffiarp cutting inftrument, are forcibly torn afunder; and when, inftead of a fmooth equal furface, the edges are ragged and unequal: and wounds are faid to be con- tufed which are made with a blunt or obtufe body. Contufed and lacerated wounds are in many cir- cumftances effentially different from fimple incifed wounds ; but in nothing more than in this, that while they are commonly more hazardous, they feldom at firft exhibit fuch alarming appearances. Thus, a fim- ple cut, which commonly heals with eafe, is often attended with a much greater retradion of the divid- ed parts, and with more profufe haemorrhagy, than a contufed or lacerated wound of much greater extent. It is a frequent effed, indeed, both of contufion and laceration, to prevent the effufion of blood, by which inattentive observers, in forming opinions of thefe wounds, are very apt to be deceived : for a haemor- rhagy is the moft alarming fymptom with which wounds are attended, when it does not occur to any alarming extent, they are apt to conclude that noth- ing dangerous can enfue. Praditioners of experience, however, will not be deceived by this : for it has long been known, that injuries of this kind prove al- ways more dangerous than other wounds; and that the more violent the contufion or laceration is, the lefs blood is always poured out; infomuch that there are inftances even of limbs being torn off without any haemorrhagy taking place. *- The pain of lacerated and contufed wounds is not always in proportion to the extent of the injury. Thus, in leffer contufions, the pain is often fevere, ■* lT,*T'> a /^ 216 Of Lacerated Chap. III. while there is little or none where the nerves are en- tirely destroyed. The immediate effed, both of laceration and contu- fion, is fwelling or tumefadion in the retraded edges of the wound. This feems to arife from an effufion of blood or ferum among the parts that have fuffer- ed: when the violence has not been fevere, this effu- fion commonly terminates in fuppuration; the con- tufed parts feparate from thofe beneath in the form of (loughs ; and a cure of the remaining fore is obtained by the means that I have noticed when fpeaking of fimple incifed wounds. But when the parts are fo much injured as to have their texture much destroy- ed, and efpecially when any of the larger arteries have been obliterated, there is always caufe to fufped that mortification may enfue. In found constitutions, and where the wound is not extenfive, even this will not often prove fatal: for in fuch circumftances the mor- tified parts commonly foon fall off, and a cure is ac- complifhed in the ufual manner. But in wounds at- tended with contufion or laceration to any confidera- ble extent, if the habit of body is not perfedly good, the gangrene which enfues is always to be confidered as hazardous: for the gangrene does not neceffarily flop with the parts which have been injured ; but is apt to proceed to thofe which were not immediately hurt by the accident. And again, even where mortification does not fuc- ceed immediately to wounds of this kind, if the parts have been either feverely lacerated or contufed, in- flammation often occurs, with fuch feverity as termi- nates in mortification, notwithftanding of all we can do to prevent it; and in whatever way it is induced, it proves always dangerous ; for befides the rifk of parts immediately neceffary for life being deftroyed by it, the abforption of putrid matter from a gangre- nous furface proves often fuddenly fatal, even when the fize of the fore is fo inconfiderable as to give no caufe to fufped danger. Sed. IV. and Contused Wounds. 2VJ It is therefore obvious, that in the treatment of contufed and lacerated wounds, our principal objed is to guard againft the acceffion of gangrene. But it is likewife clear, that this is not always to be done by the fame means : for we may readily fuppofe, that much advantage may be derived from bloodletting, and other evacuations, where the injured parts are much inflamed, while no benefit would otherwife pro- bably refult from them. This, however, is a point of importance, and merits particular confideration. In lacerated or contufed wounds, where the parts are much injured, it is the common pradice to give large quantities of bark almoft immediately, and to apply warm dreffings and other antifeptics to prevent the acceffion of gangrene. It is evident, however, that the indifcriminate application of this pradice muft frequently do harm: for however beneficial it may be in particular cafes, where gangrene has alrea- dy taken place, it muft neceffarily be inapplicable, and be very likely to do much harm where fymptoms of inflammation ftill continue; and unlefs mortification adually exifts, it is not clear that in any inftance it ever proves ufeful; for although we have various proofs of the efficacy of bark, in putting a flop to the progrefs of gangrene, I have never been fenfible of any advantage being derived from it, when ufed as a preventative. Gangrene may arife in thefe wounds from two cau- fes : from the ftoppage of the circulation by the total deftrudion of large blood veffels ; and from violent inflammation. Gangrene proceeding from inflammation is here moft to be dreaded ; for that which arifes from the deftrudion of blood veffels is by no means frequent. The inflammation therefore which takes place in la- cerated wounds, demands always our clofeft atten- tion. No remedy proves more effedual in lacerated and contufed wounds than a free difcharge of blood from 218 Of Lacerated Chap. III. the injured veffels; fuch quantities therefore fhould in every cafe be difcharged as the nature of the wound may indicate, and the ftrength of the patient may ad- mit. After this, if the divided arteries continue to throw out blood, they muft be fecured with ligatures ; for till the difcharge of blood is flopped, the patient will not confider himfelf as fafe; nor can the wound be examined with accuracy. The parts are now to be cleared of all extraneous bodies, as far as this can be done with propriety, and are to be placed as much as poffible in their natural fituation; but no kind of future fhould be employed for their retention. If the violence done to the parts has been confiderable, and efpecially if accompanied with much pain, it may be neceffary to take blood repeatedly in the courfe of the cure ; and the beft method of doing it is by means of leeches, applied as near as poffible to the edges of the fore. Indeed no remedy I have employed proves fo certainly ufeful in lacerated or contufed wounds as the difcharge of blood in this manner ; for it not only tends to prevent the inflammatory fymptoms from running high, but very commonly renders the pain moderate, even when it has previoufly been fevere. It ought never therefore to be omitted; but the prac- titioner fhould take care that it be proportioned to the violence or urgency of the fymptoms, and like- wife to the ftrength of the patient: for the difcharge of a fmall quantity of blood will in fome cafes of con- tufion or laceration prove fully fufficient; while in others, it is neceffary to repeat the operation once and again. As foon as a fufficient quantity of blood is dif- charged, the parts affeded, after being dreffed with pledgets of any emollient ointment, fhould be com- pletely covered with a warm emollient poultice ; and this, together with warm fomentations, ffiould be re- newed three or four times a day, fo as to promote, with as much certainty as poffible, the formation of pus. To induce fuppuration in lacerated wounds, is Sed. IV. and Contused Wounds. 219 indeed an objed of the firft importance : it generally relieves* all the fymptoms; and till fuch time as it takes place, we have often reafon to dread the event. We commonly find, when fores of this defcription become covered with good pus, that the pain and tenfion abate; and fuch of the parts as have been much lacerated and contufed, and which hitherto have been floughy or perhaps black with mortifica- tion, begin now to feparate from thofe beneath; and this being accomplifhed, they may in general be cur- ed in the fame manner with wounds of any other kind. Nay, when brought to this healing ftate, we may often attempt with fafety to forward the cure by drawing the edges of the retraded fkin into contad, either by means of the uniting bandage, or with ad- hefive plafters ; for although this would be improper in the commencement of thefe wounds, while there is any rifk of the tenfion and inflammation proceeding too far, it may with much propriety be advifed when there is no longer reafon to be afraid of thefe fymp- toms. When praditioners are immediately called, and have employed the means that I have mentioned in due time, they will very commonly prove fuccefsful: but it frequently happens, whether from the violence of the injury, the tendency in fome constitutions not only to inflammation but to gangrene, or from the proper remedies not being timeoufly applied, that all the fymptoms become daily worfe, and, notwithftand- ing repeated bloodlettings both general and local, all thofe parts which were at firft inflamed become black and mortify. In this fituation we do not truft to eva- cuations. Whatever tends to debilitate muft now be avoided ; and we know from experience, that in fuch circumftances, no remedies prove fo ufeful as thofe which invigorate and reftore the tone of the fyftem. With this view, the patient ffiould be defired to live upon nourifhing food. He fhould be allowed as large a quantity as he can take, of good wine, or ftrong 2io Of Lacerated Chap. III. malt liquor; and Peruvian bark fliould be given in as large dofes, and thefe as frequently repeated, as his ftomach will'permit. Indeed bark is perhaps the on- ly medicine on which we ought to depend ; and as We know from experience that it may with fafety be given in great quantities, this fliould always be done without further limitation than neceffarily arifes from the ftate of the ftomach. We may remark, too, that bark proves in general ufeful nearly in propor- tion to the quantity employed ; and it often happens, that large dofes are not more naufeated than thofe that are not half the quantity. Where a large quan- tity of bark fhould be taken in a fhort fpace of time, as is always the cafe in gangrene, it ffiould never be given in lefs than dofes of a dram, or even two drams, when the patient can bear it; and thefe ffiould be re- peated every hour. Bark, in fome cafes, feems to prove more powerful when conjoined with the vitrio- lic acid : elixir of vitriol may therefore be given along with it. In gangrene arifing from debility, opium frequently proves ufeful; and as it does not counter? ad the bark, the two remedies may with fafety be pre- fcribed together. In the mean time, the ftate of the fore requires par- ticular attention. As long as any tendency prevails in the contiguous parts to inflammation, the beft ap- plications, perhaps, are warm emollient poultices and fomentations; for, as I have elfewhere fhown, that the feparation of mortified parts is commonly effeded by the formation of matter between them and the ad- joining found parts, we neceffarily derive moft advan- tage from whatever tends to promote fuppuration.* But as no fuppuration will occur where no inflamma- tion exifts, when there is no reafon to imagine that it will otherwife happen, we ffiould endeavour to pro- mote a tendency towards it by the ufe of warm dref- fings to the fore, and the application of ftimulants to * Vide Chap. I. where this fubjetft is mere fully confidered. Sed. IV. and Contused Wounds. 22! the contiguous parts. Muftard applied in the form of a poultice, as well as other rubefacients, have prov- ed ufeful in this manner; and I have employed with advantage a ftrong folution of crude fal ammoniac in vinegar and water. It is proper, however, to obferve, that this pradice muft be managed with caution: for a high degree of inflammation might often prove de- trimental, while in every inftance it would be unne- ceffary ; and we know from experience, that a fmall degree of it is fufficient. As foon, therefore, as it is obferved that the mortified parts are furrounded with a kind of inflamed ring, the ftimulating applications ffiould be removed, in order to give place to warm emollients, for the purpofes I have mentioned. Any parts that are completely mortified may with fafety be removed; indeed the offenfwe fmell which they produce renders this a neceffary -meafure; but, as I have elfewhere obferved, the common practice of making incifions through the difeafed parts into thofe beneath which are ftill found, fhould never be follow- ed. No advantage can be derived from it, and it may be produdive of much harm. It is recommend- ed with a view of giving more free accefs to oint- ments, and other remedies ufed as dreffings, than could otherwife be obtained ; but I have not in any inftance feen it prove ufeful, and in different cafes I have been fenfible of its doing harm: it may very readily carry the putrid matter of gangrene more deeply into the contiguous found parts than it would otherwife penetrate. In fome cafes it has evidently induced more inflammation than was neceffary; and in more inftances than one I have known fcarifica- tions prove hurtful, by exciting very troublefome haemorrhagies. By perfifting in the ufe of bark, and the other rem- edies that I have mentioned, and efpecially if the ftrength of the patient is fupported with wine and nouriffiing food, even bad cafes of gangrene will often terminate happily; the mortified parts will feparate, 222 Of Lacerated Wounds. Chap. III. and the remaining fore will heal kindly and eafily with common mild dreffings : but in other inftances, not- withftanding all our endeavours, the difeafe continues to fpread, and nothing tends to prevent its final ter- mination. When gangrene is feated in any of the ex- tremities, it is the common pradice, when other means of cure have failed, and when mortification is ftill ad- vancing, to amputate above the difeafed parts : I have elfewhere, however, ffiewn, that this pradice fhould not be adopted ; and when treating of amputation, we fliall again have occafion to confider the fubjed more particularly. In the treatment of mortification, it is a good gen- eral rule to advife evacuations of every kind with much caution. This is particularly the cafe with refped to bloodletting; but in .addition to what I have already obferved, I think it right to remark, that in all cafes of inflammation where the approach of gangrene is dreaded, and particularly in wounds attended with much contufion or laceration, till mortification adually oc- curs we ffiould proceed with freedom in an antiphlo- gistic courfe, particularly in difcharging as much blood as the degree of inflammation may appear to require ; and I infill on this point the more fully, from having often obferved much mifchief enfue from praditioners being afraid to advife it. Being afraid of finking the patient too much, they avoid the only remedy that could probably fave him : for, in fuch circumftances, it is the violence of the inflammation that we have moft reafon to dread ; and as we know of no remedy on which we can with fuch certainty depend for the removal of inflammation as bloodletting, it fliould al- ways be advifed in proportion to the ftrength of the patient and other circumftances of the cafe ; by which the acceffion of gangrene may be prevented when no other remedy would fucceed. What I have hitherto faid in this and the preceding fedions, may be confidered as common to wounds in general: we now proceed to- confider thofe wounds, Sed. V. Of Wounds in the Veins. 223 which, either from the nature of the injured parts, or from their fituation, demand a peculiar treatment. SECTION V. Of Wounds in the Veins. IT is for the moft part difficult to reftrain haemor- rhagies from wounded arteries, on account of the force with which the blood is propelled into them by the heart, and on account of their mufcular coats, which prevent them from collapfing readily. But, in the veins, neither of thefe circumftances take place ; the contradile- power with which they are endowed is very inconfiderable ; and we do not perceive that the circulation in the veins is much affeded by the adion of the heart. For thefe reafons, wounds in the veins heal with more eafe and are attended with lefs danger than wounds of the arteries : indeed we know, that the largeft veins are often much injured, and that no bad fymptom will enfue; while very troublefome confe- quences will fucceed to wounds even of fmall arteries. In general, therefore, there is no caufe to be afraid of wounds in veins : for while we have it in our power to check the haemorrhagy, we never obferve any det- riment to enfue even from the obliteration of the larg- eft external veins ; for the anaftomofing branches fo readily admit of dilatation, that they foon become fuf- ficient for carrying on the circulation beyond the parts that have been injured. We commonly find, that a longitudinal cut in a vein heals with eafe when only ffightly covered with a piece of dry lint or foft old linen : when this fails, the haemorrhagy may be always ftopped by the applica- tion of a piece of dry fponge or agaric to the bleeding 224 Of Wounds in. the Chap. III. orifice, and fecuring it with moderate preffure. But in tranfverfe cuts in the large veins, or when veins are cut entirely acrofs, it may fometimes happen, either that preffure cannot be properly applied to the wound, or that it does not prove fufficient for flopping the difcharge: in fuch cafes, efcharotics are commonly advifed, and by fome praditioners the adual cautery is employed ; but none of thefe,pan be depended on ; and they are apt to create a great deal of diftrefs. The fame remedy therefore ffiould be employed here that we daily ufe in haemorrhagy from wounds in ar- teries, namely, ligatures; which, when properly ap- plied, never fail to anfwer the purpofe. In ufing lig- atures, I have elfewhere fhewn, that the crooked nee- dle fhould feldom or never be employed, and that the tenaculum ought in almoft every cafe tb be pre- ferred. SECTION VL Of Wounds in the Lymphatics. THE lymphatics are equally liable to injuries with other parts of the body : as they often lie con- tiguous to veins, they are fometimes wounded in the operation of bloodletting ; and not unfrequently they are cut in opening buboes and other glandular collec- tions of matter. When the fmaller branches only of lymphatics are opened, they heal along with the reft of the wound ; but a wounded lymphatic is fometimes fo large, that it does not heal fo foon as the other parts, but contin- ues to pour out its contents, and in this manner to prove hurtful to the future health of the patient. We ffiould never hefitate therefore in putting a flop to the difcharge. Sed. VII. Nerves and Tendons. *2_) Various means have been propofed for effeding this. lit feme cafes we fucceed by compreffion alone: aftringents have been advifed, together with the ap- plication of dry fponge, agaric, and common puff ball; and both the adual and potential cauteries have been ufed. But when moderate preffure fails, our moft effedual remedy is to take up the injured lym- phatic with a ligature, in the fame manner as is done with wounded arteries. No objedion can be made to this ; and it anfwers the purpofe in the moft cer* tain manner. SECTION VII. Of Wourtds in the Nerves and Tendons, and kuptures of the Tendons* IN different parts of this chapter, I have had occa- fion to fpeak of the partial divifion of nerves and tendons, and of the means Which anfwer beft for the removal of thofe confequences that are fometimes found to refult from it; and when treating of blood- letting, I fhall find it neceffary again to confider the fubjed further. It muft often happen, that nerves and tendons are partially divided along with other parts; but when no pain enfues from them, praditioners feldom hear of it: in fuch cafes, they heal along with the other parts of the Wound: but in various inftances, either from fome lingular degree of irritability in the injured parts, or from a peculiarity of conftitution, the caufe ef which cannot perhaps be explained, the flighteft pundure of a nerve or of a tendon will induce very fevere pain, inflammation, convulfions* and even death. Vol. I. Q 226 Of Wounds in the Chap. III. Whenever there is caufe, from the violence of the pain, to fufped that the other fymptoms may fuper- vene, the moft effedual means ffiould be immediately ufed for preventing them: for when once convulfions take place, we are never fure of its being in our pow- er to allay them. In fome cafes, large dofes of opi- ates anfwer the purpofe: but when they do not foon prove fuccefsful, no time fhould be loft in putting the only remedy in pradice, on which we can place much dependence ; and that is, the complete divifion of the injured nerve or tendon. By this we may indeed in- duce a certain degree of infenfibility in the parts be- neath, or they may even be deprived of the power of voluntary motion; but any inconvenience which this may induce will be of little importance, when com- pared with the advantages which refult from the op- eration : for I can from experience affert, that when timoufly 'employed, and properly done, it feldom fails of complete fuccefs; while in various inftances, wounds of thefe parts have terminated in death, where this operation has been omitted. In this manner we may obviate the effed of punc- tures and partial wounds, either in nerves or tendons : but here it is neceffary to mention the method of treat- ment to be purfued in the healing of wounds or rup- tures of large tendons, when completely divided. As a complete divifion of any of the large tendons is al- ways attended with much retradion, it was long ago inculcated by praditioners, to draw the retraded ex- tremities of the ruptured tendon into contad, and to retain them in this fituation by futures : and this being done, and the limb placed in a favourable fituation, the reft of the fore was treated in the ufual way. There is no reafon to doubt of cures having been often accomplifhed in this manner: nay, where ten- dons have been merely ruptured, without any exter- nal wound, as often happens with the tendo achillis, the retraded ends of the tendon have .been laid bare by an incifion, for the very purpofe of retaining them Sed. VII. Nerves and Tendons. 227 by futures. This, however, is a very painful opera- tion ; and as the fame intention may be accomplifhed in a more fimple manner, it ought to be laid afide. When it was firft propofed to unite ruptured or wound- ed tendons by means of futures, it was the common opinion, that, in order to infure a reunion of the di- vided parts, it was abfolutely neceffary to bring them into clofe contad ; and the fame idea prevailed, not merely with refped to tendons, but with regard to bones, as well as other part6. In the treatment of fradured bones and ruptured tendons, it is no doubt a good general rule to bring the divided parts as nearly in contad as poffible : but we now know that cures may be accomplifhed where the retradion of parts is fo confiderable as to render it impoffible to draw them together ; nay, that it has often been done, even where a portion of a tendon or of a bone has been completely removed. Very con- fiderable portions of bone have been regenerated ; and although we are not certain that any part of a tendon has ever been renewed, yet fuch adhefions always take place between the retracted ends of the divided ten- don and contiguous parts, as tend in a great meafure to fupply the deficiency. Thus, I have known differ- ent inftances of the tendon of the rotula being ruptur- ed, as well as of the tendo achillis: and although the ends of the retraded tendons could never be brought within an inch of each other; yet in all of them where proper attention was given, the cures have been fo far complete, that the ufe of the limbs has been very per- fedly reftored. Some degree of ftiffnefs has often, indeed, remained for a confiderable time ; but at laft even this fymptom has very commonly been removed. Wherever a wounded tendon is fituated, or even when a tendon is only ruptured, and no injury dorie to the external parts, the limb ffiould be placed in fuch a manner as will moft readily admit of the re- traded ends of it being brought nearly together; and Q2 228 Of Wounds in the Chap. IH. when, in this fituation, the mufcles of the whole limb in which the injury has happened, ffiould be tied down with a roller, in fuch a way as to prevent them from being in any degree thrown into adion during the cure,, at the fame time that the parts ffiould be placed in fuch a pofition, as will tend moft effedually to keep them eafy and relaxed. Thus, in a wound or rupture of the tendon of the redus niufcle of the thigh, the patient's leg fliould be kept as much as pof- fible ftretched out during the cure, while the thigh ffiould be in fome degree bent, or elevated into an an- gle with the body, fo as to relax the mufcle itfelf as far as it can be done: while in fimilar affedions of the tendo achillis, the knee ffiould be kept bent, fo as to relax the mufcles of the leg; at the fame time that the foot fhould be ftretched out, fo as to admit of the ends of the ruptured tendon being brought nearly to- gether. In applying a roller to fecure the mufcles and tendons in this fituation, it ffiould be done with a firmnefs fufficient for the purpofe, while care is taken that it does not impede the circulation: with this view, fine foft flannel or cotton ffiould be preferred to linen: for being more elaftic, they more readily yield to any fwelling with which the limb may be attacked. The late Dr. Monro was the firft who gave accu- rate diredions for treating a rupture of the large ten- dons ; and he has probably done it with the more precifion, from having himfelf experienced the effeds of this misfortune in the tendo achillis. As the meth- od which he points out, and the instruments which he recommends, are fimple and judicious, and as they have in various inftances been found to anfwer the purpofe, a defcription of them will be confidered as a proper addition to this article. The different instruments ufed by Dr. Monro, with the feveral parts of each of them, are reprefented in Plate LXXIX. Fig. 9. Is a foot feck or flipper, A, of double quilt- ed ticken; from the heel of which, B, the quilted Sed. VII. Nerves and Tendons. 229 ftrap, D, is of fuch a length as to reach above the calf of the leg. Fig. i. A ftrong quilted calf piece, E, with pye holes, FF, on each fide, through which a lace, fig. 2. is to be paffed, and with a buckle, G, fo placed on its back part, that when the lacing is on the outfide of the leg, the buckle will be in the middle of the lower part. Two rows of pye holes are here reprefented, one on each fide; either of which may be ufed ac- cording to the fize of the leg. In Dr. Monro's cafe, the foot and leg were firft wrapped in foft flannel fmoked with fumes of ben- zoin, when he put on, as m fig. 3. the foot fock A, and calf piece E ; and bringing the ftrap H, through the buckle G, he could by it extend the foot, and pull down the calf to what degree might be judged pro- per, and there it was fecured with the buckle. This bandage anfwered the intention perfedly well; and it was worn night and day. It ffiould be drawn tighter during fleep, and relaxed when the patient is awake, and on his guard; during which the foot ffiould be placed upon a flool, as at I; and the calf piece ffiould be frequently fluffed, or made eafier by loofening the lace, fo as to prevent the foot from fwelling, which is apt to happen if this is omitted. To prevent the toes from becoming uneafy, the foot fock ffiould be left open at the end K, During the firft fortnight, the Dodor made no mo. tion or effort with his foot, but was carried in a chair, running on caftors, from one part of his houfe to an- other : after this he began to move the foot back- wards and forwards, fo gently as not to give pain. In a gradual manner the motions were increafed; the extenfion of the leg and flexion of the foot were ah ways ftopped on their producing any uneafinefs. On beginning to walk, the affeded leg, which was the left, was always put before the right, fo that the left foot might be as well extended as poffible. To 83° Of Wounds in the Chap. III. prevent any danger from falling, a cane was ufed in the right hand. The void between the two ends of the divided ten- don became infenfible in a few days, except that a foftnefs was felt there more than any where elfe ; but this part turned gradually thicker and harder, till a knot was formed in it of the fize of a middle fized plum. At firft this tumor was equally hard with a piece of cartilage ; but it gradually became fofter, and diminifhed fo much, that at laft it was fcarcely per- ceptible, With a view to strengthen the leg and foot, cold water was poured upon them, and immediately there- after they were well rubbed. This was firft employ- ed fome weeks after the accident: but no advantage being derived from it, the parts were afterwards ftrong- ly rubbed twice a day with unguentum althaeae, or fome other emollient; and this was continued till the limb could be ufed with freedom. In about two weeks from the time of receiving the injury, the Dodor was obliged to go abroad, when he ufed a pair of fhoes with heels two inches high, and applied the machine, which we fhall prefently defcribe, through the day, inftead of the former bandage ; which, however, was always put on at night for a month longer. This machine, fig. 8. is a piece of fteel, the middle flalk of which, L, is narrow but ftrong; the ends, MM, are thin and concave, and muft be adapted to the convexity of the foot and forepart of the leg. Three ftaples, a, a, a, ftand up from the forepart of the fteel; one in the middle of each of the broad ends, and the third in the middle of the flalk. All the fteel, except the flalk, ffiould be covered with foft leather, and the concavities of MM ffiould be well buf- fed, as the fofter rupture bandages commonly are. After putting on the fhoes and stockings, one end of this machine was put upon the broad part of the foot, nearer the toes than the buckle of the fhoe, and Sed. VII. Nerves and Tendons. 231 the other end placed upon the forepart of the leg; then one ribband, or a thong of leather, fig. 5. was put round the foot, and another, fig. 6. round the leg, to pafs through the two ftaples near the ends of the machine, and there fecured with ftraps or buckles, but without being drawn tight. A third ftrap or ribband, fig. 7. with its middle, N, applied to the hol- low of the foot immediately before the heel, had its ends paffed on each fide of the foot through a noofe, 0 0, of a fourth thong of leather, P, that came round the quarter heel of the fhoe, to be afterwards put through the middle ftaple; where, after thefe ends, q q, were drawn as tight as was thought convenient for extending the foot, they were fecured with the buckle or with knots. See the application of this machine in figure 4. This was continued for the fpace of five months ; but thofe who may find it inconvenient, might ufe in- ftead of it a thong of leather, fewed at one end to the upper and middle part of the quarter heel of the ffioe, and faftened at the other end to a garter or ftrap put above the calf of the leg. The high heeled fhoes were continued for a confiderable time: two years elapfed before they were thrown afide; by which means, and by treating the injured limb during all that period with great caution, a very complete cure was obtained; while others, who have not been fa attentive to the management of matters of this kind, have not been fo fortunate ; fome of them having the tendon ruptured a fecond, or even a third time, and others remaining ftiff and lame for a great length of time. 23* Of Wounds Chap. III. SECTION VIII, Of Wounds in the Ligaments, BY Ligaments, we understand thofe flexible bodies which ferve to cover the different articulations, and by which many of the bones are firmly tied to each other. The bones of the pelvis are united by ftrong ligaments; and we know, that feveral other bones are chiefly conneded by the fame means. But as all thefe ligaments lie deep, they are not much ex- pofed to the effeds of external violence; ahd the fame caufe puts it out of our power to apply any par- ticular treatment for injuries which may accidentally be done to them. Our obfervations at prefent will therefore be chiefly applicable to wounds of the liga- ments of joints, commonly termed Capfular Liga- ments. "■ As ligaments are not fo plentifully fupplied with nerves as fome other parts of the body, feveral anato- mists have been induced to believe that they are not poffeffed of fenfibility; by which we might be led to conclude, that injuries done to them would not pro- bably require much attention: but although nature, for obvious reafons, has not made the ligaments high- ly fenfible; and although in a healthy ftate they will bear much fatigue, without fuffering fo much as other parts of the body; yet the fad is undoubted, that they are rendered extremely fenfible by difeafe ; and that wounds inflided on them are frequently produc- tive of very alarming confequences. We have often indeed known the ligaments of joints much injured, nay violently lacerated or torn, with the heads of the bones which they furround being pufhed through them, as well as by other caufes, without any impor- tant confequences taking place; nay, in fome cafes, the wounds have healed as eafily as if no harm had Sed. VIII. in the Ligaments. 233 been done to the ligaments. Occurrences of this kind, however, are rare; for in a great proportion of cafes, the fymptoms which enfue from wounds of the joints are fevere and hazardous. The effeds produced by this kind of injury are of- ten deceitful: in general, nothing alarming appears at firft, nor for feveral days after the accident; and when the patient is treated with attention and care, I have known a week pafs over before any other fymp- tom has been obferved than ufually takes place in the moft fimple wounds. But, at length, the patient begins to feel an uneafy fenfation over the affeded joint, which by degrees turns more fevere ; when the parts become fwelled, tenfe, and fomewhat inflamed. In this fituation the pain is often fo fevere, that he can- not allow the joint to be touched : he complains of a tightnefs round the whole, as if it was firmly tied or girded ; and the inflammation, which at firft was con- fined to the joint itfelf, is now apt to fpread over the whole limb. If the wound or laceration in the capfular ligament is large, the fyncvia is often difcharged in confidera- ble quantities at firft ; but the fwelling induced by the inflammation gradually puts a flop to this, till at laft the wound becomes doughy and dry. In the courfe of a few days, however, extenfive fuppurations begin to form over the joint; and on thefe being laid open, large quantities of pus are difchaged, together with fynovia. By this the tenfion and fenfation of girding are immediately removed, and the patient obtains re-. lief; but fucceffive fuppurations commonly take place, Wrhich from time to time excite a renewal of all the fymptoms, and by which the patient's health is at laft greatly impaired. When wounds of ligaments do not heal quickly, and almoft without the formation of matter, this is in general the manner in which they terminate; at leaft it is the cafe in the larger joints, and it is in thefe chiefly that they commonly prove alarming. 234 Of Wounds Chap. III. From this hiftory of the rife and progrefs of the fymptoms, fome advantage may be derived in con- duding the cure. From this it is evident, that it is not merely the injury done to the ligament which we have to dread, but a fecondary train of fymptoms, which are apt to refult from it. Although none of the lining membranes of cavities, which are naturally ffiut up from the air, feem to be endowed with much fenfibility, it feems to be a common effed of air be- ing admitted to give them a high degree of it. Of this we have frequent proofs in wounds penetrating the thorax and abdomen; and it is chiefly to this caufe that we are to attribute thofe confequences which refult from wounds in the capfular ligaments of joints. This points out a very important circumftance in the treatment of thefe wounds, namely, the preven- tion, as far as is in our power, of air finding accefs to the cavities of capfular ligaments. In large lacerated wounds, this will, for the moft part, be impradica- ble; but in common incifed wounds it may often be very completely effeded. It ought never to be attempted, till we are certain that all extraneous bodies that have been carried in are extraded. This being done, we may very com- monly cover the wound in the capfular ligament en- tirely, by pulling the fkin fo far over it, that the wound in the one may not correfpond with that in the other; and as the fkin about the joints is fuffi- ciently lax to admit of this, it may for the moft part be eafily done. We are now to fix the fkin in fuch a manner that it may not retrad, either with futures* or adhefive plafters; but, in general the latter will prove fufficient, if affifted by the application of a pro- per bandage; and they are preferable to futures, which in this fituation are apt to excite inflammation. After the plafters are applied, the fkin and cellular fubftance ffiould be fupported in their fituation by paffing a flannel roller fpirally round the joint, fo as to produce an equal degree of compreffion over it, of Sed. vni. in the Ligaments. 235 a tightnefs fufficient for gently compreffing the parts *to which it is applied without interrupting the circu- lation. The patient ffiould be in bed while the dreff- ings are applied, fo that they may not afterwards be liable to be moved ; and the limb fhould be put up- on a pillow, and placed in fuch a fituation as admits of the fkin and other teguments being relaxed, which will be found to be different in different parts even of the fame joint. Thus, in wounds on the anterior part of the knee, the leg ffiould be kept extended during the whole progrefs of the cure ; for in this fituation, the fkin which covers the forepart of the joint is moft effedually relaxed; while, for a fimilar reafon, in penetrating wounds entering from the ham, the leg fhould be kept bent. In the mean time, in order to prevent inflamma- tion, the patient ffiould be put upon a low diet; his bowels fliould be kept open ; a moderate perfpiration fliould be excited; and he ffiould lofe a quantity of blood fuited to his age and ftrength. By wounds of the joints being treated with this ftrid attention, I have known many of them terminate ea- fily, which otherwife, there was caufe to think, would have produced both diftrefs and danger. But when thefe means do not prove effedual, or when too long negleded, and not thereafter admiffible, which is the cafe when inflammation has taken place, other reme- dies muft be employed. In this fituation, our chief objed is to leffen or re- move the inflammation; for if not fpeedily done, it will fcarcely fail to fpread over the whole joint, and terminate in an extenfive formation of matter; and this being always hazardous, nothing ffiould be omit- ted by which it can probably be prevented. The moft effedual remedy which I have ever employed for this, is local bloodletting; but, in order to prove ufeful, it muft be carried to a confiderable length. In very robuft patients, eighteen or twenty leeches fliould be applied as near to the injured part as they will bite, %$6 Of Wounds Chap. III. and repeated daily as long as the continuance of the inflammation may render it neceffary. Any of/the fimple ointments may be applied to the wound itfelf; but one of the beft applications to the joint is the fteams of warm vinegar, which prove often ufeful in preventing the formation of matter. And as the pain in wounds of the joints is in general fevere, large do- fes of opiates are commonly required to allay it. In a few cafes, I have known the pain much relieved by the external application of a ftrong decodion of white poppy heads, in the form of fomentation : but for the moft part nothing proves effedual but the inter- nal ufe of opium. A due attention to thefe means will commonly an- fwer at laft, if they have not been neglected too long, or too fparingly administered. From either of thefe caufes, however; from the injury having been parti- cularly fevere; or from fome constitutional difeafe; the inflammation will in fome cafes ftill proceed to increafe ; and, notwithftanding all our endeavours, will at laft terminate in very large colledions of mat- ter, either within the capfular ligament of the joint, in the fubftance of the ligament itfelf, or in the cellu- lar fubftance of the contiguous parts. In fuch cir- cumftances, all that art can do is-to give free vent to any matter that may form; which can only be done by making an opening in the moft depending part of the collection, as foon as the existence of pus is afcer- tained. In this manner, and by a proper ufe of emol- lient poultices and fomentations, whenever a new col- ledion appears to be forming, we have it often in our power to fave limbs, which otherwife it would be ne- ceffary to amputate : but when wounds in any of the larger joints terminate in fuppuration within the cap- fular ligaments, all who have had experience in this branch of pradice will know, that the rifk attending them is great; and that we can never, even under the beft management, have any dependence on their ter^ minating but with great diftrefs «.nd hazard. The feed. VIII. in the Ligaments. 237 principal reafon, as I have already obferved, of their continuing obflinate, is the inflammation becoming violent; which when not obviated by the means that I have ventured to advife, is apt to produce fuch large colledions of matter ; and one abfcefs is fo apt to fuc- ceed to another, that the patient is at laft exhausted, when we are often under the neceffity of removing the limb in order to fave his life. In fuch circum- ftances, indeed, there is no room to hefitate; for when the ftrength is much impaired by the frequent formation of abfceffes, if the fame difpofition contin- ues, and efpecially if any degree of hedic fever has taken place, the rifk attending any attempt to fave the limb will now be confiderable, while the chance of fucceeding will be fo fmall, that it ffiould never be advifed. But although I am decidedly of opinion, in circum- ftances fuch as we are confidering, that it is the fafeft courfe to amputate the limb ; yet I by no means agree with thofe who fay, that almoft every cafe of a wound- ed joint requires this remedy. By many it has been afferted, that wounds in any of the larger joints al- moft univerfally terminate fo unfavourably, that, in order to • fave much pain and trouble, as well as rifk to the patient, it would be the moft advifable ftep to amputate Immediately after the accident, before inflam- mation takes place. I am convinced, however, that this opinion is founded in error; and my reafons for it are thefe : Although a complete cure is not often obtained where the capfular ligaments of large joints are ex- tenfively wounded, yet in fome cafes it is otherwife^ Of this I have met with various inftances : and al- though fuch injuries will not often be fo effedually cured as to prevent much ftiffnefs in the joints in which they are feated ; yet even a complete anchylo- fis is an inconvenience to which patients ought rather to be advifed to fubmit, tha% to the pain and hazard arifing from the amputation of any of the extremities. 238 Of Wounds in the Ligaments, Chap. III. As it muft be admitted, however, that the propor- tion of limbs that are faved by this pradice is not great, when the injury done to the capfular ligaments of joints is extenfive, this argument would not merit attention, if the delay which it occafions were to pro- duce any additional hazard, or if it ffiould preclude amputation, if at any future period of the fore it might be judged advifable. This, indeed, has been alleged by praditioners: but there is much caufe to fufped that they are wrong; for many who have been accuf- tomed to amputation in the late ftages of thefe wounds, have had more fuccefs than ufually attends the prac- tice immediately after the injury is inflided. And this, in the courfe of my experience, has been fo uni- formly the cafe, that fcarcely any have died who were not previoufly fo much reduced as to render their chance of recovering very fmall indeed ; a fituation which we have it always in our power to guard againft, by advifing the operation before matters are fo far ad- vanced. Where the capfular ligament of a joint has not on- ly been wounded, but much lacerated and contufed, it may, in a few cafes, be proper to advife immediate amputation. But fuch inftances are rare ; infomuch, that I have fcarcely met with any, excepting where the ends of bones have been perhaps much fhattered, and even fplintered at the fame time. Where this has not been the cafe, I have uniformly attempted to fave the limb; and as, in a great proportion of cafes, the pradice has proved fuccefsful, without adding to the rifk of the patient where the trials have failed, I ffiaM certainly think it right to co: itinue it. % Sed. IX. Of Wounds in the Face. 239 SECTION IX. Of Wounds in the Face. IN chapter XXX. I fhall enter upon the confidera- tion of wounds of the head, which either prima- rily or eventually may affed the brain: and in chap- ters XXXI. and XXXII. we fhall treat fully of dif- eafes of the eyes, nofe, and mouth; referring, there- fore, to what is faid in thefe chapters, on thefe parts of our fubjed, I fhall at prefent offer a few obferva- tions upon external wounds of the face. In the treatment of wounds in every part of the face, one important objed is to prevent deformity. This is indeed an objed in every part of the body; but in the face it is fo effential, that the flighteft inju- ries done to it require attention. As every cicatrix is apt to leave fome degree of de- formity, we ffiould endeavour, in all wounds of the face, to have the divided parts laid as exadly and neatly together as poffible, and to retain them by thofe means which will produce the leaft mark. In all fuperficial wounds of the face, as well as in thofe which run deep, when of a longitudinal direction with refped to the fibres of the injured part, we fhould truft to adhefive plafters alone for retaining them. But wherever the edges of a wound retrad much from each other, as we cannot in any other manner retain them, futures ought without hefitation to be employed: and of thefe the twilled future, to be de- fcribed in chapter IV. fedion V. ought in general to be preferred ; for it prevents retradion with more certainty than the others, at the fame time that it does not excite a great degree of pain. In this man- ner it is more efpecially neceffary to manage all wounds of the lips, which cannot indeed in any other way be prevented from leaving much deformity: I 245 Of Wounds in the Face. ' Chap. Ill* ffiall, however, refer to chapter XXXIII. for fome further obfervations upon this point, when treating of the operation for the hare lip. Wounds in the cheeks are apt to penetrate the fa- livary duds leading from the parotid glands ; and as this is frequently produdive of much inconvenience, by the divided dud continuing to pour out the faliva long after the reft of the wound is healed, it becomes often an objed of importance to accomplish a cure. But as we ffiall have occafion to fpeak more particu- larly of this in chapter XXXIV. fedion XIV. I muft now refer to what will then be faid with regard to it. In the forehead, wounds fometimes produce haemor- rhagies which occafionally are the caufe of much dif- trefs, from our not being able, in the ufual manner, to apply ligatures upon the divided arteries, owing to their running in a groove of bone; as is the cafe with a fmall branch of the internal carotid which paffes out on each fide immediately above the eyebrows. In all fuch cafes* we ffiould, in the firft place, employ fponge, agaric, or any mild aftringent, along with gentle compreffion ; and when this fails, we may en- deavour to pull out the bleeding veffel with a tenacu- lum, and in this manner may tie it with a ligature^ I once fucceeded in this way with perfed eafe, when every other method had been tried in vain. It may fometimes, however, happen, that even this will fail. In fuch cafes, when the haemorrhagy con- tinues fo profufe as to endanger the patient, it may be proper even to remove that portion of the fkull in which the veffel is incafed ; or, in the hands of a nice operator, the intention may be anfwered by taking away the outer table of the ftoill only: for, in fome cafes, thefe arteries run for a confiderable fpace be- tween the two lamina of the bone; and in fuch in- ftances our objed may be accomplifhed by the re- moval of one of them : and thus the rifk of expofing the brain will be avoided. Sed. X. Of Wounds in the Trachea, &c. 241 SECTION X. Of Wounds in the Trachea and Oefophagus. IT is neceffary in fome cafes to make openings into the trachea and oefophagus, for allowing food and air to pafs to the ftomach and lungs, when thefe paf- fages are obftruded. I ffiall refer, however, for the method of effeding this, to chapters XXVII. and XXVIII. where thefe operations will be particularly defcribed: at prefent we are only to confider the me- thod of treating wounds in the trachea and oefopha- gus, inflided in fome cafes by accident, but more fre- quently by defign; as often happens where filicide is attempted. The trachea is feldom divided longitudinally. Tranfverfe wounds running between two of the car- tilages of which it is compofed, are more frequent. In fome cafes thefe wounds are fuperficial, and only penetrate the anterior part of the tube ; in others, they run fo deep as to divide the tube entirely. In longitudinal wounds of the trachea, a cure may be obtained by the ufe of adhefive plafters. The lips of the wound are eafily brought together; and as the retradion is never confiderable, they may very com- monly be retained by adhefive plafters. In fuch ca- fes, therefore, this ffiould be preferred to futures; and bandages are here inadmiffible, as they cannot be applied with fuch tightnefs as to have any effed upon the wound, without compreffing the trachea fo much as to impede refpiration. Even in flight tranfverfe wounds of this part, a cure may be often obtained with adhefive plafters; affifted by a proper pofture of the head, which, in every wound of this kind, ffiould be kept as much as poffi- ble bent down upon the breaft. Where this does not Vol. I. R 242 Of Wounds in the Chap. III. indeed meet with proper attention, we often find it im- poffible to make the divided parts reunite, either with plafters or any other means: it ought not, therefore, to be left in the power of the patient. The head fliould be fixed with a bandage ; and the moft fimple, as well as the moft effedual, method of doing this, is by fixing a common nightcap upon the head, and a piece of broad tape or ribbon being fewed on each fide of it above the ear, it may now be pulled down and fixed as low as is neceffary, by tying the tapes to a circular roller put round the cheft. In this fituation the head ffiould be kept for feveral days, till there is reafon to think that the parts are firmly united. But in tranfverfe wounds of the trachea, which pen- etrate deep, we ffiould not truft to adhefive plafters ; the interrupted future made with broad ligatures an- fwers better. I am doubtful, however, if the ligatures fliould ever be paffed into the trachea, as fome have advifed; for the irritation and cough which they ex- cite is very apt to do mifchief, by tearing afunder the very parts they are meant to unite ; at leaft this has been the cafe in different inftances where I have known this method pradifed. A troublefome cough was in- duced in all of them ; the flitches were torn out; and much perplexity was thus given both to the patient and furgeon. Inftead of paffing the ligatures round any of the cartilages of the trachea, and thus carrying them into the cavity of the tube, I have in different inftances fuc- ceeded merely by external flitches done in the follow- ing manner: the furgeon being provided with a num- ber of needles and ligatures in proportion to the extent of the wound, and the patient being properly placed, one of the needles ffiould be inferted at one fide of the wound, and being paffed flowly up for the fpace of an inch between the trachea and fkin, fo as to in- clude all the cellular fubftance and mufcular fibres which lie between them ; it is now to be pufhed out along with one end of the ligature; and the other ex- Sed. X. Trachea and Oefophagus. 243 tremity of the thread being alfo armed with a needle* muft in like manner be paffed through the teguments of the other fide of the wound, by entering the point of the needle at the wound, and pufhing it out on the oppofite fide, at a proper diftance from the edge of it. None of the ligatures ffiould be tied till they are all introduced ; when this is done, and the divided edges of the cut properly fupported by an affiftant, the hga- tures ffiould be fecured with running knots, fo as to admit of their being eafily untied, if this fhould be ne- ceffary ; adhefive plafters fhould be applied over the whole ; and the head ffiould be firmly fecured in the manner that I have mentioned. In palling the ligatures, care ffiould be taken to run the needles clofe to the cartilages of the trachea, fo as to include whatever may afford them any fupport: for which purpofe, flat needles ffiould be employed* with a flight degree of curvature, as is reprefented in Plate IV. fig. 5. Whether or not this method will fucceed where the trachea is completely divided, I cannot as yet deter- mine, having had no opportunity in fuch a cafe of putting it in pradice : but as it has fucceeded where all the anterior part of the tube was divided, there is reafon to imagine that it would not often fail. At any rate, it ffiould always be propofed in the firft place ; for even when it does not fucceed, we are not thereby prevented from employing other means of relief. In fuch inftances we are reduced to the neceffity of paff- ing the ligatures round one or more of the cartilages of the trachea, which, with a curved needle, may be eafily done: care ffiould be taken, however, to enter both ends of the ligature from the infide of the tra- chea, when by pufhing the point of the needle out- ward all rifk is avoided of doing harm. To give the practice as much chance as poffible of proving fuccefsful, as many ligatures fhould be intro- duced as may feem fully neceffary for retaining the r 2 244 Of Wounds in the Chap. III. divided ends of the trachea in contad: in general, three -flitches will be fufficient; one in the' middle of the prominent part of the trachea, and another on each fide towards the ends of the cartilaginous rings. Wounds of the oefophagus are to be managed near- ly in the fame manner with thofe of the trachea : but they are more dangerous, on account of the difficulty of reaching the oefophagus from its deep fituation; from the under part of it, when entirely feparated from the reft, being apt to fall altogether within the fternum; and from the difficulty of fupporting the patient with nourishment. Thefe wounds are likewife to be confidered as dan- gerous, from their vicinity to large arteries and nerves. If the recurrent nerves are divided, the voice may be deftroyed ; and if any of the deep feated branches of the carotid arteries are wounded, the patient may die from lofs of blood. In wounds of the trachea and oefophagus, our firft objed fhould be to fecure the blood veffels that have been cut, not only in order to prevent the lofs of blood, but to obviate the cough and ficknefs, which greatly aggravate the injury, and which are often the confequence of blood finding accefs to the ftomach and lungs. Every veffel therefore that pours out blood, whether artery or vein, ffiould be tied with a ligature whenever it can be accomplifhed. When wounds in this fituation are not extenfive, but confined nearly to the boundaries of the trachea and oefophagus, the artery which goes to the thyroid gland will probably be the largeft that is cut; for it is commonly in this fituation, immediately below the thyroid cartilage, that attempts are made upon the throat. But in wounds of greater extent, the jugular veins, and even the carotid arteries, are fometimes di- vided. In almoft every inftance, wounds of thefe ar- teries prove quickly fatal; but when one of the caro- tids is only partially hurt, it may be poffible to fave the patient by fecuring the bleeding veffel with a Iiga- Sed. X. Trachea and Oefophagus. 245 ture both above and below the cut: this at leaft ffiould always be attempted ; and I think it probable, when one artery only is cut, that the attempt would fucceed. There is no reafon to doubt of its proving fuccefsful in wounds of the jugular veins : but where thefe veins are only wounded, without being cut entirely acrofs, we may with propriety endeavour to effed a cure by compreffion. When flight compreffion only is necef- fary, it may be applied by a circular roller round the neck; but when much preffure is required, as this cannot be employed without impeding refpiration, we are under the neceffity of ufing a machine for proted- ing the trachea. In Plate III. fig. 1. an inftrument is delineated, which anfwers this purpofe very effedu- ally. As foon as the haemorrhagy is ftopped, we ffiould proceed to unite thofe parts of the oefophagus which have been divided ; and in doing it, if the wound is not very extenfive, it will be of much importance, both to the operator and patient, to have it enlarged in every diredion that may be neceffary for bringing the injured parts eafily and completely into view, by which the ligatures will be introduced with more ac- curacy than can otherwife be done. In paffing the threads, the needles fhould be entered from within, and pullied outwards, in the manner direded above for wounds of the trachea : and in both cafes, the ends of the ligatures ffiould be left of a fufficient length to admit of their hanging out of the external wound in the teguments. The interrupted future appears to be beft adapted for this operation. In longitudinal wounds of the oefophagus there is reafon, from the refult of different cafes, to imagine that cures might frequently be accompliffied without the affiflance of ligatures. But in tranfverfe wounds of this part, it is the fafeft pradice to employ one or more flitches, according to the extent of the injury, by which the food will not fo readily efcape during 246 Of Wounds Chap. III. the cure, and by which a reunion of the divided parts will be more readily obtained/ SECTION XI. Of Wounds in the Thorax, § 1. General Remarks on Wounds in the Thorax, TO the confideration of wounds of the thorax, it will be proper to premife a fhort account of the boundaries of this cavity, and of the vifcera which it contains, The thorax is an extenfive cavity, of an irregular oval figure, bounded anteriorly by the flernum, late- rally by the ribs, behind by the vertebras of the back, above by the clavicles, and below by the diaphragm, a firm mufcular expanfion, which ferves as a partition between it and the cavity of the abdomen. The diaphragm does not pafs in a dired line from one fide of the cheft to the other: in fome parts it falls much lower than in others, by which the extent of this cavity is in different parts very unequal. On cutting the thorax diredly acrofs about the middle of the flernum, and looking down upon the diaphragm, we find it round and prominent in the middle, with its edges ftretching down to its feveral attachments. In its higheft and moft anterior point, it is fixed to the cartilasro enfiformis ; from whence it defcends ob- liquely, and is attached as it goes along to the feventh, eighth, and all the inferior ribs; while, behind, it is fixed to the upper vertebrae of the loins. From this it is evident that the back part of the thorax is much more deep and capacious than the anterior part of it: Sed. XI. in the Thorax, 247 a point with which praditioners ffiould be very ex- adly acquainted, otherwife their ideas of wounds in thefe parts will often be erroneous. Thus, were this not to be kept in view, we would be apt to imagine that no injury would be done to the lungs by wounds running diredly acrofs the body, after entering any part of the cavity of the abdomen : whereas no in- ftrument can pafs in this diredion even at the diftance of feveral inches beneath the upper part of the abdo- men, without penetrating the cavity of the thorax; and, for the fame reafon, all wounds which pafs di- redly acrofs the body from the inferior and back part of the thorax, muft neceffarily pafs through the abdo- men. The whole cavity of the thorax is lined by a firm membrane termed the Pleura, which adheres every where to the flernum, to the ribs, intercoftal mufcles, and diaphragm. Each fide of the cheft has a diftind pleura; which uniting together near the middle of the breaft, and running tranfverfely from the flernum to the vertebras, form two cavities which have no communication with each other. This membranous partition is termed the Mediaftinum. It adheres firm- ly, as one membrane, to the flernum through its whole length; but the two pleurae recede from each other near to the vertebras, to admit of a paffage for the aorta and oefophagus. The heart, inclofed in the pericardium, occupies a confiderable part of the left cavity of the thorax : the reft of this divifion, with all the right fide of the cheft, is chiefly filled with the lungs. The only other parts lodged in the thorax are, the aorta, oefophagus, thoracic dud, thymus, and large blood veffels about the heart. In a ftate of health, the lungs do not adhere to the pleura; but it often happens, that very firm and extenfive adhefions are produced by inflammation of thefe parts. The thorax is expofed to every variety of wound ; but the diftindion that chiefly merits attention, is that which arifes from their depth. Superficial wounds, 248 Of Wounds Chap. III. not running deeper than the common teguments, when rightly treated, are feldom produdive of any important confequences ; but even the flighteft injury which penetrates the cheft, will, in fome inftances, be attended with the moft alarming fymptoms; and thofe again are ftill more dangerous, that are accom- panied with wounds in any of the vifcera of the tho- rax. Wounds in the thorax may therefore be divided into three kinds: thofe which affed the common te- guments only; fuch as merely penetrate the cavity, without doing any further injury ; and thofe by which fome of the vifcera are likewife hurt. Our firft objed in thefe wounds is, to difcover whether they have penetrated the cheft or not; which in general may be done by attending to the following circumftances: by the patient being put into that fituation in which the wound was inflicted, and in this ftate making a particular examination with the fin- gers, or probe, of the diredion and depth of the wound; by the form of the inftrument, and the length to which it feemed to be pufhed ; by any mild liquid which may be injeded returning immediately or lodging in the wound ; by air being difcharged dur- ing refpiration by the wound ; by an emphyfematous fwelling appearing over the contiguous teguments ; by the quantity of blood difcharged from the wound being confiderable or otherwife; by the appearance of the blood; by blood being difcharged from the mouth ; and by the ftate of the pulfe and refpiration. Each of thefe circumftances we ffiall confider in the order they are mentioned. It is obvioufly a matter of importance to pay at- tention to the pofture of the patient during the ex- amination of every wound ; but in none more than in wounds of the thorax, where, from the variety of mufcles which may be injured, and from the mobility of the ribs, wounds may in one pofture appear to be fuperficial, which in others are found to penetrate to a Sed. XI, in the Thorax. 249 great depth ; for if any part of a rib, of a mufcle, or even of the cellular fubftance, is forced by the pof- ture of the patient into the courfe of a wound, neither the finger, probe, nor injedions, will pafs with that eafe which the free examination of fuch injuries re- quires. In all fuch cafes, therefore, before we pro- ceed to examine the diredion and depth of the wound, the patient ffiould be placed as nearly as poffible in the pofture he was in at the time of receiving it. In fome cafes, the opening is fo large, that we dif- tinguiffi with the eye whether a wound has penetrat- ed to the depth of the cavity or not; or we introduce one of the fingers, which is better than any probe, when it can be paffed forward without lacerating the contiguous parts; but when the opening is too fmall to admit of this, we are under the neceffity of ufing a probe; and the beft fubftance for this purpofe is a common bougie. When we mean by probing a fore to difcover whether any extraneous body is lodged or not, or whether the bones beneath are carious or in a found ftate, a metallic probe is better. But for ex- amining the depth and diredion of a wound,.nothing anfwers fo well as a firm and tolerably thick bougie; which neither gives fo much pain to the patient, nor is it fo apt to be pufhed beyond the depth of the wound into the contiguous foft parts, as the common fmall probe. This, indeed, will not often happen with practitioners of experience, as they will not only make ufe of probes in every cafe with caution, but will be fenfible that they are often employed unnecef- farily : for even in wounds of the thorax, we fhould not fearch for their depth with too much anxiety; as, by doing fo, more harm may be done than could be compenfated by any advantage to be derived from the difcovery. It is highly proper to examine, in a cautious way, into the direction and depth of fuch wounds; but the younger part of the profeffion ffiould know, that much harm has been done by ex- aminations of this kind being carried too ftr: and 250 Of Wounds Chap. III. they ffiould likewife know, that it is perhaps of more importance to be acquainted with the diredion of an external pundured wound, which does not run deep- er than the cellular fubftance above the ribs, or per- haps to the intercoftal mufcles, than to know, by means of the probe, whether a wound reaches to the cavity of the cheft or not: for even where we find, in the moft evident manner, that a wound goes to the depth of this cavity, if no bad fymptoms occur, little or no advantage is obtained from the difcovery ; and where fuch fymptoms take place as are known to pro- ceed from a penetrating wound, and of which we fliall afterwards treat, we are thus rendered equally certain of the nature of the cafe as if a probe had paffed eafily into the thorax. Some advantage may be obtained in thefe inqui- ries, from our attending to the fize and figure of the inftrument; the diredion it feemed to take ; and the depth to which it was pufhed: thefe are points of which we cannot always receive exad information ; but it is fometimes otherwife, particularly in duels, where a furgeon is frequently attending, and where the by- standers are often fo much interested, as to be able to give a diftind account of this and of every other point that relates to them. When by either of thefe modes of inquiry, we are made certain of the depth of a wound, it would be unneceffary as well as improper to carry our refearch- es further: but when this remains in doubt, it may in fome cafes be afcertained by the injeding of mild liquids. If the liquor returns immediately, there will be reafon to think that the wound is fuperficial, or at lead that it does not pafs into the thorax; but when it lodges either altogether, or in confiderable part, without railing any outward tumefadion, there will be no caufe to doubt of its having reached the cavity. In throwing in liquids for this purpofe, it ffiould ne- ver be done with much force, as in this manner parts might be torn afunder, w;hich were not previoufly Sed. XI. in the Thorax. 251 hurt; and the mildeft liquor only ffiould be ufed, as it might prove dangerous to apply any thing poffeffed of ftimulating powers to the furface of an irritable part. Honey and water are commonly ufed for this purpofe ; but warm water alone is lefs irritating, and ffiould therefore be preferred. When air is difcharged by the wound during infpi- ration, there is caufe to fufped that the lungs are wounded. But although this is ufually confidered as one of the moft certain proofs of a wound having pen- etrated the cheft, it is proper to remark, that it is far from being decifive. Wherever the lungs adhere to the pleura, a wound may penetrate to a confiderable depth ; nay, it may pafs entirely acrofs the body, with- out entering what is properly termed the cavity of the cheft ; and we know that air is frequently difcharged at wounds in the thorax where there is no reafon to fufpe.d that the lungs are hurt; for when no adhe- fions take place between the pleura and lungs, the ex- ternal air, if it gets accefs by a penetrating wound, will pafs between them, and will neceffarily be forced out at every infpiration ; a circumftance which inva- lidates the certainty of this tell. In judging, there- fore, of the weight which is due to it, we ffiould, in the firft place, caufe the patient to make feveral full in- fpirations, in order to force out any air from between the pleura and lungs ; and at the end of each, the contiguous fkin fhould be fo drawn over the wound, as to prevent any more from finding accefs. In this manner nearly the whole will foon be difcharged; when, if we ftill find that air ruffies forcibly out dur- ing infpiration, we may with certainty conclude that the lungs are injured. Emphyfematous fwellings fometimes appear as the confequences of wounds of the thorax, by the air from the lungs finding accefs to the furrounding cel- lular membrane. This, however, will feldom happen in extenfive wounds ; as in thefe the air from the lungs will readily be difcharged outwardly : but it is 252 Of Wounds Chap. III. by no means unfrequent in pundured wounds, efpe- cially in fuch as have an oblique diredion. It is ob- vious, however, although this is a certain proof of the lungs being injured, that it may fometimes happen without any communication with the cavity of the cheft, for the reafon mentioned in the laft paragraph. When the quantity of blood difcharged from thefe wounds is confiderable, we may with good reafon con- clude, that they have not merely paffed into the cheft, but alfo that fome of the vifcera are wounded ; for, excepting the intercoftal arteries, which run upon the inferior border of each rib, all the blood veffels of the mufcles and teguments are fmall; and as we can by compreffion eafily put a flop to haemorrhagies from the intercoftal veffels, we may in almoft every inftance difcover immediately whether the blood comes from the cheft or not. Even the appearance of blood difcharged from thefe wounds may lead to a knowledge of their depth. It is a known fad, that blood coming diredly from a wound in the lungs, has a more red, and particularly a more frothy appearance, than blood from any other part, owing probably to its being mixed with the air in the bronchias ; fo that when blood affumes this ap- pearance, we have much caufe to conclude that the lungs are injured. When blood is fpit up by the mouth, immediately after a wound in the thorax, there is little reafon to doubt of the lungs being hurt. For although we ought not to conclude from the abfence of this fymp- tom, that the lungs have not fullered, for they may be wounded without any blood being difcharged by the mouth ; yet we may be convinced, that fome in- jury is done to them, when blood isadually difcharg- ed from them. In our inquiries into the nature of thefe .wounds, the ftate of the pulfe and refpiration require particular attention. In wounds which do not penetrate deeper than the common teguments, neither the pulfe nor Sed. XI. in the Thorax. 253 breathing are at firft affeded, nor do they produce any other confequences for the firft two or three days, than wounds in other parts of the body : but wounds which go to the depth of the thoracic cavity, and more efpecially fuch as affed the lungs or other parts contained in it, may often be diftinguifhed by the im- mediate effed which they produce both upon the pulfe and breathing. When the lungs are injured in a part which adheres to the pleura, the wound may pafs to a confiderable depth without any extravafation taking place into the cavity of the cheft ; in which cafe, no immediate effed may enfue: but when either blood or air finds accefs to this cavity, the lungs are imme- diately compreffed, by which the breathing becomes difficult, and the pulfe feeble, oppreffed, and intermit- ting ; fo that when thefe fymptoms take place, we may at once give a decided opinion of the nature of the cafe. By due attention to thefe circumftances, we may, in almoft every inftance, determine with much certain- ty whether a wound has reached the cavity of the thorax or not: and this being fixed, we are next to proceed to the method of treatment. We ffiall firft advert to thofe wounds which do not go deeper than the common teguments or mufcles, and afterwards to thofe which penetrate deeper. § 2. Of Wounds in the external Teguments of the Thorax. Wounds of the thorax not going deeper than the fkin and cellular fubftance, do not give any caufe for anxiety, as they heal with the fame eafe, and are to be treated in the fame manner with fimilar wounds in other parts of the body : but when they reach the mufcular fubftance between the ribs, and efpecially when they run among thefe parts for a confiderable way like finufes, there is always reafon to fe:-r that at laft they may penetrate the cavity of the thorax ; for ft54 Of Wounds Chap. IIL when fores in this fituation are not in every refped properly treated, and if any matter that forms in them is not regularly difcharged, it is apt to pafs deeper and deeper, till at laft it penetrates the pleura itfelf. In all fuch cafes, therefore, it ffiould be our firft objed, to give a free vent to the matter. In open incifed wounds, all that is neceffary is, by means of eafy dreff- ings, to preferve their lips or edges from adhering till they fill with granulations from the bottom : but pundured wounds ffiould either be laid open through their whole extent, i9r a feton paffed from one end of the finus to the other. When not very extenfive, the ffiorteft and eafieft method is to lay them freely open with a fcalpel and diredor, and then to heal them from the bottom like incifed wounds from any other caufe: but when a pundure runs to any confiderable length, the method of cure by a feton anfwers better. By paffing a feton along the courfe of the finus, we prevent it from healing outwardly till the whole is equally filled up ; and this being done, if the cord is gradually diminifhed, and at laft removed, a moderate degree of preffure continued upon the parts for a few days longer, will feldom fail to effed a cure. Some, indeed, advife the cure of fores of this kind to' be in every inftance attempted with preffure alone. v But al- though preffure often proves fuccefsful in other parts of the body, particularly in the extremities, where it can be applied with exadnefs along the whole courfe of a finus, and continued for a fufficient length of time without rifk ; yet in wounds of the thorax, the fame advantages do not refult from it: for here a continu- ed equal preffure cannot be applied in a fufficient de- gree, without impeding refpiration. When a cure is, however, to be attempted by preffure, it muft be done writh a roller paffed firmly round the thorax, fupport- ed by what is termed a fcapulary put over the ffioul- ders : but when a feton has been previoufly ufed, the preffure may be applied with flips of adhefive plafter Sed. XI. in the Thorax. 255 laid along the courfe of the wound, and fixed upon the contiguous fkin. This method of cure, by laying the finufes open, or by the infertion of a feton, to thofe not much ver- fant in this branch of pradice, may appear to be unneceffarily fevere; for by many of the older wri- ters we are told, that our objed may be accompliffi- ed in a more eafy manner, namely, by keeping the external openings of the fores pervious, by the ufe of tents, till they are firmly healed from the bottom. In wounds which penetrate to the cavity of the thorax, tents, efpecially thofe that are hollow, prove often ufeful; and as they may be ufed with fafety, they ffiould not be fo generally condemned as fome mod- ern praditioners have affeded to do. But in punc- tured wounds which do not go to this depth, as our great objed is to avoid every rifk of the matter find- ing accefs to the thorax, whatever can tend to impede the difcharge of it, ffiould by all means be avoided. So that in fuch cafes tents ffiould never be ufed : they would frequently do harm, in the manner I have mentioned; in many cafes they would fail entirely; and if they ffiould ever fucceed, the cure would prove much more tedious, and often more painful, than the mode of treatment that I haye advifed. In every wound of importance, diet and other parts of regimen merit particular attention : we frequently find, indeed, that praditioners fail entirely, where otherwife they would fucceed, merely from patients being allowed more freedom in food, drink, and ex- ercife, tnan is confiftent with fafety. In wounds of the thorax, attention to thefe points is ftill more ne- ceffary than in fimilar affections of other parts: for as the parts contained in the thorax are highly effen- tial to life, and as they are very liable to infhir.c, even from injuries that do not penetrate deep, every precaurion fliould be employed by which it can be prevented. Hence, for fevr-.:! days at leaft, or even till there appears to be no fiuihcr chance of the r-arts 256 Of Wounds Chap. III. becoming inflamed, the patient fhould be kept upon low diet; animal food and ftrong liquors of every kind fhould be avoided; the bowels ffiould be kept open with mild laxatives; and when the pulfe re- quires it, a due proportion of blood fliould be taken. Reft of body and perfed quietnefs is of much im- portance in thefe wounds; for they are affeded by the leaft degree of motion ; even coughing, laughing, or much fpeaking, is apt to do harm, and ffiould therefore be as much as poffible avoided. § 3* Of Wounds which penetrate the Cavity of the Thorax, Wounds that penetrate the thorax, are always hazardous, and therefore merit particular attention : even fuch as merely penetrate the cheft, are often at- tended with important confequences, for the mere contiguity of the lungs and other vifcera adds much to the danger. At prefent, we are to treat of fimple penetrating wounds, not conneded with any injury done to the contained parts. It is now known, that in a ftate of health the lungs fill the fpaces allotted for them in the two fides of the thorax, fo completely, that they are every where in contad with the pleura, both in the ftate of infpira- tion and expiration : and it is alfo known, that great diftrefs in breathing is induced, by air, blood, or any extraneous matter being admitted between them. Now, in penetrating wounds of the thorax, excepting where the lungs morbidly adhere to the pleura, it is fcarcely poffible to prevent both air and blood from being admitted: the external air ruffiing in at the wound foon fpreads over the whole correfponding ca- vity; and when the intercoftal artery or any other blood veffel is divided, if the external opening be not fufficiently large, any blood that is evacuated is apt to fall down between the pleura and lungs to the very bottom of the cheft; by which, difficulty of breath- Sed. XL in the Thorax, 257 ing immediately takes place, along with all the other fymptoms which ufually attend a compreffed ftate of the lungs. In Chap. XXVI. I ffiall find it neceffary to confid- er fully, not only the fymptoms which fluids colleded in the cheft are apt to induce, but the method of re- lieving them by the operation of the paracentefis : to avoid repetitions, I ffiall now refer to what will then be faid upon this part of our fubjed, and at prefent ffiall offer a few obfervations upon the means of pre- venting fuch collections as may require the affiflance of that operation. In wounds which do not penetrate to the depth of any of the vifcera, but which merely pierce the pleu- ra, almoft the only artery which can be cut, that can afford any quantity of blood, is the intercoftal; and being of a confiderable fize, no time ffiould be loft in tying it whenever it is found to be wounded. As it runs in a groove in the inferior edge of the rib, it is difficult to put a ligature round it; but, with due at- tention, it may in every inftance be done. In free incifed wounds, the bleeding orifice will be brought clearly into view ; but in fmall pundured wounds, as the artery cannot be diftindly feen, there is a neceffity for laying the parts fufficiently open with the fcalpel. When the artery is thus laid bare, vari- ous means have been propofed for fecuring it. For the reafon that I have juft mentioned, a crooked nee- dle cannot be paffed round it. We are therefore told by fome, that the only method of doing it is to pafs a firm broad ligature round the rib, and by means of it to tie a doffil of lint upon the orifice of the artery; while others condemn this pradice, from the injury which it muft neceffarily do to the pleura; for this membrane cannot in this operation be feparated from the rib, fo as not to be included in the ligature; fo that instruments have therefore been propofed for ob- viating this inconveniencv. The intention, however, Vol. I. S 258 Of Wounds Chap. III. of thefe instruments, is to comprefs the intercoftal ar- tery, without hurting the pleura ; but as none of them I have met with anfwer this purpofe, I do not think it neceffary to delineate them : thofe who wiffi to fee them, may look into the fecond volume of Memoirs of the Royal Academy of Surgery at Paris. It is luckily, however, in our power to fecure this artery in a much more fimple manner. By dilating the wound fufficiently, we may with a tenaculum, fomewhat more bent at the point than ufual, draw the bleeding veffel out of its groove, fo as to tie it in the ordinary way ; at leaf! in thin people this may be eafily done : and where it is found, ejlher from the ribs being deeply covered with fat, or from any other caufe, that it cannot be fecured in this manner, it may always be done in the manner I have mentioned, by paffing a firm broad ligature round the rib, and thus tying a fmall doffil of lint upon the bleeding artery. In this way a portion of the pleura will no doubt be included in the ligature ; but it does not appear from experience, that this proves hurtful, and with fufficient caution we may always avoid the lungs. When the lungs do not adhere to the pleura, they collapfc in fome degree immediately on the external air being ad- mitted through the wound to the cavity of the cheft. And even when they adhere, we may eafily feparate as much of them with the point of the finger as will admit of the paffage of the ligature. When a praditioner is called immediately, he may in this manner prevent any great quantity of blood from being emptied into the thorax; and as foon as the haemorrhagy is ftopped, he fhould endeavour to expel all the air that has found accefs by the wound to the furface of the lungs ; for till this is done, the breathing will remain oppreffed, nor will the patient be able to bear the application of the neceffary dreff- ings. In Chap. XXVI. different methods of expelling air from the furface of the lungs will be mentioned ; but the fimpleft and eafieft is this: while the wound Sed. XI. in the Thorax., 259 yet remains open, let the patient in a flow gradual manner, make a full infpiration, by which a confider- able part of the colleded air will be difcharged at the wound : this being done, the fkin muft be inftantly drawn over the fore, fo as to cover it completely dur- ing expiration ; and if the wound is again moderate- ly opened during infpiration, the whole quantity will in this manner be foon expelled. After which vthe lips of the wound fliould be drawn exadly together, and in this fituation fhould be fecured with flips of ad- hefive plafter, care being taken to fupport the whole with the napkin and fcapulary bandage. In this manner, wounds of the thorax will frequent- ly heal, which, if left to themfelves, or if treated in the ufual way by allowing them to remain open, might produce much diftrefs : but in fome cafes, either from a confiderable quantity of blood having been thrown out from the intercoftal artery before the ligature was applied ; from the oozing of blood from the fmaller ramifications of the intercoftal arteries ; or perhaps from a fubfequent formation of pus ; oppreffed breath- ing will fupervene, notwithftanding all that can be done to prevent it. When this takes place from the formation of mat- ter, an opening ffiould be made to difcharge it in the manner to be hereafter advifed in the chapter on Ey- pyema ; and in this cafe the opening ffiould be made in the mofl depending part of the thorax. But when it occurs immediately after a wound, and while the blood yet remains fluid, we may often be able to dif- charge it at the wound itfelf, and when this can be done, it ffiould always be preferred ; for we are not to imagine that the thorax can in any part be laid open but with fome rifk of harm being done by it. When fymptoms, however, of oppreffed breathing oc- cur from a wound In the upper part of the thorax, as the effufed blood cannot be difcharged by it, we are obliged to make a perforation in the under part of the i 2 260 Of Wounds Chap. III. cheft as foon as the fymptoms become fevere: it is proper, however, to obferve, that this operation ffiould never be advifed while the fymptoms are moderate: for we have daily inftances of fmall quantities, not on- ly of blood but other fluids, being abforbed ; and as the rifk attending a perforation in this place is proba- bly greater than would occur from fmall quantities of blood being allowed to remain, it ffiould not be advif- ed as long as the breathing continues tolerably free. § 4. Of Wounds of the Lungs. In a preceding part of this fedion, I have enumer- ated the fymptoms which indicate a wound in the tho- rax to have penetrated the lungs : and although the danger in this cafe is greater than in wounds which merely penetrate the pleura, yet the method of cure fuited to the one is fo nearly the fame with what I have advifed for the other, that it is fcarcely neceffary to enlarge on it further. It is proper, however, to obferve, that as the haz- ard arifing from wounds in the lungs is confiderable, the caution with which they are treated fhould be pro- portionally great. Inftances indeed have occurred of their healing with eafe and fafety; but they are fb rare, that I do not hefitate to fay, that every injury done to the lungs is to be confidered as extremely hazardous. The danger arifing from wounds in the lungs, orig- inates, in the firft place, from the haemorrhagy being apt to proceed farther than the ftrength of the patient will bear ; and, afterwards, from abfceffes forming in the fubftance of the lungs which frequently terminate in phthifis. The haemorrhagy is moft readily checked by plen- tiful venefedion ; by the patient being kept in a cool apartment, and at perfect reft; by the ufe of mild laxatives ; and by low regimen. Befides reft of body, it is of much importance to keep the lungs as free Sed. XI. in the Thorax. a6l from adion as poffible. Hence coughing, laughing, and even much fpeaking or deep infpirations, fhould be rigidly guarded againft. Due attention to this is neceffary in every wound of the thorax, particularly in thofe affeding the lungs ; for when the lungs are wounded, they can never be fully diftended with air without ftretching every blood veffel that has been hurt. Notwithftanding, however, of our utmoft attention, the patient will fometimes fink under the lofs of blood ; in other cafes, blood will be colleded in large quan- tities between the pleura and lungs, fo as to impede refpiration; or abfceffes will form, as I have already obferved, in the fubftance of the lungs. I fhall now proceed to offer a few remarks on the management of abfceffes in the lungs. Matter colleded in the fubftance of the lungs from a wound, may be difcharged in three different ways. It may be fpit up by the mouth ; it may be difcharg- ed by the abfcefs burfting into the wound itfelf; or it may be emptied into one or other of the cavities of the cheft between the lungs and pleura. When an abfcefs in this fituation opens into the bronchias, there may be fome rifk at firft of immedi- ate fuffocation; but when this danger is over, by a confiderable quantity of the matter being difcharged, if there is no hereditary tendency to phthifis, a cure will often be accompliffied by the means ufually ad- vifed in fuch cafes, namely, by a diet that is light and of eafy digeftion, and at the fame time fufficiently nourifhing ; and by daily moderate exercife, by which any matter colleded in the abfcefs is brought up with more eafe than by any other means. A fea voyage too proves ufeful in this view, at the fame time that it tends to brace and invigorate the fyftem ; or when a voyage cannot be obtained, we advife riding on horfeback. When pus colleded in the lungs is dif- charged in this manner, the bufinefs of a furgeon be- comes nearly unneceffary; but when the abfcefs eith- 262 Of Wounds Chap. III. er empties itfelf into the cheft, or points outwardly at the wound, we have it often in our power to fave the patient by an operation, when otherwife he would in- evitably die. When an abfcefs burfts into the cheft, the matter ffiould be difcharged in the manner we ffiall advife in chapter XXVII. But when the wound by which the colledion is produced remains open, fo as to ad- mit of the matter to point towards it, as foon as this is difcovered, either by a fmall oozing of pus taking place, or by the introdudion of the finger between two of the ribs, we ffiould at once determine on treat- ing it on the fame principles, and in the fame manner with abfceffes in any other part of the body, namely, by making an opening into it of a fufficient fize for difcharging all that it contains. The delicate nature of the part in which the matter is feated may deter fome from adopting this pradice; but it does not re- quire much argument to fliow, that a patient in fuch circumftances runs much more rifk of iuffering by the matter being allowed to remain, than by making an opening into the abfcefs. By this he avoids the haz- ard of immediate death, which commonly happens from large abfceffes burfting into the bronchiae; at the fame time that it prevents the matter from paffing into the cavity of the cheft between the pleura and furface of the lungs ; and thus obviates the neceffity of a fecond operation. Nay, in cafes of this perilous nature, I would even go farther: when from a previ- ous difcharge of matter we know that an abfcefs has formed in the lungs as a confequence of a wound ; when a ftoppage of this difcharge takes place, and is fucceeded by all the ufual fymptoms of a frefli collec- tion of matter ; fuch as an increafed difficulty of breath- ing ; difficulty in lying on the found fide ; frequent ffiivering fits ; and a hedic pulfe ; as in fuch a fitua- tion there will be no reafon to doubt of matter being colleded, and as the patient muft remain in the ut- moft hazard till it ij difcharged, I ffiould think it ad- Sed. XI. in the Thorax. 263 vifable to enlarge the external wound not only of the common teguments, but of the intercoftal mufcles, and to extend the opening for the fpace of two or three inches; by which more freedom will be given for fearching with the finger for the feat of the abfcefs ; and whenever this is difcovered, I would not hefitate, at whatever depth it may be, to open it, by running a biftoury along the finger, and puffiing it flowly into it. In the courfe of my own experience, I have had different cafes of this kind ; in which, by this decisive pradice, I had the fatisfadion of faving lives, which otherwife there was much caufe to think would have been loft. This was the opinion of other pradition- ers who attended along with me; and I was fo much convinced in all of them, of matter being colleded internally which produced the danger, and of nothing being able to fave the patients but the difcharge of it, that after warning them of their danger, and receiv- ing their approbation, I was refolved to carry the opening into the fubftance of the lungs to the full length of my finger, rather than leave them to their fate. In every inftance I found it neceffary to go to nearly the length of my finger ; and at this depth I was fo fortunate as to reach an abfcefs containing at leaft half an Engliffi pint of matter. The patients were inftantly relieved ; and although they were pre- vioufly fuppofed to be in the utmoft danger, with fcarcely a poffibility of recovering, they are now, after feveral years have elapfed, in perfed health. In making an opening into fuch a deep feated ab- fcefs, the incifion ffiould be carried forward in the moft gradual manner, fo that no more of the lungs may be hurt than is neceffary: but when once the matter appears, the abfcefs ffiould be laid as freely open as may be proper for an entire difcharge of it. In the fubfequent treatment of thefe abfceffes, our chief objed is to preferve a proper aperture for the difcharge of the matter: for if this be not done till the abfcefs fills from the bottom, a new colledion will 264 Of Wounds Chap. Ill, take place, and the patient will foon be reduced to the fame ftate of uncertainty and danger as before. In wounds which do not penetrate deeper than the teguments or mufcles of the thorax, I have obferv- ed above, that no kind of tents fhould be employ- ed ; and that they ffiould rather be laid open through their whole length, or be treated by means of a feton, as is done with fores of a fimilar na- ture in other parts of the body. But as this is im- pradicable in penetrating wounds, we are in thefe under the neceffity of inferring a tube into the open- ing, and of caufing it to be continued of a fufficient fize and length during the whole courfe of the cure: the tube ought, indeed, to be continued as long as any matter is difcharged. Tubes of lead being more foft and pliable than thofe of any other metal, are therefore to be preferred : they fhould be broad, and of a round oval form, rather than altogether round ; and they ffiould always be furniffied with a brim con- fiderably broader than the opening of the fore, to ob- viate every poffibility of their falling into the cheft. By inattention to this point, a tube of four inches in length, and of a correfponding thicknefs, paffed alto- gether into the cavity of the breaft of a gentleman who had ufed it for fome time; and notwithftand- ing various attempts to extrad it, it ftill remains lodg- ed. It was fixed in the ufual way, by a thread, to a bandage going round the body; but the thread break- ing, it immediately flipped in. This happened up- wards of eight years ago. It does not indeed excite much uneafinefs, but it had an evident effed in in- creafing the quantity of matter difcharged from the wound. I have met with fome cafes of wounds in the cheft, where folid tents have anfwered the purpofe equally well with tubes ; and they may always be ufed when the parts do not contrad fo clofely round them as to prevent the matter from being freely difcharged : but whenever they flop up the paffage fo much as to pro- duce any colledion of matter between one dreffing Sed. XI. in the Thorax. 265 and another, they ffiould undoubtedly be laid afide, and tubes ufed inftead of them. As tents had been ufed for a great length of time in almoft every wound which penetrated beyond the common teguments, Bellofte, and fome other furge- ons of obfervation, ventured at laft to lay them in a great meafure afide. I have already had occafion to obferve, that this, to a certain length, was highly proper; but I cannot agree with fome modern prac- titioners who affert, that tents and tubes do mifchief in every cafe, and that they ffiould never be employ- ed. Where the difcharge from a wound or abfcefs continues free and uninterrupted till a cure takes place by the parts filling up from the bottom, I would never advife either a tent or a tube to be ufed. But when the external opening of a wound heals up long before the parts beneath are united, and matter col-, leds and again burfts out, as has happened in differ- ent inftances with me in penetrating wounds of the cheft, it muft be from want of experience only, or from a defire of appearing lingular, that we refufe to employ the only certain method with which we are acquainted of obviating this inconvenience, and of faving the patient a great deal of pain, trouble, and danger. In extenfive wounds of the thorax, where any part of the flernum or ribs have been removed, a portion of the lungs fometimes protrudes, and does not rea- dily recede. When a praditioner is called foon after the accident, the protruded part ffiould be replaced as quickly as poffible; but when a portion of the lungs has been long expofed to the air, and efpecially if much hurt by the accident, we fliould, in the firft place, fee whether it is in a ftate of mortification or not; and all that is clearly and completely mortified ffiould certainly be cut off before the found parts are replaced. If the incifion is confined to a part that is entirely gangrenous, there will be no rifk of inducing either haemorrhage or any other fymptom; and by 266 Of Wounds Chap. III. removing parts which are in this ftate of difeafe, we prevent all the bad confequences which might enfue from their being returned into the thorax. § 5' Of Wounds of the Heart and large Veffels conneded with it, and of Wounds of the 'Thoracic Dud. Wounds of the heart and large veffels conneded with it, are at all times attended with much danger, nor is the greateft exertion of praditioners able to lef- fen it. Of fuch a hazardous nature indeed are inju- ries done to thefe parts, that in every inftance we may pronounce that they will terminate fatally : for al- though we are told in books, of the heart itfelf being wounded without any fatal confequences having en- fued, there is much caufe to fufped that thefe ac- counts are founded on fallacy or error. We can, however, conceive that the heart may be flightly in- jured without proving inflantly fatal; but even the flighteft wound in it muft probably at laft end in death : for the weaknefs induced in this manner upon a particular part, will render, it very liable to yield to the ftrong and conftant adion of this organ; and when once an aneurifm is formed in it, it will not fail to proceed quickly to a fatal termination. The moft likely method of preventing this, or at leaft of delaying it, is to leffen the adion of the heart by copious bloodletting; by low diet; keeping the bowels moderately open'; and avoiding bodily exer- tion : if in fuch circumftances it is poffible to fave a patient, thefe will be the moft certain means of doing it; at any rate they will tend to prolong life, which in fome cafes is of fo much moment that a few days or even a few hours may be of great importance. The fame obfervatiorts are applicable to wounds in the large blood veffels about the heart. They are to be confidered as nearly of equal importance and dan- ger, and to be treated- in the fame manner with wounds of the heart itfelf. Sed. XI. in the Thorax. 267 There is ftill another organ of importance feated in the cheft, which it is proper to mention here, namely, the thoracic dud; for although wounds in this canal will in mofl inftances terminate in death, yet fome advantage may, in particular circumftances, be deriv- ed from their being properly treated. The thoracic dud, after leaving the receptaculum chyli, runs along the fpine near to the aorta: and at the fifth or fixth vertebra of the back, it paffes behind the aorta; and afcending to the left fubclavian vein, it there dischar- ges the chyle. v We judge of the thoracic dud being wounded, from the part at which the wounding inftrument en- tered ; from the difcharge being either altogether white like chyle, or mixed with a confiderable pro- portion of chyle ; and from the patient becoming dai- ly weaker than he ought to be from a wound of the fame fize in any other part, owing to the nutritive part of his food being carried off before any advan- tage is derived from it. With a view to prevent the diameter of this canal from being diftended, which at the fame time will tend to leffen the extent of the wound, the patient ffiould be kept upon a very fpare diet; any food which he takes ffiould not be at regular meals, but in fmall quantities frequently repeated; nor fhould he be per- mitted to take a large draught even of the weakefl li- quor. The bowels fhould be kept open ; bodily ex- ertion of every kind, and much fpeaking, or whateV- er tends to quicken reipiration, ffiould be avoided. § 6. Of Wounds of the Diaphragm, Mediaftinum, and Pericardium. We judge of the diaphragm being injured from the fituation of the wound, and from the nature of the attending fymptoms. As this mufcle is in conftant action during refpiration, any injury done to It is ne- ceffarily attended with difficult breathing; and with 263 Of Wounds Chap. III. much pairi during infpiration, not merely in the wound itfelf, but over all thofe parts of the cheft to which the diaphragm is attached: the patient complains of pain over all the region of the ftomach: ficknefs, vomiting, and a troublefome degree of hickup take place; pains in the fhoulders fometimes occur, to- gether with cough, delirium, a quick hard pulfe, and other fymptoms indicating inflammation and fever. Involuntary laughter is mentioned too as a fymptom which injuries done to the diaphragm fometimes pro- duce ; but I have not in the courfe of my experience perceived that the obfervation is well founded. It is a common idea among praditioners, that wounds in the tendinous part of the diaphragm will in every cafe prove mortal, but that injuries done to the mufcular parts of it do not fo readily end in dan^. ger. There is much reafon, however, to believe, that few wounds in the diaphragm are cured, whether in the tendons or mufcular parts of it; nor is it evident from obfervation, that there is more danger to be dreaded in the one cafe than in the other, The fymptoms of which we have moft reafon to be afraid, are thofe which proceed from inflammation. With a view to prevent their acceffion, or to render them moderate when they have already appeared, bloodletting is to be chiefly depended on; together with gentle laxatives ; large dofes of opiates conjoin- ed with mufk; warm fomentations over the abdomen and thorax; quietnefs ; and low diet. By thefe means ftridly purfued, a patient, in fuch circumftances, will have perhaps a better chance of doing well than by any other mode of treatment; but his recovery will by no means be certain. A ftrid antiphlogistic courfe, and large dofes of opium, may probably obviate all the primary fymptoms. But however fmall a wound in the diaphragm at firft may be, the conftant action and tenfion of this mufcle will be apt to render it daily wider; and we know from various histories of wounds in this part, that they fel- Sed. XI. in the Thorax. o,6g dom arrive at any magnitude, without admitting a portion of the ftomach, of the colon, or fome other part of the bowels, to pafs from the abdomen into the thorax ; by which the moft violent pain is produced, together with fome other fymptoms which ufually ac- company a ftrangulated gut in cafes of hernia: in fuch circumftances, a ftrangulated gut is greatly more dangerous than hernia in its more ordinary form ; for were we even able to remove the ftridure, by making an incifion into the cavity of the abdomen, as the paf- fage into the thorax would ftill remain pervious, a re- turn of the strangulation might foon be looked for. Wounds in the mediaftinum require no peculiarity of treatment. The circumftances which we have moft caufe to dread are, a lodgment of blood in one or both cavities of the cheft, inflammation and fuppura- tion with their ufual confequences. But the obferva- tions that I have had caufe to fuggeft, on the man- agement of penetrating wounds in other parts of the cheft, apply with equal propriety to thefe; fo that we need not enter further upon them at prefent. Nor is it neceffary to enter minutely on the confid- eration of wounds in the pericardium. As this bag contains a fluid which we fuppofe to be neceffary for the eafy motion of the heart, wounds of this part may prove dangerous, from their tendency to prevent this fluid from being colleded, as well as from their al- lowing it to fpread through the cavity of the cheft. It appears, however, from various obfervations, that wounds of the pericardium do not prove fo hazard- ous as at firft fight might be fuppofed. They require the fame general method of treatment with penetrat- ing wounds of the thorax, which we have already had occafion to confider. All penetrating wounds of the cheft, where the cure does not happen without the formation of mat- ter, are apt to heal flowly; rnd in fome cafes, efpeci- ally where abfceffes have formed, a difcharge of mat- ter will continue for a great length of time, nay, in 27° Of Wounds Chap. III. fome cafes, for life, notwithftanding all our endea- vours to prevent it. As this is an inconveniency which patients are at all times anxious to remove, pradition- ers become neceffarily much interested in the method of treating it. With "a view to leffen the difcharge, and even to heal the fore through its whole extent, aftringent, and what are ufually termed vulnerary in- jedions have been advifed. But although I have known them frequently employed even by furgeons of reputation, and under the belt and moft cautious management, I have feldom feen them ufed without producing harm; and I do not recoiled a fingle in- ftance of their producing any advantage. They are apt to irritate and inflame the lungs and contiguous parts ; and, inftead of healing the fore or abfcefs, they often extend it further, by tearing open the furround- ing cellular fubftance. For this reafon, in penetrating wounds of the tho- rax, I do not hefitate to fay, that injedions ffiould be laid entirely afide: and, however difagreeable a tedi- ous difcharge in this fituation may prove, we ffiould truft entirely to the means that I have already advifed for preventing the matter from lodging, by preferving as free and depending an opening as the nature of the cafe will admit. SECTION XII. Of Wounds in the Abdomen. % i. Anatomical Defcription of the Abdomen and Parts contained in it. THE Abdomen, or lower belly, is the largeft cavi- ty of the body : above, it is bounded by the di- aphragm, which divides it from the thorax ; behind, Sed. XII. in the Abdomen. 271 it is fupported by the vertebras; the upper part of both fides is covered by the inferior ribs ; the reft of it is all bounded by the abdominal mufcles, except- ing the moft depending part of it, which terminates in the pelvis, from the contents of which it is only feparated by the peritonaeum, a firm extenfive mem- brane, which not only lines all the cavity, but affords a coat to all the vifcera contained within it, being re- fleded in a very Angular manner over them. Anatomifts divide this cavity into different regions. The middle and upper part of it, reaching from the xiphoid cartilage to within a fmall fpace of the umbi- licus, is termed the Epigaftrium ; the fpaces on each fide of this are termed the Hypochondria ; the umbi- lical region extends from three inches above the na- vel, to the fame diftance beneath it: and all the parts between this and the pubes are termed the Hypogaf- tric region. In the treatment of wounds in the abdomen, a mi- nute acquaintance with the parts contained in it, and of their relative fituation with refped to each other, and to the divifions or regions which we have juft defcribed, is a point of much importance. I ffiall here give a general defcription of the different vifce- ra : a more particular knowledge of them is beft ac- quired from diffedion. The parts contained in the abdomen are, the ftom- ach and inteftines ; the mefentery, omentum, liver, gall bladder and duds ; pancreas, receptaculum chy- li, fpleen, kidneys, ureters, and upper part of the uri- nary bladder; the aorta, vena cava, and other large blood veffels and nerves. The ftomach is a large membranous bag, placed in the upper part of the abdomen, immediately below the diaphragm : it ftretches from the left hypochon- drium, where the molt capacious end of it is feated, obliquely acrofs the epigaftrium, and terminates before it leaches the right hypochondrium. The ftomach has two openings; one termed the fuperior orifice or 272 Of Wounds Chap. III. cardia, where the oefophagus terminates; and the oth- er the pylorus, or inferior orifice, where the duode- num, the firft of the fmall inteftines, begins. The car- dia lies nearly on a line with the eleventh vertebra of the back, the large extremity of the ftomach ftretch- ing confiderably to the left; and the pylorus lies fome- what lower, and nearly two inches to the right of the vertebrae. It is proper, however, to obferve, that the fituation of the ftomach and of thefe two openings is confiderably affeded by the quantity of food contain- ed in it: fo that a wound of the ftomach, when full, may be diredly oppofite to an external wound in the teguments, and yet be feveral inches lower when empty. The inteftines commence, as I have juft obferved, at the pylorus, and are continued by many turnings or convolutions to the anus. This canal is in different parts of it diftinguifhed by different names: the up- per part of the tube is termed the fmall inteftines; and the under part of it the larger, from its diameter being larger in the one part than in the other. Even different parts of thefe great divifions of the inteftines have received different names ; the upper part of the fmall guts, extending about a foot in length from the pylorus, is termed the duodenum ; the next portion of the canal, from being commonly found empty, is termed jejunum. This, in an adult of full growth, is fuppofed in general to be about four feet and a half long; and is chiefly fituated in the umbili- cal region. All the under part of the fmaller intef- tines is diftinguifhed by the name of ileum, from its lying almoft entirely within the cavity formed by the offa ilea on oppofite fides of the abdomen. After making feveral convolutions from one fide to the oth- er, it at laft terminates in the ccecum, the firft, of the great inteftines fituated under the right kidney. From the ccecum, which is a round fhort fac with a fmall vermiform procefs, the colon originates: this is the largeft of all the inteftines; and as it occupies a confid- Sed. XII. in the Abdomen, 273 erable part of the abdominal cavity, the courfe of it merits particular attention. After leaving the right kidney, to which it is attached, it rifes and paffes un- der the liver, fo as to be in contad with the gall blad- der, by which it is tinged of a deep yellow colour : from this it is continued in the form of an arch over the duodenum to the under part of the ftomach ; and paffing into the left hypochondrium, it is there at- tached to the fpleen and to the left kidney. This curvature is termed the great arch of the colon. It now runs downward and backward; and again turn- ing up, fo as to form the figure of S, terminates at the top of the os facrum in the laft of the great guts, termed the redum, from its running nearly in a ftraight line, till it terminates in the anus. The inteftines being very pliable, and of a great length, have neceffarily much freedom of motion ; but as this would render them liable to be entangled in each other, nature has provided a thin membra- nous web, termed the mefentery, which running along the courfe of the inteftinal tube, ferves to conned it with fufficient firmnefs to the vertebrae. The mefen- tery is evidently a produdion of the peritonaeum: in its duplicature we meet with a number of fmall glands, which often become fo enlarged by difeafe a$ to be felt outwardly through the abdominal mufcles; and ferves as a fupport to the ladeals, blood veffels, and nerves of the inteftines. The omentum is a fine thin membrane, which comes into view on dividing the mufcles of the abdomen and peritonaeum. In gen- eral it does not pafs beneath the umbilicus: but in corpulent people, when much filled with fat, it fome- times defcends to the very bottom of the belly ; and in cafes of hernia, we frequently meet with it in the fcrotum. This membrane is evidently intended as a protec- tion to the bowels; to afford them an additional warmth ; and probably by the fat which it contains Vol. L T 274 Of Wounds Chap. HI. to lubricate their external furfaces, fo as to admit of their playing with more freedom on each other. The liver is a large glandular body, fituated in the right fide, immediately under the diaphragm : it is di- vided into two lobes ; one termed the great, and the other the fmall lobe. The great lobe lies in the right hypochondrium, which it fills almoft entirely : It refts on the right kidney, and covers a portion of the great arch of the colon: a confiderable part of the fmall lobe lies in the epigaftrium ; the reft of it paffes over the ftomach towards the left hypochondrium. The liver is of a very irregular figure; its outer furface is arched, correfponding to the figure and fize of the arch of the diaphragm. On the under fide, it is in fome parts flat, and in others concave, according to the figure of the parts with which it is in contad. It is of a confiderable fize and thicknefs on the right fide ; but towards the left its thicknefs decreafes, fo that at laft it terminates in a thin edge. The liver is kept in its fituation by feveral ligaments attached to the diaphragm and contiguous parts. The gall bladder is a pyriform bag, feated in the concave fide of the liver. The bile, after being fe- creted by the liver is lodged in this bag, from whence it is conveyed into the inteftines through the dudus choledochus, which enters the duodenum by piercing its coats in an oblique diredion, about five inches be- low the pylorus. The pancreas is a conglomerate gland, lying in a tranfverfe diredion between the liver and fpleen, im- mediately under the ftomach. The liquor fecreted by this gland is carried into the duodenum by a fmall dud, which in fome cafes terminates in the gut itfelf, and in others near to the extremity of the dudus cho- ledochus. The receptaculum chyli is a fmall membranous bag, through which the chyle paffes from the inteftines to the left fubclavian vein by means of the thoracic dud. Sed. Xn. in the Abdomen. 275 This bag, or fac, lies upon the firft vertebra of the loins, a little to the right of the aorta. The fpleen is a large fpongy body, feated in the left hypochondrium, between the ftomach and falfe ribs, under the diaphragm, and immediately above and contiguous to the left kidney. ^ In Chap. XV. Sed. II. I ffiall find it neceffary to give a particular defcription of the kidneys, ureters, and bladder; fo that we ffiall not enter upon it at prefent. But, befides the feveral vifcera which I have mentioned, the aorta, vena cava, and the large blood veffels and nerves which fupply the bowels, lie all within the cavity of the abdomen. The fame diftindions may be enumerated of wounds of the abdomen, that I have mentioned of wounds of the thorax. They may either be confined to the common teguments and mufcles, or they may pene- trate the cavity; or a penetrating wound may be complicated with wounds of one or more of the vif- cera. § 2. Of Wounds of the Teguments and Mufcles of the Abdomen, In one point of view, wounds of the teguments and mufcles of the abdomen do not merit more attention than fimilar injuries in other parts of the body; but they become highly important from the contiguity of the abdominal vifcera, and from the danger of thefe being ultimately injured by the negled or mifmanage- ment of an external injury. Our firft objed is to difcover, whether a wound has penetrated the abdomen or not; and whether any of the vifcera are injured. When the wound is ex- tenfive, and any portion of the vifcera protrudes, the nature of the cafe is evident; but in fmaller wounds, where no part of the bowels appear, it is often diffi- cult to judge whether they penetrate the abdomen or t 2 2j6 Of Wounds Chap. III. not. In general, however, this may be determined by attention to the following circumftances : by a pro- per examination with the fingers or probe, after put- ting the patient as nearly as poffible into the pofture in which he received the wound ; by attending to the form and fize of the inftrument, the depth to which it run, and the diredion it appeared to take ; by the quantity of blood difcharged at the wound being con- fiderable or not; by the ftate of the pulfe and other attending fymptoms ; and by the difcharge of fasces, bile, or any other of the abdominal fecretions. When the. wound is of fuch a fize as to admit the finger, we may always determine with certainty wheth- er it reaches the cavity of the abdomen or not; as in this cafe the finger will come into contad with the vifcera: but probes ffiould be ufed with much cau- tion ; and unlefs the inftrument paffes eafily in, with- out force, in a dired line, and to fuch a depth as to convince us that it has reached the cavity, little or no dependence ffiould be placed on it: for the parts here are fo foft, and of fuch a yielding nature, that a probe with very little force will pafs among them almoft in every diredion to a confiderable depth. It is fcarcely neceffary to obferve, that it is particularly proper, in every inquiry of this kind, to put the patient as near- ly as poffible into that pofture in which he received the wound. And the loofe texture of the parts fliould prevent us from ufing injedions, as is frequently done with a view to determine this queftion. In wounds of the thorax, where the parts are firmer and more intimately conneded, injedions may be ufed for this purpofe more fafely ; but in the abdomen they are apt to fpread among the mufcles and cellular fub- ftance, by which the teft is rendered uncertain, at the fame time that mifchief is apt to enfue from the pain and inflammation which it excites. The depth to which the inftrument has paffed, or the diredion in which it run, cannot always be afcer- tained ; but when this information can be obtained, Sed. XII. in the Abdomen. 277 it will affift us in judging of the nature of the wound. By comparing the fize of the external opening with the fize of the inftrument, we may be led to deter- mine the depth to which it has paffed. When the quantity of blood difcharged from a wound in the abdomen is confiderable, we may with much certainty conclude, that fome of the large in- ternal veffels have been hurt; for excepting the epi- gaftric artery, which runs in the interior part of the abdomen in the courfe of the redus mufcle, none of the teguments or mufcles of thefe parts have arteries of fuch a fize as to afford much blood. It is proper, however, to obferve, that even the largeft artery in the abdomen may be wounded without any blood being difcharged externally ; for if the outward opening is not large, and efpecially if the wound runs in an ob- lique diredion, the blood, inftead of being difcharged at the opening, will be extravafated into the cavity of the belly, where large quantities may be colleded, ev- en without any remarkable degree of tenfion taking place. In fuch cafes, however, we are foon led to fufped what has happened, by the fymptoms which enfue. The patient complains of debility and faintnefs; his pulfe becomes low ; he is feized with cold fweats ; and if the difcharge of blood is not ftopped, all the other fymptoms of approaching death foon make their appearance. It fometimes again happens, that we become certain of a wound having penetrated the abdomen, by the difcharge of fasces ; of bile ; of the pancreatic juice, or even of chyle: and in fome cafes, the fame certain- ty is obtained by large quantities of blood being thrown up from the ftomach, or difcharged by the redum. Urine may be difcharged by a wound which does not penetrate the belly ; for the kidneys and ureters, as well as a confiderable portion of the bladder, may with propriety be faid to lie behind the peritonaeum; but 278 Of Wounds Chap. III. they are in general to be treated in the fame manner with penetrating wounds of the abdomen. When, again, none of thefe fymptoms take place; when neither the finger nor probe can be eafily intro- duced ; when there is no difcharge from the wound that leads to fufped the vifcera to be wounded; when the pulfe remains natural, and the pain is moderate; there will be much caufe to hope that it has not paff- ed to a greater depth than the common teguments or mufcles. In the treatment of thefe wounds, we are to be en- tirely direded by the depth to which they penetrate, and by the fymptoms which take place. When a wound in the abdomen does not run deep- er than the common teguments or mufcles, if none of thefe parts have been removed, none of thefe fymp- toms will be of much importance, at leaft this is com- monly the cafe, where the habit of body is good, if the patient has not fuffered from mifcondud or neg- led. Our views here ffiould be nearly the fame with what has been already advifed in wounds of the tho- rax. The principal objed is to prevent inflammation and the lodgment of matter. This we do by blood- letting ; a low diet; the ufe of laxatives; reft of body ; and proper attention to the wound. But for a more particular detail of the proper treatment of fuch a wound, I ffiall refer to the laft fedion. It is proper, however, to remark, that wounds in the boundaries of the abdomen, in one circumftance, differ materially from fimilar injuries in the thorax. As the mufcles and other foft parts of the cheft, are every where fupported by bone, the lungs and other vifcera contained in the breaft do not readily puffi out at the wound: but as the coverings of the abdomen are of a foft yielding nature, having anteriorly no bone to fupport them, and many of the contained parts having no very clofe attachments, they are apt to puffi forward and protrude wherever any unufual degree of weaknefs is produced. In all wounds, there- Sed. XII. in the Abdomen. 279 fore, of the abdomen, even where they do not pene- trate, fome caution is neceffary on this confideration alone; efpecially when any portion has been removed of the teguments or mufcles. The patient ffiould be kept as much as poffible in a horizontal pofture dur- ing the cure; and when he attempts to fit or walk, the weakened parts fhould be fupported by a proper comprefs, and a firm, fomewhat elaftic bandage of flannel, paffed two or three times round the body; a caution which ought to be perfifted in for a consid- erable time after the cure of the fore is complete. Want of attention to this, has been the caufe of many diftrefsful cafes of hernia, which otherwife would not have happened. § 3* Of Wounds which penetrate the Cavity of the Ab- domen, but which do not injure any of the contained parts. Although an inftrument may have penetrated the abdomen to a confiderable depth, we have much reafon to hope that none of the vifcera are wounded, as long as the parts remain free from much pain and tenfion, the pulfe foft, and the fkin of a natural heat: but even in this ftate of fuch a wound, we are not to conclude that there is no hazard; for wounds in thefe parts, which at firft exhibit no appearance of danger, often terminate fatally at laft. It is proper, however, to obferve, that this may of- ten be traced as an effed of improper management, which praditioners have it frequently in their power to prevent: for although fome inftances will occur of thefe wounds ending fatally, where no fymptoms ap- peared of the vifcera being hurt, and where after death this was found to be the cafe, yet this will not ufual- ly happen when the wounds have been properly treat- ed from the firft. The danger here arifes chiefly from two caufes: from the air finding accefs to the cavity of the abdo- i8a Of Wounds Chap. III. men, by which the different vifcera are apt to become inflamed; and from the fubfequent formation of mat- ter, which, not finding an opening, will neceffarily colled within the peritonaeum. In every wound, therefore, of this kind, after fe- curing any blood veffel of the teguments or mufcles that may be divided, we ffiould endeavour, with as much certainty as poffible, to prevent the air from getting accefs to the abdomen. In fmall wounds of thefe parts, this will be done with moft eafe and cer- tainty by the lips of the cut being drawn together, and fecured with flips of adhefive plafter: and as a further fecurity, a comprefs and flannel roller, fuch as I have mentioned above, may be put over the whole: the fame precautions with refped to blood- letting ; a ftrid antiphlogistic regimen, and reft of body, already pointed out as neceffary in more fuper- ficial wounds of the abdomen; fhould be here very carefully obferved, where the danger is ftill more con- fiderable. Under this management, thefe wounds, when fmall, will often heal by the firft intention ; but when they continue open for fome time, they ffiould be dreffed as feldom as poffible, and the dreffing renewed with as much expedition as the nature of the cafe will ad- mit, fo that the unneceffary admiflion of air may as much as poffible be avoided. It will fometimes, however, happen, even that the moft exad attention will not prevent the acceffion of bad fymptoms. At firft, thefe will be fuch as pro- ceed from inflammation, and will be removed with molt certainty by further evacuations of blood, and attention to the other circumftances that I have enu- merated ; or they will prove fatal, by ending in mor- tification ; or they may terminate, as I have mention- ed above, in the formation of matter. It is this laft occurrence which we have now to advert to. In any other part of the body we would advife an opening to be made immediately for the purpofe of Sed. XII. in the Abdomen. 281 difcharging the matter: but in thefe depofitions in the abdomen, we can never difcover with certainty, whether any colledion has taken place or not, till it has continued for a confiderable time: for the mat- ter here lies fo deep, that a fmall quantity cannot be diftinguifhed ; nor would it be proper for the dif- charge of a fmall quantity of matter to incur that danger which always attends the free admiflion of air to the abdomen ; and in fmall colledions this could not be avoided, as the opening would require to be made in a flow gradual manner with a fcalpel, as in fuch cafes the trocar could not be plunged in with- out much rifk of hurting the vifcera. Inftead of fuch an attempt, therefore, we ffiould do nothing as long as the quantity of matter continues moderate, and while no bad fymptoms have yet taken place. In- deed this fliould be a general rule in all wounds of the abdomen, never to inquire with much anxiety ei- ther for colledions of matter, or for fuch parts as from the nature of the wound there might be caufe to fufped ffiould be injured, till the acceffion of bad fymptoms renders it neceffary : for much handling of- ten does mifchief; while frequently no danger enfues from wounds which at firft were attended with very alarming fymptoms. Nav, we know, that in differ- ent inftances a perfon has been run through the body with a fmall fword without any of the vifcera being injured, and the patient has done well, without any bad fymptom taking place. And we likewife know, that violent inflammation will fometimes terminate fa- vourably, without the formation of matter; and even when matter is formed, that it is fometimes carried off by abforption, fo as to leave no veftige of its hav- ing ever exifted. It is the adual prefence, therefore, of bad fymptoms produced by thefe colledions of matter, or the quantity of matter becoming fo con- fiderable as to prove inconvenient to the patient, that ffiould indicate the propriety of letting it out bv mak- ing an opening into it. But as foon as we find this 282 Of Wounds Chap. III. to be the cafe, we ffiould not hefitate; and whenever the quantity will admit of the trocar being employed, we may draw it off with eafe and fafety : for by in- ferring the inftrument in an oblique diredion, no air will be admitted; by which the chief rifk which at- tends this operation will be avoided. I have been the more particular upon this, from having known different inftances of thefe collec- tions ending fatally, where the matter contained in them was difcharged, and where there was not previ- oufly any appearance of danger. As it was in all of them evident that matter was colleded, an opening was made to difcharge it; and as in all of them the matter was fuppofed to be feated either in a particular cyft, or in the fubftance of the mufcles, and not in the cavity of the abdomen, it was done by making a fmall opening into it with a fcalpel. But the moft violent fymptoms of inflammation occurred in the courfe of the firft two days ; and the patients foon died; and I conclude that it was by the free admif- fion of air to the cavity of the abdomen that thefe fymptoms were induced; for after death the matter was found to be lodged in that cavity; and I have fince that time, in three fimilar cafes, drawn large quantities of purulent matter off with a trocar, where it was evidently feated in the abdomen, without any bad confequences taking place. In drawing off matter from the abdomen, we do it in the fame manner, and under the fame caution, as will be hereafter advifed for the difcharge of ferum by the operation of the paracentefis, of which a par- ticular account will be given in chapter XXV. Penetrating wounds of the abdomen may prove dangerous from another caufe. Confiderable portions of the bowels are fometimes protruded, without any other injury being done to them; and this of itfelf may be produdive of fatal confequences. The moft certain method of preventing danger in fuch cafes, is to return the protruded parts quickly Sed. XII. in the Abdomen. 283 into the abdomen. By many we are defired in the firft place to foment the parts with warm emollient decodions, or to cover them for fome time with the web or omentum of fome new killed animal: but thefe authors do not recoiled, that during the time loft in making thefe preparations, the protruded parts may probably fuffer more than can be gained by applying them; while furely the moft natural, as well as the beft fomentation for parts injured in this manner, is the heat and moifture of the patient's bel- ly. In recommending thefe applications, it is faid, that they not only remove the dry parched ftate of the parts which expofure to the air is apt to induce ; but that they enable us to judge with more certainty whether they are in a ftate that admits of their being with fafety returned into the abdomen or not: for it is alleged, even by writers of reputation, that parts which are apparently in a ftate of incipient gangrene, and which otherwife we might be afraid of puffiing into the abdomen, may, by a proper ufe of thefe fo- mentations, be fo far recovered as to render it fafe and proper to return them. But although this opinion has been very generally received, and the pradice followed which it incul- cates, it appears to me to be fo fraught with impro- priety and danger, that I did not judge it right to pafs it over without mentioning in ftrong terms the idea I entertain of it. Much mifchief may be produced by it, and I fee no advantage that can accrue from it. By many it is faid, that no part of the inteftines fliould be returned into the abdomen that have once acquired any tendency to gangrene, on account of the faeces being likely to burft into the abdomen, which undoubtedly would end in the death of the pa- tient : when we are certain that this would happen by the parts being adually in a ftate of gangrene, to re- turn them to the abdomen would no doubt be hiehly improper, as it would be depriving the patient of his only chance of recovering, that of fecuring the ends 284 Of Wounds Chap. III. of the found parts of the gut at the mouth of the wound, by which there might be fome poffibility of their uniting afterwards, as in different inftances has happened ; and by which he would at leaft be certain of having at all times a free difcharge for the fasces. But although in this fituation the pradice to which I allude is to be confidered as the only one to be adopted, yet when gangrene has not adually taken place, as there will ftill be caufe to hope that the natural heat of the belly may tend to prevent it, the parts ffiould be inftantly returned. When parts protruded from the abdomen are cov- ered with fand, duft, or any other extraneous matter, it will no doubt be proper that this fliould be remov- ed before they are replaced ; and with this view, bath- ing them in warm milk, or in milk and water, may anfwer better than any other method. But this is perhaps the only caufe that can render the pradice neceffary. Some addrefs is neceffary in returning fuch parts of the inteftines as have been protruded in the eafieft manner. The patient ffiould be put into that pofture which will moft effedually relax the parts in which the wound is feated, with his head and chefl fome- what lower than the abdomen and buttocks, fo that the weight of the bowels may tend to drag in the pro- truded parts. When in this fituation, the furgeon having his fingers dipped in warm oil, ffiould endea- vour to replace the parts by beginning his preffure at the one end of the gut, and continuing it along the doubling or curvature to the other. In this manner, when the opening is not very fmall, any portion of the bowels will be replaced without any further en- largement of the wound: and when any part of the omentum, or any of the other vifcera, are protruded, they will be ftill more eafily returned. But confider- able parts of the inteftines are frequently pufhed out at fuch fmall pundures, that they cannot be returned but with much more preffure than fhould ever be ap- Sed. XII. in the Abdomen. 285 plied to them. In this cafe, our objed will be more eafily accomplifhed, and with lefs hazard to the pa- tient, by enlarging the opening, than by the applica- tion of fo much force as is generally required in puffi- ing .any confiderable portion of gut through a fmall aperture. Some dexterity, however, is neceffary in enlarging an opening in this fituation. When the aperture is of fuch a fize as to admit the finger of the furgeon, it may be done with eafe and fafety : but in fome cafes it is fo completely filled with the parts which pafs through it, that this is impradicable. In this fituation, we are advifed by authors to infert a diredor between the bowels and parts to be divided, and to enlarge the opening by cutting upon it, either with a fcalpel or biftoury. This, however, muft be attended with much hazard ; for we can never diftin- guifhed with certainty wether fome plies of the bow- els are elevated by the diredor or not, as this will fometimes happen notwithftanding all our care to pre- vent it. Inftead of following this method, I have in different cafes enlarged the opening, by making an incifion through the teguments and mufcles with a fcalpel, in the fame gradual manner that we operate in cafes of hernia ; taking care, as foon as the perito- naeum is laid bare, to introduce the end of a probe pointed biftoury between it and the cut, and dividing it as far as may be neceffary, which now may be done with fafety. If in this manner the opening is enlarg- ed fo as to receive the point of the finger, it may af- terwards be increafed at pleafure, by inferting the fin- ger fo as to ad as a condudor for a biftoury or fcal- pel : but till it can be done in this way, no cutting inftrument ffiould ever be paffed into the abdomen; for although much ingenuity has been ffiown in the invention of instruments with wings to proted the bowels in this part of the operation, yet none of them anfwer any other purpofe than to render the operation more complex. ( 286 Of Wounds Chap. HI. In enlarging a wound in this fituation, it ffiould be done as much as poffible in the diredion of the muf- cular fibres of the parts; and, for an obvious reafon, the incifion ffiould not commence at the top but at the bottom of the wound, and be carried downwards. We may thus enlarge the opening to any neceffary extent, always taking care not to make it larger than the nature of the cafe may require. And this being done, the protruded parts ffiould be replaced with as much expedition as poffible in the manner I have ad- vifed. In returning bowels to the abdomen, it has fometimes happened, through confufion or miftake in the operator, that they have been pufhed in between the layers of the abdominal mufcles. This ffiould be guarded againft with the utmoft attention ; for when left in this fituation, the patient will be nearly in the fame danger as at firft. Indeed this will be the cafe, if they be not placed altogether within the perito- naeum. The accident to which I allude may happen in any part of the belly, when a furgeon is not fufficiently ac- curate and attentive: but it is moft likely to occur in wounds that pafs through either of the redi mufcles, owing to the fheaths of thefe mufcles being particular- ly loofe and flaccid ; and it will more readily happen in corpulent people than in others, owing to the great depth of fat and cellular fubftance, which, in fubjeds of this defcription, lie above and between the different mufcles of the abdomen. Inftead of enlarging the opening in the abdomen, it has been propofed to difcharge the air contained in the protruded portion of gut, by making holes in it with a needle, by which it may be fo much diminifh- ed as to admit of its being eafily replaced at the fame opening. As this has been mentioned by writers of experience, I think it right to fpeak of it; but it is chiefly with a view to caution the younger part of the profeffion againft it. It may indeed be done with more eafe to the operator; but this appears to be the Sed. XII. in the Abdomen. 287 only argument in its favour : for although fome may have recovered on whom it has been pradifed, yet furely the fmalleft opening made into the gut muft be attended with more danger than is likely to arife from the external opening in the teguments and mufcles being fomewhat enlarged. And befides, in reducing a portion of gut, however diftended it may be with air, we may often render it perfedly flaccid, by preff- mg the air back into that part of the gut which re- mains in the abdomen ; and if done with caution, it may with entire fafety be attempted. Indeed no trial ffiould ever be made for the redudion of a portion of inteftine much inflated, till we have endeavoured in this manner to reduce the fize of it. After the bdWels are replaced, our next objed is to preferve them in their fituation till the wound is fo firmly cicatrized that they may not again fall out. When the opening is fmall, this may be done by lay- ing the patient in a proper pofture, with his head and buttocks elevated ; by preventing coftivenefs ; and by a firm roller of flannel paffed feveral times round the body, fo as to fupport the injured parts till they are united. But in extenfive wounds of the abdomen, it is found, even when they are treated with every poffi- ble attention, that it is difficult, and in fome cafes im- poffible, by ordinary dreffings and bandages, to pre- vent the bowels from falling down. In fuch cafes, we are under the neceffity of drawing the fides of the wound together with futures; an operation common- ly termed gaftroraphy. Various methods have been propofed for making this future ; but the common interrupted future, or the quilled future, which is merely a variety of the other, anfwers the purpofe better than any of them. Much care and attention, however, is neceffary in paff- ing it, particularly in avoiding the bowels, which eve- ry where lie contiguous to the parts to be united. The furgeon being provided with a number of broad flat ligatures, fufficient for the extent of the 288 Of Wounds Chap. HI. wound, and of a ftrength that will retain the parts to- gether, each ligature fliould be armed with two large curved needles, one towards each end ; and the pa- tient being laid in a pofture that moft effedually re- laxes the injured parts, the furgeon fhould now infert the forefinger of his left hand into the wound, and being fure that it is in contad with the peritonaeum, without any of the bowels lying between them, he ffiould now pafs the point of one of the needles along his finger to the diftance of an inch from the edge of the wound ; and having fecured the other end of it with the thumb and forefinger of his right hand, he muft now puffi it outward, fo as to make it pierce the fkin at a fimilar diftance from the wound in the tegu* ments. One of the needles being paffed, the other muft in like manner be pufhed through the oppofite fide of the wound, by paffing it alfo from within out- ward. Both needles might indeed be paffed by en- tering them outwardly, and puffiing them in upon the finger; but we could not in this manner avoid the bowels with fuch certainty; a point of great impor- tance, and therefore requiring the niceft attention. The firft needles ffiould be paffed within half an inch of the upper part of the opening; and the others ffiould be continued to within an equal diftance of the bottom, at the diftance of three quarters of an inch from each other; for as the retradion of parts divi- ded in this manner is more to be dreaded than any other occurrence, it ought in a particular manner to be guarded againft. The ligatures being all inferted, the parts ffiould now be fupported by an affiftant; and a proper knot being tied upon each of them, the whole extent of the wound ffiould be covered with a pledget of lint fpread with any adhefive ointment, for the purpofe of preventing the air from finding accefs. After this the parts ffiould be fupported with a roller : the patient fliould be put to bed, and treated in the manner we have direded above, with bloodletting, Sed. XlL in the Abdomen, 289 and a low regimen, in proportion to the violence of the fymptoms which fupervene. In performing this operation, I have faid that the ligatures fhould be continued to within half an inch of the bottom of the wound ; which is contrary to the ufual pradice. In general an opening is left be- neath, with a view to difcharge any matter that may form in the courfe of the cure ; but there is no fuffi- cient reafon for doing fo. Inftead of proving ufeful, it obvioufly does harm, by giving free accefs to the air, which in every wound of the abdomen ffiould be particularly guarded againft. The opening cannot be preferved without the affiflance of a tent, by which much irritation and pain is induced ; nor does it ever anfwer the purpofe of difcharging the matter, if not accidentally fituated near to the under part of the ab- domen. I am clearly of opinion, therefore, that the whole extent of the wound ffiould be treated in the fame manner ; and if matter ffiould afterwards form, that it will be better to truft to its being abforbed, than to place any dependence on this precarious meth- od of cure. Any praditioner who prefers the quilled future, may eafily convert the one that I have defcribed into it, by introducing each of the ligatures double. After all the ligatures are paffed, a fmall roll of plafter, or a piece of large bougie, ffiould be paffed through the different loops, which ought all to be on one fide of the wound ; and a fimilar roll being placed on the op- pofite fide between each of the ligatures, they muft now be tied upon it with running or bow knots, of a due degree of tightnefs ; care being taken during this part of the operation, to have the fides of the wound properly fupported by an affiftant. When the parts are properly and equally drawn to- gether, we feldom find it neceffary to remove the liga- tures till the parts are united, which they commonly are in fix or feven days if kept in clofe contad, and Vol. I. U 290 Of Wounds Chap. III. if no unufual caufe has occurred to prevent it. But when the ligatures give much pain, and the patient complains of much tenfion over the abdomen, the knots ffiould always be untied and kept perfedly loofe, till by bloodletting, fomentations, and gentle laxatives, thefe fymptoms are removed, when the parts may be again drawn together and fecured as before. I have hitherto been fuppofing that the protruded part confifts of a portion of the alimentary canal only, this being the part which in wounds of the abdomen is moft frequently pufhed out; but, it is proper to re- mark, that the other vifcera are alfo liable to be pro- truded, particularly the ftomach and omentum. This, however, does not vary the method of treatment, which ought to be nearly the fame, whichever of the vifcera are pufhed out. The parts fhould in every inftance be replaced as quickly as poffible, and retain- ed in the manner I have mentioned. We are now to confider the treatment of wounds in the abdomen accompanied with injuries done to one or other of the vifcera. And in the firft place, I fhall fpeak of wounds of the alimentary canal, as be- ing both moft frequent and moft apt to induce im- portant confequences. § 4. Of Wounds of the Aliamentary Canal. In a former part of this fedion, I have obferved, that wounds of the inteftines may be difcovered by the difcharge of blood from the mouth and by the anus, as well as by the difcharge of faeces from the wound in the teguments : we likewife judge of this point by the difcharge of fetid air from the wound, and from the depth and diredion in which the instru- ment appeared to run. By thefe circumftances being kept in view, and the fymptoms which wounds of the inteftines commonly produce, being duly confidered, fuch as naufea, fick- nefs, violent gripes, or pains through the abdomen, Sed. XII. in the Abdomen. 291 cold fweats, and faintings, we may in general decide with certainty whether the gut is injured or not. But unlefs the wounded part is brought into view, little or no advantage is gained by the difcovery ; for, while it remains undifcovered, our method of treatment muft be nearly what ought to be advifed for wounds which merely penetrate the cavity of the abdomen. Authors indeed dired us to fearch for the wounded part of the gut; but as the danger arifing from thus expofing the contents of the abdomen, would proba- bly be more than that of allowing the wounded part to remain, this attempt ought never to be made ; ef- pecially as we know that wounds of the inteftines have healed without the injured part being difcovered. When we find, however, that a wound is inflided on a portion of protruded gut, it ought not to be re- placed till the opening is fecured with ligatures. .— Different methods are propofed for this. Le Dran thinks that it may be done with moft fafety by what he terms the looped future ; while the generality of praditioners prefer the Glover's future. The looped future is performed in the following manner : one end of the wound is to be held by an afliftant, while the furgeon does the fame with the other; and the nee- dles, which ffiould be round, straight, and fmall, car- rying each of them a thread a foot long, muft be equal to the number of flitches intended to be made. As many of the ligatures are now to be paffed through both lips of the wound as appear to be neceffary, tak- ing care to keep them nearly a quarter of an inch from each other. The threads being all paffed, and the needles removed, all thofe on one fide of the cut ■muft be tied together with a knot at their ends, and thofe on the oppofite fide muft afterwards be fecured in the fame manner. They are now to be joined to- gether, and twifted two or three times round, fo as to form a kind of a cord: by this means the divided parts of the inteftine are puckered together, fo that u 2 292 Of Wounds Chap. HL the flitches, which before were diftant about a quarter of an inch, are now brought clofe to each other. The future being thus finished, an affiftant muft hold the two ends of the twifted threads, whilft the furgeon re- places the inteftine in the manner that has been al- ready defcribed. The threads are to be fecured to the bandage employed for covering the dreffings ; and after remaining till the wound in the gut may be fup- pofed to be healed, they are then to be untwifted; and all the ends of one fide being cut off clofe to the external wound, they muft now be drawn flowly and feparately away.. The principal objedion to this method of Hitching thefe wounds is, that in fome degree it muft contrad the diameter of the gut, by which dangerous obstruc- tions might afterwards be produced. Inftead of it, therefore, the Glover's future, as it is termed, is com- monly pradifed. In making this future, a fmall, fine round needle ffiould be ufed, armed with a thread of waxed filk. The furgeon laying the lips of the wound exadly together, muft perforate both at the fame time; and carrying the needle to the fame fide at which it entered, he muft now make a fecond flitch at a fmall diftance, namely, at the eighth part of an mch from the firft ; and in the fame manner muft continue, by a proper number of flitches, to draw the whole extent of the wound together. This being done, a fufficient length of the thread is to be left out at the external wound, for the purpofe of drawing it away when we fuppofe the wound in the gut may be united. Even this method of treatment, however, muft tend to leffen the diameter of the gut, a difficulty which may be avoided, and the operation be performed with the fame degree of fecurity, by entering the needle al- ways from the infide of the gut, and puffiing it out- ward. The operation ffiould commence near to one end of the wound : the needle being pufhed through one fide of the gut, the ligature fhould be drawn for- Sed. XII. in the Abdomen. 293 ward, and retained by a knot formed on the end re- maining in the infide. The needle muft now be car- ried, straight acrofs, and entered in a fimilar manner, fo as to pierce the oppofite fide of the wound alfo from within ; but the following and every fucceeding flitch will not be oppofite to each other. When the operation is rightly performed, the needle will be car- ried from one fide of the wound, in a diagonal line, to the other, and will enter the gut at the diftance of two tenths of an inch from the point from which it came on the oppofite fide. In this manner the fides of the wound may be drawn clofely and exadly to- gether, without leffening the diameter of the gut in any degree ; and the end of the ligature may at laft be-fecured and cut off clofe to the other extremity of the wound, if the gut is to be put freely into the ab- domen ; or it may be left of a fufficient length to hang out at the wound in the teguments, if it is the mean- ing of the operator to retain the wounded part of the inteftine in contad with the external opening. This indeed is ufually done, that we may have it in our power, as it is faid, to draw away the ligature on the wound of the gut being cured. It is probable, how- ever, whatever future may be employed, if more than one or two ftitches have been paffed, that it will be difficult, or even impoffible, to get the ligature away, without hurting the inteftines. I would never advife, therefore, with a view to this, that the ligature ffiould be left out at the wound ; lefs danger will arife from cutting it entirely away, and allowing the ftitches to remain : a confiderable part of it will fall into the cav- ity of the gut; and in fuch circumftances, the danger of the patient from other caufes is fo great, that any additional rifk that can occur from the remaining part of it, muft be fo trifling, as not to deferve notice. But in extenfive wounds of the inteftines, and whenever there is much caufe to fear that the operation will not fucceed, with a view to prevent the faeces from being emptied into the abdomen, it may be proper, by means 294 Of Wounds Chap. HI. of the thread ufed for the ligature, to retain the injur- ed part in contad with the wound in the peritonaeum. But of this we fhall prefently fpeak more particularly. This is the method of treatment which I would ad- vife when the gut is not cut entirely acrofs; and, however fmall a wound of the inteftines may be, it ought always to be fecured with a ligature: for al- though it is alleged by fome, that we ffiould rather truft to nature for the cure of a fmall opening in a gut than to infert a ligature ; to me it appears that the opinion is by no means well founded ; infomuch that I would not leave even the fmalleft opening that could admit either faeces or chyle to pafs without Hitching it up. Much danger may enfue from omit- ting it, and the hazard of the patient cannot be in- creafed by the pradice being adopted. When again, any part of the alimentary canal is cut completely acrofs, a difference of pradice is re- quired. When both ends of the divided gut protrude at the wound, it ffiould be our endeavour to bring them into contad in fuch a manner as to admit of their uniting; and it may be done in different ways. It has been done by Hitching the two ends of the gut to the peritonaeum and abdominal mufcles, exactly oppofite and contiguous to each other; and although in this manner the faeces muft be difcharged for fome time by the wound, yet different inftances have oc- curred of the two ends of the gut adhering together, and being completely united in the courfe of a fhort time : of this feveral cafes have fallen within my own obfervation. In fuch circumftances, we are commonly advifed to plug up the opening in the end of the upper extrem- ity of the gut, not only with a view to keep the pa- tient clean and comfortable, by preventing the fasces from being at all times pufhed out, but to prevent, as we are told, the gut from contrading, and its diame- ter from being reduced. I am convinced from expe- rience, however, that this precaution is unneceffary ; Sed. XII. in the Abdomen. 295 and I know that it proves hurtful. Inftead of intro- ducing tents or doffils, the outward fore ffiould be dreffed as lightly as poffible ; and if care is taken to keep the patient clean, nature alone will do the reft. This is, perhaps, the beft method of managing this variety of wound ; but the fame intention may be an- fwered by inferting the upper extremity of the divided gut into the end of the other, and Hitching them to- gether. In this fituation it would be difficult to draw the divided parts together with a needle and ligature, without hurting the oppofite fides of the gut, in any other way than by keeping it extended by means of fome round body inferted into it. For this purpofe it has been propofed to make ufe of a tube of thin pafte- board or paper; but as this might be laid hold of, and kept firm by the ligature, a fmall roll of tallow is preferable, as the tallow will afterwards melt, and pafs eafily off with the faeces. A piece of it, nearly equal to the diameter of the gut, fhould be inferted into the end of the upper part of it; and being afterwards paff- ed into the other, fo as to carry the one, to the ex- tent of an inch or thereby, into the other, the two portions of gut ffiould be now ftitched together with a fmall round needle armed with a fine thread. The ftitches ffiould be carried completely round the gut; and, in order to give them as great a chance as poffi- ble of fucceeding, they might even go twice round ; firft at the edge of the under portion of gut, and af- terwards about an inch beneath, near to where the upper part of it terminates. In the infertion of one extremity of the gut into the other,' I have defired, for an obvious reafon, that the end of the upper portion fhould be put into the other; but it requires fome attention to make the diftindion. The peristaltic motion is commonly more remarkable in the upper divifion than in the under; but the moft certain method of judging, is to obferve at which of the ends the faeces or chyle are difcharged: an inver- fion of the ufual motion of the bowels might indeed 296 Of Wounds Chap. III. produce a deception; but as this is not a common oc- currence, we are not to fuppofe that at this particular time it is likely to happen. In wounds of thefe parts, a portion of divided gut fometimes hangs out at the wound, while the other end of it has flipped into the abdomen. In fuch cir- cumftances, authors in general advife the end of the gut to be flitched to the peritonaeum and other parts contiguous to the wound. If it proves to be the up- per part of the gut, the patient, it is faid, may live un- der the inconvenience of an artificial anus, and if not near to the upper part of the fmall inteftines, that a fufficient quantity of chyle may be carried into the blood for his fupport and nouriffiment. But in the event of its proving to be the under part of the gut, although death would certainly enfue, were we to reft fatisfied with this, it has fcarcely been fuppofed that we ought to proceed further. I clearly, however, think, that this will never prove fatisfadory to the feelings of any praditioner poffeffed of that degree of fortitude which our art requires, and who has that regard for the fafety of his patient which every furgeon ought to poffefs. And although I have advifed, in wounds of the inteftines, when no part of them protrudes, where we cannot therefore know whether the wound is large, or only a fmall pundure, and where the injured part may be fo fituated that it could not be reached without opening the greateft part of the abdomen, and turning out perhaps the whole alimentary canal, that we had better allow the patient to have the chance of recovering without any attempt to make a difcovery, and which he may do if the wound is fmall, than to propofe a meafure, which of itfelf might be produdive of more hazard than the injury for which it was meant to be a reme* dy. Yet, when we are certain of the gut being com, pletely divided by one end of it hanging out of the wound, as this will give much caufe to imagine that the other is at no great diftance, I think it ought by Sed. XII. in the Abdomen. 297 all means to be fearched for, by enlarging the exter- nal wound, fo as to admit of the fingers of the opera- tor being inferted into the cavity of the abdomen. Even where the upper part of the gut is protruded, it is worth while to fubmit to this inquiry, merely in or- der to have fome chance of avoiding the loathfome in- convenience of an artificial opening for the faeces ; and, where the upper part of the gut has flipped in, the patient can have no chance for further existence if it is not difcovered. In fuch circumftances, there- fore, we fhould not hefitate on the meafures to be purfued. In wounds of the abdomen, the inteftines, befides being protruded and wounded, are fometimes morti- fied ; and they are fometimes mortified without being wounded. But whether mortification be combined with a wound or not, the method of treatment ffiould be nearly the fame. Where only a tendency to gangrene takes place, from the parts being much inflamed, they ffiould be returned immediately into the abdomen, for the rea- fons that I have given already. But whenever they are entirely mortified, the black dead fpot will foon fall out, and the remainder being thus reduced nearly to the ftate of a fore from any other caufe, the fame method of cure will become applicable. Authors, in general, have treated of wounds of the fmall and great inteftines feparately ; but no neceffity appears for this ; they are nearly of the fame nature, and require the fame method of treatment. The leaft injury done to the bowels is always hazardous, and in every inftance our prognofis ffiould be doubtful. But it is faid, that wounds are more particularly danger- ous in the fmall than in the large inteftines ; from their being more apt to induce violent degrees of in- flammation : I have not obferved, however, that this is confirmed by experience. 298 Of Wounds Chap. III. § 5. Of Wounds in the Stomach. In wounds of the abdomen, we conclude that the ftomach is injured, from the part at which the inftru- ment entered, and from the depth and diredion in which it appeared to run; from the patient being feized with vomiting of blood ; from his complaining of a great and unufual degree of ficknefs ; of languor and singultus ; and from the food and drink being dif- charged at the wound foon after they are fwallowed. All wounds in the upper part of the left hypochon- drium which pafs to any confiderable depth, as like- wife thofe of the epigaftrium, can fcarcely avoid the ftomach; but wounds of any part of the abdomen may reach it when they run in an oblique diredion; and, it ought to be noticed, as I have elfewhere ob- fervedy^hat wounds may penetrate the ftomach when it is full, which would not touch it when empty. Wounds of the ftomach muft always be confidered as dangerous, and a doubtful prognofis only fhould be given; for although many inftances are recorded of their being cured, yet they are not fo frequent as to warrant us in the courfe of pradice to exped them. The fame plan of treatment which I have advifed in wounds of the inteftines* applies with equal pro- priety to wounds of the ftomach. When the wound- ed portion protrudes, it ffiould be flitched up, and re- placed as quickly as poffible. But even where it does not protrude, it ought to be fearched for; and when the anterior part of the ftomach only has fuf- fered, it will not be difficult to difcover. We ffiould not, however, be deterred from the inquiry by the feat of the wound; for we may be able to reach it wherever it may be, excepting in the posterior part of the ftomach. * Sedlion VI. of this Chapter. Sed. XII. in the Abdomen. 299 It is to be obferved, that wounds of the ftomach are more readily difcovered than wounds of the intef- tines ; for thefe laft are more concealed by convolu- tions of themfelves, as well as by other vifcera. In wounds of the ftomach and bowels, the patient fhould be put upon as ftrid a regimen as his ftrength will bear: not only with a view to prevent inflamma- tion, which, as I have formerly obferved, is the moft dangerous fymptom that can occur, but to prevent the injured parts from being diftended, by which they might be materially hurt. Inftead of regular meals, a fpoonful or two only ffiould be allowed at once; and no more ffiould be given even in this way than is merely neceffary to fupport life. In wounds of the ftomach and upper part of the inteftines, we might venture in a great meafure, and at leaft for fev- eral days together, to truft to nourifhing glyfters: but this ffiould be carefully avoided in wounds of the great guts ; as the injeded liquor might more readily be forced in this way into the cavity of the abdomen than if taken by the mouth. § 6. Of Wounds of the Omentum and Mefentery. I have already defcribed the fituation of thefe parts ; but we have no means of judging whether they have fuffereri in wounds of the abdomen or not, if they are not protruded. When it is found that a protruded portion of omentum is injured, we ought to fee whether any part of it is nearly feparated from the reft or not: for whatever part of it is in this ftate ffiould be immedi- ately removed; or when it has become cold, with much reafon to dread that it will mortify, it will be proper to remove it alfo. But when no appearance of this takes place, we ffiould advife it to be immedi- ately returned into the abdomen. In chapter IX. when treating of hernia, it will be neceffary again to enter upon the confideration of 3°° Of Wounds Chap. III. this; at prefent, therefore, we ffiall refer to that part of our fubjed. In wounds of the mefentery, what we have moft to be afraid of, is the difcharge of blood or chyle into the cavity of the abdomen; for as the ladeals, to- gether with a great number of arteries and veins, run in the duplicature of this membrane, it can fcarcely be injured without fome of them fullering. When- ever any portion therefore of the mefentery protrudes, it ought to be examined with accuracy: and when any of its arteries are divided, they ffiould be imme- diately tied with ligatures ; the ends of which being left out at the wound, will admit of their being taken away as foon as they are entirely feparated. §7. Of Wounds of the Liver and Gall Bladder. From the anatomical defcription that I have given of the contents of the abdomen, it appears that the liver will be apt to be hurt by every wound that pen- etrates either the right hypochondrium or epigaf- trium. The liver does not appear to be poffeffed of much fenfibility: many inftances have occurred where fu- perficial wounds of the liver have healed with the fame eafe, and have not induced more alarming fymp- toms than ufually arife from wounds of the fame ex- tent in any other part of the body. But wounds of the liver which pafs to any confiderable depth, are al- ways to be confidered as dangerous, from the great quantity of blood which is fent to it, as well as from the interruption which they may give to the forma- tion of bile, one of the moft important fecretions in the body : and they are apt to prove particularly haz- ardous, from their allowing the bile, which foon be- comes putrid, to be poured into the cavity of the ab- domen. We judge of the liver being hurt, from the fitua- tion and depth of a wound ; from the quantity ox Sed. XII. in the Abdomen, 301 blood that is difcharged being more confiderable than could probably be afforded by any blood veffels of the integuments or mufcles ; from bile being difcharg- ed along with the blood ; from bile tinged with blood being carried into the bowels, and difcharged both by the ftomach and anus; from the abdomen being apt to fwell and become tenfe; and from pain being felt on the top of the fhoulder, a frequent fymptom in different affedions of the liver. All that we can do in wounds of the liver, is to guard as much as poffible againft exceffive haemor- rhagies, and to difcharge any colledions of blood or bile that may form in the abdomen when they be- come confiderable. We endeavour to prevent or put a flop to the haemorrhagy by bloodletting, gentle lax- atives, keeping the patient cool, and at perfed reft both in body and mind. And we difcharge collec- tions of blood, bile, or matter, by making an opening in the moft depending part of the abdomen, or wher- ever they may happen to form. Wounds of the gall badder are by experience found to prove more dangerous than wounds of the liver; for they are ftill more difficult to heal, at the fame time that they are more certainly produdive of ex- travafation of bile into the abdomen. Inftances in- deed have happened, of the bile being fo completely obflruded in its paffage from the gall bladder to the duodenum, that the bladder has fwelled fo as to pro- duce much external tumefaction : and, in fome cafes, thefe fwellings, after burfting or being opened, have continued to difcharge bile for a confiderable time ; and at laft have been known to heal without produc- ing any extravafation into the abdomen, or other alarming fymptoms. This, however, proceeds from the previous diftenfion of the bladder having produc- ed adhefions between it and the neighbouring parts ; by which, when an opening is made into it, the bile is prevented from fpreading. But few inftances have occurred of wounds in the gall bladder having this fa- 302 Of Wounds Chap. HI. vourable termination. To procure as free a vent for the bile as poffible, and to difcharge it by an opening, fuch as I have mentioned, when it colleds in the ab- domen, is perhaps all that art ought to attempt. § 8. Of Wounds of the Spleen, Pancreas, and Recep- taculum Chyli. When the fpleen is laid bare, we eafily difcover whether it is injured or not; but as this organ does not afford any particular fecretion by the appearance of which we might be determined, and as wounds of it do not excite any remarkable fet of fymptoms, it is difficult to judge merely from the depth or direction of a wound, whether it is hurt or not. It is obferved, indeed, that blood difcharged immediately from the fpleen is of a peculiar deep red colour; but this teft is not entirely to be trufted ; nor are we to Conclude from the quantity of blood being confiderable, which a wound in the region of the fpleen may difcharge, that the fpleen itfelf is certainly injured; for it lies fo near to large blood veffels belonging to other vifcera, particularly to the emulgent arteries and veins, that no certain judgment can be formed from this circum- ftance. The fame obfervations which we have made upon wounds of the liver, will apply with equal propriety to wounds of the fpleen; only we may fuppofe, that the danger attending the latter will not be fo confid- erable, as they will not put a flop to any material fe- cretion. As the pancreas lies deeply covered with the other vifcera, any injury done to it can feldom be difcover- ed : but as a divifion of the dud of this gland will prevent the fecretion which it affords from being car- ried to the bowels, this may, by interrupting or im- peding digeftion, do much injury to the conftitution ; and as the liquor will be effufed into the cavity of the abdomen, it may thus be produdive of colledions, Sed. XII. in the Abdomen. 303 the removal of which may ultimately require the af- fiflance of furgery. Wounds of the receptaculum chyli will be diftin- guifhed from their fituation, and from the difcharge being a thin milky liquor. They muft neceffarily be attended with much danger, as they will deprive the patient of the greateft part, or even of all the nou- rishment which he ought to derive from his food. They can never in any way become the objed of fur- gery, but by producing colledions in the abdomen which may require to be difcharged. § 9. Of Wounds of the Kidneys and Ureters. In a fubfequent part of this work,* I ffiall have occafion to mention the fituation of the kidneys ; an accurate knowledge of which is an objed of much importance in judging whether penetrating wounds in thefe parts may have injured them or not; but, in general, this may be afcertained by the fymptoms which take place. The external coverings of the kidney may be hurt without any fymptom of importance being induced ; but neither the pelvis of the kidney, nor the ureters, can be penetrated without producing fome or perhaps all of the following fymptoms : the patient complains of violent pain, not merely in the part itfelf, but over the whole loins ; in the groin, yard, and even in the tefticles ; he is liable to fevere ficknefs and vomiting; the urine is paffed with pain and difficulty, and along with it more or lefs blood is ufually difcharged ; and although the greateft part of the wound may heal, a fiftulous opening commonly remains during life. When the kidney is pierced by a wound entering from the belly, the urine is apt to be extravafated in- to the cavity of the abdomen : but when wounded from the back, or even from the fide, the urine will * Vide Chapter XV. Section U. 304 Of Wounds Chap. III. either pafs diredly out at the opening, or it will fpread through the contiguous cellular fubftance ; for the kidney being fituated behind the peritonaeum, the urine will not in this cafe find accefs to the belly. The rifk, therefore, with which wounds of this organ may be attended, will depend in a great meafure on this. When the urine paffes into the abdomen, the danger will be very great; but when this does not happen, if the patient furvives the haemorrhagy which at firft takes place, he may have a tolerable chance to efcape with the inconvenience of a fistulous opening, at which the urine will continue to be difcharged. Inftances indeed have occurred, even of this being at laft cured; but they are fo rare that they are fcarce- ly to be looked for. All that art can in fuch circum- ftances with propriety attempt, is to prevent the urine from lodging; and, if the fides of the opening be- come callous, to render them raw from time to time, either with the fcalpel or lunar cauftic, by which they may at laft be made to unite. § 10. Of Wounds of the Bladder. The bladder, v/hen empty, lies altogether within the bones of the pelvis ; but when filled with urine, it rifes much higher, infomuch, that when the urine is long obftruded, the belly not unfrequently rifes above the umbilicus. In judging, therefore, whether injuries done to thefe parts have penetrated the blad- der or not, we muft know whether it was empty or full. But for the moft part this point is eafily deter- mined ; as in general the urine comes away by the wound, and even that which paffes by the urethra is at firft always tinged with blood. The danger arifing from wounds of the bladder is in fome degree in proportion to their fituation. As the upper part of the bladder lies within the cavity of the abdomen, pundures that penetrate into it are apt to pruduce an extravafation of urine into the belly, by Sed. XII. in the Abdomen. W which the moft dangerous fymptoms are commonly induced : while the under part of the bladder, not being covered with the peritonaeum, is often wound- ed, without any fymptom of importance taking place, as we daily obferve in the operation of lithotomy, as it is now practifed in the lateral method. The pain that attends wounds in the bladder is of- ten relieved by fomenting the under part of the ab- domen and peritonaeum, with flannel prefled out of warm water; while by taking blood in proportion to the ftrength of the patient, advifing gentle laxatives, and a low diet, we endeavour to prevent inflamma- tion, the moft dangerous fymptom attending wounds of this organ. And when inflammation has already taken place, we try to remove it by farther evacua- tions of blood; by dofes of opiates proportioned to the degree of pain ; and by the femicubium. Indeed, warmth applied in this manner feems to have a more certain effect in removing the pain and tenfion of the abdomen which thefe wounds are apt to induce, than almoft any other remedy. When, again, the upper part of the bladder is in- jured, together with the rifk which occurs from in- flammation, we have the additional hazard, that I have already taken notice of, arifing from extravafa- tion of urine. As the danger with which this is attended is always vety confiderable, efpecially when the urine paffes in- to the abdomen, it might give the patient fome further chance of recovering, to treat wounds of this kind in the bladder upon the fame principles, and in the fame manner, that I have advifed for wounds of the intef- tines ; that is, by ftitching up the wounded part either with the Glover's future, or in the manner I have propofed in a preceding part of this fedion, as may be feen in § 4. The Glover's future might anfwer equally well with the other; and here it might be uf- ed with more freedom than in the inteftines-, as the Vol. I. W 306 Of Wounds Chap. III. bladder can more readily admit of being fomewhat di- minifhed in its capacity. As yet I have not put this propofal in pradice,,but I mean to advife it in the firft inftance that may occur. To prevent the inconvenience and danger arifing from the extravafation of urine into the abdomen, it has been propofed to draw the opening in the bladder forward to the external wound, and to ftitch it to the peritonaeum and contiguous parts. This may be ea- fily done when the anterior part of the bladder is wounded; but when the opening lies behind, to draw it forward and retain it at the wound would be pro- dudive of much pain, and might ultimately be attend- ed with more danger than it was meant to prevent. In fuch circumftances, I would rather truft to the wound being neatly ftitched up, when the parts ffiould be immediately replaced, and the patient treated in the manner I have advifed for fimilar injuries done to the inteftines. § n. Q/" Wounds of the Uterus and its Appendages. The uterus is a ftrong mufcular bag peculiar to the female fex, of a triangular figure, and fituated be- tween the bladder and rectum. In an unimpregnated ftate, it lies altogether within the bones of the pelvis; but during pregnancy, it rifes fo high in the abdomen as to touch the umbilicus and even the ftomach; while at the fame time, the inferior point of it, term- ed the os tineas, terminates in the vagina, a fmooth membranous ffieath which runs contiguous to, and terminates beneath, the urethra. The uterus is firmly attached by different ligaments to the contiguous parts: by the ligamenta lata on each fide, which appear to be doublings of the peritonae- um ; and by the ligamenta rotunda, which arife from the upper corners of the fundus uteri, and paffing down through the openings in the external oblique mufcle, are loft in the upper part of the thigh. By Sed. XIL in the Abdomen. 307 the tubas fallopianas, which arife near to the liga- menta rotunda, the uterus communicates with the ovaria, two fmall round bodies placed within an inch and a half of its fundus. From the uterus ftretching, and occupying differ- ent parts in the different periods of geftation, it is ev- ident that wounds, which in one ftate might injure it, in others will pafs confiderably above it: fo that in judging from the fituation and diredion of a wound in thefe parts, this circumftance ought not to be over* looked: in extenfive wounds, we may know at once, by examination with the fingers, whether the uterus is injured or not: but in others, where this is not ad- miffible, we muft judge entirely from the fymptoms Which take place. In an unimpregnated ftate, a wound of the uterus is not productive of fymptoms very different from thofe arifing from wounds of the contiguous parts. But during pregnancy, wounds of this organ either induce fymptoms of an approaching abortion ; or the quantity of blood difcharged outwardly by the wound, or extravafated into the cavity of the abdomen, will be confiderable. ^ At leaft this in general is the cafe, when the injury is important; for, during pregnancy, the quantity of blood fent to the uterus is confidera- ble ; and we know from experience, that haemorrha- gies which occur from it in this ftate, feldom flop till after delivery ; by which the uterus is allowed to con- trad, fo as to comprefs and fupport the injured veffels. In all injuries, therefore, of this kind, where fymp- toms of approaching abortion occur, nothing ffiould be done to prevent it; and where fymptoms of this kind do not take place, and whenever there is caufe to fufped that the patient may fuffer from lofs of blood, if the delivery cannot be accomplifhed in the ufual way, the child ffiould be taken out by the caefa- rian operation. In a fubfequent part of this work I fhall have occafion to defcribe the method of perform- w 2 308 Of Wounds in the Abdomen. Chap. III. ing this operation; but in cafes fuch as we are now confidering, the eafieft, and perhaps the beft, meth- od of doing it, is to enlarge both the external opening and the wound in the uterus to a fize that will admit of the child being taken out. In other circumftances, wounds of the uterus muft be managed nearly in the fame manner with other penetrating wounds of the abdomen. Befides the feveral vifcera in the abdomen and pel- vis, which we have thus been confidering, many large blood veffels and nerves pafs through thefe parts, which are alfo liable to be wounded : but as no rem- edies with which we are acquainted can afford any re- lief in divifions of the nerves ; and as the large blood veffels here lie too deep for any chirurgica! affiflance, they very univerfally end fatally. A patient may in- deed linger long under the paralytic fymptoms which fucceed to injuries done to thefe nerves ; but a divi- fion of the large blood veffels of the abdomen in eve- ry inftance proves quickly fatal. I have thus finiflied the confideration of wounds of the thorax and abdomen; and it will be obferved, that I have entered minutely into it. To this I was induced, not merely by the importance of the fubjed, which I confider, however, as one of the moft materi- al that praditioners meet with, but with a view to ex- cite the attention of beginners to an intimate acquaint- ance with the moft ufeful part of anatomy, that of the thoracic and abdominal vifcera. In the preceding fedions I have treated feparately of all thofe wounds, which, from the fituation, or any other peculiarity of the injured parts, may require any variety in the method of treatment. The extremities indeed are liable to wounds which require a mode of management that I have not yet fpoken of, namely, thofe wounds which are complicated with fradures of the contiguous bones : thefe, however, will more pro- perly fall to be confidered when we come to treat of compound fradures. The only other varieties of Sed. XIII. Poifoned Wounds. 309 wound which we have now to fpeak of, are poifoned or envenomed wounds, and gunffiot wounds. SECTION XIII. Poifoned Wounds. OUNDS may be poifoned in various ways: the bites of feveral animals, particularly thofe of the viper, afford examples of poifoned wounds ; and the flings of the tarantula, of wafps and bees, are of the fame nature. It is evident, too, that poifon is conveyed to wounds by the bites of mad or enraged animals, particularly by the bites of mad dogs: and they may be poifoned by the matter or fecretion of various kinds of fores, as well as by the juices of difr ferent vegetables. The flings of wafps and bees, and other infeds of this climate, although produdive of much pain, fel- dom terminate in any fymptom of importance : the application of vinegar or fpirit of wine to the part af- fected immediately after the injury, will often prevent the pain, tenfion, and inflammation, which otherwife would fupervene: and when once thefe fymptoms take place, they will for the moft part be more effec- tually relieved by waffling with cold water, or immerf- ing the parts in water, than by any other remedy. For the iting of a fcorpion, we are advifed to kill the animal, and apply it to the injured part, or to cover the part with a dead toad or fome other animal fup- pofed to he of a poifonous nature. There is much caufe, however, to imagine that this pradice is found- ed in prejudice ; and we are told, that of late the fame remedies have been found to prove ufeful in the flings of infeds in warm climates, that we have juft men- w 3IQ Poifoned Chap, in. tioned for the flings of bees and other infeds of this Country. As the bite of a viper proves fometimes fatal, it de- ferves at all times particular attention. It is true, in- deed, that it often heals eafily without any fymptom of importance being induced by it; for the poifon of this animal being contained in a fmall bag at the root of each tooth, which it can difcharge or retain at plea- fure, it would appear that it does not throw it out if it be not excited to irritation. But as we can never judge with certainty whether the wound be poifoned or not, we ought in every cafe to be upon our guard. To prevent the poifon from entering the fyftem is the objed we fhould have in view, This, however, can only be done when the affiflance of praditioners is procured immediately: for although there is reafon to fuppofe that fome other poifons, even when applied to recent wounds, do not immediately enter the circu- lation ; yet we know from various circumftances, that this is by no means the cafe with the poifon of the viper, which commonly begins to operate upon the fyftem in the fpace of a few hours. The patient com- plains of a violent burning pain in the injured part, which foon begins to fwell. Tenfion and inflamma- tion take place, not merely over the affeded limb, but often over the whole body. The patient becomes faint and languid, the pulfe low and feeble ; he com- plains of giddinefs, naufea, and vomiting ; of a fixed pain in the region of the heart; the whole furface of the body becomes yellow like the fkin of a jaundiced patient; the urine appears of a deep yellow, and is evidently ftrongly impregnated with bile; cold fweats take place, along with convulfive twitchings in differ- ent parts of the body ; and if relief is not quickly obi tained, death foon clofes the fcene. With a view to prevent the acceffion of thefe fymp* toms, the injured part ffiould either be cut out imme-. diately or deftroyed with the adual or potential cau. tery. The fooner this is done, the more effedual it Sed. XIII. Wounds. 3*1 va\\ probably prove ; but it ffiould always be advifed a6 long as no bad fymptom has appeared. In former times fudion was much employed for the removal of poifon in wounds; in fome cafes by instruments kept for the purpofe, but moft frequently by the mouth ; and it was found, where the fkin of the mouth was entire, that it might be done with fafety. This might frequently prove fuccefsful; but where the life of a patient is fo nearly concerned, that remedy only ffiould be advifed which will with certainty prevent the poi- fon from entering the blood. We ffiould not there- fore hefitate to advife the injured part to be immedi- ately cut out; and with a view to render the pradice as effedual as poffible, we ffiould endeavour to excite a plentiful fuppuration over the furface of the fore. This may be done by the application of ftimulating ointments, when the patient does not complain of pain and tenfion; and by the ufe of emollient poultices, when much inflammation takes place. But when it appears that the poifon has already en- tered the fyftem, this local treatment of the fore is not to be trufted. In fuch circumftances, the application of warm oil, not merely to the fore, but over the whole body, has been much recommended ; and it is faid that fome advantage has been derived from the internal exhibition of oil: two fpoonfuls of fine olive oil, given every hour, is faid to have allayed the moft violent fymptoms which the bite of a viper ever ex- cites. From fome late obfervations, however, the ef- ficacy of this remedy is much to be doubted; and it would appear that a plentiful fweat, kept up for a confiderable time, is the moft certain method yet dif- covered, not merely of mitigating the fymptoms, but of removing them altogether. By whatever means a fweat is induced, it is found to prove ufeful: but ex- perience ffiows, that fmall dofes of the volatile alkali, frequently repeated, is for this purpofe more to be trufted than any other remedy. A particular prepa- ration of this kind, eau de luce, has been much re- 3*2 foifoned Chap. III. commended; twenty drops of it to be given every hour. But there is reafon to fuppofe, that any other form of the volatile alkali will prove equally effedual, AU the varieties of theriac, as well as many other remedies, are recommended for the bites of vipers ; nay, different remedies are advifed for the bite of ev- ery vaiiety of this animal. But as we do not find that- any of them are to be trufted, it is not neceffary to enumerate them. The moft formidable wound of a poifoned nature which we meet with in this country, is the bke of a mad animal; for although inftances daily happen of thefe wounds healing without exciting any fymptonj of importance, yet whenever they terminate in hydro- phobia, the utmoft danger js to be dreaded. Indeed the inftanoes of patients recovering from this dreadful fyrnptom are fo rare, that we defpair in every cafe of any remedy proving ufeful: a variety of noftrumg have been held forth to the public, by which we are told that hydrophobia may not only be prevented, but even cured when it has actually taken place. I have not heard, however, of any well attefted fad of this having happened. As a preventative of hydrophobia, nothing with which we are acquainted can be depended on, but an immediate removal of the injured part, either with the fcalpejl,, or the adual or potential cautery ; which, when accompanied with a plentiful fuppuration upon the fore, has, in different inftances, appeared to an* fsver the purpofe: that is, patients who have been treated in jthis manner have efcaped, while others bit at the fame time by the fame animal have fuffered. The fooner that the injured part is removed, the more effedual the operation will prove: but we had better advjfe it even at the dijftan.ce of feveral days, than deprive the patient entirely of the chance which it afford*.; efpecially as there is reafon tvo imagine that ijhis poifon does not enter the fyftem fo quickly as a yariety of others are pbferyed to do j ai leaft this muft Sed. XIII. Wounds. 3*3 be the cafe, if we can judge from the time at which it begins to operate. For we know, that in moft in- ftances none of the fymptoms induced by the bites of mad animals, appear till feveral weeks after the acci- dent; and it has been known that a perfon has re- mained perfedly well after the bite for the fpace of fix months, and at laft has been fuddenly feized with hydrophobia. Whenever we are certain, therefore, that a perfon has been bit by an enraged animal, we ffiould advife the part to be cut out at whatever peri- od this may be, provided no fymptom has appeared of the poifon haying entered the fyftem, at the fame time that the fore ffiould be kept open for a confider- able time by the application of fome irritating oint- ment. While we place moft confidence in this treatment, the advantages fo be derived from other remedies ffiould not be negleded. Sea bathing has in all ages been much famed as a preventative of thefe fymp- toms : we have few well attefted cafes, however, of any benefit being procured from it. By many prac-' titioners, mercury is much depended upon, particu- larly fridions with mercurial ointment, and applying jt as a dreffing to the fores; and as this may be em- ployed along with any other plan of treatment that may be adopted, it may be right in every cafe to ad- vife it. It will often happen, however, that neither thefe nor any other means we can employ will prove ufe- ful ; and as the province of furgery affords no reme- dy for the fymptoms which accompany hydrophobia, as foon as they take place, the unhappy fufferer ffiould immediately receive all the affiflance which phyficians of experience and obfervation can give. When wounds are poifoned by the matter of dif- eafes, as fometimes happens to furgeons iri the treat- ment of fores, particularly in thofe of the venereal ai d cancerous kinds, the beft pradice would be to remove the virus immediately, in the manner \ have juft men- 314 Poifoned Wounds. Chap. III. tioned in cafes of poifoned bites, by cutting out the part affeded, or burning it with a hot iron. With refped to the venereal poifon, a timid patient may in- deed hefitate in the ufe of fuch a formidable remedy, when he knows that we are poffeffed of an antidote which feldom fails: many, however, would endure the momentary pain of a burn or a cut, in preference to the flow operation of a mercurial courfe. And in cafes of fores coming into contad with the matter of a can- cer, we ffiould not hefitate in adopting the pradice immediately ; for hitherto we are not poffeffed of any remedy upon which dependence can be placed for the cure of this difeafe. This would likewife be the moft eligible pradice in wounds infeded with any of the vegetable poifons. \Ve are told, however, that in thofe parts of the world where alone it can be neceffary, antidotes are univer- fally known for every poifon of this kind; and that the Indians, when they are wounded, can difcover im- * ^mediately whether the instruments with which they "are hurt have been poifoned or not. . With refped to metallic poifons, they do not at prefent fall within our confideration; for however deleterious they prove when taken into the ftomach, they do not appear to prove otherwife hurtful when applied to wounds, than by irritating or corroding the parts with which they come in contad. We are told, indeed, that inftances have occurred of thefe poifons entering the fyftem even when applied to wounds; and this is mentioned as a reafon for our not ufing the different preparations of lead with fuch freedom as is now univerfally done. But although remedies of this clafs are now daily employed, I have not heard of a fingle well marked cafe of their prov- ing noxious: nay, it is to be doubted, whether even the fait or fugar of lead, as it is termed, proves hurt- ful, even when taken in confiderable quantities into the ftomach. We know that in fmall dofes it may be ufed with fafety; and I have much reafon to think Sed. XIII. Of Gunfhot Wounds. 3*5 that it may be taken even in large quantities, with more freedom than is commonly imagined, from its having happened in different inftances with patients of my own, who by miftake have fwallowed and re- tained large cupfuls of a ftrong folution of ceruffa acetata, without any bad fymptom being induced. I ■ ■ M —3 SECTION XIV, Of Gunfhot Wounds. AS wounds made by fire arms are fuppofed to be very different from others, they are ufually treated of in feparate chapters. I think it right to ad- here to a cuftom which has long prevailed; but at the fame time I muft obferve, that this difference con- fifts chiefly in the fymptoms being for the moft part more fevere and violent in gunffiot wounds than in' others. Till of late, moft of the fymptoms induced by gunffiot wounds were fuppofed to originate from poifon carried in with the ball; and it was alfo ima- gined, that the ball cauterized or burned the parts as it paffed along. We now know, however, that thefe opinions are both ill founded; that the injured parts do not fuffer either by poifon, or from the immediate application of heat; and that all the phenomena pe- culiar to gunffiot wounds, proceed from the violent contufion produced by the paffage of the ball. Of this we are rendered certain, from there being no poi- fon contained either in gunpowder, or any of the ar- ticles of which balls are ufually made; and from ob- serving that fymptoms of a fimilar nature are often induced by contufed wounds produced by very dif- ferent caufes. We may, therefore, with much propriety, fay, that gunffiot wounds are altogether of the contufed kind: 316 Of Gunfljot Chap. III. an idea confonant to the method of cure, and which will tend to do away that myftery which hitherto has tended to overfhade this branch of pradice. It has been a prevailing opinion, that there is fomething fo lingular in the nature of gunffiot wounds, as to ren- der it improper for any praditioners to take the charge of them, but fuch as have had opportunities of attending fleets and armies, and of ferving, as it were, an apprenticefhip to this branch of practice. There is no good foundation, however, for this opinion; and I have no hefitation in faying, that gunffiot wounds ffiould be managed upon the fame principles, and in the fame manner, with every variety of wound attended with an equal degree of contufion. In gunffiot wounds, the fymptoms we have moft Feafon to dread are, inflammation, gangrene, and a fuppuration fo abundant as to exhauft the ftrength of the patient. Thefe are therefore to be chiefly kept in view, and our pradice will be more or lefs fuccefsful in proportion as they are mild or fevere. In fome ca- fes the contufion is fo violent and extenfive, that the patient fuffers from the injured parts being immedi- ately attacked with gangrene. But, for the moft part, inflammation is the fymptom from which the greateft danger arifes; for, if not kept moderate from the firft, it feldom fails to terminate either in gangrene or in extenfive colledions of matter. To prevent or remove inflammation ffiould there- fore be confidered as our firft objed in the treatment of gunffiot wounds ; and as nothing tends with fuch certainty to accomplish this as local bloodletting, any veins or arteries divided by the ball, ffiould be allow- ed to difcharge freely before they are tied : excepting indeed where fome of the larger arteries have fullered, I believe it would be a good general rule for pradi- tioners, in gunffiot wounds, not to check any haemor- rhagy that may take place. In this they would be warranted, not merely by the well known powerful influence of local bloodletting in preventing inflam- Sed. XIII. Wounds. 317 mation in general, but by many well attefted fads, all tending to ffiow that it proves particularly ufeful in gunfhot wounds. Among other proofs of this, it may be mentioned, what almoft every army furgeon has obferved, that fome of the moft remarkable cures of gunffiot wounds have happened where patients, from neceffity, have been left for a confiderable time upon the field of battle; by which much more blood is commonly loft than is ufual with fuch as, from their rank, are more early taken care of. In all gun- ffiot wounds, therefore, we ffiould at once determine upon taking as much blood as the ftrength of the pa- tient will permit; and where the parts are fo much contufed, that the veffels which have been divided do not afford a fufficient quantity, a circumftance by no means unfrequent, inftead of taking it from the arm or any diftant part of the body, it fhould be drawn off by the application of leeches to the injured parts ; or when thefe are wanting, by cupping and fcarifying the contiguous found parts. In general, if this pradice is carried a fufficient length at firft, inflammation will not take place; but when this has not been done, and when the parts afterwards fwell and inflame, the ope- ration fliould be repeated once and again according to circumftances. Our next objed is to remove any extraneous body that may be lodged in the wound, as far as this can with propriety be done. When a ball has not pene- trated deep, and efpecially when the wound is left en- tirely open by a portion of fkin and teguments being completely removed, there is little difficulty in clear- ing away whatever might do harm. But when a wound runs to a considerable depth, and efpecially if a counter opening has not been made by the ball paff- ing out at the oppofite fide, any fearch that is made for extraneous bodies ffiould be done with much care and circumfpedion. When treating of Pundured Wounds in Section III. of this chapter, the confider- ation of this was entered upon. I fhall now refer to 3t8 Of Gunfhot Chap, ni- the obfervations, which at that time were fuggefted ; and at prefent ffiall only remark, that when extrane- ous bodies lodged in gunffiot wounds can be taken away without injuring the contiguous parts, it ought always to be done ; but when much pain is likely to be excited, or a-high degree of inflammation endan- gered by the attempt, we ought to defift. In fuch circumftances, it will be better to truft to the extra- neous bodies being afterwards difcharged along with the matter of the fore ; to nature puffiing them out; or to the parts in which they are lodged being accuf- tomed to their refidence. From much experience we know, that in almoft every inftance bullets ffiould be allowed to remain in whatever part they are lodged rather than that much force ffiould be employed to extrad them. A ball lodged in the fubftance of a bone, is perhaps the only exception to this general rule : a ball cannot indeed be extraded from a bone but with much difficulty ; and therefore it is in gen- eral allowed to remain. I have known feveral instan- ces of this; but in all of them much pain and danger to the patient, as well as trouble and perplexity to the praditioner, enfued. The unyielding nature of bone, occafions, upon the lodgment of a foreign body in its fubftance, great pain, tenfion, and fwelling over all the contiguous parts. To prevent thefe, the extrac- tion of the ball, when it can be done without hazard of the patient's life, ffiould be attempted, as foon af- ter the accident as poffible, and before the parts be- come fwelled and pained. Different forceps have been invented for extrading bullets from wounds, and fome have propofed to do it with fcrews : fcarcely any of thefe instruments, how- ever, have anfwered the purpofe for which they are meant; and excepting where a bullet can be eafily laid hold of with common forceps, no inftrument ffiould ever be employed : for, befides tearing and irri- tating the injured parts, they are apt to catch the con- tiguous mufcles, or other foft parts, by which much Sed. XIH. Wounds. 3*9 mifchief is commonly done. There muft always be a rifk of this when the wound runs deep ; but it ought to be more particularly avoided in wounds of the tho- rax and abdomen, where laying hold of any of the contiguous parts would neceffarily produce much dan- ger. When a ball is not deeply lodged, but lies near to the mouth of a wound, fo that the furgeon can fee it, forceps may with fafety be employed ; but when- ever it lies deeper than this, if it is judged proper to extrad it, a counter opening, as it is termed, ffiould be made upon it, fo as to admit of its being taken out with the fingers. It will commonly happen, indeed, that balls may be extraded with much more eafe both to the patient and furgeon, by judicious openings of this kind, than by the ufe of forceps or any other in- ftrument. The pain and terror which the making of thefe openings are fuppofed to excite, are the princi- pal objedions to which they are liable ; but it ffiould be remembered, that in fuch circumftances, it is not the prefent eafe and conveniency of the patient that fo particularly merit attention, as his future advantage and fafety. Nor will the pain induced by cutting di- redly upon a bullet be fo confiderable, as the tearing it out from a deep wound with forceps. Where the courfe of a ball is of confiderable length, this will always be the eafieft method of taking it out, when the pradice is not forbidden by the contiguity of large blood veffels and nerves : but when the wound is only of fhort extent, inftead of cutting upon the ball, by making a fmall opening into it, it anfwers better to lay the finus open through its whole length ; by which the ball is not only more eafily taken out, but the cure is afterwards more readily accompliffied. Indeed, this pradice ffiould be generally adopted, even when the ball is not lodged. When the two openings made by the entrance and exit of a ball are not veiy diftant from each other, and when with fafety they can be laid into one, it ffiould alw ays be done as foon as poffible after the accident; by which the veffels 320 Of Gunfhot Chap. IIL which have been injured will be more freely unloaded than they poffibly could be in any other manner ; ev- ery kind of extraneous matter that the ball may have carried in, will be brought into view ; and the fides of the finus being allowed to collapfe, the fize of the fore will thus be diminifhed. This being done, the parts affeded ffiould be cov- ered with pledgets of an ointment formed of wax and oil, and an emollient poultice be laid over the whole; a pradice which proves much more fuccefsful, as well as more agreeable, than the application of warm ftim- ulating dreffings; which, till of late, were univerfally ufed in all cafes of gunffiot wounds. The pain and irritability which almoft uniformly attend this kind of injury, point out the propriety of the moft foothing applications. For the moft part thofe that I have mentioned anfwer the purpofe ; but in fome cafes the preparations of lead anfwer better ; particularly Gou- lard's cerate, or the common wax ointment impregna- ted with a fmall proportion of faccharum faturni. An opiate fhould now be administered ; and the part af- feded being placed in the eafieft and moft convenient pofture, the patient ffiould be laid to reft. The formation of matter in every fore attended with contufion, is an objed of the firft importance; for till this takes place, there is often reafon to fufped that gangrene may fupervene. With a view to haften it, the warm poultices ffiould,be frequently renewed ; and they ffiould be continued till the tenfion and fwelling which ufually attend wounds of this kind is removed, and till the fore has acquired a healthy gran- ulating appearance, when it will fall to be treated in the manner I have already advifed for fores proceed- ing from any other caufe. Gunffiot wounds are commonly defcribed as being covered from the firft with deep floughs or efcars; and various remedies are advifed for removing them. Every appearance, however, of this with which they are attended, proceeds entirely from contufion ; and Sed. Xin. Wounds. 321 if the injury be not large and extenfive, the flough covering the wound is not often perceptible ; or it is fo thin and inconfiderable, that it diffolves and comes away with the matter of the firft or fecond dreffing. In fuch cafes therefore, it requires no particular atten- tion. And even when it runs to a greater depth, it commonly feparates, fo as to be eafily removed as foon as a free formation of matter has taken place : for ev- ery flough of this kind is a real mortified fpot; and I have elfewhere endeavoured to fhow that nothing tends to feparate mortified parts fo readily from thofe that are found, as a free fuppuration being induced upon them. In the early ftages of gunffiot wounds, emollient poultices prove more ufeful than perhaps any other remedy : but it is neceffary to remark, that they ffiould not be continued after the effeds that I have mention- ed are produced : for when employed too long, they not only tend to excite too much relaxation, and to render the parts foft and fpongy, but are apt to induce too copious a formation of matter; from which the patient is often in greater danger than from any other circumftances attending his fituation : for although it is a point of the firft importance, in every gunffiot wound, to encourage the formation of pus to a certain extent; yet we find univerfally, that in great quantities it proves very prejudicial, and when once excited, that it is with much difficulty checked. I think it alfo right to obferve, that this fuperabundance of matter is very apt to proceed from a different caufe, namely, from the inflammation being allowed to run too high, by which extenfive effufions and confequent abfceffes take place, among the contiguous mufcles. This cannot in any way be fo effedually prevented as by copious bloodletting immediately after the injury. It is chiefly with the view indeed of preventing this diftrefsful occurrence, that I have advifed the pradlice of early bloodletting in all gunffiot wounds; and with Vol. I. X 322 Of Gunfhot Chap. III. thofe who have had opportunities of perceiving the in- conveniencies that arife from thofe extenfive fuppura- tions that enfue from this being omitted, no other ar- gument will be required to ffiow that in every inftance it ffiould be adopted. In whatever manner a too copious flow of matter has been induced, the pradice to be followed muft be the fame. Every colledion that appears mufl be dif- charged by a depending opening ; the limb ffiould be laid in that pofture which moft readily admits of its running off; the patient fliould be fupported by a nourishing diet; and the bark ffiould be plentifully given. It is in this ftate indeed of gunffiot wounds that bark ads with moft advantage ; when the inflam- matory fymptoms are moftly gone, and when the pa- tient is suffering from too copious a difcharge. In this fituation it often proves highly ferviceable; but in order to ad with advantage, it ffiould be given in large quantities. Elixir of vitriol proves in fuch cafes a powerful addition to bark. When, notwithftanding a liberal ufe of thefe medi- cines, and a proper attention to the other circumftan- ces of the cafe, the difcharge ftill continues copious, we will commonly find that it is kept up by detached pieces of bone, or by pieces of cloth, or other extra- neous bodies, having been carried' in with the bullet. In fuch circumftances, nothing will tend to leffen the quantity of matter till the extraneous body is remov- ed ; for while it remains, it will irritate and inflame the contiguous parts, and effufion and fuppuration will enfue. The fore ought therefore to be again exam- ined ; and any loofe body or detached pieces of bone that are difcovered ffiould be removed. When the irritation is kept up by pieces of cloth, as they are too foft to be difcovered by the probe, they are apt to pafs unnoticed. Hence, where there is caufe to fufped that any article of this kind is lodged in wounds, it muft be taken out in fome other manner : aiid when Sed. XIII. Wounds. 323 the parts are fo fituated that a cord or feton can be paffed along the paffage made by the ball, nothing will prove more fuccefsful. I have met with different inftances of pieces of cloth being brought Out with the daily drawing of a cord, which were not fufpeded to be lodged ; and in confequence of which the fores Were foon cured, after various attempts to heal them had been made in vain. I have already advifed opium as an ufeful medicine in the early ftages of gunffiot wounds: by tending niore effedually than any other remedy to abate irri- tation, it proves often ferviceable in leffening the dif- charge of thefe fores, even when they have been of long duration, and when various other medicines have been employed without advantage. It ffiould there- fore be ufed with freedom whenever the difcharge ap- pears to be kept up by pain or irritation. Although extenfive haemorrhagies do not always fucceed immediately to gunfhot wounds, yet they fome- times take place afterwards. This feems to proceed from the divided arteries being left open, when the mortified floughs, which contufions ufually produce, fall off. About this time, therefore, practitioners ffiould be much on their guard againft fuch an occur- rence, efpecially when the injury is extenfive, or feat* ed near to any of the large blood veffels. The hae- morrhagy is often preceded by great heat in the injur- ed parts, and with a throbbing pulfatory paim At this period it may in feme cafes be prevented by plen- tiful bloodletting, efpecially by the application of leech- es to the contiguous parts; but when once the hae»» morrhagy appears, if the veffels are large, nothing but ligatures will anfwer the purpofe. As the dlC charge is often fo fudden and violent as to induce much hazard before the affiflance of praditioners can be procured, patients in fuch circumftances fhould be Furniffied with a tourniquet, with diredions to the fer- x 2 P4 Of Gunfhot Chap. III. vant in attendance to apply it on the firft appearance of blood. Hitherto I have not mentioned the fcarifying of gunfliot wounds ;- a pradice recommended by almoft every writer upon this fubjed, and till of late very univerfally believed to be right. By fcarify.'tig tha /ores, it was fuppofed that the floughs with which they are fometimes covered would fooner feparate, and the cure be thereby haftened : later experience, however, ffiows that this reafoning is fallacious; and inftead of proving ufeful, that fcarifications here very commonly do harm: they create additional pain and inflamma- tion, at the fame time that they evidently extend the furface of the fore, while no advantage appears to arife from them. They ffiould therefore be laid altogether afide. Even the dilatation of gunffiot wounds, fo much recommended of late, ffiould be employed with caution. When the paffage of a ball is not extenfive, and the parts through which it has gone, can with fafety be laid open, it would be right in every cafe to do it with freedom from one end of the finus to the other: no harm could accrue from it; and I have found from experience, that in thefe circumftances, it tends to forward the cure ; but I have never been able to difcover what advantages are to be derived from the mere dilatation of the external opening of a gun- ffiot wound : the views of thofe who propofe it are to give a more free difcharge to the matter than it would otherwife have, but in deep narrow wounds, formed by piftol or mufket balls, as an increafe being given to the diameter of one £art of the finus will have no ef- fed whatever upon the reft of it; and as it muft evi- dently do harm, by enlarging the wound, while no benefit can probably accrue from it; I do not hefitate to fay that the practice ffiould be laid afide. Where a wound is either fo fituated that it would be danger- ous to lay it open from one end to the other, or of too great extent for this pradice to be adopted, the Sed. XIII. Wounds. 325 paffing a cord, as I have already advifed, along the finus, often anfwers our purpofe. This, however, ffiould never be attempted till the firft or inflamma- tory ftage of the wound is over: for while any degree of pain or tenfion remains, the irritation which the cord excites is very apt to do harm. But it fometimes happens even that a cord cannot be employed, owing to the fituation and diredion of the wound. In fuch cafes, after the pain, tenfion, and other fymptoms of inflammation are removed, and a free fuppuration is induced, the fore muft be treated in the manner that I have advifed when fpeak- ing of pundured wounds: a proper application of preffure along the courfe of the finus will, in fuch circumftances, often effed a cure when it cannot be obtained in any other manner. By fome it may be fuppofed, that fomething might here be faid of the method of managing mortification when excited by gunfhot wounds ; but *it appears to be unneceffary, as this fymptom has already been ful- ly confidered as a confequence of inflammation.* I think it right, however, to remark, that in gunffiot wounds, nothing in general proves fo effedual in pre- venting mortification as plentiful bloodletting. It will not indeed prevent thofe parts from mortifying which have been feverely contufed: but it is not this that in fuch cafes we have moft reafon to dread ; for gan- grene which occurs from contufion, is commonly cir- cumfcribed, and is not apt to fpread. It is that vari- ety of gangrene which fucceeds to the inflammatory ftage of gunffiot wounds, of which we have molt caufe to be afraid. But when bloodletting is freely pradifed, gangrene feldom takes place, and the fame remedy likewife anfwers beft in preventing it from fpreading. As bark proves frequently ufeful in mortification, it is almoft univerfally given in gangrene arifing from * Vide Chap. I, 326 Of Gunfhot Chap. III. gunffiot wounds. I am, however, convinced, that the practice is often founded in error, and that much mif- chief is done by it. When gangrene takes place in debilitated habits of body, bark may be given with fafety; and in fuch circumftances it proves often the moft effedual remedy. But mortification from gun- ffiot wounds happens moft frequently in ftrong pletho- ric patients, where tonics of every kind do harm, and where bloodletting and other evacuations prove com- monly ufeful. In the fubfequent ftages even of this variety of gangrene, if it continues to fpread after all the fymptoms of plethora and inflammation are gone, bark may be employed with propriety ; and in fuch circumftances it ffiould be given with freedom ; but it ffiould never be advifed while the inflammatory ten- fion and pain continue. In offering thefe obfervations upon gunffiot wounds, I have hitherto been fuppofing that the injury is cir- cumfcribed, or at leaft not fo extenfive as to preclude hopes of faving the injured limb ; and it is proper to remark, that with due care and attention, wounds of this kind may be often cured, and limbs faved, where the firft appearances were very alarming. But when a limb is injured in fuch a manner that there is no reafonable hope of faving it, it would be improper to perfift long either in thefe or any other means of cure that have yet been propofed, By doing fo, the patient would fuffer much unneceffary pain and trouble, while his ftrength might be fo much impaired, as to give him no chance of recovering afterwards from the re- moval of the limb. But the attempt to fave limbs which have fuffered much by gunffiot wounds, gives rife to a queftion of importance, that merits particular difcuffion. In the various battles which occurred in the laft German war, the number of wounded men was often furprifingly great; of courfe the amputation of limbs became frequently neceffary. By many it was imag* Sed. XIII. Wounds. 327 ined that the practice was carried much further than it ought to have been; and it was even alleged, that limbs were often wantonly removed, which with much eafe and fafety might have been faved. Amongft others who were of this opinion, Mr. Bilguer, furgeon to the armies of his Pruffian Majefty, wrote a treatife, in which he endeavours to prove, that amputation of limbs is rarely neceffary, as almoft every injury, for which it is ufually advifed, will admit, he thinks, of a cure, by more gentle means. As nothing but real neceffity can ever juftify the re- moval of a limb, the public were much indebted to Mr. Bilguer for his attempt: there is much reafon, however, to believe, that the zeal with which he ap- pears to be animated, has made him carry his restric- tions too far; and that numbers would fuffer much unneceffary pain, trouble, and hazard, were they to be generally adopted. Mr. Bilguer thinks, that fcarcely any cafe of gun- ffiot wound can be fo bad as to require amputation. Even where the fofter parts are much lacerated, and the bones and joints much injured, we ought always, he thinks, to attempt to fave the limb : and he afferts, that by this pradice more lives will be faved than can ever be done by the ufual method of proceeding to immediate amputation. After all the attention, how- ever, that I have been able to give to a fubjed of fuch importance, in the courfe of my own pradice, and after much information obtained from others of ex- perience and obfervation, I am of opinion, that much harm would enfue by admitting this as an univerfal rule. I would advife in every cafe where the flefhy parts of a limb only are merely divided, to make fome trials for faving it ; and they will often fucceed. Where all the mufcular parts of a limb are much lacerated and contufed, it would no doubt be in vain to attempt to cure it; on the contrary, it ffiould be removed at once. But when any confiderable por- 328 Of Gunfhot Chap. III. tion of the flefhy parts of a limb remains unhurt, al- though the others may be injured in the fevereft man- ner, if none of the large joints have fuffered, we ffiould never defpair of being able to fave the limb. The contufed parts may indeed mortify and throw off, and thus an extenfive fore will enfue ; but from daily ex- perience, we know that the largefl fores will heal ; and if in this we ffiould be difappointed, we ftill have it in our power to advife amputation, while both the patient and furgeon have the fatisfadion to think that nothing has been omitted from which any benefit could probably have enfued. And on the fubjed of Amputation, I ffiall afterwards have occafion to ffiew, that the operation proves ufually more fuccefsful when a fore has been of fome duration, than when employ- ed immediately after the accident. But when any of the large joints are much injured by the ends of the bones which compofe them being ffiattered or fplintered, immediate amputation ffiould always be advifed: for the inflammation which fuc- ceeds to thefe wounds comes on quickly; and when inflammation takes place, the operation can never be employed, till it is altogether removed. The height to which inflammation is in fuch cafes apt to proceed, is a powerful argument in favour of early amputation : for when large joints are materially hurt, the parts foon become highly inflamed, notwithftanding of all that can be done to prevent it; fo that no time ffiould be loft in putting the operation in practice. It muft indeed be allowed, that out of a great number of pa- tients, fome few might in fuch circumftances fave their limbs, even where the joints have fuffered in the worft manner: but we cannot allow with Mr. Bih guer, that this is a fufficient reafon for the pradice which he recommends being generally admitted. It is not the fuccefs which may attend a few cafes by which praditioners ffiould be direded, but that which enfues from a general courfe of practice. And this J Sed. XIII. Wounds. 329 think may be confidered as certain, that in the cir- cumftances we are now confidering, more lives would be loft by attempting to fave the injured limbs, than by removing them foon after the wounds have been received ; at the fame time that the practice would be attended with much lefs trouble and pain to the pa- tient : for the fore produced by the amputation of a limb is trifling indeed, when compared with extenfive lacerated wounds of the large joints. In the prefent improved method of operating, a flump often heals in the courfe of two or three weeks ; whereas wounds in the joints, even when they terminate moft favour- ably, often continue obftinate, and produce much perplexity and diftrefs for feveral months. When in gunffiot wounds any'of the large bones are fradured, through any confiderable part of their extent, and when this is accompanied with much laceration of the correfponding foft parts, immediate amputation of the limb will be the belt pradice, and ought to be advifed. But where a gunffiot wound not very extenfive is merely accompanied with a fim- ple fracture of a contiguous bone, or even where the bone is fradured in different parts, if the injury does not extend to the joint, we ought perhaps in every in- ftance to endeavour to fave the limb. By removing the detached pieces of bone, and treating the fore with attention, we have often the fatisfadion to obtain a cure, and to reftore patients to the ufe of their limbs, who otherwife might have remained lame for life, or who might have been deprived of them entirely. It is proper, however, to remark, that although the attempt fhould always be made, where a patient is to remain in a fixed fituation, and where the regular at- tendance of praditioners can be procured ; yet after engagements, whether at fea or land, where thofe that are wounded muft be frequently moved about, and v, here a deficiency of furgeons and nurfes very com- monly prevails, I believe it would be a good general 33© Of Gunfhot Wounds. Chap. III. rule to proceed to immediate amputation, in every cafe of gunffiot wound accompanied with fradures of any of the contiguous large bones. By doing fo, a few limbs might fometimes be removed, which with much care and attention might be preferved; but I am convinced, that more lives would be faved by it than by attempting, in fuch circumftances, to purfue any other method of treatment. We ffiall have occa- fion, however, to enter more fully upon the confider- ation of this fubjed, in fpeaking of Amputation. Chap. IV. Of Burns. 331 CHAPTER IV. OF BURNS. BURNS affume different appearances, according to their degrees of violence, and manner in which they are produced. Thus, burns which merely irritate the furface of the fkin, differ materially from thofe which corrode or deftroy it; while thofe again have a different afped from fuch as affed the mufcles, tendons, ligaments, and other deep feated parts ; and we know that fuch as are produced by boiling water, and other liquids, differ materially from thofe that are produced by the dired contad of hot metallic bodies, or of burning combustible materials. Burns which do not deftroy the cuticle, and which irritate the fkin only, ad nearly in the fame manner with cantharides and other veficantia. The irritation with which they are accompanied, excites an increaf- ed adion in the exhaling veffels of the parts affeded, by which vesications are formed in extent and num- ber proportioned to the violence of the burn ; but when the fkin or fubjacent parts are deftroyed, no ve- ficles take place. In this cafe, a black mortified flough is firft obferved; and when this feparates and is thrown off, an ulcer is left of a depth correfpond- ing to the degree of heat by which it was produced. In every cafe of burn, the pain is fevere ; but for the moft part it is more confiderable where the fkin is merely much fretted or irritated, than where the degree of heat has been fuch as to deftroy the fkin en- tirely. In deep extenfive burns, mortification fometimes takes place fuddenly, but the fymptoms that we have 332 Of Burns. Chap. IV. moft caufe to dread are pain and inflammation. The pain and irritation which burns excite, are in fome in- ftances fo violent, that all our efforts are apt to fail in preventing them from inducing the very higheft de- gree of inflammation ; and when the furface of a burnt part is^arge, the effeds of this inflammation are not confined to the injured fpot: they are apt to excite fever; and in many cafes fuch a degree of torpor is induced, as at laft ends in death. In the treatment of every variety of burn, our firft objed ffiould be to procure eafe. Where the fkin is not deftroyed, but feems to fuffer merely from irrita- tion, an abatement of pain may be procured by the application of remedies of very different and even of very oppofite natures : by dipping the part affeded in very cold water, and keeping it for fome time im- merfed in it, the pain will often be rendered very fup- portable; while on the other hand, immediate eafe is often experienced from plunging the injured part fud- denly into hot water: emollients are often employed, and in fome cafes with immediate relief; but, in gen- eral, aftringent applications anfwer better. One of the beft applications for this variety of burn is ftrong brandy, or any other ardent fpirit: it excites a mo- mentary additional pain; but this foon fubfides, and is fucceeded by an agreeable foothing fenfation. This remedy proves moft effedual when the parts can be kept immerfed in fpirits ; but when this cannot be done, they ffiould be frequently moiftened with pieces of foft linen completely foaked in it. Of late ftrong vinegar, has been much employed for burns ; acetum lythargyrites, folutions of faccharum faturni, and Gou- lard's faturnine water, make ufeful applications for the fame purpofe; and as a proof that it is the aftrin- gency of th^ remedy from which the effeds refult, the fame benefit is derived from a ftrong folution of alum or even from common ink. It is the common opinion, that remedies of this kind prove chiefly ufeful by preventing thofe vtfica- Chap. IV. Of Burns. 333 tions or ferous exfudations with which fuperficial burns are ufually attended : but I do not find that the obfervation is well founded ; for I have always re- marked, that they procure an abatement of the pain fooner where thefe vefications have already appeared, than when they are employed fo early as to prevent them from rifing, which they frequently do when ap- plied immediately on a burn being inflided. Whatever remedy we employ, it ought to be con- tinued as long as the pain remains; and in extenfive burns, where the irritation is great, along with exter- nal applications, opium ffiould be given in dofes ade- quate to the degree of pain. Even the ftupor with which patients with large burns are apt to be attack- ed, is more readily removed by opium than any other remedy. As this fymptom is probably induced by fome degree of effufion upon the brain, and appears to be the effed of that fevere irritation which always accompanies burns, we may readily conceive that opiates ffiould here ad as the moft ufeful remedies ; and, accordingly I have found, in various inftances, that they have done fo. With refped to the management of vefications in burns; by fome we are advifed to open them imme- diately, while others affert that they fhould never be meddled with. In judging from my own obfervation, I would fay, that they ffiould never be opened till the pain is gone : for during this period, the pain be- comes always more fevere on the air getting accefs to the cavities of the vefications ; but when the irrita- tion produced by the burn fubfides, they may be opened with fafety ; and at this period it ought al- ways to be done; for w hen the ferum is allowed to rell long upon the fkin beneath, it is apt to render it tender, and even to induce fome degree of ulceration, which in this manner we prevent. Even at this time the VL-ficles ffiould be opened with fmall pundures, inftead of large incifions, fo that as little air may be admitted as poffible. And after the ferum i* difcharg- 334 Of Burns* Chap. IV, ed, the beft application that can be made is a thin liniment of wax and oil, or Goulard's form of a fat- urnine ointment, Oil by itfelf is too thin, as it runs quickly off; and ointments of the ufual confiftence give more pain than liniments, as their fliffnefs pre- vents them from being applied or removed fo eafily, In this manner all fuch burns as we are now con- fidering may in general be cured, excepting where they are fo extenfive as to excite much inflammation and fever. In fuch circumftances, bloodletting, and other remedies* adapted to the particular fymptoms, muft be advifed ; and when the injured part is found to ulcerate, which often happens in fevere burns, thofe remedies muft be employed which the nature of the fore may render neceffary, and for which I muft refer to the different fedions of Chap. V. where every va- riety of ulcer will fall to be confidered. When, again, burns are from the firft attended with lofs of fubftance, as ufually happens when they are produced by hot metallic bodies, cooling emolli- ent applications prove moft effedual: the part being kept conftantly moift with a liniment compofed of equal parts of lime water and linfeed oil often gives immediate eafe; and the eafieft way of applying it is, to daub the parts frequently over with a foft pencil well foaked in it. The application and removal even of the fofteft coverings excites much pain; and I have always found in this kind of bum, that no harm en- fues, during the firft two or three days, from the in- jured parts being expofed to the air. It often, indeed, gives relief when no advantage is derived from any application. But as foon as the pain and irritation arifing from the burn are removed, the parts ffiould be covered and treated in the fame manner as ulcers arifing from any other caufe. The liniment that I have mentioned of lime water and linfeed oil, is per- haps the beft that has yet been employed in this kind of burn. In fome cafes, however, I have found that more immediate eafe has been procured from the apt Chap. IV. Of Burns. 335 plication of a faturnine ointment; and bathing the parts in a weak folution of faccharum faturni in fome inftances gives relief. In burns arifing from the explofion of gunpowder, fome of the grains of the powder are apt to be forced into the fkin. At firft they produce much irritation ; and if not foon removed, they commonly leave marks, which afterwards continue fixed and permanent. They ffiould therefore be picked out with the point of a needle, or any other fmall inftrument, as foon as poffible after the accident; and with a view to prevent inflammation, as well as to diffolve and carry off any particles of the powder which might remain, the parts affeded ffiould be kept covered for two or three days with emollient poultices. In other refpeds, injuries of this kind are to be treated in a fimilar manner with burns produced in any other way. When parts which lie contiguous are burnt, they are apt to adhere to each other, if means be not fall- en upon to prevent them. This is more particularly the cafe with the fingers and toes, and with the nof- trils and palpebrae. The fureft method of preventing it, is to keep pledgets covered with any proper dreffing inferted between them during the courfe of the cure. In the treatment of ulcers arifing from burns, the parts are apt to become foft and fungous, and to rife above their natural level. On this being perceived, any emollient applications that have been previoufly ufed ffiould be laid afide ; fuch as are moderately af- tringent ffiould be employed inftead of them ; and gentle compreffion with a roller proves particularly ufeful. Bathing the parts with a common faturnine wafli, or with lime water, or a folution of alum, fre- quently fucceeds ; and one of the beft ointments in this fituation is calamine cerate : by perfi fling in thefe means, any fungous excrefcences that arife, will, for the moft part, be foon removed ; but when this does not happen, they muft be taken down by the ufe of burnt alum in fine powder, blue vitriol, or lunar cauftic. 33$ Obfervations on Chap. V* CHAPTER V. On the Theory and Treatment of Ulcers. SECTION I. General Obfervations on Ulcers* VARIOUS definitions have been given of the term ulcer ; but what I understand by it is, a folution of continuity in any of the fofter parts of the body, difcharging either pus, fanies, or any other matter. Ulcers have been diftinguifhed by different appella- lations, according to the particular circumftances with which they are attended; and if thefe had been taken from charaderiftics fufficiently diftind, and of any re- al importance in the cure, they would certainly have been material, and ought to be retained. But as it is evident, that many of them are taken from circum- ftances either not fufficiently obvious, or from fuch as are merely accidental, and that do not afford any real diftindion ; to adhere to thefe would be improper, in fo far as it would continue to lead^to complex and difficult practice, when more fimple treatment would anfwer better. With the view of avoiding this difficulty, the fol- lowing arrangement of ulcers is propofed ; and it will be found to comprehend every vaiiety of fore that praditioners meet with. Ulcers may be divided into two general claffes. In the firft, I mean to comprehend all thofe that are merely local, and that do not depend upon any consti- tutional difeafe ; and, in the fecond, all thofe that pro- ceed from any general affedion of the fyftem. Sed. I. Ulcers in general. 337 The varieties of local ulcers are, i. The fimple purulent ulcer. 2. The fimple vitiated ulcer, 3. The fungous ulcer. 4. The finous ulcer. 5. The callous ulcer. 6. The carious ulcer. 7. The cancerous ulcer; and, 8. The cutaneous ulcer. And in the fecond clafs of ulcers are included the venereal, the fcorbutic, and fcrofulous ulcers. In the following fedions, I ffiall endeavour to point out the different appearances of thefe varieties of ul- cers, together with the method of cure beft adapted to each of them; but before proceeding to do fo, I ffiall offer a few general obfervations upon ulcers, and chief- ly on the caufes, prognofis, and method of cure. The caufes which, in different circumftances, may give rife to ulcers, are exceedingly various; but in general they will be found to proceed from one or other of thofe that follow. 1. From fuch as may be termed occafional or ex- citing caufes ; filch as, inflammation, from whatever caufe it may arife, when it terminates either in gan- grene or the formation of matter ; wounds ; bruifes ending in fuppuration ; and burns. 2. From fuch as may be confidered as predifpofing caufes; of which kind, are all difeafes of the fyftem attended with determinations to, or affedions of, par- ticular parts: fuch as fevers of every kind that termi- nate in what are called critical abfceffes; alfo lues ve- nerea ; fcrofula ; and fcurvy. 3. They may proceed from a combination of the two foregoing caufes. Thus, a flight fcratch, or ex- coriation, which in a found perfon would heal eafily, in a habit tainted with difeafe will frequently produce a very difagreeable and tedious ulcer. Vol. I. Y 338 Observations on Chap. V. The caufes of ulcers being various, the prognofis to be given muft alfo be fo. 1. It muft depend upon the nature of the different exciting caufes. 2. Upon the fituation of the fores ; and, 3. On the time of fife and habit of body of the patient. With refped to the firft of thefe, it is evident, that the occafional caufe muft have confiderable effed on the nature and duration of ulcers. Thus, an ulcer produced by a fimple wound, inflided with a clean cutting inftrument, will, ceteris paribus, heal more ea- fily, than a fore that enfues from a fevere bruife, or from a wound produced by a foul or ragged inftru- ment. In Chap. HI. we had occafion to fee, that pundur- ed wounds are of more difficult cure than fuch as are freely laid open ; and ulcers produced by pundured wounds, are in like manner of difficult treatment ; but the caufes of this having been pointed out when fpeaking of pundured wounds, it is not neceffary at prefent to confider the fubjed further. The cure of ulcers may be influenced by their fitu- ation, in two different ways. 1. With refped to the nature and organization of the parts on which they are feated ; and, 2. From their being fituated on the trunk of the body, or on the upper or lower extremities. Thus, it was long ago remarked, and the remark has fince been confirmed by obfervation, that ulcers in flefhy parts heal more eafily, than when tendons, aponeurofes of mufcles, glands, periofteum, or bones, are injured. The pain occafioned by fores in foft mufcular parts is not fo confiderable, the difcharge is generally better conditioned, and the cure commonly advances more quickly ; and, whether ulcers are feated in the cellu- lar membrane, in the tendons, periofteum^ or bones. Sed. I. Ulcers in general. 339 the cure commonly proceeds more eafily in the trunk of the body than in the extremities. The depending fituation of the latter feems to be the chief caufe of this ; for the fluids having, in the extremities, to proceed in a diredion contrary to their own gravity ; wlienever the folids lofe their tone, or fuffer in their arrangement, fwellings of the cedematous kind very naturally occur. And, when ferous fwell- ings arife in the neighbourhood of ulcers, they tend not only to increafe.the quantity, but to vitiate the quality of the difcharge ; and thus the cure is protrad- ed, till the parts, by reft and proper management, have again recovered their natural tone. Hence, a material part of the cure in ulcers of the legs is obtained from the limbs being kept in a hori- zontal pofture : and on the fame principle we account for the effeds of the laced flocking in the cure of ul- cers, where it feems to ad entirely by preventing this kind of fwelling: of this, however, we ffiall fpeak more particularly hereafter. The fituation of ulcers with refped to the contigui- ty of large blood veffels and nerves, from the danger of thefe at laft becoming affeded, ffiould, likewife, in- fluence our prognofis; and, ulcers feated upon, or very contiguous to, any of the large joints, or upon either of the cavities of the cheft or abdomen, will always be confidered as more hazardous than ulcers in other parts of the body. I had alfo occafion to obferve, that the prognofis in ulcers ffiould be much influenced by the age and ha- bit of the patient. Thus, in young healthy people, the fecretions are commonly better conditioned, than in the old and unhealthy, in whom the fecreting organs feldom per- form rightly their different functions ; and as the va- rieties of matter difcharged from ulcers are to be con- fidered almoft entirely as fecretions from the general mafs of blood, their being of a good or a bad quali- y 2 340 Observations on Chap. V. ty, muft depend greatly on a healthy ftate of the fol- ids, fo that we need not wonder at their being fo much influenced by the general health of the patient. The cure of ulcers depending, therefore, upon fuch a number of circumftances, a juft prognofis, it is evi- dent, can only be obtained from a due attention to all of them. The firft circumftance to be afcertained in the man- agement of ulcers, is the propriety of attempting to cure them or not: that it is proper to endeavour to heal every recent fore, is univerfally allowed ; but when ulcers have been of long duration, or when they appear to have had any effed in carrying off, or m preventing, any difeafe to which the fyftem has been liable, it has always been confidered as danger- ous to remove them; and, accordingly, almoft every author who has written upon the fubjed, has expreff- ly determined againft it, as being an uncertain and dangerous pradice. Ulcers that afford a copious difcharge, and have been-of long duration, it would no doubt be impru- dent fuddenly to heal up, as the fyftem might proba- bly fuffer from the retention of a large quantity of fluids, which it had been accuftomed to throw off by means of thefe drains. Many cafes, indeed, have ended fatally, from ulcers in this fituation drying up fuddenly, either of their own accord, or by the im- prudent ufe of aftringents. On the other hand, however, the diftrefs arifing from anr extenfive fore, difagreeably fituated, and which may not perhaps terminate but with the life of the patient, is an inconvenience to which few are will- ing to fubmit, and makes it an objed of importance, the difcovery of fuch a plan of treatment as may ren- der it fafe for patients in this fituation to have them removed. With due caution, the cure of every ulcer may, I «thiok, be attempted ; the only requifite precaution, in Sed. I. Ulcers in general. 341 habitual fores, being the introdudion of an adequate drain in the form of what we ufually term an iffue. An iffue being introduced, and brought to dif* charge nearly equal to what the ulcer was accuftom- ed to afford, the latter may be cured with fafety; and if it has not been of long duration, the fize of the if- fue may be gradually leffened, and at laft perhaps re- moved entirely. But where an ulcer has been of long continuance, or feems to have been instrumental in preventing any other difeafe, the iffue ffiould, without hefitation, be continued of the fame fize for life : but even this may be done with little inconvenience when compar- ed with the trouble attending a large ulcer. This pradice might, from reafoning alone, be con- fidered as fafe. For, if a drain equally copious is firft introduced, and afterwards kept open, the heal- ing of the ulcer for which it was inferted, however old it may have been, could never probably do harm; but from experience I can fay, that nothing proves more effedual in the cure of old ulcers, than iffues ; and I have not known an inftance of any patient be- ing injured by the oldeft fores being cured, where the precaution was taken of having an iffue previoufly inferted. The objedions made to this practice, are, 1. That an artificial iffue gives nearly the fame trouble as a natural ulcer. And, 2. That nature having been long accuftomed to the difcharge of a particular kind of morbid matter afforded by the ulcer, we ought not, by innovations, to run any rifk of diverting her ftated and ufual ope- rations. The firft of thefe arguments is eafily anfwered; for it cannot be admitted, that a fimple iffue, for which we can choofe the moft convenient fituation, will ever prove fo troublefome as ulcers ufually do. Of this, indeed, we daily meet with proofs; few complaints 342 Observations on Chap. V, proving more perplexing to patients than ulcers in general do, while we feldom hear of any real diftrefs from iffues. The other objedion alleged againft the healing of old ulcers, is the fuppofed danger to the conftitution, from the retention of a particular kind of morbid matter, which by their means many have imagined it may have been accuftomed to throw off. By thofe who fupport this objection it is alfo faid, that although the matter of an iffue may be equal in quantity to that of an ulcer, ftill the difference to the constitution may be material, from the matter which they afford being different ; for while the difcharge of iffues is commonly a mild bland pus, the matter of many ulcers is thin, ffiarp and acrid. At firft view, this argument appears to be of im- portance, and it has probably, with many, been the chief caufe of the practice in queftion being rejeded. On due confideration, however, it will not appear to be of much weight; for it can be eafily ffiown, that it is more by the quantity than the quality of the mat- ter difcharged by ulcers and iffues, that they prove ufeful or otherwife to the conftitution. Thus, it is obferved, that the ftoppage of even a pea iffue, that has difcharged nothing but the mildeft and moft fimple pus, proves equally dangerous, as the ftoppage of an ulcer difcharging nothing but matter of the moft acrid kind ; which would not be the eafe, if the common opinion upon this point was well founded. And, that the quantity difcharged by ulcers ffiould have an important effed on the fyftem, will not ap-. pear furprifmg, when we relied on the large propor- tion of fluids requifite for the fupply of an iffue, of even a moderate fize, with pus. For, befides the quantity that appears and is difcharged at the differ- ent dreffings, a large exhalation and abforption like- wife, of the more thin ferous parts, is conftantly and Sed. I. Ulcers in general. 343 at all times going on ; which circumftance alone ac- counts for the debilitating effeds frequently produced by iffues, which in point of fize are very inconfider- able.* Were we, indeed, certain, that fuch acrid and pu- trefcent matters, as are frequently difcharged by ul- cers, previoufly exifted in the blood, and that fuch fores ferved merely as drains for thefe ; this would, no doubt, prove a very weighty argument: but as it ; ■ is probable, nay, I may fay, certain, that it is by the4^J ulcer only that fuch kinds of matter are formed, ano/ J? that none of them previoufly exifted in the blood, we.f- ;j are induced therefore to confider this argument as o£ 7 little importance, *' Very little confideration, indeed, will make it aj^- pear, that no fuch varieties of matter as are frequjpit- ly obferved to flow from ulcers, ever exifted Mrthe blood. No analyfis of the blood has ever be^able to difcover them : nor can it be conceived, how fluids fo acrid, and fo different from the blood of a healthy perfon, can circulate in the delicate and irritable vef- fels of the human frame, without producing immedi- ate danger. Now, it is well known, that the dif- charge from fome ulcers, efpecially from thofe gen- erally termed phagedenic, is often fo acrid, as not only to excoriate the furrounding parts, but even fometimes to render it dangerous for a furgeon to ap- ply the neceffary dreffings. The difcharge which in feme inftances of ophthal- mia takes place from the eyes, has been known to be fo acrid, as to corrode the neighbouring parts ; and the ferous evacuation of blifters, although commonly inoftenfive, is fometimes poffeffed of fo much acrimo, ny, as to produce deep ulcerations in the parts to which they have been applied. * Upon this fuhjecl Sir John Pringle remarks: " As near as I could " guefs, an ounce of ferum, upon ftandiDg fome days, did not furnifli more M of this matter, viz. pus, than what might be produced by the daily run- " ning of a pea iffue, or of a feton." Vide Exper. *iv. appendix to Dif-< cafes of the Army. 344 Observations on Chap. V. In fome cafes of fcurvy, indeed, a confiderable de- gree of putrefcency, even of the blood itfelf, no doubt, frequently takes place : but it is not in the ulcers which occur in fcurvy, that fuch corrofive humours, as we are now defcribing, are ever obferved; the pha- gedenic ulcer of authors being materially different from the true putrid ulcer, as defcribed by Lind and other writers on fcurvy. Befides, though it were proved that thefe varieties of matter adually exifted in the blood, even in a completely formed ftate, how is it poffible, that by means of ulcers, or any other drains, the morbid flu- ids chiefly ffiould be evacuated, and thofe only left behind that are mild and innoxious ? a circumftance which, however improbable it may appear, muft be afferted by thofe who fupport the opinion in queftion. The obvious infufficiency of this theory ffiould in- duce us to rejed it, though we could not propofe a more fatisfadory opinion in its place. But, as the various appearances and alterations which take place in the difcharge of ulcers, feem evidently in a great meafure to depend on fome peculiarity of the folids, we are therefore more eafily induced to conclude, that other fuppofitions do not merit much attention. The general feat of ulcers is in the cellular mem- brane. Now, it is well known, that naturally there is fecreted into the cells of this membrane, as there id into every cavity of the body, a thin tranfparent fe- rum, the principal intention of which is to keep thefe parts moift, and to facilitate the adion of fuch muf- cles as are conneded with them. It is this chiefly, with a greater proportion of the coagulated part of the blood, which, with a due degree of heat, as I have elfewhere ffiown, forms that matter which we call pus ;* and which we fuppofe, and indeed find, to be, the natural difcharge of ulcers in a found healthy ftate of the body J and it is fome change induced up- • Vide Chap. I. SecL l, 2, and j. Sed. I. Ulcers in general. 345 on the nature of this fluid, which occafions the vari- eties in the difcharge from ulcers, and from the fame ulcer at different periods. Thefe changes, though they may frequently be, in fome degree, influenced by different circumftances, as will hereafter be obferv- ed, muft yet, in a great meafure, depend upon fome particular affedion of the veffels that feparate fuch fluids from the blood : for by means of an external topical application, we can often change the appear- ance entirely of the matter of an ulcer in the courfe of a few hours ; which in this manner could not be done, were the change produced upon it to depend on an alteration to be eifeded on the general mafs of blood. Very confiderable differences we may fuppofe will take place in the difcharge of ulcers from the differ- ence of the caufes by which they are produced: thus, a burn is very likely to produce a different effed from a cut; a bruife, from a pundure; and fome differ- ence may likewife occur from the ftate of health in which the patient may be at the time. In what manner thefe different caufes operate in producing fuch various effeds upon the folids or fe- creting veffels of ulcers, is not, perhaps, to be eafily explained, nor can we determine precifely what the particular changes they induce upon fuch parts really are. But, as almoft all the caufes of ulcers, with which we are acquainted, tend to excite irritation, it is probable that they all ad by producing fome inflam- matory affedion on the extremities of fuch veffels as empty into the fores ; and therefore that the nature of the difcharge which an ulcer yields, will depend much upon the degree of inflammation that in this manner is excited. I have already endeavoured to ffiow, that one cer- tain effed of inflammation is to propel a greater quan- tity of the red globules of the blood into the fmaller lets of veffels, than naturally they are intended to 346 Observations on Chap. V. tranfmit.* This, when it takes place in veffels open- ing into ulcers, and efpecially when the inflammation is fevere, will render the matter very different, both in colour, fmell, and acrimony, from genuine pus, which I have already endeavoured to prove is pro- duced from pure ferum only. Upon this principle, many of the varieties of mat- ter met with in fores, may be explained: but other circumftances likewife occur which may have fome influence in their produdion. The degree of heat, in which the part is kept, and the remora of the flu- ids for a longer or ffiorter period in the cavities of fores, muft have no fmall influence on the confiftence of the difcharge. From one or other of thefe circumftances, or from different modifications of all of them, the various ap- pearances of matter which wounds and ulcers afford, are clearly explained, without having recourfe to that inexplicable dodrine of their pre-exifting in the fyf- tem. But although it were otherwife, and that we could not fo eafily account for the differences which daily take place, in the difcharge of fores ; yet that they depend in a great meafure on fome peculiar ac- tion or conformation of the veffels in the part affed- ed, feems to be ftill more probable than any other opinion that has yet been advanced ; and is juft as certain as various circumftances under our daily ob- fervation, for which we cannot account, but of whofe reality no kind of doubt can be entertained. Thus, in what manner the nerves, which in their ftrudure are all fo fimilar, ad in the produdion of hearing, vifion, tafte, and all the different fenfes, is, perhaps, impoffible ever to determine ; as is alfo the adion of the liver, fecretory organs of the mouth, ear, &c. in producing fluids of fuch different natures from the fame mafs of blood, and which did not feem to cxift in it before : onlv that the fads are fo, nobodv * Vi neceffary in the cure of ulcers : as in this refped it ads merely by the degree of compreffion which it gives, it muft evidently prove equally benefi- cial in whatever part of the body fores may be feated ; and accordingly, I have found, that ulcers in the arm, and wherever a conftant moderate preffure can be ap- plied, have received more benefit from this than from almoft any other remedy. Preffure for this purpofe is moft conveniently made, both in the legs and elfewhere, by a broad roller ap- plied fpirally, from the under extremity of the limb to a little above the difeafed part. In ulcers of the legs, the roller ffiould commence at the toes, and be carried to the knee joint, or at leaft to two inches above the difeafed parts: and, even in ulcers of the thighs, the bandage ffiould commence at the toes, oth- erwife it is apt to produce cedematous fwellings of the parts beneath : with a roller, compreffion can be made 3581 Observations on the Chap. V. more diredly on a particular fpot, than with the laced flocking; it is more conveniently applied, and it gen- erally gives lefs uneafinefs to the patient. It is like- wife more eafily obtained : for the difficulty of fitting a laced flocking, with that exadnefs which it requires, is fo great, that we can feldom get it done ; whereas a roller may at all times be eafily procured. Rollers, for this purpofe, ffiould be about two inch- es and a half broad ; and on experience we find, that they anfwer better of cotton, or thin flannel, than of linen or filk. They not only keep the parts warmer, which, in every ulcer, proves ufeful; but the foftnefs and elafticity of the flannel and cotton prevents them from fretting and galling the parts to which they are applied ; an inconvenience we daily meet with in ufing bandages of linen. In the application of this bandage, it will be under- stood, that it ffiould be done in fuch a manner as par- ticularly to fupport the fkin, and thus to draw the edges of the fore as nearly as poffible together. For as no regeneration of new ikin ever takes place, it comes to be an objed of the firft importance, both in the treatment of wounds and ulcers, to prevent as much as poffible the retradion of the divided fkin, for all fuch parts as it cannot be made to cover, have af. terwards for their protedion a thin fearf fkin only, which, both in point of ftrength and appearance, is much inferior to the cutis vera, From due attention to this, much affiflance may be obtained in the cure of wounds and ulcers ; for, in moft situations, every wound not attended with much lofs of fubftance, may be made to heal by the reunion of the divided parts.; a pradice which in every wound that can occur we are to confider as the moft eligible method of cure : when it can be done immediately on a wound being inflided, it ffiould always be advifed ; but when it has either at firft been negleded, or con- fidered as impradicable, it may frequently be accom- pliffied afterwards hi a. later period of the difeafe. Sed. II. fimple purulcpt Ulcer. 359 lor, in large wounds, when a free fuppuration has come on, and the inflammation which originally took place has partly fubfided, the fides of the wounds, or ulcers as they then are, may by proper compreffion be either entirely united, or brought fo far to approach ' each other, as greatly to diminifh the vacancy; a cir- cumftance which tends much to fhorten the cure, and to render it in every refped more eafy. In the application of preffure for this purpofe, it will be understood, that it is not to be employed while much inflammation remains ; but as foon as this fymp.- tom is nearly removed, it may always with fafety be put in pradice. The application of moderate preffure proves fo gen- erally ufeful, that after the inflammatory ftage of ul- cers is over, it ought in, perhaps, every inftance to be employed : cures may no doubt be accompliffied by other means; but I will venture to fay, that in the moft troublefome of all fores, namely, habitual ulcers of the legs, more lafling cures will in general be ob- tained by a proper application of preffure, than by any other means with which we are acquainted. § 5. Of the Advantages to be obtained from Art, in the Produdion of Granulations in Sores. The chief advantage which in the produdion of granulations accrues from art in the cure of fores, is the removal of fuch caufes as tend to retard the nat- ural exertions of the fyftem ; and although the differ- ent obftrudions which nature meets with in her pro- grefs are exceedingly various, yet they may all be re- duced to two general heads, namely, to fuch as may be confidered entirely as internal, and thofe again which operate merely as external or local caufes. Under the firft of thefe heads are included all dif- eafes of the conftitution, for we find by experience, that a healthy ftate of the fyftem only, is capable of producing found granulations* 360 Observations on the Chap. V, Hence the cure of ulcers in lues venera, fcrofula, and fcurvy, can never be permanently effeded if the general difeafe of the conftitution be not firft corred- ed or removed. We alfo find, that the growth of new parts is im. peded by the fyftem being either too much emaciated, or in fuch a height of tone and vigour, as to be par- ticularly liable to difeafes of the inflammatory kind; and I may here obferve, that to obviate the effeds of either of thefe ftates of the conftitution, is no incon- fiderable part of the method of cure in ulcers of eve- ry defcription. The local obftrudions, again, which occur to the formation of new parts in ulcers, are of various kinds; but they may all be reduced to two general heads ; namely, to fuch as ad folely in a mechanical manner by exciting irritation ; and thofe that are evidently of a corrofive nature. From daily obfervation, we find, that granulations in fores, are, ceteris paribus, moft quickly formed when the part is kept free from pain ; and the caufe is obvious : for irritation, in whatever way it is pro-. duced, muft excite, in the extremities of the divided veffels, a preternatural degree of fpafm or ftridure ; a ftate entirely oppofite to what we have ffiown to be the moft favourable for the produdion of new parts ; for as this very probably depends, as we have already had occafion to fee, on an elongation of the divided veffels, the more completely that thefe are relaxed, the more readily will fuch an extenfion advance. And we accordingly find, that whatever tends to keep up much inflammation in fores, has a certain effed in putting a total flop to the produdion of new parts. Hence the neceffity of removing from wounds and U^ers, every extraneous body, or whatever tends to produce irritation ; and from this alfo we account for the great advantage of dreffing feldom, and of ufing mild rpplications, inftead of continuing the ancient Sed. H. fimple purulent Ulcer. $61 pradice of dreffing frequently, and often with very complex irritating applications. The other fet of local caufes that tend to obftrud the formation of new parts, are chiefly all thofe vitia- ted discharges, which, by negled or improper man- agement, are fo apt to occur in every ulcer ; for, al- moft every variety of matter, that differs much in col- our or confiftence, from good pus, is found to be more or lefs acrid : infomuch, that in fome inftances it not only prevents granulations from rifing, but cor- rodes and deftroys the contiguous parts. In all fuch ulcers, our chief objed is to corred this acrid matter, which we moft readily do by whatever is capable of converting it into what is termed lauda- ble pus; the means beft adapted for which will in the enfuing fedions be particularly defcribed. Thefe obstacles to the growth of new parts being removed, nature will always, as far as poffible, carry on their formation ; and when, in due time, the va- cancies produced by fores are fupplied, the only part of the cure that remains to be completed, is the for- mation of a cicatrix. This, too, is commonly an ef- fort of nature ; but it may frequently be promoted by art. Whilft any deficiencies in fores remain to be filled up, and whilft the parts are for this purpofe ftill ffioot- ing and extending, the mildeft applications, as I have obferved already, are the moft proper; but, when the lofs of fubftance has either been repaired entirely, or to fuch a degree as the ftrength and other circum- ftances of the patient will permit, thofe applications, which, in the extending ftate of the veffels would have been prejudicial, now become proper and necef- fary. Thus, mild flyptic powders and waflies, by con- trading or corrugating the extremities of fuch veffels as have been divided, and producing an exficcation of that inorganic cellular fubftance in w hich thefe veffels are enveloped, tend to induce over the furface of fores 36*2 Observations on the Chap. V. that thin covering we term cicatrix ; which, although at firft always tender and delicate, yet in courfe of time it commonly acquires greater ftrength, by re- ceiving a farther addition of thicknefs from the fame cellular fubftance by which it was at firft in a great meafure produced. Having premifed thefe general obfervations upon the manner in which the cure of fores feems to be accomplifhed, and which apply in a great meafure to every vaiiety of ulcer, we now proceed to the more particular treatment of the fimple purulent ulcer. § 6. Remarks on the Indications of Cure, and on the Remedies employed for the Cure of the fimple puru- lent Ulcer. In the cure of this variety of ulcer, as little inflam- mation, and no preternatural fwelling are fuppofed to take place, but merely a. vacuity, either from a real lofs of fubftance, or fro^ a retradion of parts limply divided, the difcharg- at the fame time being mild and purulent, the only indications that occur, are, 1 ft, To diminifh, as much as poffible, any vacancy that the ulcer may have occafioned ; and, 2d, To promote the formation of a cicatrix. For the more effedual accomplishment of the firft of thefe, the concurrence of two circumftances is re- quired ; namely, the formation, to a certain extent, of new granulations ; and the diminution or decay of fuch parts as lie immediately contiguous to the ulcer. I have formerly fhown, that either a confiderable degree of inflammation, or the prefence of acrid mat- ter, are alike detrimental to the produdion of new parts ; fo that this part of the cure ffiould confifl chiefly or entirely, in fuch a mode of treatment as tends moft efTeduaiiy to the prevention of both. In the firft place, we ffiould avoid the ufe of the feveral warm gums, balfams, and fpirituous tuidurcs, Sed. II. fimple purulent Ulcer. 3^3 recommended by all the old writers, and ftill too generally continued by many of the moderns. For although, in fome varieties of ulcer, remedies of this clafs may be ufed with fafety, and in certain circumftances with advantage, yet, in the fimple pu- rulent ulcer, they very commonly do harm, and ought to be laid afide ; as ought alfo every application that can irritate or excite pain : for whatever has this ef- fed, muft increafe the inflammation ; and, confe- quently, for the reafons that I have formerly given, muft neceffarily retard the cure. Even the common bafilicon and linimentum Arcasi of the fhops, are, for the fame reafons, improper ; for every ointment with any large proportion of refin or turpentine, always excites irritation. The only advantages that we are here to exped from ointments, is their allowing the dreffings to be renewed with- lefs pain than they otherwife could be : and hence a compofition of the blandeft materials, is, for fuch purpofes, preferable to every other, fuch as the unguentum fimplex of our Difpenfatories ; or ointment prepared with white wax, fpermaceti, and fiuffi olivo i;l\, without any other addition. In lores of this defcription, ointments impregnated with the preparations of lead, fometimes prove ufeful; and as Goulard's cerate is a very neat preparation of this kind, I think it right to infert the prefcription which he gives for it. Take four ounces of refined wax, and one pound of oil ; and keep them over a flow fire till the wax is melted, taking care to ftir them gently. Having previoufly mixed four ounces of what he terms ex- tradum faturni, with fix pounds of water, add it by little and little to the wax and oil, now cooled in a veffel of a proper fize.* Let them be well incorpo- rated together with a wooden fpatula, always taking * For the preparation of the extra&um faturni, fee Chapter I. Sec- tion II. 364 Observations on the Chap. V. care to let the quantity of water firft put in, be tho- roughly abforbed before more is added : this cerate may be made ftronger or weaker, by adding more or lefs of the extrad. This, as well as every ointment, ffiould be prepared in fmall quantities, as it is of much importance in the treatment of fores to employ fuch dreffings only as are perfedly freffi and free from rancidity. Pledgets of lint, fpread thin with either of thefe ointments, feldom excite pain, nor do they ever pro- duce any kind of inconvenience; for, although oily applications to fores have been condemned by feme, from an apprehenfion of their turning rancid ; yet I can fay, from experience, that under proper manage- ment they never become fo. Nor is it eafy to fup- pofe, that any fuch preparation, as thofe I have men- tioned, when compofed of freffi materials, can ever become putrid between the dreffings of fores, which very rarely ought to be more diftant than twenty-four hours from each other. The frequent dreffings of fores is now very gener- ally, and very properly, condemned ; but as pradi- tioners are apt to run into oppofite extremes, we find by fome that once in fix or eight days is judged fuffi- cient. It rarely, if ever, happens, however, that this can be proper. It affords no advantage to the fore : and I can affert, from frequent evidence of both meth- ods, that the cure proceeds more eafily when the dreff- ings are changed daily, than when not renewed fo fre- quently : it tends alfo to render the patient much more comfortable, and to preferve the air of his apart- ment in a more pure ftate than it otherwife poffibly can be. I am therefore clearly of opinion, that al- though the dreffings of fores ought not to be frequent- ly renewed, that the contrary extreme would prove ftill more hurtful ; efpecially in hofpitals, where the air is feldom i'o pure as it ought to be. The circum- ftance by which we fhould be chiefly direded in the dreffing of fores, is the quantity of mutter which they Sed. II. fimple purulent Ulcer. 365 afford : no application fhould be removed till it can be done with eafe ; but whenever there is much mat- ter in the cavity of an ulcer, the dreffings fhould be renewed daily. The chief objedion that has been fuggefted to the frequent drefling of fores, is the effed which much expofure to air is known to produce upon them ; but when new drelimgs are prepared, and immediately ap- plied on the others being removed, no inconvenience of this kind can occur. This I may, however, re- mark, is a point of fuch importance as to merit very ferious attention ; for the too free admiflion of air to fores, always interrupts the cure, not only by ading as a powerful caufe of irritation, but by tending to vitiate the nature of the difcharge. Another objedion has been made to the ufe of unc- tuous applications in fores, namely, that they are apt to render the parts foft and flabby, and that they thus tend to prevent the new granulations from being fo firm as they ought to be. This I know, indeed, is the effed of a long contin- ued ufe of warm emollients, efpecially of fomentations and poultices : but ointments, fuch as thofe that I have mentioned, very thinly fpread, never ad in this man- ner, and they always prove more agreeable than dry lint; which, unlefs the fores to which it is applied are plentifully covered with matter, is apt to excite much irritation, and in fome degree tends to produce the fame effed as gentle efcharotics ; a circumftance that feems to have been well known to the writers of the laft century, who frequently recommend dry lint for fuppreffing the undue growth of parts, when in the cure of fores it takes place in too great a degree. I have long objeded to the indifcriminate ufe of dry charpee or lint in fores. This will appear from the preceding paragraph, which was publifhed many years ago, and I have not had reafon to alter my opinion. The effed of cuftom, however, is fo powerful, that it may be long before the ufe of dry lint is fo univerfal- 366 Observations on the Chap. V. Iy laid afide as it ought to be : but, after much expe- rience, I am clearly of opinion, that a general ufe of it as a dreffing, tends greatly to retard the cure of ul- cers ; and whoever will have the refolution to deviate from eftablifhed pradice, and will employ any mild ointment inftead of it, will receive much fatisfadion from doing fo. When fpeaking of mild dreffings, I wiffi to have it understood, that it is in the fimple pu- rulent ftate of ulcers only, in which they chiefly prove ufeful. After all that has yet appeared to the contra- ry, not only in the writings of ancient authors, but even in thofe of fome modern praditioners, I am per- fedly convinced, that, in this ftate of an ulcer, a cure will be more eafily and more quickly obtained by mild dreffings, than by any other : but in the floughy foul ftate of fome fores, dreffings of this kind, it muft be owned, have little or no effed ; and in fuch circum- ftances fome of the warm irritating ointments, to be afterwards pointed out, are the only means from which relief can be obtained. The next circumftance of importance is the meth- od to be purfued for preferving the matter of ulcers in a purulent ftate; and as purulent matter is the mildeft and leaft acrid difcharge that ulcers ever af- ford, nothing ffiould be omitted that can tend to pre- ferve it in this ftate. In the variety of ulcer that we are now confidering, the principal attention which this requires, is the pre- fervation of a due degree of heat in the part affected. This, in every part of the body, is neceffary; but more particularly in the arms and legs than elfewhere, for the natural heat of the extremities is lefs than it is in the trunk where the adion of the heart has more influence. In chapter I. when treating of inflammation, I have endeavoured to ffiow, how neceffary a due degree of heat is for the formation of pus in cafes of abfcefs. It is equally fo in the treatment of ulcers, and there- fore merits particular attention: the want of this in- Sed. II. fimple purulent Ulcer. %6y deed is not an unfrequent caufe of the moft fimple ulcers degenerating into thofe of the moft inveterate kind. Whilft any degree of inflammation remains in ul- cers, the beft method of applying heat, is by the fre- quent renewal of warm emollient cataplafms : but, as foon as the inflammatory fymptoms are nearly gone, remedies of this kind fhould be laid afide ; for they rend to relax the parts fo powerfully, that a long con- tinued ufe of them is apt to induce, as I have already obferved, too much laxity or want of tone wherever they are applied : and the fame purpofe may be then anfwercd equally well, by applying over the dreffings, compreffes of cotton, flannel, or any other covering that moft effedually retains heat. The benefit refulting from due attention to this mode of management, I have frequently experienced ; and although not of fo much importance in the treat- ment of ffcnple ulcers, as in thofe of a worfe kind, yet even in the flighteft it ffiould never be omitted. In almoft every ulcer, poultices prove ufeful in one ftage or other of the cure : and although in thofe at- tended with much inflammation, they may no doubt prove ferviceable as emollients ; yet the degree of heat which they afford, by tending to promote a good fuppuration, is, I am perfuaded, the chief advantage which they ever produce. But poultices, when ufed with this intention, if not frequently renewed, rather do harm than good; and, in order to obtain all the advantages that may be de- rived from them, they ffiould be renewed at leaft eve- ry three hours. But this fubjed having been fully confidered in the firft chapter, it is not neceffary to enter upon it again; for, the fame obfervations apply with equal force and propriety here. The circumftances that I have noticed, namelv, the prevention of irritation by mild dreffings, and the prefervation of a proper degree of heat in the part af- feded, arc the moft certain means both of promoting 368 Observations en the Chap. V. the growth of new parts, and for obtaining and keep- ing up a difcharge of good matter. They ffiould both therefore be kept in view in the cure of ulcers: eith- er till there is no farther deficiency to fill up, or till the farther produdion of new parts is no longer to be expeded. The next moft important part of this indication in the cure of ulcers, is to be obtained, as I have already obferved, from gentle compreffion: and this, it may be remarked, ffiould be employed at the fame time, and be ufed along with the feveral applications we have juft been confidering ; for as foon as the inflammato- ry ftate of an ulcer is over, and a difcharge of good matter induced, flight compreffion, by means of a roller, may be immediately applied and continued during the remainder of the cure. If ffiould be ap- plied in fuch a way as not only to. produce gentle preffure upon the parts immediately furrounding the ulcer, but alfo to ferve as a fupport to the fkin and other teguments, fo as to prevent their • retradion, which otherwife, in large ulcers, is very apt to hap- pen. When, by due perfeverance in the various means of cure that I have thus pointed out, any lofs of fub- ftance in ulcers is at laft as far as poffible fupplied, the next indication of cure comes then to require at- tention, and that is, the formation of a cicatrix. For the moft part, we obferve, that fores cicatrize foon after the procefs of incarnation, if we may fo term it, is at an end ; but this does not always hap- pen, for in fome inftances, even where every deficien- cy appears to be fupplied, ftill a cure is difficult to accomplish: the furface of the fore remains raw, and at the fame time difcharges confiderable quantities of matter. In fuch cafes, it becomes neceffary to lay afide the ointment employed for the preceding part of the cure, and to ufe applications of a more ltyptic or aftringent nature. Sed. II. fimple purulent Ulcer. 36a In this view, unguentum album prepared with ce- rufs, and cerate prepared with lapis calaminaris, are commonly ufed ; but they anfwer beft when the fores are at the fame time bathed with lime water, a folu- tion of faccharum faturni, or any other aftringent waffi : by bathing the fores with one or other of thefe, two or three times daily, and dreffing with one of thefe ointments, a cure may frequently be obtained when we would not fucceed with emollients: ardent fpirits, too, often anfwer the purpofe, of putting a ftop to the difcharge of fores in this ftate, and of drying or corrugating the foft cellular fubftance upon their furface into a firm cicatrix. In fome inftances, again, a cicatrix does not form from the new granulations being fo confiderable as to rife above the furface of the contiguous parts. In fuch cafes, we- depend upon a proper application of efcharotics: of thefe the beft for common ufe is blue vitriol and calcined alum ; and when they do not fuc- ceed, nothing weaker than lunar cauftic will fucceed. In flight cafes, indeed, a cure is often accompliffied by the ufe of dry lint alone; a pretty tight bandage being at the fame time applied over all. This, I muft however obferve, is a ftage of ulcer which frequently proves more perplexing than any other part of the cure : for it often happens, even in the moft healthy people, and when the preceding part of the cure has gone very properly on, that a cicatrix cannot be induced, and the granulations newly form- ed continue raw, and do not ffiow any tendency to heal: m this fituation, when the means that I have mentioned do not anfwer, compreffes moiftened in French brandy, being applied under the roller, will often accomphffi a cure ; or fpirits ufed in this man- ner may be alternated with tindure of myrrh, or with a folution of blue vitriol in water; a pradice which in different inftances I have found to fucceed, when the means ufually employed have failed. Vol. I. A a 37° Observations on the Chap. V, I have thus enumerated fuch local applications as prove moft ufeful in the cure of thefe ulcers ; but in the courfe of the cure, other circumftances fometimes occur, which likewife merit attention. In every ulcer, even in thofe of the moft fimple kind, reft of body is particularly requifite ; infomuch, that, when it is not advifed, no remedy with which we are acquainted can be depended on for a cure; and in ulcers of the legs, it is even neceffary to keep the difeafed limb at reft, and as much as poffible in a horizontal pofition. Reft and a horizontal pofture have indeed been confidered by almoft all pradition- ers, both ancient and modern, as neceffary for the cure of ulcers in the legs; but in fome late publications, it is afferted, that reft is fo far from being neceffary, that a cure is juft as eafily performed whilft patients are going abroad as when under ftrid confinement. In fome very flight ulcerations, this may fometimes be the cafe; and, with the affiflance of a tight band- age or laced flocking, applied fo as completely to fup- port the parts, even fores of a worfe kind may be cur- ed, and the patients at the fame time allowed to move about. But, in general, fo far at leaft as my experi- ence goes, the regulations upon this point, enjoining ftrid confinement in ulcers of the extremities, as hand- ed down to us by ancient writers, appear to be well founded; for according as they are more ftridly fol- lowed or not, the cure commonly advances quickly or otherwife. It often happens, indeed, as I have obferved above, that ulcers even of a bad kind, are cured without any affiflance from confinement or a horizontal pofture of the limb. This 1 have frequently met with; and at this time I have different cafes under my care, of ul- cers going on towards a cure, whilft the patients are daily going abroad. But their being allowed to take this liberty, has always arifen from neceffity ; as there is nothing of which I am more convinced, than that ulcers of the legs will cure fooner, more eafily, and to Sed. II. fimple purulent Ulcer. 371 more real advantage, whilft the limb is preferved in a horizontal pofture, than when the patient continues to take exercife. But when the circumftances of pa- tients prevent us from receiving the advantages to be derived from confinement, we are reduced to the ne- ceffity of attempting the cure by Other means ; and, in fuch circumftances, nothing anfwers fo well as pref- fure applied with a roller in the manner that I have uniformly mentioned in this as well as in the former editions of this work. As confinement, during the cure of ulcers on the legs, proves always inconvenient, various means have been propofed for rendering it unneceffary; and it has not only been faid, that cures may be performed without any affiflance from confinement or a horizon- tal pofture, but by fome it is alleged, that thefe points of attention are even prejudicial.* I have already remarked, that ulcers of the legs may be healed while patients are daily going abroad j and efpecially if a due degree of compreffion is contin- ued. But, notwithftanding all the arguments adduc- ed in favour of the pradice, I have not yet heard of any which ought to fet afide the opinion that I have endeavoured to inculcate, namely, that a horizontal pofture is highly proper for the cure of every ulcer of the lower extremities. The means propofed by Mr. Underwood, I have tried on various occafions ; they have fometimes proved fuccefsful; but, whatever may have been the cafe with others, they have never, in the courfe of my experience, effeded cures fo eafily and fpeedily, or which have proved fo permanent, as the means that I have pointed out, of employing mild dreffings to fimple fores, together with a horizontal pofture in every ulcer of the leg. * This has been afferted by other writers; but it has been more fully enlarged upon of late, in a very ingenious Treatife upon Ulcers of the Legs, by Mr. Underwood of London. a a 2 372 Observations on the Chap. V, In almoft every ulcer, diredions have been given by praditioners, for the regimen of the patient; and, irt general, a low fpare diet is prescribed. Such regu- lations, however, very commonly do harm ; for they feldom fail to relax the habit of body, and to hurt the nature of the difcharge. Full living ought certainly to be avoided, for whatever excites fever, proves in the management of ulcers always hurtful; but while this ffiould be duly guarded againft, it is equally pro- per to avoid the pernicious confequences of living too low. The difcharge of purulent matter is fo apt to produce debility, that, in large ulcers, this circum- ftance alone proves always hurtful if the conftitution is not at the fame time enabled to fupport it by a pro- per allowance of food. We always find indeed, that the cure of ulcers goes on more eafily when the pa- tient is kept in his ufual habit of body, than when his fyftem is much reduced by a low regimen : nay, I have had many opportunities of obferving, that ulcers even of the worft kinds, may be foon made to heal by the ufe of a nourifhing diet alone, after having obsti- nately refilled all the ufual remedies under a low re- gimen. For the fame reafons that a low regimen is impro- per, the ufe of purgatives, and whatever tends to ex- cite debility, ffiould be avoided. Nor have I ever per- ceived, that in this variety of ulcer, internal medicines prove ufeful. I know that medicines of various kinds are frequently given, particularly bark, nitre, and cool- ing purgative falts. But in the fimple purulent ulcer, which we are now confidering, I have never perceiv- ed that any advantage has been derived from medi- cines : the affedion is merely local, and local reme- dies ought to be depended upon for the cure. When, indeed, the matter of a fore is in too great quantity, and efpecially when it is thin and acrid, bark, fteel, and other tonics, may be given with advantage : but when the local applications that I have mentioned do Sed. III. fimple vitiated Ulcer. 373 not corred this, it will commonly be found to origi- nate from fome general difeafe of the conftitution ; a different fpecies of ulcer will be therefore produced, and other remedies will confequently be required. SECTION III. Obfervations on the fimple vitiated Ulcer, § i. Of the Symptoms, Caufes, and Prognofis, of the fimple vitiated Ulcer. I CONSIDER every ulcer as vitiated, in which the difcharge is materially different from that of the purulent ulcer defcribed in the laft fedion. The moft frequent appearances of the matter of ul- cers in this vitiated ftate, are, i. A thin green coloured difcharge, termed fanies. 2. A fomewhat red, and generally very acrid mat- ter, termed ichor. And, 3. A more vifcid glutinous kind of matter, called fordes. This laft is frequently of a brown appearance, fomewhat refembling the grounds of coffee, or gru- mous blood mixed with water. They are all of them much more fetid than purulent matter, and none of them are altogether free from acrimony ; but that which we generally term ichor, is the moft acrid of any, being frequently fo ffiarp and corrofive, as to de- ftroy the contiguous parts. From the acrimony of this kind of matter, the ul- cers do not fill up with new granulations: they rath- er become more extenfive: and, inftead of a red heal- thy complexion, they are either of a dark brown, or 374 Observations on the Chap. V. of a black floughy appearance. The pain in all of them is confiderable ; generally more or lefs in pro- portion to the acrid ftate of the matter. This variety of ulcer may be induced by wounds, burns, bruifes, and every other caufe that can produce the fimple purulent ulcer; for even that variety of ulcer, however mild it may have been, if either neg- leded, or improperly treated, is apt to degenerate in- to the vitiated ulcer which we are now confidering. It is here alfo proper to obferve, that this alteration in ulcers, from the 0mple to thofe of a more invete- rate kind, happens more frequently in particular parts than in others : thus, from the tendons and aponeuro- tic expansions of mufcles not affording the ferum re- quired for the formation of purulent matter, ulcers feated in thefe parts commonly. prove more trouble- fome and inveterate than thofe that are feated in the cellular membrane, where the fecretion of a fluid pro- per for this purpofe generally takes place. In vitiated ulcers, that are merely local, and not conneded with any difeafe of the fyftem, when not of long duration, and more efpecially in healthy patients, we may always give a favourable prognofis. But, when the reverfe of this takes place; when the patient is old; the ulcer extenfive, inveterate, and of long Handing ; the prognofis ffiould always be- doubtful, at leaft, in fuch circumftances the cure will always be tedious and for the moft part uncertain, § 2.. Of the Cure of the fimple vitiated Ulcer. I have already remarked, that the matter of ulcers becoming vitiated, proceeds, in general, from fome particular affection of the folids or fecreting organs in the parts difeafed, whereby fluids are feparated from the blood which cannot be converted into good pus. The caufe of this I have alfo endeavoured to explain ; and, from the arguments I have advanced, it appears, I think, to confift in different degrees of inflamma- Sed. IH. fimple vitiated Ulcer. 375 tion, or of increafed adion in the veffels of the parts difeafed, occafioned by one or other of the exciting caufes which give rife to ulcers. Befides the arguments already adduced in fupport of this opinion, it feems to be further confirmed by the nature of the remedies found to prove moft effec- tual in the cure, which are chiefly fuch as prove moft powerful in eafing pain and abating irritation. Thus, warm fomentations and poultices frequently prove ufeful, not only by the relief which they afford from pain, but in altering the nature of the difcharge, and converting it into purulent matter : this I have known happen from the firft or fecond application of a poultice, although, as I have formerly obferved, poultices ffiould never be long perfevered in after the inflammation for which they are applied is removed, as they are apt to render the ulcerated parts too foft and fpongy. In fevere degrees of pain, however, remedies of this kind do not always prove fuccefsful. And while much pain continues, the matter will not become bet- ter, nor will the fores affume a healing appearance : it therefore becomes an objed of the firft importance, in this variety of ulcer, to remove the inflammation, by the prefence of which the cure is for the moft part chiefly impeded.. When warm emollients fail, we employ opiates, local bloodletting, and efcharotics. In this view, we frequently derive advantage from the internal exhibition of opium ; and I have alfo known pledgets of foft lint dipped in laudanum, and applied to the furface of an ulcer, remove the pain, and induce a favourable appearance over the whole. This purpofe is alfo frequently obtained from the ap- plication of leeches to the edges of a fore, which, in fome inftances, I have known give relief when every other remedy has failed. When the leeches can be made to fix upon the fore itfelf, they commonly an- 37^ Observations on the Chap. V. fwer beft; but when this cannot be done, they ffiould be applied as near as poffible to the pained parts. In this vitiated ftate of ulcers, when the fymptoms do not foon yield to emollients, we frequently fucceed by the ufe of cauftic and efcharotics. Thefe, when firft applied, excite more pain than emollients; but this foon fubfides, and leaves a pleafant foothing fen- fation over the whole parts. When this kind of dreffing fucceeds, the quantity of matter foon becomes lefs ; from being thin, acrid, and offenfive, it becomes bland and purulent; and freffi granulations of a heal- thy appearance fprout up over the whole furface of the ulcer, which foon begins to contrad. I am now, therefore, in the daily pradice of ufing remedies of this clafs, which I conftantly employ as foon as emol- lients appear not to anfwer the purpofe. In fome ulcers, a mixture of red precipitate, or any other efcharotic, with bafilicon or wax ointment, an- fwers all the purpofes to which I allude ; but when they do not fucceed in this form, they commonly an- fwer when applied in dry powder over the furface of the fore : occafionally, however, we meet with cafes in which even this does not anfwer, and in thefe the application of lunar cauftic often fucceeds. The cauftic ffiould be applied not merely to the edges of the ulcer, but over the whole furface, and renewed every third or fourth dreffing, till the matter becomes thick and purulent, and the granulations affume a healthy appearance. Immediately after touching an ulcer with cauftic, the parts ffiould be covered with dry lint, as ointments of every kind tend to blunt the adion of cauftic. For the intermediate dreffings, nothing anfwers better than a mixture of bafilicon and red precipitate, in the proportion of a drachm or four feruples of the latter to an ounce of the oint- ment. For general ufe, as an efcharotic, in ulcers, red precipitate, or hydrargyrus nitratus, as it is now com- monly termed, is perhaps the beft we can employ; Sed. III. fimple vitiated Ulcer. 377 verdigris finely levigated, is alfo ufed occafionally for the fame purpofe, likewife corrofive fublimate, and even arfenic ; but all of thefe excite more pain than precipitate, while they do not in any circumftance appear to be preferable. For the purpofe of changing the nature of the dif- charge in this vitiated ftate of ulcers, and converting it into a ftate of purulency, a variety of other appli- cations have at different times been recommended. At one period the gaftric juice of fheep and other ani- mals was much extolled as a dreffing for this kind of fore, and of late the power of rhubarb has been re- commended ; but after having amply tried them both, I have not found that either of them anfwer any good purpofe. While with local applications we endeavour to bring ulcers into a healing ftate, the habit of body ffiould not be negleded. When the patient is much reduced, his ftrength ffiould be fupported by a full allowance of food, while any tendency to plethora and inflammation ffiould l>s kept down by a low regimen. When this vitiated ftate of ulcers occurs in weak or emaciated patients, Peruvian bark proves common- ly ufeful. In order, however, to anfwer any material purpofe, it fhould be given in larger dofes than we commonly employ. In the quantity of four or five drachms daily, it not only gives tone to the fyftem, but for the moft part has an obvious influence in cor- reding the nature of the difcharge. But, in plethoric habits, and efpecially where there has previoufly been much tendency to inflammation, the bark ffiould be ufed with caution : in thefe cir- cumftances, indeed, it ffiould feldom be given to any extent, till the tendency to inflammation has in a good meafure difappeared. With due perfeverance in the remedies and plan of management which I have thus pointed out, if the fyftem is not otherwife unhealthy, the difcharge will 37§ Observations on the Chap. V. at laft become purulent, and this being accompliffied, the moft material part of the cure will in a great mea- fure be obtained ; for the parts being no longer cor- roded and kept down by conflant immerfion in acrid matter, they commonly foon put on a healthy appear- ance ; and new granulations being now at liberty to form, any lofs of fubftance produced by the ulcer, is foon, as far as poffible, fupplied. Ulcers being thus brought to a healing condition, are to be treated during the remainder of the cure in the manner that I have mentioned in the laft fedion, that is, with mild dreffings, with due attention to the prefervation of a proper degree of heat in the parts affeded, together with the application of gentle pref- fure with a roller, from the time of the inflammatory fymptoms being removed. It frequently happens, however, in this as in every ulcer of long duration, that although the parts, with proper management, may be brought to put on a healthy appearance ; and although the difcharge may be converted into the beft kind of pus ; yet ftill the fore cannot be made to cicatrize, but continues to dif- charge as plentifully as ever. In fuch circumftances, iffues often anfwer a good purpofe ; and where ulcers have been of long dura- tion, as the cure will feldom prove permanent if an adequate drain be not introduced, we ought in every inftance to advife it. For, befides the danger arifing from the pradice of healing old ulcers before new drains are inferted, any cicatrix we obtain generally foon burfts open, as the neceffary effed of that redundancy of fluids induced by the retention of thofe which the conftitution had been accuftomed to throw off, for a fupply of pus to the ulcers. In every ulcer, therefore, of long duration, the firft part of the cure ffiould confift in the introduction of an iffue of fuch a fize as may afford a quantity of matter in fome degree proportioned to the difchi.rge. Sed. III. fimple vitiated Ulcer. 379 And although the fituation of fuch drains has com- monly been chofen as near to the ulcer as poffible ; yet, provided the fame quantity of matter is difcharg- ed, the fituation of the iffue need not be an objed of attention ; and therefore, that which is moft conve- nient for the patient may be fixed upon. Since the firft editions of this work were publifhed, the advantages to be obtained from iffues in the cure of habitual ulcers, have in various inftances been ex- perienced. In fome, cures were obtained by iffues, when every other means of relief had previoufly fail- ed ; and in others, the fores broke out again upon allowing the iffues to dry up, and were again cured by having recourfe to the fame means. Various inftances might likewife be given from au- thors, not only of the difficulty of curing habitual ul- cers if an iffue be not previoufly inferted, but of very pernicious confequences being induced by it. But as the experience of every practitioner muft have fur- nifhed inftances of this, I do not think it neceffary to refer to books for authorities. In fores which have not been of long continuance, however extenfive they may be, it would be highly improper to put the patient to the trouble of an iffue for their cure. In recent ulcers, the fyftem has not been fo long accuftomed to the difcharge as to induce any rifk from a ftop being put to it; but in ulcers of long continuance, I muft again fay, that a cure can never be attempted with fafety, unlefs an iffue of an adequate fize is previoufly inferted. As iffues of every kind are attended with fome in- convenience, they feldom prove agreeable to patients; and from this confideration, praditioners are fre- quently induced to difpenfe with them : the leaft con- fideration, however, muft render it evident, that no motive of this kind ffiould meet with attention. It is chiefly in the vitiated ulcer, that the internal ufe of nitre has been recommended ; but, although I have given it, in this as well as in other varieties of 380 Observations on the Chap. V. fores, in very confiderable quantities, and with every neceffary attention, I cannot fay that I ever obferved any obvious benefit refult from it. Sores, indeed, have been cured, in which nitre was ufed; but unlefs the roller and other local applications were employed at the fame time, this remedy, in any of the trials that I have made of it, never accompliffied a cure. SECTION IV. Obfervations on the fungous Ulcer* § 1. Symptoms and Caufes of the fungous Ulcer. BY the term fungus, I here mean to exprefs every preternatural rifing of the furface of a fore. For the moft part, this kind of excrefcence is foft and fpongy, but in fome inftances it is of a more firm tex- ture than healthy granulations. Thefe excrefcences are not commonly painful, al- though, in fome inftances, it is otherwife; and the difcharge which they afford, varies according to the variety of ulcer with which they happen to be con- neded. Thus, when a hyperfarcofis, the term commonly given to flefhy excrefcences in fores, occurs merely from negled, in a fimple purulent ulcer, the difcharge frequently continues good ; while, in ulcers difcharg- ing vitiated matter, the difcharge ufually continues to be of the fame nature. With refped to the caufes of this formation in fores, I have already obferved when fpeaking of the fimple purulent ulcer, that in healthy young people, the new granulations are apt to puffi forward too much, fo as to rife above the furface of the neighbour- ing parts. This, by purfuing the diredkns which Sed. IV. fungous Ulcer. 381 were then given, we have it often in our power to pre- vent ; but when thefe are negleded, as is often the cafe with poor people, a degree of fungus is apt to rife, which it frequently proves very difficult to re- move. Another variety of fungus is produced in wounds, by the new granulations being allowed to rife and ad- vance before they are fufficiently found at bottom. In this manner, whether from matter lurking beneath, or from extraneous bodies lodging in the difeafed parts, the granulations ftill continue to advance ; but, inftead of cicatrizing when on a level with the con- tiguous parts, they go on rifing beyond them, till the difeafe we are now confidering is of fome duration. When in this manner a fungus has commenced, it continues to increafe, till the caufe is difcovered by which it was produced, and on this being removed, if the constitution is otherwife found, the fungus for the moft part fubfides quickly. § 2. Of the Cure of the fungous Ulcer. The cure of thefe excrefcences muft in a great meafure depend upon the caufe by which they are in- duced : when produced merely by an overgrowth of parts, and where no difeafe or carious bones are found to lurk at the bottom of the fore ; when the tumor is extenfive, and does not rife to any great height, we ffiould immediately have recourfe to efcharotics. Of thefe a great variety has been ufed ; even the adual cautery has been propofed, and by others, we are advifed to remove at once all fungous parts with a fcalpel. Either of thefe would in every cafe prove effi&ual, and more expeditious than perhaps any other that can be mentioned: but they have fuch an appearance of feverity, as to deter almoft every one from fubmitting to them ; efpecially as it is well known that all fuch excrefcences as we are now confidering, can juft as 382 Observations on the Chap. V. certainly, though perhaps not fo quickly, be removed by more gentle remedies. Excrefcences of a foft texture may frequently be removed by calcined alum alone : covering the fun- gous parts with the powder every fecond or third day, will often prove effedual; but when the protuberant parts have acquired much firmnefs of texture, alum alone does not anfwer : in this cafe, one of the moft effedual applications that I have ever employed, is a powder compofed of equal parts of calcined alum and red precipitate finely levigated : fcarcely any fungus, however firm it may be, refills the power of this ef- charutic. For feveral years paft, I have been in the pradice of ufing it frequently, and it feldom fails to anfwer the purpofe. Next to this is lunar cauftic, which ads more quickly, and does not produce more pain than cauftic of the weakeft kind ; it feldom fails to produce the proper effed, which is not the cafe with the others ; and it is not fo apt to run and fpread over the contiguous parts, which is frequently a very troublefome circumftance attending the other. The cauftic ffiould be melted in water ; and a fmall bruffi or pencil being dipt in it, in this manner it ffiould be applied to fuch parts as are to be deftroyed: and this being done either daily, or every fecond day, the fungus will be-removed in a longer or ffiorter time, according to the fize and firmnefs of the tumor. A ftrong folution of verdigris in water, of crude fal ammoniac, or blue vitriol, will alfo occafionally fuc- ceed in removing thefe excrefcences. Cafes, however, fometimes occur, in which fome variety of pradice becomes neceffary : I have made trial of various articles ; but none ever proves fo gen- erally ufeful as lunar cauftic, or the mixture I have mentioned, of calcined alum and red precipitate. I have fometimes ufed ftrong folutions of filver and crude mercury, in fpirit of nitre; and the effeds of thefe, as may readily be imagined, are always power- Sed. IV. fungous Ulcer. 3*3 ful: they are nearly the fame, indeed, being only fomewhat more powerful than thofe we commonly experience from lunar cauftic, this kind of cauftic be- ing merely a folution of filver in the nitrous acid, evaporated to drynefs. One ounce of pure quickfilver will diffolve in an ounce and half of ftrong fpirit of nitre ; and this forms, perhaps, as ftrong a cauftic as can be prepared. For other purpofes, where milder preparations are neceffa- ry, the ftrength of the remedy may be reduced by ufing a fmaller proportion of mercury and a weak ni- trous fpirit: but for the removal of a hard callous ex- crefcence, the ftrongeft folution ffiould be employed; it gives no more pain than the weakeft, and it always proves more effectual: but in ufing it, either for warts, or thofe fungous excrefcences we are now confider- ing, it ought never to be applied to any extenfive fur- face at once. When the fungus is not large, the fo- lution may be applied over the whole of it; but, in extenfive fores, it anfwers better to apply it to a fmall portion at once ; and if different parts of an excref- cence are touched daily, the whole will in general be foon removed. After the application of any kind of cauftic, the parts ffiould be covered with dry lint; and not, as is commonly done, with any kind of ointment, which always deftroys the adivity of cauftic. We have hitherto been fuppofing, that the furface of the fungus is of confiderable extent, and not much raifed above the contiguous parts: but whenever the bafe is narrow, and the height of the excrefcence con- fiderable, the mofl expeditious and eafieft method al- ways is, to take it off with a ligature. When the excrefcence is narrow at the bafe, and in any degree pendulous, a ligature can be applied and eafily kept on ; but v. hen the tumor is broader below than above, it requires fome attention to prevent it from flipping off.' It may always, however, be done in the following manner. 3^4 Observations on the Chap. V. A ftrong needle, with an eye near to its point, and fixed in a handle, being pufhed through the tumor at its bafe, two waxed ligatures muft be introduced at its eye, when the needle muft be again drawn back, fo as to leave the threads with their ends hanging out at each fide of the excrefcence. A firm ligature is now to be formed round one half of the tumor, by the two extremities of one of the threads ; and in like manner the other half is to be included by the other two, and each of the ligatures being from time to time properly tightened, both halves of the tumor will for the moft part foon fall off. The hint of this pradice was taken from the defcription of a curved needle re- commended by Mr. Chefelden, for the extirpation of difeafed tonfils, which, in certain cafes, without fome fuch contrivance, could never be done with fafety. The fungus being, in this manner, removed, the fore is to be treated in the manner that I have advifed for fimple purulent ulcers. The other variety of fungus proceeds, as I have obferved already, from matter or other extraneous bodies lodging in fores, by which the granulations which form above them, inftead of being firm and healthy, are of a foft fpongy texture, and of a pale unhealthy afped. The cure of this confifts entirely in giving vent to any matter that may be lodged, or removing any por- tion of bone, or other extraneous body from the fore. This being done, the excrefcence begins foon to de- cay, and healthy granulations forming from the bot- tom of the fore, a cure is afterwards obtained with common dreffings alone: efcharotics have no influ- ence in the cure, for while any extraneous bodies re- main concealed in fores, the granulations fprout up almoft as quickly as they are deftroyed, and on thefe being removed, all the newly formed parts difappear fo quickly, that it is not neceffary to apply cauftic for the purpofe. Sed. V» finuous Ulcer* 385 Thefe are the only varieties of fungus, which, in local ulcers, ever prove troublefome; excepting, per- haps, that which occurs as a fymptom in carious ul- cers, and of which an account will be given in its proper fedion* SECTION V. Obfervations on the finuous Uker* § 1. Ofthe Symptoms and Caufes of the finuous Ulcer, HERE only a fmall portion of an ulcer is ex- pofed to View, the matter which it affords, colleding either in the cellular fubftance immediately below the fkin, or among the contiguous mufcles, and difcharging itfelf by one or more openings, gives rife to what we term a finuous Ulcer* Thefe finufes ferving as refervoirs, both for the matter that forms in the body of the fore, and for that which proceeds from their own cavities, makes the difcharge, when the matter of the finufes is preff- ed into them, appear to be more confiderable than their extent of furface would give caufe to fufped. A finus, as thus defcribed, is the mofl fimple ftate of the difeafe: but, by long continuance, or by the ufe of aftringent applications, it is liable to become hard and Callous through its whole courfe; and, in this fituation, from its fuppofed refemblance to a pipe, it is termed a fiftula ; of which nature is the fiftula in ano, a well known troublefome difeafe. The moft frequent caufe of the formation of finufes in ulcers, is the want of a free vent to the difcharge; Vol. I. B b w 386 Observations on the Chap. V< which, naturally falling to the moft depending part of a fore, if it does not there get eafily oft", it is apt to in- finuate into the foft yielding fubftance of the cellular membrane, in which it proceeds, till it fomewhere or other makes an opening for itfelf, either upon the fur- face of the body, or into fome of the neighbouring cavities. Tight bandages, when applied diredly upon ulcers, and not made to ad likewife upon the neighbouring found parts for fome way both above and below the fores, are not unfrequently attended with this effed: they ffiould always therefore be applied with much care and attention. In all recent finufes, and even in thofe of long du- ration, when the parts are fo far acceffible as to admit of being properly treated, and when the conftitution in other refpeds is healthy, we may very commonly give a favourable prognofis. But when of long con- tinuance, and efpecially if the finufes open into any of the joints, or when the parts are of difficult accefs, the cure, in fuch cafes, becomes both difficult and doubtful. § 2. OJ the Cure of the finuous Ulcer. In cafes of recent finus, we are direded by all the ancient writers on furgery, and likewife by many of the moderns, to make ufe of what they term vulne- rary or healing injedions. And, in the more advanc- ed ftates of the difeafe, when, by long continuance, the fides of the finufes have become callous, efcharo- tic injedions and powders are recommended: but none of thefe are to be trufted; and the too frequent ufe of them has often rendered hard and callous fuch finufes as before were of the moft fimple nature. Others, again, have advifed to lay the different finufes open from one end to the other, and, by cut- ting out all the hardened parts, to convert the whole- Sect. V. finuous Ulcer. 3«7 into one common ulcer, and to proceed afterwards with the cure in the ordinary way. In this manner we might no doubt frequently fuc- ceed ; but, befides the great pain, and very unfeemly cicatrix, which this operation never fails to produce, it cannot, in every cafe, with fafety be put in pradice. Thus, when finufes run to a very great height up the redum, we cannot make the attempt; and when, as is frequently the cafe, they penetrate deep, and run below either large blood veffels, tendons, or nerves, this mode of treatment becomes altogether in- admiffiblei But although the pradice were not in any degree hazardous, it ought in almoft every inftance to be laid afide; fince we can, by a more fimple and lefs pain- ful operation, be always as certain of proving fuccefs- ful, as by a fimple incifion, or by an entire deftrudion of the parts. The intention of cure in all cafes of finus, is to pro- duce a coalefcence of their fides, fo as to deftroy any vacuity that may have taken place. The eafieft and perhaps beft means of accomplish- ing tliis, is, firft to make a depending orifice for a free exit to the matter, and then, by gentle irritation, to induce, on the internal furface of the finus, a flight degree of inflammation, which, by experience, is known to be the ftate moft favourable for producing adhefion between the divided parts of an animal bo- dy 5 fo that a firm union of the fides of the finus may in due time be obtained. Now, both thefe intentions are fully anfwered by the introdudion of a feton, from the orifice in the ul- cer along the courfe of the finus, to its other extrem- ity ; where an opening, large enough to receive it, ought to be made in the manner already pointed out in cafes of abfcefs. The cord of cotton or filk fhould at firft be fuffi- ciently large for the fize of the finus ; to be dimin- ifhed gradually, as the cure advances, by taking away b b 2 388 Observations on the Chap. V. a thread or two from its thicknefs every fecond or third day. At laft, when the difcharge is much leff- ened by the vacuity occafioned by the finus being filled up, the feton fhould be totally withdrawn ; and a bandage being applied with fome tightnefs over the part, and continued for a fufficient length of time, a Complete cure will thus for the moft part be effeded. The firfl flep to be taken, then, in all cafes of finus, is to difcover the diredion in which they run j which commonly we can eafily do, either by the in- troduction of a probe, or obferving where the matter points on being allowed to colled, and from whence it comes, on the part being preffed. And into every finus opening into the ulcer, a feton ffiould be intro- duced. This method of curing finufes, by the ufe of fe- torts, is free from all manner of danger, and is ad- miffible in a great proportion of cafes : even when finufes run deep among mufcles and blood veffels; and when it would be unfafe, therefore, to ufe either the fcalpel or acrid injedions; a feton, introduced by means of the diredor, in the manner I have mention- ed, may be always employed with fafety and advantage. Neither is the practice confined to cafes of recent finus : it anfwers nearly equally well in thofe of long duration : hence, there is reafon to think, that it would anfwer in fiftula in ano, were it not rendered inadmiffible from the fituation of the parts affeded. In fimilar affedions in perineo, I have known it ufed with much advantage : and in this fituation, indeed, it is particularly proper ; as the cicatrix produced by the opening of a long finus in the ufual way, with a fcalpel, proves in thefe parts frequently more trouble- fome and painful to the patient, than even the origin- al difeafe which it was meant to cure. The finufes being at laft filled up, the ulcers with which they were conneded, muft be cured in the or- dinary way, by the means pointed out in the differ- ent fedions of this chapter. Sed. VI. callous Ulcer. 389 SECTION VI. Obfervations on the callous Ulcer. § 1. Of the Symptoms and Caufes of the callous Ulcer. AN ulcer is faid to be callous, when inftead of contrading, its edges keep at a fland, turn rag- ged, and at laft, by acquiring a preternatural thick- nefs, rife confiderably above the level of the contigu- ous parts : and, as it is generally from negled, or im- proper treatment, that ulcers become callous, the dif- charge which they afford is commonly a thin vitiated matter. It is chefly in this ulcer that varicofe veins are met with, efpedally in ulcers of the leg. This feems to be owing, not only to the difficulty which the blood in this fituation meets with in its return to the heart; but, in a great meafure to the ftridure which the cal- lofities produce on the courfe of the veins. This variety of ulcer has by many been termed va- ricofe ; from their fuppofing them to proceed from, and to be as it were fed by, matter furniffied from thefe fwelled veins, which frequently have the appear- ance of opening into them. This error, however, muft have arifen from want of attention to the caufe of thefe fwellings in the veins ; together with the miftaken notion which hitherto has prevailed of the formation of pus, which formerly was fuppofed to circulate with, and to be depofited from, the blood ; but which I have endeavoured in Chap. I. to demonstrate to be an opinion void of foundation. Ulcers feldom become callous from any other caufe than negled and improper treatment. When injudi- ciously treated, either by irritating or relaxing applica- 39Q Observations on the Chap. V. tions, or when entirely negleded, fo that fungous ex- crefcences are either allowed to arife, or dreffings and other extraneous bodies permitted to remain too long in their cavities ; fuch fubftances come at laft to ad as impediments to the further contraction of the ul- cers. And, the fmall veffels of their edges being thus prevented from proceeding further in a right diredion, are forced to puffi upwards, and fometimes even back- wards, till, by the effed of preffure produced by the ufual bandages, they naturally come to acquire a morbid hardnefs or callofity ; which, as long as it may be allowed to remain, very effedually prevents the further progrefs of the cure, however judicioufly the fores may in other refpeds be treated, § 2. 0/ the Cure of the callous Ulcer. In our treatment of callous ulcers, the firft ftep to- wards a cure ffiould be the removal of their edges; for till this is accompliffied, however well the difeafe may be otherwife managed, the procefs of cicatrization will not take place. In recent cafes, warm emollient cataplafms, when continued for a due length of time, by foftening the callofities, will frequently, without any other applica- tion, anfwer every intention of cure. But it is only in the earlieft periods of the difeafe that thefe prove effedual: for when of long duration, and the edges of the fore have acquired much preternatural hard- nefs, no emollients, or any other difcutients, ever pro- duce any obvious benefit. The only remedies upon which we can place de- pendence, are the fcalpel and cauftic : and as the laft, when properly managed, is equally certain with the other, it fhould, as the eafieft, for the moft part be employed ; and, for reafons that I have given in a former fedion, the lunar cauftic ffiould be preferred. The folution of filver or of mercury, of which a de- fcription was given in the fedion on fungous ulcers, Sed. VI. callous Ulcer. 391 may be ufed with equal propriety here : either this, or the lunar cauftic, ffiould be applied every two days to the callous edges of the fores, by which they will be foon deftroyed. In this manner, and by continuing the poultices as long as the fores remain foul, they foon affume the flafe of fimple purulent ulcers, when by common treatment a cure is for the moft part ea- fily obtained. In the lift of fymptoms, varicofe veins were men- tioned as one. Thefe, we might imagine, on the caufe being removed by which they were produced, would likewife difappear. This, however, is feldom the cafe ; for when blood veffels by distention have been deprived of their tone, they do not foon recover it. In the treatment, therefore, of the callous ulcer, it is not enough to remove the caufe which originally pro- duced thefe fwellings in the veins : fome fupport muft be given to the weakened parts, in order to enable them with more certainty to recover the ftrength which they have loft. Npthing has ever anfwered this purpofe fo well as the laced flocking, or fpiral bandage, which I have al- ready mentioned fo frequently in the cure of ulcers. In order to prove ufeful, however, it muft be continu- ed for a great length of time. With this attention, it feldom fails to anfwer, and to render unneceffary that painful operation, fo frequently advifed, of extirpating, as in cafes of aneurifm, the difeafed or fwelled parts. The effed of preffure in the cure of fores, I have already taken different opportunities to mention ; but it proves in a particular manner ufeful in ulcers with callous edges. In fores of this defcription, the hard- nefs or callofity of their edges, is not the only imped- iment to a cure; the contiguous parts are always much tumefied ; and this tumefadion muft be entire- ly removed, before any permanent cure can be ob- tained. This fwelling of the contiguous parts originates moft probably from obftrudion in the fmaller veffels of the 39* Observations on the Chap, V. edges of the fores, in confequence of preffure produc- ed by the callofities which furround them: and ac- cordingly it fometimes fubfides entirely by the appli* cation of emollient poultices alone. But when thi$ does not happen, prelfure obtained by a proper and continued ufe of a flannel roller, will very commonly prove fuccefsful, SECTION VII. Obfervations en the carious Ulcer. J i. Of the Symptoms and Diagnofis of the carious Ulcer. EVERY fore feated upon, or communicating with, a carious bone, may be termed a carious ulcer. Caries appears to be the fame difeafe in bones with fphacelus or gangrene of the foft parts; as 1 think, is obvious, both from the fymptoms, caufes, and meth- od of cure, The bones not being fo plentifully fupplied with blood veffels as the fofter parts of the body, the anaf- tomofing of different veffels does not occur fo fre- quently in them ; fo that, when any confiderable ar- tery of a bone is deftroyed, the parts which it fupplied naturally fuffer more than any of the fofter organs would do from an injury of a fimilar nature. And, as all the blood veffels of bones are known to pafs to them through their furrounding membrane the periofteum, upon which they generally run for a confiderable way before they penetrate deeper, it is not uncommon for a bone to become carious which has not otherwife been injured than by having a final! portion of its membrane deftroyed. Sed. VII. carious Ulcer. 393 I do not, however, mean to fay, that a caries muft neceffarily fucceed to the deftrudion of part of the periofteum ; for the contrary often happens : and un- lefs the injury has been fo confiderable, as at the fame time either to affed the ftrudure of the bone itfelf, or to occafion, as I have already obferved, the destruc- tion of fome principal artery, a caries will never occur from the periofteum being abraded ; but whenever an accident has produced either of thefe effeds, the oth- er will almoft conftantly take place. From the firft appearance of a bone after being laid bare, if it has not been much injured, we can never at once determine whether caries will fucceed or not. In mere abrafions of the periofteum, I would, from a number of obfervations, conclude, that there is at leaft an equal chance that it will not: a ffiort time, however, will commonly refolve the uncertainty. For if, at the end of the fourth or fifth day, a bone that has been denuded ftill retains its natural appear- ance, we may in general, with certainty, conclude, that caries will not fucceed; and may accordingly proceed with the cure, as if the wound was of the moft fimple nature, which we could never with pro- priety do, whilft any uncertainty continued of the ftate of the bone ; and hence the importance of being foon able to determine whether a bone laid bare is to be at- tacked with caries or not. For, if a cure fhould be attempted in a cafe where caries is to follow, and if the fore ffiould be made to cicatrize, all the new parts would be again to deftroy,- much unneceffary pain would be given to the patient, and a permanent cure much longer delayed than if proper meafures had been taken at firft. When a denuded bone is to become carious, it ufu- ally ffiows itfelf in a ffiort time. By the end of the fourth or fifth day, the bone begins to lofe its natural healthy appearance : it turns firft of a pale white, and then gets a flight tinge of yellow; and whenever this 394 Observations on the Chap. V. begins to appear, there can be no further doubt of what will enfue. It fometimes remains, however, in this ftate, for a confiderable time, and by degrees gets a more deep tallow like appearance; in which ftate it commonly continues for a longer or ffiorter time, according to the degree of violence with which the injury has been inflided : afterwards it goes through the different fta- ges of brown and dark, till it has acquired a black of the deepeft dye, a period at which we may fuppofe this portion of bone to have arrived at the higheft de- gree of mortification. The difcharge is never of the confiftence of good pus: it is generally confiderably thinner; and from the firft appearance of a caries, it acquires a very dif- agreeable fetor, which always turns more confiderable as the different ftages of caries advance ; and at laft becomes dark, or even black, at the fame time that it is frequently very acrid. As the feveral degrees of blacknefs or mortification go on, fmall foramina or holes form over its whole furface, which, by degrees, increafe both in fize and number, till even the moft folid bones acquire a kind of fpongy appearance. In this fituation, the mortifi- ed portion generally becomes loofe, and, when preffed upon, a confiderable quantity of greafy kind of mat- ter, with an intolerable fetor, can commonly be forced out from the different openings ; which fo taints the whole difcharge from the ulcer, and gives it fuch a very peculiar fmell, as renders it fcarcely poffible for any praditioner who has once known what it is, ever to be deceived with refped to the existence of caries. Indeed, this alone affords almoft as certain a distinc- tion in cafes of latent caries, as any that can be given. In ulcers attended with a carious bone, the new granulations never have a healthy appearance; they are foft, and more flabby than natural; and, inftead of being red and florid,-they have commonly a dark brown complexion. * Sed. VII. carious Ulcer. 395 The granulations, however, commonly advance quickly enough ; and they would frequently proceed too far, if not prevented by art; a piece of attention always neceffary, till the difeafed parts of the bone are either call off by the efforts of nature, or are cut out by art, fo as to admit of the fore being firmly heal- ed from the bottom. And, when negleded for any confiderable time, thefe foft produdions frequently in- creafe fo remarkably, as to form very large and trou- blefome excrefcences, I have hitherto been fuppofing, that only a portion of the fubftance of a bone is difeafed ; in which cafe a cure is fometimes obtained by a fingle lamina only calling off. But the fame phenomena take place when a caries has been fo confiderable, as to affed the whole circumference of a bone. Only, in this cafe, the ca- ries generally advances more quickly ; and, in the courfe of the cure, it is often neceffary that the whole fubftance of the bone, in the difeafed part of it, ffiould be removed. Such are the appearances of caries, produced by ex- ternal accidents, laying a bone fairly open to view : but caries likewife occurs in a more latent manner, particularly in ulcers of long duration. Ulcers of long continuance above the tibia, and other bones not thickly covered with foft parts, by the matter infinuating to the periofteum, and there pro- ducing inflammation and fuppuration of that mem- brane, by which the bone itfelf is apt to be eroded, very often give rife to caries ; and this, as long as it continues, prevents effedually the cure of the ulcers, notwithftanding the ufe of every remedy that can be employed. For when, in fuch circumftances, a cica- trix is induced, the cure never proves permanent; for the difeafe, in the courfe of a ffiort time, always breaks out again. In cafes fuch as we are confidering, when the ulcer |s neither deep nor extenfive, and the bone ftill remains covered, a caries is not always eafily difcovered; fo 39^ Observations on the Chap. V. that praditioners are frequently, for fome time, at a lofs how to proceed : with due attention, however, and efpecially with the aid of experience in fimilar circumftances, the ftate of the bone may, in general, be eafily difcovered. When by the introdudion of a probe at any open- t ing that may be formed, if a roughnefs is difcovered on the furface of the bone, the cafe at once becomes obvious. Such information, however, is not always to be ob- tained ; for frequently there is no evident opening in the furface of the fore ; fo that no inftrument can get admiflion ; and at other times, even when an opening fufficiently large is met with, and when a caries cer- tainly exifls, the difeafed part cannot be reached with the probe on account of the obliquity or winding di- redion of the finus which leads to it. Although, in fuch cafes, however, the bone itfelf cannot be immediately reached ; if fufficient attention is given to the appearance of the fore, and to the na- ture of the difcharge, we need not often remain long in doubt. When the bone is carious, any new parts which may have formed in the ulcer, are commonly, as I have remarked already, foft and flabby ; and, inftead of forming a regular furface, the new granulations fprout up unequally, and inftead of a healthy red ap- pearance, they have a dark brown complexion. Thefe circumftances, when they take place, togeth- er with the difcharge of a thin, dark, greafy matter from the ulcer, accompanied with the peculiar offen- five fetor, which caries always affords, point out the real ftate of a bone, with almoft as much precifion as if the bone itfelf was clearly expofed to view. § 2. Of the Caufes and Prognofis of the carious Ulcer. All thofe accidents which can occafion denuda- tion, lofs of fubftance, or erofion of a bone, have Sed. Vn. carious Ulcer. 397 commonly been enumerated as the caufes of caries. But it is a circumftance well known to praditioners, that the common teguments and periofteum are fre- quently deftroyed, without any degree of caries tak- ing place ; and that even a confiderable lofs of fub- ftance in a bone may occur, without being followed by this appearance. The caufes, therefore, of caries, may be faid to be, whatever can, by erofion or otherwife, deftroy the circulation in the whole or in any part of a bone. In this view, may be mentioned, wounds affeding either the periofteum or bones, violent contufions, and inflammation of the periofteum, from whatever caufe it may proceed, when it ends either in abfcefs or gangrene ; the acrid matter of ulcers penetrating to and destroying the periofteum ; and the applica- tion of acrid fpirits and powders, to bones merely laid bare ; a pradice recommended very univerfally by almoft all the ancient writers on this part of furgery. Blood effufed upon a bone by the rupture of an arte- ry or a vein, is very apt to produce caries; and I may alfo mention as a frequent caufe of caries, the pref- fure produced upon bones by large deep feated tu- mors, which evidently ad by destroying the circula- tion in the periofteum and bone beneath. I have obferved above, that lofs of fubftance in a bone does not always produce caries. Thus, very confiderable portions of the cranium, are frequently taken out when fradured, without any caries of the remaining part of the bone taking place; and, that this likewife happens occafionally in other parts of the body, I have had various opportunities of obfery- ing. That fuch occurrences, however, do not fo fre- quently take place in other bones as in thofe of the cranium, cannot be denied ; and the reafon probably is, that by a greater proportion of blood Veffels going to the bones of the fkull than to any of the long bones, any violence which might otherwife be fuffi- 398 Observations on the Chap. V. cient for putting a ftop to the circulation in the injur- ed part, may by this mechanifm be prevented ; and if no ftoppage is given to the circulation, no caries will enfue, for it is to this alone, as I have already endeavoured to ffiew, that in a great proportion of cafes caries is to be attributed. In every inftance of caries, the prognofis muft de- pend upon a variety of circumftances : the principal of which are, The fituation of the difeafed parts; the nature and organization of the affeded bone ; the nature and degree of.the infliding caufe; the extent of the dif- eafe ; the age and habit of the patient. Thus, it will readily be allowed, that caries in any of the bones of the fkull, ribs, or vertebras, by thofe parts being conneded with organs fo immediately ne<« ceffary for life, muft be attended with more rifk, than a caries of the fame extent, in any of the bones of the extremities. For a fimilar reafon, caries feated near to any of the joints, from the danger of thefe becoming affed- ed, is always attended with more rifk than when the difeafe is confined to the middle of a bone. The confiftence or texture of a bone, too, has no fmall influence in every cafe of caries ; exfoliations being much more tedious, in the hard and compad bones, than in thofe that are foft and vafcular. Thus, although caries is attended with more rifk in the fkull than elfewhere, if it admits of a cure at all it never in this fituation proves nearly fo tedious as in the hume- ' rus, femur, or tibia. The nature of the caufe by which caries is produ- ced, ffiould likewife have fome influence on the prog- nofis. Thus, a wound with a ffiarp cutting instru- ment, that may have deftroyed not only fome of the periofteum, but even part of the bone itfelf, does not generally produce fuch a deep or extenfive caries, as commonly fucceeds to fevere contufions of bones with / perhaps no immediate lofs of fubftance. Sed. VII. carious Ulcer. 399 The extent of the difeafed part, is alfo a circum- ftance of much importance in the cure of caries. This is, no doubt, the cafe in every ulcer, but it is more particularly fo in all cafes of caries ; for we conftantly find that much more time, in proportion, is required for the feparation of a large piece of fpoil- ed bone, than what in general is fufficient for the re- moval of a fmaller portion. And, laftly, the patient being young or old, heal- thy or otherwife, are circumftances which neceffarily have much influence on the progrefs of the cure. This happens indeed in every ulcer, but in a more re- markable degree where caries takes place than in oth- ers, owing to ulcers of this defcription being com- monly fo tedious, that few constitutions are able to fupport the difcharge, if they have not previoufly been robuft and healthy. Thefe are the leading circumftances requiring our attention, in the treatment of ulcers attended with ca- rious bones ; and it is from a due attention to all of them that a juft prognofis is to be formed. § 3* Of the Cure of the carious Ulcer. Caries being a difeafe of the fame nature in the bones, with mortification in the foft parts, no cure it is evident can with propriety be attempted, till the re- moval of the difeafed parts is accompliffied. For if an union of the foft parts ffiould be obtained* the dead portion of the bone beneath not having any connedion with the contiguous found parts, by thus ading as a caufe of irritation, would foon produce an abfcefs or colledion of matter, and in this manner would force open the parts newly united. In a healthy ftate of the constitution, the feparation of mortified parts from fuch as remain found, is, in general, accomplifhed by a natural exertion of the fyftem. 400 Observations on the Chap. V« The courfe which nature follows in effeding this, feems, as I have formerly remarked when treating of gangrene, to be through the intervention of a flight degree of inflammation, which forms as it were, a boundary between the found parts and fuch as are dif- eafed. Inflammation thus induced is foon fucceeded by a ferous exfudation from the mouths of the found vefj fels : to this fuppuration enfues, together with the for- mation of new granulations over the furface of the found parts below, by which all the difeafed parts are foon completely feparated and thrown off. This happens in the mofl evident manner in mortis fication of the fofter parts of the body; and it requires very little attention to difcover the fame phenomena in every cafe of caries. Only, from there being in the bones, as I have formerly remarked, a more fparing distribution of blood veffels, and confequently not fuch a difpofition to inflammation, the exertions of nature, for the removal of caries, are feldom fo obvious or fo quickly accompliffied. From thefe confiderations, it is obvious, that out chief indication in the cure of caries, is to excite, and continue as long as may be neceffary, fuch a degree of inflammation in the adjoining found parts of the bone, as may be requifite for the total feparation of thofe that are difeafed. With a view to this, the difeafed part of the bone muft be laid freely bare. In fome inftances, this may be done by a fimple incifion along the courfe of the Caries, but in others we find it neceffary to make a crucial incifion, or even to take away part of the teg- uments altogether. And till the difeafe of the bone is entirely removed, it is neceffary, from time to time, to prevent the formation of new parts, at leaft in fo far as might obftrud the feparation of the caries. In former times, it was the prevailing practice, when a bone was laid bare, whether carious or not, to cover every part of it with powders and tindures of aloes, Sed. VII. carious Ulcer. 401 euphorbium, myrrh, and other warm gums. This was probably fuggefted with a view to corred the fe- tor and putrefaction that always take place in caries ; and from cuftom only it has by fome been continued ; for the only effeds which thefe applications 'can pro- duce, further than that of correcting putrefadion, is to irritate and inflame the foft parts of the fore, without having the leaft influence on the more material difeafe of the bone. For, when the caries is not quite fuperficial, thefe fubftances can never penetrate to, or affed the found parts of the bone, where alone, by the irritation they would excite, fome benefit might accrue from them. And again, when no caries has appeared, thefe ap- plications to bones merely denuded of the periofteum, can never, in any refped, be neceffary; while they may frequently be the means of inducing difeafe which otherwife would not have appeared. Another remedy much recommended by almoft every author, in the more advanced ftages of caries, is the adual cautery. It ought, however, to be en- tirely exploded ; for, in whatever way we fuppofe it to be applied, it muft certainly do harm. If applied in fuch a manner as entirely to deftroy the difeafed parts of the bone, the found parts beneath, from the degree of heat that is neceffary for this pur- pofe, would commonly be fo much injured, as to be foon rendered equally carious with thofe intended to be removed. And, on the contrary, when ufed in a more limited manner, the difeafed part of the bone will not be re- moved, whilft at the fame time much rifk would be incurred of retarding the natural exertion of the fyf- tem for the removal of the difeafe : for even a very moderate heat will affed the deftrudion of fuch gran- ulations as nature may for this purpofe have already formed ; and the jufl degree of heat, I may here re- mark, that is neceffary for destroying the morbid Vol. I. C c 402 Observations on the Chap. V. parts, without affeding the found, it is fcarcely poffi- ble to determine. When, for any particular reafon, the adual cautery may not be judged proper, it has been recommended by many, to employ artificial cauftic preparations ; and by others, we are advifed, as the ffiorteft procefs, to ftrike off at once all the difeafed parts of the bone with a chifel and mallet. But the objedions to the ufe of the cautery, which I have ftated above, hold equally ftrong with refped to thefe: fo that every application of this precarious nature ffiould be entirely laid afide ; efpecially as we have it in our power to accomplish the fame indication in a much more fafe and certain manner. For the purpofe of exciting the neceffary degree of inflammation, the moft effedual method, and which, in flight cafes of caries, proves always fufficient, is to make a number of fmall perforations over all the fur- face of the difeafed bone, to fuch a depth as to give the patient a flight degree of pain, and no farther. This operation being renewed every third or fourth day, the difeafed portion of bone, in the courfe of a ffiort time, not only lofes cohefion between its own parts, but a gentle inflammation being, by the fame means, raifed and kept up till a free fuppuration is pro- duced, the whole mortified mafs is generally, in a fhort time thereafter, entirely thrown off from the found parts beneath. Thefe perforations are very conveniently and effec- tually made by a pin or perforator, fuch as is ufed for fixing the head of the trepan ; which being fixed in the handle of that inftrument, it is thereby wrought with much eafe and expedition. Although this operation, in general, anfwers the purpofe in flight cafes of caries, when not of great ex- tent, and which do not penetrate deeper than the firft or fecond lamella of a bone ; yet when the caries is extenfive, and goes deep into the fubftance of a bone, Sed. VII. carious Ulcer. 4©3 it fhortens the procefs greatly, if, inftead of the perfo- rator, a fmall head of a trepan is employed. This inftrument being applied at proper distances over the furface of the caries, and carried to fuch a depth as to excite a flight degree of pain, that degree of inflammation which I have ffiown to be fo neceffa- ry for the cure, is thus very quickly induced : and at the fame time, by converting, as it were, an extenfive caries into fo many diftind parts, the feparation of thefe from the found bone below comes to be more eafily accompliffied, than if the whole furface had ftill remained in one continued piece. As foon as any of the parts become loofe, their final feparation may be always haftened, by daily infinua- ting below them the end of a common fpatula or le- vator, fo as to prefs their edges gently upwards. The head of a trepan is frequently employed for taking out a piece entirely when bones become cari- ous through the whole fubftance of their different la- mellae ; but, in the ftate of the difeafe which we are now confidering, the caries is not fuppofed to have penetrated to fuch a depth, and confequently fuch a pradice cannot with propriety be advifed. After the ufe of either of thefe instruments, the ul- cer is to be dreffed in the ufual manner. Only, as long as any of the caries remains, the putrefcency and fetor of the matter are commonly fo confiderable, that it becomes neceffary to employ fome remedies to cor- red it. For which purpofe, a ftrong decodion of Jefuit's bark and walnut tree leaves is frequently ufed with advantage: and a folution of camphor in weak brandy is alfo an application by which this fetor of morbid bones is removed. The carious part of the bone ffiould be daily dreffed with pieces of foft lint foaked in either of thefe, whilft the reft of the fore may be treated in the manner I have advifed in Sed. II. for the fimple purulent ulcer. This putrefcency of the difcharge afforded by cari- ous ulcers, is likewife much corrected by the applica- c c 2 404 Observations on the Chap. V. tion of lime water : if the fores are frequently moift- ened with foft cloths dipt in lime water, the matter feldom becomes very offenfive; and as this remedy feems to have fome influence in destroying the cohe- fion* of offeous matter, it ffiould in mofl inftances be employed. Since I firft employed lime water in ulcers attended with carious bones, I have met with different inftances of exfoliations being much promoted by the continued ufe of it. As foon as the carious parts are all removed, the whole being then in the ftate of a fimple purulent ul- cer, will fall to be treated accordingly : for, although we are particularly direded by authors, never, in any cafe of caries, or of denuded bone, to make ufe of ointments, or greafy applications ; yet, as there was never any juft reafon given for this prohibition, I long ago made trial of ointments in every cafe of caries; and, no inconvenience having enfued, I have fince that period been in the daily pradice of applying them as freely to bones as to other parts. Of the great variety of books which I have had oc- cafion to confult upon this fubjed, none have afforded me more fatisfadion than a Treatife on Carious Bones, by the late Dr. Monro ; and I am happy to find, that the pradice I have ventured to recommend, is fupport- ed by the authority of fiich an eminent praditioner ; who, after fpeaking of the application of unduous fubftances to bones, not only admits of it as fafe, but recommends the pradice as exceedingly ufeful; and fays, " I can now, after a great many trials, affure " you, that no medicines fo effedually prevent the cor- " ruption of bones laid bare, and ajfift to cover them " fo foon with fleffi, as ointments."* * In the fame ingenious Differtation, may be feen a particular account of the feveral fpecies of caries; with a lift of authors in different ages, from Hippocrates downwards, who have written upon it, with the feveral methods of cure propofed by each of them. Vide Monro's Works, 4to. Edin. 1781, p. %%it &.c. Sed. VII. carious Ulcer, 405 Hitherto we have been fuppofing, that the difeafe does not penetrate far into the fubftance of a bone : but when the reverie of this is the cafe, and a confid- erable portion, perhaps, of the whole circumference of a bone is difeafed ; or when the difeafe extends even round a whole bone, as in many inftances is the cafe ; the ffiorteft procefs in this fituation is, to take out at once all the difeafed parts, either with the head of a trepan frequently applied, or by means of a fmall fpring faw. Many inventions have been propofed for cutting out portions of carious bones which lie deep : with a view to proted the contiguous parts from the opera- tion of the faw, it has been advifed to cover them with thin plates of fteel; and faws of various forms have been invented for dividing the bone. Almoft every part of furgery is already too much loaded with machinery ; but no operation with which we are acquainted, feems to require lefs aid from new instruments than the removal of a portion of carious bone. In whatever part of the body the difeafe is feated, the teguments and mufcles which cover the caries ffiould be freely divided ; and, when the bones of any of the extremities become carious, if this is done to a proper extent, fo as to admit of a piece of firm leather being inferted below the bone, for the purpofe of proteding the foft parts on the oppofite fide of the limb, a common straight faw will anfwer, in almoft every cafe, better than any other. But when the bone lies deep, a fmall fpring faw of a cir- cular form may be employed for dividing fuch parts of it as cannot be eafily reached by the common faw. Thus, either by the ufe of the trepan, or with a faw, any portion of a difeafed bone may be removed ; a pradice which may frequently be employed to much advantage in the fkull, in the bones of the hands and feet, and in thofe of the legs and arms, when the ca- ries does not run into the necks and heads of the bones, fo as to affed the joints : in which event if 406 Observations on the Chap. V. an anchylofes does not enfue, or if nature does not by fome means or other effed a cure, amputation of the limb muft almoft always become neceffary at laft ; a caries of the extremities of large bones being one of the many complaints for which art has not as yet dif- covered a remedy. But, whenever caries is confined to the middle of any of the bones of the extremities, excepting, per- haps, in the thigh, where the thicknefs of parts is con- fiderable, amputation of the limb ffiould never be ad- vifed for it: for, with due perfeverance and attention, if the patient's health is not injured, nature may, in general, be fo far affifted by removing the difeafed parts, that a complete cure will at laft be obtained. And in no cafe whatever ffiould we defpair, when the carious part can, with fafety be removed: for, how- ever extenfive the difeafe may be, if we can complete- ly remove it, nature will feldom fail on her part to fill up the vacancy ; there being many inftances on record, even of whole bones being regenerated. I have already obferved, that in caries of the larger joints, amputation of the difeafed limb is almoft the only remedy on which we have to depend : it has, however, been propofed, and even attempted, to fave limbs in this fituation, by cutting out the ends of the carious bones. Mr. Park, an ingenious furgeon of Liverpool, has publifhed a treatife upon this fubjed, in which he gives the hiftory of a difeafed knee joint, where this operation fucceeded. Although much me- rit, however, is due to whoever makes any probable attempt for faving limbs which otherwife would be amputated, and although the public is much indebted to Mr. Park for the trouble he has taken to promote the fuccefs of this operation, yet, from various cir- cumftances, there is much reafon to think, that it will never prove to be of general utility : befides other objedions which occur to it, the rifk which attends it is evidently greater than what ufually refults from the amputation of limbs: the extent of ulcer induced by Sed. VII. carious Ulcer, 407 it is greater ; the fuppuration is of courfe more plen- tiful ; and the matter not fo freely difcharged. I do not here, however, think it neceffary to enter more fully into the difcuffion of this point, as I ffiall have occafion to fpeak of it more particularly in the chap- ter upon amputation. During the treatment of caries, it muft be under- stood that the fame attention is requifite to the habit of body of the patient, to his diet and other articles of regimen, as in other varieties of ulcers. Thus, if he is of a full inflammatory conftitution, all heating and very nourifhing articles of food ffiould be abstained from ; while a nourifhing diet ffiould be allowed, if the fyftem is low and emaciated, as from the long continuance of caries is moft frequently the cafe. In fuch cafes, too, as tonic remedies are much Wanted, Peruvian bark becomes particularly ufeful, and it ffiould always be given in large quantities. The bark ineeed is almoft the only medicine which, in caries we find it neceffary to advife ; but when the parts that cover a carious bone become painful, as in fome inftances is the cafe, we are then under the ne- ceffity of having recourfe to opiates ; and, as the pain is in fuch circumftances commonly induced by the distention of the periofteum, in confequence of the bone becoming enlarged, 1 have frequently made trial of flight fcarifications, or of bleeding with leeches di- redly on the pained parts ; by which means relief is fometimes obtained, when it cannot be procured by any other means. I may here alfo remark, in addi- tion to what has been faid ijpon this fubjed in a former fedion, that in every variety of ulcer attended with much pain, leeches applied either upon the edges of the fores, or diredly on the ulcer itfelf, are often attended with the beft effeds, infomuch that I am now in the daily habit of ufing them, whenever a fore becomes fo inflamed and painful as to refift the influ- ence of poultices and the other means ufually em- ployed for relief. 408 Observations on the Chap. V. In every carious ulcer, as foon as the difeafed part of the bone is taken away, the fore which remains is to be treated in the manner that I have already advif- ed for the management of that variety of ulcer, to which, at the time, it may appear to belong. SECTION VIII. Obfervations on the cancerous Ulcer. § i. Of the Symptoms and Diagnofis of the cancer- ous Ulcer. CANCERS have been generally divided into oc- cult and open. By the firft are meant thofe hard glandular fwellings accompanied with frequent fhooting pains, which, for the moft part, terminate in open cancerous ulcers, the ufual appearances of which are thefe : the edges of the ulcer are hard, ragged, and unequal, very painful, and reverfed, being fome- times turned upwards and backwards, and in other inftances inwards. The whole furface of the fore is commonly unequal : in fome parts fungous excref- cences arife, whilft in others deep excavations take place. The difcharge for the moft part is a thin dark coloured, fetid ichor ; and often fo acrid as to exco- riate, and even to deftroy, the neighbouring parts. In the more advanced ftages of cancer, from fome of the blood veffels of the ulcer being eroded, large quanti- ties of pure blood are often difcharged. Patients labouring under the real cancerous ulcer, univerfally complain of what they term a burning heat over the whole ulcerated furface; and this we may remark is for the moft part the moft tormenting fymptom attending the difeafe. Sed. VIII. cancerous Ulcer. 409 Thefe are the moft frequent fymptoms of cancer ; but the appearances which this difeafe affumes are fo various, that it is almoft impoffible in any defcription to comprehend all of them. In addition to this, however, I may remark, that we derive fome affiflance in the diagnofis of thefe ul- cers from their fituation, for although cancers occa- fionally occur in every part of the body, yet we meet with the greateft proportion, either evidently in the fubftance of one or more glands, or in thofe parts where glands are known to be molt numerous. Thus, fix times the number occur in the lips and breafts of women, than in all the reft of the body befides. § 2. Of the Caufes of Cancer. Various opinions have been fuggefted by authors on the caufe of cancer, and various remedies have been recommended for the cure. But the little fuc- cefs which ftill attends our treatment of cancer, ffiows, that the opinions which have been formed of it, have been more founded in theory alone, than on pradice and obfervation; for there is no difeafe to which the human frame is liable, that has baffled the power of art more than this variety of ulcer. Although an acquaintance with the theory of can- cer might throw fome light on the method of cure; yet as all that has hitherto been faid upon the fubjed, is merely fpeculative, and not fupported by experi- ence, any account we could give of it, would neither afford entertainment nor inftrudion. Before going farther, however, I ffiall examine with attention the opinion that has hitherto very commonly prevailed, of cancer proceeding from a general affedion of the fyftem. This is a point, I may remark, of much importance in pradice : for were it once eftablifhed, that cancers are at firft always local, no objedion could be made to their cure by extirpation, as at prefent there is by 4 ict Observations on the Chap. V. many, who contend, that cancers, in every inftance, proceed originally from fome difeafe in the fyftem ; and confequently, that removing them can have no other effect than to make the difeafe again break out in the fame or fome other part of the body ; in which they fay they are confirmed, from the little fuccefs that we derive from the extirpation of cancer; the difeafe, as they allege, generally returning, in a great proportion of all that are cut. If this argumant were founded in fad, it would no doubt merit much attention ; though, even in this cafe, it would not be conclufive againft the operation, as I ffiall hereafter endeavour particularly to ffiew : it will foon however be demonstrated, and to many indeed is already known, that a much greater proportion re- cover and do well after the extirpation of cancers, than many are apt to imagine ; and it is probably the fault of furgeons, or of patients, only, who generally delay the operation too long, that the number of thofe who recover is not greater than hitherto it has been. It is of the more importance to have the point in queftion confidered, as the only account of the fuccefs from extirpation, which, till lately, has appeared in this country, gives fo bad a profped of recovery, that it feems to have had the effect of deterring many from fubmitting timeoufly to this operation ; which, for ev- ery cafe of cancer, is the only remedy upon which we can depend for a cure. I alfo think it probable that the fame publication, as coming from good authority, has had much influence, even with praditioners, in making them more averfe to the extirpation of cancers, than they otherwife prob- ably would have been. The publication to which I allude, is that of the late juftly eiteemed Dr. Alex. Monro, in Vol. V. of Edinburgh Medical Effays; where the Dodor fays, " Of near fixty cancers which I have been prefent at " the extirpation of, only four patients remained free " of the difeafe at the aid of two years : three of thefe Sed. VIII. cancerous Ulcer. 411 " lucky people had occult cancers in the breaft, and " the fourth had an ulcerated cancer on the lip." The dodor likewife obferves, that of the few he had an opportunity of feeing the difeafe relapfe in, it was always more violent, and made a quicker progrefs, than it commonly did in others on whom no operation had been performed. He therefore propofes by way of queftion, " whether ought cancerous tumors to be " extirpated, or ought the palliative method only to " be followed when they cannot be refolved ?" and, upon the whole, he concludes againft their extirpation, except in fuch as are of the occult kind, in young healthy people, and that have been produced by bruif- es or other external caufes. In all other cafes, the Dodor obferves, it ffiould be the patient's earueft en- treaty only, after the danger of a relapfe has been ex- plained, that ffiould make a furgeon undertake the operation. That Dr. Monro, from obferving the difeafe return fo frequently, ffiould be of this opinion, is not furprif- ing : and if no better fuccefs ffiould, in general, at- tend the extirpation of cancers, it would no doubt be an objedion to the pradice ; and this efpecially, if all the cafes which relapfe, ffiould be attended with more inveterate and more painful fymptoms, than ei- ther occurred before the operation, or than probably would have taken place, if the tumors had not been extirpated. But the experience of many praditioners fince Dr. Monro's publication, has been attended with much greater fuccefs ; and one late publication, which I ffiall prefently notice, puts it beyond a doubt, that a much greater proportion have recovered from cancers by means of extirpation, than of thofe which were treated in the fame manner in the courfe of his expe- rience. It will not therefore appear to be improper, to attempt to difcover the reafon of the Dodor's great want of fuccefs in fuch cafes, in comparifon with what 412 Observations on the Chap. V. others have met with ; and this, it is prefumed, it will not be difficult to do. It may, I think, be confidered as certain, that the fooner cancers are removed, the greater will be the chance of a permanent cure, and vice verfa. Now, it is probable, that the high rank which Dr. Monro bore in his profeffion, both as an anatomift and furgeon, would be the means of his being confulted in more bad and old cafes of cancer, as well as of other difea- fes, than perhaps any other praditioner of his time. Patients in the country, with flight cafes of cancer, have them generally taken off by their own furgeons; but whenever they become inveterate, by long stand- ing or otherwife, they always refort to a town ; to the capital, when they can conveniently do fo ; and there the moft eminent in his profeffion is naturally confult- ed. This being the cafe, we need not wonder at the want of fuccefs in many of the operations performed in fuch cafes of cancer as occurred to Dr. Monro. From the caufe to which I allude, a great proportion of the whole would be of the worft kind ; fo that we need not be furprifed either at the bad fuccefs of the operations that were advifed, or at the opinion which the Dodor afterwards formed of them. While fuch unfavourable cafes as thefe would moft frequently occur to Dr. Monro in private pradice; thofe which he would meet with at the infirmary would, in general, be equally bad. For in every hof- prtal, it is commonly the worft cafes that are met with ; as, before applying for this kind of affiflance, private furgeons are ufually confulted, who generally retain the patient under their own management, if the cafe does not appear to be defperate, or if any reputation is likely to be got from an operation : while, on the contrary, when the difeafe is evidently inveterate, and when an operation therefore would be attended with much rilk, the patient is always fent to a public hof- pital. So that no fair judgment, from the refult of fuch experience, in cancerous cafes efpecially, can ev- Sed. MIL cancerous Ulcer. 413 er be formed, unlefs at the fame time thefe different circumftances are properly confidered, and due allow- ance made for them. This, in my opinion, is the only way in whieh the great want of fuceefs which attended the extirpation of cancers in the courfe of Dr. Monro's experience, can be accounted for ; and it explains it, I think, in a very fatisfadory manner : fo that the only conclusion that can be drawn from this part of the Dodor's pa- per, is, that there is little chance of fuccefs from ex- tirpation in the more advanced ftates of cancer ; a circumftance which ought, therefore, to make us ad- vife the operation in the earlieft flages of the difeafe, when there is much reafon to think that in general it would fucceed. Such expedations will perhaps, by many, be con- fidered as too fanguine; and they no doubt would be fo, if the fuccefs which in general attends the opera- tion, was all that could be attained; but that it has hitherto for the moft part proved unfuccefsfui, ffiould not be imputed either to the nature of the difeafe, or to the fault of the remedy; but entirely to its being, in a great proportion of cafes, delayed too long, till the fyftem has become fo much infeded, that we ffiould rather wonder at the operation fucceeding fo frequently, as even in the general courfe of pradice it appears to have done. This being a very important pradical queftion, I think it right, in fupport of the opinion which I have given of it, to introduce a ffiort abftrad from a late publication on cancers, by the late Mr. James Hill, an eminent furgeon in Dumfries, who, in the courfe of an extenfive pradice, had more experience in the treatment of cancer, than often falls to the ffiare of an individual. In the year 1772, the date of this publication, Mr. Hill had extirpated from different parts of the body, eighty-eight genuine cancers, which were all ulcerated except four; and all the patients, except two, recov- ered of the operation. 414 Observations on the Chap. V. Of the firft forty-five cafes, only one proved unfuc- cefsful; in three more, the cancer broke out again in different parts; and in a fifth there were threatenings of fome tumors at a diftance from the original difeafe. Thefe tumors, however, did not appear till three years after the operation, and the woman was carried off by a fever before they had made any progrefs. All the reft of the forty-five continued well as long as they* lived ; or are fo, fays Mr. Hill, at this day. One of them furvived the operation above thirty years ; and fifteen were then alive, although the laft of them was cured in March, 1761. Of the next thirty-three, one lived only four months ; and in five more the cancer broke out afrefh, after having been once healed. The reafon why, out of forty-five cafes, only four or five proved unfucceff- ful, and fix out of thirty-three, was as follows : " The extraordinary fuccefs I met with," continues our author, " made cancerous patients refort to me from all corners of the country, feveral of whom, af- ter delaying till there was little probability of a cure by extirpation or any other means, forced me to per- form the operation, contrary both to my judgment and inclination." Upon a furvey in April, 1764, made with a view to publication, the numbers flood thus : total cured of different ages from eighty downwards, fixty-three; of whom there were then living, in all thirty-nine. In twenty-eight of that number, the operation had been performed more than two years before, and in eleven it had been done in the courfe of the laft two years. So that, upon the whole, after a courfe of thirty years pradice, thirty-nine of fixty-three patients were alive and found; which gives Mr. Hill occafion to obferve, that the different patients lived as long after the extirpation of the cancers, as, according to the bills of mortality, they would have done, had they never had any cancers, or undergone any operation. Sed. Vin. cancerous Ulcer. 415 The remaining twenty-five, which completes the eighty-eight, were cured fince the year 1764. Twen- ty-two of thefe had been cured, at leaft, two years; and fome of them, it may be remarked, were feventy years, and one ninety years old. In the year 1770, the fum of the whole flood thus : of eighty-eight cancers, extirpated at leaft two years before; not cured, two; broke out afreffi, nine ; threatened with a relapfe, one ; in all, twelve ; which is lefs than a feventh part of the whole number. At that time there were about forty patients alive and found, whofe cancers had been extirpated above two years before. I have been the more particular in giving this ac- count of Mr. Hill's fuccefs in cafes of cancer, as it is the lateft, and perhaps the moft confiderable, even in point of number, that the public was ever favoured with: and I am the more readily induced to it, from having affifted at many of the operations ; and from knowing that no fallacy or miftake could occur in the relation, Mr. Hill having been fo exad, as to keep a register of every cafe of importance that came under his management. From thefe and other authentic fads, which if ne- ceffary might be adduced, of the fuccefs attending the extirpation of cancers, there is much reafon to con- clude, that the difeafe, in general, is local; and that a general cancerous taint feldom, or perhaps never, occurs, but in confequence of the cancerous virus be- ing abforbed from fome local affedion. The particular nature of the cancerous virus, I do not pretend to know; nor will it perhaps ever be dif- covered : but it is not unreafonable to fuppofe, that external accidents merely, may produce fuch an effed upon particular parts, as to induce the formation of a matter, even as acrid as that of cancer. Thus we have daily inftances of vitiated fores pro- ducing very acrid matter, which could not previoufly have exifted in the blood : and, if this is the cafe, 416 Observations on the Chap. V. why may not fome peculiar affection of a part contri- bute to the formation of cancerous matter ? the one may be conceived a. priori, juft as probably to occur as the other; and it does, I apprehend, as certainly do fo. The ordinary fituation of cancers may, in fome meafure too, account for the difcharge which they afford being even more acrid and virulent than that of any other kind of ulcer. For being in general feated in the glands, which are known, even in more fimple affedions, never to produce good matter, it is not im- probable, but, by fome peculiar irritation applied to a gland, that fuch a difpofition may be induced in it, as to terminate in the formation even of cancerous mat- ter ; which being allowed to remain, and abforption to take place, the whole fyftem comes at length to be as it were faturated with it; and thus a general affec- tion, or what may be termed the cancerous diathefis, is produced, from what at firft was only a local ulcer. I have thus endeavoured to ffiow, that cancer may be produced by external accident merely, without hav- ing recourfe to the fuppofition of any internal affedion. But thofe who think that the latter always previoufly takes place, allege, that, " Although external violence fometimes apparently excites cancer; yet that it would never be produced in this manner, unlefs a predifpo- fition fubfifted in the habit at the fame time; and that although cancers from this caufe fucceed in fome inftances to external accidents, yet that in moft in- ftances they occur without the intervention of any violence whatever." That this is the cafe will not by any praditioner be denied: but it may however, be explained upon very different principles from what it commonly has been ; and in a manner, too, that will rather tend to confirm the opinion of cancer being, in general, a lo- cal difeafe. I have already obferved, that, in a great proportion of cafes, the glands appear evidently to be the feat of Sed. vm. cancerous Uiccr. 417 the difeafe; which renders it probable, that, in all, they are the parts originally affeded ; and that the neighbouring foft parts come only to fuffer in confe- quence of their vicinity to thefe : or perhaps, in fome few cafes, cancerous ulcers may break out in parts not glandular, from the whole fyftem being tainted by the abforption of difeafed matter from the long continuance of a cancerous gland in any one part. This being the cafe, we may eafily conceive how fingle glands may become affeded, without the inter- vention of any evident external caufe : for the circu- lation in the glands, being carried on by a fet of vef- fels much more minute than thofe with which other parts of the body are fupplied, obftrudions will more readily and eafily form in them; and a gland being once obftruded, the stimulus and irritation which it excites, may, it is probable, have nearly the fame ef- fed, and be attended with the fame confequences, as commonly occur from a blow or a bruife. In this manner, too, without having recourfe to any peculiar cancerous difpofition in the fyftem, we may account for all thofe cafes of cancer that occur from inflammation in the breafts of women; as likewife thofe which fo frequently happen to women about the period at which the menfes leave them; and alfo for fuch as fometimes fucceed to fevers and other dif- eafes, and of which, in fome inftances, they feem, as it were, to be the termination. In every affedion arifing from any of thefe caufes, there is always a preternatural flow of blood, or of fome other fluid, to the difeafed part 1 which, when it happens to be to the cellular fubftance, an abfcefs is produced ; when to the pleura, membranes of the eye, or any fuch parts as from their firmnefs of texture do not favour the extravafation of fluids, violent inflam- mation enfues; and, when the fubftance of a gland is the part to which a determination is made, it being neither, as we know from experience, fo proper as Vol. I. D d 418 Observations on the Chap* V. the cellular membrane for the formation of pus, nor from its foftnefs fo fufceptible of inflammation as a membrane, an indolent hard fwelling, is, merely by the obftrudion and diftention of the veffels of the gland, very naturally produced. And a tumor of this kind having once taken place, it generally remains for fome time in its original indolent ftate, till, by in- creafe of bulk, or perhaps from external violence, an irritation fufficient to excite fome confiderable degree of inflammation is applied to it; which, being pre- vented by the nature of the affeded part from ending in fuppuration, generally at laft terminates in what we call cancer, as in other foft parts of the body it would in gangrene, if not previoufly refolved, or brought to fuppuration. This objedion, therefore, of cancer appearing more frequently without than with the intervention of ex- ternal accident, does not, when properly confidered, appear to be of any importance : and from the whole of what has been laid, this conclusion, I think, may be drawn, that cancers, in very few inftances, ever arife from a general difeafe of the fyftem; but, on the contrary, are, at their firft appearance, almoft al- ways local. Such a conclufion, were we better acquainted vith the nature of cancer than as yet we are, would, it is probable, appear to be founded in fad. The reafons for adopting it, appear to be ftronger than any that have been adduced in fupport of the contrary opi- nion ; and, at any rate, it can never prove fo detri- mental to mankind, as the contrary opinion would do, were it univerfally adopted ; for, by preventing pa- tients with cancer from having the difeafe extirpated, it would, as long as it prevailed, be the means of their neglecting the only remedy which, fo far as we know, ought ever to be trufted. •With refped to that circumftance, taken notice of in the paper lately quoted from Dr. Monro, of cancer being always more violent, and making a quicker Sed. Vin. cancerous Ulcer. 419 progrefs upon returning after extirpation, than in pa- tients on whom no operation had been performed, this may in fome inftances be the cafe, although I have met with no inftances of its being fo : but were it even to happen frequently, yet ftill it would not be a valid objedion to the pradice of extirpation; and would appear only to be an additional reafon for our advifing the operation at an early period of the dif- eafe, in order to guard as much as poffible againft the poffibility of a return. § 3' Of the Treatment of Cancer. From all that has been hitherto faid, it is evident, that, in the treatment of cancer, no benefit is to be expeded from internal medicines : nor is any depen* dence to be placed on external applications, further than with the view of palliating particular fymptoms. Various remedies have at different times been held out to the public as cures for cancer; but none was ever more extolled than cicuta ; a remedy, however, which, in this country, has by no means anfwered the expedations that at firft we were led to form of it. The inefficacy indeed of cicuta has now proved fo univerfal, that there feems little occafion here to fay any thing with refped to it: I ffiall only juft oofes-ve^ that although in a great number of cafes I have known it exhibited with all manner of attention; yet, in real cancer, I never knew it, nor indeed any other reme- dy, produce a cure. In fimple cafes of enlarged glands, I have frequent- ly, indeed, known cicuta prove ufeful ; and in the advanced ftages of cancer, where excifion has not been agreed on, I have in different inftances known it give relief, and render the difcharge lefs acrid than it was before ; but this is all the credit that it merits, and the removal of cancer by extirpation being the only d o 2 42 o Observations en ihe Chap. V. remedy upon which dependence ffiould be placed, it ought in every inftance to be advifed almoft as foon as the difeafe is known to exift. Some remarks will be given on the mode of opera- ting for the removal of cancer when we come to treat of cancer of the mamma and teftis. It may not, however, in this place, be improper to offer a few general obfervations on the fubjed. i. The removal of cancer ffiould, even in the flight- eft and moft trivial cafes, be done with the fcalpel in preference to cauftic ; the ufe of which, though in one form or another much recommended by many, ought, for obvious reafons, to be laid afide. The irritation generally produced by cauftic, to- gether with the pain and inflammation which enfue from it, are, in all cafes of cancer, very ftrong objec- tions againft it. Plunket's remedy, which is evident- ly a kind of cauftic, and which appears to confift chiefly of arfenic, has, like every other medical fecret, been greatly extolled ; but it is not probable, if the cafes in which it has been ufed were known, that it would be found to have produced any advantages which might not more fpeedily, and with more cer- tainty, have been obtained from the fcalpel. '2. In whatever part of the body cancer is feated, every part of it ffiould be removed, otherwife no ad- vantage will be derived from the operation. Even every indurated gland in the neighbourhood of a can- cerous fore, ffiould juft as certainly be taken away as the ulcer itfelf; for if allowed to remain, a return of the difeafe may with certainty be looked for. Although it is always proper, however, to extirpate every part that is difeafed, none of the external tegu- ments fhould be ever unneceffarily deftroyed, nor ffiould more of them be taken away than is altogether requifite: for the fmaller the cicatrix that remains af- ter the cure, the lefs will be the confequent irritation: and, perhaps from this circumftance, too, the chance will be lefs of the difeafe returning, Sed. VIII. cancerous Ulcer. 421 At leaft, in the infirmary of this place, the extir- pation of cancerous lips has for a confiderable time paft proved much more fuccefsful than this operation ufually does ; and the only obvious caufe for it is, that during that period, in a great proportion of cafes, the operation has been performed in the manner com- monly pradifed for the hare lip ; whereby a very nar- row cicatrix is always left. I alfo think it right to obferve, that very extenfive ulcers in thefe parts admit of being cured in this man- ner ; for the lip being compofed of parts of eafy ex- tenfion, it cannot, but frorri experience, be imagined, how far they may be brougjm to ftretch. In fome in- ftances, where more than half of the under lip has been taken away, I have brought the remaining parts to ftretch fo far, as to admit of a cure in the hare lip form, and with little deformity being produced. And, in like manner, in cancers of the mamma, when the external teguments are not wholly difeafed, fo much of them may, in general, be preferved, as will be fuf- ficient for covering a confiderable part of the wound, by which the cure will be accompliffied, both with more certainty and expedition than it otherwife would be. When the fkin and teguments which have thus been preferved, can be retained in their fituation, ei- ther by the uniting bandage, or pieces of adhefive plafter, it ought always to be done ; but in general it anfwers better to fecure any loofe portions of the parts which have been divided, by means of the interrupted or twifted futures. The difference of pain produced by this is inconfiderable ; and we are always more certain of fecuring the fkin widi ligatures, than by any other means. In the ordinary method of extirpating cancerous breafts, a very extenfive fore is always left: by the retradion of the divided fkin, it frequently appears to be at leaft twice the fize of the tumor newly remov- ed : by this means a copious fuppuration takes place, 422 Observations on the Chap. V. which in weakly constitutions is apt to do harm ; the cure is always tedious ; and the cicatrix which re- mains, being of confiderable extent, the parts are af- terwards more expofed to injuries. No more fkin fliould therefore be removed than is really difeafed : if a fimple incifion is made through the fkin and cel- lular fubftance along the courfe of the tumor, all the found teguments which cover it may thus be fepara- ted from it; and on the tumor being extirpated, and the teguments again replaced, they may be retained in their fituation in the manner I have mentioned, either by ligatures, the uniting bandage, or with the affiflance of adhefive plafters. InTnis manner I have, in differ- ent inftances, accompliffied the cure of fores remain- ing after the extirpation of cancerous breafts, in the fpace of three weeks or a month ; which, in the ufual method of performing this operation, would not have healed in lefs than eight or ten weeks. 3. After all the cancerous parts have been removed, if the fore cannot be entirely covered by fuch portions of the fkin as have been faved, and if any confiderable quantity of blood is difcharged by the fmaller veffels, the remaining wound ffiould be dreffed in the ufual manner with dry lint; but when this does not happen, no dreffings anfwer fo well as pledgets of one or oth- er of the mild ointments that I have already had oc- cafion to mention; and, when the dreffings can be eafily removed, by a free fuppuration coming on, the fore being now in the ftate of a fimple ulcer from any other caufe, muft be treated accordingly, and a cure promoted as quickly as poffible. 4. Some little time before the fore heals up, an if- fue fliould he introduced, fo that it may come to dif- charge freely before the cicatrix is formed. This is particularly proper when the difeafe has been of long duration, or produced by a redundancy of fluids in the fyftem, either from fuppreffed menfes, or any oth- er caufe, In this manner, iffues I conceive may fre- Sed. VIII. cancerous Ulcer. 423 quently prove ufeful in preventing the return of can- cers after extirpation. It has been fometimes advifed, as the beft method of forming an iffue, to keep the part open from whence a cancerous tumor has been extirpated. I ftrongly fufped, however, that the irritation produced by an iffue, diredly upon the old feat of a cancer, may fome- times do mifchief: and as all the advantages attend- ing the pradice are probably to be obtained from if- fues wherever they are feated, I would therefore al- ways advife the fore itfelf to be healed quickly, and an iffue introduced in fome other part. After cancers of the mamma it was at one time a frequent pradice in the royal infirmary here, to put a feton into the fide near to the original feat of the difeafe: as it appeared to produce confiderable advantages, and as the fide is perhaps as convenient a fituation for a drain as any Other, it may therefore be preferred. Thefe are, in general, the different circumftances re- quiring attention in the extirpation of cancers : and as, from what has already been faid, the removal of the difeafed parts feems to be the only effedual reme- dy in cancer, there are few circumftances only, which ffiould ever prevent us from putting it in pradice : and thefe, in general, are, 1. When cancerous ulcers, and fcirrhous glands, have appeared in different parts of the body, the re- moval of one of thefe, as it would not probably prove effedual, fo, in fuch circumftances, the operation ought not to be advifed. 2. When a cancerous tumor adheres fo firmly to the parts beneath, that the whole cannot be removed, whilft at the fame time it might be dangerous to ex. firpate along with it thofe parts with which it is con- neded, extirpation can never be advifable. Thus can- cers adhering to the trachea arteria, or to the coats of a large artery, can never, without much hazard, be extirpated. 424 Observations on the Chap. V. One inftance of the raffinefs of a furgeon, in at- tempting an operation in fuch circumftances, fell with- in my own knowledge. In an attempt to cut out a large fcirrhous tumor, feated upon, and lying imme- diately contiguous to, the femoral artery, and fo high in the thigh, that a tourniquet could not be applied, the artery was unfortunately opened, and the patient died immediately. But the attachment of cancerous tumors to the cir- cumjacent mufcles or tendons, ffiould never entirely prevent their extirpation; for confiderable portions of thefe may, without much inconvenience, be taken away along with them. Thus we are often under the neceffity of taking away large portions of the pedoral mufcle along with cancerous tumors of the mamma, and for the moft part without any important confe- quences. In a paper upon cancer, by the celebrated Monfieur le Cat of Rouen, inferted in the firft volume of Me- moirs of the Academy of Surgery at Paris ; the au- thor is clearly of opinion, that extirpation is the only remedy to be depended on, and advifes it in the moft defperate cafes. On the point which we are now con- fidering, he goes a much greater length than from ex- perience I could venture to do : but, independent of the authority of fuch a refpedable author, and of the inftances he mentions of the fuccefs of his pradice, I think there is no caufe to doubt of its being better to follow his advice, than to allow a patient labouring under cancer to remain with the certain profped of fuffering a miferable death, without making trial of the only remedy which art can afford. For, however fixed a cancerous tumor may be, if the parts to which it adheres, can, without much danger, be removed, and if the cafe is otherwife favourable, the operation ought undoubtedly to be advifed.* * Upon this fubjecT: M. le Cat expreffes himfelf thus: " L'adherence d'un cancer aux m.tfdes pscioratix, aux cites mime, ne iera pas un excufe vala- L'e, fi ces m.-jlLs, fi ces attaches de la tumeur aux cotes, pcuvent tire empor- tcs, de fagon qu'il ne ivfte que de i»in au dela." Loo :iutt«. Sed. VHI. cancerous Ulcer. 425 This was my opinion feveral years ago, when the firft edition of this work was publifhed. Since that period, I have met with many inftances of very bad cancers, particularly of the mamma ; in fome of which, attachments occurred to the periofteum of the ribs ; and in others, the difeafe was found to extend to the correfponding clavicle, and frequently by a chain of indurated glands to the very bottom of the armpit. Very few cafes, however, have occurred, in which, by cautious diffedion, the difeafed parts were not totally extirpated ; and in every inftance where this was found to be pradicable, much advantage was evidently de- rived from it: many have, no doubt, experienced re- turns of the difeafe; but in many, no return of the difeafe has been as yet experienced ; and, even in thofe cafes which relapfed, much relief has been de- rived from the operation, by the pain, and mifeiy of the patient being for fome time removed by it; whilft, in no inftance, were the fymptoms which enfued from a return of the difeafe more fevere than thofe to which the patient had previoufly been liable. 3. This operation ought never to be advifed, where the difeafed parts are fo fituated as to prevent them from being totally removed, as is the cafe in cancers of the uterus, of the live*-, redum, and fome other parts. When, from the existence 'of one or all of thefe caufes, a cancer ' .nnot with prop iety be removed, our next objed a to palliate the liferent fymptoms, fo that the dife;..:: may be renrh d as eafy as poffible. Whatever' '";!it excite heat •■ inflammation, ffiould be carefully ** arded againft : a diet confining almoft entirely of n : 1 and vegetable;, I have found to anfwer beft : aninv! food, fpirits, win'-, and fermented liquors of every k^-1. excepting fmall beer and fpruce beer, do harm* And I have uniformly found, that the pro- grefs of earn er has been haftened by bodily fatigue, and whatever cxciies anxiety, or an uneafy ftate of mind. 426 Observations on the Chap. V. The fetor of cancerous ulcers being at all times dif- agreeable, and the matter ufually thin and acrid, are circumftances which, in the treatment of this difeafe, merit particular attention. In this view, hemlock frequently proves ufeful, both as an internal medicine and an external application. For internal u'e, two preparations of the remedy are commonly ufed ; the powder, and extrad : but as the powder feems to pof- fefs all the virtues of the extrad, and not being liable to be injured in the preparation, it fhould, for this rea- fon, be in general preferred. The extent of the dofe, and number of repetitions, can only be determined by trial; and are circumftances to be at all times regula- ted by the ftrength of the patient, and ftate of the ftomach at the time. » When recent hemlock can be got, a quantity of the juice being mixed with the common emollient poultice, affords a very ufeful application for cancer- ous fores ; and in the winter feafon, when the juice cannot be obtained, the dry powder made into a poul- tice in the fame manner, anfwers nearly the fame pur- pofe. Carrot poultices are frequently ufed for leffen- ing the fetor of the difcharge; and in this view they often prove ufeful. I have commonly found, howev- er, that hemlock proves ftill more effedual. A good difcharge being obtained, the common un- guentum cereum is the mildeft and moft fimple appli- cation we can employ, and the parts ffiould be dreff- ed with it more or lefs frequently, as the difcharge is more or lefs copious: care, however, fliould be taken at the different dreffings, to prevent as much as poffi- ble the admiflion of air, winch in every ulcer, but more efpecially in cancer, always does harm, both by exciting irritation, and in vitiating the difcharge. The violent fhooting pains which prove always fo diftrefsful in cancer, become frequently moderate by a continued ufe of cicuta; but when this does not happen, opiates muft be employed ia dofes fufficient for the purpofe. Thefe pains, too, are fometimes re- Sed. VIII. cancerdtis Ulcer. 427 Heved by warm emollient fomentations ; and, in oth- er inftances, by bathing the parts from time to time with a weak folution of faccharum faturni. One very diftrefsful fymptom of the late ftages of cancer requires particular notice. I mean the haemor- rhagy, which, in fome inftances, occurs from the ar- teries, corroded by the acrimony of the matter, and in others from the veins on the furface of the tumor becoming turgid, and burfting from time to time: when blood proceeds from arteries deftroyed by the progrefs of the difeafe, doffils of foft lint dipped in tindure of myrrh or ather, and applied with gentle preffure, is perhaps the beft remedy we can employ ; but when it proceeds from the burfting of turgid veins, we have it in our power to prevent it, by opening one of them occafionally with a lancet, fo as to take away an ounce or two at once: this relieves the painful burning fenfation with which patients labouring un- der cancer, are often feverely diftreffed, and it prevents that fudden eruption of blood to which they are liable, and which, by coming unexpededly, proves much more alarming than when they are prepared to look for it: neither does the operation appear to be hazar- dous : it was firft propofed and adopted by a patient whom I faw along w ith Dr. Gilchrift and Mr. Harley of Dumfries : the lady herfelf, from being frequently alarmed, and incommoded with the blood burfting out in the night time, and in fome inftances w?hen in company, infilled at laft on the turgid veins being opened ; it anfwered the purpofe completely ; and I have fince that period advifed the fame operation to x others, with equal advantage : it gives little or no pain ; the relief derived from it is confiderable ; and it is done without hazard, for the flow of blood from the orifice made with the lancet, is, for the moft part, inconfiderable. With due attention to the circumftances I have pointed out, particularly to the prefervation of a well . onditioned difcharge, and by a well timed ufe of opi- 428 Observations on the Chap. V. ates, very bad cafes of cancer may in fome inftances be fo far palliated, as to render them, in fome meaf- ure, tolerable; though never to fuch a degree as to prevent the fufferers from regreting daily their not having, in due time, had recourfe to extirpation. Various remedies have at different times been pro- pofed for the cure of cancers, of which, in the courfe of this treatife, I have taken little or no notice. Of thefe, cicuta, belladona, and different preparations of arfenic, have been moft frequently employed. But although cicuta, as I have obferved above, has, in fome inftances, appeared to coned the difcharge of cancer eus fores, yet neither this nor any other remedy, fo far as I know, has ever accomplifhed a cure. We have heard of arfenic proving ufeful in cancers, not only as an external application, but as an internal remedy : but although I have employed it in various cafes, the refult of thefe trials has never proved in any degree adequate to the accounts which have been giv- en of it; while even the fmalleft dofes, when long continued, have excited fevere degrees of naufea, pains in the bowels, and othtr fymptoms of poifon. In a publication by the late Mr. Juftamond of Lon- don, we find an efcharotic much recommended for the removal of cancer: it was long employed in Vi- enna and other parts of Germany ; and as Mr. Jufta- mond, whofe experience in cancer appears to have been extenfive, fpeaks highly of it, I think it right to mention it. Although ! have often ufed it, however, I have not as yet obferved any real advantage to en- fue from it ; but as no remedy fhould be haftily re- jeded, when recommended by an author of reputa- tion, I am refolved to give it a further trial. This application is a compofition of fteel and fal ammoniac infufed in fpirit of wine, with a certain proportion of oil of tartar and fpirit of vitriol. The edges, as well as the hard tumors or excrefcences, which frequently arife in cancerous ulcers, are, by Mr. Juftamond's method kept conftantly moft with this liquid ; and Sed. vm. cancerous Ulcer. 429 during the ufe of it, he likewife recommends an in- ternal ufe of fleel and fal ammoniac in the form of Mores martiales. In other ulcers attended with a difcharge of thin fetid matter, and in which tonics appear to be indica- ted, I have in different inftances ufed the flores mar- tiales with advantage; but, as I have already obferv- ed, neither this, nor any other medicine, has ever, in the courfe of my experience, produced any material benefit in cancer. The flores martiales, may be given either in the form of pills, or in powders. They feldom produce ficknefs, and may therefore be given in larger dofes than thofe commonly employed. The firft ffiould not exceed twelve or fifteen grains ; but in a gradual manner they may be increafed to half a drachm or more, to be repeated three, four, or five times daily. In every cafe where fteel medicines are proper, the flores martiales, by conveying the remedy in a very fubtile form, are perhaps preferable to any other pre- paration.* • Thofe who have not an opportunity of perufing Mr. Juftamond's treatife, may wifh to have the prefcription for the liquid which he re- commends fo warmly as an application in cancer. It is as follows: R. Ramentor. ferri lotor. et fupra ignem in vafe aperto ficcatorum et minutiffime contuforum, falis ammoniaci in pulverem redadti, aa unc. iv. Mixta dentur in retortam terream optime in fundo et circumferentia lege artis minutam, imponatur hxc capella?, admoveatur vas vitreum recipiensj quod bene lutetur: dctur ignis in gradu digeftionis ; et dum retorta cale- fieri incipit, augeatur fucceflive ad fublimationis, finitaque fublimatione ad calcinationis, gradum. Hoc fa&o fucceflive refrigeratione commitatur retorta, et ex refrigerata fractaque accipatur calcinatum in fundo hasrens> caput mortuum teratur, et fubigatur minutiffime in mortario lapideo ; dein fubactum imponatur in vas vitreum, et affundantur fpiritus vini rec- tificatillimi, empyreumaticum odorem non redolentis, lb. ij. Agitentur faepius primis o&o horis : poft viginti quatuor horas agitatis, denuo inftil- letur, tribus quatuorve interftitiis obfervatis, acerrinii, ut vulgo vocatur, olei vitrioli nigri unc. i.; ad quamvis inftiliationem femper mixta a^itan- do; dciude in quiete permittantur per virginti quatuor hora9; his ebr.iis, decantetur thuStura; refiduo vero in fundo, affundantur prions Ipiritus vini lb. ij. Agitentur iterum pluries, dein extracrio de novo relinquatur per viginti quatuor horas; i:is tranfaclis ii:fi!iLtur iterum, ut prius, o'ei vitrioli fupraditti unc. i. Tfervefcentia finLa vero, infundantur fpiritus tartari limplicis unc. iv. Agitentur, ct finita ajitatione aliquoties repetita relinquauiur in vaje per vigi.iti quatuor horas; his elaplis fecunda i.x^ 430 Observations on the Chap. V. SECTION IX. Obfervations on the cutaneous Ulcer. § i. General remarks on cutaneous Affedions* FEW difeafes are lefs understood by praditioners, than thofe of the fkin. This, indeed, is the cafe, both with fuch as are attended with fever, and thofe that are not: it is, however, more efpecially fo with the latter, which only it is here neceffary to mention ; thofe of the exanthematous kind, as they are termed, belonging more properly to the province of medicine. The appearances of fkin difeafes are exceedingly various, and the defcriptions given of them by authors very confufed and intricate : different authors have given different names to the fame appearances; erup- tive difeafes are enumerated by old writers, which are now never to be met with ; and difeafes of a fimilar nature, though ftill, in fome refpeds, different, are defcribed by modern authors, which do not formerly appear to have been known. It is indeed greatly to be wiffied, that a more complete investigation were given of all that relates to the hiftory and theory, as well as to the treatment, of cutaneous difeafes, as fcarcely any part of the practice of medicine requires it fo much. To give a particular detail of all the varieties of thefe difeafes, would of itfelf require an extenfive vol- ume, and it would alfo be foreign to our purpofe : all that I propofe is to give a few general obfervations upon fuch eruptions as, when negleded or improper- ly treated, are apt to give rife to ulcers. folutio mifceatuf prion decantat.-e, et optime fimul agitentur; tunc parata eft ad ufum Panacea nostra anti cancrosa. This was originally publifhed by Dr. Francis Xavcrius de Mare, m a treatife which he published fome years ago at Vienna. He had long kept this liquid a fecret, but at laft made it public in the year 1767. Sed. IX. cutaneous Ulcer. 431 § 2. 0/ the different Species of Herpes. A variety of cutaneous eruptions have been de- fcribed by authors under the general term of herpes ; but many of thefe are taken from very trivial circum- ftances, and from fuch as have no influence on the cure. Every neceffary diftindion of all the varieties which have been enumerated, are, I think, compre- hended in the four following varieties, namely, the herpes farinofus, puftulofus, miliaris, and exedens. The firft of thefe, the herpes farinofus, or what may be termed the dry tetter, is the moft fimple, both in its confequences and method of cure. It ap- pears indifcriminately in different parts of the body ; but moft commonly on the face, neck, arms, and wrifts, in pretty broad fpots of fmall red pimples. Thefe are generally very itchy, though not otherwife troublefome : and after continuing a certain time, they at laft fall off" in the form of a white powder, fimilar to fine bran, leaving the fkin below perfedly found; and, again returning in the form of a red efflorefcence, they fall off, and are renewed as before. The fecond variety of the difeafe, viz. the herpes puftulofus, appears in the form of puftules, which originally are feparate and diftind, but which after- wards run together in clufters. At firft they feem to contain nothing but a thin watery ferum, which after- wards turns thick and yellow; and, exfuding over the whole furface of the part affeded, it at laft dries into a thick cruft or fcab: when this falls off, the fkin below frequently appears entire, with only a flight degree of rednefs on its furface ; but occafionally, when the matter has probably been more acrid, on the fcab falling off, the fkin is found in a ftate of ul- ceration. Thefe eruptions appear moft frequently on the face, behind the ears, and on other parts of the head ; and they occur moft commonly in children. 432 Observations on the Chap. V. The third variety of herpes, viz. the miliaris, breaks out indifcriminately over the whole body j but more frequently about the loins, breaft, perinaeum, fcrotum, and inguina, than in other parts. It generally ap- pears in clufters, though fometimes in diftind rings or circles, of very minute pimples, which, from their refemblance to the millet feed, has given rife to the denomination of the fpecies. The pimples are at firft, though fmall, perfedly feparate; and contain nothing but a clear lymph, which, in the courfe of the difeafe, is excreted upon the furface, and there forms into fmall diftind fcales: thefe at laft fall off, and leave a confiderable degree of inflammation below, that ftill continues to exfude freffi matter, which likewife forms into cakes, and fo falls off as before. The heat and itching in this variety of herpes prove commonly diftrefsful; and the matter difcharged from the pimples is fo tough and vifcid, that any dref- fings that may be applied to them adhere firmly, and excite much uneafinefs on being removed. All the varieties of herpes are ufually, in England, diftinguifhed by the names of tetter, ffiingles and ring- worm ; but the laft is moft frequently applied to that which we are now confidering, the herpes miliaris. The herpes exedens, fo called from its destroying or corroding the parts which it attacks, appears com- monly at firft in the form of feveral fmall painful ul- cerations, all colleded into larger fpots of different fizes and of various figures, with always more or lefs of an eryfipelatous like inflammation. Thefe ulcera- tions difcharge large quantities of a thin, ffiarp fe- rum ; which fometimes forms into fmall crufts, that in a fhort time fall off; but moft frequently the dif- charge is fo thin and acrid, that it fpreads along the neighbouring parts, where it foon produces the fame kind of affection. Though thefe ulcers or excoriations do not, in gen- eral, go deeper than the cutis vera, yet in fome the difcharge is fo very corrofive, as to deftroy the fkin, Sed. DC* cutaneous Ulcer. 433 cellular fubftance, and occafionally even the mufcles. It is this which ffiould properly be termed the depaf- cent or phagedenic ulcer, from the great deftrudion of parts with which it is accompanied; but herpetic ulcerations of every kind being commonly, though improperly, fuppofed to be conneded with fcurvy, they have in general been diftinguifhed by the appel- lation of fcorbutic. Whereas, there is nothing more certain, than that herpes is generally, if not always, conneded with that ftate of the fyftem, probably the moft oppofite of any to that which takes place in true fcurvy. The fymptoms are all of the inflammatory kind ; whilft in fcurvy, they proceed evidently from a high degree of putrefadion. And, befides, the real fcorbutic ulcer, hereafter to be def";ibed, exhibits appearances perfedly different from herpes ; infomuch that there is fcarcely a pof- fibility of mistaking the one for the other; and the remedies neceffary in the two difeafes are juft as op- pofite as their feveral fymptoms and appearances are different. Herpes exedens appears, at times, in every part of the body, but moft frequently about the loins, where it often fpreads to fuch a degree as to fu'rround the whole circumference of the waift. It feems to be ea- fily communicated by contagion, that is, by the appli- cation of the virus, either through the intervention of clothes, fpoons, or other table uter.fils. This, indeed, is the cafe, in fome degree, with herpes in every form ; but we do not meet with it fo frequently with herpes farinofus as with the others, probably from the fkin remaining dry, and not difcharging mattter. § 3. Of the Cure of the cutaneous Ulcer. Till of late, it was very univerfally believed, that every variety of herpes arcfe from a morbid affedion of the fyftem ; and various internal remedies have ,e- Vol. I. E e 434 Observations on the Chap. V. cordingly been recommended by every author who has written upon the fubjed. It has even been con- fidered as a dangerous pradice to attempt the cure of thefe eruptions, in any other way than by correding the original diforder of the fluids, by which they were at firft fuppofed to be produced. That this fliould fo long have remained uncontro- verted by regular praditioners, cannot be accounted for, as, from the writings of many of them, it appears, that cutaneous affedions were in former times fre- quently and eafily cured, as they ftill are by itinerants, with local applications alone. This might have been expeded foon to have over- turned the opinion which prevailed of the nature of thefe difeafes, and which feemed to have no other foundation than antiquity for its fupport. Modern praditioners, however, not being fhackled by fuch authority, have, in many inftances, ventured to dif- pute, and boldly to deviate from, the opinions of their predeceffors ; and the improvements which have uni- verfally refulted from this free fpirit of enquiry, have never yet given them caufe to repent their having done fo. This, in no inftance, has been more remarkable, nor attended with more ufeful confequences^ than in the treatment of cutaneous eruptions, which, from having been very perplexed and intricate, will foon, there is caufe to hope, become a very fimple and eafy part of the praditioner's employment. Inftead of the tedious and debilitating courfes of medicines which patients diftreffed with thefe erup- tions were formerly put under, and which they are ftill perhaps too frequently obliged to undergo, it is now found, that herpetic eruptions are much more certainly and fpeedily removed by local remedies alone. This, probably, is one reafon, among others, why all thefe eruptions are claffed among local difea- fes, in the genera morborum of our late juftly cele- brated profeffor Dr. Cullen ; and which, without Sed. IX. cutaneous Ulcer. 435 any other fandlon, would, of itfelf, be fufficient au- thority for their being here confidered as of a local nature.* That internal remedies may fometimes prove ufe- ful in cutaneous eruptions, will not, probably, ever be doubted ; but that they ad by correding particu- lar kinds of acrimony, fuppofed to exift in the mafs of blood, is very improbable. Nor does the benefit fometimes derived from medicines given internally, render it lefs certain that thefe eruptions are entirely local. Thus, in many difeafes of the fkin, antimonials fre- quently prove ufeful. But the chief advantage we derive from them, feems, in a great meafure, to de- pend on the determination which they produce to the fkin, and the perfpiration which they keep up ; which frequently from want of cleanlinefs, and fometimes from other caufes, being long retained on the furface of the body, and there turning acrid, may often I conceive, give rife to eruptions. And accordingly we find, that all of thefe remedies prove more or lefs ufe- ful, according as they are more or lefs powerful in keeping up a free perfpiration. By thofe who maintain that acrimony of the fluids is the moft common caufe of thefe difeafes, it is fup- pofed, that the beneficial effeds of antimonials and other diaphoretics, depend entirely on their evacuat- ing or carrying off the morbid matter, with which the blood is imagined to abound. Many arguments, however, evince the futility of this opinion. It cannot be ffiewn how morbid matter, fuppofing it really to exift, can be more readily evacu- ated by fudorifics, than the other parts of the blood with which it mull in the courfe of the circulation be intimately mixed. But what puts it beyond a doubt * The character given by Dr. Cullen, of the clafs Locales, in which herpes is included, is, " Partis, noa totius corporis, affe&io." Vid. Synop. Nofolog. Method, Edinburgh SL E i 43° Observations on the Chap. V. that thefe medicines ad by preserving a free perfpira- tion, and not by evacuating any fluids particularly morbid, is, that the fame advantages are frequently obtained from warm bathing, and other remedies ap- plied to the parts affeded only. From this view of the theory of herpetic eruptions, many of the fymptoms can be more clearly explained than on any other fuppofition. I cannot here, how- ever, enter upon the full difcuffion of thefe, and I fhall only obferve, that by this we may account for the partial appearance of thefe eruptions, an occur- rence that we daily meet with where they form in An- gle fpots, without affeding any other part of the fkin. This we cannot fuppofe would happen, were they produced by difeafe of the fyftem ; while it may rea- dily occur from a local ftoppage of perfpiration, oc- cafioned by the application of fuch caufes to particu- lar parts as we know to be generally followed with this effed. Ajid upon this principle, as I have al- ready remarked, we account for, much more obvi- oufly, than on any other, the operation of the feveral remedies ufually employed in the cure of herpes. In conduding the cure, the chief circumftance re- quiring attention is, that not only the parts affeded, but even the whole furface of the body, be kept as clean and perfpirable as poffible : for which purpofe, nothing is of more importance than frequent warm bathing, accompanied with gentle fridions with clean linen cloths; which, in dry herpetic eruptions, may be applied even to the difeafed parts ; but in the oth- ers, efpecially where the fkin is tender, or in a ftate of ulceration, thofe parts only can be rubbed which have not been attacked. With due attention to cleanlinefs alone, almoft all the slighter degrees of herpes may be cured : I often fucceed with no other remedy but waffiing the difeaf- ed part daily with foap and wrier: in all varieties of the difeafe, particularly in dry herpetic eruptions, lime water is an ufeful application : the difeafed part* Sed. IX. cutaneous Ulcer. 437 ffiould be bathed with it three or four times a day, and in like manner we often employ a faturnine folu- tion with advantage, or a folution of the vegetable al- kali in water, in the proportion of two drachms of pure alkali to four ounces of water. In the more inveterate varieties of herpes, the moft effedual waffi I have employed is a weak folution of corrofive fublimate, in the proportion of ten grains to each pound of diftilled water. A due perfeverance in the ufe of thefe remedies ve- ry commonly proves fuccefsful in the milder varieties of thefe eruptions ; but when the difeafe is inveterate, of long duration, and difcharging large quantities of matter, other remedies muft be employed. The internal exhibition of antimonials frequently proves ufeful, particularly when conjoined with a de- codion of farfaparilla, mezereon, or gum guaiacum. Fifteen or twenty drops of the vinous tindure of an- timony, taken three or four times a day in a cupful of decodion of guaiacum, feldom fails to excite a free difcharge by the fkin, from which, in all cutane- ous eruptions, much advantage is commonly derived. It is chiefly in herpetic eruptions that Plummer's pill, a compofition of fulphur, antimony, and mercury, proves ufeful. In this view, too, crude antimony proves likewife ufeful, whether by itfelf or conjoined with gum guai- acum : it ffiould be finely levigated, and it may with fafety be given to the extent of two drachms daily. Where plethora prevails, laxatives prove particu- larly ufeful, and we chiefly prefer thofe of the faline kind, fuch as foluble tartar, Glauber's fait, Rochelle or Brazil fait, or cream of tartar; and fea water is often employed for the fame purpofe. In all herpetic affedions of long duration, iffues prove ufeful: we do not advife them in flight degrees of the difeafe, but a permanent cure can feldom be obtained without them, where the eruption is either extenfive or of long continuance. 43 8 .Observations on the Chap. V. Parts affeded with herpes, particularly with herpes exedens, are very apt to inflame, and the remedies moft frequently employed for this, are, warm fomen- tations and poultices : I have feldom found, however, that they anfwer the purpofe, and in no cafe whatever does the fuperiority of faturnine applications appear more confpicuoufly than in this. Emollients very univerfally promote the fecretion of that acrid hu- mour which always prevails here ; and thus, inftead of removing inflammation, they rather in fuch inftan- ces tend to promote it: whereas, the different fatur- nine applications appear not only to corred the acri- mony of the matter, but tend greatly to prevent it from fpreading fo far as it otherwife would do. In all fuperficial ulcerations of the herpetic kind, the faturnine and fublimate folutions, already pointed out, prove in general effedual; but whenever the ul- cers have penetrated to the mufcles and other deep feated parts, an ointment prepared with calcined zinc I have commonly found to anfwer better: about two drachms of zinc in fine powder, to fix drachms of axunge or fimple ointment, feems to be in general a proper proportion. It leffens the inflammation, and has often a confiderable effed in altering the nature of the difcharge from a thin acrid fanies to a thick purulent matter. Goulard's form of unguentum faturninum, for which I have already given the prescription, is alfo, when newly prepared, a very proper application for the fame purpofe. But it ought never to be ufed af- ter being long kept; for the lead feems thereby not only to lofe its adivity, which it in fome meafure, in unctuous preparations, always does ; but that oint- ment, probably from being prepared chiefly of ax- unge, or of wax and oil, without any addition of the antifeptic gums and refins, is more apt to turn rancid than almoft any other ointment in common ufe. By a due continuance of the remedies which I have thus pointed out, Vvliillt; proper attention is at the fame Sed. IX. cutaneous Ulcer. 439 time given to cleanlinefs, the moft troublefome varie- ties of herpes will in general be removed. But in fome inftances, notwithftanding the ufe of thefe, and every other remedy, they ftill continue obftinate, and even become more inveterate. In this fituation, fulphureous mineral waters often prove ufeful, fuch as thofe of Harrowgate and Moffat, by which I have known cures accompliffied, where ev- ery other remedy had previoufly been tried in vain. It is proper, however, to remark, that it is not from the internal ufe of thefe waters that we derive advan- tage, but from their frequent application to the difeaf- ed parts. The eruption ffiould be bathed four or five times in the courfe of every day, and every fecond night the whole body ffiould be immerfed for the fpace of fifteen or twenty minutes in the water, heated to eighty-eight or ninety degrees. Herpes frequently continues to refill the remedies employed for it, from being combined with other dif- eafes : in fome inftances we meet with it combined with lues venerea, but more frequently with itch : con- neded with itch, it forms a very obftinate difeafe, what may be confidered as a tertium quid, or a pro- dudion of the two : this in its appearance is exceed- ingly loathfome, not lefs fo perhaps than the lepra de- fcribed by the ancients, and it frequently proves al- moft as inveterate. When combined with lues venerea, no remedy will be of any avail till a courfe of mercury is employed, and in all cafes of this kind the moft effedual prepa- ration of mercury is corrofive fublimate, now termed hydrargyrus muriatus corrofivus. Befides bathing the parts two or three times a day with a weak folu- tion of this preparation, fuch as I have mentioned above, the patient ffiould take as much of the medi- cine internally as he can eafily bear : I think it right, however, to remark, that it anfwers much better in very fmall dofes than in thofe ufually given: a grain of corrofive fublimate being diffolved in three ounces 440 Observations on the Chap. V. of diftilled water, from one to two tea fpoonfuls of the folution may be given three times a day, and con- tinued with fafety for a confiderable time, but more than this very commonly excites ficknefs, retching, and pain in the ftomach and bowels. In herpes conjoined with itch, fulphur is the moft effectual remedy, particularly in thofe herpetic erup- tions to which children are liable. When the ufual remedies therefore do not fucceed, fulphur ffiould al- ways be employed: and to praditioners of experi- ence, it is fcarcely neceffary to remark, that fulphur vivum, as it is termed, in fine powder, proves more certainly effedual than the flowers of fulphur. As this remedy evidently lofes much of its ftrength by the procefs of sublimation, this preparation ffiould never be employed for any cutaneous eruption. Even in this vaiiety of herpes, fulphur fometimes fails : in fuch cafes I have known a cure accompliffied by a due per- feverance in the internal exhibition of corrofive fubli- mate, as mentioned above, which appears indeed to be nearly, if not entirely the fame, with fome of the an- tifeorbutics fo liberally difpenfed to the public by the itinerants of the prefent day. There is a variety of herpes to which, in fome con- stitutions, efpecially in females, the face is particularly liable ; and no variety of the difeafe proves either more diftrefsful to patients, or more perplexing to praditioners. All the common preparations of ful- phur, as well as different ointments and waffies of the mercurial kind, are commonly employed with little or no advantage; but the following combination of ful- phur with faccharum faturni, I have feldom known to fail. !$>. Lac. fulphuris - - 3ij. Sacch. faturni - - £)j. Aq. rofarum - - %vi\\. M. The eruption to be bathed with this morning and evening, care being taken to ffiake the vial when ufed. Sed. IX. cutaneous Ulcer. 44! In what manner this remedy ads, I know not: but I have known different inftances of a complete cure being obtained by a frequent ufe of it. When, however, it may be thought proper to maka ufe of mercury inftead of fulphur, an ointment term- ed in the difpenfatories unguentum citrinum, may be employed with advantage. But as this ointment is prefcribed with two great a proportion of mercury, it frequently ads as a cauftic, and excites much irrita- tion. This, however, is eafily prevented, whilft at the fame time all the advantages of the remedy are pre- ferved, by ufing a fmaller proportion of mercury : half an ounce of mercury diffolved in an ounce of ftrong fpirit of nitre, mixed with a pound of axunge or freffi butter, have, upon trial, been found to be proper proportions : or, as this ointment is apt to be- come too hard, it may at firft be made with a double proportion of mercury and fpirit of nitre; and, by adding an equal quantity of axunge at the time of uf- ing it, with a fifth or fixth part of olive oil, nearly the fame ftrength of the remedy is preferved, whilft, at the fame time, an ointment is obtained of a better con- fiftence. This makes a very effedual and perfedly fafe oint- ment for all fuch eruptions as are combined with lues venerea or itch, and may be ufed for itch in prefer- ence to other mercurials, by thofe who, on account of its offenfive fmell, or for other reafons, do not in- cline to employ iVilnhur. Indeed, no preparation of mercury, in the courfe of my experience, has ever proved fo ufeful as this ointment; not only in real herpes, but even in common itch. It only indeed re- quires to be more generally known, in order to be very univerfally employed in herpetic eruptions. By a proper and continued ufe of the feveral reme- dies that I have mentioned, and particularly by due attention to cleanlinefs, almoft every cafe of herpes may at laft be removed. 442 Observations on the Chap. V. Children are liable to eruptions, which by authors are defcribed as diftind and different difeafes, but which may all be traced to one or other of the varie- ties of herpes which I have enumerated : thus, tinea capitis, and crufta ladea, are commonly defcribed as diflinct difeafes, and as different from each other ; but they are of the fame nature, and are only to be con- fidered as varieties of the fame fpecies of herpes : they feem evidently, indeed, to belong to the fecond, or what I have termed herpes puftulofus, and appear to differ only in fituation ; the tinea being exadly on the hairy fcalp, what the crufta ladea and other fuch eruptions are upon the face. The means of cure that I have enumerated for her- pes in general, apply with equal propriety to any of thefe; but in the tinea capitis a peculiarity occurs from its fituation, which, in the treatment, requires attention ; the hair, by occafioning a more confidera- ble remora of the exfuded matter than is met with in any other variety of herpes, produces in it a greater degree of acrimony, which fometimes gives rife to bul- bous fwellings at the roots of the hair; and hence it has been fuppofed, that thefe fwellings, by being per- haps the firft parts that are difeafed, tend to produce and keep up all the other fymptoms : fo that we are advifed in the cure of tinea, to extrad entirely all the hairs by the roots, either with pitch plafters, or fome other adhefive application. This, however, is always attended with much pain ; it fometimes produces very fevere degrees of inflam- mation ; nor is it ever a neceffary meafure in the firft ftages of the difeafe: for though in long continued cafes of tinea, thefe tuberosities at the roots of the hair fometimes become fo confiderable as to render the cure more tedious than it otherwife would be; yet, merely by keeping the hair fhort, and the parts affed- ed clean, a cure may always be accompliffied without having recourfe to that difagreeable and painful oper- ation of extrading the hair. Sed. IX. cutaneous Ulcer. 443 I have already recommended a watery folution of corrofive fublimate as an external application for dif- ferent eruptions ; but in no variety of herpes does it prove fo obvioufly ufeful as in tinea capitis ; infomuch that, except in very inveterate cafes, a cure may gen- erally be obtained by the ufe of this remedy alone. I have already had occafion to fpeak favourably of iffues in eruptions of every kind when of long dura- tion ; but in thofe which prevail in childhood, they feem to be ftill more neceffary, and more ufeful, than in the advanced periods of life ; for, as children par- ticularly liable to thefe eruptions are commonly of grofs plethoric habits, it is fcarcely poffible often to remove thofe eruptions to which they are liable, with- out in the firft place introducing adequate drains. Indeed, iffues alone, with due attention to cleanli- nefs, will frequently, in the firft years of childhood, get the better of all thefe complaints, without the af- fiflance of any other remedy ; and they do not prove fo hurtful to the conftitution as the frequent ufe of purgatives, which in fuch cafes are commonly employ- ed. Purgatives no doubt, frequently prove ufeful by unloading the fyftem of fluids, which might probably do harm if allowed to remain, but never in fuch an eafy gradual manner as is done by iffues. An objedion is commonly made to iffues, that they are apt to become fo far habitual as to prevent them from being afterwards healed, without confiderable riik. No hazard however of this kind occurs from them in childhood ; for, about the fifth or fixth year, when children are able to take more regular exercife ; when the fyftem, having acquired a firmer tone, is rendered more capable of preferving a due balance be- tween the folids and different contained fluids ; and when, in fad, the latter are never fo abundant as in the preceding years of childhood ; there is not then the fame neceffity for fuch drains, and it might even in fome inftances prove hurtful to continue them long- er. We accordingly obferve, about this period, that 44*4 Observations on the Chap. V. many of the eruptive difeafes which had prevailed be- fore, now difappear entirely : nature then requiring a greater fupply of fluids for the different fecretions, throws off by their means, what had formerly been difcharged by eruptions upon the furface. SECTION X. Obfervations on the venereal Ulcer. § i. Varieties of the venereal Ulcer. RY venereal ulcers, in general, are meant, fuch as ) proceed from a fypliilitic affedion of the fyftem. But as chancres may with equal propriety be termed venereal ulcers, although not always conneded with a general infedion, yet, in order to prevent confufion and ambiguity, it will here be proper to enter upon the confideration of thefe alfo. Venereal ulcers, then, may be divided into two va- rieties ; namely thofe which appear as primary fymp- toms of the difeafe, and fuch as may more properly be confidered as fymptomatic. Of the former kind are chancres in general, wheth- er upon the parts of generation, communicated by ve- nereal inercourfe; upon the nipples and breafts of women, by nurfing infeded children; or on the lips and parts adjacent, communicated by falutation : for, all fuch fores, though feated on different parts, are of one and the fame nature. Thofe ulcers, too, may fometimes be reckoned primary, which remain after the opening or burfting of buboes arifing from infec- tion lately communicted, and before there is any pro- bability of the whole fyftem being difeafed. Sed. X. venereal Ulcer. 445 Thefe ulcers again, I confider as fymptomatic, which proceed from the matter of infedion having en- tered the fyftem. Of this kind are thofe which fuc- ceed to old buboes, or appear along with other vene- real fymptoms a confiderable time after infedion ; the moft ordinary fituations for which are, the throat, pal- ate, nofe, the parts immediately above the bones of the cranium, tibia, humerus, and other hard bones thinly covered with fielh. Although this diftindion cannot always be afcer- taired in venereal feres, yet in a great proportion of cafes, it may be eafiiy done, either by information from the patient, or from the appearances which the ulcers exhibit. If, foon after expofure to infedion. an ulcer ap- pears upon the parts to which there is caufe to ima- gine the virus has been applied, together with fwel- lings of the glands in the courfe of the lymphatics, we may be almoft convinced that thefe are local affec- tions, and that they ffiould be confidered accordingly as primary fymptoms. Ulcerations thus produced bv the immediate application cf the venereal virus, are in general termed chancres: they appear, at firft, as fmall miliary fpots, which foon rife and form little veficles, that difcharge fometimes a thin acrid ferum, and at other times a more thick yellow matter. Chan- cres are generally hard and painful ; and, together with the glandular fwellings already defcribed, are commonly attended with more or lefs inflammation. Ulcers produced by the virus having entered the fyftem, are diftinguiffied from chancres, as likewife from every other variety of ulcer, by information from the patient; by their fituation; and by their appearances. Whenever an ulcer is fufpeded to be venereal, cer- tainty with regard to it may frequently be obtained from the patient. Thus, if a perfon, at the time la- bouring under other fymptoms of fyphilis, is attacked with one or more ulcers, whether in confequence of 440 Observations on the Chap. V* external injuries or not, if they refill the common methods of cure, there will be little reafon to doubt of their being venereal. It fometimes happens, however, that fuch informa- tion is not to be obtained : for patients infeded with lues venerea often refufe to acknowledge it ; while others are infeded without having fufpicion of their being fo. In fuch circumftances, we muft be dired- ed by the fituation and appearances of the ulcer itfelf. A great proportion of veneral ulcers from an old infedion, appear, as I have already remarked, imme- diately above the bones, and particularly upon thofe moft thinly covered with mufcles. They firft appear in the form of a red, or purple coloured efllorefcence, not circumfcribed, but in general rather diffufed. This at laft forms into a number of fmall puftules, which ooze out a thin fretting ferum. At firft thefe puftules, when obferved through a glafs, appear per- fedly diftind ; but they at laft run together, and form one large ulcer, whofe edges, are commonly ragged and fomewhat callous ; accompanied with a copper coloured appearance of the fkin for a confiderable fpace beyond the boundaries of the ulcer. Thefe ulcers have frequently a very remarkable ap- pearance, being hollowed as it were into the form of a cup, generally narrow and contraded at the bot- tom, with the edges rifing gradually till they reach the outward circumference. This at leaft is generally the cafe, unlefs the bones beneath are carious, and then the fores are for the moft part filled up with foft fungous excrefcences. Venereal ulcers are not commonly attended with much pain ; at leaft, not with fo much as, from their extent and appearances, might be expeded. In fome inftances, however, it is otherwife ; and the difcharge, although at firft thin, at laft commonly affumes a very particular and charaderiftic appearance, being of a confiftence rather more tough and vifcid than good pus; with a very loathfom. fee-tor, though not the Sed. X. venereal Ulcer. 447 ordinary fmell of putrefcency ; and a very fingular green colour. Thefe are the moft common appearances of old ve- nereal ulcers; and when they occur upon any of the fituations that I have mentioned, we may almoft al- ways, with certainty, conclude, that they proceed from lues venerea. The diftindion that I have propofed of venereal ul- cers into primary and fymptomatic, is, in the treat- ment of the difeafe, a matter of confiderable impor- tance : for the primary ulcer might be frequently re- moved without the aid of internal medicine, merely by converting an incipient chancre into the ftate of a fimple ulcer, either by cutting out the fpot, or destroy- ing the venereal matter contained in it with cauftic. But although a cure might in this manner be in fome inftances obtained with fafety, yet having no means of diftinguifhing whether the virus has entered the fyftem or not, the cure even of the flighteft chan- cre fliould never be trufted to any other remedy than the internal ufe of mercury ; with this material differ- ence, however, that in this incipient ftage of fyphilis, a very fmall quantity of the remedy commonly proves fufficient, whereas a much larger quantity is required for the cure of old venereal ulcers. Another circumftance of importanc is alfo pointed out by this diftindion: in ulcers from an old infec- tion, we ffiould never make ufe of mercurials and oth- er dreffings, with a view to heal them quickly ; but ffiould rather truft to the internal exhibition of mer- cury, and in the mean time continue to apply fuch remedies only as are neceffary for keeping the parts clean and eafy. By healing ulcers of this defcription with internal medicines only, we obtain the moft convincing proof of the virus being extinguiffied : but while for this reafon I judge it to be the beft pradice in venereal ul- cers of hv.yr duration, I do'not agree with thofe who think that it ffiould be applied to chancres : in recent 44$ Observations en the Chap. V. ulcers* produced by the application of the venereal vi- rus to a particular fpot, and not conneded with any difeafe of the fyftem, mercury given internally does not ad with fuch certainty in the cure, and accord- ingly we often find, that, after it has been ufed in this manner for a great length of time, we are obliged to employ external remedies at laft. This, however, is not the greateft objedion to the pradice: for as long as a chancre continues open, there is much more reafon to fufped that the fyftem may be injured, than if the chancre or fource of that matter had been healed foon after its appearance. But in anfwer to this it is faid, that if the pradice was adopted, of treating chancres witli the internal ufe of mercury only, no rifk would occur from their be- ing kept open ; as mercury, by ading as a certain an- tidote to the venereal virus, would foon exert its in- fluence on the fyftem, in fuch a manner as to prevent the virus from having any further influence. Such reafoning, however, is, in pradice, not to be trufted. For, in the firft place, though mercury in general proves a certain cure for lues venerea already fubfifting in the conftitution; yet, even where it has been previoufly exhibited in large quantities, it does not prevent a new infedion from taking place : of this I have met with many inftances, and every prac- titioner muft have done fo. But again, although we were even certain, that, on a proper quantity of mercury being thrown in, no further infection could take place from the introduc- tion of a larger portion of venereal matter; yet we can never be fure that the medicine will fo foon en- ter the circulation as to produce this prophyladic ef- fed. For when we confider how frequently pradi- tioners are difappointed in attempting to introduce a fufficient quantity of mercury, either from the fault of the preparation, from its running off by ftool, or from fome other caufe, no dependence, it is evident, ought to be placed upon this. Sed. X. venereal Ulcer. 449 Upon the whole, therefore, the cure of chancres and of all venereal ulcers of the primary kind, ffiould be haftened as much as poffible, not only by internal medicines, but by the aid of external applcations. § 2. Of the Cure of the venereal Ulcer. In all cafes of chancre our objed is to deftroy the virus in the part to which it has been applied, and to throw in fuch a quantity of mercury as may prevent the fyftem from being injured : in common pradice, cauftic is applied to chancres as foon as they appear, for the purpofe of converting them as fpeedily as pof- fible into the ftate of fimple fores ; but I have elfe* where endeavoured to ffiew, that it anfwers better to give mercury for feveral days before applying the cauftic, as the irritation produced by cauftic, applied to chancres before mercury is employed, has an evi- dent influence in promoting the abforption of the vi- rus, and in thus producing buboes : * after mercury has been given for five or fix days, lunar cauftic may be applied with freedom, and it ffiould be done in fuch a manner as to form an efchar of confiderable thicknefs : this being thrown off, the fore may be dreffed with fimple wax ointment as long as it con- tinues clean, but on the leaft appearance of becoming foul, the ointment ffiould be mixed with a fixth or eighth part of calomel or red precipitate finely levi- gated. In this manner almoft every chancre may in gen- eral be cured, and with much lefs mercury than if al- lowed for any confiderable time to remain open. By long continuance, however, and from negled of proper remedies, even thefe primary ulcers, come to put on all the appearances of fuch as depend upon • Vide a Treatife on Gonorrhoea Virulenta and Lues Venerea, in two volumes 8vo. in which this as well as various other points rtiatiye to the venereal difeafe, are more fully confidered. Vol. I. F f 45° Observations on the Chap. V. a general infedion ; in which fituation their treat- ment muft vary accordingly : inftead of placing much dependence on external applications, we in this cafe truft chiefly to a well directed courfe of mercury. Two different modes are employed for throwing mercury into the fyftem; the one by the mouth, and the other by introducing it through the abforbents on the lkin by means of fridion: but as the firft of thefe is liable to many inconveniencies which do not attend the other, the latter ffiould in general be preferred. When the firft editions of this work were printed, I entertained a different opinion upon this point, but I think it fair to acknowledge, that more extenfive ex- perience has convinced me, that I was wrong, and that the beft method of ufing mercury is in the form of undion, by which we for the moft part avoid that ficknefs at ftomach, pains in the bowels, and violent purging, which mercury, given by the mouth, is very apt to induce, and by which the constitution, is often greatly injured. Occafionally, however, we are under the neceffity of giving mercury by the mouth: in fuch inftances thofe preparations ffiould be preferred that we obtain from fimple triture, and of thefe the quickfilver pill of the Edinburgh Difpenfatory is perhaps the beft : they prove commonly more effedual, and are feldom attended with any of the inconveniencies which often enfue from the exhibition of the calces of mercury. But whatever preparation of mercury is employed, it fhould be always continued till the mouth becomes fore, this being the moft certain indication of the me- dicine having entered the fyftem : nor is it proper to ftop at this point, as is commonly done : it has hith- erto been very univerfally fuppofed that venereal ul- cers, as well as every other fymptom of fyphilis, will be cured with as much certainty by fuch a quantity of mercury as is merely fufficient for making the mouth fore, provided it be continued for a due length of time, as by the greateft quantity wre can give : I own Sed. X. venereal Ulcer. 45 * too, that at one time I was alfo of this opinion, but after much experience in this branch of bufinefs, I am now convinced, that our pradice in fyphilis would prove much more certain, were we in every inftance, and particularly in all fymptoms of long continuance, to give as much mercury as the patient can with fafe- ty bear : in the treatife to which I have already refers red, I have endeavoured to ffiew, that it is not upon the long continuance of a courfe of mercury that we ought to depend, but upon the quantity of the medi- cine thrown into the fyftem in a ffiort fpace of time : an alterative courfe, as it is termed, in which mercury is given only fo far as to render the gums flightly fore, will frequently prove effedual in recent cafes ; but even in thefe, it often fails, with whatever care it may be conduded, and in thofe of long duration, no de- pendence ought to be placed on it. The quantity of mercury to be given, and the time to which the courfe ffiould be carried, are circum- ftances to be chiefly determined by the effeds of the medicine, and muft ultimately reft on the judgment of the praditioner in attendance ; but I may obferve in general, that the mercury ffiould be continued for two or three weeks after every fymptom of fyphilis is removed. It fometimes however happens, that venereal ulcers do not heal, although the virus by which they were produced is removed : in this cafe we depend upoii due attention to local management, and chiefly upon the repeated application of cauftic, which in fores of this defcription proves often tfie moft effedual reme- dy : cauftic not only ads by deftroying that tendency to fungous excrefcences, which often prevails in thefe fores, but it alfo proves ufeful by ading as a ftimulus to parts which have long remained in a ftate of inac- tion : by a proper application of cauibc, I have known fuch a healing tendency induced in fores, that cures have been accompliffied in a ve*t ffiort fpace of time, F F 2 4$i Observaikns on the Chap. V. when all the ordinary remedies had for a confidera- ble time before been ufed in vain. While the whole furface of the ulcer is touched with lunar cauftic eve- ry fecond or third day, it ought to be dreffed daily with bafilicon or wax ointment, impregnated with a fixth or feventh part of red precipitate, finely levi- gated. SECTION XI. Obfervations on the fcorbutic Ulcer. § I. Of the Symptoms and Caufes of the scorbutic Ulcer. THE feveral varieties of fcurvy enumerated by au- thors, namely, the muriatic, the alkaline, &c. fo named from the nature of the caufes fuppofed to pro- duce them, are now known to be falfe and improper diftindions ; the true fcurvy being always of the fame nature, and always produced by the fame caufes, wherever thefe occur, in whatever climate, and whe- ther at fea or land. Among other fymptoms of fcurvy enumerated by Dr. Lind in his ingenious treatife on this fubjed, the ulcers which are fo common in that difeafe, are par- ticularly defcribed ; and as he gives a very clear and diftind idea of them, I ffiall here tranfcribe verbatim, the Dodor's defcription of them. " The distinguishing charaderiftics of fcorbutic ul- cer are as follow : they afford no good digeftion ; but a thin fetid fanious fluff, mixed with blood ; which at length has the true appearance of coagulated gore lying caked on the furface of the ulcer, and is with great difficulty wiped off or feparated from the parts below. Sect. XI. scorbutic Ulcer. 453 " The fleffi underneath thefe floughs feels to the probe foft or fpongy, and is very putrid. No deter- gents or efcharotics are here of any fervice ; for though fuch floughs be with great pains taken away, they are found again at next dreffing, where the fame fanguineous putrid appearance always prefents itfelf: their edges are generally of a livid colour, and puffed up with excrefcences of proud fleffi arifing from be- low under the fkin. " When too tight a compreffion is made in order to keep the fungus from rifing, they are apt to leave a gangrenous difpofition ; and the member never fails to become cedematous, painful, and for the moft part fpotted. " As the difeafe increafes, they at length come to flioot out a foft bloody fungus, which the failors ex- prefs by the name of bullock's liver ; and indeed it has a near refemblance to that fubftance when boiled, both in colour and confiftence. It often rifes in a night's time to a monftrous fize ; and, although de- ftroyed by cauteries, adual or potential, or cut fmooth with a biftoury, in which cafe a plentiful haemorrhagy generally enfues, it is found at next dreffing as large as ever. They continue, however, in this condition a confiderable time, without affeding the bones. " The flighteft bruifes and wounds of fcorbutic perfons degenerate into fuch ulcers : their appearance, on whatever part of the body, is fo lingular and uni- form ; and they are fo eafily diftinguiffied from all others, by being fo remarkably putrid, bloody, and fungous ; that we cannot here but take notice of the impropriety of referring moft of the inveterate and obftinate ulcers in the legs, with very different ap- pearances, to the fcurvy."* This accurate defcription of the fcorbutic ulcer comprehends almoft the whole appearances which it ever affords: only it may be remarked, that at land, • See land's Treatife on the Scurvy. 454 Observations on the Chap. V. unlefs in very particular fituations, and from a con- flant expofure to all the more adive caufes of fcurvy, fuch inveteracy as is defcribed by Dr. Lind, is not of- ten met with : but in every country, and none, per- haps, more frequently than in fome parts of this, flighter degrees of the fame kinds of fores very often occur, forming what by praditioners in general are termed foul or malignant ulcers. In the Royal Infirmary of this place, fores of this kind are frequently met with, accompanied fometimes with the mofl charaderiftic fymptoms of fcurvy, foft fpongy gums. In the worft cafes, however, that I ever met with here, there never was the appearance of fuch'a high degree of putrefcency in the fyftem as we are told happens frequently in long voyages at fea. The reafon of this may be, that fuch complaints of the fcorbutic kind as occur in this country, appear generally among the loweft clafs of people, and pro- ceed rather from the want of a fufficient fupply of food, than from confinement to any that can be con- fidered as particularly feptic, or as predifpofing to fcurvy. In fuch patients, the putrid diathefis feldom ever prevails to fuch a degree as to produce ulcers in parts previoufly found; but it never fails to ffiow itfelf in ulcers either already formed, or in fuch wounds as happen to be inflided while this ftate of the fluids fub- fifts. Indeed, many of the ulcers upon the legs, and other parts, of our poor people, frequently partake, more or lefs, of the real fcorbutic difpofition ; as is evident both from their appearances, caufes, and par- ticularly from the method of cure ; a good nourifhing diet contributing more towards a cure, than all the applications that we ufually employ. The immediate or proximate caufe of thefe ulcers, as well as of every other fcorbutic fymptom, may be referred to a certain degree of putrefcency in the flu- ids ; which again may be induced by a variety of cauf- es, but of which the moft material are, living con- Sed. XI. scorbutic Ulcer. 455 ftantly upon fait provifions ; a total want of vegeta- bles ; with expofure to a cold moift atmofphere. Many other exciting caufes of fcurvy might be men- tioned ; but as this would lead to a more extenfive difcuffion of the fubjed than is here intended, for fur- ther information, Dr. Lind, Sir John Pringle, Huxham, and other authors who treat more diredly on the fub- jed, may be confulted. § 2. Of the Cure of the scorbutic Ulcer. The cure of fcorbutic ulcers, it is evident, muft de- pend chiefly upon the putrid diathefis by which they were produced, being correded ; for which purpofe vegetables of all kinds, but efpecially thofe of an acef- cent nature, with milk and whey, are found to be al- moft certain remedies. The different fecretions, efpe- cially thofe by the fkin and kidneys, ffiould be gently promoted ; and as the matter of perfpiration is in a particular manner much obftruded in fcurvy, our be- ing able to reftore it, is found to have much influence in the cure ; probably by carrying off many of the pu- trid particles with which the fluids in fuch cafes always abound. Gentle laxatives, too, for the fame reafon, prove ufeful, and in this view, tamarinds and cream of tartar with manna, anfwer well. Thefe, together with a total abstinence from falted food, and guarding againft other exciting caufes of the difeafe, very commonly effed a cure of every fcor- butic fymptom, and, among others, of thefe ulcers; the beft external applications for which, are, antifep- tics of the moft powerful kinds. Lind recommends unguentum JEgyptiacum and mel rofarum acidulated with fpiritus vitrioli. Thefe, in general, are the remedies which prove moft effedual, and which are commonly employed in very bad cafes of fcurvy ; but in the putrid ulcers moft frequent in this country, the feptic ftate of the fluids, as I have obferved above, feldom advances to 456 Observations on the Chap. V. fuch a high degree, as to render it particularly necef- fary to confine patients to what may properly be call- ed an antifcorbutic courfe. The common malignant or fcorbutic ulcer of thia climate proceeding more frequently from a real defi- ciency of food, than from any other circumftance, putting the patients by degrees upon a full allowance, with a daily, though moderate, proportion of gener- ous wine, has always a powerful influence on their re- covery. This, I muft obferve, is a point of more importance in the cure of thefe ulcers, than is commonly imagin- ed, and the attention of praditioners fliould be more direded towards it than we generally find it to be, Inftead of preferibing medicines for the cure of ulcers of this defcription, more advantage would accrue from a nourishing diet, and efpecially when to this is con- joined a moderate proportion of wine, or, what I have frequently imagined has anfwered better, a proper al- lowance of porter or ftrong beer. The foul old ul- cers of poor people in every country, are moft fre- quently induced by indigence, and are kept up by a real want of nouriffiment. In all fuch cafes, there- fore, the pradice of hofpitals would probably prove more beneficial, by laying the ufe of internal medi. cines almoft totally afide; and employing the favings thus produced, in furnifliing fuch a diet as I have ven- tured to fuggeft. Peruvian bark, however, is a remedy which, in ul- cers of this kind, proves frequently ufeful; it com- monly, indeed, proves more ferviceable here than in any other variety of ulcer. When given in fufficient dofes, a circumftance to be entirely determined by the ftate of the ftomach, it feldom fails of producing, in the courfe of a few days, a confiderable change for the better. In the fcorbutic ulcers, indeed, of this country, the bark is almoft the only internal medicine I have ever found neceffary. Sed. XI. scorbutic Ulcer. 457 With refped to the ufe of mercury in this kind of fore, it ought to be kept in view, that in ulcers really fcorbutic, inftead of acting as a remedy, if given in any confiderable quantity, it proves always hurtful. Lind, from a great deal of experience, fays, with re- fped to this point, " mercury, in a truly fcorbutic ul- cer, is the molt pernicious medicine that can be uf- ed."* So that a proper diftindion between fores of this nature, and the feveral varieties of herpes or erup- tive difeafes commonly termed fcorbutic, appears in the method of cure to be a matter of no fmall impor- tance : in the latter, mercury may not only be given with impunity, but in fome inftances with much ad- vantage ; whereas, in the other, this can never be done but with much hazard. Peruvian bark, as an external application, too, an- fwers exceedingly well in thefe ulcers ; pledgets dip- ped in a ftrong decodion of bark, and applied to the fores, have generally a confiderable effed in correding the fetor and putrefcency of the difcharge: but the beft application for this purpofe is the carrot poultice, which, when conjoined with the internal ufe of bark, and a proper regimen, in the courfe of a ffiort time, generally correds the putrefcency which prevails, fo effedually, that the fores being dreffed for a few days longer with pledgets of bafilicon and red precipitate, with a view to procure the removal of any floughs that remain, a cure is afterwards commonly eafily ob- tained, merely by attending to the diredions formerly pointed out for the management of ulcers in general, and particularly to the introdudion of an iffue, along with moderate compreffion with a roller. What I have hitherto faid of the treatment of fcor- butic ulcers, applies, in a great meafure, with equal force to every fore connected with a putrefcent ftate of the fluids, from whatever caufe it may have arifen. Thus, thofe ulcers that remain after critical abfceffes * Vide Treatife on the Scurvy, Part II. Chap. u. 45 8 Observations on the Chap. V. fucceed to putrid fevers, require the fame general method of cure : and the fame will probably prove moft effedual in thofe which fucceed to the plague ; but as we have no opportunities of feeing the plague in this country, I cannot from experience venture to affert it- SECTION XII. Obfervations on the fcrofulous Ulcer. § i. Of the Symptoms and Caufes of the fcrofulous Ulcer. SCROFULOUS ulcers, are fuch fores as remain after the opening or burfting of thofe fwellings which appear in different parts of the body as fymp- toms of the fcrofula or evil. From the frequent occurrence of fcrofula, it is fuch a well known difeafe, that it is almoft unneceffary to defcribe it. It begins with indolent, fomewhat hard, colourlefs tumors ; which at firft chiefly affed the conglobate glands of the neck ; but, in procefs of time, it attacks the cellular fubftance, ligaments of the joints, and even the bones. In fcrofula the fwellings are much more moveable than thofe of the feirrhous kind ; they are generally fofter, and feldom attended with much pain : they are tedious in coming to fuppuration : in feme inftances they difappear in one part, and again form in other parts, of the body. I may likewife mention, as char- aderiftic circumftances of this difeafe, a fine foft fkin, a kind of fulnefs of the face, with generally large eyes, and a very delicate complexion. Sed. XII. scrofulous Ulcer. 459 Scrofulous ulcers feldom yield a good difcharge; affording, upon their firft appearance, a vifcid, glairy, and fometimes a whitiffi curdled matter, which after- wards changes into a more thin watery fanies. Their edges are frequently, though not always, painful; and are conftantly much raifed or tumefied. As long as the fcrofulous diathefis fubfifts, thefe ulcers often re- main for a great length of time, without fhowing any difpofition either to heal or to turn worfe ; at other times they heal quickly, and again break out in fome other part of the body. A variety of caufes have been mentioned as tending to produce fcrofula; namely, a crude indigestible food ; bad water; living in damp fituations ; the dif- eafe being hereditary, and in fome countries endemic. Many other caufes have been enumerated by au- thors ; but thefe we cannot propofe to confider at pre- fent : this, however, may be obferved, that whatever may, in different circumftances, be the exciting or predifpofing^ caufes of fcrofula, the difeafe itfelf either depends upon, or is at leaft much conneded with a debility of the conftitution in general, and of the lym- phatic fyftem in particular; for it very commonly at firft appears in the conglobate or lymphatic glands; and that debility has at leaft a confiderable influence in producing it, is probable, not only from the evident nature of many of the caufes which appear to give rife to fcrofula, but from fuch remedies as prove moft fer- viceable in the cure, which are all of the tonic invigo- rating kind. §2.0/" the Cure of the fcrofulous Ulcer. It was long fuppofed, that fcrofula depended on an acid acrimony of the fluids ; and this, it is probable, gave rife to the ufe of burnt fponge, different kinds of foap, and other alkaline fubftances, as being the beft corredors of acidity. But although a foUrnefs of the ftomach and priinae vise is a frequent fymptom in fero- 4°o Observations on the Chap. V. fula; yet this ought not to be imputed to a general acefcency of the fluids, but merely to that relaxation which fo univerfally prevails in this difeafe. Nor is it probable, that acrimony of any kind oc- curs in fcrofula, of which we have a proof in the long continuance of matter colleded in the different fwel- lings which take place in this difeafe, without occa- sioning either much pain, or fhewing any tendency to corrode the furrounding parts ; there being many in- ftances of thefe colledions fubfifting even for years, without exciting uneafinefs: and, in fad, the feveral remedies recommended for correding the acrimony fuppofed to exift in fcrofula, never have, at leaft fo far as I have feen, any influence in the cure. Gentle mercurials and cicuta have fometimes ap- peared to prove ufeful, as refolvents, in fcrofulous fwellings; but nothing has fuch influence as a fre- quent and copious ufe of Peruvian bark, conjoined with fea bathing. Chalybeate and fulphureous wa- ters, too, have frequently proved ferviceable in fcro- fula ; and a long continued ufe of mild aperients of the faline kind has likewife had fome influence in re- folving the tumors. Moderate exercife proves always ufeful, particularly in dry air, and in a temperate cli- mate. Till the fcrofulous diathefis is eradicated, no per- manent cure of the ulcers can be looked for, and all that ffiould be done to the fores, is to give a free vent to the matter, fo as to prevent effedually the forma- tion of finufes. The beft applications for common ufe in fcrofulous ulcers, are the different faturnine preparations: of which the watery folution of faccharum faturni, ace- tum lythargyri duly diluted, Goulard's cerate, and unguentum faturninum, are to be preferred ; for they tend to prevent the fpreading of fcrofulous fores, which otherwife is apt to happen, and to remove that inflammatory complexion which they fo frequently put on when relaxing applications are long continued. Sed. XII. scrofulous Ulcer. 461 When the granulations become fungous, as often happens in thefe ulcers, any ointment we employ fliould be ftrongly impregnated with red precipitate, and in fome cafes, it even becomes neceffary to apply more powerful efcharotics, fuch as calcined alum, either by itfelf, or mixed with red precipitate, finely levigated. In fome inftances fcrofulous fores prove more ob- ftinate than ufual, and at the fame time the granula- tions cannot be kept down, from one or more of the contiguous bones being carious. In this cafe, no cure can be obtained till the difeafed parts of the bone are thrown off, which fometimes happens when the mid- dle parts of the large bones are affeded, but never when the difeafe extends to the joints. When the bones of a joint are difeafed, our only refource is to amputate the limb, a pradice feldom adopted in fcro- fulous patients, from a dread of the difeafe returning in fome other part of the body ; but, in a fubfequent chapter, I will ffiew, that in various inftances, it may be proper to deviate from this, as I have ofen done with the moft obvious advantage. In the cure of fcrofulous ulcers, tonics of every kind prove ufeful: Peruvian bark, of which I have already made mention, ffiould be continued, together with fea bathing, and an invigorating diet: of late, a preparation of terra ponderofa has alio been ufedas a tonic, under the form of what is termed muriated barytes ; and although it, no doubt, often fails, I have in various inftances made ufe of it with very obvious benefit. The dofe, at firft, is eight or ten drops to an adult, in a glafs of water; to be repeated three times a day, and increafed gradually to twenty, thirty or forty drops, if they do not previoufly excite ficknefs. In long continued fcrofulous ulcers, iffues prove al- ways ufeful, and the preffure which we derive from a proper application of the laced flocking, or of a fpi- ral roller, is often one of the moft ufeful remedies we can employ: it prevents thofe fungous granulations, 462 Observations on the Chap. V. to which ulcers conneded with fcrofula are particu- larly liable, and by which alone a cure is often pre- vented, which otherwife would take place. SECTION XIII. General Corollaries relating to the Management of Ulcers, IN the preceding fedions, I have endeavoured to point out every circumftance of importance in the cure of ulcers : at prefent I ffiall exhibit, by way of conclusion, fuch general corollaries as feem to refill* from what has been faid. 1. It appears, except in a few inftances, namely, in lues venerea, fcrofula, and fcurvy, that ulcers are always to be confidered as local. 2. That, excepting in one or other of thefe difea- fes, the varieties in the matter of ulcers, depend al- ways on fome particular affedion of the folids in the part difeafed, and not on any morbid ftate of the fluids. 3. That ulcers appear to be ufeful or prejudicial, not by the quality of the matter which they difcharge, but by the quantity: and, accordingly, that the cure even of the oldeft ulcer is rendered fafe by the intro- dudion of fuch an iffue as will yield the fame quan- tity of fluids, which the fyftem, by means of the ul- cer, has been accuftomed to throw off. 4. That, in the cure of ulcers, the firft circum- ftance to be determined, is, whether they are to be confidered as general or local. If they appear to be of the former kind, fuch remedies muft be advifed as are known to be moft effedual for removing the dif- eafe with which they are combined : in other refped*, Sed. XIII. Management cf Ulcers. 463 the treatment of thefe is nearly the fame with that of local ulcers. 5. That, in the treatment of ulcers of every kind, the chief objed to be kept in view, is, to reduce them as quickly as poffible to a ftate of purulency; for which purpofe the remedies have been pointed out in the feveral preceding fedions. 6. When brought to this fituation, the cure is to be accompliffied by due attention to the three follow- ing circumftances: 1. The introduction of an iffue, of fuch a fize as may carry off nearly the fame quantity of fluids which the fyftem, by means of the fore, has been accuftom- ed to throw off. 2. The prefer vation of the matter in a purulent form, the feveral means for which have been already pointed out; but the moft important, it may here be remarked, are, obviating every kind of irritation, and preferving, in the parts affeded, a proper degree of heat. 3. The application of gentle preffure, not only upon the ulcer itfelf, but on the neighbouring found parts alfo. In the courfe of this work, I have often had occa- fion to fpeak of the influence of preffure in the cure of ulcers. In addition to what has already been faid upon this point, I think it right to obferve, that this remedy is not as yet fufficiently known, otherwife it would be more generally employed. Thofe who have not ufed it freely would fcarcely give credit to the ac- counts which I could give of its uriverfal utility in the cure of fores; but, from much experience of its effeds in almoft every variety of ulcer, I can venture to affert, that thofe who have not employed it, have deprived their patients of the moft powerful' application hitherto propofed for the cure of ulcers. Thefe are, in fhort, the principal pomts to be kept in view in the cure of ulcer;-., as in diff -ent ptntc of the preceding factions have be.11 more fuily explained. 464 General Observations Chap. VI. CHAPTER VL OF SUTURES. SECTION I. General Obfervations on Sutures. AS futures are often neceffary, not only in the treatment of wounds, but in almoft every chi- rurgical operation, the fubjed obvioufly merits partic- ular attention. A variety of futures have been pradifed by fur- geons, each of which has, from long experience, been applied to a particular purpofe; namely, the inter* rupted future ; the quilled future; the glover's, and the twifted future. Many others are enumerated by authors ; but thefe four are the only futures at prefent in ordinary ufe ; and even of thefe, fome might with propriety be laid afide. * The intention of every future, is to unite parts, which, either by accident or defign, have been divi- ded. Another mode of effeding this^is through.the intervention of adhefive plafters : and this, by fur- geons, has been termed the falfe or dry future, in opposition to thofe that are performed by the needle, which are denominated the true or bloody future. But as the method of uniting divided parts, with the affiflance of plafters, has already been noticed in chap- ter II. when treating of wounds, it will not be necef- fary to enter upon the fubjed here. Sed. II* on Sutures. 463 SECTION II. Of the Interrupted Suture. IN deep wounds, when a reunion of the divided parts is intended, we, for the moft part, have re- courfe to the interrupted future ; but from what has already been fully explained, when treating of wounds, and from what will prefently further appear, it does not feem to be fo well adapted to this purpofe as the twifted future. When it is determined, however, to make trial of the interrupted future, the following is the eafieft mode of performing it. In every wound where futures are neceffary, it has commonly been confidered as good pradice, to carry the needle and ligature to-the bottom of the fore, fo as to give as little room as poffible for matter colled- ing underneath ; and the ufual method of effeding this, is by introducing the needle from without in- wards, and again from the bottom of the wound to the fame diftance on the oppofite fide. But this fu- ture, it may be remarked, is much more neatly, and at the fame time more eafily performed, by paffing both ends of the thread from within outwards; as may be readily done by ufing two needles upon each thread, inftead of one. A needle being put upon each end of the fame thread, and each needle Ijeing inferted at the bottom of the fore, and pufhed out- wardly, fo as to pafs out at a proper diftance from the edge of the wound, the needles are then to be taken off, and the threads allowed to remain till all the liga- tures are paffed which the extent of the fore feems to require. The number of ligatures neceffary for any wound, muft in a great meafure depend upon the extent of the divided parts. By authors, in general, it has been Vol. I. G g 466 Of Sutures. Chap. VI « laid down as an eftablifhed rule, that one future is fuf- ficient for every inch of wound. It will frequently, indeed, happen, that this number is fufficient; but in fome inftances, particularly where mufcular parts are deeply cut tranfverfely, and where confequently a great degree of retradion takes place, more flitches are ne- ceffary : whenever a number of angles, too, occur in wounds, more ligatures are required than in straight wounds of the fame extent; for, at every angle, how- ever inconfiderable it may be, there ought to be a future. In paffing the ligatures the fkin ffiould be pierced at a fufficient diftance from the edge of the wound: for if they do not comprehend a thicknefs of parts, in fome meafure proportioned to the depth of the wound, and to the extent of retradion that may take place, they will be apt to cut through the parts entirely. By fome, we are defired to enter the ligatures, at a diftance from the edges of the fore, nearly equal to the depth of the wound. This rule, however, will not always anfwer in pradice. Thus, in very deep wounds, fuch, for inftance, as are three inches or up- wards in depth, there can be no neceffity for carrying the ligatures three inches from the edges of the fore ; and again, in very fuperficial cuts, it fometimes hap- pens that the ligatures ought to be paffed out at a dif- tance from the edges of the wound greater than its depth. It ought not, in almoft any cafe, to be lefs than half an inch from the edge of the fore; and it will feldom happen, even in the largeft wounds, that the diftance of an inch is not found to be fufficient. It will be readily understood, that the ftrength of the ligatures, and fize of the needles, ought always to be proportioned to the depth of the fores and retrac- tion of parts. The feveral fizes of needles reprefent- ed in Plate III. are fuch as are found to anfwer beft ; and the ligatures to be ufed along with them ought to be fuch as nearly, though not entirely, fill the eyes of Sed. II. Of Sutures. tf7 the needles. In order to make the ligatures pafs with more eafe, to render them more durable, and at the fame time to make them more fufceptible of a flatten- ed form, which does not fo readily cut through the contained parts as thofe that are round, they ought all to be well waxedi As foon as the threads are all pafled, the lips of the wound ffiould be preffed together and fupported by an affiftant, till all the ligatures are firmly tied ; be- ginning either in the middle of the wound, or at one end, as the operator may incline : in tying the knots* it is ufual to pafs the ends of the threads twice through the firft nooie ; and when this is done, fome have im- agined that there is no neceffity for more than one knot upon each ligature ; but as two knots are eafily made, and as every chance of their giving way is in this manner prevented, this precaution ffiould not be omitted. It is a pradice with fome furgeons to infert a piece of lint between the firft and fecond knots, or between the firft knot and the fkin below, in order to fave the fkin from the preffure of the knots ; but no advantage of importance, is derived from it, while it prevents the knots from being made with fufficient ac- curacy. By fome, we are defired not to bring the knots of the ligatures immediately upon the edges of the wound*, but rather to carry them to one fide upon the found teguments : but whoever has tried both methods, will at once be fenfible, that this is no improvement; for in no way can both fides of the fore be fo equally fup* ported, as when the knots are paffed immediately above the lips of the divided parts. g o 2 46*8 Of Sutures. Chap. VL SECTION IIL Of the Quilled Suture. AS the quilled future is ftill employed by fome praditioners, I fhall here mention the mode of performing it. In deep wounds, attended with much retradion, it is always neceffary to affift the operation of the liga- tures, by means of bandages fo applied as to afford as much fupport as poffible to the divided parts : but, even with every affiflance of this kind, it fometimes happens, that the divided parts cannot be kept togeth- er ; retradion occurs to a greater or leffer degree, and the ligatures cut afunder the parts that they were at firft made to furround. With a view to prevent the teguments and other parts from receding, it was long ago propofed to add to the interrupted future what was fuppofed would af- ford an additional fupport; namely, quills, or pieces of plafter rolled up into the form of quills ; one of which being placed on each fide of the wound, the doubling of the ligature is made to include the one, and the knot to prefs diredly upon the other, inftead of being made immediately on the edges of the fore, as was direded for the interrupted future. It is at once evident, however, that the ligatures muft here make the fame degree of preffure on the parts through which they pafs, as they do in the in- terrupted future ; and this being the cafe, it is equally obvious, that the interpofition of thefe fubftances can- not be of any ufe. This future is accordingly now very rarely pradifed, and it is probable that it will be foon laid entirely afide. Sed. V. Of Sutures. 469 SECTION IV. Of the Glover's Suture. THIS future receives its name from being that which glovers commonly ufe. As it is exceed- ingly fimple, and very univerfally known, it does not here require a particular defcription : I ffiall therefore juft ffiortly obferve, that it confifts in a feries of ftitch- es all conneded with each other, and continued in an oblique fpiral diredion along the courfe of the divided parts intended to be kept together. This future has hitherto been univerfally employed for reuniting fuch parts of the inteftines as have been divided by wounds : but, in treating of injuries of the inteftines, I ffiall endeavour to fliow, that the fame end may be more perfedly attained, and probably with lefs danger, by means of the interrupted future; fo that as this future has almoft never been applied to any other purpofe, it will likewife in all probability foon fall into difufe. SECTION V. Of the Twifted Suture. BY the term twifted future is meant that kind of ligature, by which parts, either naturally or ar- tificially feparated, are united together, by means of ftrong threads properly twifted round pins or needles pufhed through the edges of the divided parts. This future is commonly employed for uniting the parts in the operation for the hare lip; and this in- deed is almoft the only ufe to which it has been hith- erto applied: but I may here remark, that it may 47? Of Sutures. Chap. VI. with much advantage be put in pradice in other caf- es, particularly in all artificial or accidental divifions of the lips or cheeks : and, in every wound in other parts that does not run deep and in which futures are neceffary, this future is preferable to the interrupted or any other. In very deep wounds, for inftance in all that ex- tend to a greater depth than an inch, the interrupted future is the only one that is admiffible ; for, in all deep cuts, the pins neceffary in the twifted future can- not with propriety be employed, as they cannot be in- troduced to fuch a depth, and afterwards fo twifted with ligatures as to reunite the divided parts, without exciting fevere pain. In fuch wounds, therefore, we muft of neceffity employ the interrupted future. But it may here be remarked, that wounds of this depth requiring the aid of futures, are feldom met with : fo that, in by much the greateft proportion of wounds requiring futures, the twifted future may be in our power ; and whenever it is fo, it ought certainly to be preferred, as being obvioufly better calculated, even than the interrupted future, for the retention of divide ed parts. The pins made ufe of for twilling the threads upon, ffiould be of a flat form, fo as not to, cut the parts through which they pafs fo readily as the ligatures employed in the interrupted future ; and thus we obviate one great objedion to the latter ; for, every praditioner muft be fenfible of this being the chief inconvenience of the interrupted future, that when mufcular parts are divided, fo as to produce much retradion, the ligatures employed for retaining them, almoft conftantly cut them through before they unite ; an occurrence wffiich the flatnefs of the pins that we employ for the twifted future, is particularly well calculated to prevent. The pins ufed in this operation have commonly been made of filver; and, in order to make them pafs with more eafe, they are made with fleel points. As gold pins, however, are capable of receiving a fuf- Sed. V. Of Sutures. 47i ficient degree of ffiarpnefs, which renders fteel points unneceffary; and as gold is more cleanly than filver, from its not acquiring fo readily that kind of cruft which immerfion in fluids is apt to produce upon the other; pins of this metal are therefore better. The form and fize of pins reprefented in Plate IV. are by experience found to be the beft for every ordi- nary purpofe; but for particular cafes, the fize muft no doubt be fubjed to fome variety. The manner of performing this operation is as fol- lows : the divided parts muft, by the hands of an af- fiftant be brought nearly into contad ; leaving juft as much fpace between the edges of the wound, as to allow the furgeon to fee that the pins are carried to a proper depth. This being done, one of the pins muft be introduced through both fides of the wound, by entering it on one fide externally, puffiing it forwards and inwards to within a little of the bottom of the wound, and afterwards carrying it outwards through the oppofite fide, to the fame diftance from the edge of the fore that it was made to enter at on the other. The diftance at which the needle ought to enter from the edge of the fore, muft depend on the depth of the wound, and degree of retradion that takes place ; but whatever the deepnefs of the wound may be, the pins ffiould pafs within a very little of its bot- tom ; otherwife the parts which lie deep will run a rifk of not being united, which will be very apt to give rife to fores or colledions of matter. In paffing the pins through the fides of the wound, if the fkin and other teguments are not more firm than ordinary, it may commonly be done with the fingers alone, efpecially if the pins are made with fmail heads or knobs for the fingers to prefs upon; but when firmnefs of parts and other circumftances ren- der the entrance of the pins difficult, the inftrument termed by the French porte-aiguille, very effedually removes this inconvenience. In Plate IV. fig. 1, is reprefented the beft form of this inftrument that has yet been invented. 4/2 Of Sutures. Chap. VI. The firft pin being paffed in this manner near to one end of the fore, and the parts being ftill fupport- ed by an affiftant, the furgeon, by means of a firm waxed ligature, paffed three or four times round and acrofs the pin, fo as nearly to form the figure of 8, is to draw the parts through which it has paffed into clofe contad; and the thread being now fecured with a loofe knot, another pin muft be introduced in the fame manner at a proper diftance from the firft; and the thread with which the other was fixed, being loofened, and in the fame manner carried round this pin, others muft be introduced at proper distances along the whole courfe of the wound, and the fame ligature ffiould be of a fufficient length for fecuring the whole. The number of pins to be ufed, muft depend upon the extent of the wound. But whether the wound is large or of fmall extent, a pin ffiould be inferted near to each end of it, otherwife the extremities of the cut are apt to feparate, fo as not to be afterwards eafily reunited. In large wounds, the pins being introduc- ed at the diftance of three quarters of an inch from each other, will in general anfwer; but, in wounds of fmaller extent, a greater number of pins are neceffary in proportion to their dimenfions. Thus, in a wound of an inch and half in length, three pins are requifite; one near to each end, and another in the middle: whereas, five pins are fuffi- cient for a wound of three inches and a half long, al- lowing one to be within a quarter of an inch of each end of the wound, and the others along the courfe of it, at the diftance of three quarters of an inch from each other. The pins being all introduced and fecured in the manner I have mentioned, nothing remains to be done, but to apply a piece of lint, wet with mucilage, or fpread with any emollient ointment, along the whole courfe of the wound, in order to exclude the external air as much as poffible. Sed. V. Of Sutures. 473 With the view of preventing the ends of the pins from hurting the fkin below, it is ufual to apply a fmall bolfter of lint under each of them; but as this always does harm, by tending to prefs the pins againft the parts through which they have paffed, it ought certainly to be omitted. When, however, the patient complains of being hurt by the ends of the pins, this may be eafily prevented by introducing between them and the fkin beneath pieces of thin linen, fpread with adhefive plafter. In order to give as much chance as poffible to this operation, it has commonly been advifed, immediate- ly after the pins are fecured, to apply the uniting bandage over the whole, with the view of fupporting the contiguous parts. The leaft refledion, however, renders it evident, that every degree of preffure made in this manner muft do harm; for, the bandage be- ing made to reft immediately upon the pins, a confid- erable degree of pain muft of courfe enfue from it; which happens indeed in fuch a degree, that, in every inftance in which I have known it employed, it either did harm, by preffing upon the pins, or, if this did not happen, no advantage was derived from it, from its not being applied with fuch tightnefs as to afford any fupport to the parts below. In fome inftances, indeed, I have employed adhefive plafters with obvi- ous benefit, along with the twifted future : by apply- ing a portion of plafter, fpread upon leather, between every two of the pins, .we are enabled to draw the parts very forcibly together with pieces of thread or fmall tape previoufly attached to each portion of the leather, and where the retradion of the divided muf- cles is more than ufual, this precaution ffiould never be omitted: I have had recourfe to it with much ad- vantage in the operation for the hare lip. We have next to confider the length of time which the pins ffiould be allowed to remain. When they remain long, they generally do harm, by the irritation and confequent retradion of parts, which they are apt 474 Of Sutures. Chap. VI. to produce; and again, if not long enough continu- ed, that degree of adhefion is not formed between the divided parts that is neceffary for their retention, fo that the effed of the operation is in a great meafure, if not entirely, loft. In wounds of no great depth, I have, by experi- ence, found, that firm adhefion takes place in the fpace of five days; and that fix, or at moft feven days, are fufficient for wounds of the greateft depth. But, in fpeaking of this, it muft always be under- stood, that the patient's ftate of health will have much influence on the length of time that may be neceffa- ry. In fpecifying the time required for this purpofe, the operation is fuppofed to be done in a healthy ftate of body. When the patient labours under difeafe it is impoffible to afeertain this circumftance with preci- fion: in fuch cafes we muft be determined by the age of the patient and ftate of his conftitution at the time. As foon as the pins are withdrawn, the uniting bandage may be applied with much advantage as a fupport to the parts newly united ; but, as flips of ad- hefive plafter, when applied, as I have advifed above, to each fide of the cicatrix, may be made to anfwer the purpofe in a more exad manner, this mode of fupporting the parts will in general be preferred. As the twifted future, when properly performed, is a very neat operation ; as its confequences are in gen- eral of importance; and as it may, with much ad- vantage, be made to fuperfede the ufe of almoft every other future, a few inftances only excepted, I have here judged it proper to confider it with more atten- tion than has hitherto been commonly bellowed on it. Chap. VII. Of the Ligature of Arteries, EffV. 475 CHAPTER VII. Of the Ligature of Arteries, and other Means employed by Art for putting a ftop to Hamorrhagies. IN every wound, whether produced by accident, or by furgeons in performing operations, the firft cir- cumftance requiring attention, is the haemorrhagy ; which may proceed either from one or more large ar- teries, or it may be produced by a general oozing from the fmaller veffels over the furface of the fore. A furgeon being called to a perfon lofing much blood from a large artery, the firft ftep to be taken, is, to put a temporary ftop to the difcharge, by means of preffure, till by the application of ligatures a more effedual remedy is obtained. In the head, as well as 'in the trunk of the body, the eafieft way of effeding this is to prefs doflils of foft lint or dry fponge upon the mouths of the divided arteries, either by the hands of an affiftant, or by the proper application of a ban- rage : or, when preffure can be effedually applied to the fuperior part of the artery, it ought to be prefer- ded ; as it not only fecures the veffel equally well, but more readily admits of a ligature being afterwards ap- plied to the divided part of it. When, again, haemorrhagies take place in any of the extremities, and where preffure can be made with eafe on the fuperior parts of arteries, for fuch cafes we are in poffeffion of a remedy, which, when fkilfully applied, never fails to put an immediate ftop to all further lofs of blood : I mean the tourniquet. Till the invention of this inftrument, and it was not known till the laft century, furgery remained ex- tremely defedive indeed. No operation of impor- tance could be performed on any of the extremities. 476" Of the Ligature Chap. VII. but with much hazard ; fo that large wounds fre- quently proved fatal from the want of it, which oth- erwife would have been attended with no danger. As the invention of the tourniquet is claimed by different perfons, and even by different nations, I ffiall not here pretend to fay from whence it originally came: but whoever was the inventor, the firft with which the world was made acquainted, was exceed- ingly fimple; infomuch, that we are now apt to be furprifed at the difcovery having been left to fuch a late period. A fmall cuffiion being placed upon the courfe of the principal artery of a limb, a circular rope or bandage was made to pafs twice round it; and a fmall wooden handle being then introduced into one of the folds of the rope, for the purpofe of twilling it, the cuffiion by thefe means was preffed with fo much force upon the artery, as to put an effedual flop to the circulation in all the under part of the limb. Mr. Petit, an eminent furgeon of Paris, was the firft who improved this inftrument: he conneded the circular bandage with a ferew, which was fo contriv-' ed as to produce the preffure chiefly on the principal arteries, without materially affeding the reft of the limb. It had alfo this advantage over the other in- ftrument, that the operator himfelf could manage it, without employing an afliftant; but it was liable to one great inconvenience from the very circumftance which, by the inventor, was confidered as an improve- ment. This inftrument of Mr. Petit being made to ad upon the principal arteries only, the fmaller vef- . fels communicating with thefe, not being properly compreffed, difcharge blood freely from the inftant they are cut; and as this proves always troublefome in the courfe of operations, different improvements have of late been made on it. Fig. i. Plate II. repre- fents the beft that has yet been invented. By means of this inftrument in its now improved ftate, the blood is very eafily and effedually ftopped; and as it graips the whole member equally, all the Chap. VII. of Arteries, tffc. 477 collateral branches, as well as the principal arteries, are equally compreffed by it. It has alfo this mate- rial advantage over every other inftrument of this kind, that, when properly applied, a fingle turn, or even half a turn of the fcrew, is fufficient either for allowing a flow of blood, or for putting a total ftop to it. The manner of ufing it, is this: Let a cuffiion, three inches in length, by one inch and a half in diameter, be formed of a linen roller, tolerably firm, but yet not fo hard as to render the preffure produced by it painful: this being placed up- on the courfe of the principal artery of the limb, let it be firmly fecured by one or two turns of a circular roller of the fame breadth with the cuffiion itfelf. The inftrument A, with the ftrap conneded with it, being now placed upon the limb, with the handle of the fcrew B on the fide of the member oppofite to the cuffiion upon the artery, the ftrap C is to be car- ried round the limb diredly over the cuffiion, and to be firmly conneded on the other fide to the buckle D. In thus connecting the ftrap and buckle together, it ought to be done with much firmnefs, fo that the fcrew may afterwards operate with as much advantage as poffible, in producing a fufficient degree of pref- fure. When proper attention is given to this, a fin- gle turn of the fcrew proves fufficient, as I have ob- ferved above, for putting a ftop to the circulation of blood in the limb ; but when the ftrap has not been made tight at firft, feveral turns of the fcrew become neceffary ; which never fails to prove troublefome in the courfe of an operation, and which ought there- fore to be guarded againft. When it is therefore determined, that any further lofs of blood from a divided artery is to be prevented, preffure on the fuperior part of the veffel fhould be immediately applied, by the hands of an affiftant, or bv a proper bandage, when the cut is on the head or trunk of the body ; and by the tourniquet in any of the extremities. 47s Of the Ligature Chap. VlL The patient being in this manner fecured from im- mediate danger, the praditioner muft endeavour to prevent a return of the haemorrhagy on the tourni- quet being removed. The ancients, as I have obferved above, were igno- rant of the ufe and application of the tourniquet, and they were equally deficient in the employment of means for giving a permanent fecurity againft the flow of blood from divided veffels. It will therefore readily occur to praditioners of the prefent day, that in this imperfed ftate of chirurgical knowledge, they muft in all important operations have incurred much rifk of doing harm: to the fmaller veffels they appli- ed doffils of linen covered with aftringent powders or tindures; and for divifions of the larger arteries, fearing with hot irons was their only refource. On this laft remedy, however, although it com- mands a temporary ftoppage of the blood in every cafe of haemorrhagy, we ought not to place much de- pendence ; for, if not carried to a greater depth than in general is confiftent with fafety, the puliation of the larger arteries very foon overcomes all the refift- ance produced by the efchar obtained from the cau- tery. In ancient times, however, when this was the mofl effedual remedy with which the, world was acquaint- ed, praditioners were under the neceffity of employ- ing it; and, at that period, it is not furprifing to find them exercifing their genius in inventing a variety of ftyptic applications : but fince furgery became enrich- ed with that material improvement of fecuring the larger arteries with ligatures, a pradice eafily effeded, and with very little pain to the patient, we are rather furprifed to find that remedies of this clafs are ftill fearched after. If the ufe of ligatures were in itfelf attended with difficulty ; if, by experience, it had been found to produce any dangerous confequences ; or, if it had been frequently known to fail in anfwer- ing as a full fecurity againft the haemorrhagies of the Chap. VII. of Arteries, fcrV. 479 largeft arteries; in any of thefe events, it ought to be the bufinefs of praditioners to endeavour to procure a more effedual remedy. But, as the ligature of ar- teries is very fimple in its nature ; as the pain arifing from it is trifling ; as few inftances occur of any thing bad being produced by it; and efpecially as, when properly performed, it never fails to prove a fure pre- ventative againft all lofs of blood from the larger ar- teries ; there can be no good reafon for anxioufly feeking after other remedies. Agaric, common fponge, and other fungous fub- ftances have been much extolled for their flyptic pow- ers ; and chalybeate and vitriolic folutions, as well as all the variety of mineral acids, have in different forms been held forth to the public as effedual reme- dies of this nature ; not only as noftrums, by thofe of lefs liberal principles, but, what is more furprifing, in fome inftances by praditioners of charader. With the former clafs of men, this happens as a common occurrence in the courfe of their profeffion, and is therefore to be expeded ; but a perfeverance in queft of new ftyptics on the part of furgeons of repu- tation, who are well acquainted with the beneficial ef- feds of ligatures, muft proceed from a degree of nice- ty and refinement, which may create much trouble to themfelves, and which in all probability can never be produdive of any advantage to their patients. I may therefore venture to fay, that it ffiould be confidered as an eftablifhed maxim in furgery, that in haemorrhagies from the larger arteries, no flyptic whatever ought to be trufted, and that we fliould place dependence only on the ufe of ligatures : I ffiall now therefore proceed to confider the eafieft and moft ef- fedual method of putting this remedy in pradice. Various methods have been propofed for fecuring arteries with ligatures. The pradice now in common ufe, is, by means of a curved'needle, to pafs a ligature of fufficient ftrength round the mouth of the bleeding veffel, including a quarter of an inch all round of the 480 Of the Ligature Chap. VH. contiguous parts,* and afterwards to form a knot up- on the veffel and other parts camprehended in the noofe. One important objedion, however, to this pradice, is, that the nerves accompanying the blood veffels, to- gether with a confiderable portion of the mufcular fubftance through which they pafs, muft always be ti- ed with ligatures formed in this manner. From this circumftance, much unneceffary pain is produced, by the nerves and contiguous parts being compreffed along with the arteries ; and, in fome inftances, fevere con- vulfions have arifen from this, not only of the part chiefly affeded, but of the whole fyftem. Spafmodic twitches frequently take place after the amputation of limbs, and are often the fource of much diftrefs. In fome inftances, this fymptom is no doubt the effed of other caufes ; but in various cafes it has happened, that the cleareft proof has been obtained of its arifing from the ligatures of arteries applied in an improper manner. When convulfions occur after amputations, and the ufual means of preventing them are found to fail, effedual relief may be frequently ob- tained by undoing the ligatures, fo as to remove the compreffion upon the nerves; care being taken at the fame time to renew the ligatures upon the arteries alone, without comprehending any of the contiguous parts. Thus, it is not from the mere application of liga- tures to blood veffels, but from the improper manner in which the operation is performed, namely, the in- cluding nerves and other parts, inftead of tying the arteries alone, that the bad fymptoms in fuch cafes proceed. Praditioners have commonly been afraid of tying arteries by themfelves, without the intervention of fome of the furrounding parts: this has happened from an idea that has prevailed of the coats of blood * Sharp's Surgery,—on Amputation. Chap. VlL of Arteries, &c. 481 veffels not being fufficiently firm to bear a degree of compreffion neceffary for the prevention of haemor- rhagy. This, however, proceeds upon the fuppofition, of the coats of arteries not being fo ftrong as they really are ; and that a great degree of force is neceffary for retaining their fides in contad. But it is now well known, that even very fmall ar- teries are poffeffed of much firmnefs; and it is alfo known, that even in the largeft arteries of the arm and thigh, a very flight degree of compreffion is fuf- ficicnt, not only for restraining haemorrhagy, but for fecuring the ligature on the very fpot to which it is firft applied : in fmall veffels, the force neceffary for this purpofe is trifling indeed; being much lefs than is commonly employed. It has alfo been objeded to this mode of fecuring blood veffels by themfelves, that the ligatures are more apt to flip than when fome of the furrounding parts are tied along with them ; and, in fome inftan- ces, it is faid that arteries retrad fo far, that they can- not in any other way be laid hold of, than with the crooked needle in the ordinary method. Long and repeated experience, however, of a few individuals, in regard to this mode of taking up arte- ries by themfelves, has put the fad beyond a doubt, that it is as^ fecure as any other yet invented. Fatal haemorrhagies, after capital operations, either from in- attention, or fome other caufe, fometimes indeed hap- pen in the hands of the moft expert furgeons, but they occur more frequently when the curved needle has been employed, than when the blood veffels are fecured t>y themfelves, without any of the contiguous parts being included. From the refult of my own experience, indeed, I fliould be induced, even in this point of view, to draw a conclufion in favour of the pradice I recommend. For both among hofpital patients, and in private, Vol. I. H h 4&2 Of the Ligature Chap. VII. I have known different deaths occur from the bleed- ing of ftumps after the apputation of limbs : and whether this proceeded from the ligatures having flip- ped from the arteries; or, that fome of the veffels which did not appear during the operation, had been of courfe paffed over, and had afterwards burft out; I ffiall not pretend to determine: but in all of thefe, the crooked needle only had been ufed during the ope- ration ; and it has fo happened, that I never met with a fingle inftance of a fimilar occurrence where the ar- teries were fecured by themfelves with the tenaculum ; an inftrument to be hereafter mentioned. In a few inftances it may happen, that a bleeding veffel, by lying at the bottom of a deep wound, can- not be laid hold of in any other manner than by paff- ing a curved needle and ligature round it. Such oc- currences, however, are fo rare, that I have met with few inftances in which haemorrhagy could not be as eafily restrained with the tenaculum, as with the crook- ed needle. In all operations whatever, to fave unneceffary pain, is a very important point. The objed in view ought no doubt to be attained in the moft complete manner; but that mode of operating, which is equally effedual with any other, at the fame time that it is the leaft painful to the patient, ought in every inftance to be preferred. Now, with refped to the point in quef- tion, as I have already made it appear that arteries may be tied with as much fafety by themfelves as when conneded with any of the neighbouring parts, the difference of pain arifing from the two modes of operating, ought at once to give the preference to that which is produdive of the leaft degree of it. When any of the contiguous parts, particularly when the nerves, which generally accompany blood veffels, are included in the fame ligature with an arte- ry, a circumftance fcarcely to be avoided when the curved needle is employed, a very fevere degree of pain is often excited by tying the knot. I have known Chap. VII. of Arteries, CsrV. 483 Various inftances of patients, bearing the amputation of limbs, and of cancerous breafts, without shrinking, but who complained feverely of the pain excited by tying the arteries with the crooked needle: while, on the contrary, the pain arifing from the ufe of the ten- aculum, is fo trifling, that, when properly done, even the molt timid patients feldom complain of it. For fome time after I firft made ufe of the tenacu- lum, curiofity induced me, in different inftances, to put the point in queftion to the teft of experiment: and to render the trial fair and decisive, it was always made upon the fame fubjed, under the fame opera- tion. Different veffels were fecured in the ordinary manner with the crooked needle ; whilfl others were laid hold of with the tenaculum : but fo great was the difference, that the one feldom gave much uneafi- nefs ; while the patient commonly complained of the other as the moft painful part of the whole operation. Among other advantages attending the tying of ar* teries with the tenaculum, there is one which I have not mentioned : it often happens after the amputation of limbs, as well as in other operations, that the liga- tures do not come eafily away, from their being made to run fo deep as with the curved needle is commonly neceffary. In fome inftances, much pain and trouble has occurred from this, the ligature remaining im- moveable for a great many weeks : and after all, I have known it neceffary to cut it out with a fcalpel. But when the tenaculum is ufed, every rifk of this is avoided, as the ligatures generally drop of their own accord, in the courfe of the third or fourth dreffing of the fore. I ffiall, therefore, confider it as a pradice that ffiould be eftablifhed, that in forming the ligature of arteries, the nerves and other contiguous parts ought to be avoided. For the purpofe of performing this with eafe and fafety, various kinds of forceps have been invented, h h 2 4$4 Of the Ligature Chap. VII. with which the divided arteries are laid hold of and pulled out, fo as to admit of the ligatures being ap- plied. For 4he larger blood veffels, forceps have been found to anfwer; but for fmaller arteries, they are not fo ufeful as the tenaculum, reprefented in Plate III. fig. i. and 8. And as a hook of this form anfwers equally well in the larger arteries alfo, the ufe of for- ceps may therefore be laid afide. The manner of uf- ing the tenaculum is this. In order to difcover the arteries to be tied, the tour- niquet with which they are fecured muft be slackened by a turn or two of the fcrew ; and the moment the largeft artery of the fore is difcovered, the furgeon ffiould fix his eye upon it, and immediately reftrain the blood with the tourniquet again. A noofe hav- ing been previoufly formed on the ligature, and paffed upon the tenaculum, the operator ffiould now puffi the point of the inftrument through the artery ; and at the fame time ffiould pull it out to the extent of an eighth part of an inch or thereby : the noofe ffiould now be pulled over the point of the tenaculum by an affiftant; and being preffed fufficiently upon the arte- ry, a knot ffiould be formed with it of fuch tightnefs as may be neceffary : in forming this ligature, the furgeon's knot, as it is termed, ffiould be preferred : it is done by paffing the thread twice through the firft noofe, and as fome additional fecurity is obtained by forming a fecond knot above the firft, it ffiould never be omitted. It is eafily done ; and on fecurity in this point, the patient's life may in a great meafure depend. The ftrength of the ligature ffiould always be pro- portioned to the fize of the artery; but this is a cir- cumftance to be at all times determined by the judg- ment of the praditioner, as muft alfo the force to be employed in forming the knots. To what was alrea- dy faid upon this point, I ffiall here add, that a very trifling force is fufficient for fecuring even the largeft Chap. VII. of Arteries, &c. 485 arteries : and that, after fuch a force has been appli- ed, as evidently restrains the flow of blood, no further compreffion ffiould be made. The principal artery being in this manner fecured, all the arteries which have been cut muft be taken up in a fimilar manner, by firft loofening the tourniquet - in order to difcover them, and afterwards applying a ligature upon each. It often happens, however, that the lofs of blood, in the courfe of an operation ; a tendency to deliqui- um which may continue for fome time ; the fear which the patient labours under; and the degree of cold to which the fore is expofed; have altogether fuch an effed upon the fmaller arteries, as to prevent them for the time from difcharging their contents : and as arteries left in this ftate, without being fecured, generally burft out afterwards, a circumftance which always occafions much trouble to the praditioner, as well as pain and rifk to the patient, nothing ffiould be omitted that can in any manner of way tend to pre- vent it. With this view, the tourniquet ffiould be made per- fedly loofe ; any coagulated blood on the furface of the fore ffiould be carefully waffied off with a fponge and wrarm water; and the patient, if likely to faint, ffiould take a glafs of wine, or fome other cordial: and after all, the furgeon ought to examine, with the moft m;nute attention, the courfe which the veffels of the part ufually take. This being done, every artery that can be diftin- guiffied, ffiould be fecured with a ligature ; for fuch as may feem to be very fmall, while the part is yet expofed to the air, may difcharge large quantities of blood after the patient becomes warm in bed ; when the folids are thereby relaxed, and the fluids expand- ed : and, as no harm can arife from ligatures being applied to every artery that is cut, it ought in every inftance to be done. 486 Of the Ligature Chap. VII. When the principal arteries of a flump have been taken up, and blood ftill continues to be difcharged, but which appears to come from a few fmall veffels only, the furgeon, unlefs he is much accuftomed to this kind of bufinefs, is apt to think, from their tri- fling appearance, that he need not be at the trouble of tying them, and that the preffure of the neceffary ban- dages will prove fufficient: where the difcharge pro- ceeds from the whole furface of a wound, and when no particular veffel can be diftinguiffied, we muft of neceffity truft to this remedy ; but, whenever an ar- tery can be difcovered, of whatever fize it may be, it ought unquestionably to be fecured with a ligature. I have infilled the more upon this, from having often obferved both diftrefs and danger induced, by want of attention to this part of an operation, and from fome late publications having very improperly endea- voured to ffiew, that there is no rifk in leaving all the fmall arteries untied that are cut in operations ; a pradice fraught with much perplexity to pradition- ers, and with the utmoft hazard to patients. When, from the deepnefs of a wound, or from any other caufe, fome particular artery cannot be properly fecured with the tenaculum ; we are under the necef- fity, as I have already obferved, of trufting to the crooked needle, and the following is the mode of ufing it, The operator ffiould be provided with needles of various fizes, and of different forms. The needles in ordinary ufe, are for many purpofes too much crook- ed ; for, in general, they are more eafily managed when their curvatures are lefs. The needles that I have mentioned for the interrup- ted future, reprefented in Plate III. anfwer equally well for the ligature of arteries, Thofe in common ufe are made with three edges, one on each fide, and a third on the concave part of the needle. There is no neceffity, however, for more than two. Needles enter, indeed, more eafily with two Chap. VII. of Arteries, &c. 487 than with three edges ; and as the third edge on the concave fide renders them liable to injure arteries and other parts in the courfe of their introdudion, it ought to be omitted. A needle of this ffiape, armed with a ligature of a fize proportioned to itfelf, and to the veffel to be tak- en up, is to be introduced at the diftance of a fixth or eighth part of an inch from the artery ; and being carried at leaft one half round the artery, at a depth fufficient for retaining it,it muft now be drawn out; and being again pufhed forward, till it has completely en- circled the artery, it is again to be pulled out, and a knot tied in the manner that I have advifed in ufing the tenaculum. In this manner, either by the ufe of the crooked needle, or the tenaculum, every haemorrhagy arifing from the divifion of one or more arteries, may in gen- eral be restrained ; but it frequently happens, that confiderable quantities of blood are difcharged, not from any particular veffel, but from all the fmall arte- ries over the furface of a wound : in wounds of great extent, particularly after the extirpation of cancerous breafts, and in other operations where extenfive fores are left, this kind of haemorrhagy often proves trou- blefome, from being very difficult to fupprefs. Haemorrhagies of this kind feem evidently to pro- ceed from two very different and oppofite caufes ; which, in the method of cure, require particular at- tention. Firft, They fometimes take place in very robuft constitutions, and proceed either from too great a quantity of blood in the arteries and veins, or from an excefs of tone in the veffels themfelves; or perhaps, from both of thefe caufes being combined. But, fec- ondly, They appear to happen moft frequently in con- ftitutions quite the reverfe of this, namely, in fuch as are weak and relaxed, either from a putrid diffolved ftate of the blood, from want of tone in the veffels, or in feme inftances from a concurrence of both. 488 Of the Ligature Chap. VII. In healthy patients, when the fluids are not tainted with putrefcency, and the folids are poffeffed of their natural tone, as foon as the large arteries of a wound are fecured, the fmaller veffels for the moft part re- cede within the furface of the furrounding parts : this they do in confequence of that contradile power with which, in a ftate of health, they are endowed, and from the ftimulus of the external air to which they are now expofed. This of itfelf would often prove fufficient for restraining haemorrhagies from fmall ar- teries ; but in the found ftate of conftitution to which I allude, another powerful agent is provided for pro- ducing the fame effed. From the extremities of the divided veffels which at firft difcharged red blood, there now, in their contraded ftate, oozes out a vif- cid fluid, containing a certain proportion of the coag- ulable part of the blood; and this on fpreading over the furface of wounds, has, by its balfamic agglutina- ting powers, a very confiderable effed in restraining the haemorrhagy. Where the conftitution is found, and where neither of thefe ftates of difeafe preponderates over the other, it is obferved, as foon as the larger arteries of wounds are fecured, that nature, in the manner I have defcrib- ed, generally puts a ftop to all further difcharge. So that when this does not happen, and when a tedious oozing continues from the furface of a fore, we ought to pay particular attention to the habit of body with which it is combined. In young vigorous patients, where the tone of the mufcular fibres is confiderable, the moft effedual means of putting a ftop to this variety of haemorrha- gy, is to relax the vafcular fyftem, either by opening a vein in fome other part, or by undoing the ligature on one of the principal arteries that have been tied, fo as to allow it to bleed freely : thofe violent fpafmodic twitchings, too, fo frequent after the amputation of limbs, when they do not depend on a nerve being tied Chap. VII. of Arteries, cjf>. 489 in the ligature with the artery, are in this manner more effedually relieved than by any other means. By the fame means, the patient from being in a fe- brile heat and much confufed, foon becomes tranquil: the violent pulfation of the heart and larger arteries abates, and the blood not being propelled with fuch impetuofity, the fmaller veffels of the part are thereby left at more liberty to retrad ; and as in this ftate they do not pour forth red blood fo freely, they are the more readily covered with that vifeid glutinous fluid which I have already ffiewn to be one of the moft important means provided by nature for the cure of haemorrhagies. At the fame time that we thus endeavour to allay the commotion produced in the fyftem, the patient ffiould be kept exceedingly cool; wine and other cor- dials ffiould be avoided ; cold water, acidulated either with the mineral or vegetable acids, fhould be his on- ly drink; motion of every kind ffiould be guarded againft ; and the wound being covered with foft lint, moderate preffure ffiould be applied over the whole furface of the fore with a proper bandage. In every extenfive wound, attended with this kind of haemorrhagy, and particularly when violent fpaf- modic affedions of the mufcles fupervene, together with the means that I have mentioned, large dofes of opiates often prove ufeful: by allaying irritation and pain, they often prove more beneficial than any other remedy. As foon, therefore, as a fufficient quantity of blood has been difcharged, and the wound is dreffed, and the patient laid to reft, a dofe of opium, proportioned to the violence of the fymptoms, fhould be given. It muft, however, be remarked, that in all fuch circum- ftances, opiates ffiould be given in large dofes, other- wife, inftead of anfwering any good purpofe, they feem frequently rather to do harm ; fo that, when- ever opium is employed, it ought to be in fuch quan- tities as may be fufficient for the intended effed. 49° Of the Ligature Chap. VII. Although this kind of haemorrhagy fometimes oc- curs in firm constitutions, yet it is certainly more fre- quent in relaxed enfeebled habits, where the folids have loft part of their natural ftrength, and the fluids have acquired fome degree of putrefcency. As the veffels in this fituation are fuppofed to be deprived of that degree of tone of which we wiffi them to be pof- feffed, inftead of restraining the patient from cordials, as is ufually done in cafes of haemorrhagy, a moder- ate ufe of wine ffiould be prefcribed ; for nothing tends fo much in fuch circumftances to reftrain hae- morrhagies, as a well direded ufe of cordials. By tending to invigorate and brace the folids, they ena- ble the arterial fyftem to give a due refiftance to the • contained fluids, while the fame caufe has no incon- fiderable effed in reftoring to the fluids that vifcidity of which in all fuch inftances we fuppofe them to be deprived. When, therefore, tedious haemorrhagies occur in relaxed debilitated habits, a free ufe of Port, Madeira, or any other wine equally good, ffiould be allowed ; a nourifhing diet alfo becomes proper ; the patient fhould be kept cool ; and the mineral acids, from their known utility in every kind of haemorrhagy, ought alfo to be prefcribed. Reft of body is likewife I proper ; and opiates, when indicated either by pain or fpafmodic affedions of the mufcles, ought never to be omitted. Together with remedies of this kind, particular dreffings, appropriated to the ftate of the injured parts, ffiould be applied. I have already remarked, that in firm healthy constitutions, as foon as the difcharge of blood which naturally occurs in large wounds is over, the parts come foon to be covered with a vifeid coag- ulable effufion from the mouths of the retraded arte- ries ; but in constitutions of an oppofite nature, where the folids are much relaxed, the blood in general is in fuch a diffolved ftate as to afford no fecretion of this kind. Chap. VII. of Arteries, EffV. 491 In order to fupply as much as poffible the deficien- cy of this natural balfam, different artificial applica- tions have been employed. Covering the parts with flarch or wheat flour has fometimes proved ufeful; and I haVe known gum arabic, myrrh, and galba- num, in fine powder, prove fuccefsful when thefe have failed. Applications of this kind, indeed, have been ufed with fuccefs in all fuch haemorrhagies, with whatever habit of body they are combined ; but they prove more particularly ufeful in relaxed constitutions, at- tended with a diffolved ftate of the blood, and an en- feebled mufcular fyftem. We may here alfo ufe a remedy which in circumftances of this kind very fel- dom fails ; but which, in thofe of an oppofite nature, ought never to be employed. The remedy to which I allude is alcohol, or any other ardent fpirit, impreg- nated with as great a quantity as it can diffolve, of myrrh, or any other of the heating vifcid gums. The balfamum traumaticum of the fhops, a remedy of this kind, has long been famed for its influence in fuch cafes ; but the indifcriminate ufe of this, and remedies of a fimilar nature, which has long prevailed with fome praditioners, I am confident has done much harm ; for," as they all ad as ftimulants, they of courfe tend to aggravate every fymptom in wounds conned- ed with tenfe fibres, when much pain, and efpecially when fpafmodic mufcular affedions prevail. But, in constitutions of an oppofite nature, where the blood appears to be in a diffolved ftate, and the arterial fyf- tem feems evidently to require a ftimulus, remedies of this clafs prove highly ufeful: infomuch that where the haemorrhagies in fuch constitutions prove diftrefs- ful, no remedy anfwers better than lint, immerfed in a balfam of this kind. By due perfeverance in this mode of treatment, haemorrhagies of this kind will for the moft part be foon restrained: but when this does not happen, and when, notwithftanding of thefe, a difcharge of blood 492 Of the Ligature of Arteries, &c. Chap. VII. ftill continues; together with the means that I have advifed, an equal moderate preffure ffiould be applied over the whole furface of the fore, and continued as long as the neceffity of the cafe may indicate. In finishing the dreffings of wounds of this clafs, after the lint and compreffes have been applied, a bandage ffiould be adapted to the part in fuch a man- ner as to produce an equal preffure over the whole furface of the fore. But it fometimes happens, that no bandage can be made to produce the defired ef- fed : in fuch cafes, the hand of an affiftant is our beft refource.. The hand being firmly applied over the dreffings, fo as to produce an equal preffure, will com- monly fucceed when no other remedy has any effed. Having thus endeavoured to point out the nioft ef- fedual means of putting a flop to haemorrhagies, we ffiall now proceed to confider the different modes em- ployed by art for effeding a difcharge of blood when indicated by the existence of fome difeafe in the con- ftitution. Sed. T. Of Bloodletting. 493 CHAPTER VIII. OF BLOODLETTING. SECTION I. Of Bloodletting in general, BLOODLETTING, whether we confider it as to its influence on the fyftem, or with refped to the nicety with which it ought to be performed, is perhaps one of the moft important operations in fur- gery. From being fo frequently pradifed, and every pretender to knowledge in the healing art being ah1" to perform it, the public have been induced to con- fider it as trivial with refped to its execution ; but every praditioner of charader will acknowledge, that, in order to perform it properly, the greateft nicety, fteadinefs, and accuracy, are required. Every other operation in furgery I have frequently feen well per- formed ; but I have feldom feen bloodletting with the lancet corredly done. When properly performed, it is a neat operation; but when not done with exad- nefs, it is the very reverfe. I do not here mean to confider the various caufes which in different circumftances point out the propri- ety of abftrading blood from the fyftem ; nor do I intend to enter upon a particular difcuffion of the dif- ferent effeds of general and topical bloodletting: thefe considerations, as being highly important, would of themfelves extend to a great length, fo that they will not be looked for in a fyftem of furgery. All that is here intended, is to defcribe the various modes of performing the operation of bloodletting. 494 Of Bloodletting. Chap. VIIL In all inflammatory difeafes not entirely local, the method of taking away blood, as eftablifhed by imme- morial padice, is, by fuch means as difcharge the quantity to be taken, at an opening made with a lan- cet, either in an artery or a vein. Whether there is any real difference in the effeds which thefe two modes of difcharging blood produce, it may be difficult, with precifion, to determine ; but there is reafon to think, that, independent of the quantity taken, the difference is of lefs importance than is commonly imagined. The latter of thefe termed phlebotomy, and the form- er arteriotomy, are the means employed for what we term general bloodletting ; the particular confideration of which we ffiall prefently enter upon. But it often happens in local inflammation, that lit- tle benefit is derived from general bloodletting, while confiderable advantage is obtained from what we term topical or local bloodletting in which blood is difcharg- ed from the difeafed part, by dividing a number of the fmall veffels by which it is fupplied. The means em- ployed for this I ffiall hereafter point out, while, in the mean time, we proceed to confider phlebotomy. Wherever a vein can be reached with fafety, an opening for the difcharge of blood may be made in it with a lancet; but the following are the parts from whence blood is ufually taken in this manner; the veins of the arm at the flexure of the cubitus ; the jugular veins ; and the veins of the ankles and feet. In particular inftances, blood is alfo advifed to be tak- en from the veins of the hand, of the tongue, and of the eyes, and penis, as well as other parts. Some general obfervations relate equally to this op- eration in whatever part of the body it is pradifed ; thefe I ffiall in the firft place point out, and ffiall af- terwards proceed to treat particularly of bloodletting in the arm and other parts. I. In this as in every operation, the pofture of the patient, as well as of the operator, merits particular attention, and it ought to be different, according to the effeds that we wifh to refult from it. Sed. I. Of Bloodletting, 495 In fome difeafes, it is the objed of this remedy, to difcharge a large quantity of blood without inducing fainting : when this is the cafe, and when from for mer experience it is known that the patient is liable" to faint during the evacuation, a horizontal pofture, either upon a bed or on a couch, ffiould be advifed, for every praditioner knows that fainting does not fo readily take place in a horizontal pofture, as when the patient is ered. It fometimes, however, happens, that one material advantage expeded from bloodletting, is its inducing a ftate of deliquium ; as is the cafe in ftrangulated hernia, where a general relaxed ftate of the fyftem proves fometimes ufeful. In all fuch circumftances, inftead of a horizontal pofture,. the more ered a pa- tient is kept, the more readily will fainting be induc- ed. So that the particular objed in view from the operation, muft at all times determine this matter. While we thus attend to the pofture of the body, the particular pofition of the limb or part to be oper- ated upon, muft not be overlooked. In every opera- tion, it is a point of importance, to have the patient feated in a proper light, but in none is it more mate- rial than in bloodletting. The beft general rule that can be given for it, is, that the patient ffiould be fo placed, that the principal light of the apartment ffiall fall diredly on the part to be operated upon, fo that the vein to be opened may be made as apparent as pof- fible. When clear day light can be obtained, it ought to be preferred ; but when this cannot be pro- cured, one or more candles ffiould be ufed. But, whatever may be the pofition of the part it- felf, and whether the patient is placed on a bed or a chair, the furgeon fliould ahvays be feated. The ope- ration may, no doubt, be done while the furgeon is Handing: and it is perhaps moft frequently perform- ed in this manner : but it can never be done either with fuch fteadinefs or neatnefs, as when the operator is firmly feated. 496 Of Bloodletting. Chap. VIIL II. From the coats of veins being more flaccid than thofe of arteries, and from the circulation which takes place in veins being flow, an opening made in a vein will not difcharge freely if the vein be not cut entire- ly acrofs, unlefs the blood is ftopped in its return to the heart by means of a ligature placed between the heart and that part of the vein in which the opening is made. The patient being properly feated, our next ftep therefore is, by means of a proper bandage, fo to comprefs the vein intended to be opened, as to pre- vent the blood from returning to the heart; and for the fame reafon, an equal degree of preffure, it is ob- vious, ffiould be applied to all the other veins of the part; for, were this to be negleded, the communica- tion preferved by the collateral branches would ren- der the preffure upon any particular vein of little im- portance. But, befides producing a more free dif- charge of blood than could be otherwife obtained, this preffure upon the veins, by caufing an accumu- lation of their contents, tends to bring them more ob- vioufly into view, and confequently renders it eafier for the furgeon to make a proper opening than might otherwife be in his power. Although compreffion, however, to a certain ex- tent, is neceffary for the purpofes of accumulating blood in the veins, and for afterwards difcharging it at an opening made by the lancet, it is at the fame time obvious that any confiderable degree of preffure, inftead of forwarding thefe purpofes, would obftrud them entirely; for, if the preffure meant to be appli- ed to the veins only, fhould be carried fo far as to af- fed the arteries, all farther accefs of blood to the veins would be cut off, fo that no difcharge of im- portance would take place at any opening that could be made. Whenever we mean, therefore, to dif- charge blood in this manner, the preffure ought to be moderate: it ffiould always be carried fo far as effec- tually to comprefs the veins, but never to fuch a Sed. I. Of Bloodletting. 40/7 length as to obftrud the circulation in the corref- ponding arteries. When we fee that the preffure raif- es the veins more confpicuoufly into view, and if at the fame time the pulfation of the artery is diftindly felt in the inferior part of the limb, we may then be fure of its being applied in a very proper degree, and that it ffiould not be carried farther: for by the fwel- ling of the veins we are fure that they are fufficiently compreffed; and by the arteries continuing to beat, it is evident that a continued flow of blood paffes in- to them. III. The reflux of blood to the heart being in this manner cut off, we have next to advert to the beft method of opening the vein. Different instruments have been invented for this purpofe, but two only have been retained in ufe. Thefe are, the lancet and phleme. This laft, on being placed immediately on the part to be cut, is, by means of a fpring, ftruck fuddenly into the vein, and forms an opening of the exad fize of the inftrument. The phleme, in various parts of Germany, has ac- quired fome reputation, particularly in taking blood from the jugular veins : but various objedions occur to it, fo that it is not likely ever to be in general ufe: from the nature of the inftrument, the deepnefs to which it ffiould go, ought to be regulated before mak- ing ufe of it: now, we know well that this can never be afcertained ; for we frequently find it neceffary, af- ter the introdudion of a lancet, to go much deeper than was at firft fuppofed to be requifite ; fo that when a phleme is ufed, unlefs we employ one in eve- ry inftance of a length which cannot be frequently required, difappointments muft often take place. But the moft material objedion to this inftrument is, that where arteries or tendons lie beneath the veins, and in danger of being hurt in the operation, the ^fk is much greater with the phleme than with the lan- cet: for when the lancet is ufed, after the vein is Vol. I. I i 498 Of Bloodletting, Chap. VIII. opened, the orifice may be enlarged at pleafure with- out an additional rifk, merely by carrying the inftru- ment forward along the courfe of the vein, at the fame depth to which it was at firft introduced ; where- as the phleme, after entering the vein, mult pafs di- redly down to its full depth ; which adds greatly to the rifk of wounding the parts underneath. Befides, in ufing a lancet, we have it more in our power to command an orifice of a determined fize, than with the phleme: fo that, without hefitation, we may venture to pronounce the phleme to be an in- strument in no degree neceffary; but, for fuch as in- cline to ufe it, the moft convenint form of one is re- prefented in Plate II. fig. 2. The manner of ufing the phleme is this. The bandage for producing the turgefcency of the veins being applied in the manner already direded, the point of the inftrument A, with the fpring properly bent, muft be fo placed upon the part of the vein to be opened, that an orifice of an oblique diredion may be made in it on the fpring B being let loofe. The fubfequent management is the fame here as when the lancet is ufed, and will be prefently pointed out. In ufing the lancet, the form of the inftrument is a point of the firft importance, although it feldom meets with that attention which it merits: the form of lan- cet in ordinary ufe, reprefented in Plate VI. fig. 3, ffiould never be employed in bloodletting: it is well calculated for opening abfceffes; but it ought never to be ufed in this nice operation. The moft obvious objedion to this form of lancet is, that the broadnefs of its fhoulders makes a wound in the external teguments, perhaps three times the fize of the opening made in the vein ; which adds no advantage to the operation; while it gives much un- n^effary pain in the firft inftance, at the fame time that it often renders it difficult to ftop the flow of blood: I may alfo mention, that the wounds made by Sect. I. Of Bloodletting. 499 it are fo extenfive, that they are apt to terminate in partial fuppurations, which always prove both difa- greeable and painful to the patient. The fpear pointed lancet, reprefented in Plate VI. fig. 1, and 2, is an inftrument well calculated for the purpofe of venefedion. From the acutenefs of its point, it enters the vein eafily, a circumftance of no fmall importance with many: it makes the opening in the vein nearly equal to the orifice in the tegu- ments 5 and the difcharge of blood at an opening made with one of thefe lancets, is commonly ftopped with eafe, immediately on the ligature being removed. For thefe reafons, the fpear pointed lancet fliould be preferred; and although, with timid praditioners, the acute point of this inftrument may appear to ren- der more dexterity neceffary in ufing it than the broad ffiouldered lancet; yet the difference in this refped is fo inconfiderable, that all who give it a fair trial will foon be able to ufe it with equal freedom. Indeed no furgeon ought to be trufted in letting blood with the one, whofe fteadinefs and dexterity would in any de- gree be doubted with the other. IV. The form of lancet being thus fixed on, we come now to fpeak of the method of ufing it. The furgeon and patient being both properly feated, and the ligature applied, that vein ffiould be made choice of, which, while it appears fufficiently confpicuous, is not fo loofe as to roll, on being compreffed : fome veins, although they rife fufficiently, yet roll fo much, that they are more difficult to open than others which lie at a greater depth. That vein, therefore, is to be preferred, which not only rifes, fo as to become obvi- ous, but which appears to be conneded with fome de- gree of firmnefs to the contiguous parts. It is fcarce- ly neceffary to obferve, when a vein appears to be fo immediately conneded with a contiguous artery or tendon, that there muft be fome riik of injuring thefe parts in the operation, if another vein not liable to 1 1 2 500 Of Bloodletting. Chap. VIII. fuch hazard can be procured, it ought undoubtedly to be preferred. Veins may lie diredly above both arteries and ten- dons, and yet no manner of rifk be incurred in open- ing them, provided the operator is fufficiently fteady and attentive ; but it muft be admitted, that in fome inftances veins are fo nearly and intimately conneded with thefe parts, as to render it hazardous even for the moft dexterous furgeon to attempt this operation. The vein being at laft made choice of, the furgeon, if he is to ufe his right hand in the operation, muft take a firm hold of the member from whence the blood is to be drawn, with his left, and, with the thumb of the fame hand, he muft now make fuch a degree of preffure upon the vein, an inch and half or two inches below the ligature, as not only to render the fkin, and teguments tenfe, but at the fame time to interrupt all communication between the under part of the vein, and that portion of it lying between the ligature and thumb placed as thus directed. The lancet being bent to fomewhat more than a right angle, the operator muft now take it between the finger and thumb of his right hand ; and, leaving at leaft one half of the blade uncovered, muft reft his hand on the middle finger, ring finger, and little fin- ger, all placed as eafily as poffible near to the vein from whence the blood is to be taken ; and having pufhed the point of the inftrument freely through the fkin and teguments into the vein, he muft now carry it forward in an oblique diredion, till the orifice is of a proper fize ; taking care, during the time of pufhing on the lancet, that the point of it be kept in as ftraight a diredion as poffible, to prevent it from injuring the parts below. The inftrument is now to be withdrawn ; and the furgeon removing the thumb of his left hand, the vein muft be allowed to empty itfelf freely into cups pro- vided for the purpofe. j Sed. I. Of Bloodletting. 50 i It is here of importance to obferve, that the limb fliould be kept fteadily in the fame pofture during the whole time that the blood is flowing off; otherwife, the orifice in the fkin is apt to flip over the opening in the vein ; a circumftance which always proves in- convenient, and in fome inftances exceedingly trou- blefome, by the blood from the vein paffing into the furrounding cellular fubftance. In taking hold of the lancet, I have direded the fcales to form rather an acute angle with the blade of the inftrument. It will even anfwer when they are more widely feparated ; but a farther feparation proves always troublefome, by throwing the fcales too much back upon the hand of the operator. The length of inftrument that ought to projed be- fore the finger and thumb, is another circumftance requiring attention ; for unlefs a fufficient quantity is left uncovered, the furgeon cannot ad with freedom. In lancets of an ordinary length, one half of the blade, as I have mentioned already, ffiould always be left out. The entry of the lancet into the vein is the next circumftance deferving notice ; and it is readily dif- covered ; for as foon as the point has entered the vein, the refiftance to its farther progrefs is immedi- ately diminifhed, and as foon as the opening is in any degree enlarged, the blood begins to rufli out, and thus gives the cleareft proof of this part of the opera- tion being complete. On being thus rendered fure that the lancet has got into the vein, I have alfo de- fired that it may be carried forward in an oblique di- redion, taking care to keep the point of it in the fame elevation from the inftant it has paffed fairly through the coats of the vein ; and to this part of the opera- tion the moft particular attention is required. To the want of caution in this important point, much of the rifk attending this operation may be affigned. The propriety of an oblique diredion for the courfe ©f the orifice is obvious: for, when quite longitudi- 502 Of Bloodletting. Chap. VIII. nal, the fides of the wound are apt to clofe, fo as not to admit of a free difcharge; while, on the other hand, when the vein is cut entirely acrofs, troublefome confequences commonly enfue from the wound being difficult to heal: an orifice fomewhat oblique with refped to the courfe of the vein, is therefore prefera- ble to either. But the material circumftance to be kept in view, is the diredion of the point of the lan- cet after it has got fairly into the vein. By almoft: every author who has written on bloodletting, as foon as the lancet has got into the vein, in order to extend the orifice to a fufficient length, we are direded, very properly, to carry the inftrument forward: but in what manner are we defired to do fo ? by raifing the heel of the lancet, as it is termed, at the fame time that the point and edge of it is in fome degree pufhed forward, fo as to make the point of the inftrument the centre of motion. The reafon of this laft diredion is, that the internal orifice of the vein may not be farther extended up- wards than the external wound in the fkin and other integuments ; ecchymofes, or effufions of blood into the cellular fubftance, being the frequent effed of a different management when broad ffiouldered lancets are ufed: but when the fpear pointed lancet is ufed, this may be always avoided ; as, from the narrow point of the inftrument, it may with fafety be carried on In the cavity of the vein as far as is neceffary. When the operation is properly done, the orifice in the vein muft be nearly of the fame extent as the wound in the fkin ; and by the fame management we avoid that important rifk which muft always occur from an implicit obedience to the diredion I have mentioned : for one certain effed of raifing the heel, or back part of the lancet, is, that the point muft in the fame proportion be depreffed ; and the confequence of lowering the point, already perhaps Hiding along the under fide of the vein, muft in all fuch circum- ftances prove extremely hazardous ; for if, in this fit- Sed. I. Of Bloodletting. 503 uation, the point of the inftrument is depreffed, which muft undoubtedly happen when the heel is elevated, it muft for certain pais through the back part of the vein ; fo that if either an artery, nerve, or tendon, lie contiguous, they muft of neceffity be wounded ; and I am perfedly convinced, that this alone has often been the origin both of wounds in the arteries, and of pricks in the nerves and tendons. This pradice, therefore, as being highly dangerous, ought in every inftance to be laid afide. The fize of the orifice in bloodletting ffiould at all times depend on the nature of the difeafe for which the evacuation is prefcribed. When it is meant to difcharge a large quantity of blood fuddenly, either with a view to excite fainting, or for any other caufe, the orifice ought to be large ; but in common prac- tice, no neceffity occurs for this. In ufing a fpear pointed lancet, an orifice of an eighth part of an inch in length will in general an- fwer every purpofe; but when a broad fhouldered lan- cet is ufed, an opening of twice that fize becomes ne- ceffary ; for with this inftrument the orifice in the vein will feldom be more than half the extent of that in the fkin. After withdrawing the lancet, I have defired that the thumb of the left hand ffiould be removed from the fpot on which it was placed : it may perhaps ap- pear that feme circumftances are here pointed out, with unneceffary minutenefs, and this among others may poffibly be confidered as one : but it muft be remembered, that the whole of this work is chiefly meant for beginners, to whom every circumftance in operations of importance ought to be explained : now one material ufe of the thumb placed below the point where the lancet enters, is, to keep the parts firm, fo as to prevent the vein from rolling. But another ad- vantage derived from it is, that by making a fufficient degree of preffure upon the vein, it prevents any blood from efcaping between the time of removing 504 Of Bloodletting. Chap. VIII. the lancet, and the application of a cup for receiving the blood. During this period a good deal of blood is often difcharged, to the great annoyance both of the patient, the operator, and byftanders ; a circum- ftance which, with due attention, may very common- ly be prevented. V. When the vein is properly cut, and the orifice made fufficiently large, there is leldom any difficulty in procuring all the blood that is wanted. But we are in fome cafes difappointed in this, either from the orifice of the fkin having receded from the opening in the vein, or from the patient having become faintifh ; circumftances always unfavourable to a free difcharge of blood. When it happens from fainting, a ftream of freffi air ffiould be admitted to the apartment, wine or fome other cordial fliould be adminiftered, and the patient ffiould be placed in a horizontal pofture. By thefe means he will in general foon recover; but if ftill the blood ffiould not flow freeiy, the member ffiould be placed in every variety of pofture that may tend to bring the opening in the fkin to correfpond with that of the vein, which will foon be known to have happened by the blood beginning to flow. Throwing the mufcles of the part into conflant ac- tion, by giving the patient a cane, or any other firm fubftance, to turn frequently round in his hand when the operation is done in the arm, will often excite a conflant flow of blood from a vein, when all other means have failed : and, laftly, when the pulfe in the inferior part of the member is feeble, and cannot be eafily diftinguiffied, we may judge that the ligature is too tight, and may have it in our power to excite an immediate flow of blood, by removing or ieffening the compreffion thus improperly made upon the ar- teries. VI. A quantity of blood proportioned to the cir- cumftances of the cafe, being thus' difcharged, the preffure upon the fuperior part of the vein fhould be Sed. I. Of Bloodletting. 5°5 removed ; and this being done, if the fpear pointed lancet has been ufed, all further difcharge of blood will in general ftop. It fometimes, however, happens, that the blood continues to flow freely even after the ligature is removed. When this is the cafe, the ope- rator ffiould comprefs the vein both above and below the orifice with the finger and thumb of one hand, fo as to prevent any farther lofs of blood : this being done, the limb ffiould be waffied, and entirely cleared of blood : the orifice muft alfo be cleared of every particle of blood, and the fides of it being laid exad- ly together, a piece of court plafter, or any other that is fufficiently adhefive, ffiould be fo applied as to re- tain them. This will in many inftances render a ban- dage unneceffary ; but when the blood has iffued with much violence during the operation, and has been difficult to ftop after the removal of the ligature, in fuch inftances it is right to apply a fmall comprefs of linen over the plafter, and to fecure the whole with a roller round the limb. Before applying the plafter, I have direded the orifice to be cleared of every particle of blood ; a cir- cumftance, I may remark, of more importance than is commonly imagined : by inattention to this point, and want of exadnefs in clofing the orifice, painful fwellings and confequent fuppurations are often indu- ced, which with eafe might be prevented. When the operation is properly done, the wound heals by what furgeons call the firft intention, that is, by the parts adhering without the formation of matter; but this can feldom happen, if the lips of the fore have not been neatly laid together after all the blood has been cleared away. There is ftill another important argument for neat- nefs in this matter. Among other troublefome confe- quences arifing from bloodletting, inflammation fome- times occurs in the cavity of the vein ; and as nothing tends more to produce this than the admiflion of air, 506 Of Bloodletting. Chap. VIII. this circumftance of itfelf ftrongly points out the pro- priety of attention to the point in queftion. For al- though inflammation in the internal furfaces of veins is not frequent, yet in various inftances it is met with ; and as the confequences arifing from it, if fuppura- tion enfues, muft commonly prove fatal, they ought in every inftance to be ftridly guarded againft. VII. We come now to treat more particularly of fome troublefome confequences which occafionally proceed from bloodletting, and which every operator ought to be as much as poffible prepared to obviate. The molt material of thefe are, tumors produced by blood effufed from the orifice of the vein into the fur- rounding cellular fubftance ; wounds of the artery ly- ing contiguous to the vein ; pricks of the nerves and tendons ; and laftly, inflammation, induced in the in- ternal cavity of the vein, as has juft been mentioned. Thefe we fhall, under feparate heads, proceed to con- fider. * ' Among other reafons which I have given for preferring a fpear point- ed lancet, it was obferved, that with it the operation is done with lefs pain than with the broad fhouldered lancet: and the prevention of pain is of fuch import,-nee, that nothing should be omitted that can in any de- gree tend to infure it. In every operation our inftruments fliould he in the moft complete or- der; but in none is this 01" more importance than in bloodletting. Well tempered lancets will anfwer tolerably well after being frequently ufed ; infomuch that I have heard even well employed furgeons affert, that they have ufed one or two lancets only during the courfe of many years' prac- tice, without their ever being in the hands of a cutler. But it is certain, that every time a lancet is ufed, it muft be more or lefs injured; and as the prevention of pain is with moft patients a point of no fmall impor- tance, 1 think it ought to be laid down as a rule not to be departed from, never to ufe the fame lancet twice, without putting it into the hands of a cutler. This I have long been in the practice of doing, not only with lancets, but with every cutting inftrument; and the trouble and expence attending it is jncpafiderable, when coapared with the advantage derived from it* Sed. IT. Of Bloodletting. 507 SECTION II. Of a Thrombus, or Ecchymofis. I HAVE already defired, that in bloodletting, the member ffiould be retained in the fame pofture, till the whole quantity of blood intended to be taken is difcharged. When this is negleded, a fmall tumor is apt to form immediately above the orifice in the vein, by the blood infinuating into the cellular fub- ftance of the neighbouring parts. This kind of tu- mor, when round and fmall, is termed a thrombus ; and when more diffufed, an ecchymofis. Immediately on the appearance of thefe fwellings, the ligature ffiould be removed ; and the member be- ing put into that pofture in which it was held when the lancet was introduced, the ligature may be again renewed. A free return of blood will probably in this manner be induced; by which, if the tumor be not entirely removed, it will at leaft be prevented from becoming larger. It fometimes, however, happens, that thefe fwel- lings come at once to fuch a fize, as entirely to pre- clude every poflibility of finishing the operation at the orifice firft made in the vein. Even here, however, the ligature ffiould be immediately removed as the moft effedual method of preventing an increafe of the tumor. By continuing the bandage on the vein, as is often done, the blood ftill continues to be forced into the furrounding cellular fubftance; by which, fuch degrees of fwelling are induced as are apt to create a good deal of trouble, which, with due attention, might, in every inftance, be prevented. In this fituation, it would be vain to exped any confiderable quantity of blood from the orifice firft made. The only way in which the operation can be completed, is by malting another opening, not in the 5o3 Of Bloodletting. Chap. VIII. fame vein, which in fuch circumftances would feldom bleed freely, but in any other that lies moft conve- nient. When thefe tumors do not become large, they are for the moft part eafily difperfed : in this ftate, indeed, they feldom require attention ; but w-hen they become larger than ufual, an immediate application of difcu- tients fhould be advifed. Astringents are to be more depended on than any other remedy, and of this clafs brandy and other ardent fpirits are perhaps as ufeful as any. Compreffes, wet in a folution of crude fal ammoniac in vinegar, and applied with moderate pref- fure, have likewife proved effedual. Inftances, however, fometimes happen, although not frequently, of the colledion of blood being in too great quantities to admit of being all abforbed : in fuch cafes, as no fuppuration can happen, from noth- ing but red blood being contained in the tumor, which cannot be converted into purulent matter, it ought to be immediately laid open as foon as there is reafon to fuppofe that no farther diminution of fize will proba- bly occur from abforption. This being done, and the coagulated blood evacuated, the fore falls to be' treat- ed like any ordinary wound. But thefe tumors are in general of little importance when compared with other accidents which fometimes proceed from bloodletting. The firft of thefe of which we are to treat, are wounds of arteries. SECTION III. Of Wounds of the Arteries. IN all the fmaller arteries, openings may be made with little or no rifk ; but we know from experi- ence, that wounds in the larger arteries often prove hazardous, and feldom heal eafily. Sed. III. Of Bloodletting. 509 When, in bloodletting, we have reafon to fufped that an artery has been wounded, by the lancet having paffed through the vein, and that blood is difcharging at the fame orifice, both from the artery and vein, it becomes a matter of importance for an operator to know with precifion whether it is fo or not. There is only one way in which complete certainty can be obtained on this point; and it is this : When the blood comes from the vein only, if a degree of preffure is applied both immediately above and below the orifice fufficient for compreffing the fides of the vein, all farther evacuation of blood ffiould inftantly ftop, even when the preffure is not fo con- fiderable as to affed the artery below ; but if part of the blood comes from a wound in the artery, this preffure upon the vein, inftead of putting a ftop to the difcharge, will rather tend to increafe it. When at the fame time the blood is difcharged per faltum, this will no doubt ferve as a farther proof, but this reft of itfelf, I may remark, is not fo decifive as is t commonly imagined ; for, a vein lying immediately contiguous to a large artery, receives the influence of the arterial pulfation in fuch a degree, that any orifice made in it difcharges blood very nearly in the fame manner as if the artery itfelf was cut. No other proof, however, is neceffary of the artery being wounded, than the one I have mentioned ; for, if after the veins are thoroughly compreffed, both above and below the orifice, blood ffiould ftill flow with force, no doubt could remain of the artery being wounded. In all fuch trials, it is fcarcely neceffary to obferve, that in compreffing the veins, care ffiould be taken not to af- fed the artery. In fuch circumftances, it is the common pradice to tie up the part with as much firmnefs as poffible, in the firft place with different compreffes placed over the orifice of the vein; and left thefe ffiould not be fufficient, a piece of money or other hard fubftance is commonly added, and the whole fecured with a roller 510 Of Bloodletting. Chap. VIIT, very tightly applied. But what are we to exped from much preffure applied in this manner ? it will not be faid, that it ffiould be fo confiderable, as to comprefs the artery itfelf; for, in that cafe, a ftop would be put to the circulation in the whole limb; while, again, if the force is in fuch a degree as to comprefs the fides of the veins only, one certain ef- fed of this muft be, to occafion a confiderable refift- ance to the flow of blood from the artery : and the blood being thus obftruded in its natural courfe, will neceffarily be much more readily effufed at the open- ing in the artery, than if the veins had been all left free and pervious to receive and tranfmit it. In all fuch cafes, therefore, inftead of applying much preffure, fuch means ffiould be advifed as will with moft certainty tend to relax the veins ; and in order to command the blood, the lips of the wound ffiould be laid together, and retained by ftraps of ad- hefive plafter, without any bandage. And as there is not a more effedual method of relaxing the whole fyftem, and the vafcular fyftem in particular, than by difcharging large quantities of blood quickly, as foon as it is known that an artery is hurt, as much blood ffiould be difcharged by the orifice newly made, as the patient can eafily bear. In this manner, and by enjoining ftrid attention to reft of body, in order to prevent as much as poffible the undue adion of the arterial fyftem, and by keeping the body cool, with the ufe of gentle purgatives, a low diet, and farther bloodlettings when neceffary, there may always be fome chance of fuch wounds in arteries being brought to heal: whereas, when much preffure is made upon the veins, the blood being thereby prevented from flowing through them, muft neceffarily be forced out at the newly formed orifice in the artery ; and which muft therefore, in the moft certain manner, prevent it from healing : in this manner there is reafon to think that many aneuriiinal fwellings have been pro- Sed. II. Of Bloodletting. 511 duced, which, under the mode of treatment I have advifed, would not have taken place. In wounds of arteries, however, it frequently hap- pens that no treatment whatever will fucceed; the orifice in the artery will not reunite, and blood in large quantities is effufed into the contiguous parts. Even in this ftate of the injury, ftrong preffure is of- ten advifed, with a view to diffipate the tumor: but unlefs the fwelling is foft, and the blood contained in it ftill remains fluid, no preffure whatever will difcufs it; for, whenever the accumulated blood has become firm, we cannot fuppofe that preffure will drive it back by the paffage from whence it came. Nor does it appear, that in fuch circumftances, preffure tends to forward the abforption of extravafated blood. From theory alone we might be induced to draw this con- clusion ; and in fad I have not met with an inftance of preffure in fuch cafes affording any advantage. There is indeed a variety of aneurifm, formed by an artery being wounded by a lancet after paffing through a vein, in which moderate preffure proves ufeful. When an artery wounded in this manner, lies quite contiguous to the correfponding vein, the open- ing between the vein and artery, in fome inftances, remains pervious after the external orifice in the vein is clofed, fo as to produce a dired comlnunication be- tween the one and the other; and the vein in this manner receiving the full force of the arterial pulfa- tion, while its coats are not poffeffed of firmnefs fuf- ficient to refill it,' a fwelling of the vein of neceffity takes place. In all fuch inftances, we may readily fuppofe, that moderate preffure will prove ufeful, by tending to fupport the diftended vein, and thus pre- venting any farther increafe of its bulk; but in no other fwelling arifing from blood effufed from an ar- tery, can preffure anfwer any good purpofe; while, for the reafons I have enumerated, there is much caufe to fufped that it has often done harm. 512 Of Bloodletting. Chap. VIII. When we are certain that an artery has been open- ed, and that the tumor produced by it, arifes from blood colleded in the cellular membrane around it, if keeping the limb in an eafy relaxed pofture, and the veins free from preffure, together with the other means that I have pointed out, do not anfwer, no other mode of treatment will be produdive of any advan- tage. The tumor ftill continuing, by the communication between it and the artery being kept up, and none of the means employed for difperfing it, proving effec- tual, the difeafe in this ftate is to be confidered as an aneurifm, a variety of tumor of which we ffiall fpeak more particularly in chapter IX. SECTION IV. Of Wounds or Pricks in the Nerves and Tendons. OUNDS of arteries, as well as thofe of ten- dons, ought never to happen in the hands of a good furgeon; for, as arteries and tendons may both be diftinguifhed by the finger, and their fituation thereby afcertained, it muft always be the fault of the furgeon, if the point of his lancet is not fo direded as to avoid them. One principal caufe of thefe accidents in bloodletting, is, as I have endeavoured to ffiow, the ordinary pradice of depreffing the point of the lancet, after it has entered the cavity of the vein. This, however, I have ffiown to be always unneceffa- ry, and in many inftances highly dangerous. But al- though, by proper attention to this part of the opera- tion, we may always with certainty avoid the arteries and tendons; yet it may be faid, that the nerves, which are fo fmall as not to be previoufly diftinguifh- ed, run at all times a great rifk of being injured ; and w Sed. IV. Of Bloodletting. 513 we know, that when wounded, the moft alarming fymptoms take place, that ever fucceed to the opera- tion of bloodletting. But although the nerves cannot previoufly be dif- tinguiffied, yet, if a proper diredion is given to the lancet, fo as to prevent the point of it from paffing through the back part of the vein, the fame means which tend to fecure the arteries and tendons, will, with almoft equal certainty, prove a fafeguard to the nerves: for, if the operator enters his lancet, as ought always to be done, on the fuperior part of the vein, and does not cut the vein entirely acrofs, by puffiing it through the oppofite fide of it, he will feldom or never injure the contiguous nerves: for the nerves, though they run near to the veins, yet they either lie immediately below them, or fo far down upon their fides as to be out of all rifk of being wounded, if the orifice is made in the upper part of the vein only. I may venture to affert, that the nerves are never injur* ed by a lancet entering the anterior part of a vein: it is always on the oppofite fide of the vein that any mifchief of this kind is produced, when the lancet, as 1 have already obferved; is pufhed entirely through ; which it ought never to be, and which every furgeon ought to have fteadinefs enough to prevent. But although, with very ordinary care and atten- tion,, accidents of this kind may be guarded againft, and although I have ffiown, that the furgeon is almoft in every inftance to blame when they take place; yet experience tends to evince, either from want of atten- tion, or from want of fteadinefs on the part of the operator, that however eafily fuch inconveniencies might be avoided, yet ftill they frequently occur. Nerves, and even tendons, are fometimes pricked, when the dreadful train of fymptoms which fuch ac- cidents ufually produce, are, of courfe, very apt to enfue. Vol. I, K k 5*4 Of Bloodletting. Chap. VIII- In fome cafes the patient complains of an exquifite degree of pain, inftantly on the lancet being intro- duced ; and this we may always confider as a certain mark of a nerve or tendon being pricked: with due care and attention, the violence of pain will often abate, and at laft ceafe entirely, and no danger will enfue; but in fome inftances the pain, inftead of abat- ing, gradually becomes worfe; the lips of the fore become hard and inflamed; and in the courfe of a day or two from the operation, a thin watery ferum begins to ooze from the orifice. If relief is not foon obtained, thefe fymptoms gen- erally continue in nearly the fame ftate for feveral days : thereafter the pain becomes ftill more diftreff- ful; but inftead of being ffiarp and acute, it is now attended with the fenfation of a burning heat. The fulnefs in the lips of the wound becomes more con- fiderable, and the fwelling in the neighbouring parts extends over the whole member, from the foot up- wards over the thigh, when the operation has been done in the lower extremity; and from the elbow down the fore-arm, and upwards along the humerus over to the pedoral mufcle and other contiguous parts, when at the ufual place of bloodletting in the arm. The parts at laft become tenfe and hard ; an erysi- pelatous inflammatory colour frequently appears over the whole ; the pulfe by this time is generally hard and quick; the pain is now intenfe ; the patient reft- lefs ; twitchings of the tendons occur; in fome a lock- ed jaw fupervenes ; and, all thefe fymptoms continu- ing to increafe, it moft frequently happens, that the mifery of the unfortunate patient is only terminated by death. Bloodletting, from being fo frequently pradifed, may by many be confidered as an operation neither fo difficult to perform, nor fo dreadful in its confequen- ces, as thofe that I have enumerated ; and it muft be allowed, that they are not frequent; but they happen Sed. IV. Of moodlefting. .515 often enough to evince the importance of this opera- tion. In the courfe of my experience I have known many inftances of bloodletting ending in death, and the dreadful train of fymptoms I have mentioned oc- curred in all of them. Different opinions have prevailed refpeding the caufe of thefe fymptoms : by fome they have been imputed to wounds of the tendons; while by others the tendons are fuppofed to be destitute of fenfibility, and that the painful fymptoms which fometimes fuc- ceed to bloodletting, proceed entirely from wounds of the nerves. By Mr. John Hunter of London, thefe fymptoms are fuppofed more frequently to proceed froijl an in- flamed ftate of the internal furface of the vein, than from any other caufe. Such a ftate of the vein he has often traced in horfes that have died of fuch fymp- toms from venefedion, where the internal coat of the vein was always found much inflamed, not only in the neighbourhood of the part where the orifice was made; but in fome along the whole courfe of the vein, even to the heart itfelf. Some inftances have al- fo occurred, of the fame appearances in the human body, where the veins after death were found highly inflamed. And on other occafions, inflammation hav- ing in this manner been once excited, fuppuration has at laft enfued from it; and the matter thus produced, being in the courfe of circulation carried to the heart, Mr. Hunter fuppofes, that in fuch cafes death may have been induced by that caufe alone. There can be no reafon to doubt the fad held forth by Mr. Hunter, that in fuch inftances the vein in which the orifice has been made, has fometimes after death been found inflamed : but, however ingenious his arguments may be, for concluding that this ftate of the vein is the original caufe of all the bad fymp- toms ; and although we muft allow, that inflamma- tion of a vein muft tend to aggravate all the fymptoms k k 2 516 Of Bloodletting. Chap. VIII. previoufly induced by other caufes, yet I think we may conclude, that it could not in any inftance ac- count in a fatisfadory manner for their firft produc- tion. In all the inftances of this dreadful malady which I have met with, the patient at the very inftant of the operation, felt a fevere degree of pain. In fome cafes, the viulence of the pain was almoft infupportable. Now, this we can never fuppofe to happen from the mere pundure of a vein ; for although the coats of veins are not perhaps entirely destitute of feeling, yet we know that they are not endowed with much fenfi- bility. This inflamed ftate of the veins, therefore, which in fome cafes has been obferved after death, muft be confidered rather as the effed, than the caufe, of thefe fymptoms; and that they fliould frequently excite inflammation in the contiguous veins, is highly probable. In the courfe of a ffiort time from the op- eration, when the febrile fymptoms commence, fuch a degree of hardnefs and inflammation is induced over all the contiguous parts, that it would be furprifing indeed if the vein, which is thus perhaps furrounded with inflamed parts, ffiould not be inflamed likewife. We may therefore confider this inflamed ftate of the veins as a confequence, rather than the caufe, of thefe fymptoms; and of courfe we revert to the opi- nion of their proceeding either from the wound of a nerve or tendon. Some have indeed attempted to ffiow, as I have al- ready remarked, that tendons are almoft totally desti- tute of fenfibility ; and therefore, that wounds of ten- dons can never account for the various fymptoms which fometimes enfue from bloodletting. There is reafon, however, to think, that, in differ- ent inftances, the fame train of fymptoms have been induced by each of thefe caufes ; that in one inftance a wounded nerve, and in others pricks of tendons, have given rife to them. Being decidedly of this opinion myfelf, I think every perfon muft be fo, who Sed. IV. Of Bloodletting. 5^7 has attentively confidered the fubjed ; but as the fame method of treatment proves equally applicable, wheth- er the difeafe has originated from the wound of a nerve or tendon, I do not think it neceffary to enter upon a more minute difcuffion of the queftion. Hav- ing in a former fedion ffiown how fuch accidents may be almoft always avoided, we ffiall now proceed to confider the means beft calculated for preventing the fymptoms coming to an alarming height, when it is difcovered that, either from inadvertence or any other caufe, the mifchief has adually happened. Whenever a patient, at the time of the operation, complains of an exquifite degree of pain, we may con- clude that fome parts have been wounded which ought not to have been touched. When this unfortunately happens, if proper attention is immediately given, much may be done to obviate the acceffion of thofe fymptoms which otherwife will undoubtedly take place. In order to prevent as much as poffible the accef- fion of inflammation and other fymptoms, a large quantity of blood fhould be immediately difcharged at the orifice newly made; the limb, for feveral days, fhould be kept in a ftate of perfed reft ; care ffiould be taken that the mufcles of the part are preferved in as relaxed a ftate as poffible; the patient fliould be kept cool; on a low diet; and, if neceffary, gentle laxatives ffiould be administered. By this management alone, the fatal fymptoms that I have enumerated, may frequently be prevented; and when they take piace where thefe precautions have been omitted, we may often conclude' that they proceed more from negligence in the fubfequent treat- ment, than from any thing peculiarly bad in the na- ture of the original accident. If, however, notwithftanding of the means that I have advifed, the fymptoms continue to increafe, if the lips of the orifice turn hard and more inflamed, if the pain becomes more confiderable, and efpecially if 51 a Of Bloodletting. Chap. VIII. the fwelling begins to fpread, other remedies mult be employed : in this fituation, leeches applied upon the lips of the wound, frequently give relief; and when the pulfe is full and quick, it even becomes neceffary to evacuate large quantities of blood, by opening a vein in fome other part. The external remedies ufually employed here, are, fomentations and warm poultices; but I have feldom known any advantage arife from them : on the idea of their being able to induce a free and kindly fuppu- ration in the wound, and having reafon to think, from their effeds in fymptoms of the fame kind arifing from other caufes, that they would prove equally ufeful here, I muft own that in various inftances I adopted the pradice in the greateft poffible degree. Unfortu- nately, however, the advantages refulting from it nev- er anfwered my expedation ; fo that at laft I was in- duced to make trial of very different remedies. Although, on firft entering on the free ufe of warm emollients, I did not particularly advert to the caufe of their failure, yet I now think that it may be eafily explained. The parts principally concerned here be- ing almoft entirely membranous, and being therefore, as I have elfewhere ffiown,* incapable of yielding pu- rulent matter, a continued courfe of warm emollients, inftead of producing the wiffied for effed, muft pro- bably render all the fymptoms more fevere ; for when remedies of this clafs do not induce a free fuppura- tion, they tend, by the heat which they convey, to ad as a ftimulus, and hence increafe the inflammation : and in fad we find, that all thefe applications, inftead of proving ufeful, rather do harm. The heat of the part is here one of the molt diftrefsful fymptoms ; fo that inftead of affording relief, any additional warmth rather tends to augment this very tormenting fource of uneafinefs. The lips of the wound, not being ca- pable of yielding good matter, are, by the additional • Vide Chap. L Sed. IV. Of Bloodletting. 5*9 heat which warm poultices and fomentations convey to them, rendered ftill more hard, fwelled, and of courfe more painful, and the fwelling alfo becomes more diffufed over the reft of the limb. By Ambrofe Pare, Dionis, Heifter, and others, in- ftead of emollients, oil of turpentine, tindure of myrrh, and other heating applications, are recommended. That thefe would not prove effedual, 1 cannot from experience pretend to fay ; for fufpeding that they might prove too powerfully irritating to parts render- ed already exquisitely fenfible by difeafe, I have never ventured to ufe them: but I can from repeated expe- rience affert, that cooling aftringent applications afford much more eafe, and prove much more effedual, than warm emollients ; and of this clafs, the moft effedual I have ever employed are the faturnine remedies: the parts affeded being alternately covered with cloths wet with a folution of faccharum faturni, and pledgets fpread with Goulard's cerate, are kept more cool and eafy than by any other remedy I have ufed. In all fuch cafes, therefore, as foon as a fufficient number of leeches have been applied, and have dif- charged freely, the fwelling fliould be covered with pieces of foft linen wet in a faturnine folution; and thefe being kept conftantly moift for the fpace of a few hours, ffiould be fucceeded by Goulard's cerate ; and thus every part in any degree fwelled or pained, fhould be alternately covered with one or other of thefe applications, as long as thefe fymptoms continue. The febrile fymptoms muft at the fame time meet with attention : the patient ffiould be kept cool, and on low diet: his fkin ffiould be kept moift with Do- var's powder : gentle laxatives ffiould be given when neceffary, and if the pulfe becomes full, hard, or quick, farther quantities of blood ffiould be taken. In violent degrees of pain, opiates ffiould be freely given, and when twitchings of the tendons and other convulfive fymptoms fupervene, they become ftill more neceffary. In order, however, to have much influ- 5*0 Of Bloodletting. Chap. VIII. ence in this ftate of the complaint, they require to be given in full dofes ; otherwife, inftead of proving ufe- Wl, they conftantly aggravate the fymptoms, not only by increafing the heat and reftleffnefs, but by render- ing the fyftem more irritable, and therefore more fuf- ceptible than it was before of the pain arifing from the wound: whenever opiates, therefore, are in fuch circumftances employed, the dofes ought to be large. It often happens, however, in this very alarming fituation, either from negled at firft, or from an im- proper fubfequent treatment with warm emollients, that opiates and the other remedies I have mentioned are afterwards ufed in vain : the fever, pain, and fwel- ling of the parts, continuing, convulfive twitches 6f the mufcles at laft fupervene, all tending to indicate the moft imminent danger. In this fituation, if we do not immediately employ the moft effedual remedy, the patient muft foon be cut off; and the only reme- dy from which any real advantage can enfue, is a free and extenfive divifion of the parts in which the orifice producing the mifchief was at firft made. From the repeated experience of ages, we know, that much more pain and diftrefs is excited by the partial divi- fion either of a nerve or tendon, than from their be- ing cut entirely acrofs, Now, the intention of this operation is to complete the divifion of the nerve or tendon that have been wounded by the point of the lancet,, and which I am induced in all fuch cafes to confider as the chief caufe of the fubfequent diftrefs. As the operation, however, is attended with much pain, and being put in pradice for the removal of fymptoms from which it is perhaps difficult to per- fuade the patient that any danger is to be dreaded, all the remedies I have mentioned ffiould firft be employ- ed before it is propofed : but, at the fame time, care ffiould be taken, that the fymptoms be not allowed to advance too far before we advife it; for when the pa- tient is much weakened by the feveriffi fymptoms hav- ing continued long violent, neither this nor any other Sed. IV. Of Bloodletting. 521 remedy with which we are acquainted, has much in- fluence. As foon, therefore, as the remedies I have advifed have been fairly tried, and are found to be in- adequate, we fliould immediately propofe a free divi- fion of the parts chiefly affeded ; and the manner of doing it is this. As all the contiguous parts are now fuppofed to be much fwelled and inflamed, it is impoffible to get clear accefs either to the nerve or tendons, but by means of a large and extenfive incifion ; and as this cannot be done but with the rifk of opening the con- tiguous arteries, the firft ftep to be taken, is to guard againft this occurrence by applying a tourniquet on the upper part of the limb. This becomes neceffary, not only for preventing the lofs of blood which would enfue from a divifion of any of the large arteries, but for preventing that interruption which would other- wife happen from a conflant difcharge of blood from the fmaller veffels during the operation. The tourni- quet indeed is more particularly requifite for this pur- pofe, than for any other ; for although it is proper, by means of it, to guard againft the danger of wound- ing any of the large arteries, yet, with proper caution, this may for the moft part be avoided. The tourniquet, then, being properly applied, a tranfverfe cut ffiould be made with a common fcalpel, in the parts chiefly affeded, and it ffiould run in a diredion exadly acrofs the original orifice in the vein. In no operation is it more neceffary than in this, to ad with freedom in laying the parts fufficiently open by a free incifion. A fmall incifion excites nearly the fame pain with a larger cut; and it has this material difadvantage, of preventing the furgeon from proceed- ing in the future fleps of the operation with that eafe and expedition which the nature of the cafe very commonly requires. The fkin and other teguments being thus freely di- vided, the operator rnuft make one flight incifion af- 522 Of Bloodletting. Chap. VIII. ter another, taking care, if poffible, to avoid the larg- er arteries and veins ; and he is to go on in this way, to difcover the wounded nerve ; or if there is no pof- fibility of doing fo, he muft ftill continue to proceed in this gradual manner, till he has divided every part between the fkin and periofteum ; the tendons, larger arteries, and veins excepted. At this time the tourniquet fliould be loofened ; when in all probability the patient will exprefs much fatisfadion at what has been done : for, if the part is thus divided which was originally pricked by the lan- cet, immediate relief will be obtained ; while, on the contrary, if the pain remains violent, we may be there- by convinced that the mifchief lies in one or other of the tendons. An accurate examination, therefore, fhould now be made, by clearing the parts with a fponge ; and that tendon lying moft contiguous to the vein in which the orifice was made, will moft proba- bly either be found pricked, or in an evident ftate of inflammation ; but at all events, whether any fuch ap- pearances are difcovered or not, there ffiould be no hefitation in dividing that tendon which lies moft con- tiguous to the vein ; or if two or even three tendinous extremities ffiould lie in the way, and are all there- fore equally liable to fufpicion, they ought all to be cut acrofs: this being done, relief will for the mofl part be immediately obtained ; and, at any rate, this being done, every attempt will have been made from which there could be reafon to exped any advantage. The parts being thus freely divided, the tourniquet fhould now be undone, and fuch arteries as have been wounded, ffiould be fecured with ligatures. The parts are then to be covered with eafy dreffings, and after- wards treated in the fame manner as a wound from any other caufe. The means of relief which I have thus advifed, if every circumftance be not' duly weighed, may proba- bly be confidered as fevere ; for an incifion in thefe parts, carried to fuch a depth, muft no doubt be at- Sed. IV. Of Bloodletting. 523 tended with much pain, while the divifion of one or more tendons will produce a partial lamenefs of the whole member : but if we confider for a moment the importance of the objed in view, all fuch fears muft immediately fall to the ground : it is not a trifling ad- vantage we are in purfuit of, nor ffiould fuch a pain- ful operation be ever propofed but in the moft urgent circumftances. In the prefent inftance, however, the patient's life is obvioufly to depend on the event of this operation ; fo that the moft timid operator, if ca- pable of refledion, muft admit the propriety of put- ting it in pradice ; and from the event of every cafe that has once advanced to the length for which I have advifed this operation, it may with certainty be**pro- nounced, that patients in fuch circumftances are in the utmoft hazard ; fo that in fuch a defperate fitua- tion, no remedy that affords any tolerable chance of a recovery, however painful it may be, can with pro- priety be condemned. From reafoning alone, we might conclude, that in fuch circumftances no other remedy would prove fo fuccefsful; but when the propriety of the meafure is enforced by the fuccefsful iffue of repeated trials, no argument adduced againft it can meet with much at- tention. In various inftances of lefs importance, I have known much advantage derived from this prac- tice ; and, in one inftance, from bleeding in the me- dian cephalic vein of the arm, the fymptoms had got to fuch a height, and had fo obstinately refilled every other remedy, that there was much caufe to dread that death muft have enfued, had it not been for the effeds of a free and very deep divifion of the pained parts. The patient, from being in exquifite pain, and in imminent danger, experienced almoft inftantaneous relief; and the fwelling, which had previoufly con- tinued obftinate, began foon to abate, and a perfed recovery was obtained in much lefs time than could have been looked for. 524 Of Bloodletting. Chap. VIII. There is not therefore, a point in furgery, of which I am more convinced, than of the propriety of this operation in all fuch defperate cafes as the one of which we have been treating ; but to fuch as have not met with occurrences of this kind, the remedy propofed will not only appear to be too violent for the difeafe, but they will alfo be induced to confider the length of difcuffion I have gone into as more prolix than neceffary : a fingle inftance, however, of the dreadful fymptoms induced by this kind of accident, will be fufficient to convince any one, of the fubjed we have thus been confidering, being perhaps one of the moft important in the department of furgery. All that I have hitherto faid on bloodletting, re- lates to the operation in general: I fliall now proceed to confider the operation as it is done in particular parts; and firft of bloodletting in the arm. SECTION V. Of Bloodletting in the Arm. BLoodletting is more frequently pradifed on the forepart of the arm at the joint of the elbow, than in any other part. The veins are in general more confpicuous in this place ; but no other reafon can be affigned for it. On the contrary, the near contiguity of nerves, tendons, and large arteries to thefe veins, makes it more hazardous here than in other parts. From this, I have often been induced to confider our fixing on this part for the ordinary ope- ration of bloodletting as a very important error ; efpe- cially as blood may be drawn from veins in other parts, with the fame eafe as from thofe of the arm, and with lefs danger; particularly from the veins of the neck, hands, ankles, and feet, Sed. V. Of Bloodletting. 525 Bloodletting in the lower extremities has chiefly been confined indeed to a particular fet of difeafes, ef- pecially to thofe of females: but no good reafon can be affigned for this; for it is now known, that, in general bloodletting, the place from whence the blood is drawn, is of little importance, and that the effed:s of the operation depend almoft entirely on the quan- tity difcharged in a longer or fliorter time. Bloodletting at the arm may be fafely performed by furgeons of fteadinefs and attention, as in the hands of fuch men there is little or no rifk of the lancet go- ing deeper than the vein, and in this cafe nothing bad can enfue : but in common pradice, it would be bet- ter to fix upon fome other part. It may almoft al- ways be done with eafe in the hands, feet, and ankles ; and if the operation is properly performed, the fame quantity of blood may be drawn from the veins of thefe parts, as from thofe of an equal fize in any oth- er part of the body. But whether this idea ffiould ever be generally adopted or not, it is at leaft certain, if the cautions I have pointed out are proper in other parts, they are much more fo in the arm, where the veins lie fo very contiguous to parts which cannot be wounded, but with the rifk of producing fymptoms of the moft alarming tendency. Having already confidered the various fleps of the operation of bloodletting, fo far as they relate to it in a general view, in order to avoid repetitions, nothing will be mentioned now but what is particularly re- quired in taking blood from the arm. In applying the ligature for compreffing the veins, it ffiould be placed a"h inch or an inch and half above the joint of the elbow ; and, in order to prevent the ends of it from coming in the way of the lancet, the knot ffiould be made on the outfide of the arm. In general, one knot might anfwer ; but a flip knot be- ing made above the firft, renders it more fecure, and it is very eafily done. 526 Of Bloodletting. Chap. VIIL In making choice of a vein from whence blood is to be taken, the general rules we have laid down up-» on this point, in the firft fedion of this chapter, muft be kept in view. That vein which appears moft con- fpicuous, at the fame time that it rolls leaft under the fkin, ffiould in general be made choice of; but when an artery is found to lie immediately below, and quite contiguous to the vein, the operator, if not perfedly fatisfied with his own fteadinefs, ought rather to pre- fer another. For the moft part, however, the artery lies fo lowr in this place, that the median bafilic vein, un- der which it commonly runs, may be opened with fafety; and as this vein is ufually more confpicuous than the others, it is for this reafon in general to be confidered as the beft. Befides, we prefer the medi- an bafilic, from its being lefs deeply covered with ceh lular fubftance than the cephalic or median cephalic; and by lying towards the inner part of the arm, it is more thinly covered with the tendinous expanfion of the biceps mufcle, than either of the others. From thefe circumftances, the operation is alfo attended with lefs pain in this than in the other veins ; a con- fideration which in every operation merits our regardj In bloodletting at this part of the arm, although it may be done with the right hand, either upon the right or left arm of the patient; yet we do it more neatly with the right hand upon the right arm, and with the left hand on the left arm of the patient; and whoever attempts the contrary, muft find that it can- not be done but in an awkward manner, as the oper- ator cannot in any other way apply his hand properly to that part of the arm on which it ought to reft. In corpulent people, the veins fometimes lie fo deep as not to be difcovered by the eye; but when they are fenfibly felt by the fingers, even although they cannot be feen, they may be opened with freedom. In a few inftances^ however, they can neither be dif- tinguifhed by the eye, nor with the finger : in this cafe, the ligature fliould be removed, from the upper Sed. VI. Of Bloodletting. 5*7. part of the arm, and applied about half way between the elbow and wrift, by which the veins below will be brought into view ; and wherever a vein can be evi- dently obferved, there can be no danger in performing the operation. This I have often found neceffary, nor has any inconvenience ever enfued from it. SECTION VI. Of Bloodletting in the Jugular Vein. INFLAMMATION of the throat and of the eyes, as well as other affedions of the head, frequently require blood to be taken from the contiguous parts; particularly from the external jugular veins : the man- ner of opening thefe veins is this : There is only one ramification of the jugular vein, namely, the principal posterior branch, that can eafily be brought fo much into view, as to be with propriety opened ; and even this lies deeply covered, not only with the fkin and cellular fubftance, but with the pla- tifma myodes mufcle, fo that a good deal of preffure is required to raife it. With a view to produce this, the thumb of the operator is commonly placed upon the vein, fo as to comprefs it about an inch or inch and half below where the opening is to be made. This, however, is feldom fufficient, as the blood, on being ftopped in its progrefs through this branch, finds an eafy paffage to the other veins ; fo that ulefs the principal vein on the other fide of the neck is alfo compreffed, the vein to be opened can never be fully diftended. In order to diftend it fufficiently, a firm comprefs of linen ffiould be applied on the largeft vein on the oppofite fide of the neck ; and a garter, or any other ligature, being laid over it, a firm knot ffiould be tied below the oppofite armpit; taking care 528 Of Bloodletting, Chap. VIII. to make fuch a degree of preffure, as may put an en- tire ftop to 'the circulation in the vein, which in this way is eafily done, without obftruding refpiration. This being done, and the patient's head properly fupported, the operator, with the thumb of his left hand, muft make fufficient preffure upon the vein to be opened, while, with the lancet in his right hand, he ffiould penetrate at once into the vein ; and, before withdrawing the inftrument, the orifice fhould be made fufficiently large for the intended evacuation. It may be proper to obferve, that a larger opening is neceffary in the neclc than in the arm, otherwife the quantity of -blood is procured with difficulty : and, befides, there is not here the fame neceffity for caution on this point that there is in the arm: for in the neck, we meet with no difficulty in putting a ftop to the blood: after removing the ligature, all that is com- monly neceffary, even when the orifice is large, is to clofe it with a flip of adhefive plafter. In order to bring the vein more clearly into view, fo as afterwards to be able to open it with more accu- racy, fome have direded, that the fkin, cellular fub- ftance, and mufcular fibres covering the vein, ffiould be previoufly divided with a fcalpel. This, however, is unneceffary; and it renders the operation both more painful and more tedious than when done with the lancet at once. END OF VOLUME FIRST. I.. i ■ -1 {/K^A/V- 1 > '2 / liW #* V>, >' wt> <:-( ^i; i *tx. '^t^-Sfe.'i^ ;i